Alfred S. Evans (Auth.), Alfred S. Evans (Eds.) - Viral Infections of Humans - Epidemiology and Control (1976, Springer) (10.1007 - 978-1-4613-3988-5) - Libgen - Li

Viral Infections
of Humans
Epidemiology and Control
Viral Infections
of Humans
Epidemiology and Control
Edited by
Alfred S. Evans
Yale University
PLENUM MEDICAL BOOK COMPANY

New York and London
Library of Congress Cataloging in Publication Data
Main entry under title:
Viral infections of humans.
Includes bibliographies and index.
1. Virus diseases. 2. Epidemiology. 3. Virus diseases-Preven-
tion.1. Evans, Alfred S., 1917-
RA644.V55V57 614.5'7 76-9650
ISBN-13: 978-1-4613-3990-8 e-ISBN-13: 978-1-4613-3988-5
DOl: 10.1007/978-1-4613-3988-5
First paperback printing 1978
© 1976 Plenum Publishing Corporation

227 West 17th Street, New York, N. Y. 10011
Plenum Medical Book Company is an imprint of

Plenum Publishing Corporation
All rights reserved
No part of this book may be reproduced, stored in a retrieval system,

or transmitted, in any form or by any means, electronic, mechanical,
photocopying, microfilming, recording, or otherwise, without
written permission from the Publisher
Dedication
This book is dedicated to Dr. John R. Paul, who introduced me to the field of
epidemiology and to the concepts of clinical and serological epidemiology; to
Dr. Thomas F. Francis, who arranged and supervised my Master of Public
Health degree (in epidemiology) at the University of Michigan' School of
Public Health; to Dr. William D. Stovall, who taught me the potential contribu-
tions of the public health laboratory to epidemiology and to preventive
medicine; to Dr. David See gal and Dr. John R. Talbott, my mentors in clinical
medicine; and to Dr. Ernst J. Witebsky, Dr. Paul F. Clark, and Dr. Victor C.
Seastone, my teachers and associates in immunology and microbiology.
A. S. Evans
Contributors
ABRAM S. BENENSON, Department of Community Medicine, University of
Kentucky College of Medicine, Lexington, Kentucky
FRANCIS 1. BLACK, Department of Epidemiology and Public Health, Yale
University School of Medicine, New Haven, Connecticut
CARL BRANDT, Laboratory of Infectious Diseases, National Institute of Allergy
and Infectious Diseases, National Institutes of Health, Bethesda, Mary-
land; Children's Hospital National Medical Center of D. c., Washington,
D.C.; and George Washington University School of Medicine, Depart-
ment of Child Health and Development, Washington, D.C.
JACOB A. BRODY, National Institute of Neurological and Communicative
Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
JORDI CASALS, Department of Epidemiology and Public Health, Yale Univer-
sity School of Medicine, New Haven, Connecticut
ROBERT M. CHANOCK, Laboratory of Infectious Diseases, National Institute of
Allergy and Infectious Diseases, National Institutes of Health, Bethesda,
Maryland, and Children's Hospital of D.C., Washington, D.C.
FRED M. DAVENPORT, Department of Epidemiology, School of Public Health,
University of Michigan, Ann Arbor, Michigan
FLOYD W. DENNY, Department of Pediatrics, School of Medicine, University of
North Carolina, Chapel Hill, North Carolina
G. DE-THE, International Agency tor Research on Cancer, Lyon, France
WILBUR G. DOWNS, Department of Epidemiology and Public Health, Yale
Arbovirus Research Unit, Yale University School of Medicine, New
Haven, Co:g.necticut
ALFRED S. EVANS, WHO Serum Reference Bank, Section of International
Epidemiology, Department of Epidemiology and Public Health, Yale
HARRY A. FELDMAN, DepartmeI!t of Preventive Medicine, State University of
New York, Upstate Medical Center, Syracuse, New York
HJORDIS M. Foy, Department of Epidemiology and International Health,
viii Contributors
School of Public Health and Community Medicine, University of Wash-

ington, Seattle, Washington
CLARENCE JOSEPH GIBBS, JR., Laboratory of Central Nervous System Studies,
National Institute of Neurological and Communicative Disorders and
Stroke, National Institutes of Health, Bethesda, Maryland
W. PAUL GLEZEN, Department of Pediatrics, School of Medicine, University of
ELI GOLD, Department of Pediatrics, University of California, Davis, Califor-
nia
J. THOMAS GRAYSTON, Department of Epidemiology and International Health,
School of Public Health and Community Medicine, University of Wash-
ington, Seattle, Washington
JACK MERRIT GWALTNEY, JR., Department of Internal Medicine, University of
Virginia School of Medicine, Charlottesville, Virginia
J. H. C. Ho, Institute of Radiology, Queen Elizabeth Hospital, Kowloon, Hong
Kong
DOROTHY M. HORSTMANN, Department of Epidemiology and Public Health
and Department of Pediatrics, Yale University School of Medicine, New
Haven, Connecticut
WILLIAM E. JOSEY, Department of Gynecology and Obstetrics, Emory Univer-
sity School of Medicine, Atlanta, Georgia
HyUN WHA KIM, Laboratory of Infectious Diseases, National Institute oi
Maryland; Children's Hospital National Medical Center of D.C., Wash-
ington, D.C.; and George Washington University School of Medicine,
Department of Child Health and Development, Washington, D.C.
FRANK A. LODA, Department of Pediatrics, School of Medicine, University of
ROBERT W. MCCOLLUM, Department of Epidemiology and Public Health, Yale
JOSEPH 1. MELNICK, Department of Virology and Epidemiology, Baylor College
of Medicine, Houston, Texas
GEORGE MILLER, Department of Pediatrics and Department of Epidemiology
and Public Health, Yale- University School of Medici~, New Haven,
Connecticut
ARNOLD S. MONTO, Department of Epidemiology, School of Public Health,
University of Michigan, Ann Arbor, Michigan
C. MUIR, International Agency for Research on Cancer, Lyon, France
ANDRE J. NAHMIAS, Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia
Contributors ix
GEORGE A. NANKERVIS, Department of Pediatrics, Case Western Reserve

University School of Medicine at Cleveland Metropolitan General Hospi-
tal, Cleveland, Ohio
JAMES C. NIEDERMAN, Department of Epidemiology and Public Health, Yale
JAMES M. OLESKE, Department of Pediatrics, Emory University School of
Medicine, Atlanta, Georgia
ROBERT H. PARROTT, Laboratory of Infectious Diseases, National Institute of
Maryland; Children's Hospital National Medical Center of D.C., Wash-
ington, D.C.; and George Washington University School of Medicine,
Department of Child Health and Development, Washington, D.C.
ROBERT E. SHOPE, Department of Epidemiology and Public Health, Yale
THOMAS H. WELLER, Richard Pearson Strong Professor of Tropical Public
Health and Head, Department of Tropical Public Health, Director, Center
for Prevention of Infectious Diseases, Harvard School of Public Health,
Boston, Massachusetts
Contents
Chapter 1 Epidemiological Concepts and Methods
Alfred S. Evans
1. Introduction 1
2. Definitions and Methods 1
3. The Agent. 5
4. The Environment . 5
5. Routes of Transmission 6
5.1. Respiratory 6
5.2. Gastrointestinal 8
5.3. Skin 9
5.4. Genital 9
5.5. Genitourinary 9
5.6. Personal Contact 10
5.7. Water and Food 10
5.8. Arthropod Borne 10
6. Pathogenesis 10
6.1. Respiratory 10
6.2. Gastrointestinal 11
6.3. Systemic Infections 11
6.4. The Exanthem 11
6.5. Infections of the Central Nervous System. 12
6.6. Persistent Viral Infections 12
7. Incubation Period 13
8. The Immune Response 14
8.1. Humoral Immunity 14
8.2. Local Immunity (Secretory IgA System) 15
8.3. Cell-Mediated Immunity . 15
8.4. Immune Responses in the Pathogenesis of Viral Diseases . 16
9. Patterns of Host Responses . 16
9.1. The Biological Gradient 16
9.2. Clinical Syndromes 18
XII Contents
10. Diagnosis of Viral Diseases 22

10.1. Collection 22
10.2. Requests for Testing 23
10.3. Interpretation of Tests 24
11. Proof of Causation 24
12. Control and Prevention 28
13. References 28
14. Suggested Reading 32
Chapter 2 Surveillance and Seroepidemiology

Alfred S. Evans
1. Introduction 33
2. Surveillance 33
2.1. Historical Background 33
2.2. Elements of Surveillance 34
2.3. Other Surveillance Methods 37
2.4. Surveillance in Research Studies 38
2.5. Publications on Surveillance 39
2.6. Predictive Surveillance 39
3. Seroepidemiology 40
3.1. Introduction 40
3.3. Methodology 41
3.4. Advantages and Limitations 42
3.5. Uses of Seroepidemiology 42
4. References 49
Chapter 3 Adenoviruses
Hjordis M. Foy and J. Thomas Grayston
1. Introduction 53
2. Historical Background 53
3. Methodology Involved in Epidemiological Analysis 54
3.1. Sources of Data 54
3.2. Interpretation of Laboratory Tests 55
4. Characteristics of the Virus . 55
5. Descriptive Epidemiology 56
5.1. Synopsis of Descriptive Epidemiology 56
5.2. Epidemiological and Clinical Aspects of Specific Syndromes 56
6. Mechanisms and Route of Transmission 62
7. Pathogenesis and Immunity 63
8. Pattern of Host Response 63
9. Control and Prevention . 64
Contents xiii
10. Unresolved Problems 65

11. References 65
Chapter 4 Arboviruses
Wilbur G. Downs
1. Introduction 71
3.1. Sources of Mortality Data 74
3.2. Sources of Morbidity Data 75
3.3. Serological Surveys 75
3.4. Laboratory Methods 76
4. Biological Characteristics of Virus Affecting the Epidemiological
~tt~ ~
5. Epidemiology 77
5.1. Incidence and Prevalence 78
5.2. Epidemic Behavior 78
5.3. Geographic Distribution 79
5.4. Temporal Distribution 79
5.5. Age and Sex 79
5.6. Other Factors 79
6. Mechanism and Route of Transmission 80
8. Patterns of Host Response 85
8.1. Clinical Features 85
8.2. Diagnosis 85
10. Characteristics of Selected Arboviruses 87
10.1. Arboviruses of Importance in the United States 87
10.2. Other Arboviruses Affecting Human Beings in the
United States 91
10.3. Arboviruses Affecting Human Beings Outside the United States 92
11.1. The Viruses 95
11.2. The Vectors 96
11.3. The Vertebrate Hosts 96
11.4. Transmission Cycles Involving Virus, Vector, and Vertebrate 96
11.5. Disease in the Vertebrate Host 97
11.6. Control. 97
12. References 98
xiv Contents
Chapter 5 Arenaviruses
Jordi Casals
1. Introduction 103
3. Methodology 103
3.1. Mortality 103
3.2. Morbidity 104
3.3. Serological Surveys. 104
3.4. Laboratory Diagnosis 104
4. The Viruses 105
4.1. Biochemical and Physical Properties 105
4.2. Morphology and Morphogenesis 105
4.3. Antigenic Properties 106
4.4. Biological Properties 107
6. Lymphocytic Choriomeningitis 109
6.1. Descriptive Epidemiology. 109
6.2. Mechanism and Route of Transmission 110
6.3. Patterns of Host Response . 112
6.4. Treatment and Prevention. 112
7. Argentinian Hemorrhagic Fever 112
.7.2. Mechanism and Route of Transmission 113
7.4. Treatment, Control, and Prevention 115
8. Bolivian Hemorrhagic Fever 115
8.4. Treatment, Prevention, and Control 117
9. Lassa Fever 117
9.1. Descriptive Epidemiology . 117
9.3. Patterns of Host Response. 118
9.4. Treatment and Disposition of Patients 119
9.5. Prevention and Control 119
10. Unresolved Questions 119
10.1. Vaccines 119
10.2. Early Diagnosis of Lassa Fever and Evacuation of Patients 120
10.3. Hemorrhagic Fever with Renal Syndrome 120
11. References 121
Contents XV
Chapter 6 Coronaviruses
Arnold S. Monto
1. Introduction 127
3. Methodology 128
3.1. Sources of Mortality Data 128
3.3. Serological Surveys . 129
4. Biological Characteristics of the Virus 130
5.4. Age 136
6. Mechanisms and Routes of Transmission 137
9. References 139
Chapter 7 Cytomegalovirus
Eli Gold and George A. Nankervis
1. Introduction 143
3. Methodology 144
3.1. Mortali ty 144
3.2. Morbidity 144
4. Biological Characteristics of the Virus 145
5.1. Prevalence and Incidence 146
5.3. Age and Sex. 149
5.4. Temporal Distribution . 150
5.5. Occupation 150
5.6. Race/Socioeconomic Setting 150
6. Mechanism of Transmission 150
7.1. Pathogenesis 151
xvi Contents
7.2. Immunity 152

8.1. Neonatal Infections . 152
8.2. Infection of Children and Adults 153
9. Immunization . 156
11. References 156
Chapter 8 Enteroviruses
Joseph L. Melnick
1. Introduction 163
3.1. Sources of Mortality Data. 165
3.4. Virus Isolation from Surface Waters as an Indicator of
Community Infections . 167
Pattern 171
4.1. General Properties 171
4.2. Reactions to Chemical and Physical Agents 171
4.3. Antigenic Characteristics 172
4.4. Host Range in Vivo and in Vitro 173
4.5. Replication of Enteroviruses . 174
5.1. General Epidemiology of Enteroviruses 176
5.2. Epidemiological Patterns of Poliomyelitis 183
6. Mechanisms and Route of Transmission 186
7.2. Immunity 188
8. Patterns of Host Response and Diagnosis 189
8.1. Clinical Syndromes 189
8.2. Diagnosis 192
9.1. Schedules of Oral Vaccine Administration 195
9.2. Problems Associated with Oral Polio Vaccine . 196
Contents xvii
9.3. Current Status of Immunization for Poliomyelitis in the United

States 197
9.4. "Social Failures" of Vaccine Administration 198
9.5. Nonspecific Control Measures 200
9.6. Control of Other Enterovirus Infections 201
11. References '. 201
Chapter 9 Epstein-Barr Virus

Alfred S. Evans and James C. Niederman
1. Introduction 209
2. History 209
3. Methodology 210
3.1. Mortality Data 210
3.2. Morbidity Data 211
4. Biological Characteristics of the Agent 213
4.1. The Virus 213
4.2. Proof of Causation of Infectious Mononucleosis 214
5.1. Prevalence and Incidence 215
5.2. Epidemic Behavior . 217
5.5. Age 219
5.6. Sex 219
5.7. Race 220
5.8. Occupation 220
5.9. Occurrence in Different Settings 220
5.10. Socioeconomic Factors 221
8.2. Diagnosis 225
10. Unsolved Problems 227
11. References 228
xviii Contents
Chapter 10 Viral Hepatitis

Robert W. McCollum
1. Introduction 235
3.1. Mortality 236
3.2. Morbidity 236
4. Biological Characteristics of the Human Hepatitis Viruses 239
5.1. Viral Hepatitis Type A . 240
5.2. Viral Hepatitis Type B . 241
6.1. Viral Hepatitis Type A . 242
6.2. Viral Hepatitis Type B . 243
7.1. Viral Hepatitis Type A 245
7.2. Viral Hepatitis Type B 245
9.1. Type A 247
·9.2. Type B 247
11. References 249
Chapter 11 Epidemiology of Herpes Simplex Viruses

1 and 2
Andre J. Nahmias and William E. Josey
1. Introduction and Social Significance 253
2. Evolutionary and Historical Background 254
3.1. Mortality 254
3.2. Morbidity 255
4. Biological Characteristics of HSV-1 and HSV-2 257
5.1. General Epidemiology . 258
Contents xix
5.2. Epidemiological Aspects of Specific Clinical Entities 260

8. Patterns of Host Response . 265
8.1. Mouth and Respiratory and Gastrointestinal Tracts 265
8.2. Lips 265
8.3. Eyes 266
8.4. Skin 266
8.5. Urogenital Tract . 266
8.6. Nervous System. 266
8.7. Fetus and Newborn 266
9.1. Prevention of the Initial Infection 267
9.2. Reducing the Source of Virus Transmissible to Others 268
10.1. Reporting 268
10.2. Virological Aspects 268
10.3. Host Factors 268
10.4. Control and Prevention 268
11. References 269
Chapter 12 Influenza Viruses

Fred M. Davenport
1. Introduction 273
3. Epidemiological Methodology 275
3.2. Morbidity Data . 276
4. Biological Characteristics of the Virus . 278
5.1. Incidence and Prevalence Date 278
5.5. Age 284
6. Transmission 287
XX Contents
7.2. Immunity 288

8.2. Diagnosis 289
9. Control Measures . 290
11. References 291
Chapter 13 Measles
Francis L. Black
1. Introduction 297
4. Biological Characteristics of the Virus. 300
5.1. Incidence . 300
5.5. Age 304
5.6. Sex 305
5.7. Race 305
5.8. Occupation 306
5.9. Social Setting 306
5.11. Nutrition 307
6. Transmission 307
8.1. Clinical Features of Unusual Forms 310
8.2. Diagnosis 311
lb. Unresolved Problems 312
10.1. Vaccine Distribution 312
10.2. Unusual Reactions Following Killed Vaccine 313
10.3. Measles and Multiple Sclerosis 313
11. References 313
Contents XXI
Chapter 14 Mumps
Harry A. Feldman
1. Introduction 317
3. The Agent. 318
4.1. Sources of Data . 318
5.2. Survey Data 321
5.3. Epidemic Behavior and Contagiousness 322
5.6. Age 323
5.7. Sex 323
5.8. Race and Occupation 323
8.1. Common Clinical Features 326
8.2. Involvement of the Central Nervous System 327
8.3. Involvement of the Heart 328
8.4. Orchitis and Sterility 328
8.5. Mumps and Diabetes 328
8.6. Other Complications 329
11. References 332
Chapter 15 The Parainfluenza Viruses

W. Paul Glezen, Frank A. Loda, and Floyd W. Denny
1. Introduction 337
2. History . 337
xxii Contents

~~rn m
5.1. Incidence-Prevalence Data 339
5.5. Age Distribution 341
5.6. Sex 342
5.7. Race and Occupation 342
5.8. Occurrence in Special Epidemiological Settings 342
5.9. Socioeconomic Factors . 342
7.2. Immunity 343
8.1. Clinical Manifestations 344
8.2. Diagnosis 345
9. Control and Prevention Based on Epidemiological Data 345
11. References 346
Chapter 16 Rabies
Robert E. Shope
1. Introduction 351
3.1. Sources of Mortality Data . 352
Pattern 354
Contents XXlll
5.5. Age, Sex, Race, Occupation, Socioeconomic, Nutritional, and

Genetic Factors 356
8.2. Diagnosis 358
9.1. Epidemiological Methods 359
9.2. Immunization Concepts and Practice 359
10.1. Epizootiology of Wildlife Rabies 361
10.2. Rabies-Related Viruses 361
10.3. Vaccines 361
11. References 361
Chapter 17 Respiratory Syncytial Virus

Robert M. Chanock, Hyun Wha Kim, Carl Brandt, and
Robert H. Parrott
1. Introduction and Historical Background . 365
Pattern 367
4.1. Incidence and Prevalence Data 367
4.3. Geographic Distribution . 370
4.5. Age 371
4.6. Sex 371
4.7. Race 371
4.8. Occupation. 371
4.9. Occurrence in Different Sehings 371
4.10. Socioeconomic . 372
4.11. Other Factors, Nutrition, Genetics, etc. 372
xxiv Contents

7.1. Symptoms 376
7.2. Diagnosis 376
9. Unsolved Problems 378
10. References 379
Chapter 18 Rhinoviruses
Jack Merrit Gwaltney, Jr.
1. Introduction 383
3.1. Surveillance and Sampling 384
3.2. Methods of Virus Isolation and Propagation . 384
3.3. Methods Used for Serological Surveys and Antibody
Measurements 385
4. Characteristics of Virus Affecting the Epidemiological Pattern 386
4.1. Physical and Biochemical Characteristics 386
4.2. Biological Characteristics 387
4.3. Antigenic Characteristics 387
5.1. Incidence and Prevalence of Infection 388
5.2. Occurrence in Different Settings . 392
7. Pathogenesis 395
8. Immunity 396
9.2. Apparent/Inapparent Infection Ratio 399
12. References 401
Chapter 19 Rubella
Dorothy M. Horstmann
1. Introduction 409
3. Methodology 410
Contents XXV
3.2. Morbidity Data . 410

4. Biological Characteristics of the Virus . 411
5.5. Age and Sex . 414
8.1. Clinical Manifestations 417
8.2. Serological Responses 418
9. Control . 419
9.1. Vaccine Development 419
9.2. Responses to Rubella Vaccines 419
9.3. Vaccination of Children 420
9.4. Vaccination of Women of Childbearing Age 420
9.5. Management of the Rubella Problem in Pregnancy 421
9.6. Use of ,,-Globulin 421
11. References 423
Chapter 20 Smallpox
Abram S. Benenson
1. Introduction 429
3.3. Surveys 432
4. Biological Characteristics of the Virus. 434
5.1. Incidence and Prevalence Data 435
xxvi Contents
5.5. Age 438

5.6. Sex 438
5.7. Race 439
5.8. Occupation 439
5.10. Socioeconomic Distribution . 440
5.11. Other Factors . 440
6.1. Period of Communicability 440
6.2. Contact Spread . 440
6.3. Airborne Spread 440
6.4. Spread by Fomites 441
6.5. Vectors 441
6.6. Animal Reservoirs 441
7.2. Immunity 443
9. Control and Prevention Based on Epidemiological Data 446
9.1. Control Programs . 446
9.2. Immunization Concepts and Practice 447
11. References 451
12. Suggested Reading . 455
Chapter 21 Varicella-Herpes Zoster Virus

Thomas H. Weller
1. Introduction 457
1.1. Definition 457
1.2. Social Significance 457
2.1. Clinical Recognition 457
2.2. Association of Varicella with Herpes Zoster 458
2.3. Isolation and Propagation of the Etiological Agent of Varicella-
Zoster. 458
4. Biological Characteristics of V-Z Virus Affecting the
Epidemiological Pattern . 461
Contents xxvii
4.1. Latency in the Human Host: Primary Infection, Latency, and

Reactivation 461
4.2. Failure of V-Z Virus to Persist in Scabs or Fomites: Limited
Period of Communicability 461
5.1. Data on Incidence and Prevalence 461
5.5. Age 466
5.6. Sex 468
5.7. Race 468
5.8. Occupation 468
5.9. Occurrence of Varicella in Different Settings 468
6.1. Varicella 469
6.2. Herpes Zoster 470
7.1. Varicella 470
7.2. Herpes Zoster 471
8.1. Clinical Patterns 473
8.2. Diagnosis 474
9.1. General Concepts 474
9.2. Interruption of Transmission 475
9.3. Modification or Prevention of Varicella 475
10.1. Prevention 476
10.3. Epidemiological Unknowns 476
10.4. In the Laboratory 477
11. References 477
Chapter 22 Epidemiology of Burkitt Lymphoma

George Miller
1. Introduction 481
3. Methodology 482
xxviii Contents
3.1. Mortality and Morbidity Data 482

4. Biology of Epstein-Barr Virus 482
4.1. Structure and Morphology 482
4.2. EBV Cell-Associated Antigens 483
4.3. CeIlJVirus Relationships 483
4.4, Cell Transformation and Oncogenicity 484
4.5. Relationship of EBV to Burkitt Lymphoma 485
5, Descriptive Epidemiology 487
5.2. Geographic Factors , 489
5.3. Age and Sex. 489
5.4. Genetic and Other Host Factors 490
7. Pathogenesis 490
7.1. Cell Transformation 490
7.2. Immunological Surveillance 491
8.1. Clinical and Pathological Features 492
8.2, Serological Features 493
9. Therapy and Control 494
9.1. Chemotherapy 494
9.2. Malaria Control 494
9.3. Vaccines 494
11. References 495
Chapter 23 Epidemiology of Cervical Cancer

Andre J. Nahmias, William E. Josey, and James M. Oleske
1. Introduction 501
2. History 502
3. Methodology 502
3.1. Mortality and Morbidity of Cervical Neoplasia 502
3.2. Studies Relating HSV to Cervical Cancer 503
4. Biology of the Cancer and the Virus 504
4.1. Cervical Cancer . 504
4.2. Herpes Simplex Viruses 505
5.1. Incidence and Mortality Data 508
5.2. Lifetime Risk 508
5.3. Age 508
Contents XXIX
5.4. Geographic Distribution . 509

5.5. Socioeconomic Status . 509
5.6. Ethnic or Religious Origin 509
5.7. Other Variables . 509
7.2. Immunity 512
8.1. Clinical and Pathological Features 512
8.2. Serological Features 513
9. Therapy and Control. 513
10.1. Control of Cervical Cancer with Available Knowledge 514
10.2. Establishing a Causal Role of HSV in Human Carcinogenesis 514
11. References . 515
12. Suggested Reading . 518
Chapter 24 Chronic Neurological Diseases: Subacute Sclerosing

Panencephalitis, Progressive Multifocal Leukoencephalopa-
thy, Kuru, Creutzfeldt-Jakob Disease
Jacob A. Brody and Clarence Joseph Gibbs, Jr.
1. Introduction 519
2. Subacute Sclerosing Panencephalitis 520
2.2. Historical Background . 521
2.3. Methodology 521
2.4. Biological Characteristics of the Virus 521
2.6. Pathogenesis and Immunity 522
2.7. Patterns of Host Response 522
2.9. Unresolved Problems 523
3. Progressive Multifocal Leukoencephalopathy 523
3.1. Introduction and Historical Background 523
XXX Contents
4. Kuru 525
4.6. Mechanisms and Routes of Transmission 526
5. Creutzfeldt-Jacob Disease 528
5.6. Mechanisms and Routes of Transmission 531
6. Summary and Comparison 533
8. References 534
Chapter 25 Nasopharyngeal Carcinoma

G. de-The, J. H. C. Ho, and C. Muir
1. Introduction 539
3. Methodology Involved in Epidemiological and Virological Studies 540
3.2. Sources of Morbidity (Incidence) Data 541
3.3. Sources of Relative Frequency Data 541
3.5. Sociological Surveys 543
4. Biological Characteristics of EBV in Its Relationship with NPC 545
5.1. Incidence, Frequency, and Geographic Distribution 546
5.3. Sex and Age. 548
Contents xxxi
5.4. Occupation 549

5.5. Change of Risk on Migration 550
5.6. Environmental Factors . 550
5.7. Genetic Factors 551
5.8. Epidemiological Behavior of EBV 551
6. Mechanism of Transmission 553
8.1. Clinical Course of NPC 553
8.2. Clinical Types of Disease 554
10.1. Etiology of NPC 556
10.2. Problems Which May Be Resolved in Short-Term Projects 557
10.3. Long-Term Problems 557
11. References 558
Index . 565
I'
CHAPTER 1
Epidemiological
Concepts and
Methods
Alfred S. Evans
1. Introduction nants for many common infections lie within the

host itself. Of these, the age at the time of infection
The epidemiology of infectious diseases is con- is most crucial.
cerned with the circumstances under which both This first chapter will deal in a general way with
infection and disease occur in a population and the concepts, methods, and control techniques which
factors which influence their frequency, spread, will be explored in detail in individual chapters
and distribution. This concept distinguishes be- concerned with specific viruses or group of vi-
tween infection and disease because the factors ruses. * For fuller presentations of the epidemiolog-
governing their occurrence may be different and ical principles, see Fox et al.(44) and related
because infection without disease is common with texts. (73,80,92,106)
many viruses. Infection indicates the multiplica-
tion of an agent within the host and is determined
largely by factors governing exposure to the agent 2. Definitions and Methods
and the susceptibility of the host. Disease repre-
sents the host response to infection when it is Incidence is the number of new cases of disease
severe enough to evoke a recognizable pattern of occurring in a unit of time. The incidence rate is
clinical symptoms. The factors influencing the oc- the number of new cases over the total population
currence and the severity of this response vary at risk. The numerator in this ratio is usually
with the particular viruses involved and their based on the number of clinical cases of the disease
portal of entry, but the most important determi- in question as recognized by physicians and re-
ported to public health departments over the pe-
Alfred S. Evans . WHO Serum Reference Bank, Sec-
tion of International Epidemiology, Department of Epi- * For a fuller discussion of epidemiological concepts and
demiology and Public Health, Yale University School of principles, see Section 14: Suggested Reading at the
Medicine, New Haven, Connecticut back of the chapter.
1
2 Chapter 1 • Epidemiological Concepts and Methods
riod of a year. The denominator represents the serological surveys, and special investigations
population under surveillance. This is often the which will be described in detail in Chapter 2.
total population of the geographic area encom- Analytical epidemiology is concerned with
passed by the reporting system. In more intensive planned epidemiological investigations designed
studies, the numerator may be defined as the to 'weigh various risk factors or to evaluate a
incidence of infection (with or without disease) as hypothesis of causation. Two methods of analyti-
determined by viral excretion andlor the appear- cal study are commonly employed: the prospec-
ance of antibody between two points in time. The tive and the retrospective.
denominator may be defined as those who are The prospective method is a means of measur-
both exposed and susceptible (i.e., lack antibody). ing incidence in a population or a cohort observed
These more sophisticated definitions are usually over time. In virology, incidence studies permit
restricted to special investigations in which anti- the direct assessment of the risk of infection andlor
body andlor viral measurements are possible. of disease in a defined population group over time
Prevalence is the number of cases existing at one in terms of age, sex, socioeconomic level, and
time. The prevalence rate is the number of such other factors. Both the numerator and the denomi-
cases divided by the population at risk. The time nator are known. In practice, incidence rates are
period involved may be 1 yr or other fixed period often calculated retrospectively by using data on
(period prevalence) or a given instant of time cases and populations that have been filed away;
(point prevalence). The term period prevalence in virology, infection rates can be determined by
involves both the number of new cases (incidence) carrying out virus isolations and/or serological
and the duration of illness (number of old cases tests on materials that have been frozen away and
persisting from the previous reporting period). It on which data on the population sampled are
is used most commonly for chronic diseases. available. As such studies are not "prospective" in
In serological surveys, prevalence represents the terms of the observer, calling them "cohort," "lon-
presence of an antibody, antigen, chemical gitudinal," or "incidence" studies is more appro-
marker, or other component in blood samples from priate in a semantic sense. In addition to the direct
a given population at the time of the collection. measurement of risk, this type of investigation
The prevalence rate is the number of sera with that avoids the need of selecting controls, because one
component divided by the number of persons is merely recording the occurrence of disease or of
whose blood was tested. For viral infections, the infection in persons with different characteristics.
presence of antibody represents the cumulative The disadvantages of incidence studies are that
infection rate over recent and past years depend- they are expensive because an entire population
ing on the duration of the antibody. For neutraliz- must be kept under observation and appropriate
ing or other long-lasting antibody, it reflects the specimens collected; the lower the incidence of the
lifetime or cumulative experience with that agent. disease, the larger the denominator requiring ob-
If the antibody measured is of short duration, then servation and the higher the expense. They are
prevalence indicates infection acquired within a sometimes laborious to conduct and may require
recent period. much technical help.
Descriptive epidemiology deals with the character- Retrospective or case/control studies compare
istics of the agent, the environment, and the host, the presence or absence of certain suspected etiol-
and with the distribution of the resultant disease ogical factors in patients with a certain disease to
in terms of place, season, and secular trends. It is their occurrence in individuals without this dis-
concerned with what the late John R. Paul called ease. An example is the relation of smoking to the
"the seed, the soil and the climate."(92) The delin- occurrence of lung cancer. Since both the disease
eation of these attributes of infection and disease and the characteristic are already present at the
in a population is the "meat" of epidemiology and time of observation, the data obtained represent
this text is largely one of this descriptive nature. prevalence rather than incidence rates. The abso-
The sources of data on which this is based come lute risk of the disease in persons with different
from mortality and morbidity reports, field and characteristics cannot be measured because no
Chapter 1 • Epidemiological Concepts and Methods 3
denominators are available. Only the relative cated approach because all of the variables should
prevalence of the disease in persons having the be subject to control. Unfortunately, animal
characteristic as compared with that in persons not models may be difficult or impossible to establish
having the characteristic can be calculated. The in the laboratory, and even if they are, there is
selection and identification of appropriate controls sometimes the question of the applicability of the
in retrospective studies often pose difficulties be- results to the human host. Theoretically, the ideal
cause unrecognized biases may be present. In way would be the employment of volunteers. In
virology, an example of the case/control method the past, human subjects have participated in
would be the evaluation of the etiological role of a studies of yellow fever, malaria, hepatitis, infec-
given virus in a certain disease by comparison of tious mononucleosis, acute respiratory infections,
the frequency of viral excretion and/or antibody measles, rubella, and even syphilis. Such investi-
rises in patients having this disease with their gations involve important technical, medical, ethi-
frequency in those not having the disease. In cal, and moral issues. On the technical level, there
evaluating this relationship, it must be remem- is the question of the susceptibility of the volun-
bered that infection without clinical disease is teer to the disease under study; i.e., volunteer
common in viral infections and might be occurring adults may already be immune as a consequence
in the control group. Another recent example is of childhood infection. Second, the host response
comparison of the frequency of elevated viral anti- to many infections may result in disease in only a
body titers in the sera of patients with certain small percent of those exposed, or even of those
malignant or chronic diseases as compared to the infected, thus requiring a large volunteer group.
antibody titers in age- and sex-matched controls as Medically, there is concern for the seriousness of
a clue to causation. Examples of this are the the disease produced, and of the possibility, how-
relation of raised antibody levels of Epstein-Barr ever remote, of permanent disability or even
virus to Burkitt lymphoma and nasopharyngeal death. Finally, the moral and ethical right to use
cancer as compared to controls, or of measles human subjects in any medical experimentation is
antibody titers in cases of subacute sclerosing under debate. In today's climate, experimental
panencephalitis and multiple sclerosis in relation studies in volunteers are subject to very strict
to controls. In general, retrospective or case/control control, and work being supported by govern-
analyses are cheaper, are more quickly performed, ment, foundation, or institutional funds must be
and require smaller numbers than incidence stud- scrupulously reviewed by a committee of profes-
ies but measure relative rather than absolute risk. sional and sometimes of lay and religious repre-
Traditionally, the existence of a possible causal sentatives. This peer group is required to weigh
association between a factor and a disease is the benefits of the experiment against the risks
usually recognized in a clinical setting and its involved and to ensure that the experimental sub-
statistical significance is determined by compari- jects are fully aware of all possible consequences
son with controls using the case/control or retro- before signing a statement of "informed consent."
spective method. If the results indicate the presence Serological epidemiology is a term applied to the
of an important association, an incidence study is systematic testing of blood specimens from a de-
then set up to evaluate or confirm the observation. fined sample of a healthy population for the pres-
Thus the risk of smoking in lung cancer and that of ence or level of various components. These include
rubella infection in congenital abnormalities were antigens, antibodies, proteins, biochemical and
discovered by case/control methods and confirmed genetic markers, and other biological characteris-
by incidence and cohort analyses. Other retrospec- tics (see Chapter 2).
tive· case/control investigations such as those on An epidemic or outbreak of disease is said to
the relation between certain blood groups and exist when the number of cases is in excess of the
influenza have not been confirmed when tested expected number for that population based on past
using incidence data. (:J5i experience. This determination obviously requires
Experimental epidemiology utilizes epidemiologi- a knowledge of the number of both current and
cal models and is the most elegant and sophisti- past cases. The definition of "excess" is an arbi-
trary one. The occurrence of a large number of ulation thus far tested, no matter how remote or
cases, compressed in time, as when a new influ- isolated.
enza strain is introduced, is readily identified as The cumulative number of persons immune to a
an "epidemic." Indeed, for influenza a more so- given disease within a community has been
phisticated index has been set up by the National termed the herd immunity level. If this level is
Center for Disease Control in the United States by sufficiently high, then the occurrence of an out-
which an expected threshold of deaths from influ- break has been regarded as highly unlikely. This
enza and pneumonia in 122 cities has been estab- concept has recently been challenged, at least for
lished based on a 5-yr average. When this thresh- rubella. For example, in an open college commu-
old is exceeded, an influenza outbreak is said to nity a preexisting herd immunity level to rubella
exist. In contrast, even a few cases of encephalitis of 75% failed to prevent an outbreak of this
over a summer may constitute an "outbreak" in disease. (34) Indeed, the rubella infection rate of
areas where no cases previously existed. When 64% among those completely susceptible (Le.,
several continents are involved, a disease is said to without detectable antibody) was even higher than
be "pandemic." the 45% infection rate in the same community for
Chronic diseases pose more difficult problems a new influenza strain to which the entire popula-
in definition because their scale of occurrence tion was susceptible.(34) A rubella outbreak has
must be viewed over years rather than months or even occurred among military recruits in the pres-
weeks. In such a perspective we do have current ence of a 95% level of herd immunity: 100% of the
"epidemics" of chronic illnesses such as coronary susceptibles were infected. (57) Apparently the
artery disease or lung cancer. The key words are spread of infection is so efficient under these
"an unusual increase in the expected number of circumstances that a high level of herd immunity
cases" irrespective of whether the time period does not deter its progress. Another possibility is
involved is short or long. that reinfection of partially immune persons re-
Three essential requirements for an outbreak of sults in pharyngeal excretion and further spread of
viral disease are the presence of an infected host, virus.
an adequate nUJIlber of susceptibles, and an effec- For diseases such as smallpox the achievement
tive method of contact and transmission between of worldwide "herd" immunity of the populations
them. If the agent is not endemic within the at risk is nearing its goal. (1m Theoretically, total
community, then the introduction of an infected eradication of a disease transmitted only from
person, animal, insect, or other vector of transmis- human to human and without reinfection or per-
sion is needed to initiate an outbreak. This is sistent viral excretion may be possible in this way.
particularly important in a remote island or iso- On a practical basis it may be logistically difficult
lated population group where a virus disappears to reach all the potential pockets of human infec-
after no more persons remain susceptible, if per- tion such as nomads, isolated tribes, and urban
sistent viral excretion does not occur to permit ghetto dwellers.
infection of newborns. Rubella, for example, dis- While mathematical models have been con-
appeared from Barbados for ten years despite an structed to fit parts of the hypothetical sequence of
accumulation in the number of susceptibles to a events in an epidemic,{I·24) our knowledge of the
level representing about 60% of the popUlation dynamics of the initiation and spread of infections
and despite the existence of a large tourist is far from complete. Such issues as where influ-
trade.(39) In an isolated Indian tribe in Brazil, enza virus "disappears to" between epidemics or
antibodies to respiratory-transmitted viruses in- how many encephalitis viruses overwinter are yet
cluding measles, influenza, and parainfluenza unsolved. While persistent viral carriers, mild and
were essentially absent from the entire tribe yO) inapparent infections, and various forms of ani-
The introduction of more susceptibles or of more mal, avian, or insect reservoirs are probably im-
infected persons may tip this balance. However, portant, tl)eir modus operandi is incompletely
antibodies to viruses characterized by persistent or understood. The role played by the genetic control
recurrent viral excretion such as herpes viruses of susceptibility, of the spread of infection, and of
and adenoviruses have been present in every pop- the host response to infection needs intensive
study as reflected in human leukocyte antigen here. What is important in pathogenesis is the
types (HL-A), and in lymphocyte determinants. efficiency of spread from cell to cell, either by
direct involvement of contiguous cells or by trans-
port via body fluids to other susceptible cells; the
number of cells infected; and the consequences of
3. The Agent viral multiplication on the cell itself and on the
organism as a whole. The long-term survival of a
This section is concerned primarily with those virus in human populations depends on its ability
general properties of viruses that are important to to establish a chronic infection without cell death,
an understanding of their epidemiology and not or on an effective method of viral release into the
with their basic chemistry, morphology, genetics, environment in a manner ensuring its transport to
or multiplication. These latter aspects are dealt a susceptible host, or on a highly adaptive system
with in various microbiology and virology for biological adversity. The prime example of
textbooks. (21,41,56,59) adaptability among animal viruses is influenza A.
The chief characteristics of viruses that are of Without its property for antigenic variation it
importance in the production of infection in man would probably behave like measles or rubella
are (1) factors that promote efficient transmission viruses and be dependent for survival on the
within the environment; (2) the ability to enter temporal accumulation of new susceptibles.
one or more portals in man; (3) the capacity for
attachment to, entry into, and multiplication
within a wide variety of host cells; (4) the excre-
tion of infectious particles into the environment; 4. The Environment
(5) a means of developing alternate mechanisms of
survival in the face of antibody, cell-mediated The external environment exerts its influences
immunity, chemotherapeutic agents, interferon, or on the agent itself, on the manner of its spread,
other hostile elements. Survival of the virus might and on the nature of the host response to infec-
be achieved through mutation, recombination, tion. While viruses survive or die within defined
basic properties of resistance, or the availability of ranges of certain physical factors such as tempera-
alternate biochemical pathways. ture and humidity, there is much variability from
The spread of viruses depends on (1) the stability one viral group to another. A simple environmen-
of the virus within the physical environment re- tal factor such as cold may have different effects on
quired for its transmission, including resistance to the survival of different viruses and on their abil-
high or low temperatures, desiccation, or ultravi- ity to multiply within cells. While environmental
olet; (2) the amount of virus expelled into the characteristics play an important role in the sur-
proper vehicle of transmission; and (3) the availa- vival of a virus, they are probably of much greater
bility of the proper vector or medium for its significance in their influence on the routes of
spread. transmission and on the behavior patterns of the.
After entry through an appropriate portal, the host.
virus must escape from ciliary activities, macro- For infections requiring an insect vector, such as
phages, and other primary defense mechanisms the arboviruses, the environment exerts an ob-
during its sojourn to the target cell, find appropri- vious role in restricting the occurrence of infection
ate receptors on the cell surface for its attachment, and disease to those areas which have the proper
and be able to penetrate and multiply within the temperature, humidity, vegetation, amplifying an-
cell. The steps then include initiation of transcrip- imal hosts, and other features necessary for the
tion of messenger ribonucleic acid (mRNA), trans- insect involved. For viral diseases readily trans-
lation of early proteins, replication of viral nucleic mitted by water, such as hepatitis A virus, a warm
acids, transcription of mRNA, translation of late environment attended by poor sanitation and fecal
proteins, assembly of virions, and then viral re- contamination clearly enhances the degree of ex-
lease.(41l These aspects fall into the province of posure and the efficiency of transmission.
basic virology and will not be discussed in detail Perhaps the most crucial role of climate on
common viral diseases is exerted on the social plete this cycle (incomplete viruses), and some do
behavior of the host. In tropical settings and in the not effect efficient escape (cell-bound viruses).
summer season in temperate climates, the oppor- Many viruses are released from cells by budding,
tunity for transmission of gastrointestinal diseases acquiring a lipoprotein coat or envelope as they go
is increased through contact with water, as in through the cell membrane; these include herpes-
swimming in and drinking from polluted areas. viruses, togaviruses, myxoviruses, paramyxovi-
Warm weather also brings closer contact with dogs ruses, and coronaviruses. Nonenveloped viruses
and other animal sources of rabies and with insect not released by budding are the adenoviruses,
vectors of arboviruses. In winter people huddle parvoviruses, poxviruses, picornaviruses, and reo-
together inside, promoting the transmission of viruses. Some of these latter are released by cell
airborne and droplet infections. This spread is lysis. Once released, viruses find their way to new
amplified by the opening of schools and colleges. hosts via one or more portals such as the respira-
In addition, the environment within most houses tory tract (influenza, etc.), skin (varicella, small-
and buildings tends to be hot and dry, which pox), blood (hepatitis viruses via blood transfu-
impairs the protective mechanisms of human mu- sion, arboviruses via mosquitos), gastrointestinal
cous surfaces and may permit easier entry and tract (enteroviruses), genital tract (herpes simplex
attachment of certain respiratory viruses. type 2), urine (cytomegalovirus), and placenta (ru-
While winter clearly brings with it an increase bella, cytomegalovirus). A more detailed presenta-
in viral respiratory illnesses, heavy rains and the tion of these major routes of spread will now be
monsoon similarly influence these same diseases given.
in tropical settings. Indeed, the incidence of com-
mon upper respiratory diseases in college students
was as high in the warm climate at the University
5.1. Respiratory
of the Philippines as in the intemperate winters at
the University of Wisconsin. W,32) Viruses causing The respiratory route is probably the most im-
respiratory infections in children have also been portant method of spread for most common viral
found to be active in all climates around the diseases of man and is the least subject to effective
world.o 5 ) Community studies in India/ 87 ) Trini- environmental control. For influenza virus, the
dad, (9) and Panama(79) have indicated a high degree of transmissibility varies from one strain to
morbidity from influenza and other respiratory another and seems to be independent of other
diseases in tropical settings. As in temperate cli- attributes of the virus. Schulman(99) has compared
mates, factors tending to aggregate people inside, the features of a strain with high transmissibility
such as heavy rainfall anc\Jor schooling, also coin- (Jap 305) and one with low transmissibility (Aol
cide with the highest incidence of respiratory- NWS) in an experimental mouse model. The virus
transmitted infections in the tropics.(31,79) titer in the lung was similar for both strains, but
the virus content in the bronchial secretion was
low for the Ao/NWS strain compared to the Jap 305
strain. This higher degree of release into the respi-
5. Routes of Transmission ratory portal of exit resulted in detectable virus in
the air surrounding mice infected by the Jap 305
The major routes of transmission of viral infec- but not by the Ao/NWS strain. Once an aerosol
tions are listed in Table 1. Many viruses have was created, the stability of both strains was
several alternate routes, thus enhancing the chance similar. Protein analysis also revealed differences
of survival. The sequence of events in transmis- in the neuraminidase of the two strains; this
sion involves release of the virus from the cell, exit component is associated with dissociation of vi-
from the body, transport through the environment ruses from the cell and thus perhaps with its
in a viable form, and appropriate entry into d transmissibility. However, high transmissibility
susceptible host. did not go along with transfer of the gene for
Some viruses are released from cells at the end neuraminidase, so it was concluded that other
of the cycle of multiplication. Others do not com- factors were also involved in the efficacy of spread.
Table 1. Transmission of Viral Infections
Route of exit Routes of transmission Examples Factors Routes of entry
Respiratory Bite Rabies Animal Skin

Salivary transfer EBV in adults Kissing Mouth
? Hepatitis B Unknown ? Mouth
Aerosol Influenza and other Sneeze, cough, <2-nm Respiratory
respiratory particles to lung
viruses
Mouth -> hand or Herpes simplex, EBV Salivary Oropharyngeal
object in children, contamination of
rhinovirus, hands and objects
enterovirus
Gastrointestinal tract Stool -> hand Enteroviruses- Poor hygiene Mouth

hepatitis A
Stool -> water (or Hepatitis A Seafood Mouth
milk)
Thermometer Hepatitis A Nurse Rectal
Skin Air Poxviruses Also via objects Respiratory

Skin to skin Molluscum Abrasions Abraded skin
contagiosum, warts
Blood Mosquitos Arboviruses Extrinsic I. P. Skin

Ticks Group B togaviruses Transovarial Skin
transmission
Transfusion of blood Hepatitis B, CMV, Carrier state, free or Skin
and blood products EBV with lymphs
Needles for injection Hepatitis B Addicts Skin
Urine Rarely transmitted CMV, measles, Unknown Unknown

mumps, congenital
rubella
Genital Cervix Herpes simplex, CMV, ? Venereal Genital

rubella
Semen CMV ? Venereal Genital
Placental Vertical to embryo CMV, rubella, Congenital Blood

smallpox abnormalities,
abortion
Eye Tonometer Adenovirus Exam for glaucoma Eye
Other aspects affecting the transmission of res- group on the transmission of respiratory vi-
piratory viruses are the intensity and method of ruses. (63) At one extreme is the direct transmis-
propulsion of discharges from the mouth and sion of infection via personal contact such as
nose, the size of the aerosol droplets created, and kissing, touching of contaminated objects (hands,
the resistance of the airborne virus to desiccation. handkerchiefs, soft drink bottles), and direct im-
Much work has been done by Knight and his pingement of large droplets produced by coughing
or sneezing. This last method is regarded as a form Despite the high level of particles, the recovery of
of personal contact because of the short range of Coxsackie A21 virus itself was more frequent from
the heavy droplets formed. Sneezing and coughing coughs than from sneezes. (63) Many questions on
also create aerosols varying in size from about 1 to the mechanics of transmission of respiratory vi-
more than 20 JA,m which permit transmission of ruses remain unanswered and any generalizations
infection at a distance. The dispersion of an aero- are premature, but the methodology to answer
sol depends on wind currents and on particle size. some of these is becoming available.
In still air a spherical particle of unit density of 100
JA,m diameter requires 10 seconds to fall the height
of the average room (3 m), 40-JA,ffi particles require 5.2. Gastrointestinal
1 min, 20-JA,m particles 4 min, and 10-JA,m particles Transmission by the oral/fecal route is probably
17 min. This means that particles of under 10 JA,m the second most frequent means of spread of
have a relatively long circulation time in the ordi- common viral infections, and the gastrointestinal
nary room. Once initiated, particles of 6 JA,m or tract is the second great portal of entry of infec,
more in diameter are usually trapped in the nose tion. Viruses can directly infect susceptible cells of
while those of 0.6-6.0 JA,m diameter are deposited the oropharynx, but to induce intestinal infection
on sites along the upper and lower respiratory virus-containing material must be swallowed, suc-
tract. cessfully resist the hydrochloric acid in the stom-
Hygroscopic particles of 1.5 JA,m diameter dis- ach and the bile acids in the duodenum, and
charged by coughing or sneezing in large numbers progress to susceptible cells in the intestine. These
lose moisture and shrink in ambient air but regain cells may be the epithelial cells in the intestinal
their original dimensions from the saturated air in mucosa or in the intestinal lymphatics, as with
the respiratory tract. The site of disposition of an adenoviruses. Viruses with envelopes do not nor-
aerosol containing virus particles does not neces- mally survive exposure to these acids, salts, and
sarily represent the level in the respiratory tree enzymes in the gut. The major enteric viruses are
where the greatest number of susceptible cells poliomyelitis, echo, coxsackie, and infectious
exist for that agent. Quantitative studies have hepatitis (hepatitis A) viruses. It is known that
indicated that with four different respiratory vi- under conditions of close and prolonged contact
ruses the number of viral particles necessary to serum hepatitis (hepatitis B) virus may also be
produce infection in the respiratory tract is rela- transmitted in this way. Multiplication and excre-
tively small. With adenoviruses, for example, it is tion in the intestinal tract also occur with adenovi-
on the order of seven ,virions. The lower infective ruses and reoviruses, but this route of transmis-
dose required for nasal implantation of rhinovi- sion is not usually of epidemiological importance.
ruses and coxsackievirus indicates that this route, The rhinoviruses are acid labile and do not survive
perhaps by personal contact, leads to their effec- passage through the stomach. Unlike the respira-
tive transmission. (63) The high concentrations of tory viruses, the enteroviruses rarely produce evi-
rhinovirus particles on fingers, hands, and hard dence of local disease as a consequence of their
surfaces as opposed to the lower concentrations multiplication in cells lining that area. Thus diar-
found in aerosols suggest that infection via hands rhea, vomiting, and abdominal pain are highly
may be an important route of spread. This is unusual features of infection with these agents.
supported by the frequent inadvertent contact of Instead, their major target organs and the site of
hands with the nose or eyes.(52) If the importance major symptomatology are at a distance; hepatitis
of this mechanism is confirmed, frequent hand- viruses in the liver and enteroviruses in the central
washing may help control the spread of the com- nervous system and skin.
mon cold. Viruses excreted via the gastrointestinal tract
The size and number of viral particles in sneezes must successfully infect other susceptible persons
and coughs have varied from study to study de- via the oral/intestinal route through fecally con-
pending on the methodology employed. In one taminated hands, food, water, milk, flies, ther-
study, 1,940,000 particles were present in sneezes mometers, or other vehicles. Viruses spread via
and 90,765 in coughings, a ratio of 2.14:1.<48) these routes are subject to much greater environ-
mental control than are agents transmitted by the not formed and skin involvement occurs late in the
respiratory route. Thus good personal hygiene, disease at a time when the virus may be bound by
especially washing of hands after defecation, antibody; indeed, the antigen/antibody complex
proper cleanliness and cooking of food, pasteuri- may be responsible for the rash itself.
zation of milk, good waste disposal, andpurifica-
tion of drinking water supplies are effective pre-
ventive measures. Hepatitis A virus is remarkably
heat stable and may not be inactivated by ordinary 5.4. Genital
levels of chlorination in drinking water if the viral
content is great and has a high infectivity. Fur- The genital tract serves as a portal of infection
for both partners during sexual activity and as a
thermore, it can survive in oysters and clams over
long periods. This is especially hazardous because source of infection for the fetus as it passes down
these foods are so often eaten without cooking. the birth canal. Herpes simplex type I and II
viruses, cytomegalovirus, and rubella virus have
Hepatitis A virus and the enteroviruses also flour-
ish in certain institutional settings (mental hospi- all been isolated from cervical secretions. Cytome-
tals, institutions for retarded children, some pris- galovirus has also been isolated from male se-
men.(66) Cervical or penile lesions may result from
ons) and in countries where personal hygiene is
lacking or difficult to practice, or where poor herpes infections. There is increasing epidemiol-
environmental control is present. As some entero- ogical, virological, and serological evidence estab-
viruses may also multiply in the respiratory tract lishing an association between herpes type 2 (II)
and be transmitted by the respiratory route, this infections and cancer of the cervix. This is dis-
alternate pathway is of epidemiological impor- cussed in Chapter 23. Infections of the newborn at
tance even in the face of good personal and envi- the time of delivery can occur with herpesviruses,
ronmental hygiene. cytomegalovirus, and rubella virus. The capacity
of herpesviruses for latency emphasizes that long-
term carrier states exist. Sexual practices involving
5.3. Skin oral, genital, or anal contact may result in infec-
tions in these sites with herpesviruses and
Skin is the third important area for the entry and
cytomegalovirus.
exit of viral infections. While penetration of the
intact skin is an unlikely mechanism of infection,
the introduction of virus particles via a bite as
with rabies, or via a mosquito as with the arbovi-
5.5. Genitourinary
ruses, or via a needle or blood transfusion as with
both types of hepatitis viruses makes this route an While excretion of viruses such as cytomegalovi-
important one. Cytomegalovirus and Epstein-Barr rus and measles occurs in the urine, this portal of
virus may also be transmitted through blood exit has not been established as being of epide-
transfusions. The abraded skin may serve as th~ miological or clinical importance. Considering the
entry point of human papovavirus, which causes wide variety of viruses that can multiply in human
warts. In patients with skin lesions such as kidney tissue cultures in vitro, it is surprising that
eczema, the accidental transfer of smallpox virus renal infections in man from these viruses are
from the site of inoculation to other skin areas virtually nonexistent, or at least are not recog-
might occur. nized. It seems possible that viruses may play a
The skin serves as a portal of exit only for those role in immune complex nephritis in man as they
viruses that produce skin vesicles or pox lesions do in experimental animal models, but to date this
which release infectious particles on rupture. has not been clearly demonstrated nor has it been
These include herpes simplex, smallpox, varicella- reflected in abnormally high viral antibody levels
zoster, and vaccinia viruses. The viruses of certain in such patients. (114) Recently, adenovirus types
maculopapular exanthems may also be present in 11 and 21 have been implicated as the cause of
the skin, as in rubella, but this does not seem to acute hemorrhagic cystitis in children (see Chapter
be an important avenue of escape as vesicles are 3).
5.6. Personal Contact 6. Pathogenesis
Direct transfer of infected discharges from the As each chapter on specific viruses will deal
respiratory or gastrointestinal tract to a susceptible with the subject of pathogenesis, this discussion
person is often included under "transmission by will be limited to a general consideration of infec-
personal contact." Many viruses regarded as "res- tions involving certain local or systemic features.
piratory or airborne" in spread may in fact be Good general presentations will be found in other
more direct in their transmission mechanism, as books. (41,56)
has been previously mentioned for the rhino-
viruses. (52)
6.1. Respiratory
Infectious particles may be implanted directly on
5.7. Water and Food
nasal surfaces. from contaminated hands or from
large droplets, or may reach the lower respiratory
Outbreaks of infectious hepatitis have occurred passages from aerosols. As man continually sam-
from sewage-contaminated water, as in the large ples the environmental air about 20 times a minute
outbreak in New Delhi, India, in 1956/ 75 ) or from in breathing, it is no wonder that exposure to and
seafood obtained from fecally contaminated infection with respiratory viruses are common
waters, as shown in outbreaks associated with indeed. Furthermore, only a small number of in-
oysters in the United States(71) and in Sweden(47) fectious particles need to be implanted in appro-
and with clams in New Jersey.(23) Milk and water priate areas to induce infection. This is on the
have also served as vehicles of transmission of order of three particles for influenza A by aerosol,
hepatitis and poliomyelitis viruses. Summer out- six for Coxsackie A21 by intranasal implantation,
breaks of adenovirus type 3 infections have oc- and seven for adenovirus 4 by aerosol. (63) In
curred in association with swimming pools.(6) general, aerosol particles of 3 ILm in size reach the
alveolus and those of 6 ILm or greater are retained
in the upper respiratory tract. The mucociliary
5.8. Arthropod Borne epithelium transports particles up from the lung or
down from the nasal mucosa. (78) To reach suscep-
Mosquitos, flies, ticks, and other insects may tible cells, viruses must pass through the mucus
transmit viral infections. One kind of transmission film and make physical contact with the cell recep-
is a passive type, simply involving survival of the tors. The mucus contains mucopolysaccharide and
virus in or on the insect which has picked it up other inhibitors, such as IgA antibody in previ-
from skin lesions or the blood. This type requires ously exposed persons. Influenza virus is assisted
no incubation time in the insect vector, nor any in its spread by its own neuraminidase which
specificity for either the arthropod host or the hydrolyzes the polysaccharides of the inhibitors;
virus. Poliomyelitis and possibly hepatitis viruses the virus attaches to cell receptors by means of
may be carried in this way. On the other hand, surface hemagglutinin spikes. In the alveolus,
some viruses require multiplication in the insect small aerosol particles are ingested by macro-
vector. In this instance, virus acquired from the phages and some viruses are digested and de-
blood of the human or animal host during viremia graded by these cells; other viruses are even capa-
requires a period of multiplication within the ble of multiplication within macrophages them-
arthropod vector before it is infectious, and there selves.
is a high degree of vector/virus/host specificity. An Most respIratory viruses produce illness through
example of this is the transmission of yellow fever the direct consequences of local multiplication.
virus by Aedes aegypti mosquitos. The details of Necrosis and lysis occur with desquamation of the
arthropod transmission are described in more de- respiratory epithelium. (21l Constitutional symp-
tail in Chapter 4. toms then may result from breakdown products of
dying cells which are absorbed into the blood- same barriers that prevent cell attachment and
stream; fever is produced by the liberation of penetration may exist there as in the respiratory
endogenous pyrogen resulting from viral action on tract, including local IgA antibody. Local, hu-
polymorphonuclear leukocytes. This sequence of moral, and cell-mediated immunity follows natural
events may be modified or altered by interferon viral infections of the intestinal tract and is the
production in infected cells, by the appearance or basis for immunity following oral administration
preexistence of secretory or local antibody, or by of live vaccines such as poliomyelitis and adenovi-
the presence of preexisting or produced humoral ruses 4 and 7. Unlike with respiratory viruses,
antibody. If humoral antibody is present in the local multiplication does not produce local symp-
absence of local antibody, then a more severe toms; these occur only after implantation has oc-
reaction may occur, possibly through antigen/anti- curred in secondary sites of multiplication such as
body deposition on the cell membrane. The mech- the liver for hepatitis virus and the central nervous
anism of this is not clear, but the phenomenon has system for enteroviral infections. Exceptions are
been observed in infants with passively acquired the duovirus or rotavirus infections of chil-
maternal respiratory syncytial antibody who sub- dren.(20a)
sequently develop an infection with this virus. It
has also been seen following parenteral adminis- 6.3. Systemic Infections
tration of an inactivated vaccine that produces
Systemic infections involve viremia, with or
humoral antibody but little or no local antibody,
without additional spread along other routes.
such as experimental respiratory syncytial and
Spread via the bloodstream is the major route by
early measles vaccines when followed by natural
which many viruses locate in secondary habitats
or purposeful exposure to live virus. (6 )
where their principal effects are produced. Some
The multiplication and effect of respiratory vi-
viruses become closely associated with lympho-
ruses such as influenza virus, parainfluenza virus,
cytes in the blood during the viremia phase (mea-
rhinoviruses, and respiratory syncytial virus are
sles, cytomegalovirus, poxviruses, EB virus). Some
generally limited to the respiratory tract. Influenza
produce a chronic nonproductive infection of lym-
virus has been detected in the blood only onceoo:J)
phocytes, such as EB virus; some are free in the
but has been isolated from the spleen, lymph
plasma, as are the arboviruses, enteroviruses, and
nodes, tonsils, liver, kidney, and heart in fatal
hepatitis B virus; some have a special affinity for
cases of Asian influenza pneumonia.(SS) Systemic
red cells, such as the viruses of Colorado tick fever
spread of this type appears to be unusual and
and Rift Valley fever. Viremia may be maintained
associated with overwhelming viral infection.
by continual seeding from the liver, spleen, bone
More examples may come to light with more
marrow, and other organs. The persistence of
widespread use of immunosuppressive drugs. Ad-
hepatitis B virus, cytomegalovirus, and EB virus in
enoviruses and the enteroviruses multiply both in
the blood for months or years poses a hazard in
the respiratory tract and in the gut; viremia and
their transmission via blood transfusions. It also
secondary multiplication in the central nervous
seems possible that the viruses associated with
system are common in the latter group. Among the
viremia may join with antibody and that such
enteroviruses, however, only Coxsackie A21 acts
complexes may circulate with occasional deposi-
primarily as a respiratory virus, and its importance
tion, fixation of complement, and local tissue in-
is limited mainly to military recruits. Enterovirus
jury, especially in small blood vesE,els. This has
70 causes acute hemorrhagic conjunctivitis, and
been shown for hepatitis B antigen in relation to
the virus is present in the conjunctiva and
periarteritis. Other viral immune complexes may
throat (see Chapter 8).
involve the kidney.
6.2. Gastrointestinal 6.4. The Exanthem

Hepatitis A, enteroviruses, adenoviruses, and Our understanding of the pathogenesis of sys-
reoviruses multiply within the gut. Many of the temic infections associated with a rash such as the
pox group, measles, and rubella has been en- coxsackievirus in the spinal fluid during CNS
hanced by the fine studies of Fenner with mouse infections. (60)
pox. (40.41) In each such exanthem, there is an What has been termed a "blood/brain barrier"
incubation period of 10-12 days before symptoms for entry of the blood-borne viruses into the CNS
of illness appear. After multiplication of the virus appears to have no strict anatomical basis; rather it
at the site of implantation and in the regional appears to represent a composite of those factors
lymph nodes, a primary viremia occurs within the influencing spread to the CNS.
first few days resulting in seeding of organs such Neural spread along nerves can occur in rabies,
as the liver and spleen. A secondary viremia then poliomyelitis, and B virus infections of man. In
follows with focal involvement of the skin and rabies it appears to be the predominant if not the
mucous membranes, the appearance of a rash, and sole method of spread to the CNS, whereas it
the onset of symptoms. In mouse pox, a primary seems to be relatively unimportant in poliomyeli-
lesion then develops at the site of inoculation. tis. The axons, lymphatics, and tissue spaces be-
While the destruction of cells involved in viral tween nerve fibers represent three possible con-
multiplication and the release of pyrogens from duits for spread along the neural route.
leukocytes may be responsible for symptoms such Transmission via the tissue spaces plus direct
as fever, the appearance of antibody at this time infection and involvement of endoneural cells
suggests that antigen/antibody complexes may seems the most likely mechanism. Spread along
play an important role in the pathogenesis of the the olfactory pathway has also been experimentally
rash. The viruses of smallpox, chickenpox, herpes demonstrated for poliomyelitis, herpes simplex,
simplex, and herpes zoster are present in the skin and certain arthropod-borne viruses. The role of
vesicles of each of these diseases. this route in natural infections is uncertain. As
with respiratory viruses, those infecting the CNS
have different cell preferences: poliomyelitis has a
predilection for anterior horn cells of the spinal
6.5. Infections of the Central Nervous System
cord and the motor cortex of the brain and arbovi-
In a comprehensive review of the pathogenesis ruses have a predilection for cells of the ence-
of viral infections of the central nervous system, phalon. Herpes simplex appears to have more
Johnson and Mims(60) emphasize that one or more catholic tastes and multiplies in a wide variety of
routes of infection may be involved and that the cell types. As is also true of respiratory cells, the
pathways differ with the particular viruses, the existence of specific cell receptors for individual
host, and the portal of entry. In man, the hematog- viruses may playa crucial role in susceptibility.
enous routes to the CNS from the portal of entry
and from primary multiplication sites in the gut,
respiratory tract, parotid, or lymph nodes are
6.6. Persistent Viral Infections
clearly of importance in enteroviral infections,
mumps, lymphocytic choriomeningitis, primary The pathogenetic mechanisms discussed thus far
herpes simplex infections, and fetal infections have dealt with infections in which an acute ill-
with rubella virus and cytomegalovirus. Secondary ness results, usually after a relatively short incuba-
multiplication sites in the liver, spleen, muscle, or tion period (except for rabies) and in which recov-
vascular tissue may augment or maintain the vire- ery ensues. The virus disappears and is often
mia; the brown fat has also received attention in eliminated from the body. Another pathogenetic
this regard for a variety of viruses. Several mecha- mechanism under increasing study is one in which
nisms have been suggested as to how viruses enter the virus persists for months or years, and may
the brain from the bloodstream. This may be a result in delayed host responses. Some of these
passive process or the viruses may actually grow persistent viruses are also capable of evoking an
their way through the choroid plexus. Viral multi- acute response such as the herpesviruses, rubella
plication at this site or leakage into the cerebros- virus, the adenoviruses, measles virus, and other
pinal fluid following growth in the meningeal cells paramyxoviruses. Other persistent viruses such as
may explain the presence of echovirus and papovaviruses and polyoma viruses rarely produce
any acute illness. Still other agents called "slow seases of the central nervous system, or certain
viruses" produce chronic degenerative disease malignancies. These infections will acquire greater
years after exposure. This group includes kuru and visibility and importance as immunosuppressive
Creutzfeldt-Jakob disease of man, scrapie infection drugs are used more widely in medical therapy
of sheep, and transmissible mink encephalopathy and in organ transplant recipients.
(see Chapter 24).
Six factors favoring persistence of certain viruses
have recently been summarized by Mims(78a): (1)
persistent viruses tend to have low or no patho- 7. Incubation Period
genicity for the cells they infect, in contrast to
viruses with severe, destructive effects which in- The period from the time of exposure to the
duce acute disease terminated by death or by appearance of the first symptoms is called the
recovery and the elimination of the virus; (2) there incubation period. Viruses not requiring distant
may be an ineffective antibody response possibly spread but able to produce disease through multi-
due to tolerance, auto immunosuppression, pro- plication at the site of implantation, such as the
duction of nonneutralizing or blocking antibodies, respiratory tract, have short incubation periods on
not enough antigen on the surface of the infected the order of 2-5 days. Those requiring hematoge-
(target) cell to induce adequate antibody forma- nous spread and involvement of distant target
tion, or spread of the virus directly from cell to cell organs such as the skin or central nervous system
where antibody does not reach it; (3) there may be have incubation periods of 2-3 wk. Viruses such
an ineffective cell-mediated immune response for as rabies, dependent on spread along nerves, have
reasons similar to those involved in the poor very long and variable incubation periods ranging
antibody response [tolerance, autoimmuno- from 8 days to a year or more. The variation in
suppression, blocking antibodies, too little antigen incubation periods in different diseases is indi-
expressed on surface to infected cell, failure of cated in Fig. 1. In some diseases, early symptoms
immune cells to reach infected (target) cells]; (4) or even a rash may accompany the period of initial
there may be a defective interferon response, such invasion or viremia. This has been seen in po-
as in lymphocytic choriomeningitis in mice; other liomyelitis, dengue, hepatitis, and infectious mon-
viruses may be relatively insensitive to interferon onucleosis. In such instances, the apparent incu-
action even though it may be produced; (5) certain bation period to the appearance of these early
persistent viral infections induce neither an im- features is much shorter than the usually accepted
mune nor an interferon response; these include period; more often, this early phase is not clini-
the "slow virus" infections such as kuru and cally recognized or occurs before the patient visits
Creutzfeldt-Jakob disease; (6) lymphocytes and the physician.
macrophages are often infected in persistent viral Knowledge of the incubation period has many
infections, such as with adenoviruses, EB virus, practical uses. Epidemiologically, it helps define
cytomegalovirus, and measles virus, thus altering the period of infectiousness: a patient is not us-
the host's immune response. Interferon produced ually infectious until close to the time of the
by infected macrophages may have no protective appearance of clinical symptoms. The duration of
effect on other macrophages, although there' is infectivity depends on the persistence of the virus
normal activity on normal cell types; certain virus! and its exit into the environment. Clinically, the
antibody complexes still remain infectious after duration of the incubation period helps to identify
phagocytosis by macrophages; infected macro- the likelihood of a viral exanthem after a known
phages may be less active in releasing the same exposure or to differentiate hepatitis A from hepa-
virus from the blood, thus favoring persistent titis B infections. Prophylactically, it determines
viremia. the feasibility of prevention of the clinical illness
Such persistent and latent viral infections may by immune serum as in hepatitis A, varicella-
reactivate, producing the acute disease again, or zoster infections, rubella, and rabies, as well as the
may result in a chronic viral infection manifested potential success of rabies vaccination.
by immune complex disease, degenerative di- In addition to the viruses that produce acute
DAYS
DISEASE 10 20 30
INFLUENZA
COMMON COLD
ADENOVIRUS c::J RANGE
DENGUE _ MOST COMMON
HERPES SIMPLEX
ENTEROVIRUS
POLIOMYELITIS
MEASLES
SMALLPOX
CHICKENPOX
MUMPS
RUBELLA
INF. HEPATITIS
INF. MONONUCLEOSIS
RABIES _.~360
SERUM HEPATITIS 180
80-100
8ASED MOSTLY ON DATA FROM CONTROL OF COMMUNICABLE DISEASES IN MAN, 11th ED, 1970
Fig. 1. Incubation periods in viral diseases.
infections, there are delayed effects of certain com- seases, the estimated incubation period from a
mon viruses in which the "incubation period" defined point of exposure to a suspected carcino-
may be several years. An example is the relation of gen to the development of disease has ranged from
measles virus to subacute sclerosing panencephali- 0.27 yr for the development of pancytopenia after
tis, in which infection in infancy may be associ- chloramphenicol to 36 yr for the appearance of
ated with involvement of the central nervous sys- lung cancer after exposure to asbestos.( 4 )
tem some 5-10 yr later.<'2)
Certain papovaviruses cause widespread inap-
parent infections in childhood. Rarely, reactivation
occurs later in life in the form of progressive 8. The Immune Response
multifocal leukoencephalopathy. This is seen in
patients with Hodgkin's disease in association The immunological response of the host to a
with depression of cell-mediated immunity (see virus infection plays a role not only in the devel-
Chapter 24). The term "incubation period" may be opment of specific resistance but also in the patho-
inappropriate in this setting because viral reacti- genesis of the signs and symptoms of the disease
vation appears to be involved and not a period of itself. Specific immunity to viral disease is based
primary multiplication of the virus. on humoral antibody, local antibody, and cell-
A prolonged incubation period lasting up to a mediated immunity. It is evoked either by natural
year or so is involved in natural and experimental infection or by immunization with live or killed
infections with kuru, an unusual disease of the antigens. The immune responses are dependent
central nervous system occurring in New on B-type lymphocytes derived from the bone
Guinea (46 ); similar long incubation periods are marrow and on T lymphocytes derived from the
seen in other "slow viral infections" of animals thymus.
such as scrapie in sheep (see Chapter 24).
The concept of an incubation period has also
8.1. Humoral Immunity
been applied to putative oncogenic viruses and to
chemical carcinogens in relation to the subsequent Humoral immunity is dependent on antibody
development of cancer. In various neoplastic di- found in the blood and other body fluids. Of the
five classes of immunoglobulins, IgG-, IgM-, and positive skin test reactions. In viral infections,
IgA-type antibodies are important in this type of lymphocytes and the lymphokines which they
protection. Viral-specific IgG antibodies usually produce attract macrophages and with their prod-
persist for life; those of the IgM type are short- ucts are participants in the destruction of antigen
lived and characterize the primary infection. It is and antigen-infected cells. The T lymphocyte is of
possible that persistence or reactivation of virus in key importance in the recognition and manage-
an active antigenic form may also be accompanied ment of viral and fungal infections. (2.3,50,115) When
by a prolonged or recrudescent IgM antibody re- T cells are absent, depleted, or functionally im-
sponse. Infections characterized by viremia pro- paired, severe and widespread viral or fungal
duce the most marked humoral antibody response infections may develop and latent viruses may
and the resulting immunity is usually of long reactivate. Specific receptors on T cells appear to
duration. Type B lymphocytes are primarily re- be programmed, probably by genetic inheritance,
sponsible for antibody production, but T lympho- to recognize and respond to different antigens.
cytes appear to playa helper role. There may be a special subpopulation of T lym-
Passive transfer of convalescent sera or immune phocytes for each class of antigen.
globulins may also produce protection against While the prevention of spread of viruses
those infections dependent on a viremia to reach through extracellular fluids and the blood seems to
target organs for their clinical expression; it 'does be largely dependent on neutralization by humoral
not protect against multiplication of virus at the antibody, control of viral spread from cell to cell is
site of initial implantation in the respiratory or probably dependent on cellular immunity. The
gastrointestinal tract. latter form of contiguous infection might be inter-
rupted by destroying infected cells, by severing
connections between infected and uninfected cells
S.2. Local Immunity (Secretory IgA System)
so that the virus cannot be transferred to un in-
Local antibody production is mediated through fected cells without being exposed extracellularly
immunoglobulins of the IgA class. Their presence to neutralizing antibody, or by destroying contig-
in glandular secretions and on mucous surfaces of uous uninfected cells so that virus must proceed
the respiratory tract and the gut is an effective extracellularly to reach target cells for further mul-
deterrent to viral infection at these sites. The tiplication.(83,84) An important element in the de-
production of local antibody is elicited by natural struction of infected cells is the induction of virus-
infection or by a live vaccine given by the natural induced antigens on the cell surface which makes
portal of entry. Less efficient production occurs them appear foreign to other host cells; they are
with killed vaccines given by the natural route of then destroyed by T-type lymphocytes as in graft-
infection or by live or killed vaccines given paren- vs.-host rejection.
terally. Indeed, an important limitation to the A two-phase response for stopping the cell-to-
effective prevention of infection with the paren- cell spread of herpesvirus has been postulated in
teral administration of inactivated vaccines such as which both specific and nonspecific defenses are
influenza and poliomyelitis is their failure to involved(68): the immunologically specific recog-
evoke a satisfactory local antibody response. Simi- nition phase consists of the interaction of antiviral
larly, passive immunization as in the use of 'Y- antibody, complement, and virus (or virus-in-
globulin may prevent systemic spread and clinical fected cells), as well as the stimulation of immune
disease but does not prevent primary infection. lymphocytes. This results in the generation of a
Epidemiologically, it is important to recognize that variety of biological mediators, some of which are
passively immunized individuals may continue to chemotactic for inflammatory cells. The nonspe-
be a source of spread of infection-to others. cific phase consists of the attraction of inflamma-
tory cells to the site where they exert a toxic effect
on both infected and noninfected cells and, with
S.3. Cell-Mediated Immunity
lymphocyte mediators, inhibit viral multiplication
Delayed hypersensitivity is a classic manifesta- and/or break connections between cells, forcing
tion of cell-mediated immunity as exemplified by extracellular passage of virus. A third form of
vertical spread from parent to progeny cells may Our knowledge of cell-mediated immunity and
also occur if the viral genome becomes integrated of cell-mediated tissue injury is incomplete. An
into the genome of the host cell. increasing understanding of the mechanisms in-
volved, of the relation of cellular to humoral im-
munity, and of the consequences of depressed
cellular immunity may explain why certain viruses
8.4. Immune Responses in the Pathogenesis of
persist and how such persistence may relate to
Viral Diseases
cancer, immune complex diseases, and chronic
Viral infections may produce the symptoms of infections of the central nervous system.
disease through a variety of mechanisms, some of
which are immunological in nature. (22) Antibody
produced by the virus may circulate until it 9. Patterns of Host Responses
reaches the virus and in combining with it initiate
an attack on the tissue to which the virus is The host responses to viral infections vary along
attached. Viruses may circulate in the blood, form- a biological gradient in terms of both the severity
ing circulating immune complexes with the anti- and the nature of the clinical syndrome produced.
body they have induced. The consequences of this
depend on the antigen/antibody balance and the
9.1. The Biological Gradient
size of the complex formed. (22) With large antigen
excess, the complexes are small, are excreted read- The host response to a virus may range from a
ily, and do not activate complement. With anti- completely inapparent infection without any clini-
body excess, large complexes are formed which are cal signs or symptoms at all to one of great clinical
phagocytosed and removed. The pathogenic com- severity, even of death. The ratio of these inappar-
plexes are those in balance or with slight antigen ent (or subclinical) to apparent (or clinical) re-
excess which combine with complement and de- sponses varies from one virus to another; repre-
posit in blood vessels, especially in the glomeruli sentative examples are shown in Table 2. At one
of the kidney. Together with polymorphonuclear end of the spectrum are certain infections which
cells they may evoke an inflammatory response are almost completely asymptomatic or unrecog-
and tissue injury. Immune complex nephritis is nizable in their pattern until some special event
the best-studied example of this. A third mecha- provokes a clinical response. The response may
nism of injury, referred to previously, is based on appear long after the initial infection and be due to
the induction by viruses of new antigens on the viral persistence and/or reactivation. The BK and
surface of the cell. These neoantigens are regarded JC strains of papovavirus fall in this category: no
as foreign by host cells and may evoke antibody known clinical disease has been associated with
formation and a cell-mediated response which the high antibody prevalence found for this virus
results in host cell injury or in immune complex in various population groupS.<89,10!) However, in
formation. If the virus-infected cell is a lympho- patients with Hodgkin's disease and other condi-
cyte, as in the EB virus infection causing infectious tions associated with depression of celt-mediated
mononucleosis, then the neoantigen induced on immunity, a fatal disease of the central nervous
the B cell may result in a mixed lymphocyte system may develop known as progressive multi-
response with T-cell transformation and prolifera- focal leukoencephalopathy. The virus can be iso-
tion.(5,70,112) In this situation, the atypicallympho- lated from the brain. (90) Antibody titers to papo-
cytosis characteristic of the disease may result both vavirus may reach a high level if the patient
from viral-transformed B cells and from T cells survives long enough.
entering blast formation as an immune response to A second group of viral infections are those
altered B cells. A fourth mechanism of immune which are predominantly mild or asymptomatic
viral injury might occur when the virus or the when exposure and infection occur in early child-
virus-induced antigen shares a common compo- hood, but which frequently result in symptomatic
nent with normal tissue and an autoimmune re- and sometimes severe clinical disease when infec-
sponse results. tion is delayed until late childhood and young
Table 2. Subclinical/Clinical Ratio in Viral Infections (Inapparent/Apparent Ratio)
Age at Estimated subclinical1 Percent of infection

Virus Clinical feature infection clinical ratio with clinical features
Poliomyelitis Paralysis Child ±1000:1 0.1-1

Epstein-Barr Heterophil-positive infectious 1":5 >100:1 1
mononucleosis 6-15 10-100:1 1-10
16-25 2-3:1 50-75
Infectious hepatitis Jaundice <5 20:1 5
5-9 11:1 10
10-15 7:1 14
Adult 2-3:1 50-75
Rubella Rash 5-20 2:1 50
Influenza Fever, cough Young adult 1.5:1 60
Measles Rash, fever 5-20 1:99 99+
Rabies eNS symptoms Any age 0:100 100
adult life. Examples of this are viral hepatitis, pictured as an iceberg in which clinically apparent
poliomyelitis, and EB virus infections. illness-i.e., above the water line-represents only
At the other end of the spectrum are infections a small proportion of the response pattern and the
due to measles, rabies, and Lassa fever viruses, in larger amount represents unrecognized and inap-
which clinically recognized illness usually accom- parent infections; a similar analogy may exist at
panies the infection. Indeed, in rabies infection of the cellular level. Figure 2 portrays these concepts.
man, death is almost inevitable after characteristic The cellular responses shown might be better
symptoms develop. considered as differences in the nature of the
This biological gradient of host response is often response rather than the severity of the response.
CELL RESPONSE* HOST RESPONSE

I-
o
:t----------------1
w
w
w
LYSIS OF CELL DEATH OF ORGANISM
CLASSICAL AND
~
<
~
~ INCLUSION BODY FORMATION SEVERE DISEASE Ci
OR
~ CELL TRANSFORMATION ;i.
II: OR ~
~ CELL DYSFUNCTION MODERATE SEVERITY z
::i
c _____________________-r________-+___________________ O
~ MILD ILLNESS
::. ~
:< w
II)
Ci
...J
<
~
·z
)a
.:::: ~
II)
ICEBERG CONCEPT OF INFECTION
Fig. 2. The "iceberg" concept of infectious diseases at level of the cell and at level of the host. *Hypothetical. Within
any cell population, varying patterns of cell response also occur.
COMMON COLD IN ADULTS ACUTE TONSI LLiTIS/PHARYNGITIS

IN YOUNG ADULTS
(EXCLUDING INF. MONO.) Fig. 3. The causes of acute
respiratory syndromes in
young adults.
ACUTE UPPER RESPIRATORY ACUTE LOWER RESPIRATORY

INFECTIONS IN YOUNG ADULTS INFECTIONS IN YOUNG ADULTS
(CIVILIAN) (CIVILIAN)
9.2. Clinical Syndromes agent on the basis of the clinical findings alone.
This is because these target organs have only a
The nature as well as the severity of the host limited number of ways to respond to infection
response varies widely in viral infections even and anyone of several viruses or other causative
with the same virus. These various clinical pat- agents may trigger off an identical or nearly ident-
terns may be due to different organ tropisms of the ical response. The results of specific viral tests,
virus, different pqrtals of entry, different ages at even if yielding a viral isolate or showing a serol-
the time of infection, variations in the immune ogical rise, are often available too late to make the
response, and differences in genetically controlled diagnosis during the course of the acute illness.
host responses. The clinician faced with the diag- The physician must therefore rely on epidemiolog-
nosis of a patient presenting certain respiratory or ical and clinical probabilities in making a tentative
central nervous system symptomatology, or with a etiological diagnosis. This diagnostic reasoning is
rash, may be unable to identify the etiological based on the known frequency of a certain virus in
a given clinical picture and on epidemiological chiolitis. In young children, parainfluenza viruses
features, which include age, season, year, and are also an important cause of these two syn-
epidemic occurrence. Certain infections such as dromes. The causes of pneumonia syndromes in
adenovirus pneumonia are more common in mili- infancy and young children and in hospitalized
tary recruits than in other young adults of the adults are shown in Fig. 4. It is not known
same age. A brief presentation of certain common whether the presence of Diplococcus pneumoniae
syndromes will be made. alone in throat cultures from infants and children
9.2.1. Common Respiratory Syndromes. A great indicates a true pathogen or only a carrier state.
many viruses and viral groups can evoke respira- These etiological pies emphasize the importance
tory symptoms, as can bacteria, rickettsiae, and of viruses in respiratory disease and explain the
certain fungi. In children and young adults, over failure of chemotherapy. Antibiotic therapy is thus
90% of respiratory infections appear to be viral in useful only in group A streptococcal pharyngitis
nature, although only about half of these can be and tonsillitis, Mycoplasma pneumoniae pneumonia
identified etiologically in the laboratory. In older as in young adults, and bacterial pneumonia as in
adults, especially those over 50 yr of age, bacterial adults over age 50. It is not useful therapeutically
infections are more common than viral infections or prophylactically in any viral disease.
and predominate in the severe respiratory tract 9.2.2. Common Infections of the Central Nerv-
infections that require hospitalization. ous System. Multiple agents are also involved in
A number of investigators have sorted out the the causation of acute infections of the central
relative importance of different infectious agents nervous system. An analysis of the viruses impli-
in the etiology of childhood and adult respiratory cated in causing encephalitis and aseptic meningi-
infections. (14.20.25.29.69.81.104) "Etiological pies" based tis in the United States in 1971 is presented in Fig.
on these data for four common respiratory syn- 5. Of 1891 clinically diagnosed cases of encephali-
dromes of young adults are depicted in Fig. 3. tis or meningoencephalitis, an etiological diagno-
Some 40-50% are of unknown cause. sis could be established in 37.6%. This included
In infants, respiratory syncytial virus is by far 150 arboviruses (7.9%), of which 58 were in the
the most important viral respiratory agent, pro- California group and 57 were identified as St.
ducing the syndromes of bronchitis and bron- Louis encephalitis. Mumps virus infections were
UNKNOWN
ETIOLOGY
51.4%
INFANTS AND CHILDREN HOSPITALIZED ADULTS
Fig. 4. Causes of pneumonia syndromes in infants and children and in hospitalized adults.
·Based on pure throat culture. ·"Based on pure blood culture.
UNKNOWN UNKNOWN
ETIOLOGY ETIOLOGY
62.4% 81.8%
ENCEPHALITIS ASEPTIC MENINGITIS

(1891 CASES) (4073 CASES)
Fig. 5. Causes of syndromes involving the central nervous system in the United States in 1971.
• Confirmed by virus isolation from cerebrospinal fluid and/or serological rise; not confirmed if
virus isolated from stool or throat only. From CDC Surveillance Reports, Encephalitis, July 19,
Aseptic Meningitis, May 1973.
diagnosed in 310 cases (16.3%), and this virus was ing of the clinical exanthems associated with the
the predominant cause of the syndrome. Viruses "new viruses" is given in Table 3.
associated with childhood exanthems were found 9.2.4. Gastrointestinal and Renal Syndromes.
in 126 cases (6.7%); 62.4% were of unknown Clinical syndromes involving the gastrointestinal
cause. tract or genitourinary system are rarely due to
Of 4073 cases reported as aseptic meningitis in demonstrable viruses. However, progress is being
1971, an etiological agent was identified in only made in identifying certain viral diarrheas. In
18.2% (Fig. 5). Enteroviruses were the most com-
mon cause and were involved in 15%; in these
infections the evidence was based on isolation of Table 3. Viral Causes of Common Exanthems
the virus from the cerebrospinal fluid anc\Jor serol-
ogical rise in 8.7%; in the other 6.3%, evidence Type of rash Examples
was based on an enterovirus isolate from the
1. Macular/papular Measles and measles vaccine
throat or stool without serological confirmation. Rubella
Mumps virus was the next most common cause of Echo 4,9,16
the aseptic meningitis syndrome with 90 cases Coxsackie A9, 16, B5
(2.2%); 81.8% were of unknown cause. Adeno
. 9.2.3. Common Exanthems. Acute viral syn- 2. Vesicular Varicella
dromes involving the skin are represented by the Smallpox
exanthems of childhood (measles, rubella, vari- Eczema hepaticum
cella), by various strains of coxsackievirus and Eczema vaccinatum
echovirus, by adenoviruses, especially type 7, by Herpes zoster
Coxsackie A16
EB virus in infectious mononucleosis, and by the'
3. Petechial or purpuric Coxsackie A9
presumed viral causes of roseola infantum (exan- Echo 9
them subitum) and erythema infectiosum. A list-
tropical areas, enteroviruses appear to cause infant 109 or 10 10 particles per gram of feces. This infec-
diarrhea, although the frequent presence of these tion rarely involves children over the age of 6 and
viruses in the healthy populations of these areas often occurs in winter. The incubation period is
makes measurement of their causal role difficult. about 48 h. The viruses seem to differ antigenically
Recently, several new agents have been identified from true reoviruses and orbiviruses so that the
by volunteer studies and/or electron microscopic term rotavirus has been suggested because of
analysis of stool preparations. Thus filtered stool their wheellike appearance under the electron mi-
suspension from acute diarrheal cases in adults croscope(20a,23a,42); the term duovirus has also
has produced a similar illness in volunteers. One been proposed to describe their double-shelled
such agent has been termed "Norwalk agent" from capsid structure. (2aa) The relationship of these
the town in Ohio where the isolates were ob- viruses to other agents in 378 children in Mel-
tained. (62) Papova-like particles have also been bourne, Australia, with acute enteritis is shown in
detected by the electron microscope in stools of Fig. 6; only 25% were of unknown cause. In a
adults with gastroenteritis. control group of 116 children no duovirus was
In infants and children, a virus with the appear- found, but salmonella occurred in 1%, adenovirus
ance of the orbivirus group has been seen with the and enterovirus in 8% each, and Escherichia coli in
electron microscope in biopsy material from duo- 3%. The exact terminology for and classification of
denal mucosa and in stool filtrates in cases of these assorted viruses are not yet clear. Pursuit
sporadic gastroenteritis(7,8,76); this agent has pro- along these lines will undoubtedly shed more light
duced illness in one adult volunteer. (76) Reovirus- on "viral diarrheas." At present, the rotaviruses
like agents similar to those producing acute diar- appear to be the major cause of the clinical syn-
rhea in newborn calves have also been found in drome of acute gastroenteritis in infants and
feces of young children with acute gastroenteritis. young children around the world.(2aa)
Davidson et al. (20a) report that morphologically In renal diseases, evidence of viral causation has
identical reo-like viruses were present in 48% of not been firmly established in man, except for
827 children with gastroenteritis but in only two of hemorrhagic cystitis due to adeno 11. This is
357 controls. The stools may contain as many as despite the occasional presence of viruses in the
DUOVIRUS
52%
Fig. 6. Causes of acute gastroenteritis in 378 UNKNOWN

children with enteric pathogens in feces. CAUSE
Adapted from Davidson et al. (20a) 25%
ENTEROVIRUS 2%
urine and the ability of many viruses to multiply lent infections of the central nervous system are
in in vitro tissue cultures prepared from human apt to be viral, with mumps virus, enteroviruses,
kidneys. The role of immune complex formation of and arboviruses being the most likely candidates
viruses and antibody in the causation of human in that order.
glomerulonephritis is unknown, although there is There are some common but not pathognomonic
ample precedent in animal models(86); except for features of viral diseases: they are usually nonpu-
elevated antibody titers to rubella virus in the rulent and associated with mononuclear rather
nephritis of systemic lupus erythematosus, no than polymorphonuclear infiltrates; the onset is
other leads were found in a serological study of more apt to be insidious than with a bacterial
106 cases of immune complex glomerulonephritis infection; often there are prodromal symptoms;
of unknown cause employing 13 different viral and retrobulbar headache is common. In the clini-
antigens. (114) It is likely that improved techniques cal laboratory, the presence of a normal or low
of identifying viruses and immune complexes will white count suggests a viral infection, but ty-
lead to the discovery of a role for viruses in both phoid, tuberculosis, brucellosis, malaria, histo-
acute and chronic nephritis. plasmosis, and overwhelming bacterial infections
can also produce leukopenia. The presence of
lymphocytosis and of atypical lymphocytes also
suggests a viral infection. Lymphocytosis of 50%
10. Diagnosis of Viral Diseases or more and atypical lymphocytosis of 20% or
more occur in infectious (EBV) mononucleosis,
The etiological diagnosis of a viral disease us- cytomegalovirus mononucleosis, and infectious
ually requires laboratory tests. There are four cir- hepatitis (early) in that order of frequency, but
cumstances in which a probable diagnosis of the drugs such as p.ara-aminosalicylate (PAS), dilan-
causative agent is suggested on clinical and/or tin, and tetrachloroethylene may also evoke lym-
epidemiological grounds. First, some viral infec- phocytosis. Less intense lymphocyte responses are
tions have distinctive enough clinical features that seen in a variety of viral infections such as rubella,
typical cases can be recognized if they occur in the adenovirus, mumps, herpes, and varicella infec-
right geographic area, season, and/or age group. tions. They may occasionally occur in tuberculosis,
This includes chickenpox and herpes zoster, histoplasmosis, and other nonviral infections.
herpes simplex infection of lips or genitalia, infec- The diagnostic procedures used for viral infec-
tious mononucleosis in a young adult, measles, tions are presented in individual chapters of this
mumps parotitis, paralytic poliomyelitis, rabies, book. However, there are certain common aspects
rubella, smallpox, and viral hepatitis. Second, if of collection, requests for testing, and interpreta-
there is an epidemic in which an etiological agent tion that merit comment here. A detailed descrip-
has been isolated, then most clinical syn- tion can be found in the APHA diagnostic
dromes of the same type are probably due to the handbook. (67)
same virus. Examples of this are outbreaks of
influenza, arbovirus infections, enteroviral exan-
10.1. Collection
thems, epidemic pleurodynia, and pharyngeal-
conjunctival fever. Third, special or unique epide- Materials for viral isolation should be obtained
miological circumstances may indicate the proba- from the site of the lesion, if feasible. Usually a
ble diagnOSis; croup or bronchiolitis in an infant is swab or gargles from the throat and a rectal swab
most likely due to respiratory syncytial virus, or a stool sample are useful for all suspected
jaundice in drug users or following a blood trans- respiratory and central nervous system infections
fusion is often a hepatitis B infection, and mon- and for the viral exanthems. In suspected arbovi-
onucleosis following blood transfusion and/or rus infections a sample of whole blood should be
immunosuppression is probably due to collected, and in vesicular exanthem an aspiration
cytomegalovirus. Fourth, the type of organ in- or scraping of the lesion. All such materials should
volvement may be a lead-Le., 80-90% of common be frozen immediately at -70°C and shipped in
respiratory infections are viral in origin; nonpuru- dry ice or liquid nitrogen to the nearest viral
diagnostic laboratory-usually a governmental collected or in the laboratory where the test is

(state, federal) or university laboratory. Collection performed. In infectious-disease hospitals or
and shipping kits are often available. For some units, routine collection and storage of acute and
more stable viruses, freezing may not be necessary convalescent sera from all febrile patients should
if transportation time is short. Certain laboratories be carried out in order to permit retrospective
now provide tubes with a transport medium. testing.
These include tissue culture tubes with one or
even two tissue culture cell types already grown
and ready for bedside inoculation of the specimen
and shipment to the laboratory for further 10.2. Requests for Testing
study.(77) Most common clinical syndromes have more
Serological tests are carried out on serum from a than one cause so that a request for a battery of
sample of blood, usually 10 ml collected in the serological tests should be made for most individ.
acute illness, and on a convalescent sample ob- ual cases. The laboratory needs clinical and epide-
tained 2-3 wk later; a third sample drawn about a miological information as a guide for these deter-
month after the second may be useful in some minations. At a minimum, the age of the patient
infections. The sera should be sterilely separated and the major organ system involved should be
immediately after clotting and either frozen (- 20" indicated on the request slip. The term "viral
or -70"C) or kept at 4°C. Serum may be stored in a disease" or "FUQ" keeps the laboratory at a loss as
freezer in the hospital or clinic where it has been to the best way to proceed.
Table 4. Viral Diagnosis: Some Causes of False-Positive and False-Negative Tests
A. False positive
Viral isolation
1. Persistent or reactivated virus from prior and unrelated infection has been isolated
2. A viral contaminant is present in the tissue culture or other isolation system
3. Nonspecific cytopathic effects occur due to toxicity of specimen or presence of bacteria, etc., and are mistaken
for a virus
4. Two microbial agents are present and the one isolated is not the cause of the disease
Serological rise
1. Cross-reacting antigens
2. Nonspecific inhibitors
3. Double infection, with only one agent producing the illness
4. Rise to vaccination rather than natural infection
B. False negative
Viral isolation
1. Viral specimen taken too late or too early in illness
2. Wrong site of multiplication sampled (e.g., throat rather than rectal swab)
3. Improper transport or storage of specimen-not kept frozen
4. Wrong laboratory animal or tissue culture system selected for isolation
5. Toxicity of specimen kills the tissue culture, obscuring the presence of virus
Serological rise
1. Specimens not taken at proper time-i.e., too late in illness or too close together to show antibody rise
2. Poor antibody response-low antigenicity of the virus or removal of antibody by immune complex formation
3. Wrong virus or wrong virus strain used in the test
4. Nonspecific inhibitor obscures true antibody rise
5. Wrong test used for the timing of the serum specimens
10.3. Interpretation of Tests 11. Proof of Causation
Isolation of the virus and a fourfold or greater The classical concepts of causation in infectious
rise in antibody titer between the acute and con- diseases are those elaborated by Jakob Henle
valescent sera are classical criteria for viral diagno- (1809-1885) in 1840 and by his student Robert
sis. For some viral infections, isolation of the virus Koch (1843-1910) in 1884 and 1890. These are
first and ,then tests for a serological rise against termed the Henle/Koch postulates. The basic crite-
that isolate are required. This is true of virus ria (column 1, Table 5) included the consistent
groups in which there are too many antigenically presence of the parasite in the disease in question
distinct strains to carry out a battery of serological under circumstances which can account for the
tests such as the echovirus, coxsackievirus, and pathological changes and clinical course, the ab-
rhinovirus groups. The adenoviruses, group B sence of the parasite in other diseases as a fortui-
arboviruses, and influenza A and B groups have tous or nonpathogenic parasite, and the experi-
common intragroup antigens, particularly in the mental reproduction of the disease by the
complement fixation test. These permit one test to organism after having been grown repeatedly in
be used to reflect infection for all members of that pure culture. The rigidity of these criteria and the
viral group. inability of many clearcut causes of certain di-
If it has been possible to obtain only a single seases to fulfill them was recognized by Koch
convalescent serum sample and a high antibody himself. He recognized that while the bacteria of
titer is found, or if high titers are present in both anthrax, tuberculosis, tetanus, and many animal
acute and convalescent sera without a fourfold diseases fulfilled the proof, those of many other
difference, then the question is whether these diseases did not. These latter included typhoid
results reflect current infection or persistently high fever, diphtheria, leprosy, relapsing fever, and
titers from a previous infection. Significance may Asiatic cholera. He felt particularly strongly about
be attached to these findings if the disease is a rare cholera because he himself had discovered the
one in which the presence of this antibody is causative organism. For these diseases, he felt that
unique, if the test reflects a short-lasting antibody, fulfillment of only the first two criteria was needed
or if IgM-type antibody can be demonstrated. A and that experimental reproduction of the disease
rapid drop in antibody titer in a subsequent speci- was not essential to proof of causation. Rivers
men is also suggestive of a recent infection. Se- reviewed the Koch postulates in terms of viral
quential testing of other family members may also infections in his presidential address to the Amer-
be useful as they may be in different stages of ican Immunological Society in 1937 and found
apparent or inapparent infection with the same them lacking.(96) Included in his objections were
virus. In an epidemic setting, comparison of the (1) the idea that a disease is necessarily caused by
geometric mean antibody titer of sera collected only one agent, citing Shope's work with swine
early in illness from one group of patients with the influenza in which both a virus and a bacteria are
titer in sera from another group of patients conva- required(102); (2) the necessity of demonstrating
lescing from the same illness may permit rapid the presence of viruses in every case of the disease
identification of the outbreak. produced by it; (3) the fact that the existence of
Sometimes a virus may be isolated or an anti- virus carriers must be recognized. He set forth two
body rise may be demonstrated which is not, in conditions for establishing the specific relation of
fact, causally related to the illness. Sometimes two a virus to a disease (column 2, Table 5): (1) a
viruses, or a virus and a bacteria, are implicated in specific virus must be present with a degree of
the infection, and the interpretation of their causal regularity in association with the disease; (2) the
role may be very difficult. On other occasions, no virus must occur in the sick individual not as an
virus can be isolated or a serological rise is not incidental or accidental finding but as a cause of
demonstrable when a specific virus is the real the disease. In support of the latter, he stressed the
cause of the illness. A list of some common causes importance of the experimental reproduction of
for these false-positive and false-negative results is the disease in susceptible experimental hosts with
given in Table 4. the inclusion of suitable controls to eliminate the
Table 5. Postulates of Causation
Bacteria" Viruses' Virusesc

Henle, 1840; Koch, 1890 Rivers, 1937 Immunological proof, 1973
1. Parasite occurs in every case of 1. A specific virus must be found 1. Viral-specific antibody is regularly
the disease in question and associated with a disease with a absent prior to illness
under circumstances which can degree of regularity
account for the pathological
changes and clinical course of
the disease
2. Occurs in no other disease as 2. Virus occurs in the sick 2. Antibody regularly appears during
fortuitous and nonpathogenic individual not as incidental or illness, including
parasite accidental finding but as cause a. Transient viral-specific IgM
of the disease antibody
b. Persistent IgG antibody
c. Local antibody (lgA)-at site of
primary multiplication
3. After being fully isolated from 3. Transmissible infection is 3. Antibody production is
the body and repeatedly grown produced with a degree of accompanied by presence of viruses
in pure culture can induce the regularity in susceptible in appropriate tissues
disease anew experimental hosts by means of
inoculation of material, free
from ordinary microbes or
rickettsiae, obtained from
patients with the disease, and
proper control and
immunological studies
demonstrate that the virus was
neither fortuitously present in
the patient nor accidentally
picked up in the experimental
animals
Only 1 and 2 were regarded as 4. Absence of IgG antibody indicates
essential by Koch susceptibility to the disease
5. Presence of IgG antibody indicates
immunity to the disease
6. No other virus or antibody is
similarly associated
7. Production of the antibody
(immunization) prevents the
disease
a Koch"" (see Rivers"·)).

b Rivers. (96)
C Derived from Rivers(96) and Evans.'29.)
fortuitous presence of other viral agents either in this statement because of the possible presence of
the patient or in the experimental host. The ab- passenger viruses to which antibody appeared but
sence of antibody to a virus in the patient's sera at which were not of etiological significance. He also
the onset of illness and its appearance during noted that recovery from viral infection sometimes
recovery were recognized as an important but not takes place without the development of antibodies
absolute link in causation; Rivers was cautious in and that occasionally an individual already pos-
sessing antibodies against a virus succumbs to a the disease (see Chapter 9). The web of causation
disease caused by it (i.e., reinfection or reactiva- thus is firm that EB virus causes heterophil-anti-
tion). body-positive infectious mononucleosis. (aO)
The "virologists' dilemma" was further dis- Similar seroepidemiological techniques have
cussed in 1957 by Huebner/ 58 ) who revised the been employed in studying the spectrum of infec-
Koch and Rivers postulates into the following tions produced by hepatitis B antigen (HBAg)
criteria: (1) the virus must be a "real entity," i.e., because of the difficulty of isolating the virus in
well-established on animal or tissue culture pas- the laboratory and the lack of a good experimental
sage in the laboratory; (2) the virus must originate animal (see Chapter 10).
in human tissues and be repeatedly present The most difficult and challenging problems of
therein and not in the experimental animals, cells, causation are arising in the possible relationship
or the media used to grow it; (3) the agent should between certain viruses and the development of
be characterized early to permit differentiation various malignant and chronic diseases. These
from other agents, including immunological com- include EB virus in relation to Burkitt lymphoma
parisons; (4) the virus should have a constant and nasopharyngeal cancer, herpesvirus type 2 in
association with the clinical entity in question; (5) relation to cervical cancer, measles virus in relation
the clinical syndrome should be experimentally to subacute sclerosing panencephalopathy and to
reproducible in volunteers inoculated with the multiple sclerosis, and papovaviruses in relation to
agent in a "double-blind" study; (6) carefully con- progressive multifocalleukoencephalopathy. High
ceived epidemiological cross-sectional and longi- antibody titers to the viruses in question are
tudinal studies are indispensable in establishing common in many of these conditions, but it is not
the role of highly prevalent viruses in human known if they precede the illness, accompany it, or
diseases; (7) the disease should be prevented by a occur in its wake. The persistence and/or reactiva-
specific vaccine. He also added an eighth consid- tion of these viruses under circumstances of im-
eration-financial support-which is so needed to paired cell-mediated immunity (CMI) have been
carry out the virological and epidemiological anal- postulated as a possible common mechanism. (27)
yses required in establishing proof of causation. Such an impairment in cell-mediated immunity
The problem of establishing causality for viral could arise when the viral infection occurs very
infections has been exemplified by the relation of early in infancy or during pregnancy; it might also
EB virus to infectious mononucleosis. In the be- result from the presence of a concomitant infection
ginning, no method of virus isolation existed, no (malaria) which depresses the immune response,
susceptible laboratory animal was known, and from the use of immunosuppressive drugs, from
EBV antibody was already present at the time the genetic defects in the ability of T-type lympho-
patient with infectious mononucleosis was first cytes to recognize or respond to certain viruses,
seen by the physician. The proof of causation had from serum inhibitors of cellular immunity, or
to rest on prospective serological investigations from disease-induced immunosuppression.
which fulfilled certain immunological crite- Current evidence suggests that certain cancers
ria.(29a,54.82) The most important of these were the and certain chronic diseases of man are due to the
regular absence of antibody prior to disease, its persistence and/or reactivation of common, ubiq-
regular appearance during illness, and the relation uitous viruses in an immunologically compro-
of antibody to susceptibility and immunity(:!;J·82) mised host. Those viruses with a capacity for
(see column 3, Table 5). To date, local antibody has latency such as the herpes, papova, measles, ru-
not yet been demonstrated nor has a vaccine been bella, and adenoviruses appear to be the most
developed to prevent the disease. Advances in likely candidates for the causation of these condi-
viral technology later permitted the identification tions. Present and future work to determine the
of the presence and persistence of EB virus in the elements of causation include (1) large-scale multi-
pharynx of patients having acute infectious mon- purpose prospective studies of populations, seek-
onucleosis. Human and monkey transmission ex- ing evidence of viral persistence, high viral anti-
periments with EB virus have resulted in the body levels, and/or impaired lymphocyte response
reproduction of some but not all of the features of to viral agents as a possible prelude to malignancy
and chronic disease, and then the appearance of stressed that cancer or a chronic disease will not
the disease itself as more definitive proof of causa- always result even under propitious circumstan-
tion; (2) the demonstration of the virus or viral ces. The host response will probably fall along a
genome in afflicted tissues but not in normal biological gradient from very mild to severe. It also
tissues; (3) the occurrence or reproduction of the seems likely that any given malignant or chronic
condition in man and/or experimental hosts under condition may be produced by more than one
natural or induced viral infection. It must be cause or group of causes. The current evidence on
Table 6. Viral Vaccines"
Individuals to be
Vaccine and type immunized Schedule Dose and route Age
Influenza, inactivated High-risk groups (heart Single dose in fall 0.5 ml, i.m. Adult
disease, chronic lung (prior to November)
disease, diabetes and
other metabolic
disorders)
Measles! live All infants Single dose 0.5 ml, i.m. After 12 mo; usually at
Booster needed only 1 yr
if given with
immune globulin
Mumps! live All infants, but of special Single dose 0.5 ml, i.m. Any age after 12 mo
value in children No booster needed
approaching puberty or
in males without
history of mumps or
without antibody
Polio, live To all infants and Three-dose initial Oral At 2, 4, and 6 mo;
periodically thereafter series of trivalent repeat at age Ii yr
oral vaccine and age 4-6 yr
Rabies, inactivated To those exposed to Daily for 14 days plus s.c. Any
suspected or known booster 14 and 20
rabid animals or to a days after 14-day
wild animal bite series
(skunk, fox, raccoon,
bat)
Rabies, passive In severe and known 40 initial units/kg i.m. i.m. Any
(hyperimmune sera) exposure to rabid in buttocks-give
animal given within 72 half of total dose at
h of exposure site of wound
Rubella," live Girls prior to age of Single dose Age 1 yr to puberty
conception
Smallpox, live 1. Travelers to endemic Single dose i.c. Any-repeat every 3
area yr when exposed
2. Health workers with repeatedly
potential exposure
3. Immediate and
secondary contacts of
cases
a See the appropriate chapters of this book for the details of immunizations.
b May be given at 1 yr as measles-rubella or measles-mumps-rubella combined vaccine.
viruses, cancer, and their relationship to chronic this approach is probably the most important one
neurological diseases is discussed in later chapters in preventing the disease following severe expo-
of this book. sures; it is successful because early administration
may interrupt the virus before it reaches the cen-
tral nervous system. In the past, immunoglobulin
was also used after exposure to measles, mumps,
12. Control and Prevention or rubella viruses, but such preparations are not
commonly employed today because of the availa-
The basic concept in controlling a viral disease is bility of effective live vaccines and the difficulty in
to break a link in the chain of causation. Interrup- administering the immune globulin early enough.
tion of a single known essential link may effec- Our greatest needs today for the prevention of
tively control a disease even if knowledge of other viral diseases are the development of effective
links, or of the etiology itself, is incomplete. De- vaccines against the hepatitis viruses, respiratory
spite this, very little has been accomplished in syncytial virus, parainfluenza viruses, and the
most viral diseases by environmental changes, human herpesviruses. An effective rhinovirus vac-
except for the arboviruses, in which the appropri- cine would reduce morbidity from the common
ate insect vector can be controlled. Improved water cold about 25%, but the existence of over 100
supplies, proper sewage disposal, and improved antigenetic types makes this impossible; a multi-
personal hygiene could potentially decrease the plicity of antigenic strains also deters immuniza-
incidence of poliomyelitis and other enterovirus tion against coxsackieviruses and echoviruses. The
and hepatitis A infections, but in general the available vaccines and recommended applications
results have been disappointing because so many are listed in Table 6.
pathways of infection exist. Furthermore, im- Chemoprophylaxis has not yet been very suc-
proved sanitation may delay the age of exposure to cessful in viral infections; limited applications
later childhood and young adult life, when infec- have been found in smallpox using a semicarba-
tions are more often clinically apparent and more zone preparation and in A2 influenza infections
severe. with amantadine. The logistics of identifying ex-
The difficulty of controlling infections transmit- posed persons and of administering these com-
ted by the respiratory route or through close per- pounds early enough to be effective has limited
sonal contact has directed the main thrust of pre- their usefulness.
vention to immunization of the host. The most Additional information on the control and pre-
successful of these efforts toward vaccine develop- vention of specific viral infections is included in
ment have used an attenuated live virus as the the appropriate sections of subsequent chapters of
antigen (adenovirus, measles, mumps, poliovirus, this book.
rubella, and smallpox). Administration by the nat-
ural portal of entry to produce local immunity has
also been important (poliovirus, adenovirus). In-
activated viral vaccines such as influenza vaccine 13. References
have met with limited success, although highly
purified and concentrated preparations are giving 1. ABBEY, H., An examination of the Reed-Frost theory
more promising results; a successful inactivated of epidemics, Hum. BioI. 24:201-233 (1952).
polio vaccine has also provided good protection in 2. ALLISON, A. c., The Scientific Basis of Medicine, p.
Scandinavian countries. Passive immunization is a 49, Annual Reviews, London, (1972).
short-term expedient useful only when the y- 3. ALLISON, A. c., Immune responses in persistent
viral infections, J. Clin. Pathol. Suppl. 6:121 (1972).
globulin can be administered early after exposure 4. ARMENIAN, H. K., AND LILmNFELD, A. M., The dis-
and when it contains a sufficiently high titer of tribution of incubation periods of neoplastic di-
specific antibody. Today, well-defined exposures seases' Am. J. Epidemiol. 99:92-100 (1974).
to hepatitis A, vaccinia virus, and rabies virus 5. BAUSHER, J. c., AND SMITH, R. T., Studies of the
under circumstances of high risk constitute the Epstein-Barr virus-host relationship: Autochthon-
major indications for passive antibody. In rabies, ous and allogeneic lymphocyte stimulation by lym-
phoblast cell lines in mixed cell culture, Clin. Immu- 19. CONNOLLY, J. H., ALLEN, I. V., HURwrrz, 1. J., AND
nol. Immunopathol. 1:270--281 (1973). MILLAR, J. H. D., Measles-virus antibody and anti-
6. BELL, J. A., ROWE, W. P., ENGLER, J. I., PARROTI, R. gen in subacute sclerosing paraencephalitis, Lancet
H., AND HUEBNER, R. J., Pharyngeal conjunctival 1:542-544 (1967).
fever: Epidemiological studies of a recent recog- 20. CORRIELL, 1. 1., Clinical syndromes in children
nized disease entity, J. Am. Med. Assoc. 175:1083- caused by respiratory infection, Med. Clin. North
1092 (1955). Am. 51:819-830 (1967).
7. BISHOP, R. F., DAVIDSON, G. P., HOLMES, I. H., 20a. DAVIDSON, G. P., BISHOP, R F., TOWNLEY, R. R
AND RuCK, B. J., Virus particles in epithelial cells of W., HOLMES, I. H., AND RuCK, B. J., Importance of
duodenal mucosa from children with acute non- a new virus in acute sporadic enteritis in children,
bacterial gastroenteritis, Lancet 2:1281-1283 (1973). Lancet 1:242-245 (1975).
8. BISHOP, R. F., DAVIDSON, G. P., HOLMES, I. H., AND 21. DAVIS, B. D., DULBECOO, R, EISEN, H. N., GINS-
RuCK, B. J., Detection of a new virus by electron BERG, H. 5., AND WOOD, W. B., Microbiology, Har-
microscopy of fecal extracts of children with acute per and Row, New York, 1968.
gastroenteritis, Lancet 1:149-151 (1974). 22. DIXON, F. J., Mechanisms of immunologic injury, in:
9. BISNO, A. 1., BARRATT, N. P., sEVANSTON, W. H., Immunobiology (R. A. GOOD AND D. W. FISCHER,
AND sPENSE, 1. P., Aft outbreak of acute respiratory eds.), pp. 161-166, sinauer, Stamford, Conn., 1971.
disease in Trinidad associated. with para-influenza 23. DOUGHERTY, W. J., AND ALTMAN, R., Viral hepatitis
virus, Am. J. Epidemiol. 91:6~77 (1970). in New Jersey 1960--1961, Am. J. Med. 32:704-716
10. BLACK, R. 1., WOODALL, J. P., EVANS, A. 5., LIEBHA- (1962).
BER, H., AND HENLE, G., Prevalence of antibody 23a. Editorial, Rotaviruses of man and animals, Lancet
against viruses in the Tiriyo, an isolated Amazon 1:257-259 (1975).
tribe, Am. J. Epidemiol. 91:430--438 (1970). 24. ELVEBACK, 1. R., ACKERMAN, E., YOUNG, G., AND
11. BLUMBERG, B.S., ALTER, H. J., AND VISNICK, S., A Fox, J. P., A stochastic model for competition be-
"new" antigen in leukemia sera, J. Am. Med. Assoc. tween viral agents in the presence of interference. 1.
191:541-546 (1965). Live virus vaccine in randomly mixing population,
12. BRODY, J. A., AND DETELS, R., Subacute sclerosing model III, Am. J. Epidemiol. 87:373--384 (1968).
panencephalitis: A zoonosis following aberrant 25. EVANS, A. 5., Clinical syndromes in adults caused
measles, Lancet 2:5Q(~-501 (1970). by respiratory infection, Med. Clin. North Am.
13. BYRNE, E. B., EVANS, A. 5., FONTS, D. W., AND 51:803-818 (1967).
ISRAEL, H. 1., A seroepidemiological study of Ep- 26. EVANS, A. 5., Serological surveys: The role of the
stein-Barr virus and other viral antigens in sarcoi- WHO Reference Serum Bank, WHO Chron. 21:185-
dosis, Am. J. Epidemiol. 97:355-363 (1973). 190 (1967).
14. CHANOCK, R. M., AND PARROTI, R. H., Acute respi- 27. EVANS, A. 5., The spectrum of infections with
ratory disease in infancy and childhood, present Epstein-Barr virus: A hypothesis, J. Infect. Dis.
understanding and prospects for prevention, Pediat- 124:330--337 (1971).
rics 36:21-40 (1965). 28. EVANS, A. 5., Clinical syndromes associated with
15. CHANOCK, R., CHAMBON, 1., CHANG, W., FERRIERA, EB virus infection, Adv. Intern. Med. 18:77-93
F. G., GHARPURE, P., GRANT, L., HATEM, J., IMAN, (1972).
I., KALRA, 5., LIM, K., MADALENGOITIA, J., sPENSE, 29. EVANS, A. 5., Diagnosis and prevention of common
1., TENG, P., AND FERREIRA, W., WHO respiratory respiratory infection, Hasp. Pract. 10:31-41 (1974).
survey in children: A serological study, Bull. WHO 29a. EVANS, A. 5., New discoveries in infectious mon-
37:363-369 (1967). onucleosis, Mod. Med. 42:1~24 (1974).
16. CHANOCK, R. M., PARROTI, R. H., KAPIKIAN, A. Z., 30. EVANS, A. 5., EB virus, infectious mononucleosis
KIM, H. W., AND BRANDT, C. D., Possible role of and cancer: The closing of the web, Yale J. BioI.
immunological factors in pathogenesis of Rs virus Med. 47:113-122 (1974).
lower respiratory tract disease, Perspect. Viral. 31. EVANS, A. 5., CAMPOS, 1. E., D'ALLESSIO, D. A.,
6:125-135 (1968). AND DICK, E. C., Acute respiratory disease in Uni-
17. CHRISTIE, A. B., Infectious Diseases: Epidemiology and versity of the Philippines and University of Wiscon-
Clinical Practice, E. and s. Livingstone, Edinburgh, sin students: A comparative study, Bull. WHO
1969. 36:397-407 (1967).
18. CIONGOLI, A. K., PLA'IZ, P., DUPONT, B., sVEJGAAD, 32. EVANS, A. 5., AND COMPOS, 1. E., Acute respiratory
A., FOG, T., AND JERSILD, C., Lack of antigenic disease in students at the University of the Philip-
response to myxoviruses in multiple sclerosis, Lan- pines, Bull. WHO 45:103-112 (1971).
cet 2:1147 (1973). 33. EVANS, A. 5., NIEDERMAN, J. c., AND MCCOLLUM,
R. W., Seroepidemiologic studies of infectious 46. GAJDUSEI<, D. c., AND GIBBS, C. J., JR., Slow, Latent
mononucleosis with EB virus, N. Engl. J. Med. and Temperate Infections of the Central Nervous Sys-
279:112~1127 (1968). tem in Infections of the Nervous System, Vol. XLN,
34. EVANS, A. 5., NIEDERMAN, J. c., AND SAWYER, R. The Association for Research in Nervous and Men-
N., Prospective studies of a group of Yale Univer- tal Disease, Williams and Wilkins, Baltimore, 1968.
sity freshman. II. Occurrence of acute respiratory 47. GARD, 5., AND ALLIN, K., Studies on the hepatitis
infections and rubella, J. Infect. Dis. 123:271-278 virus, in: Hepatitis Frontiers (F. W. HARTMAN et al.,
(1971). eds.), pp. 169-172, Little, Boston, 1957.
35. EVANS, A. 5., SHEPARD, K. A., AND RICHARDS, V. 48. GERONE, P. J., COUCH, R. B., KEEFER, G. V., DOUG-
A., ABO blood groups and viral diseases, Yale J. LAS, R. G., DERRENBACHER, E. B., AND KNIGHT, V.,
BioI. Med. 45:81-92 (1972). Assessment of experimental and natural viral aero-
36. EVANS, A. 5., KLEIN, G., NIEDERMAN, J. c., RI- sols, Bacteriol. Rev. 30:576-584 (discussion 584-588)
CHARDS, V., AND WANAT, J., Viral antibody levels in (1966).
nasopharyngeal carcinoma (1974). Unpublished. 49. GESER, A., CHRISTENSEN,S., AND THORUP, I. B., A
37. EVANS, A. 5., CASALS, J., OPTON, E. M., BORMAN, E. multipurpose serological survey in Kenya. I. Survey
K., LEVINE, 1., AND CUADRADO, R. R., A nationwide methods and progress of field work, Bull. WHO
serum survey of Colombian military recruits, 1966. 43:521-537 (1970).
I. Description of sample and antibody patterns with 50. GREAVES, M. F., OWEN, J. J. T., AND RAFF, M. c., T
arboviruses, polioviruses, respiratory viruses, teta- and B Lymphocytes, Origins, Properties and Roles in
nus and treponematosis, Am. J. Epidemiol. 90:292- Immune Responses, Exerpta Medica, Amsterdam,
303 (1969). American Elsevier, New York, 1973.
38. EVANS, A. 5., CASALS, J., OPTON, E. M., BORMAN, 51. GUTHE, T., RIDET, J., VORST, F., D'COSTA, J., AND
E. E., LEVINE, 1., AND CUADRADO, R. R., A nation- GRAB, B., Methods for surveillance of endemic tre-
wide serum survey of Argentinian military recruits, ponematosis and sero-immunological investigations
1965-1966. I. Description of sample and antibody of "disappearing" disease, Bull. WHO 46:1-14
patterns with arboviruses, polioviruses, respiratory (1972).
viruses, tetanus and treponematosis, Am. J. Epide- 52. HENDLEY, J. 0., WENZEL, R. P., AND GWALTNEY, J.
miol. 93:111-121 (1971). M., JR., Transmission of rhinovirus colds by self-
39. EVANS, A. 5., Cox, F., NANKERVIS, G., OPTON, E., induction, N. Engl. J. Med. 288:1361-1364 (1973).
SHOPE, R., WELLS, A. V., AN'J WEST, B., A health 53. HENLE, G., AND HENLE, W., Immunofluorescence in
and seroepidemiological survey of a community in cells derived from Burkitt lymphoma, J. Bacterial.
Barbados, Int. J. Epidemiol. 3:167-175 (1974). 91:1248-1258 (1966).
40. FENNER, F., The pathogenesis of the acute exan- 54. HENLE, G., HENLE, W., AND DIEHl, V., Relation of
thems; an interpretation based on experimental Burkitt's tumor-associated herpes-type virus to in-
investigations with mousepox (infectious ectromelia fectious mononucleosis, Proc. Nat!. Acad. Sci. USA
of mice), Lancet 2:915-920 (1948). 59:94-101 (1968).
41. FENNER, F. J., AND WHrrE, D.O., Medical Virology, 55. HOEPRICH, P. D. (ed.), Infectious Diseases, Harper
Academic Press, New York, 1970. and Row, Hagerstown, Md., 1972.
42. FLEWETT, T. H., BRYDEN, A. 5., WOODE, G. N., 56. HORSFALL, F. 1., AND TAMM, I. (eds.), Viral and
BRIDGER, J. c., AND DERRICK, J. M., Relation be- Rickettsial Infections of Man, Lippincott, Philadel-
tween viruses from acute gastroenteritis of children phia, 1965.
and newborn calves, Lancet 2:61-63 (1974). 57. HORSTMANN, D. M., LIEBHABER, H., LEBoUVIER, G.
43. FLOREY, C. DU V., CUADRADO, R. R., HENDERSON, J. 1., ROSENBERG, D. A., AND HALSTEAD, S. B., Ru-
R., AND DE GOES, P., A nationwide serum survey of bella: Reinfection of vaccinated and naturally im-
Brazilian military recruits, 1964. I. Method and mune persons exposed in an epidemic, N. Engl. J.
sampling results, Am. J. Epidemiol. 86:314-318 Med. 283:771-778 (1970).
(1967). 58. HUEBNER, R. J., The virologist's dilemma, Ann. N.Y.
44. Fox, J. P., HALL, C: E., AND ELVEBACK, 1. R., Acad. Sci. 67:430-442 (1957).
Epidemiology: Man and Disease, Collier-Macmillan, 59. JAWETZ, E., ADELBERG, E. A., AND MELNICK, J. 1.,
Ltd., London, 1970. Review Outline of Medical Microbiology, 11th ed.,
45. Foy, H. M., COONEY, M. I. c., AND McMAHAN, R. Lange Medical Press, Los Altos, 1974.
A., AlHongKong influenza immunity three years 60. JOHNSON, R. T., AND MIMS, C. A., Pathogenesis of
after immunization, J. Am. Med. Assoc. 226:75S-761 viral infections of the nervous system, N. Eng/. J.
(1973). Med. 278:2~30, 84-92 (1968).
61. JORDAN, M. e., ROUSSEAU, W. E., NOBLE, G. R., acute gastroenteritis of infancy, Lancet 1:1241-1243
STEWART, J. A., AND CHIN, T. D. Y., Association of (1974).
cervical cytomegaloviruses with venereal disease, 77. MILLER, D. G., GABRIELSON, M. 0., AND HORST-
N. Engl. J. Med. 288:932-934 (1973). MANN, D. M., Clinical virology and viral surveil-
62. KAPIKIAN, A. Z., WYATT, R. G., DOLIN, R., THORN- lance in a pediatric group practice: The use of
HILL, T. S., KALICA, A. R., AND CHANOCK, R. M., double-seeded cultures for primary virus isolation,
Visualization by immune electron microscopy of a Am. J. Epidemiol. 88:245-256 (1968).
27-nm particle associated with acute infectious non- 78. MIMS, e. A., Pathogenesis of viral infections of the
bacterial gastroenteritis, J. Virol. 10:1075-1081 respiratory tract, in: Aerobiology (I. H. SILVA, ed.),
(1972). pp. 248-259, Proceedings of the Third International
63. KNIGHT, V. (ed.), Viral and Mycoplasma Infections of Symposium, Academic Press, New York, 1970.
the Respiratory Tract, Lea and Febiger, Philadelphia, 78a. MIMS, e. A., Factors in the mechanism of persist-
1973. ence of viral infections, Prog. Med. Virol. 18:1-14
64. KOCH, R., tiber bacteriologische Forsching, Ver- (1974).
handl. X. Int. Med. Congo Berlin 1:35 (1891). 79. MONTO, A. S., AND JOHNSON, K. M., A community
65. KRUGMAN, S., GILES, J. P., AND HAMMOND, J., study of respiratory infections in the tropics. I.
Infectious hepatitis: Evidence for two distinctive Description of the community and observation on
clinical, epidemiological and immunological types the activity of certain respiratory agents, Am. J.
of infections, ,. Am. Med. Assoc. 200:365-373 (1967). Epidemiol. 86:78-92 (1967).
66. LANG, D. J., AND KUMMER, J. F., Demonstration of 80. MORRIS, J. N., The Uses of Epidemiology, E. and S.
cytomegalovirus in semen, N. Engl. ,. Med. 287:75~ Livingstone, Edinburgh, 1957.
758 (1972). 81. MUFSON, M. A., CHANG, V., GILL, V., WOOD, S. e.,
67. LENNETTE, E. H., AND SCHMIDT, N. J. (eds.), Diag- ROMANSKY, M. J., AND CHANOCK, R. M., The role of
nostic Procedures from Viral and Rickettsial Infections, viruses, mycoplasmas and bacteria in acute pneu-
APHA Inc., New York, 1969. monia in civilian adults, Am. ,. Epidemiol. 86:52~
68. LODMELL, D. L., NIWA, A., HAYASHI, K., AND NOT- 544 (1967).
KINS, A. L., Prevention of cell-to-cell spread of 82. NIEDERMAN, J. e., MCCOLLUM, R. W., HENLE, G.,
herpes simplex virus by leukocytes, J. Exp. Med. AND HENLE, W., Infectious mononucleosis: Clinical
137:70~720 (1973). manifestations in relation to EB virus antibodies, ,.
69. MACASAET, F. F., KIDD, P. A., BOLANO, e. R., AND Am. Med. Assoc. 203:205-209 (1968).
WENNER, H. A., The etiology of acute respiratory 83. NOTKINS, A. L., Commentary: Immune mechanisms
infections. III. The role of viruses and bacteria, ,. by which the spread of viral infections is stopped,
Pediat. 72:829--839 (1968). Cell. Immunol. 11:478-483 (1974).
70. MANGI, R. J., NIEDERMAN, J. e., KELLEHER, J. E., 84. NOTKINS, A. L., AND KOPROWSKI, H., How the
DWYER, J. M., EVANS, A. S., AND KANTOR, F. S., immune response to a virus can cause disease, Sci.
Depression of cell-mediated immunity during infec- Am. 228:22-31 (1973).
tious mononucleosis, N. Engl. J. Med. 291:1149--1153 85. NOTKINS, A. L., MERGENHAGEN, S. E., AND How-
(1974). ARD, R. J., Effect of virus infections on the function
71. MASON, J. 0., AND McLEAN, W. R., Infectious of the immune system, Annu. Rev. Microbiol.
hepatitis traced to consumption of raw oysters: An 24:525-538 (1970).
epidemiologic study, Am. J. Hyg. 75:90-111 (1962). 86. OLDSTONE, M. B. A., AND DIXON, F. J., Pathogenesis
72. McDONALD, J. D., AND ZUCKERMAN, A. J., ABO of chronic disease associated with persistent lym-
blood groups and acute respiratory disease, Br. phocytic chonomeningitis viral infection. I. Rela-
Med. J. 1:89--90 (1962). tionship of antibody production to disease in neon-
73. McMAHON, B., PUGH, T. F., AND IpSEN, J., Epidemio- atally infected mice, J. Exp. Med. 129:483-505 (1969).
logic Methods, Little, Brown, Boston, 1960. 87. OLSON, L. e., LEXOMBOON, U., SrrHISARN, P., AND
74. MCQUILLIN, J., GARDNER, P. S., AND MCGUCKIN, R., NoYES, H. E., The etiology of respiratory tract
Rapid diagnosis of influenza by immunofluorescent infections in a tropical country, Am. J. Epidemiol.
techniques, Lancet 2:690-695 (1970). 97:34-43 (1973).
75. MELNICK, J. L., A water-borne urban epidemic of 88. OSEASOHN, R., ADELSON, L., AND KATI, M., Clinical
hepatitis, in: Hepatitis Frontiers (F. W. HARTMAN et pathological study of 33 fetal cases of Asian influ-
al., eds.), Churchill, London, 1957. enza, N. Engl. J. Med. 260:509-518 (1959).
76. MIDDLETON, P. J., SZYMANSKI, M. T., ABBOTT, G. D., 89. PADGETT, B. L., AND WALKER, D. L., Prevalence of
BORTOLUSSI, R., AND HAMILTON, J. R., Orbivirus antibodies in human sera against J.e. virus, an
isolate from a case of progressive multifocal leu- cent staining of CSF leukocytes, Intervirology 1:127-
koencephalopathy, J. Infect. Dis. 127:467-470 (1973). 134 (1973).
90. PADGETI, B. L., WALKER, D. J., ZuRHEIN, G. M., 106. TAYLOR, I., AND KNOWLDEN, J., Principles of Epide-
ECKROADE, R. J., AND DESSEL, B. H., Cultivation of miology, Little, Brown, Boston, 1957.
papova-like virus from human brain with progres- 107. THOMPSON, W. H., AND EVANS, A. 5., California
sive multifocalleucoencephalopathy, Lancet 1:1257- virus studies in Wisconsin, Am. J. Epidemiol.
1260 (1971). 81:23(}-234 (1965).
91. PAUL, J. R., The story to be learned from blood 108. Top, F. H., AND WEHRLE, P. F. (eds.), Communicable
samples: Its value to the epidemiologist, J. Am. and Infectious Diseases, 7th ed., Mosby, St. Louis,
Med. Assoc. 175:601-605 (1961). 1972.
92. PAUL, J. R., Clinical Epidemiology, rev. ed., Univer- 109. University Health Physicians and PHLS Laborato-
sity of Chicago Press, Chicago, 1966. ries, A joint investigation: Inf~ctious mononucleo-
93. PAUL, J. R., AND WHITE, C. (eds.), Serological Epide- sis and its relationship to EB virus antibody, Br.
miology, Academic Press, New York, 1973. Med. J. 4:643-646 (1971).
94. PAUL, J. R., NIEDERMAN, J. c., PEARSON, R. J. c., 110. UNTERMOHLEN, V., AND ZABRISKIE, J. F., Sup-
AND FLOREY, DU V., A nationwide serum survey of pressed cellular immunity to measles antigen in
United States military recruits, 1962: General con- multiple-sclerosis patients, Lancet 2:1147-1148
siderations, Am. J. Hyg. 80:286-292 (1964). (1973).
95. PHILLIPS, P. E., AND CHRISTIAN, C. L., Myxovirus 111. URQUHARDT, G. E. D., AND STOTI, E. J., Rhinovire-
antibody increases in human connective tissue dis- mia, Br. Med. J. 4:28 (1970).
ease, Science 168:982-984 (1970). 112. VIROLAINER, M., ANDERSSON, L. c., LALLA, M., AND
96. RIVERS, T., Viruses and Koch's postulates, J. Bacte- VON ESSEN, R., T lymphocyte proliferation in mon-
riol. 33:1-12 (1937). onucleosis, Clin. Immunol. Immunopathol. 2:114-120
97. ROTIi:FELD, N. F., EVANS, A. 5., AND NIEDERMAN, J. (1973).
c., Clinical and laboratory aspects of raised virus 113. WIDELOCK, D., SCHAEFFER, M., AND MILLIAN, J.,
antibody titres in systemic lupus erythematosis, Surveillance of infectious disease by serologic meth-
Ann. Rheum. Dis. 32:238-246 (1973). ods, Am. J. Public Health 55:578-586 (1965).
98. SAWYER, R. N., EVANS, A. 5., NIEDERMAN, J. c., 114. WILSON, C. B., DIXON, F. J., EVANS, A. 5., AND
AND McCOLLUM, R. W., Prospective studies of a GLASSOCK, R. J., Anti-viral antibody responses in
group of Yale University freshman. I. Occurrence of patients with renal disease, Clin. Immunol. Immuno-
infectious mononucleosis, J. Infect. Dis. 123:263-270 pathol. 2:121-132 (1973).
(1971). 115. WHO Tech. Rep. Ser., Cell-Mediated Immunity and
99. SCHULMAN, J., Transmissibility as a separate genetic Resistance to Infection, No. 519, Geneva (1973).
attribute of influenza viruses, in: Aerobiology (I. H. 116. WHO Tech. Rep. Ser., Immunological and Hemato-
SILVER, ed.), Proceedings of the Third International logical Surveys, No. 181, Geneva (1959).
Symposium, Academic Press, New York, 1970. 117. WHO, The Work of the World Health Organization
100. SEVER, J. L., KURlZl(E, J. F., ALTER, M., SCHU- in 1972, Annual Report of the Director-General,
MACHER, G. A., GILKESON, M. P., ELLENBERG, J. H., WHO, Geneva (1973).
AND BRODY, J. A., Virus antibodies and multiple
sclerosis, Arch. Neurol. 24:489-494 (1971).
101. SHAW, K. V., DANIEL, R. W., AND WARSZAWSKI, R.
M., High prevalence of antibodies to BK virus, an 14. Suggested Reading
SV40-related papovavirus, in residents of Maryland,
J. Infect. Dis. 128:784-787 (1973). FENNER, F. J., AND 'WHITE, D.O., Medical Virology,
102. SHOPE, R. E., Swine influenza. I. Experimental Academic Press, New York, 1970.
transmission and pathology, J. Exp. Med. 54:349-359 Fox, J. P., HALL, C. E., AND ELVEBACK, L. R., Epidemiol-
(1931). ogy: Man and Disease, Collier-Macmillan, Ltd., Lon-
103. STANLEY, E. D., AND JACKSON, G. G., Viremia in don, 1970.
Asian influenza, Trans. Assoc. Am. Phys. 79:376-.-387 HOEPRICH, P. D. (ed.), Infectious Diseases, Harper and
(1966). Row, Hagerstown, Md., 1972.
104. STUART-HARRIS, C. H., Influenza and Other Virus McMAHON, B., PUGH, T. F., AND IPSEN, J., Epidemiologic
Infections of the Respiratory Tract, 2nd edition, Ed- Methods, Little, Brown, Boston, 1960.
ward Arnold, London, 1975. PAUL, J. R., Clinical Epidemiology, rev. ed., University of
105. TABER, L. H., ADAM, V., ELLIS, S. 5., MELNICK, J. Chicago Press, Chicago, 1966.
L., MIRKOVIC, R. R., AND Yow, M. D., Rapid diag- PAUL, J. R., AND WHITE, C. (eds.), Serological Epidemiol-
nosis of enterovirus meningitis by immunofluores- ogy, Academic Press, New York, 1973.
CHAPTER 2
Surveillance
and
Seroepidemiology
Alfred S. Evans
1. Introduction 2. Surveillance
Surveillance has been described as the systematic The traditional methods of reporting and sur-
collection of data pertaining to the occurrence of veillance are based on the occurrence of a case of
specific diseases, the analysis and interpretation of clinical disease or of a death from clinical disease.
these data, and the dissemination of consolidated They form the basis of public health control and
and processed information to contributors to the immunization programs throughout the world.
program and other interested persons.(57) The
principles have been well set forth by Langmuir
for the U.S. Center for Disease Control(41) and by 2.1 Historical Background
Raska(57) for the World Health Organization, and
were a major focus of discussion of the Twenty- The use of mortality and morbidity data as a
first World Health Assembly in 1968.(70) The tech- basis for public health action goes back for centu-
niques of surveillance have become a part of na- ries. The occurrence of the "Black Death" or pneu-
tional and international programs of disease con- monic plague in Europe about 1348 resulted in the
trol. This chapter will discuss the background and appointment of three guardians of public health
elements of traditional surveillance, the concept by the Venetian Republic to exclude ships with
and uses of serological epidemiology, and their , affected persons aboard. The detention of travelers
application to surveillance. from plague-infected areas for 40 days in Mar-
seilles (1377) and in Venice (1403) led to our
Alfred S. Evans . WHO Serum Reference Bank, .Sec- current concept of quarantine.
tion of International Epidemiology, Department of The term surveillance has been employed for
Epidemiology and Public Health, Yale University School years in the restrictive sense of follow-up of cases
of Medicine, New Haven, Connecticut of people who have had contact with plague or
33
34 Chapter 2 • Surveillance and Seroepidemiology
infectious syphilis patients to determine if disease pandemic. Influenza surveillance has continued at
developed within the limits of the incubation CDC in conjunction with the World Health Orga-
period. The dictionary defines the word in terms nization ever since and has provided critical data
of police surveillance as meaning to "watch or on the occurrence of influenza outbreaks through-
guard over a person, especially a suspected per- out the world.
son, a prisoner, or the like."(49) In public health The surveillance of hepatitis similarly followed
practice, the suspect is th~ disease. an epidemic in 1961 in which shellfish from con-
The principles of surveillance were first exem- taminated waters were identified as the source of
plified by William Farr, Superintendent of the an outbreak. Salmonella surveillance was initiated
Statistical Department of the General Registry in in 1962 following 18 hospital outbreaks. Many
London, in a series of classic letters on the causes other diseases were added to this list over time,
of death in England appearing from 1839-1870 and and now the CDC publishes special surveillance
through a collection of papers on "Vital Statistics" reports on about 20 categories of infectious dis-
published in 1885. The WHO Influenza Centers for ease. In Europe, Dr. Karel Raska was an enthusias-
recognition of influenza outbreaks and new viral tic supporter of the surveillance concept, initiated
strains were established in 1948 prior to the intro- both traditional and serological surveillance in his
duction and general use of the term. Formal devel- own country, Czechoslovakia, and promoted the
opment of the concept of surveillance is of more principles as Director, Division of Communicable
recent origin and was in response to national Disease, World Health Organization. A special
needs for disease surveillance or to major new unit called "Epidemiological Surveillance of Com-
epidemic problems. These needs involved the re- municable Diseases" was established in WHO by
quirement for a nationally centralized clearing- Dr. A. M.-M. Payne to coordinate and extend this
house of essential information in order to define program; three WHO Serum Reference Banks
the magnitude of the problem, to inform the which are currently concerned with serological
appropriate authorities on whom responsibility surveys and serological surveillance are under the
fell for public health control measures, and as a jurisdiction of this unit.* Currently only three
means of evaluating the effectiveness of such diseases are under International Sanitary Regula-
measures. Use of the term in the United States tion: plague, yellow fever, and smallpox; other
began in 1949 with the development of a modified important communicable diseases are kept under
program at the Communicable Disease Center surveillance. (58)
(CDC) called "Surveillance and Appraisal of Ma-
laria." In 1951 the concept was applied to the
residual smallpox cases in the United States. 2.2. Elements of Surveillance
Surveillance really became an established con· As applied to communicable diseases, surveil-
cept and public health practice when on April 28, lance has been defined as "the exercise of continu-
1955, the Surgeon General directed the establish- ous scrutiny of, and watchfulness over, the distri-
ment of a "Natural Poliomyelitis Surveillance Pro- bution and spread of infections and factors related
gram" in response to paralytic polio cases follow- thereto, of sufficient accuracy and completeness to
ing the use of Salk vaccine (the "Cutter incident"). be pertinent to effective control."(70) A wide vari-
This program was set up at CDC. The technique ety of sources of data on disease occurrence and on
became an effective tool in following trends in the the characteristics of the populations at risk con-
disease, in measuring the effectiveness of polio
immunization programs, and in detecting sus-
pected vaccine-associated cases. • The WHO Serum Reference Banks are located at the
Institute of Epidemiology and Microbiology, Prague,
On July 5, 1957, the Asian influenza surveillance
Czechoslovakia; Department of Epidemiology and Pub-
program was initiated and consisted of bimonthly lic Health, Yale University School of Medicine, New
reports from CDC to keep everyone informed of Haven, Connecticut; and the National Institutes of
the progress of the outbreak, including the public Health, Tokyo, Japan. A fourth established at the South
press. It served as an essential system tying to- African Institute of Medical Research, Johannesburg,
gether the massive national program to control the South Africa, is no longer an official WHO unit.
Chapter 2 • Surveillance and Seroepidemiology 35
Table 1. Elements of Surveillance occurrence of an excess of deaths from influenza

and pneumonia above the expected level has been
1. Mortality registration a sensitive index of influenza. It was first used by
2. Morbidity reporting William Farr in 1847 and has been consistently
3. Epidemic reporting reported in the United States since 1918. At pres-
4. Laboratory investigations ent, weekly data on deaths from influenza and
5. Individual case investigations
pneumonia in 122 cities are compared to the aver-
6. Epidemic field investigations
7. Surveys age number of deaths in the same week in the
8. Animal reservoir and vector distribution studies previous 5 yr. Current deaths that exceed this
9. Biologics and drug utilization "epidemic threshhold" can usually be attributed to
10. Knowledge of the population and environment epidemic influenza. Heat exhaustion and smog may
also increase deaths above this level, but such
events are geographically localized and can be
readily identified from environmental data. Unfor-
tribute to surveillance. These sources vary from tunately, the time required for reporting and ana-
country to country depending on the stage of lyzing these mortality data results in a delay of a
development and sophistication of the public month or so in recognition of an outbreak; this
health services, the quality and extent of labora- period is longer during Christmas or holiday pe-
tory facilities, the available funds, and the charac- riods for public health workers.
teristics of the indigenous diseases. The major 2.2.2. Morbidity Reporting. The reporting of
features have been summarized in ten "elements cases of specified communicable diseases is legally
of surveillance" by WHO (1968) and are listed in required in most countries and as many as 40
Table 1. entries may be involved. A simple and effective
2.2.1. Mortality Registration. Mortality registra- reporting system is the backbone of surveillance
tion is the oldest form of disease reporting and has for most health departments. The advantages are
the advantage of being legally required and of a that such reports are usually made by physicians
high order of completeness in most countries. As a who are best qualified to identify the diseases,
physician or other health practitioner is usually in laboratory confirmation may be available, and
attendance, there is a reasonable expectation that there is usually an organized system of regional or
most infectious diseases of sufficient severity to national tabulation and reporting. The disadvan-
cause death may exhibit enough clinical character- tages are (1) the absence of many viral diseases
istics to permit diagnosis. The possibility of an from the required list; (2) the notorious underre-
autopsy may also contribute to the accuracy of porting of the occurrence of required diseases be-
identification of the disease process. On the other cause of failure of physicians to notify the public
hand, some deaths such as those from coronary health authority due to lack of motivation, of
artery disease may be sudden and unattended by a secretarial help, or of time; (3) the uncertainty of
physician; multiple causes of death may be in- diagnosis (especially without laboratory confirma-
volved and the one of most public health signifi- tion)-a major issue for many viral infections; (4)
cance may be lost in the order of causation re- the variability of reporting efficiency from one
corded on the death certificate. There is often a time period to another, being in general highest
long delay in the tabulation and publication of during epidemics.
mortality data; autopsy information may not be 2.2.3. Epidemic Reporting. The recognition and
added to amend information on the original death identification of epidemic viral diseases are com-
certificate. In general, mortality data reflect inci- monly more accurate than individual reports be-
dence only when there is some relatively constant cause public health officials and laboratory facili-
ratio between deaths and cases. With the excep- ties are usually involved. This is true of outbreaks
tion of rabies, Lassa fever, and certain hemor- of yellow fever, influenza, rubella, hepatitis, vireV
rhagic fevers, most viral diseases are not fatal, so exanthems, and certain arbovirus infections: Un-
that mortality data have limited usefulness as a fortunately, this may not always be the case,
barometer of disease occurrence. However, the particularly if the viral agent produces primarily
mild or inapparent infections, or if the outbreak special importance is the follow-up of persons
occurs in areas with, poor medical care or inade- returning to their own country from areas where
quate public health and laboratory facilities. Unre- these infections are known to occur. This is done
cognized epidemics of dengue involving thou- in the United States through an alert card issued to
sands of people have taken place under such incoming travelers from foreign countries which
circumstances. Sometimes outbreaks of diseases requires notification and investigation of any ill-
such as poliomyelitis, hemorrhagic fevers, and ness developing within a defined period after
influenza may be recognized by local health au- arrival (currently 6 wk). Since the discontinuance
thorities but not reported to WHO because of fear of the requirement for routine smallpox vaccina-
of the economic impact of this knowledge on tion for U.S. travelers, the surveillance of persons
tourist or export trade. coming from infected areas is of high importance.
2.2.4. Laboratory Investigations. Laboratory This must be combined with immediate laboratory
identification of the causative agent is an almost confirmation of suspected cases through the Cen-
absolute requirement for the etiological diagnosis ter for Disease Control and the identification and
of individual cases and for most epidemics of viral immunization of all contacts if the diagnosis is
diseases; the exceptions are poliomyelitis and cer- established.
tain viral exanthems in which the clinical features 2.2.6. Epidemic Field Investigations. When
are characteristic enough to permit diagnosis. So- there is an increase in the number of cases or
phisticated laboratory facilities and experienced deaths from a disease of public health significance,
personnel are therefore needed for the isolation an epidemic team must be dispatched to make
and/or serological identification of the majority of further study. The team should include an epide-
viral infections. These may exist in the national or miologist and a virologist, with appropriate
regional public health laboratories, in specialized equipment for the collection and transportation of
virus diagnostic institutes, or in university set- specimens. These teams are usually composed of
tings. WHO has established a broad network of experts from regional or national health services
regional, national, and international reference lab- which operate in support of local health officials.
oratories for specific viral infections to assist in In the United States, the Epidemic Intelligence
this task. These include laboratories for influenza, Service and Laboratory Division of the Center for
other viral respiratory infections, arboviruses, and Disease Control in Atlanta, Georgia, fulfill this role
enteroviruses, as well as a group of about 15 other on the request of state health departments. More
collaborating virus diagnostic laboratories around routine outbreaks are handled by state or munici-
the world. A few WHO-supported multipurpose pal health departments, often assisted by labora-
viral diagnostic facilities in key areas of the world tory personnel. There is increasing need for better
which are otherwise devoid of such laboratories integration and cooperation between epidemiolo-
are also being established. The need for trained gists and public health laboratory personnel in this
personnel, special equipment, standardized anti- task. (14) The establishment of an Epidemiological
gens and antisera, protection against laboratory Investigation Unit. in affiliation with each public
infections, good water, reliable refrigeration, and health laboratory should be promoted not only for
proper sterilizing equipment makes virallaborato- epidemic analysis but also for the evaluation of the
ries expensive and difficult to maintain without need and effectiveness of immunization programs
this type of support. as well as day-to-day surveillance work involving
2.2.5. Individual Case' Investigations. The oc- both epidemiological and laboratory data. The
Cl,lrrence of a disease of public health importance public health service in England has created such a
in an area previously free of the disease or where unit(1Ol and it has been proposed for developing
control measures have been established demands countries as well. (12,15)
rapid and intensive investigation. This includes 2.2.7. Surveys. Many types of surveys of infec-
..viral infections such as smallpox, yellow fever, tious disease are used in public health work.
certain types of viral encephalitis, the hemorrhagic These may use epidemiological markers to identify
fevers, rabies (either in humans or in a new certain diseases; such markers include splenomeg-
animal species), and paralytic poliomyelitis. Of aly or positive blood smears for malaria, scars for
smallpox vaccination, and positive skin tests for 2.3 Other Surveillance Methods
tuberculosis. Immunization histories, personal in-
Additional sources of data may be utilized in
terviews, or clinic records may also be used to
supplementing routine surveillance techniques or
assess the vaccination status of the population. For
in evaluating special disease situations. Some of
many viral diseases, major reliance must be placed
these are listed in Table 2.
on antibody surveys, or, in the case of hepatitis,
2.3.1. Hospital and Medical Care. The existence
tests for hepatitis B antigen in blood specimens.
of national health plans in many countries and the
The use and application of serological surveys to
extension of prepaid health insurance schemes in
these ends are discussed in detail in Section 3 of
other areas make computerized accounting neces-
this chapter.
sary. This provides the opportunity for including
2.2.8. Animal Reservoir and Vector Distribu-
morbidity and mortality information in the data
tion Studies. Surveillance of human diseases ac-
system. Large-scale health plans such as the Kai-
quired from animals or diseases in which the
s~r-Permanente Plan in California, the Coopera-
vector is arthropod borne requires the collection of
tIve Group Health Insurance Plan in Seattle, and
data on the zoonoses and the presence of appro-
the Health Insurance Plan (HIP) of greater New
priate vectors in the area. Examples for which such
York City are now being utilized for these pur-
data are needed are yellow fever and other arthro-
poses. Centralized data-processing centers for hos-
pod-borne diseases, especially dengue and the
pitals such as the Professional Activities Services
hemorrhagic fevers, rabies, and perhaps monkey
(PAS! operating out of Ann Arbor, Michigan,
pox as a potential source of human smallpox. The
provIde another opportunity; this system, which
emergence of a group of unusual but rather lethal
c?vers some 200 hospitals and a hospital popula-
diseases such as Lassa fever and the Argentinian
tIon of over 2 million persons, is based on a
and Bolivian hemorrhagic fevers involves study of
hospital discharge sheet that incorporates much
the rodents which are suspected as the reservoirs.
useful information on diagnoses, surgical proce-
The surveillance of these infections requires a
dures, complication, length of stay, laboratory
special investigation team and/or close cooperation
data, etc.
among existing epidemiological, veterinary, and
2.3.2. Panels of Cooperating Physicians. In
entomological services.
some areas, data networks have been established
2.2.9. Biologics and Drug Utilization. The es-
by groups of cooperating physicians to record
tablishment of an effective system of determining
morbidity data and analyses of their medical care
the scale and utilization of viral vaccines and
programs. For example, the National Disease and
immune globulins may not only provide a lead to
Therapeutic Index(47) is an outcome of one such
t~e immunization status of an area but might also
oper.ation tha~ provides analyses of the frequency
gIve supplementary information to permit the rec-
of dIfferent dIagnoses in over 1500 private physi-
ognition of an outbreak or of other special prob-
cians' offices in randomly selected parts of the
lems.
United States.
2.2.10. Knowledge of the Population and Envi-
2.3.3. Public Health Laboratory Reports. The
~on.ment. The denominator used in determining
s~ate and. municipal public health laboratories pro-
incIdence and prevalence rates is the population at
VIde a WIde range of diagnostic facilities for com-
risk to the disease in the area from which the cases
are reported. Necessary information includes age,
~ex, ethnic, economic, and other demographic data
In order to interpret disease trends. Other back- Table 2. Other Sources of Surveillance Data
ground information often needed relates to sani-
~ary conditions, food and water supplies, housing, 1. Hospital and medical care statistics
Insects, nutrition, and cultural habits. The accessi- 2. Panels of cooperating physicians
3. Public health laboratory reports
bility, utilization, and quality of medical care must
4. Absenteeism from work or school
be known in order to evaluate the potential effi- 5. Telephone and household surveys
cacy of case reporting, mortality data, and other 6. Newspaper and newsbroadcasting reports
indices of the health of the population.
municable diseases. Backed by the fine laborato- (6) the person answering must be willing to coop-
ries of the USPHS Center for Disease Control in erate in the survey.
Atlanta, Georgia, these represent the predominant Household surveys by skilled interviewers form
diagnostic services in viral infections in the coun- the basis of the U.S. National Health Survey, in
try. They are supplemented by virus research and which a carefully selected random sample consist-
diagnostic laboratories in universities and a few ing of about 55,000 families is the source of data.
large hospitals. These usually operate in close An extensive series of morbidity and health analy-
communication with the public health laboratories ses and much useful surveillance information have
of the area. The consolidation and utilization of resulted from these repeated surveys. They are not
information from these various sources represent helpful in providing immediate surveillance of
the best ongoing method for surveillance of viral common diseases but reveal long-term trends of
infections. This is especially true for viral diseases importance.
since many are not reportable and because accu- 2.3.6. Newspaper and Newsbroadcasting Re-
rate diagnoses are often dependent on laboratory ports. The news media often report outbreaks of
identification of the viral agent. The use of sera disease before they have been announced by the
sent to such laboratories for multipurpose viral slower process of most health-reporting mecha-
testing will be discussed in Section 3.5.3 of this nisms. Furthermore, there may be epidemics of
chapter. nonreportable diseases picked up by an active
2.3.4. Absenteeism from Work or School. A news surveillance system that may be missed or
sensitive barometer of any major epidemic in never officially reported to public health authori-
children is an increase in school absentee rates; in ties. A systematic clipping and recording service
adults, it is a jump in absenteeism in industry. As from local news services may thus provide impor-
an absence of any duration in schools may be tant leads to an alert epidemiological surveillance
investigated by the school or public health nurse program. The earliest reports of influenza outbreak
and any significant loss of time from work may in Hong Kong, or of Lassa fever in Africa, or of an
require a physician's certificate of illness, addi- outbreak of hemorrhagic fever in South America
tional data on the nature and duration of the may be found on the pages of newspapers with
condition may be obtained. The active cooperation extensive coverage such as the New York Times.
of a few geographically representative schools and
key industries may provide public health officials
with valuable leads on epidemic illness.
2.4. Surveillance in Research Studies
2.3.5. Telephone and Household Surveys. The
Center for Disease Control has utilized telephone The methods thus far discussed contribute di~
surveys to verify the presence and the extent of an rectly to official public health agencies. In re-
epidemic such as influenza. A defined subsample search, specialized surveillance systems have been
selected from the local telephone book is sequen- established for various viruses or groups of vi-
tially called to determine if illness exists in the ruses. The Virus Watch Programs established by
household. Research studies of the occurrence of Fox and his associates in New York City and then
minor illnesses such as acute respiratory infections in Seattle, Washington, (11,30) are excellent exam-
in Tecumseh, Michigan, have used telephone ples of this method, which involves systematic
interviews as the basis of data collection. (46) The sampling of a population of families for enteric
limitations of this method are obvious: (1) the and respiratory viruses, antibody testing, and
family must have a phone; (2) someone must be at analyses of coincident illness patterns. An earlier
home to answer it; (3) the person answering must effort of special surveillance of this type was the
be aware of illnesses in other members of the extensive analyses of common illnesses in a group
family; (4) the disease involved must be character- of Cleveland families carried out by Dingle et al.
istic enough to permit recognition by a layman; (5) (13) Special population groups such as Tecumseh
the presence of illness can be inquired about over Michigan, used for analyses of chronic disease are
only short periods because of imperfect memory; also being utilized for studies of viral infections,
Table 3. Publications Dealing with Surveillance Data a
1. Worldwide
WHO Weekly Epidemiological Record
WHO Epidemiological and Vital Statisticals Report (monthly)
WHO Annual, Vol. II: Infectious Diseases; Cases, Deaths, and Vaccinations
2. North America
PAHO-Weekly Epidemiological Report
PAHO-Quarterly Information Bulletin, Pan American Zoonoses Center
P AHO-Annual Report of the Director
3. United States (USPHS)
Mobidity-Mortality Weekly Report, CDC, U.S. Department of Health, Education, and Welfare
Annual Supplement, Reported Incidence of Notifiable Diseases in the United States, CDC, U.S. Department of
Health, Education, and Welfare
Special Surveillance Reports (including the following viral diseases) from CDC, U.S. Department of Health,
Education, and Welfare
Hepatitis
Infectious mononucleosis
Measles
Neurological viral diseases (aseptic meningitis, encephalitis, enteroviruses, poliomyelitis)
Rabies
Rubella
Smallpox-vaccinia
a From National Health Survey: Health Statistics Publications, National Center for Vital Statistics.
especially acute respiratory disease. (46) In chil- 2.6. Predictive Surveillance

dren, the massive long-term study of viral infec-
tions in Junior Village carried out by Bell et al. (5) The ability to predict the occurrence of infection
at the National Institutes of Health has yielded or of an outbreak is theoretically possible if there
sequential data on the behavior of common vi- are adequate epidemiological data on hand. This
ruses in such a closed setting. has been tried with variable success for influenza
epidemics; here the problem is confounded by our
sparse knowledge of the factors governing the
emergence of new antigenic variants of influenza
2.5. Publications on Surveillance virus. For infections in which quite precise re-
quirements exist, such as an insect vector, inter-
The dissemination of data derived from surveil- mediate hosts, animal reservoirs, or special ter-
lance programs is an essential requirement for rain, the potential existence of the infection in
public health action. Table 3 lists the common certain geographic areas can be presumed and its
publications reporting current and long-term probable absence in other areas can be predicted.
trends in infectious diseases. The most current and This approach has special interest to the armed
useful are the WHO Weekly Epidemiological Re- forces because the introduction of susceptible mil-
cord and the Morbidity-Mortality Weekly Report itary units into areas in which little health data are
from U.S. Public Health Service. available poses hazardous conditions for the men
The WHO Technical Report Series provides up- and for the success of the mission. In this connec-
to-date information on various viral infections as tion, three infections have been analyzed in detail
well as other diseases, prepared by expert commit- by Baker(31 employing computer analysis of exist-
tees. ing epidemiological and ecological infor~ation:
schistosomiasis, malaria, and leptospirosis. The tious diseases and to study the behavior of
name "infectious disease prognostication" has old and newly recognized microbiological
been applied to this methodology. Similar predic- agents in different population groups.
tions might be made for viral infections such as
Serological surveys may be carried out to deter-
the arboviruses, which require insect vectors with
mine the patterns of a single agent such as poliom-
well-defined ecological features. Serological sur-
yelitis but are more commonly "multipurpose" in
veys can also provide valuable data on the poten-
tial danger of certain infections; these may be nature. This section will consider the history,
methods, and uses of seroepidemiology with par-
especially useful in areas in which health reporting
ticular reference to its application as an important
is poor, or in the case of a virus which produces
adjunct to traditional methods of surveillance of
largely subclinical infections. For example, the
presence in persons of all ages and especially infectious diseases. WHO has sponsored two ex-
pert committee reports on the subject<71.72) and a
young children of antibody to viruses such as
recent book has appeared. (56)
poliomyelitis, hepatitis B, EBV, or dengue indi-
cates the continuing activity of that agent in that Just as epidemiology is concerned with the oc-
currence and distribution of clinical cases in differ-
environment, irrespective of the apparent absence
of clinical illness or of reported cases due to these ent populations, so serological epidemiology, as
viruses. If soldiers, tourists, Peace Corps volun- noted above, is concerned with the occurrence and
teers, or other visitors who lack antibody to the distribution of various components of the blood
agent intermix with the local population and/or are that indicate past or current infection, that are
exposed to the local environment and population, biochemical markers for certain chronic diseases
infection may result. Such infection is often ac- or that reveal the genetic attributes of variou~
companied by a higher risk of clinical disease than population groups. The epidemiological character-
in the indigenous population because infection of istics are detected in the laboratory rather than at
older children and adults results in more severe the bedside. The name "serological surveys" has
host response than infection very early in life. been used interchangeably with "immunological
surveys." No satisfactory expression has been
found to indicate the whole spectrum of compo-
nents in the red cells, white cells, plasma, and
3. Seroepidemiology serum which may be measured in population
surveys.
3.1. Introduction
Seroepidemiology is the systematic collection 3.2. Historical Background
and testing of blood samples from a target popula-
The introduction of serological tests for the diag-
tion, or a representative sample thereof, to identify
nosis of disease provided the basis for later serol-
current and past experiences with infectious di-
ogical surveys. As early as 1916, the Wassermann
seases by means of antibody and antigen tests.
test was applied routinely to patients attending a
Additional uses are to seek biochemical markers
prenatal clinic at Johns Hopkins Hospital by Wil-
for various chronic diseases, to measure certain l"lams, (74) b u t thOIS was more 0 f a case-finding
nutritional components, and to characterize the
procedure than an attempt to delineate disease
genetic aspects of red cells, leukocytes, and serum
patterns. In 1930, the development of a neutraliza-
proteins. In infectious diseases, serological epide-
tion test for poliomyelitis led Aycock and Kra-
miology contributes to two broad and overlapping
mer(2) to use the procedure to define the immun-
areas:
ity pattern of a given population; this is a
1. Serological surveillance to provide supple- landmark in the history of serum surveys. In 1932,
mentary data as the basis for public health Soper and his associates(65) mapped out the oc-
planning and immunization programs. currence of yellow fever in Brazil by antibody
2. In research, as an epidemiological tool to surveys under the auspices of the Rockefeller
investigate the risk and occurrence of infec- Foundation, and this technique has been widely
used subsequently in studying arbovirus infec- Table 4. Sources of Sera for Serological
tions. Antibody surveys for influenza also date Surveillance
back to the mid-1930s. The discovery of swine
influenza virus by Shope in 1931(63) and of human 1. Planned serum survey from target populations
2. Entrance and periodic examinations of different
influenza virus by Smith, Andrewes, and Laidlaw
groups
in 1933(66) was rapidly followed by population
a. Military
studies to measure antibody to these viruses in b. Industry
persons of different age groupsY·8.31J c. Health clinics
The Yale Poliomyelitis Study Unit under Dr. 3. Blood donors in Red Cross and similar programs
John R. Paul employed serological survey tech- 4. Public health laboratories
niques as long ago as 1935/ 55 ) and his analysis a. Serological tests for syphilis (premarital, etc.)
with Riordan of the poliomyelitis pattern in Alas- b. Other immunological and diagnostic tests
kan Eskimos is a classic study.(54) He became one 5. Hospitals
of the foremost users and promoters of the concept a. Entry tests for blood chemistries or syphilis
b. Diagnostic tests for infectious disease
of serological epidemiology, and through his work
c. Blood banks
and writing(50.56) the utilization of this technique
d. Prenatal clinics
in public health practice and research studies has
become a reality. The World Health Organization
also took note of this development in 1960 and
established three WHO Serum Reference Banks to
practice and promote seroepidemiology. These Because of the cost of collecting sera from a
were located at Yale University, New Haven, Con- properly selected sample of a population, other
necticut, initially under Dr. Paul and now under sources of sera have been utilized. These have
Dr. Alfred Evans, at the Institute of Epidemiology, included utilization of blood specimens collected
Prague, Czechoslovakia, initially under Dr. Kiirt~l for other purposes, especially for routine tests
Raska, and the Poliomyelitis Research Founda- during physical examinations for the armed forces
tion, Johannesburg, South Africa, under Dr. James or industry, or during an outpatient visit or ad-
Gear. An additional bank was established in 1971 mission to a hospital. Sera sent to a public health
at the National Institutes of Health in Japan, under laboratory for serological tests for syphilis, viral
Dr. R. Kono. The activities and principles of these diagnosis, or other diagnostic tests have also been
banks have been reviewed in two WHO Technical employed. These collections of sera may not be
Reports,(7!·72) in a book/ 56 ) and in several other representative of the age, sex, and geographic
publications.05.51.52,72) distribution of the entire population; the nature of
the biases introduced must be recognized and
evaluated. However, they are economical to obtain
and sometimes may reveal important information
3.3. Methodology
on the presence or absence of a certain virus in
3.3.1. Sources of Sera. A list of several sources the community or of the occurrence of a recent
of sera for survey analysis is given in Table 4. By outbreak. For most multipurpose surveys, a rep-
far the most important method is the collection of resentative sample carefully selected from the
blood specimens and of health data from a care- community at risk is important. A broad
fully selected sample from the target popUlation at representation of all younger age groups is essen-
risk. To achieve the highest yield from this type of tial if the sera are to be used in evaluating the
study, serological surveys should be multipurpose immunization needs of the population or in meas-
in nature and include measurement of antibodies uring the impact of a vaccination program. As a
to all prevalent infections. The sera collected in rough guide for multipurpose surveys, the reports
household surveys in rural areas by WHO for the of WHO have suggested a sample of 30G--600
evaluation of the effectiveness of penicillin in mass persons divided into 25 sera per age group (e.g.,
eradication programs for yaws have also been an single-year groups under 5 yr, 5-yr groups up to 19
important source for multipurpose testing.(35) yr, and broader groups thereafter).(71·72)
The blood must be collected and separated un- and developing countries, many of these ingredi-
der sterile conditions. Aliquots of 0.5 ml each are ents for surveillance may be missing or inade-
used by WHO and CDC serum banks and are very quate, and even in highly developed countries the
useful for micro titer tests; several replicates of the reporting of communicable diseases is less than
entire collection may be prepared at the time of satisfactory and involves much variability. The use
aliquoting so they can be shipped to other labora- of serological surveys is an important means of
tories for testing. Sera are usually stored at - 20"C, supplementing morbidity information. Because
often in a commercial warehouse. Temperatures of many viral infections may be clinically mild or
-70"C are best but are expensive to maintain. inapparent, may require laboratory confirmation
3.3.2. Laboratory Tests. The antibody tests most for accurate diagnosis of even overt cases, and
suitable to serological surveys of specific viruses may not be on the list of reportable diseases, the
are detailed in each chapter of this book. The serological survey technique is an important tool:
criteria for a satisfactory test include simplicity, it reveals total infection rates (apparent and inap-
sensitivity, specificity, reliability, ability to detect parent), both currently and in the past. Selection
long-lasting antibody, minimal interference from of tests that reflect antibody of long duration
nonspecific inhibitors, the availability of satisfac- permits measurement of the cumulative experience
tory reagents, and the safety of the test for the of the population tested with the disease in ques-
laboratory technicianY6,72) The micro titer proce- tion; selection of a test based on short-lived anti-
dure developed by Takatsy in 1950 in Hungary body allows identification of a recent epidemic or
and popularized in this country by Sever in infection. Testing of two sera spaced in time
1962(62) has become the standard method in serol- permits measurement of the incidence of infection.
ogical survey laboratories. It is adaptable to a The disadvantages of seroepidemiology are the
wide variety of antibody determinations, it re- cost and effort involved in the selection and bleed-
quires a minimal amount of sera (usually 0,1 ml) ing of the target population and in the collection
and other ingredients, and large numbers of sera and analysis of data, and the need and cost of
can be efficiently tested, Several automated meth- laboratory facilities equipped to carry out the tests.
ods of dilution and' of adding various reagents There must also be a satisfactory means of measur-
have been introduced to enhance the speed of ing antibody for the particular virus to be studied,
testing even further. (72) and the method of carrying it out must be simple
enough to allow performance on a large-scale ba-
sis. Because aliquots of sera from a collection can
3.4. Advantages and Limitations be shipped long distances in the frozen state to a
The traditional methods of surveillance are number of specialized reference laboratories for
based on cases of clinical disease reported by testing, the work can be divided between partici-
physicians or identified by some survey tech- pating laboratories. The establishment and fund-
nique. The sequence usually involved includes the ing of more WHO, national, or regionallaborato-
requirements listed in Table 5. In underdeveloped ries for multipurpose testing may come in the
future. Currently the funds for seroepidemiologi-
cal surveys are grossly inadequate.
Table 5. Requirements for Surveillance Based on
Clinical Cases
3.5. Uses of Seroepidemiology
1. Occurrence of clinical illness The uses discussed below encompass both pub-
2. Sufficient severity t9 seek medical care lic health and research applications, and there is
3. Availability of medical care some overlapping in the various categories. The
4. Capability of physicians to diagnose illness utilization of serological techniques in the surveil-
5. Laboratory support of diagnosis
lance of disease (serological surveillance) is clear in
6. Reporting of disease to health department
many of the "uses" described.
7. Collection and analysis of data by health
department 3.5.1. Prevalence. The presence in the serum of
one or more antibodies to specific infectious
BARBADOS SURVEY 1972
ANTIBODY TEST
TESTED USED
EB VIRUS FA
INFLUENZA A HI
B
POLIO 1 NEUT
2
CYTOMEGALO CF
TETANUS IHA 100

Fig. 1. Results of serologic tests in Barba-
dos, West Indies (22) FA = fluorescent anti- DIPHTHERIA IHA 100
body; HI = hemagglutination inhibition; RUBELLA HI 547
Neut. = neutralization; CF = complement
fixation; IHA = indirect hemagglutination; DENGUE CF 336
ITA = fluorescent treponemal antibody ab- SYPHILIS VORL 1021 B.3
sorption.
agents at the time of collection is called antibody disease, serological prevalence data reflect total
prevalence. The antibody prevalence rate is the infection rates, representing both clinical and sub-
number of persons whose sera contain a particular clinical (or asymptomatic) infections.
antibody in the lowest dilution tested divided by Multipurpose antibody surveys have been car-
the total number of persons examined. Unlike ried out in a number of countries under World
"case prevalence," which indicates the existence of Health Organization auspices as an extension of
disease at the time of the survey, antibody preval- evaluation surveys for penicillin campaigns to
ence reflects the cumulative experience, past and eradicate yaws, as noted above. They have been
present, with an infectious agent. The prevalence largely in rural areas of Nigeria, Toga, Afghani-
rate is a function both of prior and current infec- stan, the Philippines, Samoa, Thailand, and Yugo-
tion and of the durability of the antibody pro- slavia. (;l51 Unfortunately, the results of most of
duced. these surveys have not been published. Published
Many antibodies such as the neutralization anti- multipurpose surveys include those of military
body for poliomyelitis or yellow fever virus and recruits in the United States/ 5:11 Brazil, (27) Col-
the hemagglutination inhibition antibody for in- ombia,i201 and Argentina. (21) There is an initial
fluenza, parainfluenza, rubella, measles, or arbov- report of a survey of Kenya(;121 and a recent health
iruses last for years, perhaps a lifetime. Thus the and serological survey of Barbados.(22) In the
cumulative experience of a population can be Barbados study, a 10% household sample was
measured and infection acquired in childhood can randomly selected from a middle- and lower-soci-
be detected in persons of middle or perhaps even oeconomic-level community of 10,000 persons in
old age. Some dropoff in antibody titer (sometimes Bridgetown. The results are summarized in Fig. 1
below the lowest detectable levels) may occur in and will be discussed to indicate the type of
older age groups after a childhood infection. Simi- information that can be derived from this type of
larly, the antibody to EB virus measured by the study. Antibodies to EB virus and cytomegalovirus
indirect immunofluorescent test has been found to were acquired early in life, and 95 and 79%
be of long duration; even complement-fixing anti- respectively, of those tested were seropositive.
bodies to cytomegalovirus, herpes viruses, or den- This means that clinical illness due to these viruses
gue virus have been found to persist for years would be rare because they cause mild and inap-
following infection. It should also be emphasized parent infection when acquired by young age
that, unlike prevalence data for clinical infectious groups. In contrast, rubella antibody, while pres-
Table 6. Acute Respiratory Infections and ratory infections, rubella, and infectious mononu-
Clinical Illness in 281 Yale Freshmen During the cleosis. (24.60) During the year, epidemics of
First Academic Yeara influenza and rubella occurred. The serological
infection rate for influenza was 45.2%, with 59%
Percent with serological evidence
of infected persons exhibiting clinical illness. For
of viral infection
Category rubella, the comparable figures were 19.1% in-
Yes No Total fected, of whom 39% had a clinical illness with
rash. No clinical rubella cases occurred in persons
With clinical illness 24.9 33.1 58.0 with titers 1:64 or higher. The total picture for
Without clinical illness 22.4 19.6 42.0 clinical and subclinical respiratory infections is
illustrated in Table 6. With EB virus an infection
47.3 52.7 100.0 rate of 13.1% occurred among the 49% lacking
antibody; this was clinically manifested as definite
a Adapted from Evans et al. (24)
infectious mononucleosis in 73.4% of those in-
fected. (60)
Other prospective serological studies have been
ent in 41.4% of the females, was essentially absent made of respiratory infections, rubella, EBV
from children under 11 yr old. This indicates that CMV, and other viral infections in a variety of
there had been no rubella infection for the pre- settings. They offer the advantage of (1) defining
vious 10 yr and that a female population was total infection rates, (2) identifying risk factors,
entering childbearing age without any protection and (3) relating infection rates to prior antibody
against rubella. On this basis, an active rubella levels. They are especially useful in defining the
immunization program of girls of 12 and under risk in pregnant women of cytomegalovirus and
has been initiated. A similar age pattern was seen rubella infections and the risk in the infected fetus
for all three types of dengue antibody: it was of subsequent congenital malformations. They
absent in persons under age 25, but antibody have been used to portray the infection pattern in
prevalence rose rapidly after this to reach levels of military recruits during training or in college stu-
50-60%. This suggested that dengue virus had not dents during various years. The level of antibody
been introduced in the past 25 yr and/or that in the first serum sample which protects against
mosquito and other control measures had been reinfection and/or clinical illness over the period
effective. Tests for poliomyelitis revealed low or until the next serum specimen is drawn has been
absent antibody levels in some children despite an used to evaluate the quality and duration of both
active immunization program. The information natural and vaccine-induced antibody to influenza
obtained on the patterns of susceptibility and and rubella. (24.29.37.38)
immunity to these viral infections could not have 3.5.3. Diagnostic Serology. Sera sent to large
been obtained by ordinary surveillance methods hospitals or public health laboratories for various
based on the reporting of clinical cases. tests can be frozen away for later antibody testing
3.5.2. Incidence. The appearance of antibody to against other antigens. The specimens must be
a virus in the second of two sequentially collected adequate in amount and free of bacterial contami-
specimens indicates infection with that agent nation. Specimens sent for viral antibody tests
somewhere between the two times of collection. A usually fulfill these criteria and are accompanied
fourfold or greater rise in antibody titer over a by age, sex, address, and clinical data concerning
preexisting level indicates reinfection with that the patient. There are many uses for this type of
agent. If surveillance of clinical illness can also be collection. All sera coming from patients with
maintained between serum collections, then the central nervous system or respiratory infections or
ratio of apparent (i.e., clinical) to inapparent (i.e., the exanthems can be tested at the time of receipt,
subclinical) infections can be ascertained. An ex- or later, against a battery of viral antigens in order
ample of this is a study in which a group of Yale to reveal the "etiological pie" involved in the
college students were followed clinically and serol- causation of the syndromes. The later discovery of
ogically during their freshman year for acute respi- a new agent involved in one of these conditions
permits a retrospective assessment of its impor- 3.5.4. Evaluation of Immunization Programs.

tance using sera previously collected and stored. Serological surveys should play an increasing role
An example of this was the evaluation of the in immunization programs because of the inade-
importance of California virus in the causation of quacy and imprecision of traditional surveillance
infections of the central nervous system by testing techniques in determining the need for and the
of all sera received in a state public health labora- effectiveness of a given vaccine. Currently, our
tory for this syndrome. In Wisconsin, 5.7% of 351 knowledge of the utilization of a vaccine depends
sera received in the state laboratory over the pe- on sales records of pharmaceutical houses, clinic
riod 1961-1964 revealed evidence of this infec- and physicians' data, and special interview sur-
tion(68); in Minnesota, 4.1% of 1617 retrospec- veys. In the United States, a household interview
tively tested sera contained this antibody.(4) A on immunization utilization is conducted as part
second and related application is the determina- of the national census in the fall of each year; it is
tion of the clinical spectrum associated with a based on about 35,000 households. Problems of
newly discovered virus; this is accomplished by poor memory, and of the difficulty in identifica-
testing stored sera from patients with a variety of tion of the actual immunizations given, and ques-
clinical syndromes and looking for evidence of tions relating to absentee members at the time of
infection with the new agent. the interview pose limitations to this approach.
A third application for sera stored over time is The effectiveness of an immunization program
the measurement of secular trends or antigenic is traditionally judged on the basis of clinical cases
shifts in viruses over time. This is especially useful or epidemic behavior. A program is regarded as
in relation to influenza viruses. A fourth use, effective when cases decrease or epidemics do not
employing freshly received sera for VDRL or other occur. This is a negative type of information in the
tests, is the search for influenza antibody patterns sense that, while true protection may have re-
which may reveal the beginning of an outbreak or sulted, it is also possible that the decrease in
a change in the antigen composition of currently clinical cases is due to poor reporting or that
circulating strains; this has been used by Wide- insufficient time has elapsed for another epidemic
lock(73) at the public health laboratories of New to have occurred.
York City. Comparison of the geometric mean The uses of serological epidemiology in immu-
antibody titer to influenza sera from persons in the nization programs are summarized in Table 7.
acute phase of an unidentified respiratory illness Much of this information could be obtained in no
with the titer in others convalescing from a similar other way. Serological surveillance is of particular
illness may permit early identification of an out- importance for the new epidemiological settings
break without the wait for serial samples from the created by substituting vaccine immunity for nat-
same persons. ural immunity as in poliomyelitis, measles, and
Table 7. Uses of Seroepidemiology in Immunization Programs
1. Cross-sectional surveys to determine the need for immunization programs

a. In different age groups
b. In different geographic areas
c. In different socioeconomic classes
2. Follow-up measurements of immunized persons to determine
a. The percent responding by antibody production
b. The quality and height of the antibody response
c. The duration of antibody
d. The level of protection afforded against clinical disease and asymptomatic reinfection
e. The degree of spread of live vaccines to exposed ana susceptible contacts.
3. Periodic serological surveillance to identify groups not receiving vaccines or who have inadequate antibody
responses
Table 8. Protocol for Serological Approach to Agents in Search of Disease
1. Develop serological test for mass screening

2. Test representative population groups
3. Test paired sera from infectious diseases
4. If associated syndrome is identified
a. Test for frequency of association with the agent
b. Exclude presence of agent in other infections
c. Determine frequency in close contacts
5. Carry out prospective study of susceptible persons at high risk to infection
a. For incidence of infection
b. For clinical/subclinical ratio
c. For determining clinical spectrum
d. For pattern of incidence related to antibody level
rubella, and to a lesser extent in mumps and known of the disease, if any, with which it is
influenza. Patterns of susceptibility and immunity associated. The use of seroepidemiological tech-
will now vary from place to place, from age group niques to identify possible associations is one
to age group, and in various socioeconomic set- important research application of the method. The
tings, depending on the immunization program discovery of EB virus and that of hepatitis B
instituted by the health department and the activi- antigen are examples. The sequence in developing
ties of phYSicians and clinics rather than on the an association with illness is outlined in Table 8.
inherent epidemiological characteristics of the nat- In the case of EB virus, a fluorescent antibody
ural disease. The methods of immunization prac- method developed by the Henles in 1966 provided
tice, the frequency of repeated immunization pro- the key tool. (36) The virus had been found in
grams, and the quality and duration of vaccine cultured cells derived from Burkitt lymphoma, but
immunity now constitute the major determinants it could not be isolated in the usual tissue culture
of the behavior of these diseases. systems. By application of serological techniques,
Serological surveys in several U.S. cities such as the presence of antibody to the virus was found
Syracuse, New York,c40) Cleveland, Ohio,c33) and commonly not only in sera from Burkitt lymphoma
Houston, Texas, (44) have uncovered serious defi- patients but also in sera from healthy African and
ciencies in the antibody patterns for viral diseases U.S. children. The fortuitous development of in-
for which vaccines are available. Part of the prob- fectious mononucleosis in the Henles' technician
lem lies in the failure of immunization programs provided the clue to a disease association, (36a)
to reach certain segments of the community, and which was confirmed by prospective studies car-
part lies in the loss of interest on the part of the ried out at Yale University.<23.4s.60) The sequence
public in seeking and of the physician in giving of events is presented in detail in Chapter 22 and
the available vaccines. There are also inherent has recently been reviewed.oS ) Through this ap-
difficulties in the preservation of the viability of proach, EB virus has been firmly established as the
certain live virus vaccines and inherent inadequa- sole cause of heterophil-positive infectious mon-
cies in the quantity and quality of the antibody onucleosis. (19)
response produced by some vaccine preparations. A second example of the use of seroepidemiol-
The need for surveillance programs and serological ogical techniques is the discovery by Blumberg et
surveys to evaluate immunization programs has al. in 1965(6) of a particular antigen in the sera of an
been stressed by several authors. m .37l Australian aborigine; it was uncovered in the
3.5.5. Agents in Search of Disease. The applica- course of genetic studies of ~-lipoprotein. As the
tion of new immunological and microbiological antigen could not be isolated or cultivated in the
techniques has sometimes led to the discovery of a laboratory, serological surveys using immunodif-
new antigen or a new antibody before anything is fusion tests were carried out to detect its presence
in the sera of different population groups and cific stimuli such as phytohemagglutinin and
different disease entities. The results provided the pokeweed mitogen and the mixed lymphocyte
sole initial evidence that this" Australia antigen" reaction reflects the functional integrity of the cell-
was associated causally with hepatitis B or "long- mediated immune system. The response of lym-
incubation hepatitis. "(1) Many other investigators phocytes to specific antigens to which the individ-
contributed to and expanded these studies; their ual has been previously exposed provides an addi-
contributions are reviewed in Chapter 10. tional epidemiological marker of past infection for
3.5.6. Evaluation of Immunological Function in those agents; it is especially useful for detecting
Healthy Populations. Two important develop- prior exposure to microbial agents for which anti-
ments in immunology bear on future serological body measurement is difficult or not available,
surveys. First, standardization and simplification such as tuberculosis, leprosy, fungi, and certain
of the means of measuring the various serum viruses. The sensitization of lymphocytes to tumor
immunoglobulins permit assessment of large pop- antigens, particularly viral-associated tumors, has
ulation groups to establish normal levels for these been demonstrated not only in the tumor patients
proteins in different geographic areas and to detect themselves but also in lymphocytes from house-
abnormal levels and abnormal immunoglobulins hold contacts. These observations are of poten-
in relation to various infectious diseases. The tially great epidemiological importance because
identification of illnesses associated with primary they suggest a common environmental antigen at
or secondary immunoglobulin deficiencies or with work, with cancer occurring only in a small pro-
immunoglobulin dysfunction may become possi- portion of those so exposed.
ble on a large scale. Second, there are exciting Just as the lymphocyte response to a virus indi-
advances in our understanding of cell-mediated cates prior exposure to that agent, the failure to
immunity and advances in the methods available respond to an antigen for which there is known or
for measuring altered functions. Some of the ap- probable exposure may indicate a high susceptibil-
plications in these two areas are summarized in ity to certain chronic viral diseases. For example,
Table 9. The response of lymphocytes to nonspe- the recent demonstration that lymphocytes from
Table 9. Measurement of Different Aspects of the Immune System in Seroepidemiological Studies
1. Immunoglobulin measurements of
a. Normal levels of different immunoglobulin classes
b. Deficiency states
c. High levels as reflection of chronic infections
2. Tests for humoral antibody
a. Viral-specific IgG antibody in relation to current and past infections
b. Viral-specific IgM antibody as reflection of recent or (?) persistent infections
c. Abnormally high levels of certain viral antibodies as marker of persistent viral infections
3. Cell-mediated immunity assays of
a. Lymphocyte function
(1) Absolute number of Band T cells
(2) Response to nonspecific mitogens (PHA, pokeweed, mixed lymphocytes)
(3) Response to specific viral antigens
(4) HL-A and LD antigens as genetic markers
(5) Chronic carrier status of EBV, CMV, etc.
b. Skin test responses to viral antigens
4. Search for circulating immune complexes in
a. Immune complex glomerulonephritis
b. Systemic lupus erythematosis
c. Hepatitis B infections
d. Viral exanthems
Table 10. Viral Hyperreactivity: Association of High Viral Antibody Titers and Chronic Disease
Virus Disease
Epstein-Barr virus a. Strong association: Burkitt lymphoma, nasopharyngeal cancer

b. Weaker association: Hodgkin's disease, sarcoidosis, systemic lupus erythematosis
Measles a. Strong association: subacute sclerosing panencephalitis
b. Weaker association: systemic lupus erythematosis, mUltiple sclerosis
Herpesvirus type 2 a. Strong association: cervical cancer
b. Weaker association: other tumors
Rubella Weaker association: systemic lupus erythematosis, sarcoidosis, chronic liver disease
Parainfluenza Weaker association: systemic lupus erythematosis, sarcoidosis
Papovavirus Strong association: progressive multifocalleukoencephalopathy
some patients with multiple sclerosis fail to pro- Whether these antibody increases precede the
duce migratory inhibiting factor on exposure to disease and thus indicate a causative role for the
measles virus(9,69) is an important lead to viral virus, or accompany the onset of disease due to a
persistence and to possible disease causation. The common cause, or arise as a consequence of an
adaptation of measurements of lymphocyte func- immunological impairment induced by the disease
tion to microtechniques will soon permit large- itself is currently unknown. The mechanism may
scale population and prospective studies to be vary from one disease to another. In Burkitt lym-
made. Through these surveys, individuals may be phoma and nasopharyngeal cancer, a strong causal
identified who have high viral antibody levels but association is suggested by the presence of the
no lymphocyte response to a particular antigen. virus or the virus genome in all of the cells in the
Such a setting may reflect viral persistence and affected tissues. In Burkitt lymphoma, the disease
place the individual at high risk to certain cancers, (or one closely resembling it) has been induced by
viral infections of the central nervous system, EB virus in nonhuman primates. The evidence
immune complex diseases, etc. The recent obser- bearing on many of these associations is discussed
vation that transfer factor prepared from persons in detail in other chapters of the book. From the
who have a normal lymphocyte response to a standpoint of serological surveys, the importance
specific antigen can restore function when admin- of viral hyperreactivity as an epidemiological
istered to a deficient individual offers an exciting marker is that it may make possible the identifica-
lead to therapy. tion of healthy individuals at high risk to these
3.5.7. Interrelationship of Disciplines. Seroepi- conditions and perhaps the prevention of disease.
demiological techniques can contribute to our un- Viral hyperreactivity and the failure of lympho-
derstanding of the possible links between infec- cytes to respond to specific viruses may both
tious diseases, chronic diseases, cancer, nutrition, reflect this heightened susceptibility.
and genetics. Some examples related to viral dis- b. Genetics and Viral Disease. Controversy
ease can be cited. has long existed as to whether the blood group of
a. Viral "Hyperreactivity" and Chronic Di- an individual is associated with a higher risk of
seases. The presence of higher antibody titers to certain diseases, including viral infections. For
some viruses in certain chronic conditions as com- example, retrospective studies suggested a rela-
pared with age- and sex-matched controls has tionship between blood group 0 and influ-
suggested a possible causal relationship. The pres- enza.(43) The validity of this association was
ence of such an elevated titer may be an epide- tested in prospective serological surveys which
miological marker of an increased risk of cancer or permit determination of the actual risk of infection
chronic disease, and may reflect viral persistence and of disease for each blood group. An extensive
of reactivation. Table 10 depicts some of the more prospective analysis carried out in military re-
important associations. cruits, college students, and Peace Corps volun-
teers failed to identify any clear-cut differential risk directly measured. A pool of data of this type is
of persons of different blood types to influenza, now accumulating in organ transplant centers and
parainfluenza, rubella, EBV, and certain other viral includes information on relatives and other tissue
infections.(251 In addition, no relation between donors. Long-term clinical follow-up of these indi-
serologically proved clinical influenza and any viduals with known HL-A configurations might
blood groups was found. give early clues to risk factors for various chronic
The possible relationship between human leu- diseases.
kocyte antigens (HL-A) and certain diseases is
under current vigorous investigation. Differences
ACKNOWLEDGMENTS
between the frequency of certain HL-A antigens
in persons with certain diseases as compared with
healthy controls have been found. They have been I wish to express my appreciation to Dr. Alex-
demonstrated in ankylosing spondylitis,<61I coe- ander D. Langmuir, formerly Chief, Epidemiology
liac disease, (671 psoriasis, (591 chronic active hepa- Section, U.S. Center for Disease Control, and Dr.
titis,<421 Hodgkin's disease,<2s1 systemic lupus er- Dorothy Horstmann, Professor of Epidemiology
ythematosis,<341 and others. Of particular interest and Pediatrics, Yale University School of Public
to the Virologist are recent reports on multiple Health, for many helpful comments and careful
sclerosis and nasopharyngeal cancer. In multiple review of this chapter.
sclerosis, several retrospective analyses have indi-
cated an increased frequency of HL-A3 and HL-A7
antigens as well as a specific lymphocyte determi- 4. References
nant, LD-7a. (391 Patients with these antigen pat-
terns have a more rapid course and may also have 1. ANDREWES, C. H., LAIDLAW, P. P., AND SMITH, W.,
Influenza: Observations on the recovery of virus
high measles antibody titers; their lymphocytes
from man and on the antibody content of human
may not respond to measles antigen. (9.691 In
sera, Br. J. Pathol. 16:566-582 (1935).
Chinese with nasopharyngeal cancer, a significant 2. AYCOCK, W. L., AND KRAMER, S. D., Immunity to
increase was noted in the proportion in whom less poliomyelitis in normal individuals in urban and
than two second-locus antigens were detectable, as rural communities as indicated by the neutralization
well as a significant increase in the frequency of test, J. Prevo Med. 4:189-200 (1930).
HL-A2 antigen in patients as compared with 3. BAKER, H., Infectious disease information and pre-
healthy age/sex-matched Chinese controls(641; this paredness, Presented at meeting of the Society of
suggests a link in causation. * One implication of Medical Consultants to the Armed Forces, U.S.A.,
Washington, D.C., 1973.
these observations is that there may be genetic
4. BALFOUR, H. H., JR., SIEM, R. A., BAUER, H., AND
control of the immune response; lymphocyte re-
QUIE, P. G., California arborvirus (LaCrosse) infec-
ceptors may be absent or may not respond to tions. 1. Clinical and laboratory findings in 66 chil-
specific viral antigens, leading to persistence of dren with meningoencephalitis, Pediatrics 52:680-691
the virus and perhaps to the development of (1973).
disease. At this writing these possible mecha- 5. BELL, J. A., HUEBNER, R. J., ROSEN, L., ROWE, W. P.,
nisms are only speculations. COLE R. M., MASTROT, F. M., FLOYD, T. M., CHAN-
As with earlier work with ABO blood groups, OCK, R. M., AND SHOEDOFF, R. A., Illness and micro-
the association of HL-A antigens and disease is bial experiences of nursery children at Junior Village,
currently based on retrospective analyses. As tech- Am. J. Hyg. 74:267-292 (1961).
6. BLUMBERG, B. S., ALTER, H. J., AND VISNICH, S., A
niques are improved and simplified, the distribu-
"new" antigen in leukemia sera, J. Am. Med. Assoc.
tion of HL-A types may become part of prospec-
191:541-546 (1965).
tive surveys in which the risk of infection and
7. BLUMBERG, B. S., GERSTEY, B. J. S., HUNGERFORD, D.
disease in persons of certain HL-A patterns can be A., LONDON, W. T., AND SUTNIK, A. I., A serum
antigen (Australia antigen) in Down's syndrome,
• A new antigen called "Singapore 2" has now been leukemia, and hepatitis, Ann. Intern. Med. 66:924-931
identified at this locus in nasopharyngeal cancer pa- (1967).
tients. (64al 8. BROWN, H. W., The occurrence of neutralizing anti-
bodies for human influenza virus in the sera of 22. EVANS, A. S., Cox, F., NANKERVIS, G., OPTON, E.,
persons with various histories of influenza, Am. J. SHOPE, R., WELLS, A., V., AND WEST, B., A health
Hyg. 24:361-380 (1936). and seroepidemiological survey of a community in
9. CIONGOLI, A. K., PLATZ, .P., DUPONT, B., SVEJGAARD, Barbados, Int. J. Epidemiol. 3:167-175 (1974).
A., FOG, T., AND JERSILD, c., Lack of Antigen re- 23. EVANS, A. S., NIEDERMAN, J. c., AND MCCOLLUM, R.
sponse to myxoviruses in multiple sclerosis, Lancet W., Seroepidemiologic studies of infectious monon-
2:1147 (1973). ucleosis with EB virus, N. Engl. J. Med. 279:1121-
10. COOK, G. T., AND PAYNE, A. M.-M., Epidemiological 1127 (1968).
control of infectious diseases, Br. Med. Bull. 7:185- 24. EVANS, A. S., NIEDERMAN, J. c., AND SAWYER, R N.,
187 (1951). Prospective studies of a group of Yale University
11. COONEY, M. K., HALL, C. E., AND Fox, J. P., The freshman. II. OccuITence of acute respiratory infec-
Seattle Virus Watch Program. I. Infection and illness tions and rubella, J. Infect. Dis. 123:271-278 (1971).
experience of Virus Watch Families during a commu- 25. EVANS, A. S., SHEPARD, K. A., AND RICHARDS, V.,
nity-wide epidemic of echovirus 30 aseptic meningi- ABO blood groups and viral diseases, Yale J. Bioi.
tis, Am. J. Public Health 60:1456-1465 (1970). Med. 45:81-92 (1972).
12. CRUICKSHANK, R, Epidemiological surveillance of 26. FALK, J., AND OSOBA, D., HL-A antigens and survival
communicable diseases and development of public in Hodgkin's disease, Lancet 2:1118-1121 (1971).
health laboratory facilities in the developing coun- 27. FLOREY, C. DUV., CUADRADO, R. R., HENDERSON, J.
tries, in: Fourth International Congress on Global Im- R, AND DE GOES, P., A nationwide serum survey of
pacts of Applied Microbiology, Sao Paulo, Brazil, ab- Brazilian military recruits, 1964: Method and sam-
stracts (1973). pling results. Am. J. Epidemiol. 86:314-318 (1967).
13. DINGLE, J. H., BADGER, G. F., AND JORDAN, W. S., 28. FORBES, J. F., AND MORRIS, P. J., Leucocyte antigens
JR., Illness in the Home: A Study of 25,000 Illnesses in a in Hodgkin's disease, Lancet 2:849-851 (1970).
Group of Cleveland Families, Press of Western Reserve 29. Foy, A. M., COONEY, M. K., McMAHAN, R, BOR, R,
University, Cleveland, 1964. AND GRAYSTON, J. T., Single-dose monovalent A,,!
14. EVANS, A. S., Epidemiology and the public health Hong Kong influenza vaccine-Efficacy 14 months
laboratory, Am. J. Public Health 57:1041-1052 (1967). after immunization, J. Am. Med. Assoc. 217:1067-1071
15. EVANS, A. S., Serological surveys: The role of the (1971).
WHO Serum Reference Bank, WHO Chron. 21:185- 30. Fox, J., ELVEBACK, L. R, SPIGLAND, I., FROTH-
190 (1967). INGHAM, T. E., STEVENS, D. A., AND HUGER, M., The
16. EVANS, A. S., Serological Techniques in Serological Virus Watch Program: A continuing surveillance of
Epidemiology 0. R. PAUL AND C. WHITE, eds.), Aca- viral infections in metropolitan New York families.
demic Press, New York, 1973. 1. Overall plan methods of collecting and handling
17. EVANS, A. S., Surveillance of mass vaccination pro- information and a summary report of specimens
grams, in: Proceedings of the Fourth International Con- collected and illnesses observed, Am. J. Epidemiol.
ference on Global Impacts of Applied Microbiology, Sao 83:389-412 (1966).
Paulo, Brazil (1973). 31. FRANCIS, T. F., AND MAGILL, T. P., The incidence
18. EVANS, A. S., The history of infectious mononucleo- of neutralizing antibody for human influenza virus
sis, Am. J. Med. Sci. 267:189-195 (1974). in the serum of human individuals of different ages,
19. EVANS, A. S., New discoveries in infectious monon- J. Exp. Med. 63:655--668 (1936).
ucleosis, Mod .. Med. 42:18-24 (1974). 32. GEZER, A., CHRISTENSEN, S., AND THORUP, B., A
20. EVANS, A. S., CASALS, J., OPTON, E. M., BORMAN, E. multipurpose serological survey in Kenya. 1. Survey
K., LEVINE, L., AND CUADRADO, R, A nationwide methods and progress of field work, Bull. WHO
survey of Colombian military recruits, 1966. 1. De- 43:521-537 (1970).
scription of sample and antibody patterns with ar- 33. GOLD, E., FEVRIER, A., HATCH, M. H., HERMANN, K.
boviruses, polioviruses, respiratory viruses, tetanus, L., JONES, W. L., KRUGMAN, R D., AND PARKMAN, P.
and treponematosis, Am. J. Epidemiol. 90:292-303 D., Immune status of urban children determined by
(1969). antibody measurement, N. Engl. J. Med. 289:231-235
21. EVANS, A. S., CASALS, J., OPTON, E. M., BORMAN, E. (1973).
K., LEVINE, L., AND CUADRADO, R, A nationwide 34. GRUMET, F. c., COUKELL, A., BODMER, J. G., BOD-
survey of Argentine military recruits, 1965-1966. I. MER, W. F., AND McDEVITT, H. 0., Histocompatibil-
Description of sample and antibody patterns with ity (HL-A) antigens associated with systemic lupus
arboviruses, polioviruses, respiratory viruses, teta- erythematosis: A possible genetic predisposition to
nus, and treponematosis, Am. J. Epidemiol. 93:111- disease, N. Engl. J. Med. 285:193--196 (1971).
121 (1971). 35. GUTHE, T., RIDET, J., VORST, F., D'COSTA, J., AND
GRAB, B., Methods for the surveillance of endemic 50. PAUL, J. R., Aims, purposes, and methods of the
treponematoses and seroimmunological investiga- World Health Organization Serum Banks, Yale J. BioI.
tions of "disappearing" disease, Bull. WHO 46:1-14 Med. 36:2-4 (1963).
(1972). 51. PAUL, J. R., The story to be learned from blood
36. HENLE, G., AND HENLE, W., Immunofluorescence in samples: Its value to the epidemiologist, J. Am. Med.
cells derived from Burkitt's lymphoma, J. Bacteriol. Assoc. 175:601-605 (1961).
91:1248-1256 (1966). 52. PAUL, J. R., Serological Epidemiology in Clinical Epide-
36a. HENLE, G., HENLE, W., AND DIEHL, V., Relationship miology, rev. ed., University of Chicago Press, Chi-
of Burkitt's tumor-associated herpes-type virus to cago, 1966.
infectious mononucleosis, Proc. Natl. Acad. Sci. 53. PAUL, J. R., NIEDERMAN, J. c., PEARSON, R. J. c.,
U.S.A. 59:94-101 (1968). AND FLOREY, C. DU V., A nationwide serum survey of
37. HORSTMANN, D. M., Need for monitoring vaccinated United States military recruits. 1. General considera-
populations for immunity levels, Prog. Med. Virol. tions, Am. J. Hyg. 80:286-292 (1964).
16:215-240 (1973). 54. PAUL, J. R., AND RIORDAN, J. T., Observations on
38. HORSTMANN, D. M., LIEBHABER, H., LEBoUVIER, G. serological epidemiology: Antibodies to the Lansing
L., ROSENBERG, D. A., AND HALSTEAD, S. G., Rubella: strain of poliomyelitis virus in sera from Alaskan
Reinfection of vaccinated and naturally immune per- Eskimos, Am. J. Hyg. 52:202-212 (1950).
sons exposed in an epidemic, N. Eng/. J. Med. 55. PAUL, J. R., AND TRASK, J. E., Neutralization test in
283:771-778 (1970). poliomyelitis, comparative results with four strains
39. JERSILD, c., FOG, T., HANSEN, G. S., THOMSEN, M., of the virus, J. Exp. Mer. 61:447-464 (1935).
SVEJGAARD, A., AND DUPONT, B., Histocompatibility 56. PAUL, J. R., AND WHITE, C. (eds.), Serological Epide-
determinants in multiple sclerosis, with special refer- miology, Academic Press, New York, 1973.
ence to clinical course, Lancet 2:1221-1225 (1973). 57. RASKA, K., National and international surveillance of
40. LAMB, G. A., AND FELDMAN, H. A., Rubella vaccine communicable diseases, WHO Chron. 20:31:>-321
response and other viral antibodies in Syracuse chil- (1966).
dren, Am. J. Dis. Child. 122:117-121 (1971). 58. ROLESGAARD, E., Health regulations and interna-
41. LANGMUIR, A. D., The surveillance of communicable tional travel, WHO Chron. 28:265-268 (1974).
diseases of national importance, N. Engl. J. Med. 59. RUSSELL, T. J., SCHULTES, L. M., AND KUBAN, D. J.,
268:182-192 (1963). Histocompatibility (HL-A) antigens associated with
42. MACKAY, l. R., AND MORRIS, P. J., Association of psoriasis, N. Engl. J. Med. 287:738--740 (1972).
autoimmune active chronic hepatitis with HL-A1,8, 60. SAWYER, R. N., EVANS, A. S., NIEDERMAN, J. c., AND
Lancet 2:79:>-795 (1972). MCCOLLUM, R. W., Prospective studies of a group of
43. McDONALD, J. D., AND ZUCKERMAN, A. J., ABO Yale University freshman. 1. Occurrence of infec-
blood groups and acute respiratory disease, Br. Med. tious mononucleosis, J. Infect. Dis. 123:26:>-270
J. 1:89-90 (1962). (1971).
44. MELNICK, J. L., BURKHARDT, M., TABER, L. T., AND 61. SCHFOSSTEIN, L., TERASAKI, P. I., BLUESTONE, R., AND
ERCKMAN, P. N., Developing gap in immunity to PEARSON, C. M., High association of an HL-A anti-
poliomyelitis in an urban area, J. Am. Med. Assoc. gen, W27, with anklylosing spondylitis, N. Eng/. J.
209:1181-1185 (1969). Med. 288:704-706 (1973).
45. MILLER, D., GABRIELSON, M. 0., AND HORSTMANN, 62. SEVER, J. L., Applications of a microtechnique to
D. M., Clinical virology and viral surveillance in a viral serologic investigations, J. Immunol. 88:320-329
pediatric group practice: The use of double-seeded (1962).
tissue culture tubes from primary virus isolation, 63. SHOPE, R. E., Swine influenza. 1. Experimental trans-
Am. J. Epidemiol. 88:245-256 (1968). mission and pathology, J. Exp. Med. 54:349-359
46. MONTO, A. S., AND ULLMAN, B. M., Acute respira- (1931).
tory illness in an American community, J. Am. Med. 64. SIMONS, M. J., WEE, G. B., DAY, N. E., MORRIS, P. J.,
Assoc. 227:164-169 (1974). SHANMUGARATNAM, K., AND DE TID:, G. B., Immuno-
47. National Disease and Therapeutic Index, Lea Associ- genetic aspects of nasopharyngeal carcinoma. 1. Dif-
ates, Ambler, Pa., 1969. ferences in HL-A antigen profiles between patients
48. NIEDERMAN, J. c., MCCOLLUM, R. W., HENLE, G., and control groups, Int. J. Cancer 13:122~134 (1974).
AND HENLE, W., Infectious mononucleosis in relation 64a. SIMMONS, M. J., WEE, G. B., CHAN, S. H., SHANMU-
to EB virus antibodies, J. Am. Med. Assoc. 203:205- GARATNAM, K., DAY, N. E., AND DE THE, G. B.,
209 (1968). Immunogenetic aspects of nasopharyngeal carci-
49. Oxford Universal Dictionary, Clarendon Press, Ox- noma (NPC). III. HL-A type as a genetic marker of
ford,1955. NPC predisposition to test the hypothesis that EBV
is an etiologic agent in NPC, in: Second International cellular immunity to measles antigen in multiple
Conference on Oncogenesis and Herpesviruses, Nu- sclerosis patients, Lancet 2:1147 (1973).
remberg, Germany, October 14-16, 1974. 70. WHO, Proceedings of the Twenty-first World Health
65. SOPER, F. L., PENNA, H., CARDOSA, E., SERAFIM, J., Assembly (1968).
JR., FROSBISHER, M., JR., AND PINHIERO, J., Yellow 71. WHO Tech. Rep. Ser. Immunological and Hemato-
fever without Aedes aegypti: Study of a rural epi- logical Surveys, No. 181, Geneva (1959).
demic in the Valle do Chanaan, Espirito Santo, 72. WHO Tech. Rep. Ser., Multipurpose Serological Sur-
Brazil, Amer. J. Hyg. 18:555-587 (1932). vey and WHO Serum Reference Banks, No. 454,
66. SMITH, W., ANDREWES, C. H., AND LAIDLAW, P. P., A Geneva (1970).
virus obtained from influenza patients, Lancet 2:66- 73. WIDELOCK, D., KLEIN,S., PElZER, L. R., AND SIMO-
68 (1933). NOVIC, 0., Laboratory analyses of 1957-1958 influ-
67. STOKES, P. L., ASQUITH, P., HOLMES, G. K. T., enza outbreak (NJapan) in New York City. I. Prelim-
MACKINTOSH, P., AND COOKE, W. T., Histocompati- inary report seroepidemiologic investigation and
bility antigens associated with adult coeliac disease, variant NJapan isolate, J. Am. Med. Assoc. 167:541-
Lancet 2:162-164 (1974). 543 (1958).
68. THOMPSON, W. H., AND EVANS, A. 5., California 74. WILLIAMS, J. W., The value of the Wassermann
virus encephalitis studies in Wisconsin, Am. J. Epide- reaction in obstetrics, based upon the study of 4547
miol. 81:230-244 (1965). consecutive cases, Johns Hopkins Hosp. Bull. 31:335-
69. UNTERHOLER, V., AND ZABRISKIE, J. B., Suppressed 342 (1920).
CHAPTER 3
Adenoviruses
Hjordis M. Foy and J. Thomas Grayston
1. Introduction tion and degradation, allowing purification and

molecular investigation. As much detailed struc-
Adenoviruses derived their name from the fact ture and biochemistry of adenovirus are known as
that they were first isolated from adenoid tissues for any microorganism. (62) Although many prob-
(tonsils) and have a certain affinity for lymph lems remain concerning production and use of
glands, where they may remain latent for years. adenovirus vaccines, both inactivated and live
They also invade the respiratory tract, the gas- vaccines have been developed and found effective.
trointestinal tract, and the conjunctiva. In the Subunit vaccines are possible.
respiratory tract, they may cause a variety of
clinical manifestations ranging from pharyngitis to
bronchitis, croup, and pneumonia. Adenovirus
2. Historical Background
infections are widely distributed and common.
Most infections occur in childhood.
A recognized syndrome seen especially among Within a few years after cell culture became
P!actical for isolation of viruses, Rowe et al. (1953)
military recruits is febrile acute respiratory disease
(ARD). Other disease syndromes caused by certain described an agent which caused spontaneous
degeneration of tissue culture originating from
specific serotypes of adenovirus are pharyngocon-
surgically removed human tonsils and ade-
junctival fever (PCF) and epidemic keratoconjunc-
noids.(70) Shortly thereafter, Hilleman and Werner
tivitis (EKC). Several other disease syndromes us-
(1954) reported isolation of similar agents from
ually in children (hemorrhagic cystitis,
military personnel ill with febrile respiratory dis-
pertussislike disease, skin rashes, intussusception)
have been associated with adenoviruses. ease. 41 Epidemics of such acute respiratory disease
had been a serious problem in recruit training,
Although some serotypes have been found to be
and the Commission on Acute Respiratory Di-
oncogenic in animals, oncogenicity has not been
seases of the U.S. Armed Forces Epidemiological
observed in humans. Viral hybridization and cell
Board initiated a series of studies revealing that
transformation with adenovirus have been ob-
served. (43) Because of the latency of the infections, the newly discovered agents were the cause of a
large proportion of febrile acute respiratory dis-
late sequelae are at least a theoretical possibility.
ease among military recruit populations. (Hl.21)
The viruses are unusually resistant to inactiva-
Several names were used for the new viruses, but
Hjordis M. Foy and J. Thomas Grayston . Depart- in 1956 the term adenoviruses was adopted. (25)
ment of Epidemiology and International Health, School Although the laboratory techniques for diagnos-
of Public Health and Community Medicine, University ing adenovirus infections were not available until
of Washington, Seattle, Washington the 1950s, human adenoviruses have probably
53
54 Chapter 3 • Adenoviruses
been present for a long time. Most illnesses caused tutions,<3.39.78.86) groups of families,08.30.38.45.87) and
by adenoviruses cannot be diagnosed by clinical even an entire city.(58)
observation alone. However, epidemics of acute Adenovirus infections (types 4 and 7) were first
respiratory diseases were recognized as causing recognized to cause significant illness in military
disruption in military recruit training as far back recruit populations. They have been extensively
as the Civil War. During World War II, the Com- studied in the military. Not only were illnesses
mission on Acute Respiratory Diseases defined the diagnosed with the appropriate laboratory tests,
entity termed" ARD" through epidemiological and but also serological specimens collected at the
human volunteer investigations.(2l) This syndrome beginning and end of training provided data on
was an entity often distinguishable from other susceptibility and infection rates (whether symp-
definable acute respiratory tract diseases, had an tomatic or asymptomatic). The epidemiological
incubation period of 5-6 days, and was caused by pattern of the disease in the four military services,
a filtrable agent. The finding that this syndrome including the serotypes involved under various
was caused by adenovirus suggests that this agent training conditions and at different geographic
was responsible for the similar disease at the times locations, including international differences, has
of previous military mobilization. been studied. <1.Hi.21.28,29,81 ,84)
There is also evidence that other adenovirus The epidemiological pattern of adenovirus infec-
infections were present long before the 1950s. The tion in civilian popUlations comparable to military
disease syndrome now classified as epidemic kera- recruits was found to be very different. (34) Adeno-
toconjunctivihs, caused primarily by adenovirus virus disease was uncommon among college stu-
type 8, was clinically described by German work- dents,(27) On the other hand, longitudinal studies
ers at the end of the nineteenth century.<42.44) in orphanages and children's homes revealed that
Several epidemics of conjunctivitis with fever, high rates of infection with several low-numbered
pharyngitis, and systemic symptoms centering serotypes occurred in infancy.<a.86) In such set-
around swimming baths were reported by German tings, certain viruses (types 1, 2, and 5) were often
workers in the 1920s,<64) a disease which fits the found to be endemic, whereas other serotypes (3
description of pharyngoconjunctival fever (see be- and 7) occurred in epidemics. The incubation
low). period, communicability, rate of symptomatic vs.
asymptomatic infection, spectrum of clinical mani-
festations, and cross-immunity have been investi-
gated.
3. Methodology Involved in Epidemiological When asymptomatic children were studied as
Analysis controls of clinic or hospitalized patients, adenovi-
ruses were frequently isolated. It was quickly
recognized that isolation of the virus from a sick
3.1. Sources of Data
patient did not establish a causal relationship.
A good deal of the basic information on adeno- Much of our understanding of the epidemiology of
viral disease comes from investigations of epidem- adenovirus infection in children comes from con-
ics of ARD, PCF, and EKe. Because the disease tinuous observations of panels of families con-
syndromes caused by adenoviruses are not easily ducted in Cleveland,<45) Kansas,<87) New Orle-
distinguished purely on clinical criteria in the . ails,<38) New York,<30) Seattle,(8) and also
absence of epidemics, general epidemiological India. (50) In the first studies, respiratory and ser-
studies require virus isolation and serological evi- ological specimens were utilized. The broadest
dence. Adenovirus disease is not reportable, and approach in family studies is exemplified by the
there are no national or other general population "Virus Watch" studies, <:onducted in New York
mortality and morbidity data. Manyepidemiologi- and Seattle, where biweekly collections of both
cal data come from selected representative popula- fecal and respiratory specimens for virus isolation
tion samples under appropriate surveillance. Im- were included in the routine observations. The
portant studies have included military populations latter type of studies uncovered a large number of
(especially recruits), <1.16.21.22.57 .84) children's insti- asymptomatic infections, particularly with the
Chapter 3 • Adenoviruses 55
lower-numbered serotypes, and demonstrated the useful in diagnosis of acute infections, since CF
high frequency of recrudescent shedding of virus. antibodies tend to disappear rather rapidly. The
production of CF antibodies in infants may be
poor and the test can be erroneously negative. In
3.2. Interpretation of Laboratory Tests
older persons, CF antibodies from previous infec-
Antibody tests and virus isolation with sero- tions can cause difficulty in demonstrating a new
typing have been used to provide epidemiological infection. N and HI tests are more laborious to
information on adenovirus infection. Properly in- carry out but are type specific and the antibody is
terpreted virus isolation p'fOvides the most conclu- long-lasting.
sive evidence of infection and offers the opportu- The HI and N are useful for serological epide-
nity to determine the serotype. In order to prevent miology. A variety of such studies are available,
excessive expense in popula,tion studies, isolation comparing age of acquisition of antibody by type
attempts are restricted by sampling techniques. in different population groups including interna-
Recovery of the virus is not difficult in the acute tional comparisons.(80J Caution must be employed
phase of illness in the majority of cases with upper in comparing different studies, especially of anti-
respiratory tract and eye infections. Adenoviruses body titers, because of variation in laboratory
are isolated easily in cell cultures of human origin, techniques.
especially HEK, Hep-2, and HeLa cells.(18.40) Mon-
key kidney cells are less suitable. Typical cyto-
pathogenic effect (CPE)-rounding of cells, often to
grapelike clusters-may take 1-2 wk, and some- 4. Characteristics of the Virus
times cultures must be observed as long as 4 wk
before CPE is seen. Blind passage is recommended Adenoviruses are double-stranded DNA viruses
to recover the higher-numbered serotypes (above lacking an envelope.(43.62J The capsid contains 252
7) and when the virus concentration in the speci- capsomeres and shows icosahedral symmetry. The
men is low. (2H.:l5) Demonstration of group-specific capsomeres consist of hexons and pentons. The
complement-fixing antigen identifies the isolate as size is 60-90 nm and the number of genes approxi-
a member of the adenovirus group. Serotyping is mately 50. Thirty-one immunologically distinct
usually performed in a neutralization test using types are recognized to cause human infection.
type-specific rabbit antisera. Adenoviruses are recognized by a common
Since the adenovirus is often present for a pro- group antigen in a complement fixation test. The
longed time period in the gastrointestinal tract, it common antigen consists primarily of hexons of
may be recovered from fecal or rectal swab speci- the capsid.
mens after it has disappeared from the upper By hemagglutination, the human adenoviruses
respiratory tract. Fecal excretion may continue in- can be divided into three groupS(4:J.H2J: Group I(A)
termittently for months or even years after acquisi- includes types 3, 7, 11, 14, 16, 20, 21, 25, and 28.
tion, (00) and the diagnostic significance of recov- They agglutinate rhesus erythrocytes. Group II(B)
ery from this site in illness is often in doubt. includes types 8, 9, 10, 13, 15, 17, 19, 22, 23, 24, 26,
Isolation from the respiratory tract has a greater 27,29, and 30. This group agglutinates rat erythro-
probability to be associated with illness. The virus cyte cells. Group III(C) includes types 1, 2, 4, 5, 6,
usually disappears from the eye and pharynx as 12, 18, and 31 that agglutinate rat cells partially
acute symptoms abate, but recrudescent infection and not rhesus cells. Group III includes the viruses
may also occur in the throat. A serological anti- most commonly found in humans. Several viruses
body titer rise suggests recent infection. of group I cause severe respiratory infections.
The three commonl¥ applied serological tests in With the exception of type 8, the major cause of
adenovirus epidemiology are the complement fixa- EKC, the group II viruses have been infrequently
tion (CF), neutralization (N), and hemagglutina- isolated and then usually in tropical countries.
tion inhibition (HI) antibody tests. (4:l) The com- Adenoviruses are unusually stable to physical
plement fixation test measures group-specific and chemical agents and adverse pH conditions,
antibody. It is the easiest to perform and the most resulting in prolonged survival outside the host
cells and gr:eat potential for spread. They are ether 14, and 21, which cause acute respiratory disease
resistant but are destroyed by heat at 56°C for 30 (see Section 5.2.2), occur mostly in epidemics; type
min. Type 4 is especially heat resistant. The vi- 3 is sometimes endemic, sometimes epidemic (see
ruses endure a pH range of 6.0--9.0 and tempera- Section 5.2.3). Type 8 is endemic in the Far East
tures ranging between 4 and 36°C. They survive but occurs only in epidemics (and usually iatro-
freezing with minimal loss of infectivity. genic) in Western countries (see Section 5.2.4).
The content of guanidine-cytosine in their DNA 5.1.3. Geographic Distribution. Most types
varies between 48 and 60%, and viruses with low have been recovered from all areas of the world
contents (types 12, 18, and 31) are known to be where they have been sought. Some of the higher-
oncogenic in laboratory animals, possibly reflect- numbered types (8 and above) have been isolated
ing a similar percentage of guanidine-cytosine more frequently in underdeveloped countries such
content as the host cells. Hybridization has been as Saudi Arabia and Africa.
observed between closely related adenovirus 5.1.4. Temporal Distribution. The incidence of
types. Adenoviruses can hybridize with SV40, a adenovirus-associated respiratory disease is
simian papovavirus known for its oncogenic higher in the late winter, spring, and early sum-
potential. mer than in the remaining seasons of the year.
Adenovirus-associated viruses (AAV) are small This hold true for endemic childhood diseases as
(20--25 nm), contain DNA particles, and are found well as for military recruit epidemics (see Section
only in association with adenoviruses, which act as 5.2.2). Type 3 epidemics (PCF), associated with
"helpers." AAV were originally discovered with swimming, have been described most frequently
special staining techniques in electron microscopy. in the summer.
Now their presence is more easily indicated by 5.1.5. Age. Most children have been exposed to
serological techniques. These viruses do not cause several types of the endemic viruses by the time
cytopathogenicity. They are resistant to heating, they enter school (see Fig. 1). Types 4, 7, 8, 14, and
ether, and chloroform, and can be stored at 1-4°C 21 infections may occur later in life.
for many months. They are antigenically distinct 5.1.6. Sex. There is no significant difference
from the adenoviruses. At least four immunotypes between the sexes except for ARD, a disease to
are known. So far no disease syndrome has been which primarily males are exposed.
associated with these viruses. They may become 5.1.7. Occurrence in Different Settings. The
useful as epidemiological markers since in an family constitutes the most important unit for
outbreak of pharyngoconjunctival fever in Seattle transmission of the endemic types (1, 2, 5, and 6).
almost all of those infected with adenovirus type 3 Rates of adenovirus infections (all types) are
also had evidence of infection with AAV type higher in children's institutions and daycare
3.<71l homes than in families. The incidence is higher in
lower socioeconomic groups. Types 4 and 7 (and to
some extent types 14, 21, 11) occur as a recruit
5. Descriptive Epidemiology disease. Type 3 epidemics have been associated
with swimming (Section 5.2.3).
The following synopsis outlines the major epi- 5.1.8. Occupation. ARD caused by types 4 and 7
demiological features of adenovirus infections. (and to some extent 14, 21, and 11) occurs primar-
More detailed epidemiological characteristics are ily in military recruits. Type 8 epidemics (EKC)
presented under the various clinical syndromes have been associated with shipyards and physi-
constituting the host response. cians' offices.
5.1. Synopsis of Descriptive Epidemiology

5.2. Epidemiological and Clinical Aspects of
5.1.1. Incidence and Prevalence. See Section
Specific Syndromes
5.2.1.
5.1.2. Epidemic Behavior. Types 1, 2, 5, and 6 5.2.1. Endemic Adenovirus Infections. Most
are endemic in most areas of the world; types 4, 7, children become infected with some of the com-
PERCENT ADENOVIRUS ANTIBODY reported in some studies for type 2 than for any
50 100 0 50 100 other adenovirus type.(a.5.10) The most significant
i ' ii, I I I " 'I
contribution of adenoviruses to illness is in child-
5. hood, particularly under age 5, when about 5% of
all acute respiratory illnesses can be associated
with these viruses. The symptoms are usually
nonspecific, described as stuffy nose and cough.
2. 6.
Older children acquiring adenovirus infection
often have symptoms of pharyngitis, which may
mimic and be clinically indistinguishable from
3. 7 --t_-1
r.::::::
____ ' __
streptococcal pharyngitis. (a9)
j
_____ J Studies of ill children in several hospitals and
clinics suggest that 2-7% of all lower respiratory
8.~
~ tract illnesses in young children seeking medical
care can be attributed to adenoviruses.o°. a2 ) Such
illnesses are rare under the age of 6 months, when
IlIIIII Sweden [iJU.S. _Japan ~Taiwan the child is protected by maternal antibody. The
* antibodies
No adenovirus N. T. =Not tested
disease syndromes attributed to adenoviruses in-
clude pharyngitis, bronchitis, bronchiolitis, croup,
Fig. 1. Comparison of adenovirus-neutralizing antibod- and pneumonia. Adenovirus pneumonia in chil-
ies (types 1-8) in populations of four countries. The bar dren has been particularly associated with type 7
graphs indicate the percent of antibody in children. If and occasionally the disease is fatal.(s.11,la,14,74)
adults had a higher percent of antibody, it is shown by a Adenovirus infections occur all year round, but
broken line extension. Reproduced with permission from the incidence of disease is higher in late winter,
Proc. Soc. Exp. Bio!. Med., with data added from Sterner, spring, and early summer. (9) When exposure is
G., Adenovirus infection in childhood: An epidemiolog-
equal, both sexes are equally affected.
ical and clinical survey among Swedish children, Acta
Paediat. Scand. Suppl. 142:1-30 (1962). Localized outbreaks of adenovirus pheumonia
(type 7 and 21) have been reported in native
Canadian/ 11l New Zealand/ 51) and northern Fin-
mon types of adenoviruses early in life. Types 1, 2, nish infants and children.(74) It is not known
and 5 are endemic in those parts of the world whether this severe form of infection in these
where studies have been conducted. By the age of mostly nonwhite population groups is due to ra-
1 yr, 80% of children in the New Orleans area had cial differences or to low socioeconomic status
acquired antibodies to the virus, whereas the with crowding in a cold climate. There are no
proportion with such antibodies was lower in reports suggesting that American black children
New York and Seattle,os.aS) and still slightly lower are more severely affected by adenovirus infection.
in Stockholm, Sweden. (7S) In studies including Sequelae in the form of bronchiectasis and radiol-
isolation of the adenovirus, the most frequently ucent lung have been frequently reported in these
occurring types were 1 and 2. Other frequent special groups. (11,51)
adenovirus types occurring in childhood are types The mode of transmission in early life is thought
5, 3, and 6 in that order. Neutralizing antibody to be primarily fecal-oral. (30) A child born into a
studies in children and adults in four areas of the family where other members harbor the virus in
world are summarized in Fig. 1. The highest the intestinal tract will eventually become an ex-
prevalence of adenovirus antibody is observed cretor, but it may take several months before
among crowded populations in tropical areas. intrafamilial transmission occurs. (30.S7) In families
Overall, only about 50% of childhood adenovi- where the virus is recovered, virtually all members
rus infections result in disease. (9.aO) However, this have or develop antibodies to the type recovered.
proportion approaches two-thirds when infection Figure 2 shows examples of typical fecal-oral
is associated with pharyngeal location of the virus. spread of type 2 in families with newborn infants.
A lower percent of symptomatic infection has been Transmission shown in Fig. 2 contrasts with a
..••.. •
'-
~ '~~
~~ '"
<:> I
I 2 I 3 I 4 I 5 6 I 7 8 9 10 I II I 12 I 13 14 I 15 I 16 I 17 I
e: \::
"
<:>'"
<1:' ::§~ ~
•
22 II d' 4 Y
'f 2 Y
'f
• • • • ~
• .••• Fig. 2. Spread of type 2 adeno-
virus to infants born into fami-
lies with siblings excreting the
. ...
..lS
virus. Reproduced with permis-
sion from Fox, J. P., Brandt, C.
•
? D., Wassermann, F. E., Hall, C.
30 7 d' 3 Y ~ E., Spigland, I., Kogon, A., and
'f ~ Elveback, L. R., The Virus
..
""
..:
Watch Program: A continuing
surveillance of viral infections in
metropolitan New York families .
\t~
66 18 d'17m • 0 VI. Observations of adenovirus
~
'f infections: virus excretion pat-
'f
..lS
~
::: ~ terns, antibody response, effi-
ciency of surveillance, patterns
• fecal excretion
o respiratory excretion of infection, and relation to ill-
90 3 d' 2 Y
'f
""
• •
~
,recrudescent"
<:>
~ • ..
~
.. Initial excretion ness, Am. J. Epidemiol. 89:25-50
(1969).
Months I I I 2 3 4 5 6 7 8 I 9 I 10 I II I 12 I 13 I 14 I 15 I 16 I 171
family transmission of PCF in Fig. 3, where all higher-numbered types, and studies among Afri-
became infected with type 3 shortly after the can children showed fecal excretion of types 8, 12,
onsets of the index cases, and all but the father and 16.(84) The higher-numbered serological types
were symptomatic. An infected child may first (from type 9) are usually recovered only from fecal
excrete the virus from the respiratory tract, but the specimens,!;) and with the exceptions of types 11,
virus usually disappears from this location and 12, 19, and 21 they have not been associated with
may instead be found intermittently in fecal speci- respiratory, eye, or other illnesses.
mens for extended time periods.(oO) Many appar- 5.2.2. Acute Respiratory Disease of Military Re-
ently purely enteric infections occur which are cruits. Soon after adenoviruses were first isolated
usually asymptomatic. Intermittent excretion for from cases of ARD among military personnel, it
up to 906 days has been reported.(oO) The fact that became clear that these viruses were the primary
the adenoviruses can be found in more than 50% cause of morbidity among recruits, especially
of surgically removed tonsils suggests that the among North American and northern European
infection may lie dormant for many years. (26) The forcesY6,21l Morbidity rates have been reported as
long-term effect of chronic adenovirus infections is high as fr.17/100/wk. Epidemics usually peak at
unknown. about 3-6 wk after onset of training, although
Children brought up in institutions acquire ade- sometimes the epidemic occurrence has been de-
noviruses sooner than children living at home. layed. The seasons for highest rates of adenovirus
Epidemics of infection with adenovirus types 5 infections are winter and spring, independent of
and 7 have been described in orphanages and geographic locations and climatic conditions of
daycare facilities.(o.78.s6) Whereas studies in free- training posts within the United States.(22) In one
living families rarely have revealed the presence of study it was shown that recruits from the southern
other than types 1, 2, 3, 5, and 6, the studies in United States were less susceptible than those
Junior Village,!o) an institution for homeless chil- from the North, probably reflecting a more inten-
dren in Washington, D.C., revealed spread of sive exposure to adenoviruses during childhood
Fig. 3. Sequence of illnesses in

a family where the two index Person CF 0 CF 32 F-
cases, boys of 8 and 14 yr, con-
tracted pharyngoconjunctival fe-
Sex Age
cf 38
T- E-
'-,.--J
+
• CF 32
ver through exposure in a swim- T-E- F-
ming pool. The first secondary ='-v---J t ~
family case occurred 10 days 9 37
CF 0
CF64 CF 256
after onset of the first index ~ .I.:,b
case; within 17 days, all family cf 14
* j
CF 128 CF 64
members became infected. Only .1-;E-,
the father was asymptomatic; +
cf 12 CF8
the mother's illness lasted only 2 CF 64
TtE-
days and was mild. Isolates from '-v---J t
throat and eye were obtained cf 10 CF 64 CF 256
only during acute illness (or at '!!"~.!b T-E- F-
latest 1 day after), whereas fecal
cf 8
* ~
• j
excretion las ted longer. Isolates
~
from the eyes were obtained
only from those with conjunc- cf 7
T-E- Ft
tivitis. Not shown in the illus- '-v---J
tration is the fact that all mem- I
9 2
bers developed antibodies to
AAV 3. Reproduced (modified) Days 0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 ---38 ---- 67
from Foy, H. M., Cooney, M.
K., and Hatlen, J. B., Adenovi- *Index cases, exposed by swimming on day 0
rus type 3 epidemic associated Duration of illness
!7Z21I1Z21I11' E,eye T, throat F, fee a I speci men
with intermittent chlorination of CF=Reeiprocal of CF antibody titer - = Culture negative
a swimming pool, Arch. Envi- + = Culture positive for adenovirus
ron. Health 17:795--802 (1968).
and subsequent immunity for those brought up in sionally types 3, 11, 14, and 21 have caused epi-
the South. (57) In contrast to recruits, seasoned demic ARD. (22.57.(;8,841
troops have low incidence of adenovirus infec- The epidemiology of adenovirus infection
tions, suggesting that lasting immunity is ac- among military popUlations has been studied ex-
quired early in military life(211 (Fig. 4). tensively in the United States, The situation is
The spectrum of clinical manifestations caused similar in most European countries from which
by adenoviruses in military recruits spans mild reports are available, (55,84) The incidence in the
respiratory disease, usually with fever; febrile British army and navy was less than in the air
pharyngitis, often including adenitis; and pneu- force, reflecting different manflgement of recruit
monia. Typical ARD is a febrile respiratory disease populations, with less contact between previously
with symptoms of sore throat and cough, some- and recently inducted recruits.
times coryza, headache, and chest pain. Malaise is Incidence has been reported to be low in Argen-
characteristic, and the illness lasts for approxi- tina(281 and Columbia/ 291 and among Chinese
mately 10 days. White blood cell counts are normal recruits on Taiwan/ 811 most likely caused by
or slightly elevated. It is estimated that 10% of higher rate of exposure and subsequent immunity
recruits reporting to sick bay with ARD have to adenoviruses before induction to the military.
pneumonitis on X-ray examination. Chest films The types of adenoviruses prevalent in military
characteristically have feathery or mottled infil- forces of various countries have varied, Adenovi-
trates. Deaths due to adenovirus pneumonia in the rus type 4 was rarely observed among South
military are rare, but do occur. (2;]) American forces. Types 4 and 3 were epidemic in
Epidemics of ARD are usually caused by adeno- two different garrisons in Finland,'5:;) whereas
virus type 4 and less frequently by type 7. Occa- type 7 was not. In the Netherlands, type 21 be-
50
FIELD ARTILLERY - RTC
( RECRUITS I
----
~
45 1\ SPECIAL TRAINING UNIT
I \ ( RECRUITS I
I \ ---- ... -........ FiElD ARTILLERY BATTALIONS
,
40
(SEASONED MEN I
I \
\
U)
z ~
35 I \
0 IAJ
U) IAJ
I I
II
I \
/',
U) ~ 30 I \
,,,
211: I \ / \
OIAJ I \
/ \
c(A.
25 \ I
'i \ I \
>0 v
11:0
\ r"'"'
...c( -
00. 20
\
,I
,
I '
II: II:
\ I \
- IAJ I
~A. 15 ,..../ \ r I
IAJ
II: I \ / '.•. J \
I
10
\ I
\ I
5
"
3 17 15 29 12 26 9 23 9 23 6 20 4 18
NOV. DEC. JAN. FEB. MAR. APR MAY.
1944 1945
WEEK OF ADMISSION
Fig. 4. Respiratory admission rates for two recruit groups and one seasoned army group at Fort
Bragg, North Carolina, November 1944 to May 1945. Reproduced with permission from Dingle,
J., and Langmuir, A. D., Epidemiology of acute respiratory disease in military recruits, Am. Rev.
Resp. Dis. 97:1--65 (1968).
came epidemic in 196~1961 among military re- with only a very small portion (O.~3%) of respira-
cruits. (84) On Taiwan, type 5 was found in one tory disease. C27 •34 ) In recruit training a number of
outbreak. (80 factors known to encourage epidemics exist. Per-
Despite the epidemic occurrence of adenovi- sons are brought together from different geo-
ruses in military populations, little spread has graphic areas and backgrounds, and subjected to
been noticed from the military bases to the civilian crowding and stress. This situation is known to
populations, including military dependents. An encourage spread in the military of many other
exception was Holland, where epidemics due to infections often classified as childhood diseases
type 21 were observed among the military and such as mumps, rubella, chickenpox, and menin-
children in civilian communities simultane- gococcal disease. Methods of processing recruits
ously. (84) Type 4 has been uncommonly associated may potentiate an epidemic; thus it has been
with disease in civilians. found that when new recruits are allowed to mix
The sharp contrast between the epidemiology of with those already present and presumably in-
adenovirus infections among civilian and military fected, epidemics readily occur.o) In the marine
groups remains unexplained. Studies in adult ci- corps when each training unit was kept separate,
vilian populations, including college students, the overall incidence was lower. The prevalence of
have shown that adenoviruses can be associated neutralizing antibodies in the incoming recruits to
the virus types causing epidemics has generally frequently occurs. This secondary spread may be
been low. by direct contact or possibly droplet transmission.
5.2.3. Pharyngoconjunctival Fever. Pharyngo- In a study conducted in Seattle, it was found that
conjunctival fever is a syndrome characterized by parents secondarily infected from children usually
pharyngitis, conjunctivitis, and fever. The fever is had milder symptoms, often only conjunctivitis.(3l)
often spiking in character. Either one or both eyes This suggests that they possessed some immunity,
may be involved, and only rarely is the cornea most likely humoral, but that the conjunctiva
affected. Diarrhea, coryza, and occasionally otitis lacked sufficient defense mechanism.
may be present. The tonsils may show an exudate, The incubation period is estimated at 6-9 days.
and lymphadenopathy is often observed. In a common source epidemic originating from a
In the 1920s, epidemics of a febrile disease with swimming pool open only for 1 day, the incuba-
conjunctivitis centering around swimming activi- tion period was estimated at an average of 6
ties were first described from Germany (64) and days.(46) An incubation period of 6 days was also
later from the United States.(2) The clinical epide- observed by Bell and coworkers when a patient
miological characteristics of these epidemics are exposed his physician by coughing in his face. (4)
highly suggestive of adenovirus infection, and the On the other hand, the incubation period ob-
epidemics were thought to be caused by inade- served in experimental inoculation of volunteers
quate chlorination. However, the only nonbacte- has been as short as 2 days. (6) This shortening of
rial agent known to cause conjunctivitis at that the incubation period may be dose related.
time was trachoma-inclusion conjunctivitis agent Although several' epidemiological outbreaks
(Chlamydia trachomatis), and it was believed that have been traced to common exposure at a swim-
these epidemics were caused by such agents, since ming pool or a small lake, the virus has never been
inclusions were seen in a few patients. After the isolated from the water of a swimming pool. How-
1950s when adequate diagnostic tools for isolation ever, most attempts at such isolation have taken
of both inclusion conjunctivitis and adenovirus place after the epidemic was identified, when meas-
were developed, all swimming pool-centered epi- ures to remedy the unsatisfactory conditions al-
demics have been traced to adenovirus infec- ready had taken place. Several outbreaks have
tions.(31,46,65) Thus the name "swimming pool clearly been associated with unsatisfactory chlori-
conjunctivitis" for inclusion conjunctivitis infec- nation of swimming pool water. The virus has
tions is probably a misnomer. been isolated from a water sample near a sewage
The association of pharyngoconjunctival fever outlet in a lake where swimmers had experienced
with adenovirus type 3 was first described by Bell pharyngoconjunctival fever. (48) In the laboratory,
et al. in 1955.(4) The syndrome most frequently is adenovirus type 3 appears as susceptible to
caused by adenovirus type 3 or 7, but has also chlorination as Escherichia coli bacteria.
been associated with other adenovirus types, such 5.2.4. Epidemic Keratoconjunctivitis. EKC is a
as types 1, 4, and 14. The disease may be seen disease entity which was first described by Ger-
sporadically and cause epidemics in families and man workers in the latter part of the nineteenth
other closed population groups, (4,31,78) but is best century.(42.44) During World War II when 'ship-
known as an epidemic disease centering around building flourished, it was observed in industrial
summer camps and especially swimming pools outbreaks first on Hawaii, then on the U.S. West
and smalllakes.(31,46,48,65) It usually affects children Coast, and finally on the East Coast. (44) Transmis-
and young adults. The fact that the youngest age sion probably took place in the medical facilities,
groups (under age 4), who waded rather than where the workers sought treatment for for.eign
swam, had the lowest attack rate in the original bodies and chemical irritation of the eye. .
outbreak described by Parrot et al. (65) suggests It was during this period that the disease was
that direct contact with the water, possibly allow- named "epidemic keratoconjunctivitis" because of
ing introduction of the virus into the eye or upper its clinical characteristics, but was often popularly
respiratory tract, is the important mode of spread. called "shipyard eye." The illness characteristically
However, once the virus is introduced into a has an incubation period of 8-10 days and starts
family, secondary spread to other family members with conjunctivitis which may be follicular, fol-
lowed by edema of the eyelids, pain, photopho- 5.2.5. More Unusual Syndromes Associated
bia, and lacrimation. After a couple of days, su- with Adenovirus Infections. Acute hemorrhagic
perficial erosions of the cornea may develop, cystitis is a rare self-limited disease primarily of
followed in a full-blown case by deeper subepithe- childhood, characterized by polyuria, dysuria, and
lial corneal infiltrates with characteristic round hematuria. Isolation of adenovirus type 11 from
shape, located in the center of the cornea. These this disease by use of special techniques was first
may interfere with vision and cause lasting visual accomplished in Sendai, Japan, in 1968.<6a) The
impairment. Preauricular lymph gland swelling is patients showed significant increase in antibody
common, and occasionally cervical and submaxil- titers by neutralization and CF but not by HI test.
lary lymph glands are involved. Frequently only Subsequently, isolation of adenovirus type 11 and
one eye is infected.· Constitutional symptoms may also type 21 from the urine of children with this
occur among children but are usually mild. disease was reported from Chicago.(60)
Adenovirus type 8 has been the almost exclusive Intussusception, an acute illness of infancy, is
cause of the typical disease in Western countries. characterized by "telescoping" one part of the
Rarely have other types such as 4, 10, 11, and 19 intestine into the next distal portion. The disease
been implicated. (a6.85) The virus can be isolated usually requires prompt surgical intervention be-
during the acute disease from the eye, occasionally cause of risk of necrosis as the blood supply of the
from the throat, and for a longer period from the involved bowel segment becomes obstructed.
feces. Lymph tissue enlargement from adenovirus infec-
During the last decades, outbreaks have been tion may initiate such telescoping, and based on
reported centering around the offices of ophthal- reports of high isolation rate of adenoviruses from
mologists. (44.76.79.85) Since the virus is unusually such patients, an etiological role for adenoviruses
hardy, ether and alcohol treatment of ophthalmo- has been suggested.o5.3a.69) However, although
logical instruments (in particular tonometers) is the rate of isolation of adenovirus from children
insufficient as a means of sterilizing equipment, with intussusception is higher than in children
and heat sterilization (240"C or 465"F) is necessary. serving as controls, not all patients with intussus-
Spread may also occur directly by fingers during ception have evidence of adenovirus infection,
manipulation of the lids or by use of eye solutions and the etiology of this syndrome may be com-
and ointments. Patients acquiring the infection by plex.
a visit to the ophthalmologist's office only occa- Pertussis like syndrome in association with various
sionally transmit the infection to family members. serological types of adenovirus infection has been
Direct inoculation into the eye appears necessary described. 07A9 ) Patients selected to serve as con-
to cause disease. trols have generally had less evidence of virus
In areas of Japan and Taiwan, a yearly epidemic infection. Based on the relative rarity of .this syn-
of EKC has been observed in the late summer and drome, it seems likely that the whooping observed
fall. (36) The spread presumably occurs by direct in these patients may be a manifestation of host
contact between children and between family response rather than a syndrome specific to ade-
members. Possibly the more crowded and less noviruses.
hygienic living conditions promote the spread of
the virus. It is also noteworthy that many of the
higher-numbered serological adenovirus types 6. Mechanisms and Route of Transmission
were first isolated from eyes in Saudi Arabia,
where trachoma is highly endemic, suggesting Adenovirus infections in man are spread from
environmental and hygienic requirement for person to person by various routes. Although
spread of both these eye diseases. (7) Serological many lower animals have adenoviruses, there is
studies in the late 1950s revealed that 40-60% of no evidence that these are human in origin or that
Japanese and Taiwanese school children have ac- animal adenoviruses infect humans. There is no
quired neutralizing antibody to type 8, whereas known spread by vectors. In childhood and in
virtually no U.S. children have antibodies to aden- family transmission, the fecal-oral route undoubt-
ovirus type 8(80) (Fig. 1). edly plays the major role. This route is the most
important for transmission of adenoviruses types appear to be characteristic. Typical intranuclear

1, 2, 5, and 6. Respiratory transmission of these virus particles have been observed in alveolar
and other types is possible at all ages in associa- lining and bronchiolar cells by electron micros-
tion with acute respiratory disease. The respira- copy. (61) In infants who recover from adenovirus
tory route is of prime importance when ARD pneumonia, severe sequelae may follow, including
becomes epidemic in military recruit camps. In radiolucent lung syndrome, bronchiectasis, and
volunteer studies, inhalation of small doses of persistent lobar collapseY1.51.74)
adenoviruses in aerosols usually resulted in infec- Neurotropism of the virus, especially type 7, has
tion accompanied by febrile acute respiratory dis- been suggested by isolation from the central nerv-
ease, sometimes with pneumoniaY9) In contrast, ous system. (S.73)
nasopharyngeal administration was much less ef- Rates of adenovirus pneumonia in children are
fective in producing disease. (6) The eye is an lower under the age of 6 months than in older
important portal of entry for virus types 3 and 7, infants, suggesting that maternally derived hu-
particularly when pharyngoconjunctival fever is moral antibodies are protective and that humoral
transmitted in swimming pools or lakes. Epidemic antibody plays a major part in the defense mecha-
keratoconjunctivitis is often an iatrogenic disease nism. Studies of volunteers have shown that even
spread by ophthalmological instruments, oint- artificial challenge with virus in persons already
ments, or fingers in physicians' offices. Adenovi- having neutralizing antibody for that type rarely
ruses occasionally cause nosocomial infections in results in .symptomatic infection. Intracellular loca-
hospitals. (4.13) tion probably protects the virus from the effect of
humoral antibody and permits persistent latent
infection.
7. Pathogenesis and Immunity The incubation period in volunteers challenged
artificially can be as short as 2 days, which may be
Most disease caused by adenoviruses is acute a dose-related response. (4) Under the natural chal-
and self-limited. Type-specific neutralizing anti- lenge, the incubation period averages 6-9 days,
body prevents symptomatic reinfection. While ad- sometimes longer, particularly in EKe.
enovirus disease is short-lasting, infection may be
prolonged and asymptomatic infections are com-
mon. Viral shedding in the gastrointestinal tract
may recur for years. Adenoviruses can be isolated 8. Pattern of Host Response
<from at least 50% of surgically removed tonsils/ 26 )
suggesting that infection may remain latent for a The host response to adenovirus infection is
very long time, possibly for life. dependent on the route of transmission and pri-
The virus may invade the bloodstream in the mary site of viral localization, and on serological
early stages of the disease and viremia has type and dose. Disease syndromes (ARD, peF,
been associated with a maculopapular skin EKC) occurring in special situations have been
rash. (8,13,37 ,74) described above. In persons with normal immune
In the rare fatal illness, the virus has been systems, the presence of humoral antibodies plays
recovered from most body organs.(S) In such a major role in determining the outcome of infec-
cases, extensive pathology is found in the lungs tion. Persons with poor IgA antibody response to
with microscopic necrosis of tracheal and bron- infection have been shown to have increased se-
chial epithelium characterized as necrotizing bron- verity of symptoms. (5(;) Postponement and spac-
chiolitis. In bronchial epithelial cells, acidophilic ing of the several routine immunizations given
intranuclear inclusions have been described, as military recruits have been associated with reduc-
well as basophilic masses of cells surrounded by tion of ARD, pointing out an interesting type of
characteristic clear halos. The latter may represent host stress immunologically associated with aden-
aggregation of larger amount of viral mate- ovirus disease. (57 .(7)
rial.(S.I1.6J) Rosette formation, a mononuclear cell Primary localization of adenoviruses in the res-
infiltrate, and focal necrosis of mucous glands piratory tract or conjunctiva results in a higher rate
of symptomatic infection than gastrointestinal lo- culture with simian virus SV40. This virus is
calization. recognized as oncogenic in animals, and in addi-
The relationship of immunotype to disease se- tion it was found that adenoviruses were able to
verity is difficult to separate from host and envi- incorporate part of the SV40 genome (hybridiza-
ronmental factors. Type 8 causes more severe eye tion) when the viruses grew in the same culture.
disease than other types. Types 4, 7, and 21 have The extensive molecular studies of adenoviruses
been associated with severe respiratory disease. had shown the possibility of the development of a
Why some infections cause pneumonia and even highly purified subunit vaccine. (47) However,
death is not well understood. Host age of 6 months production problems for such a vaccine have not
to 2 yr is dearly associated with adenoviral pneu- been solved.
monia, as is general host deprivation associated In recent years, major vaccine efforts have been
with lower socioeconomic status. Type 7 and to made with live attenuated virus given or-
some extent type 21 have been particularly associ- ally. (12,24,66,68,75,83) This approach has been based
ated with fatal infant pneumonia.(8,U,14,51,74) on the theory that by bypassing the respiratory
A concurrent or preceding infection with an- tract and introducing a live virus into the gastroin-
other virus has been suggested as a cause of severe testinal tract, where the virus was known to multi-
disease and has been observed, particularly with ply, respiratory disease could be avoided while the
measles. (4 ) It has been reported that during subject acquired solid immunity. For this purpose,
mumps infection, adenovirus excretion reap- live adenoviruses grown in human cells were plac-
peared.(aO) In studies of pneumonia etiology, an ed in enteric-coated gelatin capsules. Following
unexpectedly high rate of serological titer rises to experimental studies, this approach to immuniza-
adenoviruses was found to occur at the same time tion has been shown to be highly effective in
as antibody rises to influenza, parainfluenza, and military recruit populations. However, when type
Mycoplasma pneumoniae, which were implicated as 4 military epidemics were controlled by live, oral
etiological agents of the pneumonia. (32,40) immunization, type 7 epidemics occurred. Biva-
lent immunization has successfully controlled
these two types.(82) The fear that another type of
9. Control and Prevention adenovirus, for example, type 21, would take over
and fill the "ecological niche" has not yet been
Of the various approaches to the prevention or substantiated. (68)
control of adenovirus infections, bolstering the The experimental studies with these vaccines
host's resistance through immunization has shown have shown a number of interesting facts about
the most promise. In certain situations, environ- adenoviral spread. (20,66,8a) Neither type 4 nor 7
mental control has been effective.(52,54) Control or spread from adults infected by enteric capsules to
treatment with antiviral compounds, interferon, or susceptible adults housed together for a prolonged
interferon inducers has shown no practical period. (20.66) On the other hand, when enteric live
value. (43) adenovirus type 4 vaccine was introduced to one
Because of the major disruption and economic partner of 39 married couples and a placebo was
impact of ARD epidemics in military recruits, given to the other, viral isolates were obtained
most of the efforts at the development of human from 70% of the placebo recipients, suggesting
adenoviral vaccines have been directed at this that intimate physical contact facilitated transmis-
population. The first widely used vaccines were sion of the virus. (77) No serious symptoms were
inactivated adenoviruses grown in monkey kidney encountered in the placebo group. In another
tissue cultureY2,66) They were shown to be effec- study, conjunctivitis occurred in two of six volun-
tive against adenoviral infection with types 3, 4, teers infected in the gastrointestinal tract, proba-
and 7. However, potency varied between lots of bly by fecal-conjunctival contamination.(20) When
vaccine because of poor growth in the monkey cell children in a household were immunized by this
culture. Efforts to meet minimal standards for route, transmission of the virus (type 4) to other
military use were often unsuccessful. A major members of the household was demonstrated with
production difficulty was contamination of the cell occasional illness. (59)
There have been no efforts to protect children or fully understood. The role of the high-numbered
other civilian populations from adenovirus infec- serological types, best known for their presence in
tions by immunization with oral vaccine. Success- some underdeveloped and tropical countries and
ful immunization by the gastrointestinal route has incompletely studied in the United States, is yet to
been demonstrated with types 1, 2, and 5 in adult be determined. The role of concomitant or subse-
volunteers.(72) Since none of the virus in these quent virus infection in precipitating more severe
vaccines has been demonstrated to be significantly adenoviral disease remains to be worked out.
attenuated, there is the risk that administration of The long-term effect of latent adenovirus infec-
live vaccines to infants may cause spread of aden- tion or reactivation later in life is open to specula-
oviral disease. The practical problems of spread of tion. Oncogenicity has been shown only when
infection and the hypothetical concerns that re- human adenoviruses have been introduced into
main concerning oncogenicity would make an ef- animal models. Although the search for oncogenic
fort to immunize infants and children with live potentiality in humans by investigation for T (tu-
adenoviruses a dubious undertaking. mor) antigens has so far been negative, an onco-
Environmental control is effective in certain sit- genic effect in humans cannot be totally ruled out.
uations. Thus the evidence suggests that adequate To conduct long-term studies of human popula-
chlorination of swimming pools prevents the tions to resolve this dilemma would be a
spread of pharyngoconjunctival fever. The spread formidable task.
of keratoconjunctivitis through contaminated
ophthalmological instruments, ointments, and so-
lutions can be prevented by heat sterilization and
appropriate hygienic measures. 11. References
Since adenovirus infections in military recruit
1. ARLANDER, T. R., PIERCE, W. E., EDWARDS, E. A.,
populations appear to be associated with crowding
PECKINPAUGH, R. 0., AND MILLER, L. F., IV. An
and airborne transmission, various environmental
epidemiologic study of respiratory illness patterns in
control attempts have been tried. Modification of navy and marine corps recruits, Am. J. Public Health
the sleeping arrangements in barracks has met 55:67-80 (1965).
with, at best, limited success. (53) Attempts at dust 2. BAHN, c., Swimming bath conjunctivitis, New Orle-
suppression have been more successful, (54) ans Med. Sci. J. 79:586-590 (1927).
whereas air purification with ultraviolet light and 3. BELL, J. A., HUEBNER, R. J., ROSEN, L., ROWE, W. P.,
germicidal sprays has failed.(52,53) More extensive COLE, R. M., MASTROTA, F. M., FLOYD, T. M., CHAN-
changes in the patterns of recruit housing and OCK, R. M., AND SHVEDOFF, R. A., Illness and micro-
training can modify ARD occurrence but may be bial experiences of nursery children at Junior Village,
impractical in times of mobilization.(1) Am. J. Hyg. 74:267-292 (1961).
4. BELL, J. A., ROWE, W. P., ENGLER, J. I., PARROTT, R.
H., AND HUEBNER, R. J., Pharyngoconjunct~val fever:
Epidemiological studies of a recently recognized dis-
ease entity, J. Am. Med. Assoc. 175:1083-1092 (1955).
10. Unresolved Problems 5. BELL, J. A., ROWE, W. P., AND ROSEN, L., II. Adeno-
viruses, Am. J. Public Health 52:902-907 (1962).
Long strides have been made during the last 6. BELL, J. A., WARD, T. G., HUEBNER, R. J., ROWE, W.
decade in describing and understanding the mo- P., SUSKIND, R. G., AND PAFFENBARGER, R. S., JR.,
lecular biology of adenoviruses, yet no effective Studies of adenoviruses (APC) in volunteers, Am. J.
antiviral agent has been found. Although several Public Health 46:1130-1146 (1956).
7. BELL, S. D., JR., ROTA, T. R., AND McCOMB, D. E.,
types of vaccines have been developed, none is
Adenovirus isolated in Saudi Arabia. III. Six new
ideal and the possibility of using a purified sub-
serotypes, Am. J. Trap. Med. 9:523-526 (1960).
unit of the virus for vaccine is an attractive pros- 8. BENYESH-MELNICK, M., AND ROSENBERG, H. S., The
pect. Such a vaccine should be highly immuno- isolation of adenovirus type 7 from a fatal case of
genic but not pathogenic. pneumonia and disseminated disease, J. Pediat.
The exact mechanism whereby adenoviruses 64:83-87 (1964).
cause tissue damage and systemic disease is not 9. BRANDT, C. D., KIM, H. W., JEFFRIES, B. c., PYLES,
66 Chapter 3 • Adenovimses
G., CHRISTMAS, E. E., REID, J. 1., CHANOCK, R. M., 21. DINGLE, J., AND LANGMUIR, A. D., Epidemiology of
AND PARROTT, R H., Infections in 18,000 infants and acute respiratory disease in military recruits, Am.
children in a controlled study of respiratory tract Rev. Resp. Dis. 97:1-65 (1968).
disease. II. Variation in adenovirus infections by 22. DUDDING, B. A., Top, F. H., JR., WINTER, P. E.,
year and season, Am. f. Epidemiol. 95:218-227 (1972). BUESCHER, E. 1., LAMSON, T. H., AND LEIBOVITZ, A.,
10. BRANDT, C. D., KIM, H. W., VARGOSKO, A. J., JEF- Acute respiratory disease in military trainees: The
FRms, B. c., ARROBIO, J. 0., RINDGE, B., PARROTT, R adenovirus surveillance program, 1966-1971, Am. f.
H., AND CHANOCK, R M., Infections in 18,000 infants Epidemiol. 97:187-198 (1973).
and children in a controlled study of respiratory tract 23. DUDDING, B. A., WAGNER, S. c., ZELLER, J. A.,
disease. I. Adenovirus pathogenicity in relation to GMELICH, J. T., FRENCH, G. R., AND Top, F. H., JR.,
serologic type and illness syndrome, Am. J. Epide- Fatal pneumonia associated with adenovirus type 7
miol. 90:484-500 (1969). in three military trainees, N Engl. f. Med. 286:1289-
11. BROWN, R. S., NOGRADY, M. B., SPENCE, 1., AND 1292 (1972).
WIGLESWORTH, F. W., An outbreak of adenovirus 24. EDMONDSON, W. P., PURCELL, R H., GUNDERFINGER,
type 7 infection in children in Montreal, Can. Med. B. F., LOVE, J. W. P., LUDWING, W., AND CHANOCK,
Assoc. f. 108:434-439 (1973). R M., Immunization by selective infection with type
12. CHANOCK, R. M., LUDWIG, W., HUEBNER, R J., CATE, 4 adenovirus grown in human diploid tissue culture.
T. R, AND CHU, 1. W., Immunization by selective II. Specific protective effect against epidemic disease,
infection with type 4 adenovirus grown in human f. Am. Med. Assoc. 195:159-165 (1966).
diploid tissue culture. I. Safety and lack of oncogen-
25. ENDERS, J. F., BELL, J. A., DINGLE, J. H., FRANCIS, T.,
icity and tests for potency in volunteers, f. Am. Med.
JR., HILLEMAN, M. R, HUEBNER, R J., AND PAYNE A.
Assoc 195:151-158 (1966).
M. M., "Adenoviruses": Group name proposed for
13. CHANY, c., LEPINE, P., LELONG, M., VINH, 1. T.,
new respiratory-tract viruses, Science 124:119-120
SATGE, P., AND VIRAT, J., Severe and fatal pneumonia (1956).
in infants and young children associated with adeno-
26. EVANS, A. S., Latent adenovirus infections of the
virus infections, Am. f. Hyg. 67:367-378 (1958).
human respiratory tract, Am. f. Hyg. 67:256-266
14. CHIN-HsmN, T., Adenovirus pneumonia epidemic
(1958).
among Peking infants and pre-school children in
1958, Chin. Med. f. 80:331-339 (1960). 27. EVANS, A. S., Clinical syndromes in adults caused by
15. CLARKE, E. J., PHILLIPS, I. A., AND ALEXANDER E. R., respiratory infections, Med. Clin. North Am. 51:803-
Adenovirus infection in intussusception in children 818 (1967).
in Taiwan, J. Am. Med. Assoc. 208:1671-1674 (1969). 28. EVANS, A. S., CENABRE, 1., WANAT, J., RICHARDS, V.,
16. Commission on Acute Respiratory Diseases, Experi- NEIDERMAN, J. c., AND ACTlS, A., Acute respiratory
mental transmission of minor respiratory illness to infections in different ecologic settings. I. Argentine
human volunteers by filter-passing agents. I. Dem- military recruits, Am. Rev. Resp. Dis. 108:1311-1319
onstration of two types of illness characterized by (1973).
long and short incubation periods and different 29. EVANS, A. S., JEFFREY, c., AND NmDERMAN, J. c.,
clinical features, J. Clin. Invest. 26:957-973 (1947). The risk of acute respiratory infections in two groups
17. CONNOR, J. D., Evidence for an etiologic role of of young adults in Colombia, South America:A pro-
adenoviral infection in pertussis syndrome, N. Engl. spective seroepidemiologic study, Am. J. Epidemiol.
J. Med. 283:390-394 (1970). 93:463-471 (1971).
18. COONEY, M. K., HALL, C. E., AND Fox J. P., The 30. Fox, J. P., BRANDT, C. D., WASSERMANN, F. E., HALL,
Seattle Virus Watch. III. Evaluation of isolation C. E., SPIGLAND, I., KOGON, A., AND ELVEBACK, 1. R,
methods and summary of infections detected by The Virus Watch Program: A continuing surveillance
virus isolations, Am. f. Epidemiol. 96:286-305 (1972). of viral infections in metropolitan New York fami-
19. COUCH, R. B., CATE, T. R, FLEET, W. F., GERONE, P. lies. VI. Observations of adenovirus infections: virus
J., AND KNIGHT, V., Aerosol-induced adenoviral ill- excretion patterns, antibody response, efficiency of
ness resembling the naturally occurring illness in surveillance, patterns of infection, and relation to
military recruits, Am. Rev. Resp. Dis. 93:529-535 illness, Am. j. Epidemiol. 89:25-50 (1969).
(1966). 31. Foy, H. M., COONEY, M. K., AND HATLEN, J. B.,
20. COUCH, R. B., CHANOCK, R. M., CATE, T. R, LANG, Adenovirus type 3 epidemic associated with inter-
D. J., KNIGHT, V., AND HUEBNER, R J., Immunization mittent chlorination of a swimming pool, Arch. Envi-
with types 4 and 7 adenovirus by selective infection ron. Health 17:795-802 (1968).
of the intestinal tract. Am. Rev. Resp. Dis. 88:394-403 32. Foy, H. M., COONEY, M. K., McMAHAN, R., AND
(1963). GRAYSTON, J. T., Viral and mycoplasmal pneumonia
in a prepaid medical care group during an eight-year adenoviruses in a family study population, Ann.
period, Am. J. Epidemiol. 97:93-102 (1973). N.Y. Acad. Sci. 67:273-278 (1957).
33. GARDNER, P. S., KNOX, E. G., COURT, S. D. M., AND 46. KAJI, M., KIMURA, M., KAMIYA, S., TATEWAKI, E.,
GREEN, C. A., Virus infection and intussesception in TAKAHASHI, T., NAKAJIMA, 0., KOGA, T., ISHIDA, S.,
childhood, Br. Med. J. 2:697-700 (1962). AND MATIMA, Y., An epidemic of pharyngoconjuncti-
34. GRAYSTON, J. T., LASHOF, J. c., LOOSLI, C. G., AND val fever among school children in an elementary
JOHNSTON, P. B., Adenoviruses. lll. Their etiological school in Fukuoka Prefecture, Kyushu J. Med. Sci.
role in acute respiratory disease in civilian adults, J. 12:1-8 (1961).
Infect. Dis. 103:93-101 (1958). 47. KASEL, J. A., ALFORD, R. H., LEHRICH, J. R., BANKs,
35. GRAYSTON, J. T., LOOSLI, C. G., SMITH, M., McCAR- P. A., HUBER, M., AND KNIGHT, V., Adenovirus
THY, M. A., AND JOHNSTON, P. B., Adenoviruses, I. soluble antigens for human immunization, Am. Rev.
The effect of total incubation time in HeLa cell Resp. Dis. 94:170-174 (1966).
cultures on the isolation rate, J. Infect. Dis. 103:75- 48. KJELLEN, 1., ZETTERBERG, B., AND SVEDMYR, A., An
101 (1958). epidemic among Swedish children caused by adeno-
36. GRAYSTON, J. T., YANG, Y. F., JOHNSTON, P. B., AND virus type 3, Acta Paediat. Scand. 46:461-568 (1957).
Ko, 1. S., Epidemic keratoconjunctivitis on Taiwan: 49. KLENK, E. 1., GWALTNEY, J. M., AND BASS, J. W.,
Etiological and clinical studies, Am. J. Trop. Med. Bacteriologically proved pertussis and adenovirus
13:492-498 (1964). infection, Am. J. Dis. Child. 124:203-207 (1972).
37. GUTEKUNST, R. R., AND HEGGm, A. D., Viremia and 50. KLOENE, W., BANG, F. B., CHAKRABORTY, S. M.,
viruria in adenovirus infections: DetectIon in pa- COOPJ!R, M. R., KULEMANN, H., OTA, M., AND SHA,
tients with rubella or rubelliform illness, N. Engl. J. K. V., A two-year respiratory virus survey in four
Med. 264:374-378 (1%1). villages in West Bengal, India, Am. J. Epidemiol.
38. HALL, C. E., BRANDT, C. D., FROTHINGHAM, T. E., 92:307-320 (1970).
SPIGLAND, I., COONEY, M. K., AND Fox, J. P., The 51. LANG, W. R., HOWDEN, C. W., LAWS, J., AND BUR-
Virus Watch Program: A continuing surveillance of TON, J. F., Bronchopneumonia with serious sequelae
viral infections in metropolitan New York families. in children with evidence of adenovirus type 21
IX. A comparison of infections with several respira- infection, Br. Med. J. 1:73-79 (1969).
tory pathogens in New York and New Orleans fami- 52. LANGMUIR, A. D., JARRETT, E. T., AND HOLLAENDER,
lies, Am. J. Epidemiol. 94:367-385 (1971). A., Studies of the control of acute respiratory disease
39. HARRIS, D. J., WULFF, H., RAY, C. G., POLAND, J. D., among navy recruits, Am. J. Hyg. 48:240-251 (1948).
CHIN, T. D. Y., AND WENNER, H. A., Viruses and 53. LEHANE, D. E., NEWBERG, N. R., AND BEAM, W. E.,
disease. III. An outbreak of adenovirus type 7A in a Environmental modifications for controlling acute
children's home, Am. J. Epidemiol. 93:399-402 (1971). respiratory disease, Am. J. Epidemiol. 99:139-144
40. HILLEMAN, M. R., HAMPARIAN, V. V., KETLER, A., (1974).
REILLY, C. M., MCCLELLAND, 1., CORNFmLD, D., AND 54. LOOSLI, C. G., LEMON, H. M., ROBERTSON, O. H.,
STOKES, J., JR., Acute respiratory illness among chil- AND HAMBURGER, M., Transmission and control of
dren and adults: Field study of contemporary impor- respiratory disease in army barracks, J. Infect. Dis.
tance of several viruses and appraisal of the litera- 90:153-164 (1952).
ture, J. Am. Med. Assoc. 180:445-453 (1962) 55. MANTYJARVI, R., Adenovirus infections in service-
41. HILLEMAN, M. R., AND WERNER, J. H., Recovery of men in Finland, Ann. Med. Exp. Fenn. 44:1-43 (1966).
new agents from patients with acute respiratory 56. McCORMICK, D. P., WENZEL, R. P., DAvms, J. A.,
illness, Proc. Soc. Exp. Bio!. Med. 85:183-188 (1954). AND BEAM,W. E., Nasal secretion protein responses
42. HOGAN, M. J., AND CRAWFORD, J. W., Epidemic in patients with wild-type adenovirus disease, Infect.
keratoconjunctivitis (superficial punctate keratitis, Immun. 6:282-288 (1972).
keratitis subepithelialis, keratitis maculosa, keratitis 57. MILLER, 1. F., RYTEL, M., PmRCE, W. E., AND Ro-
nummularis), Am. J. Ophthalmol. 25:1059-1078 SENBAUM, M. J., Epidemiology of nonbacterial pneu-
(1942). monia among naval recruits, J. Am. Med. Assoc.
43. JACKSON, G. G., AND MULDOON, R. 1., Viruses caus- 185:92-99 (1963).
ing common respiratory infection in man. IV. Reovi- 58. MONTO, A. S., NAPmR, J. A., AND METZNER, H. 1.,
ruses and adenoviruses, J. Infect. Dis. 128:834-866 The Tecumseh study of respiratory illnesses. I. Plan
(1973). of study and observations on syndromes of acute
44. JAWETZ, E., The story of shipyard eye, Br. Med. J. respiratory disease, Am. J. Epidemio!. 94:269-279
1:873-878 (1959). (1971).
45. JORDAN, W. S., JR., The frequency of infection with 59. MUELLER, R. E., MULDOON, R. 1., AND JACKSON, G.
c., Communicability of enteric live adenovirus type adenovirus type 7 epidemic, Acta. Paediat. Scand.
4 vaccine in families, J. Infect. Dis. 119:60--66 (1969). 59:310-316 (1970).
60. MUFsoN, M. A., BELSHE, R B., HORRIGAN, T. J., AND 74. SIMlLA, S., YLIKORKALA, 0., AND WAsz-HoCKERT,
ZOLLAR, 1. M., Cause of acute hemorrhagic cystitis 0., Type 7 adenovirus pneumonia, J. Pediat. 79:605-
in children, Am. J. Dis. Chi/d. 126:605--609 (1973). 611 (1971).
61. NAHMIAS, A. J., GRIFFITH, D., AND SNI1ZER, J., Fatal 75. SMITH, T. J., BUESCHER, E. 1. Top, F. H., JR., ALTE-
pneumonia associated with adenovirus type 7, Am. J. MEIER, W. A., AND MCCOWN, J. M., Experimental
Dis. Chi/d. 114:36-41 (1967). respiratory infection with type 4 adenovirus vaccine
62. NORRBY, E., The structural and functional diversity in volunteers: Clinical and immunological responses,
of adenovirus capsid components, J. Gen. Virol. J. Infect. Dis. 122:239--248 (1970).
5:221-236 (1%9). 76. SPRAGUE, J. B., HIERHOlZER, J. c., CURRIER, R W.,
63. NUMAZAKI, Y., KUMASAKA, T., YANO, N., YAMAN- II, HATTWICH, M. A. W., AND SMITH, M. D., Epi-
AKA, M., MIYAZAWA, T., TAKAI, S., AND ISHIDA, N., demic keratoconjunctivitis: A severe industrial out-
Further study of acute hemorrhagic cystitis due to break due to adenovirus type 8, N. Engl. J. Med.
adenovirus type 11, N. Engl. J. Med, 289:344--347 289:1341-1346 (1973).
(1973). 77. STANLEY, E. D., AND JACKSON, G. G., Spread of
64. PADERSTEIN, R, WAS 1ST SCHWIMMBAD-KoNJUNKTIVI- enteric live adenovirus type 4 vaccine in married
TIS? Klin. Monatsbl. Augenhei/kd. 72:634-642 (1925). couples, J. Infect. Dis. 119:51-59 (1969).
65. PARROTT, R. H., ROWE, W. P., HUEBNER, R J., 78. STERNER, G., Adenovirus infection in childhood: An
BERNTON, H. W., AND MCCULLOUGH, N. B., Out- epidemiological and clinical survey among Swedish
break of febrile pharyngitis and conjunctivitis associ- children, Acta Paediat. Scand. Suppl. 142:1-30 (1%2).
ated with type 3 adenoidal-pharyngeal-conjunctival 79. SVARTZ-MALMBERG, G., AND GERMANIS, M., Adeno-
virus infection, N. Engl. J. Med. 251:1087-1090 (1954). virus type 8-associated keratonconjunctivitis: Host-
66. PIERCE, W. E., ROSENBAUM, M. J., EDWARDS, E. A., pital infections and secondary spread in Stockholm,
PECKINPAUGH, R. 0., AND JACKSON, G. G., Live and 1967, Scand, J. Infect. Dis. 1:161-168 (1969).
inactivated adenovirus vaccines for the prevention of 80. TAl, F. H., AND GRAYSTON, J. T., Adenovirus neutral-
acute respiratory illness in naval recruits, Am. J. izing antibodies in persons on Taiwan, Proc. Soc.
Epidemiol. 87:237-246 (1968). Exp. Bioi. Med. 109:881-884 (1962).
81. TAl, F. H., GRAYSTON, J. T., JOHNSON, P. B., AND
67. PIERCE, W. E., STILLE, W. T., AND MILLER, 1. F., A
WOOLDRIDGE, R. 1., Adenovirus infections in
preliminary report on effects of routine military inoc-
Chinese anny recruits on Taiwan, J. Infect. Dis.
ulations on respiratory illness, Proc. Soc. Exp. Bioi.
107:160-164 (1960).
Med. 114:369--372 (1963).
82. Top, F. H., JR., DUDDING, B. A., RUSSELL, P. K., AND
68. ROSE, H. M., LAMSON, T. H., AND BUESCHER, E. 1.,
BUESCHER, E. 1., Control of respiratory disease in
Adenoviral infection in military recruits: Emergence
recruits with types 4 and 7 adenovirus vaccines, Am.
of type 7 and type 21 infections in recruits immu-
nized with type 4 oral vaccine, Arch. Environ. Health
J. Epidemiol. 94:142-146 (1971).
83. Top, F. H., JR., GROSSMAN, R A., BARTELWNI, P. J.,
21:356--361 (1970).
SEGAL, H. E., DUDDING, B. A., RUSSELL, P. K., AND
69. Ross, J. G., POTTER, C. W., AND ZACHARY, R B.,
BUESCHER, E. 1., Immunization with live types 7 and
Adenovirus infection in association with intussus-
4 adenovirus vaccines. I. Safety, infectivity, and
ception in infancy, Lancet 2:221-223 (1962).
potency of adenovirus type 7 vaccine in humans, J.
70. ROWE, W. P., HUEBNER, R. J., GILMORE, 1. K., Infect. Dis. 124:148--154 (1971).
PARROT, R H., AND WARD, T. G., Isolation of a 84. VANDER VEEN, J., The role of adenoviruses in respi-
cytopathogenic agent from human adenoids ratory disease, Am. Rev. Resp. Dis. 88:167-180 (1963).
undergoing spontaneous degeneration in tissue cul- 85. VAS, S. I., ABRAMOVITCH, H., JACKSON, W. B.,
ture, Proc. Soc. Exp. BioI. Med. 84:570-573 (1953). DIXON, C., GROH, V., AND CHAMPLIN, R., Interna-
71. SCHMIDT, O. W., COONEY, M. K., AND Foy, H. M., tional notes: Keratoconjunctivitis due to adenovirus
Adenovirus-associated virus in adenovirus type 3 type 19-Canada, in: Morbidity and Mortality, U.S.
conjunctivitis, Infect. Immun. 11:1362-1370 (1975). Department of Health, Education, and Welfare, Vol.
72. SCHWARTZ, A. R., TOGO, Y., AND HORNICK, R. B., 23, No. 21 (1974).
Clinical evaluation of live, oral types 1, 2, and 5 86. VIHMA, 1., Surveillance of acute viral respiratory
adenovirus vaccines, Am. Rev. Resp. Dis. 109:233-238 disease in children, Acta Paediat. Scand. Suppl. 192:8-
(1974). 52 (1969).
73. SIMlLA, S., JOUPPLIA, R, SALMI, A., AND POH}EN, R., 87. WENNER, H. A., BERAN, G. W., WESTON, J., AND
Encephalomeningitis in children associated with an CHIN, T. D. Y., with collaboration of ANDERSON, N.
W., AND GOLDSMITH, R., The epidemiology of acute GINSBERG, H. 5., AND DINGLE, J. H., The adenovirus
respiratory illness. 1. Observations on adenovirus group, in: Viral and Rickettsial Infections of Man (F. 1.
infections prevailing in a group of families, J. Infect. HORSFALL AND 1. TAMM, eds.) pp. 860-891, Lippincott,
Dis. 101:275-286 (1957). Philadelphia, 1965.
JACKSON, G. G., AND MULDOON, R. 1., Viruses causing
common respiratory infection in man. IV Reoviruses
and adenoviruses, J. Infect. Dis. 128:811-866 (1973).
12. Suggested Reading KNIGHT, V., AND KASEL, J. A., Adenoviruses, in: Viral
and Mycoplasmal Infections of the Respiratory Tract (V.
EVANS, A. S., Acute respiratory infections, in: Communi- KNIGHT, ed.), pp. 65-86, Lea and Febiger, Philadel-
cable and Infectious Diseases (F. H. Top, SR., AND P. F. phia, 1973.
WEHRLE. eds.), pp. 510-532, Mosby, St. Louis, 1972. NORRBY, E., The structural and functional diversity of
GINSBERG, H. 5., Adenoviruses, Am. J. Clin. Patho!. adenovirus capsid components, J. Gen. Viro!. 5:221-236
57:771-776 (1972). (1969).
CHAPTER 4
Arboviruses
Wilbur G. Downs
1. Introduction pods include mosquitos, sandflies (Phlebotomus

and related genera and Culicoides and related gen-
Well over 350 arboviruses are distinguishable by era), hard (ixodid) and soft (argasid) ticks, and,
serological procedures. Theiler and DownS(74) list oi lesser importance to arbovirus epidemiology,
293 as of 1973. Table 1, allotting these to groups, horseflies (Tabanidae), blackflies (Simuliidae), and
illustrates the complexity of the subject, with 24 mites. Limited explorations of fleas, lice, hippo-
groups and the Bunyamwera supergroup, which boscids, muscids, streblids, and nycteribiids have
includes another ten groups. In addition, there are not yielded encouraging leads. Biological transmis-
four unassigned viruses in the Bunyamwera su- sion implies an obligatory phase of virus multipli-
pergroup and 61 entirely ungrouped viruses. Since cation in the arthropod, before transmission to the
this compilation, there have been several new next host. Mechanical transmission of an arbovirus
groupings proposed and several recently charac- can of course occur if an arthropod bites a viremic
terized viruses have been added, either to known host with the arthropod mouthparts or foregut still
groupings or to the "ungrouped" category. The virus contaminated. Such a mechanism has been
American Committee on Arthropod-Borne Viruses ppstulated for hepatitis B virus transmission. (53)
published the Catalogue of Arthropod-Borne Viruses Mechanical transmission could, in extraordinary
of the World, compiled by R. M. Taylor, in 1967,(2) arbovirus epidemic situations, be a significant
and this was supplemented by additional listings adjunct to biological transmission, although this
in 1970(3) and 197V4 ) A complete updated revi- has never been demonstrated in an epidemic.
sion of the catalogue appeared in 1975.(2) The
above publications provide a mass of digested
information on viruses individually, including
data on arthropod vectors, vertebrate hosts, isola-
tion localities, pathogenesis and pathology, and
laboratory propagation in vertebrates and cell cul- The concept of arthropod-transmitted diseases
tures, and also provide condensed bibliographies slowly evolved from a background of centuries of
for .each virus. speCUlations and hypotheses concerning various
major plagues of man, including malaria, yellow
The term arbovirus is defined in the ecological
fever, plague, typhus, filariasis, and trypanosom-
sense to include any virus of vertebrates that is
iasis, and of animals, including babesiosis, trypa-
biologically transmitted by arthropods. Arthro-
nosomiasis, African horsesickness, bluetongue of
Wilbur G. Downs Yale Arbovirus Research Unit, sheep, and equine encephalomyelitis.
Department of Epidemiology and Public Health, Yale Patrick Manson in 1878 described mosquito in-
University School of Medicine, New Haven, Connecticut fection with and transmission of the filarial worm
71
72 Chapter 4 • Arboviruses
Table 1. Arbovirus Groups and Virus Vectors"
Number of Known, presumed, or suspected vectors

viruses in - - - - - - - - - - - - - - - - - - - - Vector
Group group Mosquitos Phlebotomus Culicoides Ticks not known
Group A (alphaviruses) 20 20
Group B (flaviviruses) 42 26 8 8
Bunyamwera supergroup (bunyaviruses)
Bunyamwera 13 13
Group C 11 11
Guama 9 6 3
Capim 7 4 3
Simbu 15 8 3 4
California 10 10
Bwamba 2 2
Tete 3 3
Patois 4 3 1
Koongol 2 2
Unassigned 4 3 1
Anopheles A 4 3 1
Anopheles B 2 2
Bakau 2 2
Nyando 2 2
Timbo 2 2
Turlock 3 3
Mossuril 2 2
Mapputta 2 2
Epidemic hemorrhagic disease 2 2
of deer
Vesicular stomatitis 6 4 and (1) 1 1
Sandfly fever 15 8 7
Changuinola 5 1 3 1
Ganjam 2 2
Hughes 3 3
Kaisodi 3 3
Kemerovo 6 6
Qalyub 2 2
Quaranfil 2 2
Uukuniemi 4 4
African horsesickness 9 9
Bluetongue of sheep 12 12
Ungrouped 61 32 1 16 12
Total 293 161 21 24 52 35
a Modified from Theiler and Downs.""
Wuchereria bancrofti. Theobald Smith described 1900, and Walter Reed and associates succeeded in
tick transmission of red water fever in cattle, transmitting the virus by bite of Aedes aegypti in
caused by Babesia bigemina, in 1893. Ross in 1897 1901. Not until 1928 did Stokes, Bauer, and Hud-
succeeded in transmitting a malarial infection by son(70) demonstrate that the agent causing yellow
mosquito bite. Carlos Finlay attempted transmis- fever was indeed a virus. Indeed, biological trans-
sion of yellow fever virus by mosquito bite before mission of the viruses of yellow fever (1901),
Chapter 4 • Arboviruses 73
phlebotomus fever (1909), and dengue (1920--1924) cephalitis, dengue, and St. Louis viruses, also by
was accomplished before the viruses themselves CF test. Smithburn in 1954(691 showed that mon-
were known. Several of the most important arbov- keys immune to one arbovirus, when inoculated
iruses were identified in the 1930s, including the with a related virus, in proper sequence, devel-
viruses of eastern equine encephalitis, western oped antibodies capable of neutralizing the second
equine encephalitis, st. Louis encephalitis, Rus- virus and an increased capacity to neutralize the
sian spring-summer encephalitis, Japanese en- original virus.
cephalitis, Murray Valley encephalitis, and Rift Development of the techniques of hemagglutin-
Valley fever. This list was expanded in the 1940s ation and hemagglutination inhibition began with
by addition of several more viruses encountered Hallauer's demonstration in 1946(a21 of a hemag-
during the course of yellow fever field studies in glutinating antigen from a yellow fever virus
Africa and South America, and encephalitis stud- strain. Sabin and Buescher in 1950(611 described a
ies in the Americas. An intensified program di- hemagglutinin for Japanese encephalitis, and, in
rected toward determining the world-wide arbovi- short order, Sabin and other collaborators ex-
rus picture was initiated by the Rockefeller tended the list to include several group B and one
Foundation in 1952, and this, plus efforts of many group A arboviruses. Casals and Brown in 1954(201
investigators in other laboratories, has led to the made further additions when they prepared and
present recognition of over 350 serologically dis- used acetone and acetone-ether extracted antigens.
tinct agents. Casals in 1957(161 listed 47 viruses Clarke and Casals in 1958(221 described techniques
and in 1958(171 listed 72; by 1962 the list had which have been but little modified to date, in-
reached 161. A similar increase in numbers of cluding the sucrose-acetone technique for prepa-
recognized respiratory, enteric, and other non- ration of hemagglutinins and the kaolin and ace-
arboviruses has been paralleling the arbovirus tone techniques for extraction of nonspecific
explosion. The increase in numbers of recognized inhibitors from sera to be studied in tests for
arboviruses is directly referable to the introduction hemagglutination inhibition. Ardoin, Clarke, and
of the infant mouse intracerebral inoculation tech- Hannoun in 1969(5) described sonication and
nique for virus isolation, with cell culture methods trypsin treatment of virus preparations to achieve
playing a very minor role. The infant mouse tech- hemagglutinins in instances where commonly
nique was used by Dalldorf to isolate many of the used procedures did not work well, if at all.
coxsackieviruses, but in other areas of respiratory Casals in 1957061 outlined a scheme for classify-
and enteric virology the explosion followed intro- ing arboviruses according to serological interreac-
duction of cell culture techniques. tions, intending this as a helpful device for sub-
The systems employed for arbovirus identifica- sorting or categorizing the numerous viruses. The
tion and classification have been largely serologi- concept has been an invaluable one in bringing
cal and only recently has electron microscopy been order out of chaos, and the original schema has
extensively and usefully employed. The serological been greatly extended. Later actions of the Virus
techniques have included complement fixation Subcommittee of the International Nomenclature
(CF), hemagglutination inhibition (HI), and neu- Committee have recommended the adoption of a
tralization (N). Modem modifications of these universal system of classification in which the
classical techniques rooted in the same basic prin- properties of the virion should be the sole basis for
ciples include the use of "tagged" antibodies (fer- the establishment of taxa. The various arbovirus
ritin, fluorescein, radioactive isotopes) and anti- serogroups have been distributed among various
gens. Highly purified virus and virus component taxa such as togaviruses, including alphaviruses
preparations have been made possible by ultra- (group A arboviruses) and flaviviruses (group B
centrifugation and chromatographic techniques. arboviruses), bunyaviruses (including the viruses
With the neutralization test, Smithburn in of the Bunyamwera supergroup), rhabdoviruses,
1942(681 showed some immunological relationship and orbiviruses. This does not disturb the original
between West Nile, St. Louis, and Japanese en- arbovirus definition, which continues to insist on
cephalitis viruses. Casals 051 confirmed this rela- biological transmission as the prerequisite for in-
tionship by CF test, and Sabin in 1949(601 showed clusion in the epidemiological concept.
a relationship among yellow fever, Japanese en- A landmark in virology was the development of
attenuated strains of yellow fever virus for vac- of La Crosse virus (a California encephalitis rela-
cines in the mid-1930s.(67) The 17D yellow fever tive) in mosquitos in Wisconsin(SO) may be of
virus vaccine strain developed by Theiler and great epidemiological significance, in that it may
coworkers in the Virus Laboratories of the Interna- provide an explanation for long-term survival of a
tional Health Division of the Rockefeller Founda- virus in nature. Extrapolation from this positive
tion is in worldwide use. The French neurotropic demonstration must be done with due caution,
virus vaccine strain developed at the Institut Pas- however, remembering the unsuccessful efforts
teur, Dakar, is now but little used. Yellow fever made with numerous other arboviruses and var-
virus vaccination has neutralized a major hazard to ious species of vectors.
residents, immigrants, and tourists in the African Some of the less pathogenic of the arboviruses
and South American tropics, permitting the accel- are used as models or "tools" for biochemical and
erating development of these regions. biophysical studies with little realization of the
The input of field epidemiological teams (physi- origins of the tool or of the close relationship of
cians, entomologists, mammalogists, ornitholo- the virus to other viruses of much greater patho-
gists, virologists, immunologists, and ecologists) genicity. The possibility of genetic change in such
working on all of the continents except Antarctica, a tool virus of low virulence, inducing an exalta-
coupled with technical improvements, has been tion of virulence, has not gone unremarked.
essential in gaining an understanding of the epi- The history of the treatment of arthropod-borne
demiology of arboviruses. The basic principles virus infections can be dismissed briefly, therapy
determining the mode of propagation and trans- being directed toward the care and support of the
mission of many arboviruses have been of funda- patient. Specific remedial measures are lacking.
mental importance in our understanding of the
epidemiology of several important diseases of hu-
man beings. They may eventually contribute to an
understanding of the origin and evolution of var- 3. Methodology Involved in Epidemiological
ious virus groups. Mattingly discussed this in
Analysis
1960,<47) and there is much new knowledge now
at hand, but few reinterpretations.
3.1. Sources of Mortality Data
The material from field investigators has sup-
plied bench virologists with a number of viruses The World Health Organization publishes the
which have proven to be very useful as tools to Weekly Epidemiological Record, the Center for Dis-
permit exploration of fundamentals of virus com- ease Control of the USPHS publishes Morbidity and
position and structure, infection of the host cell, Mortality: Weekly Report, and the Pan American
replication, and transmission. Among such viruses Health Organization publishes the Weekly Epide-
are the togaviruses of yellow fever, West Nile, miological Report. Various states of the United
Sindbis, the dengues, and Semliki Forest, plus the States also send out periodic reports, as do many
encephalitogenic viruses (also togaviruses) of St. governments. These agencies report on officially
Louis, eastern, western, Japanese, and Venezuelan notified deaths, and often include additional epi-
encephalitis, the rhabdoviruses including the vesi- demiological information for important diseases.
cular stomatitis viruses (Indiana and New Jersey However valuable such reports may be for retros-
serotypes, plus Cocal, Chandipura, and Piry), the pective analysis, they are too many weeks behind
bunyaviruses (including California encephalitis the actual events to be of much service to the
virus), and the orbiviruses (including bluetongue epidemiologist in the field. It is also widely ac-
virus of sheep and the epidemic hemorrhagic cepted, although difficult to prove, that certain
disease virus of deer). diseases such as yellow fever and hemorrhagic
Transovarial passage of several tick-transmitted dengue are seriously underreported in the tropical
arboviruses has been demonstrated repeatedly, countries. Even in temperate countries; the epi-
but until recently attempts to demonstrate this demic encephalitides are undoubtedly not fully
with viruses in mosquitos were unsuccessful. The recorded. Delay in reporting presents another
recent demonstration of transovarial transmission problem, and such delay may be a serious matter
if it results in delay in application of disease on even weaker grounds-undifferentiated fever,

control measures. "PUO," "FUO," "flu," or "grippe"-then one may
presume that sporadic cases of arbovirus infec-
tions never do get reported or investigated. In-
3.2. Sources of Morbidity Data
deed, reporting of such cases is likely only when
The sources for mortality data (WHO, USPHS- they are seen in connection with an already recog-
CDC, and P AHO) serve also as sources for mor- nized epidemic. This is certainly the case when
bidity data. The morbidity reports must be re- epidemics of dengue or Venezuelan, St. Louis,
garded even more skeptically than mortality data, western, or eastern encephalitis occur, and is also
for virus diseases in general and arbovirus infec- true with yellow fever.
tions in particular. Cases of encephalitis, deter- A common pattern of events when epidemics of
mined or suspected, are indeed reported in most these diseases occur is for dozens, hundreds, even
states. Even when reported and followed up by thousands of cases to be present weeks or even
epidemiological and laboratory studies, many such months before the first specific diagnosis is made.
cases receive no specific diagnosis-"many" Prompt diagnosis of an epidemic situation is di-
meaning anywhere between 40% and 65%, de- rectly dependent on a high index of suspicion.
pending on the completeness of the workup and Individual clinicians, epidemiologists, and health
on the immediate epidemiological circumstances. services vary greatly in the degree of alertness
In the state of Connecticut, for example, al- maintained for possible epidemic incidents.
though the viruses of eastern equine, western
equine, and California encephalitis are found, and
the tick-borne agent Powassan virus is also proba- 3.3. Serological Surveys
bly present, no case of arbovirus encephalitis or Serological surveys continue to be the best
infection in man has yet been detected. Antibody source of information on world-wide prevalence of
prevalence rates to these viru'ses in the popUlation the hundreds of arboviruses, and the information
are very low also, indicating that the human popu- obtained is invaluable in extending the concepts of
lation has not been much affected. The demonstra- specific virus/arthropod vector/vertebrate host in-
tion of the presence of a virus in field studies of terrelationships. In contrast to the ubiquitous vi-
arthropod or vertebrate populations cannot be ruses causing human disease, such as measles,
used as an indication of human morbidity from mumps, and smallpox, which are found in practi-
the virus, but such demonstrations do serve to cally all human societies, no single arbovirus is
heighten suspicion, and to orient diagnosis. worldwide in distribution and only a limited
In a 1967-1968 Connecticut study(62) carried out number even extend to two continents. Even
with the help of the State Health Department, within the limits of a continent or country, the
numerous hospitals and physicians were con- occurrence of a single arbovirus remains inexora-
tacted, and some 70 cases of encephalitis or sus- bly delimited by the features of geography and
pect encephalitis were seen. Those for which no climate which determine the distribution of the
specific causative agent had been identified had specific arthropod vector(s) and the vertebrate
early and convalescent serum specimens taken and host(s) of the virus in question. Such boundaries
tested. No evidence of arbovirus activity was un- are ecologically imposed and may have no rela-
covered. tionship to political boundaries of counties, states,
In the Midwestern states, aggressive case find- or countries. In international border areas, inter-
ing and follow-up have served to uncover 50-60 national collaboration is imperative for epidemiol-
cases annually of California encephalitis, and in ogical investigations. WHO and P AHO are of
the irrigated regions of the Southwest and West great help in facilitating such collaboration, and
aggressive case hunting provides evidence of in- also actively initiate and sponsor collaborative
fection with St. Louis and western equine enceph- studies.
alitis particularly. Nonetheless, a high proportion Serological surveys can be directed toward ex-
of the encephalitis cases remain without specific ploring the immunity patterns of a population
causative diagnosis. When the clinical diagnosis is with reference to a specific epidemic situation,
threat, or control procedure. A survey of an Amer- Cell culture systems (vertebrate or insect cell
indian tribe in Amazonas, for example, can pro- cultures) can be used for virus isolation. For cer-
vide information on prevalence of yellow fever in tain viruses and certain cell cultures, the cell cul-
the region, and information on past vaccination ture systems, employing usually a O.l-ml inocu-
coverage. Again, the survey can be directed to- lum, are as sensitive as laboratory animals.
ward identifying general and specific arbovirus Arbovirus outbreaks often occur far from estab-
prevalence in regions of high and low rainfall, lished cell culture laboratories so that inoculation
high and low altitude, coastal regions and inland of more readily available laboratory animals is still
regions, forested regions and savannah regions, more widely done than inoculation of cell culture
rural and urban settings, and in relation to agricul- systems. This situation will probably change. It
tural practices of crop types, irrigation, deforesta- must be remembered, however, that intracerebral
tion, fertilization, and deinsectization. A 1970 re- inoculation of infant mice will serve to isolate a
port of Surtees et al. (71) on arbovirus epidemiol- much wider total range of arboviruses than will
ogy in a rice field development project in the Kano any single cell culture system. This factual position
Plain, Kenya, is an example of a carefully planned is not likely to change. Conversely, in the investi-
investigation, prefaced by ecological studies of the gation of a specific virus, a cell culture system
region (including agricultural practices) and em- which has been predetermined to be suited to the
bracing arthropod vector studies; virus isolation virus c::an be easier, cheaper, and as reliable as or
studies on arthropods, wild and domesticated ver- more reliable than techniques requiring laboratory
tebrates, and human beings, and serological stud- animals.
ies on man, animals, and birds. In the study of material derived from patients, it
The interpretation of serological surveys is com- is highly desirable to have a pair of serum speci-
plicated by cross-reactivity of antisera within a mens to work with. The first should be taken early
number of the groupings (alphaviruses, flavivi- in the course of illness and can serve as material
ruses, bunyaviruses, orbiviruses, rhabdoviruses, both for virus isolation and for the determination
and others). There is no magic formula to resolve of baseline serum antibody levels before the pa-
the problem. A serosurvey report based only on tient has developed antibodies to the infecting
CF or HI testing (or both) does not carry as much virus. A second serum should be obtained at least
weight as one based on neutralization test results, 3 wk after onset of illness, even as late as a month
or one with neutralization test confirmations of CF or several months after onset. A seroconversion
and HI positive-reacting sera. demonstrable between the early and later speci-
mens is strong evidence of a recent virus infection.
Even should a specimen taken early in the course
of illness not be available, a high antibody titer in
3.4. Laboratory Methods
the specimen(s) taken during convalescence may
Positive serological findings on survey sera are be meaningful, providing a provisional diagnosis
greatly bolstered by virus isolations from the vec- without possibility of actual proof.
tor, vertebrate, and human being. Virus isolation Details of the techniques of CF, HI, and virus
procedures for serum specimens require inocula- neutralization, relating specifically to arboviruses,
tion of a small amount of serum into laboratory are available in current manuals.(37,64)
animals, or cell cultures, or both. The usual inocu-
lum for intracerebral inoculation of a l-day-old
mouse is 0.02 ml, and,for the adult mouse 0.03 ml.
Mice are observed daily or more than once a day, 4. Biological Characteristics of Virus
for evidence of illness. A subpassage may be made Affecting the Epidemiological Pattern
to attempt to enhance the virulence of the virus,
and when one is assured that a virus has been Arboviruses by definition share one common
isolated a stock pool of virus is established and feature, the requirement of propagating in some
hyperimmune mouse serum or ascitic fluid is intact arthropod. Transmission by the arthropod is
prepared if needed. a necessary postlude. For some years it was con-
sidered that all arboviruses were RNA viruses, in culture systems and in 1966 reported establish-
although any explanation as to why only RNA ment of a line of mosquito (Aedes aegypti) cells in
viruses (and indeed only certain RNA viruses) continuous culture/au the susceptibility of such
would multiply in the arthropod is lacking. This cell lines to arboviruses was tested. It was early
position was challenged by the demonstration o .51l established that the cells were susceptible to infec-
that African swine fever virus, which has been tion with mosquito-transmitted viruses. Singh,
shown to multiply in and be transmitted through working with clones of mosquito cells,(H5) showed
the bite of certain ticks/ 52 ) is a DNA virus. that tick-borne group B viruses did not multiply in
The property of sensitivity to deoxycholic acid mosquito cell culture.(6H) Buckley extended these
(DCA) and to other lipid solvents and detergents observations(l2) and showed that even Phleboto-
has been useful as a screening procedure for can- mus-transmitted viruses did not multiply in mos-
didate arboviruses. However, various non-arbovi- quito cell cultures. Further observations on tick-
ruses, such as influenza virus and smallpox and transmitted viruses indicated that only Colorado
ectromelia viruses, are also inactivated by such tick .fever virus, a tick-transmitted orbivirus, gave
reagents. Theiler(73) and others also noted that evidence of growth in mosquito cell cultures.
several viruses, unquestionably able to multiply in Libikova and Buckley(40) later reported limited
arthropods and to be transmitted by arthropods, growth of Kemerovo virus, a tick-transmitted vi-
were partially resistant to the action of DCA and rus, in a mosquito cell line. Rehacek and Pesek(57)
the lipid solvents. From this beginning, Borden, have noted limited growth of eastern equine en-
Murphy, Shope, and Harrison have proposed the cephalitis in tick tissue explants. If efforts to culti-
group of orbiviruses, 00,50) which includes several vate tick tissues, Phlebotomus tissues, and tissues
important viruses such as African horsesickness, of other arthropods succeed, the problem of speci-
bluetongue of sheep, and epidemic hemorrhagic ficity can be explored from new angles.
disease of deer. The orbiviruses share morphologi- A prerequisite for the survival of an arbovirus in
cal and physicochemical features but serological nature is a period of viremia in a vertebrate host at
relationships between or among them may be a level sufficient to infect the arthropod vector.
marginal or lacking. Even with a very virulent virus and a very recep-
Another challenging circumstance relates to the tive vector, a virus titer in excess of 100,000 infec-
specificity of various arboviruses for particular tious doses of virus per milliliter of blood is
arthropod species. Many workers have attempted usually necessary. Such high levels of viremia are
to infect arthropods with many of the arboviruses. presumed to occur in the natural host system, and
Group B arboviruses can be conveniently divided often are attained in the more commonly used
into two sections: mosquito transmitted and tick laboratory animals such as mice, hamsters, guinea
transmitted. Attempts to. infect ticks with certain pigs, chicks, and monkeys. For many of the more
mosquito-transmitted group B viruses such as yel- esoteric arboviruses, however, the natural hosts
low fever virus have consistently failed. Attempts and/or natural vectors are either unavailable or not
to infect mosquitos with the group B virus of tick- known so that the postulate of a level of viremia in
borne encephalitis have likewise failed. However, the vertebrate adequate to infect a susceptible
Whitman and Aitken(Sa) have shown that an ar- vector remains undemonstrated.
gasid tick can be infected by feeding on a viremic
host, and can transmit West Nile virus, a group B
mosquito-transmitted virus. Also, L'vov et al.(44)
have shown that Tyuleniy virus, a tick-transmitted 5. Epidemiology
group B virus, can multiply in and can be trans-
mitted by a mosquito. Attempts to infect mosqui- The epidemiology of arbovirus infections in
toes with Phlebotomus-transmitted viruses have man is influenced by three major determinants: (1)
yielded conflicting results. The reverse of this has the behavior of the arthropod vector, including the
not been tried, it being difficult to manipulate ecological setting in which its breeding occurs, its
Phlebotomus flies in the laboratory. pattern and range of mobility, its biting habits and
When Grace succeeded in cultivating insect cells species preferences for feeding, its longevity, and
the factors affecting the entry, multiplication, and been demonstrated, particularly among the flavivi-
excretion of virus within the arthropod host; (2) ruses' (group B arboviruses), of which group yel-
the frequency, nature, and duration of exposure of low fever virus is a member. Such cross-reactivity
human beings to the infected arthropod vectors, as has been demonstrated not only by complement
influenced by the presence, level, and specificity fixation and hemagglutination inhibition tests, but
of hu'moral antibody, and by use in the population also by virus neutralization procedures. Theiler
of insecticides, insect repellents, and protective and Downs(74) in Tables 24, 25, and 26 of their
clothing; and (3) the requirements for the presence book show development of cross-immune reac-
of a necessary and/or amplifying vertebrate host tions in proven primary and secondary cases of
for the virus such as horses, birds, and rodents, yellow fever. Secondary means an infection in a
and of the availability of man as a diversion in the person who had had prior experience with another
arthropod-vertebrate cycle. group B arbovirus. However, the serological re-
The great variability in these three determinants sponse to the current incitant agent is usually
does not permit broad generalization on the epi- more pronounced than the reaction to other mem-
demiology of over 350 arboviruses. Instead, this bers of the serogroup, enabling specific diagnosis
section and those sections on transmission, patho- (if the current agent is included in the test). The
genesis, host response, and control will focus on whole area of cross-immune responses is regarded
the most common and important arbovirus infec- with something akin to awe. It would be a coura-
tions of man in the United States and on certain geous worker today who attempted a project such
common features. Subsequent sections will pres- as the 1937 yellow fever serosurvey, with just a
ent these in more detail and deal briefly in de- single virus and a single test. The 1937 study relied
scriptive and tabular form with arboviruses im- on a relatively insensitive testing procedure, not
portant outside the United States. very responsive to the nuances of cross-reacting
antibodies, and the mapping of yellow fever re-
sulting has required but little alteration.
Neutralization tests measure durable antibody
5.1. Incidence and Prevalence
that persists for years. High rates of antibody
No general statement can be made about inci- prevalence could result from continued, wide-
dence. This varies greatly from area to area de- spread virus activity and/or from a large outbreak
pending on the presence of an appropriate vector with a high attack rate. For example, yellow fever
and the presence or absence of an outbreak. The neutralization tests performed on sera collected
occurrence of a fresh outbreak in a region with from residents of Trinidad, West Indies, in 1953
susceptible and exposed humans may result in revealed no immunes under the age of 15 yr, and
very high infection rates. In epidemics of St. Louis therefore no apparent virus activity later than
encephalitis, for example, a high proportion of 1938. This situation changed dramatically with the
susceptibles in a region where an epidemic is in reappearance of yellow fever on the island in
progress may be infected, even though compara- epidemic form in 1954. (2a)
tively few clinical cases may be detected.(1ll Antibody patterns to California virus infection
The presence of antibody to most arboviruses in Wisconsin(49) revealed varying prevalence rates
reflects the cumulative and life-long prevalence of depending on the frequency and duration of expo-
infection. A classical arbovirus study was the sure: it was 48% of Indian forest workers, 34% of
mapping of the world-wide distribution of yellow wildlife conservation workers, 23% of veterinari-
fever by Sawyer, Bauer, and Whitman in 1937.(6a) ans, and 11% of short-term summer workers in
The virus neutralization test was performed using forestry camps.
adult white mice as test animals. Yellow fever
virus was found to be more widely distributed in
5.2. Epidemic Behavior
South America and Africa than had been earlier
suspected and was absent from Europe, Asia, and Outbreaks of arbovirus infections in the United
Australia. Much has been learned about group States involving human beings occur periodically
relationships of arboviruses since the 1937 report, and unpredictably. Table 2 summarizes the experi-
and many serological cross-relationships have ence from 1965 through 1973. Only 34 cases of
Table 2. Human Cases and Deaths: Arthropod-Borne Encephalitis (Including Colorado Tick Fever)
1965-1973"
Year EEE WEE SLE CE Totals CTF
1965 8 (4)0 172 (4) 58 (0) 59 (0) 297 (8) 188 (0)
1966 4 (2) 47 (2) 323 (28) 64 (0) 438 (32) 156 (0)
1967 1 (1) 18 (0) 11 (0) 53 (1) 83 (2) 137 (0)
1968 12 (6) 17 (1) 35 (3) 66 (0) 130 (9) 88.(0)
1969 3 (2) 21 (0) 16 (0) 67 (0) 107 (3) 114 (0)
1970 2 (0) 4 (0) 15 (2) 89 (1) 110 (3) 92 (0)
1971 4 (2) 11 (1) 57 (3) 58 (0) 130 (6) 116 (0)
1972 a (0) 8 (0) 13 (0) 46 (0) 70 (0) 162 (0)
1973 a (0) 8 (0) 13 (0) 45 (0) 66 (0) 321 (0)
---
34 (17) 306 (8) 541 (36) 547 (2) 1431 (63) 1374 (0)
" From U5PHS-Center for Disease Control, Neurotropic Viral Diseases: Encephalitis: Annual Encephalitis Summary 1972 (July 1974), and
from U5PHS-Center for Disease Control, Morbidity and Mortality Weekly Report: Reported Morbidity and Mortality in the United States
1973, 22(53), 1973.
b Number of deaths given in parentheses.
eastern encephalitis were reported during this 5.5. Age and Sex
time, of which 12 cases and six deaths were in
Infections with arboviruses can occur at any age.
1968; during the same period, 306 cases of western
The age distribution depends on the degree of
encaphalitis were reported, of which 172 occurred
exposure to the particular transmitting arthropod
in 1965, with four deaths. Outbreaks of St. Louis
relating to age, sex, and occupational, vocational,
encephalitis were first recognized in St. Louis in
and recreational habits of the individual or group
1932; recent outbreaks occurred in 1966 with 323
of individuals. For example, California virus infec-
cases, and in 1974 in Memphis, Tennessee.(78)
tions primarily involve children, especially boys
Venezuelan encephalitis produced its first out-
who climb in trees, because the mosquito vector
break in the United States in Texas in 1971.
breeds in small accumulations of water sometimes
found where tree branches join the main trunk of a
5.3. Geographic Distribution tree--an ideal spot for a child to sit or build a
treehouse. On the other hand, adult males are
Arbovirus infections are worldwide in distribu- more commonly infected with Colorado tick fever
tion and may occur whenever the appropriate virus, as they dominate the hunter and fisherman
mosquito or other arthropod vectors abound in
popUlation who become exposed to the ticks in
proximity to man and a suitable amplifying host. forested areas.
Table 3 includes the geographic distribution of Once humans have been exposed and infected,
arboviruses in the United States and Table 4 that the severity of the host response may also be
in South America, Europe, Asia, Africa, and Aus- influenced by age. WEE tends to produce the most
tralasia. severe clinical infections in young persons, and
SLE in older persons.
5.4. Temporal Distribution
In the United States, mosquito-borne arbovirus
5.6. Other Factors
infections produce human infections primarily in
the late summer and fall; Colorado tick fever has Nutritional and genetic factors are not known to
involved hunters, fishermen, and campers from directly influence the epidemiology of arbovirus
spring through fall (Table 3). infections. Socioeconomic factors may playa part
Table 3. Descriptive Epidemiology of Arboviruses Important as
Incidence and Geographic Temporal

Virus Arbovirus grouping prevalence data distribution distribution of cases
Eastern equine Group A togavirus Encephalitis rare; Eastern Seaboard Late summer and
encephalitis (EEE) immunity rates low from Massa- fall; sporadic cases
chusetts to Florida or restricted sharp
and Louisiana epidemics
Western equine Group A togavirus Encephalitis un- Virus widespread; Summer and fall;
encephalitis (WEE) common; im- human disease broadly endemic
munity rates may be restricted to West and occasional
high locally and Southwest epidemic peaks
St. Louis encephalitis Group B togavirus Encephalitis un- Widespread in Summer and fall;
(SLE) common; im- southern, central broadly endemic
Irtunity rates may be and western states and occasional
high locally epidemic peaks
California encephalitis Bunyamwera Encephalitis North Central states; Summer; broadly
(CE) supergroup, uncommon; virus occurrence in endemic; sporadic
California group immunity rates low; some eastern and cases
togavirus infections sporadic western states,
bu t cases rare or
absent
Colorado tick fever Immunity rates low; Rocky Mountain Spring through fall;
(CTF) infections sporadic states broadly endemic;
sporadic cases
insofar as they relate to life patterns in seedy ticks. Of far less importance are horseflies, mites,
suburbs, barrios, or rural regions, where insect and blackflies. There is often a high-level virus!
vector populations may flourish under conditions vector specificity.
of poor sanitation. It may emerge that cell-me- The duration of the necessary period of virus
diated immunity under genetic control plays a part multiplication within the arthropod host before it
in the nature and severity of the host response, the becomes infectious varies from virus to virus and
persistence of virus, and the formation of immune vector to vector, and is directly temperature de-
complexes, but no data are on hand to support pendent also. (82) For most viruses under average
these conjectures. summer temperature conditions, the extrinsic in-
cubation period falls in the 7-14 day range. Once
infected, vectors may remain infected and able to
transmit for many weeks or months.
6. Mechanism and Route of Transmission Transmission of virus transovarially in arthro-
pods, often referred to as "vertical transmission,"
By definition, arboviruses must be transmitted has been demonstrated (specific examples: tick-
by arthropod vectors within which multiplication borne encephalitis in ticks, LaCrosse strain of
of the virus is a necessary requirement. This California encephalitis in mosquitos, and Sicilian
biological transmission may be supplemented by sandfly fever virus in phlebotomine sandflies).
mechanical transmission in which the virus is This mechanism may be important for survival of
passively carried externally on the vector or even some arboviruses in nature, permitting overwin-
passively excreted. The primary vectors are mos- tering or survival over a protracted dry spell.
quitos, sandflies (Phlebotomus and Culicoides), and Birds are important reservoir vertebrates for the
Causative Agents of Disease in Human Beings in the United States
Occurrence in
Age Sex Race Occupation different settings
Any age Rural and suburban
Cases more severe in Rural and suburban

young
Cases more severe in Rural and suburban

older people
Any age Sylvan picnic Forested regions;

settings; woodland campsites
workers
Adults more likely to Males more likely to Hunters, fishermen, Montane foothills
be exposed be exposed outdoors people and medium
altitude slopes
viruses of EEE, WEE, and SLE, and small mam- remains undetermined, but is presumed to be in
mals for California and Colorado tick fever viruses. the vascular epithelium and the reticuloendothelial
Table 5 summarizes some features of arbovirus cells on the lymph nodes, liver, spleen, and else-
infections important in the United States. where. Liberation of virus from these organs con-
stitutes the "systemic phase of viremia" resulting
after 4-7 days in fever, chills, and aching. A
number of arbovirus infections have two phases-
this early phase and then a second phase with or
7. Pathogenesis and Immunity without a few days of freedom from illness. The
second phase may be attended by encephalitis,
Arbovirus infections are transmitted by the bite joint involvement, rash (sometimes hemorrhagic),
of the appropriate vector so that the skin repre- and involvement of liver and kidneys. In most
sents the sole portal of entry. With penetration of arbovirus infections, only the first phase occurs
the skin by the biting mouthparts of the arthro- and the disease is mild and "nonspecific." In other
pod, the virus is deposited directly into lymph or instances, the early phase may be missed and only
the bloodstream, in addition to forming a local the severe manifestations occur. The early phase is
pool. With early wide dissemination throughout accompanied by leukopenia and the second phase
the host, multiplication follows in as yet inade- often by leukocytosis. Tissue injury may be the
quately identified target cells and tissues. Viremia direct effect of viral multiplication in susceptible
in the host then provides the seedbed for infection cells, as is the case with the liver involvement in
of succeeding cohorts of biting arthropods. yellow fever. The role of immunological injury is
The site of multiplication of most arboviruses not clear, although antigenJantibody complexes are
Table 4. Important Arbovirus Infections of Human Beings in
Disease Geographic region(s) Vector{s) Vertebrate host(s)
Yellow fever (urban) New World and African Aedes aegypti Man
cities (seaports usually)
Yellow fever (jungle) New World and African Mosquitos: Haemagogus Forest primates
tropics and aedines
Dengue(s) New World and Old World Aedes aegypti and other Man; possibly a "jungle"
tropics and subtropics aedines cycle in primates
Dengue hemorrhagic fever Southeast Asia Aedes aegypti Man
Japanese encephalitis Orient, Korea to India and Culex tritaeniorhynchus and Wild birds; pigs can serve
East Indies other culicines as amplifying hosts
Murray Valley encephalitis Australia Culex annulirostris and Birds

other mosquitos
Chikungunya Africa and Asia, tropics Aedes aegypti Possibly primates

and subtropics
Tick-borne encephalitis USSR and Northpm Europe Ticks-Ixodes ricinus and Small wild mammals and
others birds
Kyasanur Forest disease India (Mysore State) Ticks-mainly Monkeys; possibly also
Haemaphysalis small mammals
Crimean hemorrhagic Southern USSR, Bulgaria Ticks-Hyalomma Probably small mammals

fever (Congo) plumbeums
Venezuelan equine Central and South America Mosquitos of several Horses; possibly small
encephalitis and southern United species mammals
States
South America, Europe, Asia, Africa, and Australasia
Features of disease in human beings
Disease pattern Description of disease Diagnosis Control measures
Epidemic Acute onset, high fever, prostration later Virus isolation, CF, Vaccination with 170
jaundice, proteinuria; fatalities HI, N tests vaccine; Aedes
common, although ratio of inapparen tI aegypti control
apparent infections is high
Endemic As above; cases occur sporadically in Virus isolation, CF, Vaccination with 170
people exposed in forested regions in HI, N tests vaccine; mosquito
Africa and New World control not
practicable
Endemic and epidemic Acute onset with rash in many cases and Virus isolation, CF, Mosquito control and
joint pains; simulates an influenzalike HI, N tests prevention against
syndrome mosquito bites; no
vaccines yet
Endemic and epidemic Serious illness with hemorrhagic CF, HI, N tests in Mosquito control
complications, shock syndrome, and animals or cell
high mortality-almost exclusively in culture system
children, and following a second
infection with a different dengue virus
Endemic and epidemic Infection usually mild, but encephalitic CF, HI, N tests Mosquito control;
complications can be serious in young vaccination with an
and in elderly; very important disease inactivated vaccine
in the Orient
Epidemic, sporadic, Infection usually mild, but encephalitis CF, HI, N tests Mosquito control
over wide areas may occur, with greatest probability in measures and
children, and high fatality rates in the protection against
young mosquito bite
Epidemic Acute onset, often with rash; rarely with CF, HI, N tests and Mosquito control
hemorrhagic manifestations; joint virus isolation
aching and swelling are prominent
features
Endemic in forested Acute onset, violent headache, fever, Virus isolation, CF, Tick control where
regions nausea, vomiting, hyperesthesia, HI, N tests possible; an
photophobia; drowsiness, delirium, inactivated vaccine
coma may follow; mortality rate about has been tried
20%
Endemic and epidemic Sudden onset, fever, headache, severe Virus isolation, CF, Protection against tick
myalgia; there may be a diphasic HI, N tests bite
course with second phase after an
afebrile period of 7-15 days; mortality
rates under 5%
Endemic Sudden onset, chills, fever, headache, Virus isolation, CF test Protection against tick
nausea, and vomiting; hemorrhagic bite
manifestations common; mortality
rates 5-10%
Probably endemic; Fever, encephalitic signs, usually mild, Virus isolation, CF, Mosquito control
sharply epidemic fatalities rare HI, N tests measures and
protection against
mosquito bites;
attenuated vaccine
exists for equines
Table 5. Mechanisms and Route of Transmission, Pathogenesis, and Immunity Features of
Transmission
Virus mechanism Vector(s) Animal reservoirs Pathogenesis in man
EEE Mosquito bite Culiseta melanura and Wild birds; penned Encephalitis,
various Aedes pheasants; equines frequently fatal;
affected but not nerve cell damage
reservoirs often focal
WEE Mosquito bite Culex tarsalis in the Wild birds; equines Encephalitis with
West; Culiseta affected but not mortality rates 2-
melanura in the East; reservoirs 18%; nerve cell
other mosquitos damage often focal
SLE Mosquito bite Culex pipiens and C. Wild birds Encephalitis, with
quinquefasciatus, C. diffuse nerve cell
nigripalpus, and damage
other culicines
CE Mosquito bite Aedes triseriatus and Small mammals Mild encephalitis
other Aedes and
Culex; transovarial
transmission
demonstrated
CTF Tick bite Dermacentor andersoni Small mammals Febrile illness of
several days
duration;
leukopenia
suspected of playing an important part in the antigen/antibody complexes is suspected of pre-

pathogenesis of the dengue shock syndrome.(33) cipitating the host responses seen clinically as
Humoral antibodies regularly appear early in the dengue hemorrhagic fever or dengue shock syn-
course of arbovirus infection and constitute the drome.(33)
major basis of immunity. Such immunity may be The long persistence of complement-fixing anti-
lifelong. No infection with yellow fever virus has body to dengue in the absence of reexposure and
been recorded in an individual who either had of reinfection(26) raises the possibility of persist-
antibodies from an earlier infection or had a his- ence of the virus, perhaps in association with
tory of yellow fever vaccination with development circulating lymphocytes. Marchette et al. (46) have
of postvaccination antibody. The presence of anti- shown that dengue virus multiplies in lympho-
bodies in the blood at the time of exposure to an cytes from individuals previously sensitized (i.e.,
infected arthropod vector provides a primary de- infected) to this virus but not in lymphocytes from
terrent to reinfection 'with the homologous virus. those not so infected.
Later infection may occur with a virus strain The role of cell-mediated immunity to arbovirus
related to but not identical with the original infect- infections has been very little studied. It is possi-
ing virus. This has been reported for dengue ble that it may be important in controlling virus
(which has four "types"). Such an event has been persistence and in determining the immunopath-
demonstrated to produce an exaggerated antibody ologicallesions suspected in certain manifestations
response, and such a response with the resulting of arbovirus infection.
Arboviruses Important as Causative Agents of Disease in Human Beings in the United States
Patterns of host response
Ratio of inapparent to
Immunity Key clinical features Biological spectrum apparent infections
Long-lasting, probably Abrupt onset, high fever, Severe cases mostly in Few mild or clinically
lifetime signs of encephalitis, small children; sequelae inapparent infections;
often becoming severe common; adults who immunity rates in
or fatal in 3--5 days recover usually have populations low
few or no sequelae
Long-lasting, probably Fever, drowsiness, and Children have sequelae, Many mild or inapparent
lifetime other signs of more severe in younger infections occur (ratio 58:1
encephalitis; remission children; adults rarely in children; 1150:1 in
is sudden, with have sequelae adults)
recovery in ~10 days
Long-lasting, probably Brief febrile illness with Cases of greater severity Ratio high, 64:1; attack rate
lifetime severe encephalitis in more frequently in of clinically apparent
small proportion of elderly patients; infections 280/100,000
cases sequelae rare
Probably long-lasting Brief febrile illness and Encephalitis of mild to Probably high
sometimes mild moderate severity in
encephalitis children and adults
Probably long-lasting Diphasic fever Affects all ages; cases in Mild and inapparent
leukopenia; CNS or children more severe infections occur; frequency
hemorrhagic undetermined
complications
occasionally in young
children
8. Patterns of Host Response 8.2. Diagnosis
Cases of arbovirus infections in the United

8.1. Clinical Features States are not likely to be diagnosed unless there is
a high degree of clinical suspicion operating. Out-
breaks of encephalitis in horses in summer, caused
Inapparent and subclinical human host re- by EEE, WEE, or VEE viruses, serve to focus
sponses predominate in most arbovirus infections. attention on febrile illness in humans associated
Clinical illness is frequently the exception rather with symptoms or signs indicating involvement of
than the rule. This varies from virus to virus. For the central nervous system. Cases with such
example, infection with WEE, SLE, and California symptoms and signs occurring in children in the
viruses results principally in mild and inapparent midwestern states such as Wisconsin, Indiana,
infections, whereas in infection with EEE virus the Minnesota, and Ohio in late summer should
host response is likely to be clinically apparent and arouse suspicion of California virus involvement.
often severe. St. Louis virus epidemic sweeps have few indica-
The range of host responses to a few of the more tors in the natural scene. Birds, although widely
frequently encountered arboviruses is seen in Ta- infected, are not clinically ill, and the primary
ble 6. The responses to individual viruses are culicine mosquitos involved in transmission are
shown in Tables 4 and 5 and in Section 10. diffusely spread throughout the United States,
86 Otapter 4 • Arboviruses
Table 6. Patterns of Host Response to Arbovirus Infections in Man
Response Examples·
Asymptomatic infection WEE, SLE, CE

Mild febrile illness WEE, SLE, CE, yellow fever
Influenzalike illness with aching and joint pains Dengue, chikungunya
Encephalitis, mild CE, WEE, SLE
Encephalitis, severe SLE, EEE, WEE, tick-borne encephalitis
Jaundice, proteinuria Yellow fever
Rash, sometimes with hemorrhagic manifestations Dengue (chikungunya?)
Shock syndrome Dengue (following secondary infection with a different
dengue serotype)
a Certain viruses have been selected for this list particularly to illustrate the range of symptoms which may be seen in populations
infected with a single virus.
especially in areas with inadequate disposal of test in sera taken during the acute and during the
waste water such as slum areas and the outskirts of convalescent phase of illness. Often the suspicion
towns. The risk may thus be generalized and of an arbovirus infection in individual cases arises
diffuse, and the prediction or pinpointing of an too late for virus isolation or for demonstration of
actual outbreak impossible. a rise in antibody titer. Under these circumstan-
Recognition of the arbovirus infection acquired ces, the presence of a high antibody titer in a
by the traveler outside the United States also single serum may be significant if the infection is
depends on the alertness of the examining physi- an uncommon one in that region, and particularly
cian. Rapid jet transport now permits exposed if antibody surveys reveal a low antibody preval-
overseas travelers to reach home and fall sick even ence, or if prior surveys have demonstrated the
within the short incubation period of such infec- absence of antibody in that community. The ap-
tions. The physician must maintain a high degree propriate procedure in suspected cases is to (1)
of suspicion when seeing CNS infections or influ- notify the health department and seek background
enzalike illnesses occurring in travelers recently epidemiological and clinical data, and (2) send
returned from areas endemic for arboviruses. acute and convalescent serum samples to the near-
Since specific diagnosis depends on the labora- est public health laboratory (usually a state labora-
tory, if the specific question is not asked the tory) with a request for antibody tests for arbovi-
laboratory is not likely to carry out the tests ruses and other encephalitis-producing viruses.
. needed for specific diagnosis. Some state laboratories may not provide this test-
It should be emphasized that arbovirus infec- ing, so a request for transshipment of sera to the
tions constitute only a small fraction of the en- Center for Disease Control (CDC) might be in-
cephalitis cases seen in the United States. For cluded. Usually the specimens should not be
example, of 1891 cases of encephalitis or menin- shipped directly to CDC.
goencephalitis reported to the Center for Disease
Control in 1971, only 7.9% were associated with
arboviruses; 16.3% were due to mumps, 6.7% to
exanthem viruses, 4.6% to other viruses, and an 9. Control and Prevention
impressive 64.5% were of unknown etiology (Fig.
1). Major control methods include (1) control of the
The laboratory diagnosis depends on the isola- arthropod vector, which may be by elimination of
tion of the virus from the blood and/or a fourfold breeding sites or modification of them by applica-
rise in titer in a complement fixation, hemagglu- tion of insecticidal substances, or by direct attack
tination inhibition, or neutralization of antibody on the adult arthropods through residual insecti-
20
ARTHROPOD-BORNE ENCEPHALITIDES, 1972
- - - CALIFORNIA ENCEPHALITIS
I~ - - - WESTERN ENCEPHALITIS
-'-' - ST. LOUIS ENCEPHALITIS
.......... " .. VENEZUELAN ENCEPHALITIS
10
O~--~~~~~~--~--~~~--~~-r~~~~--~
160
ENCEPHALITIS-ETIOLOGY UNKNOWN,1971-1972
---1972 " ........
140 ---1971 / '\
/ \
120 / \
/ \
Fig. 1. Causes of encephalitis I \
in the United States. 100
/ \
If) / \
~ 80
/ \
"o
60
/ ,
'~
40 "'",
20
OL---~--~--~--~--~--~--~--~--~--~--~~
40 POST-INFECTIOUS ENCEPHALITIS ASSOCIATED WITH MEASLES,
MUMPS, CHICKENPOX AND RUBELLA, 1972
- - - MUMPS - . - . - MEASLES
20 - - - CHICKENPOX ................. RUBELLA
F M A M J J A s o N o
cide treatment of adult resting places; (2) avoid- 10. Characteristics of Selected Arboviruses
ance of exposure to vector bites by screening of
houses, by use of protective clothing, and by
10.1. Arboviruses of Importance in the United
application of insect repellent sprays or creams
States
when outside in high-risk areas; (3) immuniza-
tion, a procedure widely used only for yellow fever Five arboviruses are of primary importance in
and Japanese encephalitis in endemic areas. Spe- human infections in the United States: eastern
cific control measures are discussed in appropriate equine encephalitis (EEE), western equine en-
sections below and are listed in Table 4 for arbovi- cephalitis (WEE), St. Louis encephalitis (SLE), Cal-
ruses of importance outside the United States. ifornia virus (CE), and Colorado tick fever (CTF)
viruses. Brief summaries of main features for the tice. The peak of occurrence of epidemics and
five viruses are presented in Tables 2, 3, and 5. human cases is late summer and early fall. The
Powassan (POW), vesicular stomatitis (Indiana) first heavy frosts signal the termination of trans-
(VSI), and Venezuelan equine encephalitis (VEE) mission. In the southern states and midwestern
are of minor importance for human disease or of states, Culiseta melanura is not found and the
very sporadic occurrence. More detailed presenta- vectors transmitting virus to the wild bird popula-
tion for all these viruses can be found in Horsfall tions include other culicine and aedine
and Tamm, Viral and Rickettsial Infections of species.
Man, (as) but for CE particularly there is a body of The incubation period in human beings is short.
new information in the periodical literature. The ratio of inapparent or mild infections to severe
10.1.1. Eastern Equine Encephalitis. Involve- infections is low (2-4:1). Immunity is probably
ment of human beings with EEE virus has been long-lasting, with no reinfections being described.
sporadic even under epidemic circumstances. Ta- Fever followed by encephalitis in 1-2 days is the
ble 2 summarizes available morbidity and mortal- principal clinical feature. The encephalitis is rap-
ity data for the United States. Serosurveys of idly progressing and often fatal, particularly in
populations, even when focused on population small children. Pathological features are those of a
groups estimated to be at greater risk, reveal very diffuse encephalitis with evidence of scattered
low rates of antibody prevalence. However, the neuronal destruction. Recovery is usually complete
high mortality associated with this infection (25- with few or no sequelae.
50%) demands continuing epidemiological vigi- Mter initial clinical suspicion, diagnosis is es-
lance. Epidemic outbreaks in equine populations tablished by virus isolation or more commonly by
in the Atlantic Seaboard states from Massachusetts serological evidence of conversion (CF, HI, or N
to Florida, in the Midwest, and in the Gulf Coast test) to EEE virus. Evidence of an epidemic involv-
states are kept in check through vaccination using ing birds and mosquitos and more particularly
a formalin-inactivated EEE vaccine. Immunization equines and human beings in a region should alert
of humans has not been considered as indicated, clinicians.
except for laboratory workers engaged in specific 10.1.2. Western Equine Encephalitis. Infection
EEE virus manipulation. of human beings with WEE is much more frequent
Without doubt, the cardinal epidemiological than with EEE (Table 2) and there is a much higher
features serving to protect human populations ratio of inapparent to apparent (diagnosed) infec-
against outbreaks of EEE relate to the localization tions, estimated in one study as 58:1 in children
and feeding habits of the principal vector, the and 1150:1 in adults.
mosquito Culiseta melanura. This mosquito breeds The major virus activity in the western and
in and remains localized to certain types of deep southwestern states is closely tied to the presence
swamp locations in areas generally remote from and behavior of Culex tarsalis populations. This
human habitation and feeds mainly on small pas- mosquito serves to transmit virus among wild
serine wild birds in such places. (S4) Other mos- birds. Since it also feeds readily on larger verte-
quitos, principally aedines, feeding on wild birds brates, it requires no secondary help from other
and on larger vertebrates may well be responsible mosquito species to generate an epidemic. Several
for the occasional and unpredictable movements of other mosquito species can also be infected and
virus from wild bird populations to larger verte- can transmit infection. The numbers of Culex tar-
brates including equines and man. The movement salis mosquitos in a region can be augmented
of EEE virus into penned pheasant flocks is not greatly by careless irrigation practices, and the
well understood, but could happen by mosquito major foci of virus activity involving human
bite or by movement of infected wild birds, such beings in the West and Southwest relate directly to
as the English sparrow, into inadequately screened major areas of crop irrigation. Proper water man-
pens. Once introduced into penned pheasant pop- agement procedures can greatly reduce Culex tar-
ulations, the virus can be transmitted from pheas- salis production, as can the coordinated applica-
ant to pheasant by pecking. Debeaking of penned tion of larvicidal measures. Vaccination with an
pheasants to abort such spread is common prac- inactivated WEE vaccine is widely used to protect
equine populations. An attenuated vaccine strain months. There have been outbreaks as far north as
has been shown to be effective. (9) Immunity con- New Jersey. The virus is transmitted by a number
ferred by natural infection is long-Ionglasting. Anti- of culicine mosquitos, including Culex pipiens, C.
body rates in human populations in irrigated re- quinquefasciatus, C. tarsalis, and C. nigripalpus, and
gions of the West and Southwest may be high. by other mosquitos. In the West and Southwest, it
Although WEE is prevalent on the Eastern Sea- is closely tied in with Culex tarsalis and irrigation
board, infections in human beings are almost practices, much as is the case with WEE, although
unknown. This is probably explainable on the SLE may reach peaks of prevalence earlier in the
basis of the vector (Culiseta melanura), as described summer season.(56) There is a diffuse endemicity
for EEE. Reinfection has not been described. over vast rural areas, with low rates of seroposi-
In view of the high ratio of inapparent or mild tives in human beings, and only occasional cases
cases to severe cases, the low figures for human of disease recognized. However, there is a more
mortality, and the millions of people potentially at marked concentration of virus activity in irrigated
risk, vaccination has not been considered neces- regions with inapparent infection rates ranging
sary in human populations. between 10 and 70%.
Mter an incubation period of several days, fever In the central and southern states, although a
is seen, and may be followed by drowsiness and diffuse spread of virus undoubtedly occurs, inter-
more pronounced signs of encephalitis. A fatal est focuses on the periodic epidemic flareups on
outcome is rare, but sequelae after encephalitis are the outskirts of towns and cities. The principal
not uncommon, particularly in small children. vectors in such outbreaks, Culex pipiens and C.
Pathological findings are those of 11 diffuse en- quinquefasciatus (and in Florida C. nigripalpus),
cephalitis and focal neuronal destruction. breed in great numbers under circumstances
Specific diagnosis is based on virus isolation, where there is inadequate disposal of waste water.
and more commonly on serological grounds (CF, Conditions are ideal for these vectors in the urban
HI, or N test), with a fourfold or greater rise in and suburban slum areas on the outskirts of towns
antibodies between early and convalescent speci- and cities. While many communities are at risk
mens considered an adequate criterion. EEE and annually, and while an annual outbreak(s) can be
VEE are the only other antigenically related group predicted with near certainty, the site(s) of such
A arboviruses in the United States, and the possi- outbreak(s) cannot be predicted.
bilities of confusion resulting from serological SLE affects all age groups, with a ratio of inap-
cross-reactivity are minimal. The laboratory diffi- parent to apparent infections reported in one
culties are confined to such problems as anticom- study°l) as 64:1, under circumstances where the
plementarity of sera (in CF), inadequate extraction attack rate for clinically apparent cases was 2801
of serum inhibitory factors (in HI), or nonreactive 100,000. In the clinically apparent infections, most
antigens (in CF, HI, or N test). Most of these cases have a benign course, with fever for a few
problems can be recognized or resolved by inclu- days, severe headache, and complete recovery. A
sion of adequate controls in the diagnostic tests few cases progress to more pronounced encephali-
employed. tis, particularly in the older age groups. Remission
The monograph of Reeves and Hammon(S6) may be dramatic, and recovery is usually com-
provides much information on epidemiological plete. Sequelae, including mental deterioration,
studies on WEE in the West. personality changes, muscle weakness, and para-
10.1.3. St. Louis Encephalitis. The first recog- lysis, are uncommon.
nized outbreak of St. Louis encephalitis in St. Diagnosis is usually made by serological means.
Louis in 1932(4a) provided epidemiological data A leukopenia or mild leukocytosis, and slight
which have been added to, but not changed in increase in spinal fluid pressure, cells, and pro-
most essential features, up to the 1974 outbreak in tein, leads to the suspicion of encephalitic involve-
Memphis, Tennessee.(78) ment, but confirmation must come from virus
SLE virus is widely prevalent in wild bird popu- isolation (very rarely accomplished) or from serol-
lations in the southern, southeastern, central, ogical conversion in CF, HI, or N test to the
southwestern, and western states in the summer specific virus antigen. In geographic regions
where other group B arboviruses are known to ample, but no cases in human beings have been
occur or are suspected, the serological conversion identified there despite continuing search.
demonstrated between the specimen taken early in The clinical features of illness are fever with
the course of illness and several weeks later must mild to moderate encephalitis. (76) Fatalities are
be evaluated with antigens or immune sera from rare; one report of autopsy findings describes
the other group B viruses of the region included in diffuse encephalitic changes of neuronal degenera-
the test. tion and patchy inflammatory response in the
There is no vaccine for SLE. Control in the face cortex and in the basal ganglia.(77) Immunity is
of an urban epidemic depends on the emergency probably long-lasting. Immunity rates are high
application of mosquito control measures. Long- only in special population groups with extensive
term control for urban and suburban localities forest exposure. (49) Reinfection probably does not
depends on good sanitation with respect to drain- occur. Protective measures are limited to protec-
age and adequate disposal of waste water. In most tion of individuals from the bite of mosquitos,
rural areas, control measures aside from general through the application of insect repellents. In
protection against mosquito bites are not feasible. specific local situations, such as extensively used
In more specific rural areas under irrigation, much campgrounds, area disinsectization can be consid-
can be accomplished through water management ered. Diagnosis, following initial clinical suspi-
and directed application of insecticides to keep cion, may be by virus isolation but is much more
mosquito populations at a low level. commonly based on serological procedures (CF or
10.1.4. California Encephalitis. There is a gap of N test) on appropriately spaced serum specimens.
a couple of decades between the first isolation of There is no difficulty in narrowing diagnosis to
California encephalitis (CE) virus from mosquitos the California subset of viruses, but difficulties do
in California by Hammon and Reeves and their remain, only partially resolved as yet, of pinpoint-
early recognition of human cases(35) and the finding the specific CE subtype unless the virus itself
ing that the virus is responsible for many mild has been isolated, either from the case (the unlike-
cases of "summer encephalitis" in the North Cen- liest but most desirable situation) or from mosqui-
tral states. Several strains of CE are recognized, (SI) tos captured in the vicinity of the infection.
but only one of these, the LaCrosse subtype, has 10.1.5. Colorado Tick Fever. Colorado tick fever
been shown to be important in the causation of (CTF), an orbivirus, tick transmitted and localized
human disease.(76) to mountainous regions of the western United
The pattern of disease occurrence, and of human States, accounts for nearly as much reported mor-
infection in general, is one relating to exposure in bidity as EEE, WEE, SLE, and CE combined (Table
sylvan settings. Cases are seen sporadically in 2), but fortunately it rarely causes serious or fatal
inhabitants and workers in forested areas, and in illness. Much of the reported morbidity is depend-
picnickers and summer visitors to such areas. This ent on the vigilance of individual physicians in the
reflects the occurrence of the main vector, Aedes Rocky Mountain area, reporting in to and submit-
triseriatus, a treehole-breeding mosquito of wide ting materials for diagnosis to health department
distribution, common locally in favorable forest laboratories. There is still undoubtedly' much un-
habitats and suburban woodlands. The virus finds derreporting due to nonrecognition of the disease.
its endemic host in the small animal populations Infection is picked up by hikers, foresters, or
of such regions. It has been shown in recent vacationers venturing into hilly or mountainous
studies(SO) that the virus can be passed transovari- areas populated by various rodents, particularly
ally (vertical transmission) in mosquito popula- ground squirrel and chipmunk species, which are
tions. This may explain virus survival in northern in tum infested by immature and adult stages of
climes, including northwestern Canada and the the wood tick Dermacentor andersoniY3) In diag-
Yukon, as well as the northeastern states of the nosed cases there is always a history of exposure
United States. to ticks, although there is not always a recollection
The recognized occurrence of the virus (includ- of tick bite.
ing subtypes) is wider than the area within which Overall antibody prevalence is low, as measured
human cases have been reported. The virus has by serosurveys of population groups, and in spite
been recovered repeatedly in Connecticut, for ex- of wide virus distribution in the endemic regions
human infections are usually sporadic and casual. zuelan equine encephalitis (VEE) is an alphavirus
However, one survey of 178 sera from sheepher- (group A arbovirus) responsible for large out-
ders revealed 32% seropositives. (29) breaks of encephalitis in horses in South and
Following a tick bite, the incubation period is 3- Central America and the West Indies. The first
6 days, with sudden onset of fever, headache, reported horse outbreak in the United States oc-
retroorbital pain, and severe muscle pains. A rash curred in 1971 in the Southwest, coincident with
is sometimes seen. There may be a brief remission an extensive outbreak in Mexico. There were 84
followed by a second bout of fever, and occasion- laboratory confirmed human cases. Lord(4Il has
ally even three or four exacerbations may be seen. summarized VEE history in the New World.
Leukopenia is characteristic, is present by the VEE is mosquito transmitted, with natural reser-
third day of fever, and becomes pronounced by voirs in small mammals rather than birds. 8 Human
the fifth or sixth day. Serious complications such cases, diagnosed as encephalitis of mild or moder-
as encephalitis or severe bleeding are limited al- ate severity, are seen in connection with horse
most exclusively to children. The immunity fol- outbreaks. Fatal infection of human beings has
lowing recovery is presumably lifelong. been described. (24)
Diagnosis is readily made by isolation of the A subtype of VEE has been found in southern
virus from the blood, the virus being associated Florida which is less virulent for horses, and
with the red blood cells.(39) The resultant viremia possibly for human beings also. Occasional human
is a regular feature throughout the illness. Virus infections have been described. (79,80)
isolation can be made by inoculation of infant 10.2.2. Powassan. Powassan (POW) is the only
mice or of KB or BHK-21 cell cultures. Virus has tick-transmitted virus of the tick-borne encephali-
been isolated from erythrocytes of patients as early tis subgroup of flaviviruses thus far encountered
as 1 day and as late as 120 days after onset of in the New World. It is a relative of tick-borne
symptoms. (29) Serological techniques are useful encephalitis virus, which is an important patho-
where virus isolation facilities are lacking. Anti- gen in the USSR and northern Europe, and of
bodies appear late, CF antibodies being detectable Kyasanur Forest disease virus, a human pathogen
4-6 wk after onset, neutralizing antibodies after 2- in Mysore State, India. Powassan virus is widely
4 wk. An indirect fluorescent antibody (IFA) test distributed in Canada and the more northern
has been shown to be useful, (25) with titers ap- states of the United States as an infection in
pearing earlier after onset of illness and reaching various small rodents. It is transmitted by hard
higher levels than CF titers. An unusual feature of ticks (Ixodidae). The original virus isolation was
this tick-transmitted reo-like virus is that in addi- from the brain of a child who died in Ontario in
tion to propagating in various mammalian cell 1959.(48) Since that time, there have been very few
cultures the virus also multiplies in a mosquito cell human immunes found in extensive antibody sur-
culture line. (86) This is in decided contrast to most veys, plus a bare smattering of cases in humans,
other tick-transmitted arboviruses. which have been nonfatal. (:l())
A formalinized vaccine has been described(75) A factor limiting the invasiveness of the virus
but has not been licensed. Protection against infor man is undoubtedly the reluctance of the vector
fection is largely a matter of protection against tick ticks, Ixodes cookei and I. marxi, to attach to and to
bite (repellents, protective clothing, avoidance of feed on human beings. Old World counterpart
tick-infested regions) and there is no specific ther- ticks, Ixodes ricinus and I. persulcatus, do attack
apy. human beings readily.
Diagnosis can be accomplished by serological
means, taking care to rule out cross-reactions from
10.2. Other Arboviruses Affecting Human Beings other flavivirus infections (particularly SLE in the
in the United States United States). The cardinal step in diagnosis is
Several other arboviruses capable of causing the initial clinical suspicion, leading to a directed
illness are thus far considered of only minor im- laboratory study.
portance as causative agents of human disease in 10.2.3. Vesicular Stomatitis Virus, Indiana Sub-
the United States. type. Epizootics of vesicular stomatitis virus, Indi-
10.2.1. Venezuelan Equine Encephalitis. Vene- ana subtype (VSI), a rhabdovirus, have occurred
92 Chapter 4 • Arbovimses
repeatedly in the United States. Mosquitos or the examining physician, uncovering a travel his-
Phlebotomus flies are suspected as vectors. Recog- tory, guessing at possibilities from such history,
nized infections in human beings are rare. Several and performing or ordering appropriate laboratory
infections occurring during an epizootic in Colo- examinations (virus isolation attempt, CF, HI, or
rado were reported. (27) Widespread immunity to N test). If the question is not asked, there is small
this virus and to VS-New Jersey is reported from likelihood of appropriate tests being performed.
Panama(72) with no evidence of illness in human Not many laboratories, furthermore, are capable of
beings. performing the required diagnostiC tests.
Diagnosis would start with suspicion, particu- In general terms, the infections listed in Table 4
larly if an epizootic is in progress, and seroconver- are not protracted febrile illnesses, but are acute.
sion is readily demonstrated by CF. Frequently physicians, baffled by a patient with
history of protracted fever, or bouts of fever over a
span of weeks, and in hopes of leaving no stone
10.3. Arboviruses Affecting Human Beings unturned, request examination for possible arbov-
Outside the United States irus infection. The possibility of an arbovirus
causing such an illness is practically nil. However,
Only a fraction of the over 350 arboviruses now it can be rewarding to examine serologically a
catalogued, possibly only a fifth, are ever involved specimen taken several weeks after an acute illness
in causation of recognizable disease in human has resolved, even though there may exist no
beings. However, several of the most important specimen from the acute phase of illness. For
and dangerous diseases afflicting mankind are example, a positive reaction for chikungunya virus
caused by arboviruses. Table 4 gives a very brief in an American tourist back from a trip to the Far
summary of the most important exotic (for the East would be certain evidence of an infection
United States) arboviruses, plus a selected group acquired overse.as and possibly could be related to
of viruses of lesser but still considerable impor- an exposure or illness specifically narrowed to the
tance. The epidemiologist or physician in the Far East trip.
United States will not encounter any of these Several of the arboviruses earlier discussed as
infections as endemic diseases (with the limited occurring in the United States also occur in Central
exception of VEE, mentioned earlier). However, and South America and some of the West Indian
with populations as mobile as is the American, islands (EEE, WEE, SLE, and VEE, for example).
there exists the possibility that any of these di- 10.3.1. Eastern Equine Encephalitis. Eastern
seases could enter the country with immigrants or equine encephalitis virus has been recovered from
with tourists coming from Africa, Asia, and South various mosquitos and birds from Canada to the
America particularly. With the common feature of Argentine. Equine outbreaks of large size occa-
incubation periods of several days, it not only is sionally occur. Cases in human beings have been
possible but has happened repeatedly that infected seen in Jamaica and the Dominican Republic,
individuals, in the incubation period and asymp- associated with EEE strains very closely related to
tomatic, can enter the country and proceed to fall the continental U.S. strains of virus. Farther to the
ill within the next few days. Also, acutely ill south, cases have rarely been recognized, yet a
patients may be evacuated from a foreign station serosurvey in one part of the Amazon Delta re-
for hospitalization in the United States. vealed a high rate of immunity in human beings
The recognition of such illness is complicated by with no history of encephalitis. (21) It has been
the fact that in the early stages differential diagno- notedC1S ) that Panamanian, Trinidadian, and
sis is almost impossible. Various causes of febrile South American strains of EEE can be distin-
illness must be reviewed: malaria, trypanosom- guished serologically from North American
iasis, typhoid fever, typhus fever, leptospirosis, strains. No studies on the comparative pathogen-
hepatitis, gastrointestinal infections with diarrhea icity of such strains have been made.
and vomiting, and the grab bag of "influenzalike" 10.3.2. Western Equine Encephalitis and st.
illnesses. The pOSSibility of arriving at a correct Louis Encephalitis. WEE and SLE viruses are also
diagnosis is directly dependent on the alertness of widely distributed south of the United States. A
very few cases of human disease have been re- rash, aching pains of the extremities, and general
ported in these countries. grippelike features. The fever curve may be of
10.3.3. Venezuelan Equine Encephalitis. VEE saddleback type. The endemic may be rarely rec-
did indeed stage a successful invasion of the ognized in indigenous populations. The epidemics
United States, even though it was a shortlived in due course may become of such size that
one, in 1971. Through the decade of the 1960s and medical personnel become aware of the situation,
to date, this virus has been responsible for many although it is certain that large epidemics may go
outbreaks of disease in equines in Latin America. unrecognized, or if recognized go unreported. Fa-
In some of these outbreaks, there have been nu- talities from the basic infection are very rare.
merous cases of encephalitis in human beings, However, in recent years an illness has been
with some fatal cases reported. Several substrains described in children in the Orient (DHF and DSS)
of VEE have been described. (85) The relationship which begins as a dengue infection, progresses
of these various substrains to the epidemiological through stages with hemorrhagic phenomena to a
pattern of epidemic and endemic VEE in Latin shock syndrome, and often terminates fatally.36
America is not fully understood as yet. Older children and adults are rarely afflicted. Var-
10.3.4. Yellow Fever. Yellow fever (YF) in urban ious explanations for this deviant syndrome have
or jungle form is a continuing threat. The two been advanced, which are summarized by Hal-
forms are nonetheless the same virus and the same stead. (33) He favors a hypothesis that the serious
disease, distinguished on epidemiological complications occur in children who have had a
grounds. The urban form is transmitted by Aedes earlier dengue infection and who react to a subse-
aegypti, a house-frequenting mosquito of the Old quent infection with a different dengue subtype
and New World tropics and subtropics. The dis- by an exaggerated production of antibodies. A
ease is a threat in mosquito-infested urban and resultant antigen/antibody complexing may then
suburban population centers. Urban outbreaks are underlie what is essentially a response in the child
secondary to the disease cycle in the jungle, where to the immune complex. This hypothesis has been
virus transmission occurs in monkey populations, challenged. (7)
the vectors being Haemagogus or aedine mosqui- Diagnosis of dengue and dengue hemorrhagic
tos. Human beings are involved in the jungle cycle fever may be on clinical grounds reinforced by
only as they are exposed through working in or virus isolation or by serological findings in CF, HI,
entering into the jungles. or N test. Diagnosis of specific dengue type can be
Many cases of yellow fever are so mild as to done only in a few specialized laboratories.
escape detection. Diagnosis may be suggested by Treatment of uncomplicated dengue is sympto-
clinical signs in a severe case and confirmed by matic. Treatment of the disease with hemorrhagic
virus isolation and serological changes. manifestations and shock is directed toward im-
Control of the disease can be achieved (for the mediate and vigorous combating of the shock
urban cycle) by control of the vector mosquito syndrome. Prompt attention can result in a marked
(Aedes aegypti). Human beings can be protected by lowering of mortality figures.
immunization' with YF-17D vaccine (not advised Control of dengue is basically control of the
for infants under 1 yr of age). A list of the centers vector mosquito, Aedes aegypti, and avoidance of
in the United States authorized to give the vacci- being bitten by mosquitos. Rudnick/ 59 ) working
nation can be obtained from the Public Health in Malaya, has evidence that forest monkeys may
Service. be involved in a "jungle dengue" cycle, with Aedes
10.3.5. Dengue and Dengue Hemorrhagic Fe- albopictus serving as a vector. Such a possibility
ver. Dengue viruses are of four recognizable sub- postpones hopes of eventual eradication of the
types (DEN types 1, 2, 3, 4) and occur in the Old disease. Vaccines for prevention of infection ~nd
World and New World tropics and subtropics. illness are being investigated.
One or more of the subtypes may be present 10.3.6. Chikungunya and O'Nyong Nyong.
wherever the mosquito Aedes aegypti abounds and Chikungunya (CHIK), an alphavirus (group A ar-
in the Orient may be associated also with Aedes bovirus), has been responsible for large outbreaks
albopictus. The illness is of acute onset, with fever, of denguelike illness in Africa and Asia. It is
spread by Aedes aegypti. It occurs in the same The outbreaks occur in the summer months and
regions of Asia as does dengue, and is possibly affect all age groups, but with peak mortality in
responsible for a small proportion of the cases of the younger age groups, pre-teenagers, and the
hemorrhagic fever-shock syndrome. A closely re- elderly.
lated virus, O'nyong nyong (ONN), associated Diagnosis is on clinical grounds, reinforced by
with epidemics of disease in human beings in East laboratory findings in serology (CF, HI, or N test).
Mrica, is spread by anopheline mosquitoes. Wild There is no specific treatment. Control may be
primates are suspected of being reservoirs for both through mosquito control. This can be very diffi-
viruses. Diagnosis may be on clinical grounds, cult in extensive rice-growing regions. In recent
buttressed by the laboratory, including virus isola- years, extensive vaccination campaigns have been
tion and specific serological changes (CF, HI, or N initiated, in Japan in particular, using an inacti-
test). Clinically, CHIK infections can be differen- vated vaccine prepared from infected infant mouse
taited from dengue, as Carey points out, (14) in brains. The vaccination program, concentrating on
that with CHIK the pains are restricted more to the children, has been accompanied by a marked re-
joints, the febrile period is shorter and not di- duction in the incidence of serious disease.
phasic, and many patients experience persistent 10.3.8. Murray Valley Encephalitis. Murray
residual joint pains following the acute episode. Valley encephalitis (MVE) is a close serological
Such analyses may help in identifying the dis- relative of SLE, JE, and West Nile viruses, with a
ease pattern in an epidemic, but it remains of similar epidemiological pattern. It is localized to
prime imponance-with yellow fever, the den- the Australian continent and islands to the north.
gues, chikungunya, and other nonarbovirus in- There is a zone of overlap presumably at some
fections such as influenza, early smallpox (before latitudinal level in the East Indies (Wallace'S line?)
the eruption appears), malaria, typhoid fever, with JE from the north and MVE from the south
rickettsioses and relapsing fever, leptospirosis, interdigitating. However, the two viruses are so
Lassa fever, and numerous other endemic and closely related serologically that the precise locali-
exotic infections-for the diagnostician to remem- zation of this level, if there is a precise localiza-
ber that the first few days of illness of an individ- tion, remains undefined. The first human epi-
ual patient may be accompanied by a disease demic of MVE was described by French in
pattern of quite unspecific character. 1952,<28) and since that time case reports have
No specific treatment exists for CHIK and ONN been very sporadic. However, in 1974 there was
infections, and control is limited to vector control widespread occurrence of cases in humans again
plus avoidance of being mosquito bitten. in Australia. (54)
10.3.7. Japanese Encephalitis. Japanese enceph- 10.3.9. Tick-Borne Encephalitis. Tick-borne en-
alitis (JE), a mosquito-transmitted flavivirus cephalitis (TBE) is a flavivirus responsible for a
(group B arbovirus), is closely related to St. Louis tick-transmitted disease of tne more northerly Eur-
encephalitis in the New World, to West Nile virus asian regions. The disease has been known under
in Africa and the Middle East, and to Murray several names, including Russian spring-summer
Valley enc~phalitis virus in Australia-New encephalitis and Far Eastern encephalitis. The
Guinea. Not only are the viruses close serological acute illness is often followed by encephalitis with
relatives, but also the ecological pattern of disease high mortality rates, and has been seen in most of
is similar, with mosquito vectors (Culex species the northern European countries, Russia, and Sib-
usually), wild bird vertebrate reservoirs, and pat- eria. The endemic virus cycle involves small mam-
terns of involvement of human beings with large mals (and to a lesser extent birds) in forested
numbers of inapparent or mild infections for each regions, and the vector ticks Ixodes ricinus and 1.
severe case seen. Nonetheless JE, affecting huge persulcatus. These ticks will feed readily on human
populations in rice-growing, suburban, and rural beings, if human beings invade the tick ecosy.stem
regions of the Orient, has been responSible for in forested lands of moderate elevation in the
large outbreaks of encephalitis in Korea, Japan, pale arctic regions. Most cases are reported in for-
China, and Taiwan, and a more diffuse scattering est and construction workers in newly opened
of cases in Malaysia, Southeast Asia, and India. regions, woodsmen, trappers, and fanners. At the
western end of distribution of this virus, human rhagic manifestations in severe cases. Virus isola-
disease is not seen, and the tick-transmitted, clo- tion and seroconversions (CF particularly)
sely related virus of louping ill has effects only on establish the diagnosis, and it has been noted that
sheep, with a virus reservoir in the small mammal the seroreactions are more pronounced and ele-
population. As earlier mentioned, the closely re- vated titers persist longer in patients with severe
lated virus in the nearctic region, Powassan, is illness than in those with mild disease. Cases are
transmitted by Ixodes marxi and I. cookei. Fortu- seen in rural regions, and are practically invariably
nately these two ticks rarely attack man, so the associated with bite of certain ixodid ticks of the
disease in the New World remains essentially a region, which infest small mammals, particularly
curiosity. Antibodies to TBE have been found in rabbits. Tick control measures have been pro-
human populations in hilly or mountainous re- posed. An immune y-globulin preparation has
gions of Italy, Greece, and Turkey. The closely been made and is under trial for treatment of
related virus causing Kyasanur Forest disease cases.
(KFD) in Mysore State, India, is also tick transmit- The situation in Africa is still a challenging
ted, and has a vertebrate host cycle in two monkey unknown. After the initial finding of several hu-
species of the region, as well as in small mammals. man cases in the 1950s (one possible fatality), no
None of the TBE subset of viruses has been found additional cases have been found. Yet the known
in countries south of the equator. It is well known range of the virus has been expanded enormously,
that ticks can be transported on birds (phoresy). with numerous isolations from ticks, cattle, goats,
With millions of birds flying south each season, in and a hedgehog, and from Culicoides (biting gnats)
both the Old World and the New World, it is not in Nigeria and from ticks in Senegal. The disease
at all comprehended why foci of infection with in man remains to be described in West Africa.
TBE have not been established south of the equa- Diagnosis is by clinical criteria (in USSR) but-
tor. tressed by virus isolation and by serological tests
Transovarial transmission of TBE and KFD vi- (CF and immunoprecipitin tests). Nosocomial in-
ruses has been demonstrated in vector ticks. fections have been reported from the USSR in
No specific therapy exists for TBE or KFD infec- hospital staff and laboratory workers.
tions. Prevention is through control of tick popula-
tions, protection against tick bite (repellents, pro-
tective clothing), and avoidance of tick habitats.
An inactivated vaccine is widely used in the USSR 11. Unresolved Problems
to protect special groups of workers, and inhabit-
ants in known TBE foci. Diagnosis is made on Unresolved problems are discussed from several
clinical grounds, reinforced by laboratory proce- points of view, relating to the viruses, the vectors,
dures of virus isolation and serological tests (CF, the vertebrate hosts, and transmission cycles in-
HI, or N test). volving virus, vector, and host. The disease in the
10.3.10. Crimean Hemorrhagic Fever and vertebrate host, which includes the host response
Congo. Crimean hemorrhagic fever (CHF) was to the pathogen, merits independent considera-
first recognized in the southern USSR as a clinical tion. Problems relating to the epidemiology of
entity in 1944. The causative virus was not finally each specific disease require a synthesis of many
isolated until the mid-1960s. In the meantime, specific items, and, finally, effective control exer-
workers in the Congo and Uganda had isolated cised at the level of the virus, the vector, or the
several virus strains from febrile human beings, to vertebrate requires thorough understanding of the
which the name "Congo virus" (CON) was ap- epidemiological background. Specific examples
plied. Casals in 1969( 9) showed that the two will help to illustrate problems.
viruses were indistinguishable.
In the southern USSR and Bulgaria, several 11.1. The Viruses
hundred cases of CHF are seen annually, with a
mortality rate as high as 15--20%. The cases pres- Much progress has been made in recent years in
ent as febrile illness, with pronounced hemor- categorizing the several hundred described arbov-
iruses and determining the biochemical, growth, tification of the host(s) is a prime need, and
and morphological characteristics in intact verte- following this a biological profile of the host,
brates, in invertebrates, and in cell culture systems involving (as is the case' for arth-ropods also) the
of vertebrate and invertebrate cells. Yet it is ob- full range of biological and ecological considera-
vious that the surface has barely been scratched. tions, as well as the degree of host susceptibility to
This includes all of the arboviruses, even such the virus.
much-studied models as Sindbis, Semliki Forest,
and the vesicular stomatitis viruses. An area still
quite unresolved concerns the extent of RNA ho- 11.4. Transmission Cycles Involving Virus,
mology which may exist between the numerous Vector, and Vertebrate
members of a given arbovirus grouping, such as Full cycles are known for very few of the arbovi-
the alphaviruses (group A arboviruses), the flavi- ruses. A skeptic may ask whether the complete
viruses (group B arboviruses), the bunyaviruses cycle is known with certainty for any arbovirus,
(Bunyamwera supergroup arboviruses), or the even for such extensively studied ones as EEE,
rhabdoviruses (of the arbovirus subset). WEE, SLE, and YF. The problem of virus persist-
ence in nature is a particularly baffling one. For
example, there are many theories and few facts to
11.2. The Vectors explain how a given virus manages to overwinter
The factors which determine specific virus/vec- or survive past a long dry season, when vectors
tor associations are still unknown. A mosquito- may practically disappear, and vertebrate popula-
transmitted flavivirus (such as yellow fever) will tions decline (or go into hibernation). Such prob-
not multiply in ticks, and a tick-transmitted flavi- lems have been explored from the angle of vector
virus (such as tick-borne encephalitis) will not populations overwintering, with some members
multiply in mosquitos. harboring virus, or vertebrate populations over-
There is a continuing need for taxonomic refine- wintering with some members infected and the
ments with respect to arthropods, such as the need infection in a latent phase, awaiting a vernal
for more information on both Old World and New reactivation stimulus. Transovarial transmission,
World mosquitos of the genera Culex and Aedes, permitting passage of. virus to generation after
and Phlebotomus and Culicoides sandflies. This generation of vector without the need for an inter-
need is generated by the increasing realization of calated vertebrate host, has received recent stimu-
their involvement with a large number of arbovi- lation from demonstrations of the phenomenon
ruses. The same remarks are pertinent for the tick wi th California encephalitis virus. (SO)
vectors. The need is equally as great for more Reeves(SS) discusses the epidemiological prob-
information on the biology, feeding preferences, lems of overwintering of arboviruses in northern
longevity, flight range, and distribution of each countries, and possible transport via infected vec-
arthropod species involved. The genetic constitu- tors on migrating birds, his discussion extending
tion of each vector species is basic to an under- to Old World as well as New World viruses. Lord
standing of what constitutes a vector, both phy- and Calishei 42 ) discuss the transport of arbovi-
siologically and behaviorally, and will become ruses in infected migrating birds along the Atlan-
increasingly important as control of vectors tic Coast flyway of the United States.
through genetic manipulation is considered. Certain of the tick-transmitted viruses, such as
Colorado tick fever and tick-borne encephalitis,
utilizing mechanisms of long persistence in ticks
11.3. The Vertebrate Hosts plus transovarial transmission of virus, exist in
For most of the arboviruses, the primary verte- endemic form in defined geographic areas. For
brate host, i.e., that host which serves as the basic mosquito-transmitted viruses such as EEE, WEE,
unit for propagation of the virus, is some creature SLE, VEE, and many others, it has been difficult to
other than man. For many of the arboviruses, the establish whether a virus is permanently endemic
vertebrate hosts are not yet determined, or are in a region or is periodically reintroduced via
recognized on the most tenuous of evidence. Iden- vectors or migrant vertebrates.
Studies of transmission cycles are tied in closely an attenuated yellow fever (17D) vaccine in use on
with simulation of cycles by models, with carefully an international scale. Attenuated dengue virus
defined parameters. Such models may permit vaccines, tick-borne encephalitis vaccines, and
computer manipulation and simulation of field vaccines for VEE, WEE, and Japanese encephalitis
conditions by varying the values applied to de- have been developed and tried on a limited scale.
fined parameters, following which epidemic Killed vaccines for TBE, EEE, WEE, and Japanese
curves can be generated. Macdonald(45) has pro- encephalitis have been used, in some cases exten-
vided a model for malaria. A model for an arbovi- sively. Hammon(34) provides a detailed discussion
rus with a vertebrate host in addition to man is of of problems.
necessity much more complex than one for a Development of methodology for fractionation
simple host/parasite relationship. Much further of viruses into component antigens provides
work on models is needed, with hope of eventual hopes for better vaccines. In the arbovirus area,
prediction of outbreaks. there has been only limited exploration of this
Specific cycles and the limits of knowledge con- potential.
cerning them are discussed under the various Control at the vector level involves continuing
specific viruses in preceding pages. work on methodology for control of arthropods.
Development of resistance to various of the chlori-
nated hydrocarbons used as insecticides has im-
11.5. Disease in the Vertebrate Host paired many control programs, and recent action
Infection in the vertebrate host (including man) banning the use of residual insecticides has fur-
has in the past received more attention in the ther intensified the need for exploration of alterna-
tive methods for vector control. Work in progress
fields of pathology and response of the host im-
at the University of California(6) and elsewhere
mune system than in the fields of pathophysiology
and host response to immunological states. The leads to the hope that isolation of clones of the
mosquito Culex tarsalis in nature, or the induction
dengue hemorrhagic fever and shock phenomena
of genetic variants in the laboratory, may lead to
have awakened an interest in the host response to
effective control strategies. Introduction into a
the presence of an immune complex as a contrib-
mosquito population of genes relating to (1) in-
uting factor to illness in the host. Treatment of
creased insecticide susceptibility, (2) reduced ca-
disease is much more likely to have success in the
pacity to support virus multiplication and/or to
area of treatment of syndromes arising from host
transmit virus, (3) alternatives in host feeding
responses to virus proliferation and antibody pro-
preferences, (4) reduction in numbers through
duction, including the formation of antigen/anti-
mutations leading to reduction in reproductive
body complexes, than in the area of specific anti-
success (sterile males, conditional lethal mutants),
viral substances. Studies of the human response to
and (5) subversions of host feeding habits merit
arboviral infections are made difficult since the
consideration. The possibility of loading mosquito
epidemics providing numbers of cases for study
populations with an insect virus innocuous to
occur usually unpredictably in time, and often far
human beings, with intent to block reproduction
from modem facilities required for detailed clinical
of viruses pathogenic for human beings, is also
investigation. being studied. (58)
Recognition of disease in the vertebrate host
Control procedures at the level of the vertebrate
calls for further development of simple diagnostic
reservoir have not received serious consideration
technics, including techniques for virus isolation,
in the arbovirus field. Certainly rodent control has
detection of immune response, and monitoring of
long been successfully applied for plague control,
impaired physiological !rtates.
and more recently for control of Bolivian hemor-
rhagic fever, caused by the arenavirus Machupo.
11.6. Control Monkey extermination for yellow fever control and
extermination of wild bird populations for control
Virus vaccines are an obvious means of control, of EEE, WEE, SLE, or Japanese encephalitis are not
yet for man and the arboviruses there exists only acceptable procedures within our society of today.
12. References ecology of Colorado tick fever virus in western Mon-

tana, Am. J. Hyg. 69:127-137 (1959).
14. CAREY, D. E., Chikungunya and dengue: A case of
1. ADLDINGER, H. K., STONE, S. S., HESS, W. R, AND mistaken identity? ]. Hist. Med. Allied Sci. 26:243-262
BACHRACH, H. L., Extraction of infectious deoxynu- (1971).
cleic acid from African swine fever virus, Virology 15. CASALS, J., Immunological relationship among cen-
30:750-752 (1966). tral nervous system viruses, J. Exp. Med. 79:341-359
2. American Committee on Arthropod-Borne Viruses, (1944).
Catalogue of Arthropod-Borne Viruses of the World, 16. CASALS, J., The arthropod-borne group of animal
U.S. Public Health Service Publication No. 1760, viruses, Trans. N.Y. Acad. Sci. 19:219-235 (1957).
Washington, D.C., 1967; and second edition, 1975: 17. CASALS, J., Viral encephalitis, in: Viral Encephalitis,
International Catalogue of Arboviruses Including Certain pp. 5-21, Charles C. Thomas, Springfield, Ill., 1958.
Other Viruses of Vertebrates. 18. CASALS, J., Antigenic variants of eastern equine
3. American Committee on Arthropod-Borne Viruses, encephalitis virus,]. Exp. Med. 119:547-565 (1964).
Catalogue of Arthropod-Borne Viruses of the World, 19. CASALS, J., Antigenic similarity between the virus
Am. J. Trap. Med. Hyg. Suppl. 19:1082-1160 (1970). causing Crimean hemorrhagic fever and Congo vi-
4. American Committee on Arthropod-Borne Viruses, rus, Proc. Soc. Exp. BioI. Med. 131:233-236 (1969).
Catalogue of Arthropod-Borne and Selected Verte- 20. CASALS, J., AND BROWN, E. V., Hemagglutination
brate Viruses of the World, Am. J. Trap. Med. Hyg. with arthropod-borne viruses, J. Exp. Med. 99:429-
Suppl. 20:1018-1050 (1971). 449 (1954).
5. ARDOIN, P., CLARKE, D. H., AND HANNOUN, c., The 21. CAUSEY, O. R., AND THEILER, M., Virus antibody
preparation of arbovirus hemagglutinins by sonica- survey of sera of residents of the Amazon valley in
tion and trypsin treatment, Am. J. Trap. Med. Hyg. Brazil, Am. J. Trap. Med. Hyg. 7:36-41 (1958).
18:592-598 (1969). 22. CLARKE, D. H., AND CASALS, J., Techniques for
6. ASMAN, S. M., Cytogenetic Observations in Culex hemagglutination and hemagglutination-inhibition
tarsalis: Mitosis and meiosis, J. Med. Entomol. 11:375- with arthropod-borne viruses, Am. J. Trap. Med.
382 (1974). Hyg. 7:561-573 (1958).
7. BARNES, W. J. S., AND ROSEN, L., Fatal hemorrhagic 23. DOWNS, W. G., AITKEN, T. H. G., AND ANDERSON, C.
disease and shock associated with primary dengue R., Activities of the Trinidad Regional Virus Labora-
infection on a Pacific island, Am. J. Trap. Med. Hyg. tory in 1953 and 1954 with special reference to the
23:495-506 (1974). yellow fever outbreak in Trinidad, B.W.I., Am. J.
8. BIGLER, W. J., VENTURA, A. K., LEWIS, A. L., WELL- Trap. Med. Hyg. 4:837-843 (1955).
INGS, F. M., AND EHRENKRANZ, N. J., Venezuelan 24. EHRENKRANZ, N. J., AND VENTURA, A. K., Venezue-
equine encephalomyelitis in Florida: Endemic virus lan equine encephalitis virus infection in man, Annu.
circulation in native rodent populations of Ever- Rev. Med. 25:9-14 (1974).
glades hammocks, Am. J. Trap. Med. Hyg. 23:513-521 25. EMMONS, R. W., DONDERO, D. V., DEVLIN, V., AND
(1974). LENNETTE, E. H., Serologic diagnosis of Colorado
9. BINN, L. N., SPONSELLER, M. L., WOODING, W. L., tick fever: A comparison of complement-fixation,
MCCONNELL, S. J., SPERTZEL, R 0., AND YAGER, R immuno-fluorescence, and plaque reduction meth-
H., Efficacy of an attenuated western encephalitis ods, Am. J. Trap. Med. Hyg. 18:796-802 (1969).
vaccine in equine animals, Am. ]. Vet. Res. 27:1599- 26. EVANS, A. S., Cox, F., NAUKERVIS, G., OPTON, E.,
1604 (1966). SHOPE, R, WELLS, A. V., AND WEST, B., 1\ health and
10. BORDEN, E. c., SHOPE, R. E., AND MURPHY, F. A., seroepidemiological survey of a community in Bar-
Physicochemical and morphological relationships of bados, Int. J. Epidemiol. 3:167-175 (1974).
some arthropod-borne viruses to bluetongue virus- 27. FmLDs, B. N., AND HAWKINS, K., Human infection
a new taxonomic group: Physicochemical and serol- with the virus of vesicular stomatitis during an
ogical studies, J. Gen. Viral. 13:261-271 (1971). epizootic, N. Engl. ]. Med. 277:989-994 (1967).
11. BRODY, J. A., BURNS, K. F., BROWNING, G., AND 28. FRENCH, E. L., Murray valley encephalitis, Med. J.
SCHATTNER, J. D., Apparent and inapparent attack Aust. 39:100-103 (1952).
rates for St. Louis encephalitis in a selected popula- 29. GERLOFF, R K., AND EKLl.{ND, C. M., A tissue culture
tion, N. Engl. J. Med. 261:644-646 (1959). neutralization test for Colorado tick fever antibody
12. BUCKLEY, S. M., Susceptibility of the Aedes albopictus and use of the test for serologic surveys, J. Infect. Dis.
and Aedes aegypti cell lines to infection with arbovi- 104:174-183 (1959).
ruses, Prac. Soc. Exp. Bioi. Med. 131:625-630 (1969). 30. GOLDFmLD, M., AUSTIN, S. M., BLACK, H. c., TAY-
13. BURGDORFER, W., AND EKLUND, C. M., Studies on the LOR, B. F., AND ALTMAN, R, A nonfatal human case
Chapter 4 • Arbovimses 99
of Powassan virus encephalitis, Am. J. Trop. Med. Replication of dengue viruses in cultures of periph-
Hyg. 22:78--81 (1973). eral blood leucocyte from dengue-immune rhesus
31. GRACE, T. D. c., Establishment of a line of mosquito monkeys. J. Infect. Dis. 133:274-282 (1976).
(Aedes aegypti 1.) cells grown in vitro, Nature (Lon- 47. MATTINGLY, P. F., Ecological aspects of the evolution
don) 211:366-367 (1966). of mosquito-borne virus diseases, Trans. R. Soc.
32. HALLAUER, c., Uber den Virusnachweis mit dem Trop. Med. Hyg. 54:97-112 (1960).
Hirst-Test, Z. Pathol. Bakteriol. 9:553-554 (1946). 48. McLEAN, D. M., AND DONOHUE, W. 1., Powassan
33. HALSTEAD, S. B., Observations relating to pathogen- virus: Isolation of virus from a fatal case of encepha-
esis of dengue hemorrhagic fever. VI. Hypotheses litis, Can. Med. Assoc. J. 80:708-711 (1959).
and discussion, Yale J. Bioi. Med. 42:350-362 (1970). 49. MONATH, T. P. c., NUCKOLLS, J. G., BERALL, J.,
34. HAMMON, W. M., Present and future of killed and BAUER, H., CHAPPELL, W. A., AND COLEMAN, P. H.,
live arbovirus vaccines, in: First International Confer- Studies on California encephalitis in Minnesota, Am.
ence on Vaccines Against Viral and Rickettsial Infections J. Epidemiol. 92:40-50 (1970).
of Man, Pan American Health Organization, Wash- 50. MURPHY, F. A., BORDEN, E. c., SHOPE, R E., AND
ington, D.C., pp. 252-259, 1967. HARRISON, A., Physicochemical and morphological
35. HAMMON, W. M., AND REEVES, W. C., California relationships of some arthropod-borne viruses to
encephalitis virus, a newly described agent, Calif. bluetongue virus-a new taxonomic group: Electron
Med. 77:303-309 (1952). microscopic studies, J. Gen. Virol. 13:273-288 (1971).
36. HAMMON, W. M., RUDNICK, A., AND SATHER, G. E., 51. PLOWRIGHT, W., BROWN, F., AND PARKER, J., Evi-
Viruses associated with epidemic hemorrhagic fever dence for the type of nucleic acid in African swine
of the Philippines and Thailand, Science 131:1102- fever virus, Arch. Gesamte Virusforsch. 29:289-304
1103 (1960). (1966).
37. HAMMON, W. M., AND SATHER, G. E., Arboviruses, 52. PLOWRIGHT, W., PERRY, C. T., PIERCE, M. A., AND
in: Diagnostic Procedures for Viral and Rickettsial Infec- PARKER, J., Experimental infection of the argasid
tions, 4th ed. (E. H. LENNETTE AND N. J. SCHMIDT, tick, Ornithodoros moubilta porcinus, with African
eds.), American Public Health Association, New swine fever virus, Arch. Gesamte Virusforsch. 31:33-
York,1969. 50 (1970).
38. HORSFALL, F. 1., JR., AND TAMM, I. (eds.), Viral and 53. PRINCE, A. M., METSELAAR, D., KAFUKO, G. W.,
Rickettsial Infections of Man, 4th ed., Lippincott, MUKWAYA, L. G., LlNG, C. M., AND OVERBY, L. R,
Philadelphia, 1965. Hepatitis B antigen in wild-caught mosquitoes in
39. HUGHES, L. E., CASPER, E. A., AND CLIFFORD, C. M., Africa, Lancet 2:247 (1972).
Persistence of Colorado tick fever virus in red blood 54. Queensland Institute of Medical Research, 29th An-
cells, Am. J. Trop. Med. Hyg. 23:530-532 (1974). nual Report, p. 3, Brisbane, Australia, 1974.
40. LIBn<ovA, H., AND BUCKLEY, S. M., Studies with 55. REEVES, W. c., Overwintering of arboviruses, Prog.
Kemerovo virus in Singh's Aedes cell lines, Acta Med. Virol. 17:193-220 (1974).
Virol. 15:393-403 (1971). 56. REEVES, W. c., AND HAMMON, W. M., Epidemiology
41. LORD, R. D., History and geographic distribution of of the arthropod-borne viral encephalitides in Kern
Venezuelan equine encephalitis, Bull. Pan Am. County, California, 1943-1952, Univ. Calif. Publ. Pub-
Health Org. 8:100-110 (1974). lic Health 4:1-257 (1962).
42. LORD, R, AND CALISHER, C. H., Further evidence of 57. lU;HACEK, J., AND PESEK, J., Propagation of eastern
southward transport of arboviruses by migratory equine encephalomyelitis virus in surviving tick tis-
birds, Am. J. Epidemiol. 92:73-78 (1970). sues, Acta Virol. 4:241-254 (1960).
43. LUMSDEN, L. 1., St. Louis encephalitis in 1933: Ob- 58. RICHARDSON, J., SYLVESTER, E. S., REEVES, W. c.,
servations on epidemiological features, Public Health AND HARDY, J. 1., Evidence of two inapparent non-
Rep. 73:340-353 (1958). occluded viral infections of Culex tarsalis, J. Invertebr.
44. L'vov, D. K., TIMOPHEEVA, A. A., CHERVONSKI, V. I., Pathol. 23:213-224 (1974).
GROMASHEVSKI, V. L., KLISENKO, G. A., GOSTINSCHI- 59. RUDNICK, A., Studies of the ecology of dengue in
KOVA, G. V., AND KOSTYRKO, I. N., Tyuleniy virus: A Malaysia: A preliminary report, J. Med. Entomol.
new group B arbovirus isolated from Ixodes (Ceratix- 2:203-208 (1965).
odes) putus Pick.-Camb. 1878 collected on Tyuleniy 60. SABIN, A., Antigenic relationship of dengue and
Island, Sea of Okhotsk, Am. J. Trop. Med. Hyg. yellow fever viruses with those of West Nile and
20:456-460 (1971). Japanese B encephalitis, Fed. Proc. 8:410 (1949).
45. MACDONALD, GEORGE, The Epidemiology and Control 61. SABIN, A. B., AND BUESCHER, E. 1., Unique physico-
of Malaria, Oxford University Press, Oxford, 1957. chemical properties of Japanese B virus hemagglu-
46. MARCHETTE, N. J., HALSTEAD, S. B., AND CHOW, J. S., tinin, Proc. Soc. Exp. Bioi. Med. 74:222-230 (1950).
62. SASLOW, A., A survey of encephalitis of unknown encephalitis studies in Wisconsin, Am. J. Epidemiol.
etiology in Connecticut June-September, 1%7, thesis 81:230-244 (1965).
for M.P.H., Department of Epidemiology and Public 77. THOMPSON, W. H., KALFAYAN, B., AND ANSLOW, R.
Health, Yale School of Medicine, 1968. 0., Isolation of California encephalitis group virus
63. SAWYER, W. A., BAUER, J. H., AND WHITMAN, 1., from a fatal human illness, Am. J. Epidemiol. 81:245-
Distribution of yellow fever immunity in North 253 (1965).
America, Central America, West Indies, Europe, 78. U.S. Department of Health, Education and Welfare,
Asia and Australia, with special reference to specific- Epidemiologic notes and reports: St. Louis encepha-
ity of the protection test, Am. J. Trop. Med. 17:137- litis-Tennessee, Morbidity and Mortality Weekly Re-
161 (1937). port, Vol. 23, pp. 294, 299 (1974).
64. SHOPE, R. E., Arboviruses, in: Manual of Clinical 79. VENTURA, A. K., BUFF, E. E., AND EHRENKRANZ, N.
Microbiology, 2nd ed., (E. H. LENNETIE, E. H. J., Human Venezuelan equine encephalitis virus in-
SPAULDING, AND J. P. TRUANT, eds.), American Soci- fection in Florida, Am. J. Trop. Med. Hyg. 23:507-512
ety for Microbiology, Washington, D.C., 1974. (1974).
65. SINGH, K. R P., Cell cultures derived from larvae of 80. WATTS, D. M., THOMPSON, W. H., YUILL, T. M.,
Aedes albopictus (Skuse) and Aedes aegypti (1.), Curro DEFoLIART, G. R, AND HANSON, R P., Overwinter-
Sci. 36:506-508 (1967). ing of LaCrosse virus in Aedes triseriatus, Am. J. Trop.
66. SINGH, K. R. P., AND PAUL, S. D., Multiplication of Med. Hyg. 23:694-700 (1974).
arboviruses in cell lines from Aedes albopictus and 81. WELLINGS, F. M., SATHER, G. E., AND HAMMON, W.
Aedes aegypti, Curro Sci. 37:65-67 (1968). M., Immunoelectrophoretic studies of the California
67. SMITH,. H. H., Controlling yellow fever, in: Yellow encephalitis virus group, J. Immunol. 107:252-259
Fever, (G. K. STRODE, ed.), McGraw-Hill, New York, (1971).
1951. 82. WHITMAN, L., Arthropod vectors of yellow fever, in:
68. SMITHBURN, K. c., Differentiation of the West Nile Yellow Fever (G. K. STRODE, ed.), McGraw-Hill, New
virus from the viruses of St. Louis and Japanese B York,1951.
encephalitis, J. Immunol. 44:25-31 (1942). 83. WHITMAN, L., AND AITKEN, T. H. G., Potentiality of
69. SMITHBURN, K. c., Antigenic relationships among Ornithodoros moubata (Murray) (Acarina, Argasidae)
certain arthropod-borne viruses as revealed by neu- as. a reservoir-vector of West Nile virus, Ann. Trop.
tralization tests, J. Immunol. 72:376-388 (1954). Med. Parasitol. 54:192-204 (1960).
70. STOKES, A., BAUER, J. H., A'JD HUDSON, N. B., 84. WILLIAMS, J. E., YOUNG, O. P., AND WATTS, D. M.,
Transmission of yellow fever to Macacus rhesus: A Relationship of density of Culiseta melanura mosqui-
preliminary note, ,. Am. Med. Assoc. 90:253-254 toes to infection of wild birds with eastern and
(1928). western equine encephalitis viruses, J. Med. Entomol,
71. SURTEES, G., SIMPSON, D. I. H., BOWEN, E. T. W., 11:352-354 (1974).
AND GRANINGER, W. E., Ricefield development and 85. YOUNG, N. A., AND JOHNSON, K. M., Antigenic
arbovirus epidemiology, Kano Plain, Kenya, Trans. variants of Venezuelan equine encephalitis virus:
R. Soc. Trop. Med. Hyg. 64:511-518 (1970). Their geographic distribution and epidemiologic sig-
72. TESH, R. B., PERALTA, P. H., AND JOHNSON, K. M., nificance, Am. ]. Epidemiol. 89:286-307 (1969).
Ecologic studies of vesicular stomatitis virus. I. Prev- 86. YUNKER, C. E., AND CORY, J., Colorado tick fever
alence .of infection among animals and humans liv- virus: Growth in a mosquito cell line, ]. Virol. 3:631-
ing in an area' of endemic VSV activity, Am. J. 632 (1%9).
Epidemiol. 90:255-261 (1969).
73. THEILER, M., Action of sodium deoxycholate on
arthropod-borne viruses, Proc. Soc. Exp. Bioi. Med.
96:380-382 (1957).
74. THEILER, M., AND DOWNS, W. G., The Arthropod- 13. Suggested Reading
Borne Viruses of Vertebrates, Yale University Press,
New Haven, 1973. Catalogue of Arthropod-Borne Viruses of the World, U.S.
75. THOMAS, 1. A., PH.ILIP, R. N., PATZER, E., AND Public Health Service Publication No. 1760 (1967);
CASPER, E., Long duration of neutralizing antibody Supplement No.1, Am. J. Trop. Med. Hyg. 19:1082-
response after immunization of man with a fonnalin- 1160 (1970); Supplement No.2, Am. J. Trop. Med. Hyg.
ized Colorado tick fever vaccine, Am. J. Trop. Med. 20:1018-1050 (1971), and second edition, 1975.
Hyg. 16:60-62 (1967), HAMMON, W. M., AND SATHER, G., Arboviruses, in:
76. THOMPSON, W. H., AND EVANS, A. 5., California Diagnostic Procedures for Viral and Rickettsial Infections,
4th ed. (E. H. LENNETIE AND N. J. SCHMIDT, eds.), ology, 2nd ed. (E. H. LENNETIE, E. H. SPAULDING, AND
American Public Health Association, New York, 1969. J. P. TRUANT, eds.), American Society for Microbiol-
HORSFALL, F. 1., JR., AND TAMM, 1. (eds.), Viral and ogy, Washington, D.C., 1974.
Rickettsial Diseases of Man, 4th ed., Lippincott, Phila- THEILER, M., AND DOWNS, W·. G., The Arthropod-Borne
delphia, 1965. Viruses of Vertebrates, Yale University Press, New Ha-
SHOPE, R. E., Arboviruses, in: Manual of Clinical Microbi- ven, 1973.
CHAPTER 5
Arenaviruses
Jordi Casals
1. Introduction illness, Bolivian hemorrhagic fever (BHF), clini

cally very similar to AHF. Other viruses, antigeni-
Arenavirus is the proposed designation for a set of cally placed in the Tacaribe group, were discov-
viruses which have a unique morphology. (76) The ered soon after: Amapari in Brazil, 1964,(71) Latino
virions are round, oval, or pleomorphic, with in Bolivia,<93) Parana in Paraguay, (92) Pichinde in
diameters between 60 and 350 nm, an electron- Colombia,<88) and Tamiami in the United States,
dense membrane with spikes or projections, and a 1965.<'6) None of these five is known to cause
number of inclusionlike, dense particles that give human illness. The last member of the group,
the virion an aspect of having been sand sprinkled Lassa virus, was recovered from patients suffering
(arenosus). Arenaviruses have an RNA genome, are from a severe disease first seen in Nigeria.
inactivated by lipid solvents, and share antigenic A serological relationship among members of
components. Since the first recognized member of this set was first observed between Junin and
this group was lymphocytic choriomeningitis Tacaribe viruses in 1963, resulting in the creation
(LCM) virus, it is considered the prototype. of the Tacaribe antigenic group(57); the other vi-
ruses, except LCM and Lassa, were easily shown
to be related to Tacaribe and Junin and placed in
2. Historical Background the group. The similarity of morphology and mor-
phogenesis between LCM and the Tacaribe group
viruses was noted in 1969,<62) and soon afterward
LCM virus has been knovvn since 1934, and soon
it was shown that there was an antigenic connec-
afterward it was etiologically associated with a
tion between them. (77) Finally, it was observed in
disease syndrome of man, acute benign aseptic
1970 that Lassa virus was antigenically related to
meningitis. Tacaribe virus, isolated from bats in
LCM and to some of the Tacaribe group agents(15)
Trinidad in 1956 and first described in 1963, has
and that its morphology conformed to that de-
not been associated with human disease.(23) The
scribed for LCM.(86)
next virus to be isolated and characterized was
Junin virus, in 1958; the virus was isolated from
patients with Argentinian hemorrhagic fever
(AHF). Five years later, in 1963, another virus, 3. Methodology
Machupo, was isolated from a fatal case of an
3.1. Mortality
Jordi Casals Department of Epidemiology and Pub- The case fatality rate of some members of this
lic Health, Yale University School of Medicine, New group is sufficiently high that deaths from "the
Haven, Connecticut disease give a good idea of the morbidity rate
103
104 Chapter 5 • Arenaviruses
provided an accurate diagnosis can be mad,. For 3.4. Laboratory Diagnosis

example, the mortality from Lassa fever is 30-60%,
from Argentian hemorrhagic fever is 3-15%, and
from Bolivian hemorrhagic fever is 5-30%. How- While a clinical diagnosis of fully developed,
ever, deaths from lymphocytic choriomeningitis typical cases of AHF and BHF can be made with
are rare. For the most part, these diseases are rare, considerable accuracy in the districts where the
limited to localized outbreaks, and confined to a diseases are endemic at the time of year when they
very few geographic areas. For those reasons, the prevail, particularly if several similar cases appear
official mortality records would be unlikely to simultaneously, it is most doubtful that a sporadic
reflect their occurrence in a country. case of LCM can be accurately diagnosed. A pres-
umptive diagnosis of Lassa fever can be enter-
3.2. Morbidity tained in known endemic areas by experienced
physicians faced with a severe or moderately se-
Epidemiological studies on arenavirus infections vere case.(591
of man are hindered by the fact that disease A specific diagnosis of these illnesses requires
reporting is uncertain and incomplete. The diag- that either the virus be isolated and identified
nosis of sporadic cases of LCM is, most likely, not from the patient's blood, excretions, or secretions,
made or is guesswork in nearly all instances unless usually early during the disease, or that develop-
laboratory aid is sought. Diagnosis of AHF in the ment of specific antibodies is shown to occur late
area and season where the disease is anticipated is in the disease or in convalescence.
confirmed by laboratory studies in about 70% of The complement fixation (CF) test has been most
clinically diagnosed cases(49,54); how many clini- useful as a diagnostic aid with these illnesses; it is
cally undiagnosed infections go undetected is not not, however, an early means of diagnosis since
known. It is doubtful that an effective reporting from 15 to 30 days from onset is required for it to
system has been devised and implemented for become positive with most patients, perhaps a
these diseases, with the possible exception of shorter time with LCM. The CF is not a specific
AHF. Because of the highly specialized type of test within the arenaviruses, certainly not between
diagnostic work required for identification of the Machupo and Junin viruses/ 47 .95 ) but since these
viruses and antibodies resulting from infection, viruses occur in different areas a diagnostic error
and because of the risk associated with certain between the two is unlikely to occur. On the other
aspects of the laboratory procedures, the knowl- hand, difficulties in the interpretation of CF re-
edge of the prevalence of the infections and ill- sults have arisen in an area where Junin and LCM
nesses caused by the arenaviruses is limited. viruses have infected man, simultaneously or se-
quentially. (49,50) In fact, in view of the known
wide distribution of LCM virus, it is conceivable
3.3 Serological Surveys
that diagnostic problems may arise when the CF
Because of the difference in duration of different test is used to diagnose Machupo or, if in Africa
antibodies, seroepidemiological surveys are car- and if LCM virus is there, Lassa viruses. Since
ried out mainly by means of the neutralization LCM virus occurs in many European countries,
test, (14,34,40) even though this is a more introduction of an exotic arenavirus in that conti-
cumbersome test than complement fixation; it nent might result in diagnostic difficulties if the
should be noted that not many extensive surveys CF test alone were used.
have been carried out, except with LCM virus. The The fluorescent antibody technique (FAT) has
complement fixation test is extremely useful as an been used advantageously for an early diagnosis of
aid to the diagnosis of a recent illness; the fact that LCM virus infection of man. (7.25) The neutraliza-
it is less type specific than the neutralization test, tion test has been used less for diagnosis of
to the point that it hardly differentiates between current illnesses and serological surveys-LCM ex-
Junin and Machupo viruses infections of man,<95) cepted-than for characterization of the viruses
does not detract from its value, because of the themselves; as will be seen in another section, it is
limited geographic distribution of these viruses. sharply specific. (9:1)
Chapter 5 • Arenaviruses 105
4. The Viruses and the second polypeptide, WIth a molecular

weight of 12,000 daltons, has no assigned func-
tion.(74)
4.1. Biochemical and Physical Properties
Buoyant density in sucrose gradients has been
The most extensive studies to determine bioch- reported as 1.17 or 1.18 glml for LCM, Pinchinde,
emical and physical properties of the arenaviruses Machupo, Junin, Tacaribe, and Amapari, and be-
have been done with LCM(n9) and Pichinde.(74) tween 1.18 and 1.2 glml for Parana virus in cesium
The picture that emerges from these studies and chloride. A noninfectious CF antigen produced by
from less complete investigations of the other these viruses has a buoyant density between 1.09
viruses in the group is one of remarkable uniform- and 1.11 glml in a sucrose gradient.(4m
ity. All arenaviruses are easily inactivated by ethyl
Through the use of various drugs that inhibit ether, chloroform, and sodium deoxycholate.
nucleic acid synthesis in infected cells in cultures, Thermal inactivation of LCM virus is accelerated
it has been indirectly shown that all arenavi- by the presence of divalent cations in the suspend-
ruses-with the exception of Tacaribe, for which ing medium. The effect of ,B-propiolactone on
no studies appear to have been reported-contain Lassa virus has been reported; the virus infectivity
RNA; compounds which preferentially inhibit is completely inactivated with a concentration of
DNA synthesis, such as halodeoxyuridines the drug between 0.1 and 0.15% with preservation
(BUDR, FUDR), have no inhibitory effect on these of complement-fixing activity.(15)
viruses.
Studies with LCM and Pinchinde viruses have
directly shown the presence of single-stranded
4.2. Morphology and Morphogenesis
RNA in the virion. Analysis of the RNA by zonal
centrifugation in 5-20% sucrose gradients and by The similarities in morphology and morphoge-
electrophoresis in acrylamide gels showed, with nesis are so marked and distinctive that they were
each virus, the presence of five components of the basis for first associating the viruses in the
molecules with sedimentation values of 31 S, 28 S, present taxon. W2 . 7(;)
23 S, (22 S for Pichinde), 18 5, and 4-6 S. It has Thin-section electron microscopy of Vero cells
been concluded that, for both viruses, the 31 5 and infected with all ten arenaviruses shows them to
23 (or 22) 5 RNAs were virus specific; the 28 Sand be indistinguishable from each other. Coinciding
18 S RNAs, which account for 25-50% of the with the highest infectious titers of the inoculated
labeled RNA in the LCM virion, represented ribo- cultures is the occurrence of a large number of
somes from the host cell located inside the virion; particles. The particles are round, oval, or pleo-
and the 4-6 S components were also of host cell morphic, 60-280 nm in diameter, have a membra-
origin. w9 .74 ) nous envelope with surface projections or spikes
The base composition of the viral RNA was approximately 6 nm long, and contain· a variable
found to differ markedly from that of the host cell number of from two to ten internal electron-dense
RNA. The RNA responsible for viral coded prod- granules about 20 nm in diameter, strongly resem-
ucts would be about 3.2 x 106 daltons, with bling ribosomes. No symmetry has been discerned
Pichinde virus.(74) with any of these viruses.(n~.(;4)
Analysis of the viral proteins by electrophoresis The particles mature by budding from plasma
in acrylamide gels has revealed, in Pichinde virus, membranes. Vero cells infected with each of the
the presence of four polypeptides coded for by the viruses contain distinctive intracytoplasmic inclu-
virus and incorporated in the virion; two of these sion bodies, consisting of a smooth matrix in
are glycopolypeptides. A polypeptide and a glyco- which are embedded dense granules similar to
polypeptide, both with molecular weights of about those seen in the virions and indistinguishable
72,000 daltons, appear to be associated with the from the host cell ribosomes. These inclusion bod-
viral nucleic acid, functioning as nucleoproteins; ies seem to match in size and location the cyto-
the other glycopolypeptide, molecular weight of plasmic inclusions observed under light micros-
about 34,000 daltons, is an envelope constituent; copy in cells infected with the viruses. w:l .(;4)
Negative-contrast electron microscopy of virus been determined whether it is a structural compo-

particles sedimented from infected cell cultures has nent of the virion.
been reported with these viruses, except for Junin, The humoral immune response with arenavi-
Machupo, and Lassa; technical or hazard consider- ruses has certain characteristics mainly observed
ations prevented their study. The results with the with LCM virus but which may also appear with
remaining arenaviruses have, again, shown de- other agents: CF and neutralizing antibodies and
cided uniformity of the viruses, with pleomorphic antibodies detected by the fluorescent antibody
particles slightly larger than in thin sections, from technique (FAT) seem to be independent.(35) CF
90 to 350 nm, pronounc~d surface projections, and antibodies against LCM in man appear relatively
no resolution of internal structure.(M) early in the disease, from 8 days to 2 months;
Electron microscopic studies of whole animals neutralizing antibodies are found later, usually not
infected with arenaviruses(64) have revealed the before 2 months after onset, and FAT antibodies
presence of particles similar to those described may be detected earlier than CF antibodies.(as) It
above in a number of tissues of Calomys callosus is easy to prepare immune sera in mice with
infected as newborn with Machupo and Latino Pichinde or Lassa virus, which react with good
viruses. No such particles have been seen in titers by CF test; the same sera may have little
hamsters infected with Junin virus and only few in neutralizing capacity when tested in a mouse neu-
the salivary gland tissue of mice infected with tralization test(88) or in a plaque reduction
Tacaribe virus. In general, only occasional virus testY5,59)
particles have been observed in the brain tissue of Antigenic relationships among arenaviruses
mice infected with LCM, Tacaribe, Lassa, or Tam- have been mainly detected by the CF test. Table 1
iami virus, while parallel studies indicate the pres- is a composite table incorporating results from
ence of specific antigen. several sources and it is an attempt to illustrate the
The particles associated with arenavirus infec- relative position of the viruses in the taxon. Tacar-
tion of cells in culture have been shown to contain ibe, Junin, Machupo, Amapari, Parana, and Latino
specific antigen material by labeling procedures, at viruses are very closely related by CF with mouse
least with LCM virus; whether all size particles are hyperimmune sera; the available fragmentary evi-
equally infectious cannot be decided by electron dence shows that Pichinde and Tamiami viruses
microscopy aione.(53) Estimates of infectious-size are not closely related to the others or to each
particles by centrifugation or filtration have given other. LCM and Lassa viruses are very distantly
sizes between 37 and 60 nm for LCM virus(43) and related to the other agents; only when the highest-
by filtration have given sizes between 70 and 140 titered antisera are used can cross-reactions be
nm for Lassa virus. OS) observed.
Results of neutralization tests, many of them
done with samples of the same sera that showed
4.3. Antigenic Properties
marked crossing by CF, are very specific. In com-
Early studies with LCM virus demonstrated the prehensive plaque reduction tests06.37.93) in which
existence of a CF antigen distinct and separable sera had homologous titers in the range from 1:32
from the infective particle by centrifugation; it was to 1:2048, generally 1:128-1:512, no cross-neutrali-
designated soluble antigen. The nature and proper- zations have been noted, even between viruses
ties of this antigen have been the subject of recent which are very close by CF, such as Machupo,
studies(33) which confirm that virion and CF anti- Tacaribe, and Junin. The same marked specificity
gen are distinct entities. The latter on inoculation has been observed when constant serum was used
into experimental animals induces formation of with varying dilutions of virus. Studies with LCM
antibodies which react in vitro with the CF antigen and Lassa viruses are less extensive but they also
but will not neutralize the virion; furthermore, show marked specificity in the N test.
repeated inoculations of CF antigen fail to induce Investigations with the FAT, especially the indi-
any protection against subsequent challenge of rect test, show this technique to be less specific
guinea pigs. It appears that the CF antigen is not than the N test; in fact, it was with this method
present on the surface of the virion; it has not that the serological association between LCM and
Table 1. Complement Fixation Test with Arenaviruses u
Serum
JUN TCR
Antigen MAC SER.1 Ser.2 Ser. 1 Ser. 2 AMA LAT PAR PIC TAM LAS LCM
Machupo 128 64 128 64 32 0

Junin 64 256 16 256 64 64 32 0 4 8
Tacaribe 64 64 512 32 32 32 0 4 8
Amapari 64 32 64 128 32 32 8 4 4
Latino 32 32 8 8 256 16 8 0
Parana 32 16 8 16 16 512 16 0
Pichinde 4 64 256 4 0
Tamiami 32 8 8 32 0 32 64 128 0
Lassa 0 0 0 0 256 4
LCM 0 0 4 4 16 256
a Composite table derived from various authors. Reciprocal of serum titers; 0, no fixation at dilution 1:4 or 1:8.
the Tacaribe group viruses was first observed. (77) isolate these viruses from other natural hosts,
Antisera to all members of the Tacaribe group including arthropods, have been reported, largely
reacted with LCM virus; LCM antisera reacted with negative results: Pichinde virus has been
with Amapari virus but little with Tacaribe. Cross- isolated from ectoparasites taken off viremic hosts;
reactions have also been observed between Lassa Amapari has been isolated from mites (Gamasi-
and LCM viruses(15) and between Latino anti- dae); Tacaribe was reported to have been isolated
serum and Pichinde antigen. (93) from a mixed mosquito pool.
Among experimental hosts, 1- to 4-day-old mice
develop fatal illness following intracerebral inocu-
4.4. Biological Properties lation of most, but not all, arenaviruses. Latino
The natural hosts and reservoirs of the arenavi- virus does not infect mice, and Parana inoculation
ruses that cause human disease are discussed in results in illness but no death; LCM virus strains,
the corresponding sections. The remaining viruses in general, are lethal when inoculated into young
have been isolated in nature from the following adult mice but not into newborn mice. Newborn
animals: Tacaribe from Artibeus bats; Amapari hamsters are lethally infected by Junin, Latino,
from Oryzomys and Neacomys rats; Pichinde from Machupo, Parana, and Pichinde viruses; guinea
Oryzomys and Thomasomys; Parana from Oryzo- pigs are susceptible to LCM and Junin viruses.
mys; Latino from Calomys; and Tamiami from All arenaviruses except LCM replicate with pro-
Sigmodon (cotton rat) and Oryzomys. * Attempts to duction of plaques under agar overlay in Vero cell
monolayers; some have marked cytopathic effect
• The genera Akodon, Calamys, Neacamys, Oryzamys, Sig- (CPE) in cells in fluid cultures. Other cells,
madan, and Thamasamys are comprised of mouselike LtCMK2 and HeLa, are susceptible to some of the
and ratlike rodents, in the tribe Hesperomyinae, viruses with CPE development. LCM virus multi-
subfamily Cricetinae, family Cricetidae, and the entire plies, reaching high titers in nearly all cells in
tribe in New World only. The genera Mus, Rattus, and
culture that have been tried, but CPE, including
Mastamys are rats and mice in the family Muridae and
are found only in the Old World (except for the estab- plaque formation, is not a feature of the multipli-
lished New World immigrants in Mus and Rattus). To cation of this virus except in rare circumstances
the untrained observer, many of the small mouselike or and particular systems.(70)
ratlike rodents of the Old and New World are indistin- A special property of arenaviruses that cause
guishable from one another, but habitats, habits, and disease of man, repeatedly described with LCM
life histories may vary greatly. and Machupo, is their capacity to induce persist-
ent tolerant infection in their natural hosts with no observations rather favor the view that direct dam-
ill effects to the host and in the absence of an age to cells by the virus best explains the disease.
immune response; the epidemiological implica- Little is known about the type and localization
tions of this fact are evident. of lesions in man following LCM virus infection
and about the multiplication and distribution of
the virus, duration of viremia, and persistence of
antibodies. With other arenaviruses, autopsy of
5. Pathogenesis and Immunity ten patients who died of AHF consistently re-
vealed generalized lymphadenopathy on gross ex-
LCM virus infection of the adult mouse is the amination; microscopically, endothelial swelling
classic example of virus-induced immunopathol- in capillaries and arterioles of all organs examined
ogical disease. Intracerebral inoculation of the was seen without exception and lymphocyte de-
adult mouse results in manifest disease and death, pletion in the spleen was generally observed. (aOJ
while infection before or soon after birth leads to a In another series/ 24 ) it was stressed that lesions in
nonpathogenic lifelong carrier state. In the neona- several organs and tissues were probably caused
tal mouse during the period of immunological by direct cytotoxic action of the virus on cells, in
immaturity, the virus does not stimulate an im- the absence of conspicuous cellular infiltration. In
mune response; since the virus is presumably connection with the diffuse involvement of the
harmless for the mouse, no ill effects result. In the endothelium of capillaries and arterioles/aD) it is
adult mouse which has reached immunological of interest to mention that disseminated intravas-
maturity, the virus incorporated in the cells stimu- cular coagulation has been described in one case of
lates an immune response from the host; it is this AHF and suggested as a pathogenetic factor in the
conflict between the host and the virus which disease. (5)
results in disease, a fatal choriomeningitis with no The result of a liver biopsy in a fatal case of
evidence of neuronal destruction. Numerous ob- Lassa fever is highly pertinent to the pathogenesis
servations(35.43) by many workers have firmly es- of the disease.(96) Diffuse hepatocellular damage
tablished the above pathogenetic mechanism for was evident, with focal necroses; a clear associa-
the disease; it is, furthermore, observed that im- tion between damaged liver cells and virus particle
munosuppressants protect adult mice against formation and maturation was observed by elec-
death due to LCM virus infection. Since, among tron microscopy, while inflammatory response
the immunosuppressing treatments, antilympho- was minimal. These findings suggested that a
cytic serum and neonatal thymectomy are effec- direct cytopathic effect was responsible for, at
tive, it appears that the immune disease is cell least, the hepatic lesions in Lassa fever and that
mediated rather than caused by antibodies. cell-mediated or humoral immunological damage
Studies with Tamiami virus(32) showed that is not a major factor.
suckling mice after intracerebral inoculation of the The most constantly reported lesion in AHF, and
virus develop an acute CNS disease with cerebellar probably in BHF, is a diffuse swelling of the
ataxia and less frequently paralysis, convulsions, endothelium of capillaries and arterioles in the
and death. Neonatal thymectomy totally prevented absence of inflammatory reaction; clinically, there
the disease in spite of the presence of virus in high is in nearly all patients an adenopathy, local or
titer in the brain tissue; it was suggested that the generalized; there are also leukopenia, late appear-
acute disease caused by lhe virus is immunome- ance of antibodies, and the fact that recovery
diated. occurs at the time when antibodies begin to build
With the present state of knowledge, no definite up; biphasic patterns of clinical disease are all but
statement can be made concerning the mechanism unknown with AHF and BHF. Finally, cell dam-
through which the arenaviruses cause disease in age, when it occurs in specific organs, appears to
man. There is nothing to indicate that lesions and be associated with a direct cytopathic action of the
disease are immunopathological or allergic phe- virus on the cell, with no cellular infiltration.
nomena, as is so clearly the case in adult mice Based on these observations, the following patho-
infected with LCM virus; clinical and pathological genesis has been suggested(40) for arenavirus in-
fections of man: the virus gains entry by the upper the .study. An etiological association between the
respiratory or alimentary route and is caught in virus and a disease of man, acute aseptic meningi-
the local lymphoid tissue of lymph nodes, where it tis, was established(75.83) by isolation of the agent
first replicates; it then invades the cells of the and demonstration of development of antibodies.
reticuloendothelial system including all the cells While at an early period it was assumed that LCM
involved in the immune and cellular immune virus was the exclusive etiological agent of acute
responses, whose functions are therefore inhibited aseptic meningitis, or Wallgren'S disease, it soon
at this time. The virus causes, directly or indi- became apparent that the virus caused only a small
rectly, extensive capillary damage resulting in cap- proportion of the cases. Traub(89) reported that a
illary fragility, hemorrhagic tendency, and hypo- colony of laboratory albino mice was chronically
volemic shock; the various organ malfunctions are infected with a virus subsequently identified as
due probably to capillary damage and edema of LCM; this finding was the beginning of a new
the parenchyma rather than actual cell damage. concept, persistent tolerant virus infections, which
When the disease regresses, no permanent damage has considerable epidemiological implications
ensues, since there has been little cell damage; with respect to LCM virus and other arenavirus
antibodies develop to a high titer. In progressive infections of man.
cases, a direct cytopathic action of the virus on the
cells follows; coagulopathy can occur but immuno-
6.1. Descriptive Epidemiology
pathology is at no time evident.
Following overt infection of man with arenavi- 6.1.1. Incidence and Prevalence. Determination
ruses, antibodies develop which have been de- of infection or illness caused by LCM virus re-
tected by complement fixation and neutralization quires a laboratory-confirmed specific diagnosis;
tests and, recently, by the fluorescent antibody in general, this is not attempted since the required
technique; no hemagglutination inhibition test is laboratories are not always available. Efforts to
available for these viruses. With LCM, AHF, and obtain a specific diagnosis usually require special
BHF, complement-fixing antibodies are generally circumstances, such as a large number of clinically
short-lived, with their titers diminishing rapIdly suspect cases appearing simultaneously(7) or the
between 6 and 12 months from onset, at the end of continuing interest of groups of investigators. (4.58.14)
which period most sera are negative; on the other Soon after the discovery of the virus and its
hand, neutralizing antibodies remain. detectable association with cases of aseptic meningitis, it
for years. (40.43) Since Lassa fever has been recog- became clearly apparent that clinical infection of
nized only within the last few years, no informa- man due to LCM virus was a rare event; later
tion is available on antibody p~rsistence. surveys supported the view.
Antibodies have been detected in persons in One of the most extensive surveys to determine
whom no specific diagnosis had been made, per- the prevalence of clinical LCM virus infection in
haps having had only a subclinical infection, par- man was conducted in U.S. military personnel and
ticularly with LCMO,14); the current view is that dependents over an 18-yr period, from 1943 to
clinically inapparent infection is rare with Junin 1960.(4.58) Examination of nearly 1600 CNS ill-
and Machupo viruses.(40l nesses revealed that only 8% were specifically
diagnosed as LCM infections; on the average,
seven cases a year occurred during the entire
period. No estimate can be made of undiagnosed
6. Lymphocytic Choriomeningitis cases or, if they existed, of subclinical infections; a
study in the United States(97) showed that 5% of
LCM virus was first isolated in 1933 in the about 1200 sera from residents of various areas had
course of investigations on the etiology of an neutralizing antibodies; it is conceivable that a
epidemic of encephalitis in St. Louis, Missouri(8); certain degree of nonspecific neutralization of vi-
the virus may have been present in the CNS tissue rus may have occurred in that study(43) so that the
of a patient who died of that illness or, more results may not be specific.
likely, derived from monkeys inoculated during Investigations in West Germany since 1960
by Ackerman et al.,<2) Scheidt et al./ 8 1) and Special attention should be given to LCM as an
Blumenthal et al. (4) indicate the extent of the occupational disease in laboratory personnel,
distribution of LCM virus in that country and the either in individuals who work with the virus or
close association between the incidence of infec- in those who work with other problems but who
tion of man and the presence of virus in the use animals-mice, hamsters, possibly monkeys-
mouse. Early observations by these investigators that may be infected. Reported laboratory acci-
had shown the rarity of the disease in a number of dents may well represent only a fraction of all the
large hospitals in the country; furthermore, anti- occurrences; in the period between 1952 and 1966,
body surveys with sera from selected individuals 45 laboratory infections with five deaths were
revealed only about 1 % of positives.(]) In a subse- documented. (87)
quent survey(14) done after the distribution of the
virus in mice had been investigated, sera from
about 2000 persons from rural districts were tested
for neutralizing antibodies; 68 of these sera, or 6.2. Mechanism and Route of Transmission
3.4%, were positive; on the basis of this survey,
Ackerman(l) estimates that as many as 1000 new 6.2.1. Spread of Virus The only known true
infections per year may occur in a population of carrier of LCM virus is the mouse from which man
about 6 million persons in rural German areas; becomes infected. Probably other species are im-
since only a minute fraction of this number are portant, particularly the hamster, from which man
clinically recognized, the inference is that most also becomes infected. Man-to-man transmission
LCM virus infections go undiagnosed or are sub- seems unlikely.
clinical. The mechanism of transmission from mouse to
6.1.2. Geographic Distribution. The virus of man cannot be stated with certainty. It would
LCM may well have worldwide distribution, appear that either the airborne route through
being present in all parts of the world where the household dust contaminated with mouse urine
house mouse is found. Well-documented proof of and other excretions and secretions or the contam-
the virus's presence has been given for European ination of food and drink by mouse excretions is
countries and North and South America; its pres- the most likely source of human disease. The
ence has also been reported in Asia, less convinc- portal of entry in these instances would be the
ingly in Africa, and not in Australia. (43) upper respiratory tract or, possibly, the upper
6.1.3. Age, Sex, and Occupation. Since LCM is digestive tract; the possibility of transmission
not usually reported, the effect of a number of through skin abrasions has also been considered.
variables on its spread and prevalence is difficult While airborne transmission appears the logical
to appraise. A seroepidemiological report from mode of human infection, acceptance of this hy-
West Germany(4) indicated that the distribution pothesis runs into problems represented by the
of antibodies was not influenced by sex or occupa- known lability of LCM virus under unfavorable
tion-whether farm work or professional or office conditions; however, no other explanation has
work; in that survey few positives were found been put forward to replace airborne or food
among persons under 20 yr of age. On the other contamination. Transmission by an arthropod vec-
hand, no influence of age was seen in hamster- tor has been investigated, but the evidence is
related outbreaks.(3.n It is possible that mouse- against it; it is worthwhile to mention, however,
associated infections are more common in rural that Aedes aegypti has transmitted the infection by
populations or in lower socioeconomic urban bite to monkeys 15 days after feeding on infected
groups and that hamster-associated cases are guinea pigs. (20)
found principally in urban centers. Further, a 6.2.2. Reservoir. In nature, the virus has been
seasonal fluctuation of cases has been suggested in isolated from various animal hosts in addition to
man, more in winter than in summer. Perhaps this man, who is most likely a dead-end. Chief among
is associated with migratory habits of the house these, for epidemiological implications including
mouse(43) and possibly with closer contact with maintenance of the virus in nature, is the house
mice in the cold months in the temperate zone. mouse (Mus musculus). In recent years, the Syrian
hamster (Mesocricetus auratus) has gained impor- LCM virus had been isolated from mice; only five,
tance as a source of infection of man, if not as a or 0.6% were positive.
true reservoir. In recent years, the Syrian hamster has emerged
From the first demonstration of LCM virus in as an important source of human infection and
house mice trapped in the homes of two persons illness caused by LCM virus. Small outbreaks had
suffering from nonbacterial meningitis/ 9 ) the occurred in the past involving persons participat-
abundance of isolations has left no doubt about ing in biomedical research work in which ham-
the close association in nature between the virus sters were usedyo.45) Between 1968 and 1971, 47
and this rodent. Furthermore, it has been shown LCM infections were described in West Germany.
that experimental mouse colonies can be chroni- These were specifically diagnosed by antibody
cally infected. (90) Studies on the nature of the detection as caused by LCM virus in persons who
infection of laboratory mice by LCM virus extend- shortly before their illness had been in contact
ing over a period of 30 yr have clearly shown that with pet hamsters; 45 of these infections were
the mouse infected in utero or within a few hours clinical, mainly influenzalike or aseptic meningi-
after birth develops a tolerant persistent infection; tis, and two had no clinical manifestations. (3)
mice thus infected circulate virus in their blood, Subsequent investigations in West Germany<26l
develop no antibodies, and maintain an active and on commercial breeding colonies showed that of
relatively normal health condition for a period of 598 animals examined, representing 11 different
time representing a good fraction of a normal breeders, LCM virus was isolated from members
mouse's life span. The epidemiologically impor- of six different colonies. According to the authors
tant feature of the tolerant persistent infection is of that study, it is estimated that close to 1 million
that wild mice so infected shed virus continuously hamsters are sold annually as pets in West Ger-
for the duration of their lives by way of urine, many; it is obvious that the importance of this
feces, and nasal and mouth secretions. The virus animal as a source of infection of man cannot be
thus excreted will contaminate households, in- overlooked.
cluding food, drink, dust, and fomites; from these, Two outbreaks of LCM in man, associated with
and by ways as yet undetermined, man becomes hamsters, have been recently observed in the
infected. In addition, new generations of mice United States. Early in 1973 an episode occurred in
become tolerantly infected at birth or in utero, thus a laboratory where hamsters were used for cancer
maintaining the carrier status of the mouse popu- work.(7) The investigation of the outbreak re-
lations; mice so infected may become the source vealed several interesting points. In all 21 persons
from which other species-hamsters, guinea pigs, became ill with a severe influenzalike illness, of
monkeys-are infected and they, in turn, may which 14 cases had occurred before LCM infection
infect man. was suspected. In addition to the 21 clinical cases,
The studies of Ackerman et al. (2) and Blumen- confirmed by FAT antibodies, there were 17 per-
thal et al. (14) are particularly illustrative of the sons who had antibodies but no illness; in other
association between infection of mice and infec- words, inapparent infections occurred. The associ-
tion of man. Sixty-five mice of 1795 trapped be- ation with hamsters was clearly seen in that 75%
tween 1960 and 1962 in 44 of 376 areas in West of 20 persons admitting to having touched the
Germany were LCM carriers, as shown by virus hamsters were seropositive, while only 17% of 61
isolation; nearly all positive trapping areas were in persons who had no contact other than entering
northern and northwestern Germany, none in the premises were positive; the latter may have
southern Germany. Serological surveys done at been instances of airborne infections. LCM virus
about the same time in which 1371 persons from was isolated from 11 of 24 hamsters tested. The
rural districts were tested by neutralization test animals appear to have been infected from virus
showed that, of 511 sera from persons in north and present in the tumor line with which they had
northwestern Germany, in or near the places been inoculated.
where LCM virus had been isolated from mice, In another extended episode, 93 human cases in
9.1 % had antibodies. The second set of sera from seven states were diagnosed and specifically con-
811 persons was from south Germany, where no firmed between December 1973 and April 1974.(25)
112 Chapter 5 • Arenavimses
The association with pet hamsters was established the CSF is under increased pressure, with slightly
in every instance; in some instances, two or three increased protein, normal or slightly reduced
cases occurred in a family. The diagnoses were sugar, and moderate number of cells, from 150 to
established by FAT and CF tests in man and 400/mm 3 •
hamsters; it appears that of several breeders whose The virus in man can be isolated from blood,
animals were tested only one had an infected CSF, and, in fatal cases, brain tissue. The best
colony. sources for isolation are blood during the febrile
The episodes in the United States and Germany period and CSF during the period of meningeal
point to the importance of hamsters as a source of manifestations; virus can be isolated from the
human infection with LCM virus; while this ani- blood and CSF from experimentally infected man
mal is not a true lifelong carrier, it can circulate for 20-25 daysy3)
and excrete virus for periods of 2 or 3 months after The animal of choice for virus isolation is the
its infection. laboratory albino mouse, 3-5 wk old; following
There are additional animal species from which intracerebral inoculation, the incubation period
the virus has reportedly been isolated in nature and signs of illness are nearly pathognomonic.
such as monkeys, guinea pigs, and dogs. The role Care must be taken to use mice from a colony
that these species play in virus dissemination to known to be free from the virus. Inoculation of
man is undetermined but it appears to be unim- cells in cultures could be used since most cells
portant. support replication of LCM virus; however, since
virus replication in general does not cause CPEor
plaques, detection of viral antigen in the cells must
6.3. Patterns of Host Response
be made by CF or FAT tests.
6.3.1. Clinical Aspects. Infection of man by The techniques employed for detection of anti-
LCM virus presents different clinical forms and body development are the CF and the indirect FAT
there may be inapparent infections. Three major tests; it has been reported that fluorescent anti-
clinical forms seem to prevail; aseptic meningitis, body appears earlier than CF antibody.130) In
influenzalike or nonnervous system type, and recent investigations of antibody determination in
meningoencephalomyelitic type. (43) The influen- man and hamsters, there has been nearly complete
zalike and meningeal are the most frequent types. agreement between the results of these two tests
The incubation period is believed to be from 6 to (Woodall, personal communication, 1974). Neu-
13 days. In the influenzalike (or grippal) type, tralizing antibodies appear much later after onset;
there are fever, malaise, muscular pains, coryza, therefore, the neutralization test is not helpful for
and bronchitis; in the meningeal type, which is an early diagnosis; it is most profitably used in
the commonest, there is a "grippe"-like beginning serum surveys. (14)
followed by definite signs and symptoms of men-
ingitis, with stiff neck, headache, and nausea,
which may remain mild and of short duration or 6.4. Treatment and Prevention
can be pronounced, last for 2 wk or longer, and
There is no specific treatment advocated; in
lead to considerable prostration.
view of the definite association with mice, it
The great majority of specifically diagnosed,
clinical infections follow a benign course; only a would appear that rodent control may minimize
few fatal cases have been reported, either follow- the risk. Monitoring of hamster colonies for pres-
ing CNS involvementl 4) or after systemic general- ence of virus and/or antibodies would be indi-
ized illness with hemorrhagic manifestations. (84 ) cated.
Chronic sequelae, although rare, have been re-
ported, including paralyses, headaches, and per-
sonality changes; it appears that the documenta- 7. Argentinian Hemorrhagic Fever
tion of most such cases is ambiguous. (43)
6.3.2. Diagnosis. Clinical and routine laboratory A disease resembling Argentinian hemorrhagic
analyses are only indicative of aseptic meningitis: fever (AHF) and with the same geographic location
seems to have been first recognized in 1943.(72) urban setting in the near absence of the main
Arribalzaga(lll gave the first detailed account of rodent reservoir (Calomys) of the virus(51.79); how-
the disease and considered it a new nosological ever, the simultaneous existence of LCM and Junin
entity; his description included extremely accurate virus in an area may create diagnostic prob-
clinical and epidemiological observations. The lems. (50l
causal agent, Junin virus, was isolated in
1958.(66.73) Annual outbreaks of the disease have 7.2. Mechanism and Route of Transmission
occurred since 1958, and the endemic zone has
7.2.1. Spread to Man. Chronic infection of ro-
been progressively increasing in area.
dents with associated viruria is the basic mecha-
nism of transmission of the virus to man; there is
7.1. Descriptive Epidemiology no evidence implicating arthropod transmis-
sion. (40.79) The mode of transmission from wild-
Collection of data concerning clinically diag- infected rodents to man has not been definitely
nosed cases of the disease and laboratory efforts to established. It may be airborne, from dust contam-
confirm the clinical diagnosis appear to be effi- inated by the excretions or secretions from ro-
ciently made through local, provincial, and na- dents, or by the oral route through ingestion of
tional Public Health centers in Argentina.<21,72) food and drink equally contaminated. Since the
7.1.1. Prevalence in Man. AHF is predomi- disease has been transmitted to human volunteers
nantly a rural disease that affects adult males with by injection,(73) it may be possible that the dis-
agricultural occupations, particularly harvesting of ease is also acquired through skin abrasions in the
maize; 80% of nearly 1000 cases recently analyzed course of farm work while materials contaminated
were of males and 63% of the total number were in with rodent excreta are being handled.
the age group between 20 and 49 yr (Maiztegui(49) Although the virus has been isolated from throat
and personal communication). swabs and urine from patients, contact transmis-
7.1.2. Geographic and Seasonal Distribution. sion between individuals is exceptional.(78)
The endemoepidemic zone was first recognized in 7.2.2. Reservoir. The possible connection be-
the northwest of Buenos Aires province; by 1958 tween wild rodents and AHF was first stated by
its area was estimated at 16,000 km 2 • Since that ArribalzagaY II Accumulated observations begin-
year, the zone has spread west and north to ning in 1958 support the close association between
include additional localities in Buenos Aires as disease and rodents in the endemic areas. The
well as sections of two adjacent provinces, Cor- main reservoir is two species of Cricetidae, Calo-
boda and Santa Fe; the affected area was estimated mys laucha and C. musculinus, which are present in
in 1970 to be 80,000 km 2 , in which lived a popula- farm fields and along hedgerows, the latter species
tion of 800,000 persons. (79) The total number of predominating in Cordoba province(79); Junin vi-
cases reported from 1958 to 1972 was about 13,000, rus has also been isolated from Akodon, Azarae,
with annual fluctuations of between 100 and 3500 and, rarely, Mus musculus. (2ll Field and laboratory
cases; the mortality rate for laboratory-confirmed investigations show that Junin virus causes a
cases studied at Pergamino has been from 10 to chronic tolerant infection in C. musculinus with
20% (Maiztegui(49) and personal communication).
persistent viremia and viruria and no development
The disease is sharply seasonal, with the out- of antibodies(79); most likely, the virus is main-
breaks beginning late in summer (February), tained in nature by infection of the rodents at
reaching a peak in autumn (May), and ending
birth. Although the virus has been isolated from
early in winter. The seasonal distribution coin-
mites,!68.73) it has not been established that they
cides with the intensification of agricultural la-
playa role in transmission between rodents or to
bors, particularly harvest of maize, and with an man.
influx of transient farm workers; at the same time,
there is an increase in the population of wild
rodents, which are considered the principal reser-
voir of the virus. While overwhelmingly a rural 7.3.1. Clinical Features. The disease presents a
disease, cases of AHF have been observed in an syndrome that includes manifestations of renal,
cardiovascular and hematic involvement; proof two agricultural workers with clinical diagnosis
nounced neurological manifestations are also de- of AHF, but with specific serological conversions
scribed, but not frequently. The disease lasts from to Junin virus in one and to LCM virus in the
7 to 14 days and terminates either with complete other.(50)
recovery with no sequelae or with death. After an Since only between 60 and 70% of patients
incubation period estimated at from 7 to 16 days, clinically diagnosed as having AHF are generally
. there is an insidious and gradual onset with chills, serologically confirmed, it had previously been
asthenia, malaise, headache, retroocular pain, suspected that other agents were active in the
muscular pains often pronounced in the costover- endemic area in epidemic times; serological evi-
tebral angle, anorexia, nausea, and vomiting. The dence of infection with group B arboviruses has
most prevalent signs at the outset are fever with been reported(54) in a number of persons diag-
temperatures up to 102-104°F, conjunctival injec- nosed clinically as AHF cases, and St. Louis en-
tion, enanthem, exanthem on face, neck, and up- cephalitis virus was isolated from one.(56)
per thorax, a few petechiae particularly in the 7.3.3. Diagnosis. Clinical diagnosis of AHF has
axilla, polyadenopathy, and muscular tenderness been confirmed either serologically or by virus
at the thigh. Three to five days after onset, the isolation in from 60 to 70% of reported cases.(55)
signs and symptoms become more pronounced in In a thorough study involving 2249 reported cases
the severe cases, with dry tongue, dehydration, over the period 1965-1972 in the city of Perga-
oliguria, hypotension, relative bradycardia, and, mino, the diagnosis was confirmed in 62% and
in the worst cases, hemorrhages from the gums was doubtful in 11 % of cases.(48,49)
and nasal cavities, also hematemesis, hematuria, During the epidemic season of AHF, there ap-
and melena; oliguria may develop into anuria. In pear to occur in the same areas other diseases of
the severe cases, there are psychosensorial and viral etiology which at the early phase present
motor alterations. Death is caused by uremic coma clinical manifestations similar to those of
or hypotension and hypovolemic shock due to AHF. (54,82) A study of signs and symptoms in a
plasma leakage, not whole blood loss. In nonfatal number of patients clinically diagnosed as having
cases, the fever diminishes by lysis, and there is AHF, in whom laboratory confirmation was
marked diuresis and rapid improvement within sought, showed that during the first week of
days; however, convalescence is prolonged. The illness a combination of asthenia, dizziness, pete-
case fatality rate has been as high as 20%; usually chiae in the axillary region or anterior chest wall,
it is between 3 and 15% in different outbreaks. and conjunctival congestion was present in 71 % of
Clinically inapparent infections appear to be very confirmed cases but in only 3.5% of nonconfirmed
rare. (37 ,55, 79) ones. When in addition are found leukopenia,
7.3.2. Simultaneous Occurrence of AHF and thrombocytopenia, and casts in the urine, the
LCM. Investigations in areas of the AHF endemic diagnostic accuracy is further increased. (82)
zone to determine the source of virus in an urban Specific diagnosis is based on isolation of virus
setting(5Z) led to the finding of antibodies against or demonstration of serological conversion. The
LCM virus in mice (M. musculus); at about the virus is isolated from the blood during the acute
same time, a strain of LCM virus was isolated from period, probably from the third to the tenth day
that species. (sO) A reexamination of antibodies in after onset, and, in fatal cases, from liver, spleen,
acute and convalescent sera from nearly 3000 cases kidney, and clotted blood. The materials are intra-
of AHF, using LCM and Junin antigens, revealed cerebrally inoculated into newborn mice 1-3 days
that in a substantial number of instances AHF old, or into guinea pigs by the peripheral or
occurred in persons who showed evidence of pre- intracerebral route. While Junin virus replicates
vious infection with LCM virus.(49) Furthermore, with CPE in several cells in culture, little has been
there were a few cases previously diagnosed as reported on the use of tissue cultures for isolation
AHF in which the serological diagnosis was of the virus from nature. (79)
changed to LCM. (49) Additional evidence of the The test of choice for demonstration of antibod-
activity of LCM virus in the endemic AHF area is ies is the complement fixation test; AHF shares
given by the simultaneous admission to a hospital with other diseases caused by arenaviruses the
characteristic that complement-fixing antibodies Department of Beni more or less annually in

develop relatively late after onset; an early sample sharply localized outbreaks. (a7.40.46) An outbreak
and a second one taken not before 30 days after which occurred in 1971 in Cochabamba, Bo-
onset seem to offer the best possibility for detec- livia}40> differed ecologically from previous ones
tion of serological conversion. and represented an extension of the virus to a new
Recent developments(49.65) have shown the si- area.
multaneous development of CF antibodies against
Junin and LCM virus antigens in patients in the
B.1. Descriptive Epidemiology
AHF endemic zone, clinically diagnosed as cases
of AHF, including some from whose acute-phase 8.1.1. Prevalence in Man. Before 1962 the small
blood Junin virus was isolated. This fact creates outbreaks affected mainly adult males and most
serious difficulties in reaching a definite diagnosis cases occurred from April to September, which is
not heretofore encountered with other arenavirus the time of highest agricultural activity. From
infections of man; as a result, epidemiological 1963, when the disease appeared in towns and
evaluation of data may be faulty. villages and larger numbers of persons sickened,
the pattern changed. Adult males still presented
somewhat higher rates of morbidity, but all per-
7.4. Treatment, Control, and Prevention
sons were affected, with little relation to sex, age,
There is no recommended specific treatment; and occupation; it was soon apparent that the
adminstration of serum from recovered individu- disease was "house associated," with the lower
als has not been generally used. Vaccination of the socioeconomic groups experiencing the highest
exposed popUlation has been advocated; however, incidence of disease. Although a seasonal pattern
there is no available vaccine. Efforts to develop a is evident, with the highest incidence from Feb-
vaccine employing an attenuated strain of Junin ruary to September, cases occur in each
virus have been reported; administration of the month. (37.46)
preparation to a small number of persons on an 8.1.2. Geographic Distribution. The main epi-
experimental basis led to the development of anti- demic centers, San Joaquin and Orobayaya, are
bodies with only relatively minor febrile reac- located in the Department of Beni, in the north-
tions. (67) eastern section of Bolivia; these centers are on an
Ecological control to reduce the· number of ro- immense flat plain east of the Andes. The prevail-
dents and exposure of man to them appears diffi- ing vegetation type is that of a grassland broken
cult to implement. The circumstances under which with "islands" of forest and numerous tree-lined
the bulk of the exposed population live and work rivers and streams.(42) The human settlements
at the time of harvest will not be likely to change where cases have occurred in the past were on
in the near future; increased mechanization of slightly elevated sites that generally escape flood-
farm work and improvement of housing condi- ing during the heavy rains; the houses are on the
tions would undoubtedly reduce morbidity.(21) edge of the forest, overlooking the grass-covered
marshlands. These villages and settlements are
heavily infested with Ca/omys callosus, a mouselike
rodent which, although pastoral, readily invades
8. Bolivian Hemorrhagic Fever and lives in houses in a manner similar to that of
the house mouse, Mus musculus. (42)
Bolivian hemorrhagic fever (BHF) was first rec-
ognized in 1959 in two rural areas in the north-
eastern part of Bolivia, Department of Beni. In late
8.2. Mechanism and Route of Transmission
1962 or early 1963, cases began to appear in a
nearby town, San Joaquin, developing into a large 8.2.1. Spread to Man. Transmission from rodent
outbreak that continued until the middle of 1964; to man is probably by contamination of food,
nearly 700 persons were ill, with a mortality of water, or air with infected rodent urine or by
1B%. The disease has continued to appear in the inoculation through skin abrasions.(40) Human-
to-human transmission can occur in rare cases of least 5 days. About 30% of the patients present
close contact/ 22 ) but it is not considered impor- hemorrhagic manifestations consisting of pete-
tant in the spread of the natural infection. There chiae on the upper part of the trunk and oral
may be, however, circumstances that promote mucous membranes and, on occasion, bleeding
such type of transmission, as shown in a relatively from gums, nose, stomach, intestines, and uterus;
recent small outbreak in Cochabamba, Bolivia, blood loss is, however, not a threat to life. (40)
which is outside the habitat of the rodent Calomys Nearly half the patients exhibit a fine intention
callosus; from an index case, acquired in the en- tremor of tongue and hands beginning 4 or 6 days
demic area, five secondary cases developed, in- from onset; about one-fourth of these may develop
cluding family and medical personnel; all cases a frank and extensive neurological disorder. Som-
were fatal except one. (40) nolence and coma are hardly ever seen, except in
8.2.2. Reservoir. The distribution of cases in a very young children. The acute disease can last for
town in the form of clusters definitely associated 2-3 wk; convalescence is long, with complaints of
with certain houses, the absence of evidence of severe generalized weakness and manifestations of
human-to-human transmission, and the equally autonomic dysfunction. Probably OWing to the
negative evidence of an arthropod vector led to the continuously elevated temperature, loss of hair
inference that a reservoir species might be in- and transverse grooving of the nails are common.
volved that lived in or near households; soon the The mortality has varied depending on outbreaks,
association of disease with a rodent, Calomys callo- ranging from 5 to 30%; clinically in~pparent infec-
sus, was firmly established. This rodent has been tion is very rare.
trapped in all households where cases have oc- 8.3.2. Diagnosis The clinical diagnosis by an
curred; houses located in sites which did not favor experienced physician, in the endemic area and in
the presence of this rodent were spared; finally, moderately severe or severe cases, is fairly accu-
the dramatic termination of the epidemic in San rate; because of the toxic condition of the patient,
Joaquin in June 1964, 2 wk after continuous trap- BHF may resemble typhus or typhoid fever. Certain
ping of C. callosus had been implemented, left clinical laboratory data help the clinician: leuko-
little doubt about the association. (42.46) Fifty per- penia, thrombocytopenia, and increased hemato-
cent of C. callosus caught wild at the time of that crit-the last indicates a bad prognosis. (40)
epidemic were infected with the virus(as); experi- A specific diagnosis is based on virus isolation
mental studies with colonized Calomys show that or development of antibodies. The most successful
on inoculation of Machupo virus the rodent devel- animal for virus isolation has been the newborn
ops a tolerant infection with persistent viremia hamster, inoculated by the intracerebral or intra-
and viruria and no development of antibodies.(41) peritoneal route. Recovery of Machupo virus from
Calomys is easily infected by oral and nasal routes, acutely ill patients is, however, quite difficult;
and also by contact with infected cagemates; about only one in five samples, mostly sera, from serol-
50% develop viremia and viruria for life. (a9) ogically confirmed cases yielded virus, most fre-
All efforts to isolate the virus from arthropods quently between the seven and twelfth day after
caught in the epidemic area at the epidemic time onset. Virus is rarely isolated from urine or throat
have been negative.(42) swabs. In fatal cases, on the other hand, virus is
easily and generally isolated from spleen and
lymph nodes.(a7)
The most convenient and efficient means for
8.3.1. Clinical Features. The disease is clinically establishing a specific diagnosis is the CF test.
so similar to AHF that a joint description is often While this test is group specific rather than type
given. (a6,a7) The incubation period is estimated at specific, no diagnostic problems have arisen with
from 7 to 14 days. The onset is insidious, and the Machupo virus due to its sharply localized geo-
fever, which has been carefully monitored in nu- graphic location. As with other diseases in this
merous etiologically confirmed cases, reaches a group of viruses, CF antibodies are relatively late
temperature between 102 and 105"F, with little in appearing; although they have been found on
diurnal variation, remaining at that level for at the fourteenth day after onset, it is advisable to
test a sample of serum between 40 and 60 days Liberia (1972), and in Sierra Leone (1970-1972).
after onset. (4S.47> The number of cases seen, or retrospectively diag-
nosed, in the outbreaks has varied from three to
8.4. Treatment, Prevention, and Control slightly over 60. Retrospective serological surveys
have demonstrated the existence of Lassa virus
Administration of convalescent plasma has been infection in Guinea(a4) and Central African Re-
advocated and used; in spite of some impressions public (Frame and Casals, unpublished).
of favorable clinical responses, its efficacy has not 9.1.2. Epidemic Types: Season, Age, and Sex
been established or denied, because of insufficient Distribution. Two types of outbreaks have been
observation. (as) observed. The first type, hospital associated, de-
Rodent control by continued trapping has been velops as a result of exposure and spread from a
the most effective single means for preventing hospitalized index case to other patients, visitors,
human infection and for terminating an epidemic; and medical staff. The index case is usually ac-
however, this approach seems unlikely to be the quired in the nearby community; between 10 and
long-term solution of the problem. Given the 20 days after admission to the hospital, a cluster of
sharply localized geographic distribution of the secondary cases develops. (17.27,61) This type of out-
disease, it would seem that vaccination of exposed break has been the rule, with one exception.
populations would be the effective answer, but no The second type of outbreak, of which there is at
vaccine is available. Attenuation of a strain of present only one example (Sierra Leone, 1970-
Machupo virus by serial intracerebral passage in 1972), occurs in the community at large. Patients
suckling mice has been reported and its possible acquire their infection at home or othercommu-
use as source for a vaccine suggested. (40) nity surroundings, rather than by exposure or
contact in the hospital with another patient. How-
ever, there is also the possibility of nosocomial
9. Lassa Fever transmission in this type of outbreak, particularly
to the hospital staff. (28)
Lassa fever was first observed in 1969, in a Tertiary cases have been recorded, but with a
missionary nurse stationed at a locality in north- few exceptions-notably by transmission to medi-
eastern Nigeria; following her admission to a hos- cal staff-they have been milder. No evidence has
pital in Jos, Nigeria, two contact cases developed been reported of further propagation of the dis-
in nurses at that hospital. (27) Because of the cir- ease. (17l
cumstances surrounding this outbreak and the fact The mortality in hospitalized cases has been
that two of the three persons affected died, the between 30 and 66% in different outbreaks, with
disease acquired from the outset a reputation for an average of 36%. The mortality following infec-
severity which subsequent events amply justified. tion, however, appears to be much lower. In the
In addition to the initial episode, four more out- Sierra Leone focus, many persons with antibodies
breaks occurred between 1970 and 1974 in Nigeria, were found who either had not been ill or possibly
Liberia, and Sierra Leone(17.28.61); furthermore, remembered a mild disease; the overall mortality
laboratory accidents have occurred in the United from Lassa virus infection in that area may have
States. (]2 .44) been only 3-5%.(28)
There is a seasonal distribution of hospital-
9.1. Descriptive Epidemiology associated outbreaks, which have occurred from
January to April, during the dry season; the Sierra
9.1.1. Geographic Distribution. The disease has Leone cases occurred through the year with some-
been observed in several localities in Nigeria (in what higher incidence in the wet season.
Lassa, 1969; in Jos, 1970; in Onitsha, 1974*), in With respect to age and sex distribution, the
.. Information relative to the episode in Onitsha was Sierra Leone outbreak with its pattern of transmis-
supplied by Dr. E. A. Smith, Federal Ministry of sion in the villages revealed no important predi-
Health, Lagos, Nigeria, and Dr. Allan S. Noonan, lection in morbidity or in case-fatality rates.(28) In
Smallpox Measles Program/CDC, Lagos, Nigeria. the hospital-associated outbreaks, the distribution
by sex and age was determined largely by the ecology of other arenaviruses. Pooled tissues of
characteristics of the exposed population; physi- heart, lung, spleen, and kidney from 325 field
cians and nurses have been particularly affected. specimens tested for the presence of virus revea1ed
only one infected species of rat, Mastomys natalen-
sis. Ten viral isolations were yielded in 46 speci-
9.2. Mechanism and Route of Transmission mens tested. (6) This species is common and
9.2.1. Spread of Virus. The transmission in a widely distributed in sub-Saharan Africa. In addi-
hospital setting is undoubtedly from person to tion to its wild habitat, it is often peridomestic,
person by either the contact or the airborne route, entering houses cind other buildings; the potential
including direct contact, droplet spread, sharing or for human contact is considerable.
drink, food, clinical instruments, objects, and Additional information is required in order to
utensils. The same mode of transmission may be settle the question of the reservoir of Lassa fever
at work in contact infections acquired in the home. virus, particularly whether other vertebrate species
In the community-centered outbreak at Sierra are involved in the natural cycle. More study is
Leone, there was definite clustering of illness and also needed on the dynamics of Mastomys natalen-
seropositivity without illness in certain house- sis popUlation and its ecology.
holds; this could be explained either by multiple
instances of human infection from the same natu-
ral source or by person-to-person transmission
following a house index case acquired from the 9.3.1. Clinical Features. Lassa fever is a disease
reservoir. (28) with generalized organ involvement manifested in
The mode of transmission to man from the severe cases by pharyngitis, pneumonitis, myosi-
natural source or reservoir-a rodent-is still un- tis, myocarditis, encephalopathy, nephropathy,
known. It may include direct contact with the and hemorrhagic diathesis. The overall spectrum
rodent and its excretions and secretions, eating of of infection of man is not yet fully known; there-
uncooked rodent flesh, or contact with food and fore, it is not possible to estimate the risk of severe
drink contaminated by the rodent; it could also be illness following infection with the virus. All ear-
airborne. The possibility of an arthropod vector lier reports(J7,27,6l.94) stressed the severity of the
appears extremely remote to explain transmission disease; however, there is evidence of milder
to man. Whether ectoparasites can transmit the forms, perhaps even inapparent infections.(28)
infection between rodents is not known. Penetra- The incubation period is ordinarily between 6
tion through a cut while performing an autopsy and 14 days. The disease has an insidious onset;
appears to have been the mode of infection of a in variable order appear malaise, asthenia, lassi-
physician, (94) and infection through a cut on a tude, headache, sore throat, muscular aches, ab-
finger may have occurred in a nurse.(27) Most dominal pains, loss of appetite, nausea, vomiting,
medical and nursing personnel probably acquire and diarrhea. Fever appears early with somnol-
the disease by droplet infection, since it has been ence, indifference, and blurred vision; the temper-
established that the virus is present in the throat ature is in the range from 101-104°F, and may
washings of patients for several days.<15,44,60) reach 107"F. Petechiae may be seen, although the
9.2.2. Reservoir. Certain similarities between disease is not severely hemorrhagic. There is
Lassa fever and the diseases caused by other marked pharyngitis with firmly adherent, white
arenaviruses, as well as the observation that Lassa patches on the soft palate, pharynx, and pillars. In
virus persists for months in the urine of experi- severe progressive forms, signs of increase in
mentally infected laboratory mice which appear capillary fragility appear with a suffusion or flush
otherwise healthy, (15) support the view that this on the skin of face and upper thorax, puffed face,
virus may have a rodent reservoir in nature. swollen neck, and markedly blurred vision. There
Among the small wild vertebrates collected in are increased oliguria and dysuria. Additional pe-
the course of investigating the Sierra Leone out- techiae appear and sometimes larger subcutaneous
break (1970-1972), attention was focused on rodents hemorrhages on the arms, legs, and abdominal
and bats, since these hosts are implicated in the walls. Pleural effusions may also occur. The acute
febrile stage lasts from 7 to 21 days; in fatal cases, hospital setting, strict measures must be instituted
death occurs usually during the course of the in order to isolate patients and those suspected of
second week, its immmediate cause being sudden having the disease. This includes the use of
cardiovascular collapse. The death rate in hospital- gloves, masks, and gowns by the staff, individual
ized cases has been from 30-66%, overall about rooms for suspected cases, thorough decontamina-
36 % .C17 .27 .44.61.94) tion of excretions and secretions, and steriliza-
9.3.2. Diagnosis. Lassa fever, unlike the other tion of instruments, bedpans, and personal
arenavirus infections, has a marked tendency to utensils. (59)
spread by human-to-human contagion. Under Evacuation and international transportation of
these circumstances, prompt diagnosis is essential patients suspected of having Lassa fever present a
in order to implement strict isolation measures. In serious problem to public health officials, which is
the affected geographic areas, a clinical diagnosis still largely unresolved.
is complicated by the occurrence of other diseases
which may resemble Lassa fever. These included
9.5. Prevention and Control
malaria, yellow fever, and especially typhoid fe-
ver. The lack of local laboratory facilities makes a Prevention at the individual level is based on
specific diagnosis unavailable. In endemic areas, strict sanitary precautions; no vaccine is available.
an illness characterized by unremitting fever with Since M. natalensis is, thus far, the only known
temperatures of 100"F or higher, persisting for 5-7 reservoir, measures that minimize contact of this
days or more, unresponsive to antibiotics and rodent with man and his habitat will be helpful.
antimalarial drugs, accompanied by pharyngitis, However, it is unrealistic at this time to base too
malaise, toxic appearance, leukopenia, and, later, much hope on the effectiveness of the control of
by facial edema, must give rise to a strong suspi- this rodent in the endemic areas.
cion of Lassa fever.(59)
A specific diagnosis is achieved by isolation of
the virus, demonstration of antibody develop-
ment, or both. Virus is isolated from the blood 10. Unresolved Questions
between the third and fourteenth day of ill-
ness,05.60) less frequently from throat washings, 10.1 Vaccines
pleural effusions, and urine. Because of the recog- With the exception of LCM virus, which appears
nized danger inherent in handling the virus, work to have worldwide distribution, the other arena-
with it including attempts to isolate it is restricted virus diseases of man have been found restricted
to laboratories with special high containment facil- to definite geographic areas which, although
ities. Development of CF antibodies between early showing a tendency to increase, are still easily
and late samples of sera is a useful diagnostic identifiable. In the case of Lassa virus, although
procedure which can be done with inactivated the areas are multiple and possibly more extensive
noninfective antigens,(15) but it is no help for an than now known, they are confined to one conti-
early diagnosis since the antibodies do not usually nent. These geographic considerations, added to
appear until 18 or 20 days after onset. the fact that some of the more exposed groups-
maize harvesters for AHF and hospital personnel
for Lassa fever-are well defined, make these di-
9.4. Tr.eatment and Disposition of Patients
seases an excellent target for preventive vaccina-
Plasma from recovered patients has been used in tion. Control of the reservoirs would undoubtedly
a limited number of instances, perhaps five or six. be effective in preventing disease or reducing its
The number is not large enough to support any incidence. At the moment, however, it does not
conclusions; nevertheless, its effect has apparently appear to be a realistic solution.
been favorable,<44.60) although in one instance it Investigations to develop a vaccine for AHF
failed to prevent a fatal outcome.(94) have been carried out to the point where a large
In view of the frequency with which the Lassa number of volunteers have been inoculated with
virus is propagated from person to person in a an experimental vaccine. Efforts to develop an
attenuated strain of Machupo virus have been ize the infection and prevent its spread to other
initiated. No attempts to develop a vaccine against areas.
Lassa fever virus have been thus far reported. In
view of the severity of these diseases, continued
efforts to develop safe and effective vaccines are
10.3. Hemorrhagic Fever with Renal Syndrome
desirable.
Hemorrhagic fever with renal syndrome is
known by numerous synonyms, among which are
"hemorrhagic nephrosonephritis" and "Korean
10.2 Early Diagnosis of Lassa Fever and
hemorrhagic fever." It has a number of clinical and
Evacuation of Patients
epidemiological characteristics similar to those
The frequency with which hospital-c.entered seen with arenavirus infections. It appears to be
outbreaks have followed admission of a patient caused by a virus, on the basis of investigations
with undiagnosed Lassa fever is a paramount carried out with human volunteers by Smorodin-
reason for an early diagnosis; although, in general, tsev et al. in 1940-1941(85) in the Soviet Union,
no such urgency seems required for the other and by Kitano et al. in Manchuria at about the
arenaviruses, there has been at least one hospital- same time. (29) The etiological agent has not been
centered outbreak of BHF. Detection of the devel- clearly maintained in a laboratory host, although
opment of antibodies is not the answer since its propagation in tissue cultures and identifica-
positive CF tests are exceptional before the end of tion by the fluorescent antibody technique have
the third week of illness. Currently, the fastest been reported. (31)
way of establishing a specific diagnosis is isolation The disease is prevalent in several sections of
of the virus in Vero cells in culture and identifica- the USSR, principally in the Far East and in the
tion by. the CF test. At the very best, 6 days is middle Volga region, Bashkiria; between several
required from the moment the specimen reaches hundred and several thousand cases occur an-
the laboratory. Furthermore, there is only one nually. (18.19) The disease also occurs in Korea,
laboratory at this time with the safe facility in where in the period 1950-1952 it affected several
which to conduct isolation attempts: the Center for thousand United Nations military personnel, par-
Disease Control, Atlanta, Georgia. Even under ticularly Americans; the same or a very similar
optimal circumstances, by the time a presumptive syndrome occurs in Sweden and has been reported
diagnosis is confirmed the index case may have in Hungary.
already infected a number of persons. The possi- Clinically the disease has a prodromal stage,
bility of applying the fluorescent antibody tech- followed by sudden onset with chills, fever, leth-
nique to smears of throat washings or to smears of argy, frontal or retroorbital headache, myalgia,
pelleted virus in a sample of serum should be costovertebral pain, suffusion of face and upper
investigated. part of thorax, petechiae or larger skin hemor-
It must be remembered that any laboratory car- rhages, and p~onounced renal involvement with
rying out virological or bacteriological procedures proteinuria, oliguria that may end up in anuria,
on febrile patients in West Africa is under risk of and low fixed specific gravity of the urine; there
encountering an unsuspected Lassa fever patient, are leukopenia and thrombocytopenia. Death is
as is also the case with any medical diagnostician associated with shock and occurs in a variable
seeing patients in the clinics or the wards. proportion of cases, from 1-2% to 25-30%; the
Transportation of suspected Lassa fever patients death rate is higher in the Far East than in the
should be reduced to a minimum compatible with European part of the USSR. (18.19.29)
good medical cind nursing care. Evacuation and Extensive epidemiological investigations in the
international transportation of expatriate person- USSR appear to have established a definite link-
nel suspected of having Lassa fever cannot be including season, place, occupation, and expo-
denied to the individual. However, such presents sure-between disease and contact of man with
a serious problem to national and international various rodents, chief among them being Cleth-
health authorities whose responsibility is to local- rionomys glareolus, Apodemus sylvaticus, A. agrar-
ius, and Microtus fortis. CIS) Soviet investigators of the virus from gray mice (Mus musculus) trapped
consider that the rodents suffer a tolerant, persist- in the two infected households, Public Health Rep.
ent infection, excrete virus in the urine, and thus 54:673-684 (1939).
10. ARMSTRONG, D., FORTNER, J. G., ROWE, W. P., AND
contaminate the human habitat. Support for the
PARKER, J. c., Meningitis due to lymphocytic cho-
view that rodents are a reservoir of the disease
riomeningitis virus endemic in a hamster colony, J.
agent is given by outbreaks in laboratory person- Am. Med. Assoc. 209:265-267 (1969).
nel who were in contact with collections of wild- 11. ARRIBALZAGA, R. A., Una nueva enfermedad epi-
caught rodents. (9il de mica a germen desconocido, hipertermica, nefro-
Only when the etiological agent of this disease toxica, leucopenica y enantematica, Dia Medico
is established in a laboratory host or system will it 27:1204-1210 (1955).
be possible to investigate its properties and deter- 12. ATKINS, J. 1., FREEMAN, S., SCHRACK, W. D., JR.,
mine its relationship with the arenaviruses. DOWNS, W. G., AND CORONA, R c., Lassa virus
infection, Morbid. Mortal. 19:123 (1970).
13. BLANC, G., BRUNEAU, J., DELAGE, B., AND POITROT,
R., Etude comparative de virus de choriomeningite
lymphocytaire d'origine humaine (W. E. ARM-
STRONG) et animale (pneumopathie du cobaye), Bull.
11. References Acad. Natl. Med. Paris 135:520-528 (1951).
14. BLUMENTHAL, W., KESSLER, R., AND ACKERMANN, R,
1. ACKERMAN, R, Epidemiologic aspects of lympho- Uber die Durchseuchung der liindlicken Bevolkerung
cytic choriomeningitis in man, in: Lymphocytic Cho- in der Bundesrepublik Deutschland mit dem Virus
riomeningitis Virus and Other Arenaviruses (F. LEH- der Lymphocytaren Choriomeningitis, Zentralbl.
MANN-GRUBE, ed.), pp. 233-237, Springer-Verlag, Bakteriol. Parasitenkd. Infektionskr. Hyg. Abt. 1 Orig.
New York, 1973. 213:36-48 (1970).
2. ACKERMAN, R., BLOEDHORN, H., KUPPER, B., WIN- 15. BUCKLEY, S. M., AND CASALS, J., Lassa fever, a new
KENS, I., AND SCHEID, W., Uber die Verbreitung des virus disease of man from West Africa. III. Isolation
Virus der lymphocitaren Choriomeningitis unter den and characterization of the virus, Am. J. Trap. Med.
Mausen in Westdeutschland. I. Untersuchungen Hyg. 19:680-691 (1970).
uberwiegend an Hausmausen (Mus musculus), Zen- 16. CALISHER, C. H., TZIANABOS, T., LORD, R D., AND
tralbl. Bacterial. Parasitenkd. Infektionskr. Hyg. Abt. 1 COLEMAN, P. H., Tamiami virus, a new member of
194:407-430 (1964). the Tacaribe group, Am. J. Trap. Med. Hyg. 19:520-
3. ACKERMAN, R., STILLE, W., BLUMENTHAL, W., HELM, 526 (1970).
E. B., KELLER, K., AND BALDUS, 0., Syrische Gold- 17. CAREY, D. E., KEMP, G. E., WHITE, H. A., PINNEO,
hamster als Ubertrager von lymphocytaren Choriom- 1., ADDY, R. F., FOM, A. 1. M. D., STROH, G.,
eningitis, Deutsch. Med. Wochenschr. 45:1725-1731 CASALS, J., AND HENDERSON, B. E., Lassa fever:
(1972). Epidemiological aspects of the 1970 epidemiC, Jos,
4. ADAIR, C. V., GAULD, R 1., AND SMADEL, J. E., Nigeria, Trans. R. Soc. Trap. Med. Hyg. 66:402-408
Aseptic meningitis, a disease of diverse etiology: (1972).
Clinical and etiologic studies on 854 cases, Ann. 18. CASALS, J., HENDERSON, B. E., HOOGSTRAAL, H.,
Intern. Med. 39:675-704 (1953). JOHNSON, K. M., AND SHELOKOV, A., A review of
5. AGREST, A., AVALOS, J. c. S., ARCE, M., AND SLEPOY, Soviet viral hemorrhagic fevers, 1969, J. Infect. Dis.
A., Fiebre hemorragica Argentina y coagulopatia por 122:437-453 (1970).
consumo, Medicina 29:194--201 (1969). 19. CASALS, J., HOOGSTRAAL, H., JOHNSON, K. M., SHE-
6. Anonymous, Follow-up on Lassa fever, Morbid. Mor- LOKOV, A., WIEBENGA, N. H., AND WORK, T. H., A
tal. 22:201-202 (1973). current appraisal of hemorrhagic fevers in the USSR,
7. Anonymous, Laboratory epidemic traced to ham- Am. J. Trap. Med. Hyg. 15:751-764 (1966).
sters, J. Am. Med. Assoc. 228:815-816 (1974). 20. COGGESHALL, 1. T., The transmission of lymphocytic
8. ARMSTRONG, c., AND LILLIE, R D., Experimental choriomeningitis by mosquitoes, Science 89:515-516
lymphocytic choriomeningitis of monkeys and mice (1939).
produced by a virus encountered in studies of the 21. COMISION, Comision Na.cional Coordinadora para
1933 St. Louis encephalitis epidemic, Public Health Estudio y Lucha Contra la Fiebre Hemorragica Ar-
Rep. 49:1019-1027 (1934). gentina, Buenos Aires, pp. 1-117 (1966).
9. ARMSTRONG, c., AND SWEET, 1. K., Lymphocytic 22. DOUGLAS, R. G., WIEBENGA, N. H., AND COUCH, R.
choriomeningitis: Report of two cases, with recovery B., Bolivian hemorrhagic fever probably transmitted
by personal contact, Am. J. Epidemiol. 82:85-91 ical and serological studies, Trans. R. Soc. Trop. Med.
(1965). Hyg. 66:409-416 (1972).
23. DOWNS, W. G., ANDERSON, C. R., SPENCE, L., AIT- 35. HOTCHIN, J., Persistent and Slow Virus Infections, Vol.
KEN, T. H. G., AND GREENHALL, A. H., Tacaribe 3 of Monographs in Virology pp. 1-211, Karger, New
virus, a new agent isolated from Artibeus bats and York,1971.
mosquitoes in Trinidad, West Indies, Am. J. Trop. 36. JOHNSON, K. M., Fiebres hemorragicas de America
Med. Hyg. 12:640-646 (1963). del Sur, Medicina 30:99--110 (Suppl. No.1) (1970).
24. ELSNER, B., SCHWARZ, E., MANDO, 0., MAIZTEGUI, J., 37. JOHNSON, K. M., HALSTEAD, S. B., AND COHEN, S. N.,
AND VILCHES, A., Patologia de la fiebre hemorragica Hemorrhagic fevers of Southeast Asia and South
Argentina, Medicina 30:85-94 (Suppl. No.1) (1970). America: A comparative appraisal, Prog. Med. Virol.
25. EMMONS, R. W., CHIN, J., NAYFIELD, C. L., WATER- 9:105-158 (1967).
MAN, G. E., FIUMARA, N. J., FLEMING, D. S., ZISKIN, 38. JOHNSON, K. M., KUNS, M. L., MACKENZIE, R. B.,
L., GOLDFIELD, M., ALTMAN, R., WOODALL, J., DEI- WEBB, P. A., AND YUNKER, C. E., Isolation of Ma-
BEL, R., AND HINMAN, A. P., Follow-up on hamster- chupo virus from wild rodent Calomys callosus, Am.
associated LCM infection, Morbid. Mortal. 23:131-132 J. Trop. Med. Hyg. 15:103--106 (1966).
(1974). 39. JOHNSON, K. M., AND WEBB, P. A., Rodent transmit-
26. FORSTER, U., AND WACHENDORFER, G., Inapparent ted hemorrhagic fevers, in: Diseases Transmitted from
infection of Syrian hamster with the virus of lym- Animals to Man (W. T. Hubbert, W. F. McCulloch,
phocytic choriomeningitis, in: Lymphocytic Choriom- and T. R. Schnurrenberger, eds.), 6th edition, pp.
eningitis Virus and Other Arenaviruses (F. Lehmann- 911-918, Charles C. Thomas, Springfield, Ill., 1975.
Grube, ed.), pp. 11:>-120, Springer-Verlag, New 40. JOHNSON, K. M., WEBB, P. A., AND JUSTINES, G.,
York,1973. -Biology of Tacaribe-complex viruses, in: Lymphocytic
27. FRAME, J. D., BALDWIN, J. M., JR., GOCKE, D. J., AND Choriomeningitis Virus and Other Arenaviruses (F. LEH-
TROUP, J. M., Lassa fever, a new virus disease of man MANN-GRUBE, ed.), pp. 241-258, Springer-Verlag,
from West Africa. 1. Clinical description and patho- New York, 1973.
logical findings, Am. J. Trop. Med. Hyg. 19:670-676 41. JUSTINES, G., AND JOHNSON, K. M., Immune tolerance
(1970). in Calomys callosus infected with Machupo virus,
28. FRASER, D. W., CAMPBELL, C. c., MONATH, T. P., Nature (London) 222:1090-1091 (1969).
GOFF, P. A., AND GREGG, M. B., Lassa fever in the 42. KUNS, M. L., Epidemiology of Machupo virus infec-
Eastern Province of Sierra Leone, 1970-1972. 1. Epi- tion. II. Ecological and control studies of hemor-
demiologic studies, Am. J. Trop. Med. Hyg. 23:1131- rhagic fever, Am. J. Trop_ Med. Hyg_ 14:813--816
1139 (1974). (1965).
29. GAJDUSEK, D. c., Virus hemorrhagic fevers, J. 43. LEHMANN-GRUBE, F., Lymphocytic Choriomeningitis
Pediat. 60:841-857 (1962). Virus, Vol. 10 of Virology Monographs, pp. 1-173,
30. GALLARDO, F., Fiebre hemorragica Argentina: Hal- Springer-Verlag, New York, 1971.
lazgos anatomopatologicos en diez necropsias, Medi- 44. LEIFER, E., GOCKE, D. J., AND BOURNE, H., Lassa
cina 30:77-84 (Suppl. No.1) (1970). fever, a new virus disease of man from West Africa.
31. GAVRILYUK, B. K., NOSKOV, F. S., AND SMORODIN- II. Report of a laboratory-acquired infection treated
TSEV, A. A., Study of haemorrhagic nephroso-ne- with plasma from a person recently recovered from
phritis virus by the fluorescent antibody technique, the disease, Am. J. Trap. Med. Hyg. 19:677-679
Acta Virol. 15:485-492 (1971). (1970).
32. GILDEN, D. H., FRIEDMAN, H. M., Ky], C. 0., ROOSA, 45. LEWIS, A. M., ROWE, W. P., TURNER, H. c., AND
R. A., AND NATHANSON, N., Tamiami virus-induced HUEBNER, R. J., Lymphocytic-choriomeningitis virus
immunopathological disease of the central nervous in hamster tumor: Spread to hamsters and humans,
system, in: Lymphocytic Choriomeningitis Virus and Science 150:363--364 (1965).
Other Arenaviruses (F. LEHMANN-GRUBE, ed.), pp. 46. MACKENZIE, R. B., Epidemiology of Machupo virus
287-297, Springer-Verlag, New York, 1973. infection. 1. Pattern of human infection, San Joaquin,
33. GSCHWENDER, H. H., AND LEHMANN-GRUBE, F., Bolivia, 1962-64, Am. J. Trap. Med. Hyg. 14:808-813
Antigenic properties of the LCM virus: Virion and (1965).
complement-fixing antigen, in: Lymphocytic Cho- 47. MACKENZIE, R. B., WEBB, P. A., AND JOHNSON, K. M.,
riomeningitis and Other Arenaviruses (F. LEHMANN- Detection of complement-fixing antibody after Boliv-
GRUBE, ed.), pp. 26-35, Springer-Verlag, New York, ian hemorrhagic fever, employing Machupo, Junin
1973. and Tacaribe virus antigens, Am. J. Trap. Med. Hyg.
34. HENDERSON, B. E., GRAY, G. W., JR., KISSLING, R. E., 14:1079--1084 (1965).
FRAME, J. D., AND CAREY, D. E., Lassa fever: Virolog- 48. MAIZTEGUI, J. 1., Epidemiologia de la fiebre hemor-
ragica Argentina, in: Proceedings, Quinto Congresso Zorzor, Liberia, March-April 1972, Am. J. Trop. Med.
Latino-Americano de Microbiologia, Punta del Este, Hyg. 22:773-779 (1973).
Uruguay, pp. 71-76 (1971). 62. MuRPHY, F. A., WEBB, P. A., JOHNSON, .\<. M., AND
49. MAIZTEGUI, J. I., Argentinian hemorrhagic fever WHrrFIELD, S. G., Morphological comparison of Ma-
(AHF), in: Proceedings, Ninth International Congress chupo with lymphocytic choriomeningitis virus: Ba-
on Tropical Medicine and Malaria, Athens, Vol. 1, p. sis for a new taxonomic group, J. Virol. 4:535-541
31 (1973). (1969).
50. MAIZTEGUI, J. I., AGUIRIUl, G. M., SABATTINI, M. S., 63. MuRPHY, F. A., WEBB, P. A., JOHNSON, K. M.,
AND ORO, J. G. B., Actividad de dos "arenavirus" en WHITFIELD, S. G., AND CHAPPELL, W. A., Arenovi-
seres humanos y roedores en un mismo lugar de la ruses in Vero cells: Ultrastructural studies, J. Virol.
zona endemica de fiebre hemorragica Argentina, 6:507-518 (1970).
Medicina 31:509-510 (1971). 64. MuRPHY, F. A., WHITFIELD, S. G., WEBB, P. A., AND
51. MAIZTEGUI, J. I., ESTRIBOU, J. P., SABATTINI, M. S., JOHNSON, K. M., Ultrastructural studies of arenavi-
AND ORO, J. G. B., Estudios tendientes a dilucidar el ruses, in: Lymphocytic Choriomeningitis Virus and
papel del Mus musculus en la epidemiologia de la Other Arenaviruses (F. LEHMANN-GRUBE, ed.), pp.
fiebre hemorragica Argentina (FHA), Rev. Soc. Ar- 273-285, Springer-Verlag, New York, 1973.
gent. Microbiol. 2:186-187 (1970). 65. ORO, J. G. B., MAIZTEGUI, J. I., AND SABATTINI, M. S.,
52. MAIZTEGUI, J. I., SABATTINI, M. S., AND ORO, J. G. B., Fiebre hemorragica Argentina en la proVincia de
Actividad del virus de la coriomeningitis linfocitica Santa Fe, Rev. Asoc. Argent. Microbiol. 5:57-58 (1973).
(LCM) en el area endemica de fiebre hemorragica 66. PARODI, A. S., GREENWAY, D. J., Rugiero, H. R.,
Argentina (FHA), Medicina 32:131-137 (1971). RIVERO, S., FRIGERIO, M., BARRERA, J. M., METTLER,
53. MANNWEILER, K., AND LEHMANN-GRUBE, F., Electron N., GARZON, F., BOXACA, M., GUERRERO, L., AND
microscopy of LCM virus-infected L cells, in: Lym- NOTA, N., Sobre la etiologia del brote epidemico de
phocytic Choriomeningitis Virus and Other Arenaviruses Junin, Dia Med. 30:2300-2302 (1958).
(F. LEHMANN-GRUBE, ed.), pp. 37-48; Springer-Ver- 67. PARODI, A. S., DE GUERRERO, L. B., ASTARLOA, L.,
lag, New York, 1973. CINTORA, A., CAMBACERES, C. G., MAGLIO, G., MAG-
54. METTLER, N. E., Estudio realizado con los sueros de NONI, c., MILANI, H., RUGGIERO, H., AND SQUASSI,
1a epidemia de fiebre hemorragica Argentina (1963) G., Immunizacion contra 1a fiebre hemorragica Ar-
que no presentaron conversion serologica para virus gentina con una cepa atenuada de virus Junin, Medi-
Junin, Medicina 26:161-169 (1966). cina 30:3-7 (Suppl. No.1) (1970).
55. METTLER, N. E., Argentine Hemorrhagic Fever: Current 68. PARODI, A. S., RUGIERO, H. R., GREENWAY, D. L.,
Knowledge, Pan American Health Organization, Sci- METTLER, N. E., MARTINEZ, A., BOXACA, M., AND
entific Publications No. 183, pp. 1-55 (1969). BARRERA, J. M., Aislamiento del virus Junin (FHE) de
56. METTLER, N. E., AND CASALS, J., Isolation of St. los acaros de la zona epidemica (Echinolaelaps echid-
Louis encephalitis virus from man in Argentina, Acta ninus, Berlese), Prensa Medica Argent. 46:2242-2244
Virol. 15:148-154 (1971). (1959).
57. METTLER, N. E., CASALS, J., AND SHOPE, R. E., Study 69. PEDERSEN, I. R., LCM virus: Its purification and its
of antigenic relationships between Junin virus, the chemical and physical properties, in: Lymphocytic
etiological agent of Argentinian hemorrhagic fever, Choriomeningitis Virus and Other Arenaviruses (F. LEH-
and other arthropod-borne viruses, Am. J. Trop. Med. MANN-GRUBE, ed.), pp. 13-23, Springer-Verlag, New
Hyg. 12:647-652 (1963). York, 1973.
58. MEYER, H. M., JOHNSON, R. T., CRAWFORD, 1. P., 70. PFAU, C. J., WELSH, R. W., AND TROWBRIDGE, R. S.,
DASCOMB, H. E., AND ROGERS, N. G., Central nerv- Plaque assays and current concepts of regulation in
ous system syndromes of "viral" etiology: A study of arenavirus infections, in: Lymphocytic Choriomeningi-
713 cases, Am. J. Med. 29:334-347 (1960). tis Virus and Other Arenaviruses (F. LEHMANN-GRUBE,
59. MONATH, T. P., Lassa fever, Trop. Doctor 4:155-161 ed.), pp. 101-111, Springer-Verlag, New York, 1973.
(1973). 71. PINHEIRO, R. P., SHOPE, R. E., DE ANDRADE, A. H.
60. MONATH, T. P., MAHER, M., CASALS, J., KISSLING, R. P., BENSABETH, G., CACIOS, G. V., AND CASALS, J.,
E., AND CACCIAPUOTI, A., Lassa fever in the Eastern Amapari, a new virus of the Tacaribe group from
Province of Sierra Leone, 1970-1972. ll. Clinical ob- rodents and mites of Amapa Territory, Brazil, Proc.
servations and virological studies on selected hospi- Soc. Exp. Bioi. Med. 122:531-535 (1966).
tal cases. Am. J. Trop. Med. Hyg. 23:1140-1149 (1974). 72. PINTOS, I. M., Epidemiologia del "Mal de los Rastro-
61. MONATH, T. P., MERTENS, P. E., PATION, R., MOSER, jos," Separata An. Com. Invest. Cient. Provo Buenos
C. R., BAUM, J. J., PINNEO, L., GARY, G. W., AND Aires 3:9-102 (1962).
KISSLING, R. E., A hospital epidemic of Lassa fever in 73. PIROSKY, I., ZUCCARINI, J., MOLINELLI, E. A., DIPIE-
TRO, A., ORO, J. G. B., MARTINI, P., AND COPELW, A. Israel Program for Scientific Translation, Clearing
R., Virosis Hemorragica del Noroeste Bonaerense: En- House, Springfield, Va., 1964.
demo-epidemica, Febril, Enantematica y Leucopenica, 86. SPEIR, R. W., WOOD, 0., LIEBHABER, H., AND BUCK-
Comision Nacional ad hoc para Estudiar el Brote de LEY, S. M., Lassa fever, a new virus disease of man
1958, Talleres Graficos del Ministerio de Asistencia from West Africa. IV. Electron microscopy of Vero
Social y Salud Publica, Buenos Aires, 1959. cell cultures infected with Lassa virus, Am. J. Trop.
74. RAWLS, W. E., RAMOS, B. A., AND CARTER, M. F., Med. Hyg. 19:692-694 (1970).
Biophysical and biochemical studies of Pichinde vi- 87. SULKIN, S. E., AND PIKE, R. M., Prevention of labora-
rus, in: Lymphocytic Choriomeningitis Virus and Other tory infections, in: Diagnostic Procedures for Viral and
Arenaviruses (F. LEHMANN-GRUBE, ed.), pp. 259--272, Rickettsial Diseases (E. H. LENNETTE AND N. J.
Springer-Verlag, New York, 1973. SCHMIDT, eds.). pp. 66-78, American Public Health
75. RIVERS, T. M., AND SCOTT, T. F. M., Meningitis in Associations, New York, 1969.
man caused by a filterable virus. II. Identification of 88. TRAPIDO, H., AND SANMARTIN, c., Pichinde virus, a
the etiological agent, J. Exp. Med. 63:415-432 (1936). new virus of the Tacaribe group from Colombia, Am.
76. ROWE, W. P., MURPHY, F. A., BERGOLD, G. H., J. Trop. Med. Hyg. 20:631-641 (1971).
CASALS, J., HOTCHIN, J., JOHNSON, K. M., LEHMANN- 89. TRAUB, E., A filterable virus recovered from white
GRUBE, F., MIMS, C. A., TRAUB, E., AND WEBB, P. A., mice, Science 81:298-299 (1935).
Arenoviruses: Proposed name for a newly defined 90. TRAUB, E., Epidemiology of lymphocytic choriomen-
virus group, J. Virol. 5:651-652 (1970). ingitis in a mouse stock observed for four years, J.
77. ROWE, W. P., PUGH, W. E., WEBB, P. A., AND PETERS, Exp. Med. 69:801-817 (1939).
C. J., Serological relationship of the Tacaribe com- 91. TRENCSENI, T., AND KELETI, B., Clinical Aspects and
plex of viruses to lymphocytic choriomeningitis vi- Epidemiology of Hemorrhagic Fever with Renal Syn-
rus, J. Virol. 5:289-292 (1970). drome pp. 1-247, Akademiai Kiado, Budapest, 1971.
78. RUGIERO, H. R., PARODI, A. S., GOTTA, H., BOXACA, 92. WEBB, P. A., JOHNSON, K. M., HIBBS, J. G., AND
M., OLIVARI, A. J., AND GONZALEZ, E., Fiebre hemor- KUNS, M. 1., Parana, a new Tacaribe complex virus
ragica epidemica: Infeccion de laboratorio y passage from Paraguay, Arch. Gesamte Virusforsch. 32:379--388
interhummano, Rev. Asoc. Med. Argent. 76:413-417 (1970).
(1962). 93. WEBB, P. A., JOHNSON, K. M., PETERS, C. J., AND
79. SABATTINI, M. S., AND MAIZTEGUI, J. I., Fiebre he- HIBBS, J. B., Immunological relationships among Ta-
morragica Argentina, Medicina 30:111-128 (Suppl. caribe complex viruses and description of a new
No.1) (1970). serotype from Bolivia, Latino virus, in preparation
80. SABATTINI, M. S., ORO, J. G. B., MAIZTEGUI, J. I., (1976).
FERNANDEZ, D., COSTIGIANI, M. S., AND DIAZ, G. E., 94. WHrrE, H. A., Lassa fever: A study of 23 hospital
Aislamiento de un "arenovirus" relacionado con el cases, Trans. R. Soc. Trap. Med. Hyg. 66:390-398
de la coriomeningitis linfocitica (LCM) a partir de un (1972).
Mus musculus capturado en zona endemica de fiebre 95. WIEBENGA, N. H., SHEWKOV, A., GIBBS, C. J., JR.,
hemorragica Argentina (FHA), Rev. Asoc. Argent. AND MACKENZIE, R. B., Epidemic hemorrhagic fever
Microbiol. 2:182-184 (1970). in Bolivia. II. Demonstration of complement-fixing
81. SCHEIDT, W., ACKERMAN, R., AND FELGENHAUER, K., antibody in patients' sera with Junin virus antigen,
Lymphocytare Choriomeningitis unter dem Bild der Am. J. Trap. Med. Hyg. 13:626-628 (1964).
Encephalitis lethargica, Deutsch. Med. Wochenschr. 96. WINN, W. c., JR., MONATH, T. P., MuRPHY, F. A.,
93:940-943 (1968). AND WHITFIELD, S. G., Lassa virus hepatitis: Obser-
82. SCHWARZ, E. R., MANDO, O. G., MAIZTEGUI, J. 1., vations on a fatal case from the 1972 Sierra Leone
AND VILCHES, A. M., Sintomas y signos iniciales de epidemic, Arch. Pathol. 99:599-604 (1975).
mayor valor diagnostico en la fiebre hemorragica 97. WOOLEY, J. G., ARMSTRONG, c., AND ONSTOTT, R. H.,
Argentina, Medicina 30:8-14 (Suppl. No.1) (1970). The occurrence in the sera of man and monkeys of
83. SCOTT, T. F. M., AND RIVERS, T. M., Meningitis in protective antibodies against the virus of lympho-
man caused by a filterable virus. 1. Two cases and cytic choriomeningitis as determined by the serum-
the method of obtaining a virus from their spinal virus protection test in mice, Public Health Rep.
fluids, J. Exp. Med. 63:397-414 (1936). 52:1105-1114 (1937).
84. SMADEL, J. E., GREEN, R. H., PALTAUF, R. M., AND
GONZALES, T. A, Lymphocytic choriomeningitis: Two
human fatalities following an unusual febrile illness, 12. Suggested Reading
Proc. Soc. Exp. BioI. Med. 49:683-686 (1942).
85. SMORODINTSEV, A A, KAZBINTSEV, 1. I., AND CHUDA- CASALS, J., AND BUCKLEY, S. M., Lassa fever, Prog. Med.
KOV, V. G., Virus Hemorrhagic Fevers, pp. 1-245, Viral. 18:111-125 (1974).
COTO, C. E., Junin virus, Prog. Med. Virol. 18:127-142 LEHMANN-GRUBE, F., Lymphocytic Choriomeningitis Virus,
(1974). Vol. 10 of Virology Monographs, pp. 1-173, Springer-
JOHNSON, K. M., HALSTEAD, S. B., AND COHEN, S. N., Verlag, New York, 1971.
Hemorrhagic fevers of Southeast Asia and South MONATH, T. P., Lassa fever, Trop. Doctor 4:155-161
America: A comparative appraisal, Prog. Med. Virol. (1973).
9:105-158 (1967).
CHAPTER 6
Coronaviruses
Arnold S. Monto
1. Introduction ain at approximately the same time. The British

Medical Research Council's Common Cold Re-
The coronaviruses are a group of RNA-containing search Unit had been studying fluids collected
agents which have been associated with respira- from persons with natural respiratory infections
tory illnesses in man and with a number of other both by standard cell culture isolation methods
diseases in laboratory and domestic animals. The and by inoculating them into human volunteers.
name for the group was adopted to describe the Rhinoviruses or other cytopathogenic agents could
characteristic fringe of crownlike projections seen be recovered from a portion of the fluids. (36)
around the viruses by electron microscopy; these There was an additional substantial portion from
projections are rounded, rather than sharp or which no agents could be isolated but which could
pointed as is the case with the myxoviruses. Like still cause colds in the volunteers. Organ cultures
the myxoviruses, the coronaviruses contain essen- of human embryonic trachea or nasal epithelium
tiallipid and are 80-160 rim in diameter.(IS) While were then used in an effort at detecting the recalci-
the animal strains are readily isolated in several trant viruses present in the fluids. A specimen,
different systems, recovery of the human strains B814, which had been collected in 1960 from a boy
has posed major problems. A number of these with a common cold, had not yielded a virus on'
strains have been isolated only in organ culture of inoculation into cell culture. After the specimen
the human respiratory tract. This factor has ren- had been passaged serially three times in human
dered difficult determination of the relationship tracheal organ culture, it could still cause colds on
among isolates and complicated efforts at under- inoculation into volunteers, which indicated that
standing the role of these viruses in human respi- replication had taken place.(5S)
ratory illness. Therefore, much of the information In Chicago during the winter of 1962, five agents
on the epidemiology of the agents has come from were isolated in primary human kidney cell cul-
serological studies. tures from specimens collected from medical stu-
dents with common colds. The viruses were ulti-
mately adapted to WI38 cultures and exhibited a
2. Historical Background type of cytopathic effect not previously seen. A
prototype strain, 229E, was selected for characteri-
The first human coronaviruses were isolated by zation and was found to be RNA containing, ether
different techniques in the United States and Brit- labile, and 89 nm in diameter, but distinct serolog-
ically from any known myxo- or paramyxoviruses.
Arnold S. Monto . Department of Epidemiology, Sera collected from the five medical students all
School of Public Health, University of Michigan, Ann exhibited a fourfold rise in neutralizing antibody
Arbor, Michigan titer against 229E. (23)
127
128 Chapter 6 • Coronaviruses
The fact that these "novel" viruses were of more ing end points in tests involving these organ
than passing significance became clear when or- culture derived strains. caO) The other OC strains
gan culture methods were added to standard cell which could not be adapted to mouse brain re-
culture techniques in a study of acute respiratory sisted adaptation to cell culture. Finally, immune
infections of adults conducted at the National electron microscopy has been added to the meth-
Institutes of Health. Six viruses were found which ods available for identifying the presence of coron-
grew in organ but not cell culture and were ether aviruses in organ culture harvests. This highly
labile; on electron microscopy the agents were sensitive technique should improve the ability to
shown to resemble avian infectious bronchitis vi- detect virus, but it is obviously unsuitable for use
rus in structure. ca9l The B814 and 229E strains in all but the most specialized studies. call
were soon also demonstrated to have a similar
structure on electron microscopy and to develop in
infected cells by budding into cytoplasmic vesi- 3. Methodology
cles.o· 2 •22l As a result of the similarity of the
human agents to infectious bronchitis virus (!BY) 3.1. Sources of Mortality Data
and also to mouse hepatitis virus (MHV), they
were collectively considered to represent a group Coronaviruses that infect domestic and labora-
of vertebrate viruses distinct from the myxoviruses tory animals produce illnesses which are some-
antigenically and structurally. cal The name corona- times fatal. In contrast, there is no documented
virus was adopted for the group to describe the report yet on record of human coronaviruses being
fringe of projections seen around them on electron involved in a lethal infection. This situation may
microscopy. c18) be a reflection of the limited number of investiga-
Except for 229E, none of the human coronavi- tions carried out as yet. It is known that these
ruses had been successfully propagated in a sys- agents frequently infect small children and reinfect
tem other then organ culture. McIntosh et al. can adults, including persons with chronic respiratory
reported successful adaptation of two of the NIH disease. csa) It would be logical to assume that
isolates, OC (organ culture) 38 and OC43, to the deaths could occasionally occur in these most sus-
brains of suckling mice. These strains were shown ceptible segments of the population, but they are
to be essentially identical antigenically but quite probably not very frequent.
distinct from mouse hepatitis virus. Only OC38
and OC43 could be so adapted; the other four OC
strains resisted such attempts. Infectious bronchi- 3.2. Sources of Morbidity Data
tis virus was known to exhibit hemagglutination Since coronaviruses usually produce respiratory
under certain conditions, but no such phenome- illnesses indistinguishable from those caused by
non had been demonstrated for the human strains many other types of viruses, it is not possible to
until OC38 and OC43 were adapted to mice. Kaye obtain data on morbidity in the absence of labora-
and Dowdle ca2 ) found that the infected brain tory identification of infection. The viruses are
preparations would directly and specifically agglu- difficult to isolate, so most workers have relied on
tinate red cells obtained from chickens, rats, and serological techniques to increase the numbers
mice. This technique greatly expanded the ability that can be studied. Investigations into coronavi-
to do epidemiological studies since it was simple rus infection have usually formed part of overall
and reproducible. evaluations of the role of viruses in general in
Other more recent developments have included respiratory illnesses. As indicated in the partial
adaptation of OC38 and OC43 to growth in cell listing in Table I, a variety of different open and
monolayers; either mouse brain or organ culture closed populations have been used for these stud-
material could be used as source of virus. cII ) Not ies. The 229E strain was originally isolated from
only was cytopathic effect available for reading of medical students in Chicago as part of a long-term
neutralization tests; also, the OC38 or OC43 virus study of respiratory illnesses in young
was found to hemadsorb red cells of rats and mice, adults. C21.2a) Employee groups have been the
making available a more precise means of evaluat- source of specimens in the National Institutes of
Chapter 6 • Coronaviruses 129
Table 1. Longitudinal Studies on the Epidemiology of Coronavirus Infection in

Humans
Location Population Virus studied
Chicago, Ill. (21) Medical students 229E

Washington, D.C."9.42) Hospitalized children 229E,OC43
Bethesda, Md."9.42) Adult employees 229E, OC viruses
Atlanta, Ga. (34) Institutionalized children OC43
Charlottesville, Va."S) Working adults 229E,OC43
Tecumseh, Mich."6.49) General community 229E,OC43
Brazil(15) Nonhospitalized children 229E
Denver, Colo."O) Hospitalized asthmatic children 229E,OC43
N. and S. Carolina(sOJ Military 229E,OC43
Health(29.42) and in the studies at Charlottesville, scribed in 1964.(25) It is now recognized that this
Virginia. (26) Infection has also been evaluated in does not indicate past experience with MHV, but
children's homes(;!4) or boarding schools,';!6) rather with human coronavirus strains which are
among military recruits,'60) and among children known to cross-react with it. In contrast, in a
hospitalized for severe respiratory illnesses in var- survey of antibodies to avian infectious bronchitis
ious parts of the world. (29) Serological methods virus, none could be found in a military popula-
have been used to detect occurrence in persons tion. Low-level antibodies were detected only in a
with acute exacerbations of asthma(4O) or chronic portion of individuals who h,ad close contact with
obstructive respiratory disease. (5;!) Patterns of co- poultry. (45) This virus is not known to cross-react
ronavirus infection have been identified among with the human strains.
the general population residing in the Tecumseh
community as part of a longitudinal study of
respiratory illness. (16,49) Volunteers have contin- 3.4. Laboratory Methods
ued to be employed, especially to determine char- 3.4.1. Viral Isolation. Only the 229E strain was
acteristics of illness not yet well defined in natural originally isolated in cell culture. It was eventually
infection because of problems associated with iso- adapted to human embryonic lung cells (WI38), in
lation of the viruses. (7.8) which it has been maintained.(2;" However, this
cell line is not a reliable system for primary isola-
tion of 229E-like agents. To date, human embry-
3.3 Serological Surveys
onic intestine (MA177) has proven the most suita-
Although relatively simple serological tech- ble cell system, but it is available only in limited
niques are now available for two coronaviruses quantities,'29) All other known human coronavi-
(229E and OC38 or OC43), extensive surveys of ruses were originally isolated in organ cultures of
antibody prevalence have not been carried out. human trachea or lung. (Z4.:l9.,,8.59) The presence of
When done, the surveys have often formed a part virus was usually detected by electron microscopy,
of studies mainly directed toward determination of or sometimes by fluorescent antibody staining of
incidence of infection. Information on prevalence impression smears. (57) Two strains which are es-
of antibody is available for populations in the sentially identical, OC38 and OC43, have been
United States,'l6.26.42) Britain,'8) and Brazil.'l5) A adapted to suckling mouse brain and to primary
special situation is the presence in man of anti- monkey kidney and BS-C-1 cell cultures.(ll.:JO.;m
body against two coronaviruses of animals. The Another cell system, L132, a heteroploid human
finding of mouse hepatitis antibodies in military lung line, has been reported to be suitable for
recruits and in children and adults from the gen- primary isolation of 229E, a related virus (LP), and
eral population was surprising when first de- the B814, the first-described organ culture
agent.(6.9) This last finding has not been con- indirect HI test for 229E virus using tanned sheep
firmed by other workers.(lIl erythrocytes has also been described. The proce-
It is conceivable that s:pecial conditions of cell dure appears to be highly sensitive and no cross-
culture are required for primary isolation of these reactions with OC43 virus were observed.(:!51
agents; this would be similar to the strict require- It was found that CF tests can be satisfactorily
ments for propagation of the rhinoviruses before performed with OC43 virus using infected suck-
the availability of WI38 cells. (52) The situation is ling mouse brain as antigen. (42) The same mouse
in sharp contrast to that found with the coronavi- brain material can also be used in the HI test for
ruses of animals. While they are rather species OC43 antibody. In this test, the hemagglutination
specific in their in vitro growth characteristics, titer was higher for rat than chicken erythrocytes,
especially on primary isolation, such isolation is but was sufficient with the chicken cells so that
easily accomplished. (44.54.55.56) they could generally be employed; this is of partic-
3.4.2. Serological Tests. Neutralization tests of ular importance in view of the spontaneous agglu-
varying degrees of complexity can be performed tination which often complicates working with rat
for all described coronavirus types. The most in- erythrocytes. Serum to be tested did not require
volved procedure must be used for those viruses treatment with receptor-destroying enzyme, but
which up to now have never been adapted to rather standard heat inactivation at 56°C, The
systems other than organ culture. (09) This tech- agglutination took place equally at various temper-
nique involves incubating serum with known vi- atures, including room temperature. (;121
rus and inoculating the mixture into cultures of Other serological tests have been developed
human trachea. Evidence of neutralization mani- which have been used more in antigenic analyses
fest by a reduction in viral yield is determined by of the different coronaviruses than in epidemiolog-
electron microscopy. For those coronaviruses ical studies. With the indirect fluorescent antibody
adapted to cell cultures, tube or plaque reduction technique, characteristic cytoplasmic inclusions
neutralization tests are available. WI38 or L132 were demonstrated with 229E, OC43, and even the
cells may be used for both methods with 229E other coronaviruses grown in organ culture. The
virus; a number of cell lines including primary last were prepared for testing by making smears of
monkey kidney and BS-C-l have been used for fragments of the infected trachea.(4]) It has also
neutralization tests involving the OC38-43 vi- been possible to demonstrate precipitin lines on
ruS.(5.9.1l) Hemadsorption rather than cytopathic gel diffusion tests with coronavirus antigens con-
effect can be used for identification of end points centrated ten- to fiftyfold. Two or three precipitin
with the BS-C-l celllines." 2 .l:ll lines were observed by Bradburne(5) in tests with
Most seroepidemiological studies have not used hyperimmune animal or human serum, but others
neutralization (N) but rather complement fixation have identified only one such line.':!:!)
(CF) or hemagglutination inhibition (HI) tests as
sources of their data. The method of preparing a
CF antigen for 229E directly from cell culture 4. Biological Characteristics of the Virus
harvests was reported along with the original
description of the viruses by Hamre and Prock- Very little information is available on the rela-
now.(2:!) By this method, the CF test detected tionship of coronavirus structure to patterns of
antibody in low titer and only for a short time after infectivity and antigenicity. The viruses resemble
infection. This observation was subsequently con- the myxoviruses in size, type of nucleic acid con-
firmed in a large study, and it was suggested that tained, and, to a certain extent morphology. The
the presence of CF antibody in a population could spikes of the virus are distinct in appearance from
be interpreted as evidence for recent activity of the those of the myxoviruses and are reported to
virus. (15) However, it was also learned that if the contain glycopolypeptides; both HA and CF anti-
antigen was highly concentrated, antibody could gens have been associated with the surface of the
be detected at a higher titer, and this antibody virion, and are presumably located in the projec-
persisted in the population so that the CF method tions. No neuraminidase has been demonstrated,
could be employed in surveys of prevalence.(5) An and therefore it has been concluded that the anti-
Table 2. Serological Relationships of the Human against pairs of serum obtained either from indi-
Coronaviruses viduals naturally infected or from volunteers chal-
lenged artificially. Such sera would be expected to
Strains tested be considerably less specific than animal antisera.
Strains tested with animal with human It has been clearly shown in several laboratories
Group antisera antisera
that 229E is quite different from OC38 and OC43
229E } Closely related but not
not only in growth characteristics but also antigen-
LP identical ically; cross-reactions can be shown by neutraliza-
II OC38 } Nearly identical OC44 tion tests, but these are demonstrable only using
OC43 very sensitive procedures. LP virus was originally
MHV isolated in organ culture and not in cell culture but
III B814 is closely related antigenically to 229E. OC43 virus
Others OC16 has a low level cross-reaction with mouse hepatitis
OC37 virus; in some reports this has been reciprocal and
OC48
in some one way. Although B814 virus is quite
EVS different from OC43, they both share some anti-
gens in common; again cross-reactions with 229E
are rare. Among the additional viruses, OC44 is
closely related antigenically to OC38 and OC43 but
gens belong to a single species present on the has never successfully been adapted to mouse
surface. By analogy, antibodies to these antigens brain or cell cultures. The four other viruses are
should be associated with protection.(28·33) listed together by exclusion, not because of any
The total number of serological types infecting demonstrated relationship to one another, but
man has not been defined. The problem here rather because they are not closely related to vi-
again revolves around the difficulties encountered ruses in the first three groups. Some low-level
in isolating the human coronaviruses. Conse- reactions with the agents in these three groups
quently, there is no way of estimating the propor- have been shown to be present, with OC16 virus
tion of existing types that have already been iso- being the most distinctly different strain.
lated. It is also difficult to determine the separate As indicated above, much of the information on
antigenic identity of types which grow only in the behavior of 229E and OC43 viruses has come
organ culture as compared with those which grow from CF and HI tests. In view of the sharing of
in cell culture. N, CF, HI, gel diffusion, and antigens among many of the viruses listed in Table
immunofluorescent techniques have been used in 2, the specificity of these procedures must be
the antigenic analyses by McIntosh et al.,'41l by carefully considered. Cross-reactions between
Bradbume,<5l and by Bradbume and Somerset.(8) 229E and OC43 have only rarely been reported
As would be expected, results have differed by when tested by CF against animal sera. With
each of these procedures, with N tests the most human serum, heterologous rises in antibody titer
specific. However, cross-reactions were commonly have been observed occasionally, but not fre-
demonstrable even by this method using animal quently enough to create problems in studies in-
antiserum or immune ascitic fluid, indicating that volving significant numbers of specimens.(lo) Of
there must be many shared antigens. greater practical concern is the occurrence of cross-
An attempt at placing the human coronaviruses in reactions between OC43 and the other organ cul-
broad groups is shown in Table 2; mouse hepatitis ture viruses. It is possible that rises in titer de-
virus (MHV) is included because of its frequent tected when using OC43 antigen in seroepide-
interrelationships with the human strains, and miological studies may result either from OC43
avian infectious bronchitis virus is omitted be- infection itself or from infection with one of these
cause it is antigenically distinct. The unadapted related viruses. Indirect evidence that the infecting
organ culture strains have been listed separately; it agent may not be OC43 itself is the dissociation
has not been possible to prepare animal antisera seen between the CF and HI tests for OC43 during
against them, and they have been tested only a particular period of time. Rises in titer by CF
Table 3. Reported Frequency of Infection or Illness with 229E and

OC43 in Four Locations
Mean incidence of infection with
Study 229E OC43
Chicago medical students(2!) 15/100/yr

Tecumseh, MichY6.49) 7.7/100/yr 17.1/100/yr
Proportion of colds associated with
229E OC43
Charlottesville, Va., employees(2(;) 1.7% of illnesses 2.4% of illnesses

Atlanta, Ga., children(3.) 3.3% of illnesses
should usually be accompanied by rises in titer by tory infections of all age groups. The total impact
HI in the same serum pairs. If this does not of coronavirus infections on the general popula-
ordinarily occur during one time period, but does tion cannot be calculated at present because not all
during a second period, it suggests that a related viral types have been identified. Only 229E and
virus but not OC43 was circulating during the first OC43 are amenable to large-scale serological stud-
period. (49) ies; ~nfection rates for other distinct types such as
Data that demonstrate the etiological role of OC16 cannot be determined. The assumption must
coronaviruses in respiratory infections derive from be made that the former two types are typical of
laboratory and field studies. The viruses do inter- the other viruses. Incidence of infection with these
fere with the action of cilia in tracheal organ agents exhibits a marked cyclical pattern, so it is to
culture, which suggests that they should have the be expected that reported rates will vary based on
same effect in vivo. In addition, volunteers have the number of seasons of high viral activity in-
been inoculated with essentially all available cluded in a particular study. Table 3 presents a
strains with production of illness. n .s) It has also summary of results obtained in four such studies.
been possible with 229E to demonstrate that natu- 5.1.1. Incidence and Prevalence of 229E Virus.
ral infection was statistically related to the produc- The activity of 229E was found to be of high
tion of illness. During the 1967 outbreak of 229E prevalence in 3 out of 6 yr of a study among
infection in Tecumseh, Michigan, illness was sig- Chicago medical students. The mean annual inci-
nificantly more common among those with infec- dence of infection during the total period was
tion than among matched individuals without in- 15%, based on person-years of observation. The
fection.(l(;) Similarly, 229E infection among criterion for identification was a reproducible two-
Chicago medical students was statistically associ- fold seroconversion determined by CF. There was
ated with illness when those with rises in titer marked year-to-year variation infection frequency,
were used as their own controls.(211 ranging from a high of 35% of those tested in
1966-1967 to a low of 1 % in 1964-1965. However,
nearly 97% of the infections occurred during the
5. Descriptive Epidemiology months from January to May, often at a time when
isolation of rhinoviruses was at a low, and sero-
5.1. Incidence and Prevalence conversions for 229E were only rarely accompanied
by a rise in titer for another respiratory agent.(211
Evidence is steadily mounting that the coronavi- The serological study of 229E activity in the
ruses are of major importance in common respira- community of Tecumseh, Michigan, initially cov-
ered 2 yr, which included one period of high sons studied. Activity in all age groups was appar-
prevalence. As with the study in Chicago, routine ent, including children under 5 yr of age.'J(;)
blood specimens were collected so that infection In other investigations of 229E activity, attention
rates could be determined; however, the study has been directed mainly toward study of associ-
group was composed of individuals of all ages ated illnesses; in such studies, sera have been
living in their homes. Over the 2 yr, infections collected before and after the illness, rather than
were detected in 7.7% of individuals tested by CF, continually on a routine basis as done to deter-
as shown in the curve in Fig. 1. However, this mine infection rates. Employees at State Farm
appeared to be an underestimate of the actual Insurance Company in Charlottesville, Virginia,
activity of the virus. Serum specimens had been were studied during an 8-yr period for rises in
collected on a regular basis, 6 months apart; rises titer for both 229E and for OC43. By CF, 229E
in titer by CF occurred most frequently in those infection could be related to 3% of the colds that
pairs in which the second specimen was collected occurred in the winter-spring and to 0.4% of colds
in April 1967, clearly indicating the peak period of that bccurred in the summer-fall. There was some
viral dissemination. CF and the more sensitive N year-to-year variation in activity, but differences
test results were combined to give an overall in the number of specimens tested from various
infection rate for the population studied; this rate, years did not permit complete identification of
34%, was remarkably similar to the 35% observed cyclical pattems.(26) Employees of the National
in Chicago at the same time. Because of the Institutes of Health with respiratory illness were
limited period of viral activity, it was possible to studied by both isolation and serology for 229E
compare illness rates of those infected with per- infection over a 6-yr period. Again attention was
sons not infected matched by age and sex; it was specifically directed toward certain segments of
estimated that 45% of the infections had produced the 6 yr, and no specimens were tested during
clinical disease. Thus the rate of 229E-associated other segments. Of particular interest once more is
illnesses during the outbreak was 15 per 100 per- the segment from December 1966 to April 1967.
16-
~I \
I \
~14 -
cr , I
I \
\
\
b 12
o t-
III I
, I \
\
\
i= I \
ZIO t- I \
<t
I \
:x: I \
~
8t- I \
~ I \
~
Z 6t-
ILl
I
.J
\
\ I
,...... .....
0
~' ~ I ~,
II::
ILl
a.. 4- ,~
... " \
\ I "
r' / ,
~
V '"~
, \ I
/I
2-
.L. ~' I I I I I I I I I T
NOV. DEC. JAN. FEB. MAR. APR. MAY JUNE JULY AUG. SEPT. OCT.
~/966~~1--------------------------1967-~------------------------~
Fig. 1. Serological incidence by CF of infection with 229E virus in Tecumseh, Michigan, 1966-1967.
134 Chapter 6 • Coronavimses
Isolation of rhinoviruses and myxoviruses was collected routinely from non-ill individuals indi-
uncommon at this time, but respiratory illness cated that an additional equal number of OC43
continued to occur. During this period, 24% of infections were occurring without the production
those persons with colds studied had rises in titer of symptoms.(341 The Charlottesville study of
for 229E. As part of the same investigation, paired adult employees was of OC43 infections along
blood specimens collected from infants and chil- with 229E. Here, too, the emphasis was on illness,
dren admitted to the hospital with acute lower and it was found in all years studied that OC43
respiratory disease during the 1967 period of 229E was associated with 5% of colds in the winter-
activity were tested for rise in antibody against the spring and with no illnesses in the summer-fall.
virus but none was found. (29.421 Again there was cyclical variation from year to
Surveys of prevalence of 229E antibody have year in the number of rises in titer detected. (2(;)
also been carried out to document past history of The original isolations of OC38 and OC43 were
infection, often as parts of longitudinal studies. A made in December and January 1965-1966 as part
general finding is that antibody is present in a of the study carried out among NIH employees
significant portion of adults who, in spite of pos- with colds. Testing of sera collected from these
sessing this antibody, can go on to have reinfec- employees indicated that during this period up to
tion and illness. Reports of antibody prevalence in 29% of the colds studied were accompanied by
adults in the United States have varied from 19 to rise in titer for OC43. In the children hospitalized
41 %, depending on the type of test used to deter- with lower respiratory disease, up to 10% of
mine antibody and the time of collection illnesses during this period were associated with
serum.(W.26.421 Children under 10 yr of age exhib- such a titer rise. However, it was impossible to
ited lower mean antibody titers than older chil- show that the relationship to disease was truly
dren or adults.(16.42) Individual sera from normal etiological. This finding was in contrast to that
healthy adults collected serially in Britain from seen with 229E, in which no rises in titer were
1965 through 1970 were tested by Bradbume and detected in such cases. (3S.42)
Somerset.(SI It is of interest that there was a In the Tecumseh study, occurrence of OC43
buildup in sera positive by CF from approximately infection was determined in the community popu-
17% in specimens collected in October-December lation over a 4-yr period. CF and HI tests were
1966 to 62% in those collected in July-September used on all specimens and neutralization tests
1967. This would suggest that the spring 1967 were used as an aid in evaluating these results in
outbreak which occurred in several parts of the selected specimens. During the total period,
United States may have taken place in Britain as OC43-related infection was detected in 17.1% of
well. the 910 persons studied for 1 yr. Most of the
5.1.2. Incidence and Prevalence of OC43 Virus. infections took place in the winter-spring months
Populations employed to study infection and ill- of 1965-1966, 1967-1968, and 1968-1969. The only
ness caused by OC43 virus have generally been winter-spring period without such activity was in
the same ones employed to study the occurrence of 1966-1967, when the 229E outbreak had taken
229E virus. Kaye et al. (34) used an additional group, place. There was good agreement between the CF
healthy children institutionalized in Atlanta, and HI tests for the 1965-1966 and the 1968-1969
Georgia, in which to identify infection by means periods but not for 1967-1968. The neutralization
of their HI test. The investigation, carried out from test was used to clarify the situation. It was found
1960 to 1967, involved collection of serum speci- that most rises in titer for the periods in 1965-1966 or
mens related to illness and also routine collection 1968-1969, whether they had occurred by CF or HI
of sera from some non-ill individuals. Infections or both, were also accompanied by rises in neu-
with the agent were detected in all years of the tralizing antibody. In 1967-1968, most CF rises in
study but with definite cyclical variation. Seasons titer were not accompanied by rises in titer in the
most involved were the winter and spring. Over- other test, nor was the reverse true; significant
all, 3% of the illnesses recorded in the 7 yr could change in neutralizing antibody in this period was
be associated with OC43 infection, with a high of exceedingly rare. It was concluded that the out-
7% in 1960-1961. Interestingly, testing of the sera breaks of infection in 1965-1966 and 1968-1969
probably were caused by agents closely related to little antibody, while 26% of adults were antibody
OC43, while the 1967-1968 activity was due to one positive.( 5 ) These findings suggest that coronavi-
of the other OC viruses which shares some anti- ruses are worldwide in distribution and cause
gens with OC43 but is more distantly related to it. similar types of illness in different localities; such
The 1968-1969 outbreak of OC43 infection was a situation has been noted with many other respi-
nearly as widespread as the prior 229E outbreak, ratory viruses.(471 An attempt was actually made
with 25.6% of the population studied showing to detect rises in antibody titer for 229E in paired
evidence of infection. Of special note was the fact sera collected from small children with lower res-
that children under 5 yr of age had the highest piratory infection in many tropical parts of the
infection rates.(49) world. No evidence of infection was found, which
Surveys of antibody prevalence have been con- is hardly surprising since no rises in titer were
ducted in several settings using OC43 antigens. found in similar sera collected as part of the same
McIntosh et al. (42) found that children began to study in Washington, D.C. m .29 )
acquire antibody to this virus in the first year of
life. By the third year of life, more than 50% had
antibody present. Among adults, 69% of individu-
als could be demonstrated to have antibody; this Because most illnesses caused by coronaviruses
indicates, in view of the high incidence of infec- are similar to those caused by other respiratory
tion with the agents in all age groups, the fre- viruses, it is impossible to identify epidemic be-
quency with which such infections must represent havior of the viruses. There is, however, great
reinfection. The high prevalence of antibody has variation in the frequency of infection both on a
been confirmed in other studies.(26,34) In Britain, seasonal and on a cyclical basis. Isolation and rises
Bradburne and Somerset followed prevalence of in antibody titer for all types of coronaviruses have
antibody for OC43 over time, as they also had been rare events outside of the period from De-
done with 229E. Each year the greatest prevalence cember through May. This is the portion of the
of antibody was found in the winter-spring pe- year in which isolation rates for rhinoviruses and
riod. The single highest point in antibody preval- other respiratory viruses often reach their low. In
ence was in January-March 1969, at the same time addition, a cyclical pattern may be discerned when
the OC43 outbreak was occurring in some parts of individual virus types are considered. In Fig. 2 are
the United States.(S) summarized data from five longitudinal studies of
coronavirus activity carried out in different parts
of the United States. In all studies, some sporadic
5.2. Geographic Distribution
activity did occur in nearly all years studied, but
Occurrence of coronavirus infection has been rises in antibody titer were concentrated in certain
documented, by either isolation or serology, from years which far exceeded the means for the entire
coast to coast in the United States. In addition to studies. Those periods are indicated as darker
the studies listed in Table 1, a 229E-like virus has areas in the figure. The times during which speci-
been isolated in California and OC43 and 229E mens were collected in each investigation are indi-
have been demonstrated to be present in Vermont cated in the figure by the large rectangle. Activity
by serological methods.(5!.5") Extensive studies of 229E was detected in all four studies at the same
have been carried out by the Common Cold Re- times, even though two were in the Midwest and
search Unit, which has demonstrated the presence two in the eastern United States. It seems possible,
of the agents in Britain. The activity of 229E virus on the basis of these data, to postulate a 2-3 yr
has been documented in Brazil in a study of cycle for this agent. The greatest number of infec-
children and adults with and without respiratory tions in Chicago was seen in 1967, after absence of
illness. Significant rises in antibody titer accom- the agent for 3 yr, which would suggest a role of
panied nonhospitalized respiratory infection in herd immunity in determining the time of reap-
the children. Prevalence of antibody was deter- pearance of the agent.
mined by CF, and, like the situation in some With OC43 the situation is quite different. As
studies in the North Temperate Zone, children had with 229E, in no investigation did 2 yr with high
Chicago Medical
Students
229 E
=====---.. ~~~-
NIH Employees
Charlottesville, Va.
Employees
Tecumseh, Mich.
Atlanta, Ga.
Children
NIH Employees
Charlottesville, \hi.
Employees
Tecumseh, Mich.
Fig. 2. Cyclic behavior of 229E and OC43 viruses observed in five longitudinal studies.
rates of infection or illness follow one another. A cross-reactions. The fact that cycling of coronavi-
possible exception was in the Tecumseh study. ruses does exist and occurs every 2-4 yr with
However, the agent which caused the rises in titer production of many infections suggests that the
in 1967-1968 did not appear as closely related number of truly different coronaviruses may be
serologically to OC43 as the agent involved in the . relatively small. This situation is unlike that seen
other two outbreaks. This observation indicates a with the rhinoviruses, in which cycling has been
problem in identifying cycling of OC43. The virus more difficult to demonstrate, in part because of
undoubtedly shares more antigens with other the large number of serotypes. (]4)
identified or perhaps unidentified coronaviruses
than does 229E (see Table 2), and these other
5.4. Age
viruses may well have cycles of their own which
may confuse the situation. In 1964-1965, high All age groups are involved in infection with
activity occurred in Atlanta and Charlottesville. OC43 virus. High rates have been noted in chil-
However, in Bethesda, just a short distance away, dren and adults during studies separately examin-
high activity was not seen in that year but in 1965- ing both groups. In the Tecumseh study, a total
1966, the same time as high activity occurred in population group was followed. During the 1968-
Michigan, many miles away. In 1968-1969, Char- 1969 outbreak, infection rates were relatively uni-
lottesville and Tecumseh data did agree with very form for all age groups, varying from a high of 29.2
high activity in both areas. Thus cycling of the per 100 person-years in the 0-4 age group to 22.2
agents was found in all studies, but the cycles did in those over 40 years of age. (49) This finding is
not agree on specific years. This may be a result of quite different from the situation that exists with
actual differences in patterns of occurrence of a other respiratory agents, such as respiratory syn-
result of differences in the serological techniques cytial virus, where a more distinct decrease in
used to identify infection, which are of greater infection rates can be observed with increase in
importance with OC43 because of the problem of age. (48) The reversal of the pattern of age-specific
infection rates customarily associated with the other agents. Because of the high frequency of
respiratory viruses becomes complete with 229E. infection in older children and adults, other sites
Infection with this virus has been more difficult to of dissemination may also be of significance. It has
demonstrate in small children than in adults. In been possible to show that the family unit is of
Tecumseh, during the 1966-1967 outbreak, highest importance in transmission since clustering of
age-specific infection rates by CF were found 229E and OC43 infections in families was observed
among those 15-29 yr of age, following a steady in the Tecumseh study.(16)
increase in infection frequency from the 0- to 4-yr- While nutritional and genetic factors have not
olds. However, when neutralization tests were been associated with susceptibility to coronavirus
used to detect infection, the 15- to 19-yr-olds still infections, there are clear indications that the vi-
had high infection rates, but the serial increase to ruses are associated with exacerbations of chronic
that point among younger age groups was much obstructive respiratory disease. Such a finding is
less steepY6) This would suggest that the appar- hardly surprising in view of the high infection
ent sparing of small children with 229E may be an rates which have been observed in un selected
artifact resulting from the relative insensitivity in older adults. It has not as yet been demonstrated
the young of the serological procedures commonly whether this represents true increased susceptibil-
employed. It would be surprising if two different ity to infection or simply a more severe form of
coronavirus serotypes behaved so differently. expression of the infection when it occurs in an
already compromised host. In addition to the situ-
ation in older individuals, there is evidence that
5.5. Other Factors
both OC43 and 229E may trigger acute attacks of
There is little evidence of a sex differential in wheezing in young asthmatics.(40.53)
infections with the coronaviruses simply because
the data have rarely been examined in such a
manner. In Tecumseh, adult females experienced 6. Mechanisms and Routes of Transmission
higher infection rates with OC43 than adult males,
which is in conformity with the usual patterns of The coronaviruses are presumably transmitted
all respiratory illnesses.(46) In Candeias's study of by the respiratory route. It has been possible to
antibody prevalence, the results were examined by experimentally induce infection in volunteers by
sex but no significant differences could be ob- inoculating virus into the nose. (7.59) No other
served. (5 ) There are no available data on occupa- route of transmission for coronaviruses seems in-
tion or racial susceptibility to infection, or on the volved in man, although animal coronaviruses are
role of socioeconomic status in influencing rates. infectious by the fecal-oral route. (56) There is
Occurrence of infection in closed or special popu- currently no direct evidence to aid in identifying
lations, such as military recruits or residents of the main mechanisms of transmission. However,
children's institutions, has been reported.(34.36.60) it is possible to compare the epidemiological be-
However, it is at present difficult to determine, havior of the coronaviruses with other respiratory
based on the relative paucity of information on the agents whose transmission mechanisms have been
behavior of the virus in open populations, more directly studied. Large-scale outbreaks of
whether they exhibit any unique features in other coronavirus infections have taken place, as in
settings. There is a suggestion that OC43 virus Tecumseh in 1967.(16) This is much more analo-
might cause acute respiratory disease in military gous to the situation seen with influenza than that
recruits. (60) If this finding is confirmed, it would with the rhinoviruses. It is likely that the former
represent a distinct departure from the types of agent can be transmitted by aerosol in addition to
illness customarily associated with that virus in large droplet, which would explain its ability to
young civilian adults. The role of the school-age spread quicklyY9) Rhinoviruses, on the other
child in dissemination of coronavirus has not yet hand, are thought to be transmitted by large
been clearly defined, but it would be surprising if droplet and may at times spread via fomites.(271 It
these infections differed in their transmission pat- is therefore probable that human coronaviruses
tern so markedly from that documented with the can be spread by aerosol as well as by large
droplet. Aerosol transmission of avian infectious illness. (34) With 229E virus, Hamre and Beem(21)
bronchitis virus has actually been documented in demonstrated that frequency of rises in titers de-
poultry. (20) tected by neutralization was inversely proportional
There is no evidence that any animal reservoir to preinfection levels of neutralizing antibody,
or vector is involved in the maintenance of infec- which would indicate that this antibody exerted
tion or transmission of the human coronaviruses. some protective effect. However, the importance
Each animal coronavirus appears to be restricted to of this neutralizing antibody could not be con-
its own species. The only known exception is the firmed when infection was detected by CF. Thus
finding of antibody of avian infectious bronchitis circulating neutralizing antibody as presently
virus in sera of poultry workers but not of con- measured may bear a relationship to modification
trols. (45) of infection but this association is not a very
strong one. Since coronavirus infections mainly
involve the surface of the respiratory tract, it is
7. Pathogenesis and Immunity likely that secretory IgA antibody plays a more
direct role in protection; this has in fact been
The incubation period of coronavirus colds is demonstrated with a swine coronavirus. (4)
relatively short. In studies involving volunteers,
the mean period from inoculation of virus to
development of symptoms was from 3.2 to 3.5 8. Patterns of Host Response
days depending on the strain, with a range of from
2 to 4 daysY·59) Following exposure, the virus The coronaviruses generally produce a coldlike
apparently multiplies superficially in the respira- illness which on an individual basis is difficult to
tory tract in a manner similar to that in which distinguish from illness caused by other respira-
multiplication occurs in vitro. Virus excretion us- tory viruses. In both induced and natural infec-
ually reaches a detectable level at the time symp- tions, the most prominent findings have been
toms begin, and lasts for 1-4 days. The duration of coryza and nasal discharge, with the discharge
the illness is from 6 to 7 days on the average, but being more profuse than that customarily seen
with some lasting up to 18 days. Serological re- with rhinovirus colds.(7) Sore throat has been
sponse either to induced or to naturally acquired somewhat less common, and in children has been
infection has been quite variable depending on associated with pharyngeal injection.(34) Experi-
the infecting strain and the serological test em- mental colds caused by B814 virus were about as
ployed. For example, among those experimentally severe as those caused by 229E; however, natural
infected with OC38 or OC43 virus who had a cold OC43 infections caused illnesses with considerably
produced, only 46% had rises in titer by HI and more cough and sore throat than did 229E infec-
23% by CF. Less than half of those infected with tions.(26) The mean duration of coronavirus colds,
229E showed a CF rise. It is not clear how the at 6.5 days, is shorter than that seen in rhinovirus
existence of titer or preinfection antibody affects colds, at 9.5 days.(7)
the magnitude of the response detected by these There is no clear evidence yet available that
tests. Rises in neutralizing antibody titer are easier coronaviruses cause severe lower respiratory ill-
to detect, and have been found ~ith sensitive ness in infants and young children. In fact, such
techniques in all volunteers experimentally in- infections were more common in one study among
fected. (5.8) the control group than among the diseased. (42)
An important characteristic of the coronaviruses Mufson et al. (50) have associated coronavirus 229E
is their apparent high rate of reinfection. In the and OC43 infection with acute lower respiratory
Tecumseh study, 81.5% of those infected with infections in children at Cook County Hospital.
OC43 actually possessed prior neutralizing anti- The lack of a comparable control group makes
body.(49) Possession of circulating OC43 HI anti- assignment of an etiological role to these viruses
body among the Atlanta children did not appear to hazardous at present, but the relationship should
playa role in modifying severity of a subsequent be sought in the future. The association of OC43
with the acute respiratory disease (ARD) syn- 10. BRADBURNE, A. F., AND TYRRELL, D. A. J., Coronavi-
drome in military recruits should also be viewed ruses gf man, Prog. Med. Viral. 13:373--403 (1971).
as tentative. 11. BRUCKOVA, M., McINTOSH, K., KAPIKIAN, A. Z., AND
Clinical disease occurred in no more than 45% CHANOCK, R. M., The adaptation of two coronavirus
strains (OC38 and OC43) to growth in cell monolay-
of those infected with 229E in Tecumseh during
ers, Proc. Soc. Exp. BioI. Med. 135:431-435 (1970).
the 1967 outbreak. (16) In Atlanta children, OC43
12. BUCKNALL, R. A., KALICA, A. R., AND CHANOCK, R.
virus produced illness in about 50% of those M., Intracellular development and mechanism of
infected.(34) It is likely that with increase in age hemadsorption of a human coronavirus, OC43, Proc.
and concomitant experience with these agents the Soc. Exp. BioI. Med. 139:811-817 (1972).
ratio of clinically apparent to inapparent infection 13. BUCKNALL, R. A., KING, 1. M., KAPIKIAN, A. Z., AND
will decrease. As with other respiratory agents, a CHANCOK, R. M., Studies with human coronaviruses.
continuum of severity of symptoms exists among II. Some properties of strains 229E and OC43, Proc.
those in whom infection results in disease, and Soc. Exp. BioI. Med. 139:722-727 (1972).
this may also be related to past experience with 14. CALHOUN, A. M., JORDAN, W. 5., JR., AND GWALT-
the viruses. NEY, J. M., JR., Rhinovirus infections in an industrial
population. V. Change in distribution of serotypes,
Am. J. Epidemiol. 99:58--64 (1974).
15. CANDEIAS, J. A. N., CARVALHO, R. P. DE 5., AND
ANTONACIO, F., Seroepidemiologic study of corona-
9. References virus infection in Brazilian children and civilian
adults, Rev. Inst. Med. Trap. 14:121-125 (1972).
1. ALMEIDA, J. D., AND TYRRELL, D. A. J., The morphol- 16. CAVALLARO, J. J., AND MONTO, A. 5., Community-
ogy of three previously uncharacterized human res- wide outbreak of infection with a 229E-like coronavi-
piratory viruses that grow in organ culture, J. Gen. rus in Tecumseh, Michigan, J. Infect. Dis. 122:272-
Viral. 1:175-178 (1967). 279 (1970).
2. BECKER, W. B., McINTOSH, K., DEES, J. H., AND 17. CHANOCK, R, CHAMBON, 1., CHANG, W., GONCALVES
CHANOCK, R. M., Morphogenesis of avian infectious FERREIRA, F., GHARPURE, P., GRANT, 1., HATEM, J.,
bronchitis virus and a related human virus (strain IMAM, I., KALRA, 5., LIM, K., MADALENGOITIA, J.,
229E), J. Viral. 1:1019-1027 (1967). SPENCE, 1., TENG, P., ANI;> FERREIRA, W., WHO
3. BERRY, D. M., CRUICKSHANK, J. G., CHU, H. P., AND respiratory disease survey in children: A serological
WELLS, R. J. H., The structure of infectious bronchi- study, Bull. WHO 37:363--369 (1967).
tis virus, Virology 23:403--407 (1964). 18. Coronaviruses, Nature (London) 220:650 (1968).
4. BOHL, E. H., GUPTA, R. K. P., OLQUIN, M. V. F., AND 19. COUCH, R. B., DOUGLAS, R. G., JR., LINDGREN, K. M.,
SAIF, 1. ]., Antibody responses in serum, colostrum, GERONE, P. J., AND KNIGHT, V., Airborne transmis-
and milk of swine after infection or vaccination with sion of respiratory infection with Coxsackievirus A
transmissible gastroenteritis virus, Infect. Immun. type 21, Am. J. Epidemiol. 91:78--86 (1970).
6:289-301 (1972). 20. GEILHAUSEN, H. E., LIGON, F. B., AND LUKERT, P. D.,
5. BRADBURNE, A. F., Antigenic relationships amongst The pathogenesis of virulent and avirulent avian
coronaviruses, Arch. Gesamte Virusforsch. 31:352-364 infectious bronchitis virus, Arch. Gesamte Virus-
(1970). forsch. 40:285-290 (1973).
6. BRADBURNE, A. F., An investigation of the replica- 21. HAMRE, D., AND BEEM, M., Virologic studies of acute
tion of coronaviruses in suspension cultures of L132 respiratory disease in young adults. V. Coronavirus
cells, Arch. Gesamte Virusforsch. 37:297-307 (1972). 229E infections during six years of surveillance, Am.
7. BRADBURNE, A. F., BYNOE, M. 1., AND TYRRELL, D. A. J. Epidemiol. 96:94-106 (1972).
J., Effects of a "new" human respiratory virus in 22. HAMRE, D., KINDIG, D. A., AND MANN, J., Growth
volunteers, Br. Med. J. 3:767-769 (1967). and intracellular development of a new respiratory
8. BRADBURNE, A. F., AND SOMERSET, B. A., Coronavi- virus, J. Viral. 1:810--816 (1967).
rus antibody titres in sera of healthy adults and 23. HAMRE, D., AND PROCKNOW, J. J., A new virus
experimentally infected volunteers, J. Hyg. 70:235- isolated from the human respiratory tract, Proc. Soc.
244 (1972). Exp. BioI. Med. 121:190--193 (1966).
9. BRADBURNE, A. F., AND TYRRELL, D. A. J., The 24. HARNETT, G. B., AND HOOPER, W. 1., Test-tube
propagation of "coronaviruses" in tissue culture, organ cultures of ciliated epithelium for the isolation
Arch. Gesamte Virusforsch. 28:133--150 (1969). of respiratory viruses, Lancet 1:339-340 (1968).
25. HARTLEY, J. W., ROWE, W. P., BLOOM, H. H., AND A. Z., AND CHANOCK, R. M., Recovery in tracheal
TURNER, H. c., Antibodies to mouse hepatitis vi- organ cultures of novel viruses from patients with
ruses in human sera, Proc. Soc. Exp. Bioi. Med. respiratory disease, Proc. Nat!. Acad. Sci. USA
115:414-418 (1964). 57:933-940 (1967).
26. HENDLEY, J. 0., FISHBURNE, H. B., AND GWALTNEY, J. 40. McINTOSH, K., ELLIS, E. F., HOFFMAN, 1. S., LYBASS,
M., JR., Coronavirus infections in working adults. T. G., ELLER, J. J., AND FULGINITI, V. A., The associa-
Am. Rev. Resp. Dis. 105:805-811 (1972). tion of viral and bacterial respiratory infections with
27. HENDLEY, J. 0., WENZEL, R. P., AND GWALTNEY, J. exacerbations of wheezing in young asthmatic chil-
M., JR., Transmission of rhinovirus colds by self- dren, J. Pediat. 82:578-590 (1973).
inoculation, N. Engl. J. Med. 288:1361-1364 (1973). 41. McINTOSH, K., KAPII<IAN, A. Z., HARDISON, K. A.,
28. HIERHOlZER, J. c., PALMER, E. 1., WHITFIELD, S. G., HARTLEY, J. W., AND CHANOCK, R. M., Antigenic
KAYE, H. S., AND DOWDLE, W. R., Protein composi- relationships among the coronaviruses of man and
tion of coronavirus OC43, Virology 48:516-527 (1972). between human and animal coronaviruses, J. Immu-
29. KAPII<IAN, A. Z., JAMES, H. D., JR., KELLY, S. J., nol. 102:1109-1118 (1969).
DEES, J. H., TURNER, H. c., McINTOSH, K., KIM, H. 42. McINTOSH, K., KAPII<IAN, A. Z. TURNER, H. c.,
W., PARROTT, R. H., VINCENT, M. M., AND CHAN- HARTLEY, J. W., PARROTT, R. H., AND CHANOCK, R.
OCK, R. M., Isolation from man of "avian infectious M., Seroepidemiologic studies of coronavirus infec-
bronchitis virus-like" viruses (coronaviruses) similar tion in adults and children, Am. J. Epidemiol. 91:585-
to 229E virus, with some epidemiological observa- 592 (1970).
tions, J. Infect, Dis. 119:282-290 (1969). 43. McLEAN, R. 1., General discussion, International
30. KAPII<IAN, A. Z., JAMES, H. D., JR., KELLY, S. J., Conference on Asian Influenza, Am. Rev. Resp. Dis.
KING,1. M., VAUGHN, A. 1., AND CHANOCK, R. M., 83: Part 2, 36-38 (1961).
Hemadsorption by coronavirus strain OC43, Proc. 44. MEBUS, C. A. STAIR, E. 1., RHODES, M. B., AND
Soc. Exp. BioI. Med. 139:179-186 (1972). TWIEHAUS, M. J., Pathology of neonatal calf diarrhea
31. KAPII<IAN, A. Z., JAMES, H. D., JR., KELLY, S. J., AND induced by coronavirus-Iike agent, Vet. Pathol.
VAUGHN, A. 1., Detection of coronavirus strain 692 10:45-64 (1973).
by immune electron microscopy, Infect. Immun. 45. MILLER, 1. T., AND YATES, V. J., Neutralization of
7:111-116 (1973). infectious bronchitis virus by human sera, Am. J.
32. KAYE, H. S., AND DOWDLE, W. R., Some characteris- Epidemiol. 88:406-409 (1968).
tics of hemagglutination of certain strains of "IBV- 46. MONTO, A. S., HIGGINS, M. W., AND Ross, H. W., The
like" viruses, J. Infect. Dis. 120:576-581 (1969). Tecumseh study of respiratory illness. VIII. Acute
33. KAYE, H. S., HIERHOlZER, J. c., AND DOWDLE, W. R., infection in chronic respiratory disease and compari-
Purification and further characterization of an "IBV- son groups, Am. Rev. Resp. Dis. 111:27-36 (1975).
like" virus (coronavirus), Proc. Soc. Exp. Bioi. Med. 47. MONTO, A. S., AND JOHNSON, K. M., Respiratory in-
135:457-463 (1970). fections in the American tropics, Am. J. Trop. Med.
34. KAYE, H. S., MARSH, H. B., AND DOWDLE, W. R., Hyg. 17:867-874 (1968).
Seroepidemiologic survey of coronavirus (strain 48. MONTO, A. S., AND LIM, S. K., The Tecumseh study of
OC43) related infections in a children's population, respiratory illness. III. Incidence and periodicity of
Am. J. Epidemiol. 94:43-49 (1971). respiratory syncytial and Mycoplasma pneumoniae in-
35. KAYE, H. S., ONG, S. B., AND DOWDLE, W. R., fections, Am. J. Epidemiol. 94:290-301 (1971).
Detection of coronavirus 229E antibody by indirect 49. MONTO, A. S., AND LIM, S. K., The Tecumseh study
hemagglutination, Appl. Microbial. 24:703-707 (1972). of respiratory illness. VI. Frequency of and relation-
36. KENDALL, E. J., BYNOE, M. 1., AND TYRRELL, D. A. J., ship between outbreaks of coronavirus infection, J.
Virus isolation from common colds occurring in a Infect. Dis. 129:271-276 (1974).
residential school, Br. Med. J. 2:82-86 (1962). 50. MUFSON, M. A., McINTOSH, K., CHAO, R. K.,
37. McINTOSH, K., BECKER, W. B., AND CHANOCK, R. M., KRAUSE, H. E., WASIL, R., AND MOCEGA, H. E.,
Growth in suckling-mouse brain of "IBV-like" vi- Epidemiology of coronavirus infections in infants
ruses from patients with upper respiratory tract dis- with acute lower respiratory disease, Clin. Res.
ease, Proc. Natl. Acad. Sci. U.S.A. 58:2268-2273 20:534 (1972).
(1967). 51. OSHIRO, 1. S., SCHIEBLE, J. H., AND LENNETTE, E. H.,
38. McINTOSH, K., BRUCKOVA, M., KAPII<IAN," A. Z., Electron microscopic studies of coronavirus, J. Gen.
CHANOCK, R. M., AND TURNER, H., Studies of new Virol. 12:161-168 (1971).
virus isolates recovered in tracheal organ culture, 52. PELON, W., Classification of the "2060" viruses
Ann. N.Y. Acad. Sci. 174:983-989 (1970). ECH028 and further study of its properties, Am. J.
39. McINTOSH, K., DEES, J. H., BECKER, W. B., KAPII<IAN, Hyg. 73:36-54 (1961).
53. PHILLIPS, C. A., MdNTOSH, K., FORSYTII, B. R., 60. WENZEL, R. P., HENDLEY, J. 0., DAVIES, J. A., AND
GUMP, D. W., AND STOUCH, W. H., Coronavirus GWALTNEY, J. M., JR., Coronavirus infections in
infections in exacerbations of chronic bronchitis, in: military recruits: Three-year study with coronavirus
Twelfth Interscience Conference on Antimicrobial Agents strains OC43 and 229E, Am. Rev. Resp. Dis. 109:621-
and Chemotherapy, Atlantic City, N.J., abst. No.6 624 (1974).
(1972).
54. PURCELL, D. A., AND CLARKE, J. K., The replication
of infectious bronchitis virus in fowl trachea, Arch. 10. Suggested Reading
Gesamte Virusforsch. 39:24~256 (1972).
55. SAIF, 1. J., BOHL, E. H., AND GUPTA, R. K. P., BRADBURNE, A. F., AND TYRRELL, D. A. J., Coronaviruses
Isolation of porcine immunoglobulins and determi- of man, Prog. Med. Viro!' 13:373-403 (1971).
nation of the immunoglobulin classes of transmissi- HAMRE, D., AND BEEM, M., Virologic studies of acute
ble gastroenteritis viral antibodies, Infect. Immun. respiratory disease in young adults. V. Coronavirus
6:6O~9 (1972). 229E infections during six years of surveillance, Am. J.
56. STAIR, E. 1., RHODES, M. B., WHITE, R. G., AND Epidemiol. 96:94-106 (1972).
MEBUS, C. A., Neonatal calf diaIThea: Purification KAYE, H. 5., MARSH, H. B., AND DOWDLE, W. R., Seroe-
and electron microscopy of a coronavirus-like agent, pidemiologic survey of coronavirus (strain OC43) re-
Am. J. Vet. Res. 33:1147-1156 (1972). lated infections in a children's population, Am. J.
57. TYRRELL, D. A. J., AND ALMEIDA, J. D., Direct elec- Epidemiol. 94:43-49 (1971).
tron microscopy of organ cultures for the detection MdNTOSH, K., KAPIKIAN, A. Z., TURNER, H., c., HAR-
and characterization of viruses, Arch. Gesamte Virus- TLEY, J. W., PARROTT, R. H., AND CHANOCK, R. M.,
forsch. 22:417-421 (1967). Seroepidemiologic studies of coronavirus infection in
58. TYRRELL, D. A. J., AND BYNOE, M. 1., Cultivation of a adults and children, Am. J. Epidemiol. 91:585-592
novel type of common-cold virus in organ cultures, (1970).
Br. Med. J. 1:1467-1470 (1965). MONTO, A., 5., AND LIM, S. K., The Tecumseh study of
59. TYRRELL, D. A. J., BYNOE, M. 1., AND HOORN, B., respiratory illness. VI. Frequency of and relationship
Cultivation of "difficult" viruses from patients with between outbreaks of coronavirus infection, J. Infect.
common colds, BT. Med. J. 1:606-610 (1968). Dis. 129:271-276 (1974).
CHAPTER 7
Cytomegalovirus
Eli Gold and George A. Nankervis
1. Introduction cal disease is much more likely to be evident in

those who are immunologically deficient because
Only a small proportion of people throughout the of neoplastic disease or treatment with immuno-
world escape infection with cytomegalovirus suppressan ts.
(CMV). The age at acquisition, the presence and Infection with CMV is commonly followed by
type of clinical manifestations, and the sites and prolonged, often intermittent periods of virus ex-
extent of virus excretion vary, but serological sur- cretion in the face of high levels of circulating
veys conducted on all continents confirm the ubiq- antibody. Dissemination of the agent probably
uitous distribution of human CMV. occurs by close contact with an excretor, although
The impression that CMV infection was uni- spread through the placenta or via blood transfu-
formly associated with severe illness of the new- sions accounts for a significant proportion of clini-
born and carried a high probability of death or cally important infections. The pathogenesis of
marked damage to the central nervous system has CMV infection can be deduced only from clinical
been modified since the availability of laboratory observations and epidemiological studies, but
procedures and the performance of prospective there is reason to believe that primary infection
studies. It is true that CMV can produce a devas- with CMV carries a greater probability of illness
tating disease in the newborn, but it has recently with significant residual effect than recurrent in-
been shown that congenital infection with CMV, fection. The factors that determine which infected
although relatively common, is usually clinically individuals are affected and which have no appar-
inapparent, generally has a benign course, and ent illness remain unknown.
may be recognized only if laboratory studies are
performed.
Most individuals develop antibody to CMV fol-
lowing unrecognized infection acquired during
childhood or the young adult years. A small pro-
Large inclusion-bearing cells originally found in
portion of normal individuals may have a form of
kidney, lung, or liver of infants who died from
infectious mononucleosis or possibly symptoms of
various causes were considered to be the result of
a respiratory illness with CMV infection, but clini-
some strange parasite, possibly a proto-
zoan. lll . 2(;'481 Goodpasture and Talboe 3;J) noted a
Eli Gold . Department of Pediatrics, University of
California, Davis, California George A. Nankervis . similarity between the appearance of these strange
Department of Pediatrics, Case Western Reserve Univer- cells, which they referred to as "cytomegalia," and
sity School of Medicine at Cleveland Metropolitan Gen- the intranuclear inclusions seen in the skin lesions
eral Hospital, Cleveland, Ohio of herpesviruses. Shortly thereafter(11(D the viral
143
144 Chapter 7 • Cytomegalovirus
etiology of these unusual cells was first postulated. 3.3. Serological Surveys
Several years later, Cole and Kuttner(15) were able
The complement fixation (CF) test has been
to transmit the guinea pig form of cytomegalia
widely used in prevalence studies to determine the
using filtered salivary gland material, indicating a
experience of different populations with CMV in-
probable viral etiology. There continued to be fections(l2·2a.25.~4.4(;.50.95.99.105) and as an indication
many descriptions of typical cells in various tis-
of infection in special groups studied prospec-
sues of infants, especially those who died in the
tively to determine seroconversion (negative to
newborn period of a hemorrhagic disease resem-
positive) and reinfection rates (fourfold or greater
bling erythroblastosis and referred to as "inclusion
rise in titer) in persons with preexisting anti-
body disease," "cytomegalic inclusion disease" body.(41.8l.8:l.91.l08.113.1211 The complement fixation
(CID) , or "generalized salivary gland virus infec-
test has been most commonly used for serological
tion." The reports by Wyatt et al./ 123 ) Fetter-
man,<28) Mercer et al. ,<78) and Margileth(74) de- surveys or clinical studies because of the relative
ease of preparing the reagents and performing the
scribing typical inclusion-bearing cells in the urine
test and because CF antibody is of long duration.
of infants with CID provided a method of diagnos-
The AD 169 strain of CMV has usually been
ing this disease in nonfatal cases. Finally in 1956
employed as the antigen because of its wide range
three laboratories almost simultaneously reported
of reactivity.m.lo5) The sensitivity of the test var-
the isolation of the etiological agent employing
ies depending on the antigen preparation, and
tissue culture techniques: Smith(loJ) from salivary
antibody levels measured in different laboratories
gland, Rowe et al. (95) from cultures of adenoid
may differ. There are data suggesting that anti-
tissue (thus AD 169), and Weller et al. (1201 from a
genic variants of CMV exist with which AD 169
liver biopsy.
does not cross-react, introducing some problems
with serological surveys based on AD 169
alone. (4.117)
3. Methodology
3.4. Laboratory Diagnosis
3.1. Mortality
3.4.1. Virus Isolation. For virus isolation, speci-
Death from CMV infectio~1.s is rare and the cause mens from the pharynx, buffy coat of peripheral
would usually be recognized only as a result of blood, breast milk, urine, stool, tears, cervix, and
special virological, serological, or histological ex- semen are inoculated onto human fibroblast cul-
amination. Death rates therefore give no indica- tures and observed for 6-8 wk for the appearance
tion of the frequency of this disease. of foci of swollen cells with intranuclear inclu-
sions. Continuous strains of human tonsil, skin!
muscle, or fetal lung fibroblasts have been suitable
3.2. Morbidity
for isolation.
As the clinical syndromes associated with CMV 3.4.2. Serological Tests. As mentioned above,
infections are not usually clinically distinctive and the complement fixation test using a single strain
are usually diagnosed only through laboratory of CMV as antigen is widely used to detect anti-
procedures, no estimate can be made of their body to CMV. It is still not possible with existing
importance through official health records. Fur- laboratory methods to determine whether infec-
thermore, most CMV infections are asymptomatic. tion with one strain of virus precludes infection
Such incidence data as are available have come with another. In the immunosuppressed individ-
from serological and/or virological studies of ual, it cannot be stated with certainty, for example,
groups at special risk-pregnant women, neo- whether CMV infection represents reactivation of
nates, individuals undergoing transfusions or or- a latent agent or introduction of a new strain via
gan transplant surgery, and heterophil-negative blood or other route. It is also possible, whether
patients with a mononucleosis-like syndrome. cross-immunity develops or not, that a difference
Chapter 7 • Cytomegalovirus 145
in ability to produce disease exists among the simplex, and other members of the herpesvirus
strains of CMV and that virulence of the organism family, but preparations of CMV grown in tissue
determines the clinical course. Indirect evidence culture may contain a large proportion of forms
would suggest that such is not the case. In the incompletely endowed with nucleic acid. These
three situations where consecutive pregnancies empty or partially empty forms are noninfectious
resulted in congenitally infected infants, only the and indicate defective virus synthesis in the in
first in each set shovyed clinical manifesta- vitro systems. Human strains of CMV appear to
tions. (24.57.102) In addition, one of premature male replicate in vitro to complete virus only in human
twins born with congenital CMV infection had tissue, in contrast to the other members of the
generalized CID and died, the other who shed herpesvirus family. As with the varicella-zoster
CMV in saliva and urine survived and was doing virus, attempts to infect cultures of human fibro-
reasonably well on follow-up at 5 months of blasts are accompanied by the development of a
age. (75) very characteristic sequence of changes which be-
Several investigators have been evaluating the gin with contraction and rounding of cells, fol-
indirect hemagglutination method (IHA) for serol- lowed by the development of intranuclear and
ogical diagnosis of CMV infectionY·32) Prelimi- intracytoplasmic inclusions, the enlargement of
nary results show rather close agreement with the individual cells, and the eventual formation of
carefully performed CF test. The IHA test appears large foci of such altered cells, some of which fuse
to be slightly more sensitive and antibody acquisi- into giant forms.
tion may be detected earlier in some cases than by Virus remains cell associated, although serial
the CF method. In addition, it reflects antibody of propagation in tissue culture may result in prepa-
both the IgG and IgM types, whereas the CF test rations with relatively large amounts of infectious
reflects principally IgG. The neutralization test, virus in the culture supernate. The agent is labile
platelet aggregation, and fluorescent antibody to low pH, fat solvents, and temperature. Preser-
techniques have also been used but are laborious vation is best achieved by rapid freezing and
and often variable in their results.04.37.B6.B9.11B) storage at - 6CY' to - 8CY'e, preferably in 30-50%
Identification of CMV-specific IgM antibody is sorbitol. Inactivation at - 2CY'C is more rapid than
important in identifying recent infection. It has at 4°C, making ordinary refrigerator temperature
been measured in an indirect fluorescent antibody acceptable for short-term storage of specimens.
(FA) test as described by Hanshaw et al. (37) and Virus isolation is best achieved by direct inocu-
the more elaborate "sandwich-type" indirect FA lation of fresh materials into cultures of human
test of Schmitz and Haas.(97) At present, these fibroblasts. Storage even by rapid freezing of sus-
methods are cumbersome and often plagued by pensions prepared in sorbitol may result in suffi-
nonspecific fluorescence. The development of sim- cient loss of infectious virus to preclude isolation
pler and more efficient separation methods for IgM from samples containing small amounts of virus.
antibody may permit direct FA or IHA tests on Infectivity of specimens is rapidly lost upon
this fraction to differentiate between primary and drying on hard surfaces or in cloth materials such
reactivated CMV infections. as diapers.
Another laboratory method employed for diag- As indicated previously, some evidence for dif-
nosis of CMV infection is the relatively insensitive ferent strains of CMV exists, but the importance of
cytological method of examining tissue, urinary these differences, if any, in the type of clinical
sediment, or smears of respiratory secretion for syndrome produced, in cross-immunity, and in
cytomegalic cells with intranuclear inclusions. long-term viral persistence is currently unknown.
As with other herpesviruses, the capacity of
CMV to produce latent infections that reactivate
4. Biological Characteristics of the Virus under various host settings is an important biolog-
ical property. The demonstration that CMV can
Individual particles of CMV are morphologically transform hamster cells(]) and produce early anti-
indistinguishable from varicella-zoster, herpes gens O ll) suggests potentially oncogenic properties
Table 1. Prevalence by Serological Survey: General Populations
Percent CMV
Author Date Place Population seroposi tive
Hanshaw(34) 1966 Rochester 0-5 rno 35

5-24 rno 3
2-6 yr 6
6---10 yr 9
10-17 yr 22
27--40 yr 38
Rowe et al. (95) 1956 Washington 6---24 rno 14
5-9 yr 33
>35 yr 81
Stern and Elek OO5 ) 1965 London 6---60 rno 4
5-10 yr 15
>35 yr 54
Carlstrorn(2 ) 1965 Stockholm 6---24 rno 36
5-10 yr 24
>50 yr 63
Jack and McAuliffe(4B) 1968 Melbourne 6---36 rno 22
10-15 yr 40
>35 yr 60
Evans et a/. (25) 1974 Barbados 1-5 yr 62
15-25 yr 77
Ernbil et a/. (25) 1969 Nova Scotia 6---12 rno 12
10-14 yr 14
>40 yr 52
Krech and Jung(56) 1970 Tanzania 6---18 rno 80
5-14 yr 100
>20 yr 99
Shavrina et a/. (99) 1973 Leningrad 7-12 rno 67
11-15 yr 63
51-60 yr 80
that deserve further study in relation to cancer, throughout the world. More complete data became
especially cervical cancer. (98) available with the development of serological
methods.
5. Descriptive Epidemiology
5.1. Prevalence and Incidence
The earliest information concerning the occur- The use of the terms "prevalence" and "inci-
rence of CMV in man came from pathologists in dence" in CMV infections presents difficulties
Holland, the United States, France, Germany, Bra- because the presence of virus in the pharynx or
zil, Hungary, and elsewhere who reported the urine or of antibody in the blood might represent
finding of typical inclusions either in the salivary (1) a primary infection (i.e., incidence), (2) persist-
gland or generalized in many organs. The propor- ence from an earlier infection (prevalence), or (3)
tion of infants in whom such changes were ob- reactivation of a latent infection (prevalence plus
served varied, but it became apparent that "cyto- incidence). The absence of demonstrable antibody
megalic inclusion disease" could be found from serum does not necessarily mean that prior
infection has not occurred, because antibody titers during their pregnancy. There were 119 living
may have dropped to levels not detected by the children born to these women; 12 or 10% were
test used or there may be antigenic differences congenitally infected with CMV. Only one of each
between the test virus and the infecting virus. The ten women who excreted virus during pregnancy
low frequency of clinical response and the lack of a had an infant with CMV infection.
characteristic syndrome associated with primary Further studies attempting to define the factors
infection also contribute to the difficulties of inter- associated with delivering an infected infant sug-
preting incidence, reinfection, and prevalence gest that primary CMV infection during pregnancy
data. In infections occurring in utero, in newborns, may carry a significant risk. A total of eight
or in infants, the incidence rate of primary infec- pregnant women among over 3000 have had pri-
tion can be more reliably calculated. mary CMV infections defined as seroconversion
5.1.1. Prevalence. The prevalence of CF anti- from negative to positive as well as the onset of
body to CMV in various population groups has cytomegaloviruria during the period of the
indicated that CMV infection is ubiquitous (Table study(82): one in the first trimester, four in the
1). The differences observed have been related to second, and three in the third. None had accom-
the speed of acquisition of infection in different panying symptoms. The woman with primary
geographic and socioeconomic settings. The pres- CMV in the first trimester had CMV-positive buffy
ence of cytomegalovirus in the urine, cervix, or coat cultures during the first and second trimesters
breast milk has also been used to reflect infection and positive urine, throat, and cervical cultures
prevalence in special groups. About 1% of new- throughout pregnancy but delivered a normal
borns in the United States have CMV in the noninfected infant. The three infants born to
urine. (8,35,68,103,104) Thirteen percent of women mothers who acquired infection during the third
undergoing examination because of suspected ve- trimester and one of the four born to second
nereal disease(49) and 4-28% of pregnant women trimester converters had congenital CMV infec-
have CMV in cervical secretions. (79,84,92) Three to tion, but all infants were clinically normal. The
six percent of the latter have viruria at the time of infection risk of an infant born to a mother who
delivery,<44.83) and a 27% prevalence of CMV in had primary CMV infection during pregnancy was
the breast milk of recently delivered CMV-seropo- 4:8 in this series, with the further suggestion that
sitive Australian mothers has been reported.(40l infection late in pregnancy was more likely to be
5.1.2. Incidence. The incidence of CMV infec- associated with a congenitally infected infant
tion and of clinical disease has been determined in (three of three in third trimester).
prospective studies of special groups as measured In a prospective study of 1040 pregnant women
by serological and/or virological tests. Table 2 in London, Stem and Tucker(1OS) reported that 11
summarizes several of these reports of CMV infec- showed antibody evidence of primary infection:
tion, and the results are discussed below. five in the third trimester, four in the second, and
a. Pregnant Women. Serological studies have two in either the late first or early second trimes-
shown that about 60% of women entering the ter. The delivery of an infected baby was associ-
childbearing years have antibody to CMV. (59,83,108) ated with primary infection early in pregnancy in
The frequency with which CMV can be isolated this study (only one of five infected infants was
from the pregnant woman appears to vary with born to a mother who had her primary infection in
age, parity, socioeconomic status, site cultured, the third trimester.) In both studies, however,
and time during gestation when she is studied, regardless of when during gestation maternal in-
but in general viruria has been found in ~12% of fection was acquired, women excreting virus at the
a large number of pregnant women. (27,44,59,79,83,92) time of delivery were most likely to have infected
In a prospective study of 1089 young pregnant infants; all nine mothers of infected infants had
women attending the prenatal clinic of a large positive virus cultures at delivery. The infected
general hospitaI,<83) 65% were found to have com- babies in both studies were normal except for one
plement-fixing antibody and 124 (11.4%) excreted infantCl08) who showed generalized hypotonia and
CMV in their urine on one or more occasions mental retardation at the age of 6 months.
....
~
00
g
;-
...
""'I
Q
Table 2. Incidence of CMV Infection in Prospective Studies
I
;S.
i
Number followed and showing evidence
of CMV infection
Initial aby
status
Ratell001
Time Number Percent CMV Num- period of
Group Setting period studied abya negative ber Aby Infected observation Reference
Pregnant women 1. All ages in London 6-9mo 1040 33.4 270 Neg. lIb 4.1 Stem and
Tucket 'OS )
2. Teenagers, Up to 9 mo 1089 35 379 Neg. 5b 1.3 Nankervis et al. (S3)
Cleveland
Young adults 1. English colleges 9mo 1457 70 713 Neg. lOb 1.4 UHP(u3)
2. Marine recruits 14wk 588 69.7 431 Mixed 4b 0.9 Wenzel et aI.<'21)
Surgical patients 1. Cardiopulmonary 3mo 212 38.7 82 Neg. 50 b 61.0 Purcell et al. (91)
bypass 130 Pos. 32b 24.6 Henle et al. (41)
2. Renal transplant 3mo 44 40.9 18 Neg. 12c 66.7 Nankervis et aI.(S1)
26 Pos. 18c 69.2
a Antibody.
·4x t Aby.
c 4x t Aby or CMV culture +.
In Barbados'2o) and Tanzania'o6) or similar CMV antibody. When a group of primarily serone-
parts of the world where CMV infection is ac- gatives was rebled 14 weeks later, four had devel-
quired early in life and nearly 100% have antibody oped CMV antibody, an infection rate of 0.9%. In
by the end of childhood, one would not expect contrast to CMV, similar surveys for EBV infection
infants to be born with congenital infection, as- in college and military groups have shown sero-
suming that primary infection during pregnancy is conversion rates of 12-13% in those lacking EBV
a prerequisite for that event. However, in popula- antibody and 25-75% of these infections have
tions where the opportunity of exposure is high, been associated with clinical infectious mononu-
the small proportion of individuals without CMV cleosis.'oo.96."3) It should be noted, however, that
antibody entering childbearing age appear to have CMV mononucleosis occurs more commonly in the
a high risk of contracting primary CMV infection 25-35 age group so that the group at highest risk
during pregnancy(108) and of delivering an infected has not been included in the prospective studies of
infant. CMV infections thus far.
Rates of recovery 'of CMV from culturing cervix c. Transfusion and Postsurgical Groups. The CMV
of pregnant women vary from 14% among the infection. rate depends on the initial antibody
Navajo,(79) 18% in Taiwan,(2) 15% in Japan,'84l status of the recipient,'41.Sll the evidence of CMV
12% in Birmingham,'92) 2% in Seattle,'3ll to 5% infection in the donor"sll the number of units
in PittsburghY9) Factors responsible may be ra- transfused,'SO) and the immunological status of
cial, seasonal, or more likely socioeconomic. Re- the recipient. This last is of special significance
covery from the cervix is more frequent than because a host compromised by natural or drug-
recovery from urine by a factor of 2 or more, and the induced immunosuppression appears to be at high
simultaneous isolation from both sites is uncom- risk of CMV reactivation. Table 2 presents some
mon, although this has not been the experience of representative data. A primary infection rate of
all investigators.'83) The frequency of positive cul- 61 % has been recorded following open-heart sur-
tures of the cervix increases as gestation pro- gery in those initially lacking CMV antibody and
gresses(79.84.92) and appears to be higher(79 ) in an antibody rise of 24.6% are now being observed
younger mothers with fewer than four pregnancies. in renal transplant patients, some of which appear
Most interestingly, infants born to mothers with to be temporally associated with kidney rejection,
proved cervical CMV infections are unlikely to have interstitial pneumonia, or hepatitis.<lo.I7.7o.71.81l
congenital CMV infection, although such infants The amount of actual disease produced by CMV
have a high risk of acquiring CMV infection during infection in this group is still controversial.
the first few months of life. Reynolds (92 ) offers the
hypothesis that the increasing rate of cervical and 5.2. Geographic Distribution
urinary excretion as gestation proceeds and the
Antibody to CMV is prevalent in adults
high rate of virus excretion in breast milk are the
throughout the world, with a range of from 37% in
result of reactivation of latent CMV infection per-
Rochester, New York,'34l to 50-60% in Nova Sco-
haps provoked by hormonal influences. tia,'23) Berlin,'42) London,'IOS) and Debrecen,
b. Young Adults. Prospective studies of young Hungary,«14) and rising to greater than 80% in
adults have indicated a very low rate of CMV
Barbados( 25 ) and Tanzania.'561 The major differ-
infection which is usually asymptomatic (Table 2).
ences are related to the speed of acquisition of
Among 1457 entering freshman college students in
infection in various geographic and socioeconomic
five English colleges and universities, 70% lacked
settings. Antibody has been detected in all popu-
CMV antibody; 713 of the 1026 lacking antibody
lations thus far tested, including the remote Tiriyo
were retested 7 months later and only ten were
Indians of Brazil who essentially lack measles and
found to have acquired antibody, an infection rate influenza antibody. (9)
of 1.4% in the susceptible group.ma) Only one of
these ten developed a mononucleosis-like syn-
drome. A similar study was made of 588 marine 5.3. Age and Sex
recruits undergoing "boot-camp" training over 14 Plots of antibody prevalence by age and sex
wk at Parris Island.<I2ll On entry, 69.7% lacked show a similar contour for most populations.
There is a loss of transplacentally acquired anti- method of spread of CMV among children. Studies
body in the first year of life, a gradual acquisition contrasting antibody prevalence among children
of antibody throughout childhood, a more rapid living together in large groups and those living at
increase in proportion with antibody during the home support this view. Children in English
young adult years, and then a leveling off in the boarding schools had antibody prevalence rates 4
rate of seroconversion. As shown in Table 1, the times those of children attending day school/IO;1
most striking difference in data from a range of and a similar magnitude of difference was demon-
socioeconomic and racial groups is the age at strable when Swiss nursery school students were
which most individuals have their primary CMV compared with a suitable control group.(5BI The
infection (i.e., first develop antibody to CMV). high frequency of antibody among children in
Fewer than half of the subjects 15 yr of age in most underdeveloped countries or in low socioeconomic
of the studies conducted in both the eastern and groups is probably also the result of crowding and
the western hemispheres had CMV antibody, but poor sanitation. Interestingly, children of migrant
in Barbados the figure was approximately 80%, farm workers in upper New York State(691 and I-
and even 100% in Tanzania. to 5-yr-olds in Egyptian villages(941 had antibody
The age at infection may influence the nature of rates similar to those reported for Barbados(251
the clinical syndrome produced. Infection during and Tanzania. (;6)
gestation may result in a congenital CMV syn- Prolonged excretion of virus in urine, saliva,
drome, while infection delayed to age 20 or over stool, tears, breast milk, and semen is characteris-
may result in cytomegalic mononucleosis syn- tic following CMV infection whether or not the
drome; this latter also occurs after blood transfu- patient is symptomatic and in spite of the presence
sion in adults. Regardless of age or sex, the major- of high levels of circulating antibody. The mecha-
ity of infections with CMV are clinically nism responsible for eventually turning off viral
asymptomatic . synthesis-or more accurately turning it off and
on, as is frequently observed-is postulated to be
related to cell-mediated immune mechanisms, but
5.4. Temporal Distribution precise data are not available. Droplet or possibly
Seasonal or yearly patterns of CMV infection fecal-oral spread is probably the route by which
have not been clearly delineated. most postnatal primary CMV infections are ac-
quired, although infection with CMV may occur
via blood in the congenital or posttransfusion
5.5. Occupation forms, via transplanted organs such as kidneys, by
No relation to occupation per se has been sexual contact (infected cervix or semen), or by
shown. ingestion of breast milk. The presence of CMV in
cervix as well as its presence and persistence in
semen(62.6;n raises the possibility of venereal
5.6 Race/Socioeconomic Setting
transmission, and one epidemiological analysis is
Many variables influence the time at which consistent with this possibility. (491 Virus in the
CMV infections are acquired, and the outcome of cervix and urine at the time of delivery in many
that infection. People in lower socioeconomic mothers provides a "sea of cytomegalovirus"
groups, especially if living in tropical settings, through which the newborn infant must pass and
acquire CMV infections earlier in life. In this be placed at high risk of infection.
group, cervical excretion of virus during preg-
nancy is common, and viruria has a high fre-
quency among neonates.
7. Pathogenesis and Immunity
6. Mechanism of Transmission There appear to be rather marked differences in

the consequences of the various forms of CMV
Close or prolonged contact with playmates who infection. Congenital infection carries a significant
are excreting virus is probably the most important risk of residual damage, especially to the nervous
system, whereas acquired infection, although oc- time, even with primary maternal infection, virus
casionally associated with illness, is apparently not replication and dissemination may be inadequate
followed by any disability even when it occurs in to result in fetal infection, but occasionally, even
the newborn. Although primary infection during with recurrent infection, dissemination and fetal
pregnancy is associated with a high probability of infection results, although classical disease is un-
infection in the newborn, the time during gesta- likely.
tion when primary maternal CMV is most likely to 7.1.2. Posttransfusion and Organ Transplant.
involve the fetus has not been defined. Recurrent The pathogenesis of CMV infection following
CMV infection during pregnancy is unlikely to transfusion or organ transplantation is not clear.
result in the delivery of an infected baby, and The major questions are whether this represents a
probably recurrent infection at any time is unlikely primary or a reactivated infection, and, if the
to be of clinical importance except possibly in the latter, whether the source of virus is the recipient,
immunodeficient patient. The differences in path- the blood of blood donors, or the transplanted
ogenesis among various types of CMV infections organs of the donor. In transfusion recipients
are discussed below. lacking demonstrable CMV antibody and trans-
fused with blood from antibody-positive donors,
some of whom have been shown to harbor CMV
7.1. Pathogenesis
in their buffy coats,<191 a primary infection seems
7.1.1. Neonatal Infection: Congenital. Early in most likely. The reservation here is how sensitive
the course of primary infection, virus is dissemi- the CF test is to identify low-level antibody and
nated widely in various organs of the host, as whether IgM responses accompany this infection.
indicated by the possibility of virus isolation from In the presence of CMV antibody in the recipient,
multiple sites. If the host undergoing primary a "mixed lymphocyte" response between donor
infection is pregnant, virus may infect the placenta and recipient lymphocytes might activate CMV in
and in some cases penetrate the placenta to infect either. At present, it has not been demonstrated
the fetus. Early studies of infants with CID that CMV resides within lymphocytes, although
showed the association between specific clinical cultured buffy coats reveal CMV after culture on a
manifestations and evidence of infection with fibroblast layer'47.64.I091; further, in vitro replica-
CMV.(1191 As laboratory methods for demonstrat- tion of complete CMV in lymphocytes has not
ing infection were more widely utilized, the spec- been shown even when stimulated by BUDR,
trum of changes occurring in congenital CMV PHA, other lymphocytes, or EBV-infected lympho-
broadened and the "expanded syndrome" was cytes. In renal transplant patients, both reactiva-
described. Later, as information from the prospec- tion and reinfection are probably important, but
tive study of groups of un selected newborns accu- clearcut implication of the immunosuppressed re-
mulated, it became apparent that congenital CMV cipient, the donor blood, or the donor kidney as
infection is not invariably associated with severe the source of the virus has been very difficult. The
mental or neurological deficit. '6.9J. IOJl presence of immunosuppression in these patients
Based on the available data, one can make a probably contributes to the high risk of CMV
number of speculations. Maternal viremia is more infection.
likely to occur with primary than recurrent infec- 7.1.3. CMV Mononucleosis. The epidemiology
tions, and if it occurs in the latter the virus titer and pathogenesis of CMV mononucleosis pose
may be low. Under certain conditions (trimester of questions very similar to those about EBV monon-
pregnancy, state of placenta, etc.), virus in small ucleosis. In both diseases, the host response ap-
quantities may cross the placenta and initiate foci pears to be associated with primary infection first
of replication in various fetal tissues. Maternal IgG acquired in young adult life, most likely through
antibody crosses the placenta as it is formed and intimate exposure to a pharyngeal carrier or acute
interacts with the CMV recently synthesized in the case. Recent studies indicate that clinical infec-
fetus. Whether the fetal infection proceeds and tious mononucleosis is an immunological response
whether clinical manifestations of CMV develop to EBV infection involving T- and B-cell interac-
may depend on the relative amounts of virus and tions.'IOO,II5) The atypical lymphocyte may repre-
immune globulin which interact. Much of the sent in part virus-transformed B-type lymphocytes
and in part T cells reacting to neoantigens induced inclusion disease, most of whom had overt clinical
by EBV on the B-cell membrane. The similarities evidence of disease at the time of birth, four of 15
of the clinical and hematological picture of CMV who survived were considered to have developed
mononucleosis to that of infectious mononucleosis normally and two others showed only equivocal
caused by EBV suggest that a similar immune evidence of retardation. (76) Another group of 12
mechanism may be at play. The major difference is children with clinical and laboratory evidence of
that CMV infection does not produce heterophil congenital CMV infection were evaluated at the
antibody. age of ~12 yr. Three were considered of average
intelligence, one was mildly retarded, three were
moderately retarded, and five were severely re-
7.2. Immunity tarded.(o)
Antibody to CMV appears regularly following Several studies indicate that infants with no
infection and, although levels may fluctuate, ap- apparent evidence of cm in the newborn period
pears to persist for life, with the exception of some may develop neurological sequelae. Hanshaw,(;!4)
congenitally infected children who gradually lose struck by the association between cytomegalic in-
their antibody. The primary immune response to clusion disease and failure of brain growth ob-
CMV is specific, and infection with another mem- served in early studies, tested sera from physically
ber of the herpesvirus family does not cause the handicapped children who had no history of cyto-
appearance of antibody detectable by the CMV CF megalic inclusion disease and found a significantly
test in a previously CMV antibody negative sub- larger proportion with CMV antibody among the
ject. The role of humoral vs. cell-mediated immun- group with microcephaly. Baron et al. (41 and Na-
ity in protection against primary infection has not kao et al. (80l were unable to confirm these find-
been studied experimentally, nor has their partici- ings. In further studies,W)n) neurological patients
pation in preventing endogenous reactivation with symptoms compatible with possible congeni-
been assessed. tal infection were found to have CMV antibody
significantly more frequently than a selected con-
trol group. The longitudinal observations of Rey-
nolds et al. (9;]) eliminate many of the hazards of
8. Patterns of Host Response these retrospective studies. Among 267 neonates
with elevated umbilical cord IgM levels, 18 clini-
Most CMV infections are inapparent and cally well were found to have laboratory evidence
asymptomatic and can be detected only by labora- of congenital CMV infection. Of 16 who were
tory study. The frequency and nature of the clini- followed, nine developed sensorineural hearing
cal response appear to depend on the age at which
infection is acquired, on the route of infection,
and on the immune status of the host. The com-
monest forms of associated clinical syndromes are Table 3. Host Responses to CMV Infections
listed in Table 3.
A. Neonatal infections
1. Congenital
8.1. Neonatal Infections 2. Acquired
B. Infection of children and adults
8.1.1. Congenital. The risk of infection and the 1. Hepatitis
pathogenesis of infection have already been dis- 2. Mononucleosis
cussed. The association between significant ner- 3. Posttransfusion CMV infection
vous system damage and congenital CMV infection 4. Posttransplant syndrome
remains unquestioned; what is not known is the 5. CMV and malignant disease
6. Other possible syndromes
frequency with which CMV infection acquired in
Encephali tis
utero leads to immediate or late clinical residual, as (Guillain-Barre syndrome)
well as the factors related to such an outcome. In a Ulcerative colitis
follow-up of 20 children with severe cytomegalic
loss. Other studies indicate that among infants by the mother, and the conclusion was drawn that
with congenital CMV infection who appear clini- the transmission of CMV from the infected cervix
cally normal in the neonatal period the presence of during birth is an important route of infection in
elevated IgM levels (not proved to be specific CMV early life, analogous to that of herpes simplex
antibody) may predict an increased incidence of virus. Transmission of CMV via infected breast
late residual effects. In a sample of nearly 2000 milk or from household contacts does not appear
un selected newborn infants, five with both CMV- to be an important source of infection for the
specific macroglobulin and elevated total IgM were young infants.'84)
observed for a period of over 2 yr. (35) Two were Acquired CMV infection in the young infant is,
microcephalic and severely retarded, one showed like the congenital form, chronic, and virus excre-
slow psychomotor development, and two were tion in urine or saliva continues for months. Al-
normal. In a similar survey/8) three infants found though the patients usually show no symptoms
to be excreting CMV in their urine within the first related to their infection, Nankervis et al. (8")
24 h of life had elevated IgM levels during the found that seven of the 21 infants in the Cleveland
first months of life. None of the three had the study had symptoms which coincided temporarily
classical signs of cytomegalic inclusion disease, with the first positive urine culture. Three had
but one developed a mold spasticity in the second interstitial pneumonia, two cases being severe
year of life and the other two remained normal. In enough to require hospitalization. One patient
the most unusual situation where two consecutive had cervical and inguinal lymphadenopathy asso-
pregnancies resulted in the birth of CMV-infected ciated with a diffuse maculopapular rash, one had
infants, one had elevated cord IgM and became mild hepatosplenomegaly with elevated SCOT and
markedly retarded, while the other with normal SePT and 17% atypical lymphocytes, one had
levels of IgM at birth developed normally.(102) mild hepatosplenomegaly with a diffuse maculo-
Nankervis et al. (8;0 reported that four of 16 infants papular rash, and one had only mild hepatosple-
with clinically inapparent congenital CMV infec- nomegaly.
tion had elevated cord IgM levels, but all were Long-term follow-up with psychometric, neurol-
apparently normal after a follow-up period averag- ogical, and audiometric testing on infants with
ing 18 months. acquired disease has not been reported, but pre-
The classical syndrome of cytomegalic inclusion liminary data indicate that they develop nor-
disease is uncommon, occurring once in 3000-5000 mally. (83.92)
births. However, congenital CMV infection has a
frequency of about 1 per 100 live births, and,
although estimates of the proportion of such in- 8.2. Infection of Children and Adults
fants who eventually develop serious sequelae are Most of the large number of children and adults
based on preliminary data, this figure is about who have antibody to CMV remain well or have a
10%.(35.108) One of every 1000 newborns, at least mild, nonspecific illness when they experience
in England and the United States, will have hear- their CMV infection. A small proportion, and this
ing loss, psychomotor retardation, or neurological figure is probably considerably less than 1%, may
defect secondary to congenital CMV infections. have one of a variety of clinical syndromes which
8.1.2. Acquired. It has been observed during have been shown to occur concurrently with CMV
the follow-up of infants born to mothers excreting infection. These include hepatitis, an infectious
CMV during pregnancy that a significant propor- mononucleosis-like syndrome, various respiratory
tion who were culture negative at birth became or gastrointestinal tract symptoms, and occasional
infected with CMV during the first few months of signs of central nervous system disease. The prob-
life. In a Cleveland study/83) 21 infants of over ability of illness accompanying CMV infection
100 excreting mothers developed viruria, 16 before appears greater in the immunodeficient person or
the age of 14 wk; others(68.92) have reported simi- in those receiving blood transfusions but has also
lar findings. In one study/92) infection of the been observed in previously well subjects. The
infant during the first few months of life could be syndromes described often overlap, especially in
correlated with late gestational cervical excretion the transplant recipient or patient with malignant
disease. The source of infection in patients with ling data to related heterophil-negative mononu-
the several clinical forms of CMV appears to be cleosis to CMV infection. In a series of studies, he
exogenous, but in several instances a number of found that among 350 patients with infectious
well-studied cases could have been "reactivated" diseases of miscellaneous etiology only one
infections. showed a rise in antibody to CMV (and that
8.2.1. Hepatitis. CMV has been associated with patient had Guillain-Barre syndrome); of 90 pa-
liver disease since the original isolation 020 ) from a tients with Paul-Bunnell-positive infectious mon-
biopsy specimen obtained from a child with cho- onucleosis, none demonstrated a significant titer
rioretinitis, hepatosplenomegaly, and cerebral cal- elevation, but 13 of 18 individuals with febrile,
cification. Hanshaw et al. (36) evaluated 20 asymp- Paul-Bunnell-negative mononucleosis had a four-
tomatic CMV-positive children as well as fold or greater rise in level of CMV CF antibody.
appropriate controls. Abnormal liver function tests Overall, CMV mononucleosis was diagnosed in
were 6 times more frequent in virus-positive than 9% of the patients referred because of "possible
in control children. Among a group of 22 children mononucleosis." Spontaneous CMV mononucleo-
and one young adult with enlarged liver and/or sis has subsequently been reported from many
spleen for which an explanation was being sought, laboratories. (18.50.55.60.73)
nine (or 39%) had viruria. CMV was also isolated 8.2.3. Posttransfusion. The syndrome of fever
from the liver of one child who died. Further with atypical lymphocytes was initially observed
studies(104.107) have indicated that liver involve- in patients who had undergone cardiac surgery
ment which is part of the congenital CMV syn- using pump oxygenators/58. 122) and the fresh
drome is not uncommon in patients with acquired blood used was suspected as the source of virus.
CMV, although in the latter group clinical mani- Subsequently, CMV has been recovered from the
festations may vary from mild transient abnormal- blood of patients with hepatitis/ 109) leuke-
ities in liver function to severe icteric disease mia/ 39 .47 ) and mononucleosis/ 5o. 61.65) and from
difficult to distinguish from other forms of hepati- immunologically depressed transplant recipi-
tis. In general, the prognosis of hepatitis associ- ents, (3.16.29) but only Diosi et al. (19) have been
ated with CMV is good; a chronic course appears able to isolate CMV from the blood of healthy
unlikely and the few deaths recorded have been in blood donors (two of 35 tested). A number of
patients with abnormal immune systems. Many laboratories have been unable to repeat the last
patients, especially adults, with CMV-related hep- results, possibly because of the methods of collect-
atitis have mononuclear cells in their peripheral ing, storing, or testing of the blood sam-
blood.(112) ples. (30.51.87)
8.2.2. Mononucleosis. Klemola and Kaari- In one series of 53 patients who underwent open
ainen(53) reported a series of patients, all but one heart surgery with an extracorporeal pump,(3) 21
adult, who developed an infectious mononucleo- had a rise in CMV antibody but only four devel-
sis-like illness characterized by fever and liver oped the typical mononucleosis-like syndrome.
involvement but no pharyngitis or significant Other studies(85) have indicated that about a third
cervical adenopathy. Laboratory studies revealed a of such patients show boosts in CMV antibody,
high percentage of atypical lymphocytes in the with only the occasional patient having an accom-
smears of peripheral blood, a negative Paul-Bun- panying illness. The volume of blood transfused,
nell test, an increase in cryoimmunoglobulins, and the age of the blood, the antibody status of the
serological evidence of recent CMV infection. This patient, and the mechanical damage to cells by the
syndrome has been observed in previously healthy pump all may contribute to the possibility of the
individuals but occurs more frequently in subjects patient showing a CMV antibody response, but
who have received large volumes of transfused the relative importance of each factor is difficult to
blood, as discussed below. Patients generally im- define. Prince et al. (90) reported a rather direct
prove within 3-6 wk with a return of normal liver association between the number of units of blood
function tests and the disappearance of atypical transfused and CMV antibody conversion; 7% of
lymphocytes from the peripheral blood. those who received 1 unit of blood but 21% of
Klemola et al. (54) have provided rather compel- those given multiple transfusions had significant
elevations in CMV antibody titer. The rate was has viremia and signs of illness. Armstrong et
over twice as high in immunosuppressed, trans- al.,(:J) for example, reported that of four renal
plant recipients. Preexisting antibody status or use transplant recipients with laboratory evidence of
of fresh blood was of little importance. A boost in primary CMV infection three had viremia and two
CMV antibody followed large-volume transfusions became ill, one with mononucleosis and the other
of fresh blood in subjects with no or low titers of with hepatitis. However, in the presence of immu-
preexisting CF antibody but in none who had CF nosuppressive therapy it is very likely that reacti-
titers of 128 or greater. However, among patients vation of latent virus and the development of
who received stored, citrated blood, none had illness can occur and possibly that infection with a
antibody rise regardless of the preoperative second antigenically different strain of CMV may
level.(85) The lack of preoperative antibody and cause illness in the previously infected subject.
the rather slow rise in antibody titer suggest that Studies differentiating primary and recurrent in-
the postperfusion syndrome is associated with a fections and antigenic variants of CMV are re-
primary infection by CMV derived from donor quired before these points can be clarified.
blood, but in some patients the antibody status S.2.5. CMV and Malignant Disease. The patient
and rapid rise make it difficult to rule out the with malignant disease may have a severe or
possibility of reactivation of an old infection with protracted illness with CMV infection/ I()) but may
antibody boost. An increased incidence of CMV not have an increased risk of acquiring such an
infection in neonates who have undergone single infection. Benyesh-Melnick, et al. (5) and Dyment
transfusion (124 ) or exchange transfusion(72) has et al. (2)) in separate studies found low rates of
also been reported. cytomegaloviruria in children with leukemia (2 %),
8.2.4. PosHransplant. Cytomegalovirus infection and Hanshaw and Weller(38) isolated CMV from
following renal transplantation may be associated the urine of three patients among 50 with leuke-
with a variety of clinical manifestations or be mia, lymphoma, or Hodgkin's disease (rate of
completely asymptomatic. The source of the virus 6%). Sullivan et al. (110) reported that when sero-
is unknown; it may be introduced with blood or conversion was used as an indicator of CMV
be present in the donor kidney or be endogenous infection nine of 16 children had fourfold antibody
in origin. rises during the course of leukemia. Henson et
Autopsy studies of patients who died following al. (43) made the observation, which is difficult to
renal transplantation during the early days of this interpret, that among children with leukemia
procedure were found in many cases to give evi- those excreting CMV had more episodes of pneu-
dence of pulmonary CMV infection. Kanich and monitis or fever with rash but not more episodes
Craighead(52) showed a good correlation between of hepatitis, fever without rash, or respiratory tract
the histological changes diagnosed as CMV and infections than those not shedding virus in the
the ability to isolate virus from lung tissue and urine.
evidence of generalized CMV infection. He also S.2.6. Other Possible Syndromes. There are sev-
found that CMV infection was much more likely to eral case reports in the literature relating specific
occur in the patient given immunosuppressive illnesses such as encephalitis(zOJ or ulcerative coli-
therapy, that the duration of such therapy affected tiS(67) with CMV infection. In most of these stud-
such probability, and that immunosuppressive ies, a change in antibody status or the excretion of
therapy did not prevent a specific antibody re- virus is shown to exist concurrently with a partic-
sponse to CMV. Later prospective studies indi- ular disease syndrome; in a few, the evidence for
cated that asymptomatic CMV infection was com- the diagnosis of CMV infection consists of the
mon in the renal transplant patient receiving demonstration of typical intranuclear inclusions in
immunosuppressive therapy and that only the various tissues. The variability in antibody titer
occasional individual developed mononucleo- and the frequency with which virus can be de-
sis ,<;)) hepatitis,<7I) or pulmonary disease. (16) tected in urine or saliva of chronically infected
There is some suggestion that the patient who patients make it very hazardous to interpret two
acquires primary CMV infection following allo- concurrent events as being cause and effect. This
graft reception and immunosuppressive therapy is emphasized by the authors of many of the
articles cited, but it is only by continuing to collect at the injection site in half the subjects, and two
such data that the final question of etiology can be developed tender adenopathy, one with reactive
resolved. lymphocytes. None of the subjects demonstrated
any disturbance of liver function tests and none
excreted virus in throat secretions or urine.
Plotkin(88) has developed a live vaccine (Towne
9. Immunization strain) by passing an isolate from a congenitally
infected infant 125 times in tissue culture. Prelimi-
If convincing evidence can be obtained support- nary testing in Switzerland indicates that paren-
ing the current impression that primary rather teral use of this vaccine will stimulate the produc-
than recurrent CMV infection during pregnancy tion of CMV antibody without significant side
may result in fetal infection and clinical illness effects.
with residual damage, then there is a reasonable Whether antibody stimulated by a live vaccine
basis for considering the use of a vaccine. How- will persist or is related to subsequent prevention
ever, there are two major areas of concern associ- of damaged congenitally infected infants is at
ated with the use of a CMV vaccine. First, there present unknown. The cell-mediated immunity
are three reports in the literature documenting response to natural vs. vaccine virus and its role in
congenital CMV infection in consecutive pregnan- protection against viral reactivation have likewise
cies. (24.57.102) Although the second infants have not been delineated. Clearly, continued studies of
been considered to be normal over short periods of the malignant potential of CMV as well as the
evaluation, it is clearly possible for a woman to complex interaction of mother, fetus, and virus
have two congenitally infected infants in separate must form a crucial background for involvement in
pregnancies. Additional data are sorely needed to the development of a vaccine to protect against
support or disprove the consistency of normality such an effective and efficient parasite as the
of the second-born infants in this situation. cytomegalovirus.
The second major area of concern is the malig-
nant potential of the herpesviruses. Members of
this group have been clearly implicated as the 10. Unresolved Problems
etiological agents of malignancy in lower animals,
and the association between herpes simplex type II Unresolved problems include whether there are
and cervical carcinoma in the human is well ac- important biological differences between CMV
cepted. In addition, Albrecht and Rapp(J) have strains, what the relative importance of various
shown that irradiated CMV is capable of causing routes of transmission is, whether primary or
transformation in hamster cells in vitro. reactivated CMV is more important clinically, and
Despite the relatively high titers of CMV which what the role of humoral and cell-mediated im-
can be obtained in supernatant fluid from roller munity is in both. In addition, the long-term effect
bottles/ 45 ) this virus probably does not multiply of congenital CMV infection needs further study,
to a high enough titer to make a killed vaccine as does the potential oncogenicity of CMV. Fi-
practical or economically feasible. Thus an effec- nally, the development and usefulness of CMV
tive live vaccine seems the most reasonable at vaccine require further investigation.
present, and it may be necessary to use a mixture
of several antigenic types or a particular strain that
cross-reacts with the overwhelming majority of the
common variants. 11. References
Elek and Stern(22) have reported on preliminary
results obtained with a live vaccine prepared from 1. ALBRECHT, T., AND RAPP, F., Malignant transforma-
AD 169, a standard laboratory strain. The subcuta- tion of hamster embryo fibroblasts following expo-
neous inoculation of this material into 26 serone- sure to ultraviolet-irradiated human cytomegalovi-
gative volunteers was followed by the develop- rus' Virology 55:53-61 (1973).
ment of antibody in 25. Mild local signs developed 2. ALEXANDER, E. R., Maternal and neonatal infection
with cytomegalovirus in Taiwan (abst.), Pediat. Res. 17. CRAIGHEAD, J. E., HANSHAW, J. B., AND CARPENTER,
1:210 (1967). C. B., Cytomegalovirus infection after renal allo-
3. ARMSTRONG, D., BALAKRISHNAN, S., STEGIR, L., Yu, transplantation, ]. Am. Med. Assoc. 201:99--102
B.,AND STENZEL, K. H., Cytomegalovirus infections (1967).
with viremia following renal transplantation, Arch. 18 .. DAVIS, L. E., TWEED, G. V., STEWART, J. A., BERN-
Intern. Med. 127:111-115 (1971). STEIN, M. T., MILLER, G. L., GRAVELLE, C. R., AND
4. BARON, J., YOUNGBLOOD, L., SIEWERS, C. M. F., AND CHIN, D. Y., Cytomegalovirus mononucleosis in a
MEDEARIS, D. N., JR., The incidence of cytomegalo- first trimester pregnant female with transmission
virus, herpes simplex, rubella, and toxoplasma anti- to the fetus, Pediatrics 48:200-206 (1971).
bodies in microcephalic, mentally retarded, and 19. DrasI, P., MOLDOVAN, E., AND TOMESCU, N., Latent
normocephalic children, Pediatrics 44:932-939 cytomegalovirus infection in blood donors, Br. Med.
(1969). /. 4:660-662 (1969).
5. BENYESH-MELNICK, M., DESSY, S. 1., AND FERN- 20. DORFMAN, L. J., Cytomegalovirus encephalitis in
BACH, D. J., Cytomegaloviruria in children with adults, Neurology 23:136-144 (1973).
acute leukemia and in other children, Proc. Soc. 21. DYMENT, P. G., ORLANDO, S. J., ISAACS, H., JR., AND
Exp. BioI. 117:624-630 (1964). WRIGHT, H. T., JR., The incidence of cytomegalovi-
6. BERENBERG, W., AND NANKERVIS, G. A., Long-term ruria and postmortem cytomegalic inclusions in
followup of cytomegalic inclusion disease of in- children with acute leukemia, /. Pediat. 72:533--536
fancy, Pediatrics 46:403-409 (1970). (1968).
7. BERNSTEIN, M. T., AND STEWART, J. A., Indirect 22. ELEK, S. D., AND STERN, H., Development of a
hemagglutination test for detection of antibodies to vaccine against mental retardation caused by cyto-
cytomegalovirus, Appl. Microbial. 21:84-89 (1971). megalovirus infection in utero, Lancet 1:1-5 (1974).
8. BIRNBAUM, G., LYNCH, J. 1., MARGILETH, A. M., 23. EMBIL, J. A., HALDANE, E. V., MACKENZIE, R. A. E.,
LONERGAN, W. M., AND SEVER, J. L., Cytomegalovi- AND VAN Roo YEN, C. E., Prevalence of cytomegalo-
rus infections in newborn infants, ]. Pediat. 75:789- virus infection in a normal urban population in
795 (1969). Nova Scotia, Can. Med. Assoc. ]. 101:730-733 (1969).
9. BLACK, F. L., WOODALL, J. P., EVANS, A. S., LIEBHA- 24. EMBIL, J. A., OZERE, R. L., AND HALDANE, E. V.,
BER, H., AND HENLE, G., Prevalence of antibody Congenital cytomegalovirus infection in two sib-
against viruses in the Tiriyo, an isolated Amazon lings from consecutive pregnancies, /. Pediat.
tribe, Am. /. Epidemiol. 91:430--438 (1970). 77:417-421 (1970).
10. CANGIR, A., AND SULLIVAN, M., The occurrence of 25. EVANS, A., Cox, F., NANKERVIS, G., OPTON, E.,
cytomegalovirus infections in childhood leukemia, SHOPE, R., WELLS, A. V., AND WEST, B., A health
/. Am. Med. Assoc. 195:616-622 (1966). and seroepidemiological survey of a community in
11. CAPPELL, D. F., AND McFARLANE, M. N., Inclusion Barbados, Int. /. Epidemiol. 3:167-175 (1974).
bodies (protozoan-like cells) in the organs of in- 26. FARBER, S., AND WOLBACK, S. B., Intranuclear and
fants, J. Pathol. Bacterial. 59:385-398 (1947). cytoplastic inclusions ("protozoan-like bodies") in
12. CARLSTROM, G., Virologic studies on cytomegalic salivary glands and other organs of infants, Am. J.
inclusion disease, Acta Paediat. Scand. 54:17-23 Pathol. 8:123--126 (1932).
(1965). 27. FELDMAN, R. A., Cytomegalovirus infection during
13. CAUL, E. 0., CLARKE, S. K. R., MOTT, M. G., pregnancy, Am. /. Dis. Child. 117:517-521 (1969).
PERHAM, T. G. M., AND WILSON, R. S. E., Cytome- 28. FETTERMAN, G. H.i A new laboratory aid in the
galovirus infections after open heart surgery: A clinical diagnosis of inclusion disease of infancy,
prospective study, Lancet 1:777-781 (1971). Am. ]. Clin. Pathol. 22:424-425 (1952).
14. CHIANG, W., WENTWORTH, B. B., AND ALEXANDER, 29. FINE, R. N., GRUSHKIN, C. M., ANAND, S., LIEBER-
E. R., The use of an immunofluorescence technique MAN, E., AND WRIGHT, H. T., Cytomegalovirus in
for the determination of antibodies to cytomegalo- children, Am. J. Dis. Child. 120:197-202 (1970).
virus strains in human serum, ]. Immunol. 104:992- 30. FOSTER, K. M., AND JACK, 1., A prospective study of
999 (1970). the role of cytomegalovirus in post-transplant mon-
15. COLE, R., AND KUTTNER, A. G., A filterable virus onucleosis, N. Engl. J. Med. 280:1311-1354 (1969).
present in the submaxillary glands of guinea pigs,]. 31. Foy, H. M., KENNY, G. E., WENTWORTH, B. B.,
Exp. Med. 44:855-873 (1926). JOHNSON, W. L., AND GRAYSTON, J. T., Isolation of
16. COULSON, A. S., LUCAS, Z. J., CONDY, M., AND mycoplasma hominis, T-strains, and cytomegalovi-
COHN, R., An epidemic of cytomegalovirus disease rus from the cervix of pregnant women, Am. J.
in a renal transplant population, West. ]. Med. Obstet. Gynecol. 106:635--643 (1970).
120:1-7 (1974). 32. FUCCILLO, D. A., MODER, F. A., TRAUB, R. G.,
HENSEN, S., AND SEVER, J. L., Micro indirect hemag- cal study of cytomegalovirus infections in Mel-
glutination test for cytomegalovirus, Appl. Micro- bourne children and some adults, Med. J. Aust.
bioI. 21:104-107 (1971). 1:206-209 (1968).
33. GOODPASTURE, E. W., AND TALBOT, F. B., Concern- 47. JACK, I., TODD, H., AND TURNER, E. K., Isolation of
ing the nature of "protozoan-like" cells in certain human cytomegalovirus from the circulating leuko-
lesions of infancy, Am. J. Dis. Child. 21:415-421 cytes of a leukaemic patient, Med. J. Aust. 1:210-213
(1921). (1968).
34. HANSHAW, J. B., Cytomegalovirus complement-fix- 48. JESIONEK, A., AND KIOLEMENOGLOU, B., tiber einen
ing antibody in microcephaly, N. Eng/. J. Med. Befund von protozoenartigen Gebilden in den orga-
275:476-479 (1966). nen eines Feten, Munch. Med. Wochenschr. 51:1905-
35. HANSHAW, J. B., Congenital cytomegalovirus infec- 1907 (1904).
tion: A fifteen year perspective, J. Infect. Dis. 49. JORDON, M. c., ROUSSEAU, W. E., NOBLE, G. R,
123:555-561 (1971). STEWART, J. A., AND CHIN, T. D. Y., Association of
36. HANSHAW, J. B., BETTS, R F., SIMON, G., AND cervical cytomegalovirus with venereal disease, N.
BOYNTON, R. c., Acquired cytomegalovirus infec- Engl. J. Med. 288:923-934 (1973).
tion association with hepatomegaly and abnormal 50. JORDAN, M. c., ROUSSEAU, W. E., STEWART, J. A.,
liver-function tests, N. Engl. J. Med. 272:602-609 NOBLE, G. R., AND CHIN, T. D. Y., Spontaneous
(1965). cytomegalovirus mononucleosis, Ann. Intern. Med.
37. HANSHAW, J. B., STEINFELD, H. J., AND WHITE, C. J., 79:153-160 (1973).
Fluorescent-antibody test for cytomegalovirus ma- 51. KANE, R c., ROUSSEAU, W. E., NOBLE, G. R.,
croglobulin, N. Eng/. J. Med. 279:566-570 (1968). TEGTMEIER, G. E., WULFF, H., HERNDON, H. B.,
38. HANSHAW, J. B., AND WELLER, T. H., Urinary excre- CHIN, T. D. Y., AND BAYER, W. L., A prospective
tion of cytomegaloviruses by children with general- study of cytomegalovirus infection in a volunteer
iZj!d neoplastic disease: Correlation with clinical blood donor population, Infect. Immun. (in press).
and histopathologic observations, J. Pediat. 58:305- 52. KANICH, R E., AND CRAIGHEAD, J. E., Cytomegalo-
311 (1%1). virus infection and cytomegalic inclusion disease in
39. HARNDEN, D. G., ELSDALE, T. R., YOUNG, D. E., renal homotransplant recipients, Am. J. Med.
AND Ross, A., The isolation of cytomegalovirus 40:874-882 (1966).
from peripheral blood, Blood 30:120-125 (1967). 53. KLEMOLA, E., AND KAARIAINEN, L., Cytomegalovi-
40. HAYES, K., DANKS, D. M., ANn GIBAS, H., Cytome- rus as a possible cause of a disease resembling
galovirus in human milk, N. Engl. J. Med. 287:177- infectious mononucleosis, Br. Med. J. 2:1099-1102
178 (1972). (1965).
41. HENLE, W., HENLE, G., SCRIBA, M., JOYNER, c., 54. KLEMOLA, E., KAARIAINEN, R, VON ESSEN, R, HAL-
HARRISON, F., VON ESSEN, R., PALOHEIMO, J., AND TIA, K., KOIVUNIEMI, A., AND VON BONSDORFF, c.-
KLEMOLA, E., Antibody responses to the Epstein- H., Further studies on cytomegalovirus mononu-
Barr virus and cytomegalovirus after open-heart and cleosis in previously healthy individuals, Acta Med.
other surgery, N. Eng/. J. Med. 282:1068-1074 (1970). Scand. 182:311-322 (1%7).
42. HENNE BERG, G., AND ANTONIADIS, G., Serological 55. KRECH, U., JUNG, M., JUNG, F., AND SINGEISEN, c.,
investigations into the epidemiology of cytomegalo- Virologische und klinische Untersuchungen bei
virus infection, International Conference of Cyto- konnatalen und postnatalen Cytomegalien, Schweiz
megalovirus Infection, St. Gall, April 1-3, 1970. Med. Wochenschr. 98:1459-1469 (1968).
43. HENSON, D., SIEGEL, S., FUCCILLO, D. A., MATTHEW, 56. KRECH, U. H., AND JUNG, M., Age distribution of
E.; AND LEVINE,S., Cytomegalovirus infections dur- complement-fixing antibodies in Tanzania, 1970,
ing acute childhood leukemia, J. Infect. Dis. in: Cytomegalovirus Infections of Man, pp. 27-28,
126:469-481 (1972). Karger, Basel, 1971.
44. HILDEBRANDT, R J., SEVER, J. L., MARGILETH, A. 57. KRECH, U., KONJAJEV, Z., JUNG, M., Congenital
M., AND CALLAGAN, D. A., Cytomegalovirus in the cytomegalovirus infection in siblings from consecu-
normal pregnant woman, Am. J. Obstet. Gynecol. tive pregnancies, Helv. Paediat. Acta 26:355-362
98:1125-1128 (1%7). (1971).
45. HUANG, E. 5., CHEN, s. T., AND PAGANO, J. S., 58. KREEL, I., ZAROFF, L. I., CANTER, J. W., KRASNA, I.,
Human cytomegalovirus. I. Purification and charac- AND BARONOFSKY, I. D., Syndrome following total
terization of viral DNA, J. Virol. 12:1473-1481 body perfusion, Surg. Gynecol. Obstet. 111:317-321
(1973). (1%0).
46. JACK, I., AND McAULIFFE, K. c., sero-epidemiologi- 59. KRIEL, R L., GATES, G. A., WULFF, H., POWELL, N.,
POLAND, J. D., AND CHIN, T. D. Y., Cytomegalovi- 74. MARGILETH, A. M., The diagnosis and treatment of
rus isolations associated with pregnancy wastage, generalized cytomegalic inclusion disease of the
Am. J. Obstet. Gynecol. 106:88~92 (1970). newborn, Pediatrics 15:270-283 (1955).
60. LAMB, S. G., AND STERN, H., Cytomegalovirus mon- 75. McALLISTER, R. M., WRIGHT, H. T., JR., AND TASEM,
onucleosis with jaundice as presenting sign, Lancet W. M., Cytomegalic inclusion disease in newborn
2:1003-1006 (1966). twins, J. Pediat. 64:278--281 (1964).
61. LANG, D. J., AND HANSHAW, J. B., Cytomegalovirus 76. MCCRACKEN, G. H., JR., SHINEFIELD, H. R., COBB,
infection and the postperfusion syndrome: Recogni- K., RAUSEN, A. R., DISCHE, M. R., AND EICHEN-
tion of primary infections in four patients, N. Engl. WALD, H. F., Congenital cytomegalic inclusion dis-
]. Med. 280:1145-1149 (1969). ease: A longitudinal study of 20 patients, Am. J. Dis.
62. LANG, D. J., AND KUMMER, J. F., Demonstration of Child. 117:522-539 (1969).
cytomegalovirus in semen, N. Engl. ]. Med. 287:756- 77. MEDEARIS, D. N., JR., Observations concerning hu-
758 (1972). man cytomegalovirus infection and disease, Bull.
63. LANG, D. J., KUMMER, J. F., AND HARTLEY, D. P., Johns Hopkins Hosp. 114:181-211 (1964).
Cytomegalovirus in semen: Persistence and demon- 78. MERCER, R. D., LUSE, S., AND GUYTON, D. H.,
stration in extracellular fluids, N. Eng!. ]. Med. Clinical diagnosis of generalized cytomegalic inclu-
291:121-123 (1974). sion disease, Pediatrics 11:502-514 (1953).
64. LANG, D. J., AND NOREN, B., Cytomegaloviremia 79. MONTGOMERY, R., YOUNGBLOOD, L., AND MEDEARIS,
following congenital infection, ]. Pediat. 73:812-819 D. N., JR., Recovery of cytomegalovirus from the
(1968). cervix in pregnancy, Pediatrics 49:524-531 (1972).
65. LANG, D. J., SCOLNICK, E. M., AND WILLERSON, J. T., 80. NAKAO, T., AND CHIBA, S., Cytomegalovirus and
Association of cytomegalovirus infection with the microcephaly, Pediatrics 46:483-484 (1970).
postperfusion syndrome, N. Eng!. ]. Med. 278:1147- 81. NANKERVIS, G. A., BRAUN, W. E., COOPER, A. R.,
1149 (1968). KUMAR, A., AND GOLD, E., A prospective study of
66. LEHANE, D. E., A seroepidemiologic study of infec- cytomegalovirus infection in renal transplant recipi-
tious mononucleosis. The development of EB virus ents, in preparation.
antibody in a military population, ]. Am. Med. 82. NANKERVIS, G. A., KUMAR, M. L., AND GOLD, E.,
Assoc. 212:2240-2242 (1970). Primary infection with cytomegalovirus during
67. LEVINE, R. S., WARNER, N. E., AND JOHNSON, C. F., pregnancy (abst.), Pediat. Res. 8:427 (1974).
Cytomegalic inclusion disease in the gastrointes- 83. NANKERVIS, G. A., KUMAR, M. L., Cox, F. E., AND
tinal tract of adults, Ann. Surg. 159:37-48 (1964). GOLD, E., A prospective study of maternal cytome-
68. LEVINSOHN, E. M., Foy, H. M., KENNY, G. E., galovirus infection and its effect on the fetus, in
WENTWORTH, B. B., AND GRAYSTON, J. T., Isolation preparation.
of cytomegalovirus from a cohort of 100 infants 84. NUMAZAKI, Y., YANO, N., MORIZUKA, T., TAKA I, S.,
throughout the first year of life, Proc. Soc. Exp. BioI. AND ISHIDA, N., Primary infection with human
Med. 132:957-962 (1969). cytomegalovirus: Virus isolation from healthy in-
69. LI, F., AND HANSHAW, J. B., Cytomegalovirus infec- fants and pregnant women, Am. ]. Epidemiol.
tion among migrant children, Am. ]. Epidemiol. 91:410-417 (1970).
86:137-141 (1967). 85. PALOHEIMO, J. A., VON ESSEN, R., KLEMOLA, E.,
70. LOPEZ, c., SIMMONS, R. L., MAUER, S. M., NAJA- KAARIAINEN, L., AND SILTANEN, P., Subclinical cy-
RIAN, J. S., AND GOOD, R. A., Association of renal tomegalovirus infections and cytomegalovirus mon-
allograft rejection with viral infections, Am. J. Med. onucleosis after open heart surgery, Am. ]. Cardia!.
56:280-289 (1974). 22:624-630 (1968).
71. LUBY, J. P., BURNETT, W., HULL, A. R., WARE, A. J., 86. PENTTINEN, K., KAARIAINEN, L., AND MYLLYLA, G.,
SHOREY, J. W., AND PETERS, P. c., Relationship Cytomegalovirus antibody assay by platelet aggre-
between cytomegalovirus and hepatic function ab- gation, Arch. Gesamte Virusforsch. 29:189-194 (1970).
normalities in the period after renal transplant, J. 87. PERHAM, T. G. M., CAUL, E. 0., CONWAY, P. J., AND
Infect. Dis. 129:511-518 (1974). MOTT, M. G., Cytomegalovirus infection in blood
72. LUTHARDT, T., SIEBERT, H., LOSEL, I., QUEVEDO, M., donors-A prospective study, Br. ]. Haemotol.
AND TODT, R., Cytomegalievirus-infektionen bei 20:307-320 (1971).
Kindem mit Blutaustauschtransfusion im Neuge- 88. PLOTKIN, S. A., Cytomegalovirus vaccine studies,
borenenalter, Klin. Wochenschr. 49:81-86 (1971). in: Cytomegalovirus Workshop Proceedings, National
73. MANDELL, G. L., Cytomegalovirus mononucleosis, Institutes of Health, Bethesda, Md., June 19,1974.
Del. Med. J. 43:155-156 (1971). 89. PLUMMER, G., AND BENYESH-MELNICK, M., A plaque
reduction neutralization test for human cytomegalo- due to viruses with similar antigenic compositions,
virus, Proc. Soc. Exp. BioI. Med. 117:145-150 (1964). Pediatrics 52:788-794 (1973).
90. PRINCE, A. M., SZMUNESS, W., MILLIAN, S. J., AND 103. STARR, J. G., BART, R. D., JR., AND GOLD, E.,
DAVID, D. S., A serologic study of cytomegalovirus Inapparent congenital cytomegalovirus infection:
infections associated with blood transfusions, N. Clinical and epidemiologic characteristics in early
Engl. J. Med. 284:1125-1131 (1971). infancy, N. Engl. J. Med. 282:1075-1077 (1970).
91. PURCELL, R. H., WALSH, J. H., HOLLAND, P. V., 104. STERN, H., Isolation of cytomegalovirus and clinical
MORROW, A. G., WOOD, S., AND CHANOCK, R. M., manifestations of infection at different ages, Br.
Seroepidemiological studies of transfusion-associ- Med. J. 1:665-669 (1968).
ated hepatitis,]. Infect. Dis. 123:406-413 (1971). 105. STERN, H., AND ELEK, S. D., The incidence of
92. REYNOLDS, D. W., STAGNO, S., HosTY, T. S., TILLER, infection with cytomegalovirus in a normal popula-
M., AND ALFORD, C. A., JR., Maternal cytomegalovi- tion: A serologic study in greater London, J. Hyg.
rus excretion and perinatal infection, N. Engl. J. 63:79-87 (1965).
Med. 289:1-5 (1973). 106. STERN, H., Elek, S. D., BOOTH, J. c., AND FLECK, D.
93. REYNOLDS, D. W., STAGNO, S., STUBBS, K. G., DAHLE, G., Microbial causes of mental retardation: The role
A. J., LIVINGSTON, M. M., SAXON, S. S., AND ALFORD, of prenatal infections with cytomegalovirus, rubella
C. A., Inapparent congenital cytomegalovirus infec- virus, and toxoplasma, Lancet 2:443-448 (1969).
tion with elevated cord IgM levels, N. Engl. J. Med. 107. STERN, H., AND TUCKER, S. M., Cytomegalovirus
290:291-296 (1974). infection in the newborn and in early childhood:
94. ROWE, W. A., Adenovirus and salivary gland virus Three atypical cases, Lancet 2:1268-1271 (1965).
infections in children, in: Viral Infections of Infancy 108. STERN, H., AND TUCKER, S. M., Prospective study of
and Childhood (H. M. ROSE, ed.), pp. 205-214, Hoe- cytomegalovirus infection in pregnancy, Br. Med. J.
ber, New York, 1960. 2:268-270 (1973).
95. ROWE, W. P., HARTLEY, J. W., WATERMAN, S., 109. STULBERG, C. S., ZUEIZER, W. W., PAGE, R. H. et al.,
TURNER, H. c., AND HUEBNER, R. J., Cytopatho- Cytomegalovirus infections with reference to isola-
genic agent resembling human salivary gland virus tions from lymphnode and blood, Proc. Soc. Exp.
recovered from tissue cultures of human adenoids, BioI. Med. 123:976-982 (1966).
Proc. Soc. Exp. BioI. Med. 92:418-424 (1956). 110. SULLIVAN, M. P., HANSHAW, J. B., CANGIR, A., AND
96. SAWYER, R. N., EVANS, A. S., NIEDERMAN, J. c., BUTLER, J. J., Cytomegalovirus complement-fixation
AND MCCOLLUM, R. W., Prospective studies of a antibody levels of leukemic children, ]. Am. Med.
group of Yale University freshmen. I. Occurrence of Assoc. 206:569-574 (1968).
infectious mononucleosis, J. Infect. Dis. 123:263--270 111. THE, T. H., KLEIN, G., AND LANGENHUYSEN, M. M.
(1971). A. c., Antibody reactions to virus-specific early
97. SCHMITZ, H., AND HAAS, R., Determination of dif- antigens (EA) in patients with cytomegalovirus
ferent cytomegalovirus immunoglobulins (IgG, IgA, (CMY) infections, Clin. Exp. Immunol. 16:1-12
IgM) by immunofluorescence. Arch. Gesamte Virus- (1974).
forsch. 37:131-140 (1972). 112. TOGHILL, P. J., BAILEY, M. E., WILLIAMS, R., ZEE-
98. SCHWARTZ, R. S., Immunoregulation, oncogenic vi- GEN, R., AND BOWN, R., Cytomegalovirus hepatitis
ruses, and malignant lymphomas, Lancet 1:1266- in the adult, Lancet 1:1351-1354 (1967).
1269 (1972). 113. University Health Physicians and P.H.L.S. Labora-
99. SHAVRINA, 1. V., ASHER, D. M., ILYENKO, V. I., AND tories, Infectious mononucleosis and its relation-
SMORODINTSEV, A. A., Antibodies to cytomegalovi- ship to EB virus antibody, Br. Med. J. 4:643--646
rus in the population of Leningrad, Vopr. Virusol. (1971).
2:156-159 (1973). 114. VACZI, 1., GONCZOLL, E., LEHEL, F., AND GEDER, 1.,
100. SHELDON, P. J., PAPAMICHAIL, M., HEMSTED, E. H., Isolation of cytomegalovirus and incidence of com-
AND HOLBOROW, E. J., Thymic origin of atypical plement-fixing antibodies against cytomegalovirus
lymphoid cells in infectious mononucleosis, Lancet in different age-groups, Acta Microbial. Acad. Sci.
1:1153--1155 (1973). Hung. 12:115-121 (1965).
101. SMITH, M. G., Propagation in tissue cultures of a 115. VERLAINEN, M., ANDERSSON, 1. c., LALLA, M., AND
cytopathogenic virus from human salivary gland VON ESSEN, R., T-lymphocyte proliferation in mon-
virus (SGV) disease, Proc. Soc. Exp. BioI. Med. onucleosis, Clin. Immunol. Immunopathol. 2:114-120
92:424-430 (1956). (1973).
102. STAGNO, S., REYNOLDS, D. W., LAKEMAN, A., CHAR- '116. VON GLAHN, W. c., AND PAPPENHEIMER, A. M.,
AMELLA, 1. J., AND ALFORD, C. A., Congenital Intranuclear inclusions in visceral disease, Am. J.
cytomegalovirus infection: Consecutive occurrence Pathol. 1:445-465 (1925).
117. WANER, J. 1., WELLER, T. H., AND KEVY, S. V., 123. WYATT, J. P., SAXTON, J., LEE, R. S., AND PINKER-
Patterns of cytomegaloviral complement-fixing anti- TON, H., Generalized cytomegalic inclusion disease,
body activity: A longitudinal study of blood do- ]. Pediat. 36:271-294 (1950).
nors, J. Infect. Dis. 127:538-543 (1973). 124. YEAGER, A. S., Transfusion-acquired cytomegalovi-
118. WELLER, T. H., HANSHAW, J. B., AND SCOTT, D. E., rus infection in newborn infants, Am. ]. Dis. Child.
Serologic differentiation of viruses responsible for 128:478-483 (1974).
cytomegalic inclusion disease, Virology 12:130-132
(1960).
119. WELLER, T. H., AND HANSHAW, J. B., Virologic and
clinical observations on cytomegalic inclusion dis-
ease, N. Engl. ]. Med. 266:1233-1244 (1962). 12. Suggested Reading
120. WELLER, T. H., MACAULEY, J. c., CRAIG, J. M., AND
WIRTH, P., Isolation of intranuclear inclusion pro- HANSHAW, J. B., Congenital cytomegalovirus infection: A
ducing agents from infants with illnesses resem- fifteen year perspective, J. Infect. Dis. 123:555-561
bling cytomegalic inclusion disease, Proc. Soc. Exp: (1971).
BioI. Med. 94:4-12 (1957). KRECH, U., JUNG, M., AND JUNG, F., Cytomegalovirus
121. WENZEL, R. P., MCCORMICK, D. P., DAVIES, J. A., Infections of Man, Karger, Basel, 1971.
BERLING, c., AND BEAM, W. E., JR., Cytomegalovi- WELLER, T. H., Cytomegaloviruses: The difficult years,].
rus infection: A seroepidemiologic study of a recruit Infect. Dis. 122:532-539 (1970).
population, Am. ]. Epidemiol. 97:410-414 (1973). WELLER, T. H., The cytomegaloviruses: Ubiquitous
122. WHEELER, E. 0., TURNER, J. D., AND SCANNELL, J. agents with protean clinical manifestations, N. Engl. ].
G., Fever, splenomegaly and atypical lymphocytes: Med. 285:203-214267-274 (1971).
Syndrome observed after cardiac surgery utilizing WRIGHT, H. T., JR., Cytomegaloviruses, in: The Herpesvi-
pump oxygenator, N. Engl. ]. Med. 266:454-456 ruses (ALBERT S. KAPLAN, ed.), Academic Press, New
(1962). York,1973.
CHAPTER 8
Enteroviruses
Joseph 1. Melnick
1. Introduction cation on the basis of further knowledge of bio-

physical and biochemical characteristics, the Inter-
The enterovirus group, named in 1957, (21) brought national Committee on Nomenclature of Viruses
together poJioviruses, coxsackieviruses, and has officially assigned family status (Picornaviri-
echoviruses, all of which inhabit the human ali- dae) to this larger taxon, with Enterovirus as one
mentary tract. These viruses share a number of genus, and Rhinovirus as another.(98a) Many pi-
clinical, epidemiological, and ecological character- cornaviruses of lower animals are also recognized,
istics as well as physical and biochemical proper- including the agents of foot-and-mouth disease of
ties. cattle and encephalomyocarditis virus of rodents.
Enteroviruses of human origin include the fol- In addition, certain plant and insect viruses
lowing: (e.g., tomato bushy stunt, turnip yellow mosaic,
acute bee paralysis viruses) have properties similar
1. Polioviruses: types 1-3. to those of the picornaviruses-as do some of the
2. Coxsackieviruses A: 23 types and several RNA-containing bacteriophages.
variants (coxsackieviruses AI-A24; coxsack- Many enteroviruses cause diseases in man rang-
ievirus type A23 is the same virus as echo- ing from severe and permanent paralysis to minor
virus 9). undifferentiated febrile illnesses. For all members
3. Coxsackieviruses B: types BI-B6. of the group, however, subclinical infection is far
4. Echoviruses: 31 types (types 1-33; echovi- more common than clinically manifest disease.
rus 10 has been reclassified as reovirus type Although certain enteroviruses have been more
1; and echovirus 28 as rhinovirus type lA). frequently responsible for epidemics involving a
5. Enterovirus types 68-71: these viruses specific syndrome, the same serotypes may at
would formerly have been classed as either other times and in other places be associated with
coxsackievirus or echovirus types (see Sec- sporadic infections having different clinical mani-
tion 2). festations or producing no symptoms. On the
other hand, different viruses may produce the
In 1963, the name picornavirus (pico = small; rna
same syndrome. For these reasons, clinical disease
= ribonucleic acid genome) was introduced as a is not a satisfactory basis for classification or-as a
larger grouping(SS) to which not only the enterovi-
rule-for diagnosis.
ruses but also the rhinoviruses would belong by
Poliomyelitis is an acute infectious disease
reason of fundamental similarities in many of their
which in its serious form affects the central nerv-
properties. With the advancement of viral classifi-
ous system. The destruction of motor neurons in
Joseph L. Melnick . Department of Virology and Epi- the spinal cord results in flaccid paralysis.
demiology, Baylor College of Medicine, Houston, Texas The coxsackieviruses produce a variety of ill-
163
164 ChapterS. Enteroviruses
nesses, including aseptic meningitis, herpangina, laboratory studies. Significant antigenic differ-
epidemic myalgia (pleurodynia, Bomholm dis- ences among poliovirus strains were documented,
ease), myocarditis, pericarditis, pneumonia, resulting in their separation into three serological
rashes, and common colds. They may also have a types; and it was discovered that polioviruses can
role in some congenital malformations, and per- be isolated and cultivated in vitro, in cell cultures
haps in some forms of diabetes. derived from primate nonneural tissue.
Aseptic meningitis, febrile illnesses with or The first strains of what are now known as
without rash, and common colds are among the coxsackievirus subgroup A were isolated by inoc-
diseases caused by echoviruses. ulation of infant mice with fecal material from two
Among the newer enterovirus types, enterovirus children suffering from paralysis during an epi-
68 has caused lower respiratory illnesses, enterovi- demic of poliomyelitis in 1948 in Coxsackie, New
rus 70 is the agent of recent epidemics of acute York.(29) Additional types, including the first of
hemorrhagic conjunctivitis, and enterovirus 71 has the coxsackieviruses of subgroup B, (97) were dis-
caused aseptic meningitis and encephalitis. covered shortly thereafter. Coxsackievirus B agents
Because polioviruses can cause the most severe were assoeiated with a syndromelike nonparalytic
disease of any for which enteroviruses are respon- poliomyelitis (aseptic meningitis) and also with
sible, these agents have received the most compre- epidemic myalgia and pleurodynia.(2BI Group A
hensive study and have served as models in stud- and B coxsackieviruses were distinguished by
ies of other enteroviruses. In this chapter, their differing pathological effects in baby mice
therefore, poliovirus studies are used frequently as (see Section 4).
illustrative of phenomena which also hold true for As soon as cultures of human and monkey cells
other enteroviruses. began to be used to search for polioviruses in stool
specimens of patients/lli still more unknown vi-
ruses were found which, unlike polioviruses and
the newly recognized coxsackieviruses, were not
2. Historical Background pathogenic for laboratory animals but produced
cytopathic effects in cultured cells. (8;.117)
A wealth of detailed information on the devel- It soon became apparent that these agents could
opment of knowledge about the enteroviruses is be isolated from healthy children(46.5o.85.113) as well
available in earlier reviews and text- as from patients with aseptic meningitis(78.1l7l and
books.(8.28.".80.81.82.1ltil Consequently, only a few of that multiple types existed.(78.1J;J) Because the rela-
the historic advances in knowledge of the entero- tionship of these newly recognized agents to hu-
viruses will be mentioned here; for more informa- man disease was unknown, and because they
tion, see Paul. (109a) failed to produce illness in laboratory animals,
Although crippling disease retrospectively rec- they were called "orphan" viruses or human en-
ognizable as paralytic poliomyelitis appears in teric viruses; later they became known as ECHO
records of early antiquity, it began to be described (enteric cytopathogenic human orphan) vi-
as a clinical entity only in the late eighteenth and ruses/ 201 a name subsequently simplified to
early nineteenth centuries, and became the subject "echoviruses. "
of intensified study after increasingly severe epi- In addition to their characteristic mouse patho-
demics began to appear in Europe and North genicity, certain of the coxsackieviruses were
America. Experimental work became possible with found to grow readily in tissue cultures; other
the successful transmission of the disease to mon- strains, serologically identical with the mouse-
keys in 1908 by Landsteiner and Popper.f<m Dur- pathogenic prototype, failed to produce paralysis
ing the next 40 yr, it was shown that the virus was in baby mice. Conversely, certain strains of echo-
regularly present in stools of patients, that subhu- viruses were found to be pathogenic for mice. As
man primates could be infected by the alimentary instances of such overlapping properties accumu-
route, and that strains could be adapted to growth lated, blurring the initial distinction made be-
in laboratory rodents, permitting an expansion of tween coxsackieviruses and echoviruses, it was
Chapter 8 • Enteroviruses 165
recommended(119) that subsequently, as new en- 3.2. Sources of Morbidity Data

terovirus types were discovered, they would sim-
ply be assigned sequential numbers, as enterovi- The sources of morbidity data for enteroviruses
rus 68, enterovirus 69, etc. The currently accepted are generally far from ideal in that most studies,
serotypes thus assigned are listed in Table 5 (Sec- necessarily conducted in localized or special
tion 8). groups, can only suggest what may occur in the
population generally. Results depend on the in-
dustriousness of the individual investigator, the
3. Methodology Involved in Epidemiological specific type of situation (e.g., military or institu-
Analysis tional), the means of data collection, and the
investigator's knowledge of prior reports in the
literature and his ability to relate his findings to
them.
In the United States, paralytic poliomyelitis, Many fruitful enterovirus studies have centered
aseptic meningitis, encephalitis, and any polio- around patients as they came to medical attention,
virus that is isolated are "notifiable," i.e., regu- or have been occasioned by outbreaks of illness;
larly required to be reported to local, state, and others have entailed observations of special popu-
national health officers. But among fatalities due to lations or have consisted of challenge experiments
enteroviruses, only poliomyelitis is generally con- with volunteers. Such investigations can yield val-
firmed by virus isolation. Thus, in deaths due to uable knowledge of routes of transmission, types
infections by other enteroviruses (such as ence- and severity of clinical illness that can be associ-
phalomyocarditis in infants), the virus responsible ated with infection, sites and duration of virus
may not be recognized unless testing facilities are excretion, and antibody responses.
available. Information reported to the U.S. Center But with a group of agents such as the enterovi-
for Disease Control is regularly and promptly cir- ruses, these studies have certain limitations: large
culated in the CDC Weekly Morbidity and Mortal- proportions of enterovirus infections are subclini-
ity Reports, and in special annual CDC surveil- cal and do not reach the attention of a physician; a
lance summaries on poliomyelitis, on aseptic single enterovirus serotype may produce a variety
meningitis and encephalitis, and on the viruses of syndromes, and a similar syndrome may be
being isolated and identified. produced by a number of different enteroviruses
In worldwide surveillance and reporting pro- as well as by members of other virus groups. In
grams of the World Health Organization, also, the special environments, especially in closed popula-
most consistently investigated enterovirus-associ- tions--e.g., children's homes or military training
ated fatalities are those involving poliomyelitis. centers where close contact, age homogeneity, and
However, increasingly broad and useful informa- unusual stresses are often involved-the patterns
tion is becoming available on other enterovirus of spread of infection may be atypical.
diseases (see Sections 3.2 and 5). Of considerable significance in filling this. gap in
The case fatality rate for poliovirus infection is the knowledge of viral ecology are studies typified
not easily determined because of the difficulties in by the Virus Watch Programs/ 35,3(;,';3) under which
diagnosing nonparalytic infections. In years of families living in normal circumstances have been
high prevalence, the case fatality rate may appear observed longitudinally over a period of years,
lower than in years of low prevalen<;,e because of with regular sampling, surveillance, and testing
the likelihood that nonparalytic poliomyelitis is procedures. In an open population, enlisted fami-
diagnosed more readily at times of epidemic prev- lies with children (or, in later periods of the
alence. The usual rate varies between 5 and 10% programs, those with a newborn infant) are main-
and is highest in the older age groups. In recent tained under continuing virological surveillance.
epidemics, in which a third of the cases occurred The principal objectives are to describe the occur-
in patients over 15 yr old, two-thirds of the deaths rence of enteric and respiratory viral infections and
were in this age group. or pOSSibly related illnesses and, by analysis of
166 Chapter 8 • Enteroviruses
such descriptive information, to determine for Even before the three serotypes of poliovirus
specific viruses or virus groups the mode and were completely delineated, and when tests for
pattern of intrafamilial spread, the relation of age antibodies could be conducted only in monkeys,
and immune status to both infection and disease, literature reports and serological surveys of a vari-
the nature of associated disease, and the frequency ety of popUlations around the globe were com-
with which it follows infection. pared with respect to antibody patterns. Through-
Virus Watch Programs serve as an important out the early studies of poliomyelitis, serological
guide for experimental design in which the family surveys continued to add essential pieces to the
is taken as the basic epidemiological unit, and in puzzle of poliovirus transmission, susceptibility,
which infection, rather than solely overt illness, is widely varying geographic and socioeconomic pat-
the focus of study. Some of the findings are terns of infection, duration of type-specific im-
included in Section 5. munity, and the shift of populations from endemic
Another important source of information con- to epidemic experience with the polio-
cerning virus infections on a global scale has come viruses. (108.109) It was found that the highest per-
into existence during the past decade, in the centages of persons possessing poliovirus antibod-
World Health Organization system for collecting ies were recorded among normal adolescents and
and distributing laboratory and epidemiological adults in tropical areas where some contemporary
information. Virus infections diagnosed by isola- "authorities" of the period believed that polio-
tion or serology are reported by WHO reference myelitis did not exist.
centers and national virus laboratories around the Today, serological surveys continue to have an
world, and the collated data are in tum distributed important role in maintaining protection against
by the WHO Virus Unit, Geneva (in WHO Weekly resurgence of epidemic poliomyelitis, by making
Epidemiological Records, WHO Quarterly and An- possible the surveillance of immunity levels. On-
nual Reports on Virus Isolations, and in other going, continuing serological surveillance is
special reports). By the end of 1973, more than 100 needed to answer such questions as the following:
laboratories in 37 countries were participating in Are significant proportions of the susceptible age
this scheme. Despite the limitations imposed by a group being reached and protected by vaccina-
wide diversity of laboratory methods, selective tion? Do the results of serosurveys parallel the
interests and responsibilities of various laborato- estimates from surveys of immunization history?
ries (e.g., a necessary sampling bias toward per- How well are antibodies induced by vaccination
sons with overt illness), and other problems inher- persisting over the years in comparison with their
ent in a program of this scope, these data are duration after natural infection? Since the answers
yielding indications of temporal trends in viral to these questions may vary from one locality to
infections, marked linkages of certain serotypes to another(;;J) and even within different population
specific clinical syndromes, trends in age inci- sectors of the same community/8;J) local immunity
dence, and other new knowledge about enteroviral patterns must be monitored to locate the specific
infections. A report by Assaad and Cockburn{J) age groups and sectors of the community in which
on the nonpolio enteroviruses reported during the declining antibody levels or failure to obtain vacci-
4-yr period 1967-1970 illustrates the very useful nation (particularly among disadvantaged inner-
analyses which can be developed on the basis of city children) is resulting in "protection gaps" (see
these WHO records (see Section 5). Sections 5 and 9).
Furthermore, despite the increasing availability
of effective poliomyelitis vaccines, there remain a
number of developing countries in which vaccina-
3.3. Serological Surveys
tion is not yet widely used. Serological surveys can
The science of serological epidemiology has determine whether patterns of naturally acquired
reached a high degree of sophistication in a rela- immunity are changing, and thus can alert the
tively short time, thanks to the pioneers who national health authorities to the growing need for
developed this field under exceedingly difficult vaccination before this need is made disastrously
conditions and with only crude tests available. clear by the occurrence of large epidemics.
Serological surveys of varying scope have con- early as 1940-1945,<76) consecutive tests of sewage
tributed data from which the history of local expo- samples reflected the seasonal prevalence of polio-
sure to enteroviruses can be read. For example, the viruses, showed that these viruses remain infec-
tests with serum collected from Eskimos in north- tive in flowing sewage for many hours, and dem-
ern Alaska(2) revealed a population heavily ex- onstrated that the viruses may be continually
posed to coxsackieviruses A4 and A10, less experi- present in sewage over'a period of several months.
enced with AI, and having no detectable previous Taken together with the incidence of clinical polio
experience with coxsackieviruses B1 and B2. In the in the community, the findings also provided a
early years of investigation of the nonpolio entero- basis for estimating the ratio of inapparent polio-
viruses, when only a few serotypes were known, virus infections to clinical poliomyelitis. From the
the proportion of seroconversions occurring in data obtained in New York City, this ratio turned
various age groups during a single year could be out to be well over 1:100.(7(;)
obtained by serological surveys conducted in a Numerous studies(o,7,)B.44,(;J,(;C;,7J,90) in developed
community before and after the summer-fall sea- countries have readily demonstrated the presence
son. The serological data, analyzed in conjunction of enteroviruses of all four subgroups in contami-
with virus isolations and monitoring of concurrent nated streams, in sewage, and in effluents from
illness patterns, yielded much of the information sewage treatment plants. In some localities, wild
now available concerning the age patterns, the polioviruses have continued to be present long
ease and routes of dissemination, and the ratio of after the introduction of oral poliovirus vaccine. In
inapparent infections to clinical illness.(90) one metropolitan area, at the same time as virulent
At present, however, general serological screen- polioviruses were revealed in the city streams,
ing to detect seroconversions or rises in antibody there was a small outbreak of paralytic poliomyeli-
titer against all possible enteroviruses is a virtual tis among unimmunized infants in the area.(B7l Of
impossibility, for such a general screening would special note is the fact that although methods
require tests against more than 70 enterovirus currently used for sewage treatment may slightly
antigens, in combined tissue culture and mouse reduce the amount of viruses present, they do not
systems (see Section 3.5). Epidemiological studies eliminate them from the effluent. In some cases,
to learn the current pattern of infection with enter- the concentration of virus in the effluent equals
oviruses in a community can much more easily be that in the influent sewage.
conducted by means of virus isolation and typing, Sampling of sewage reflects not only the pres-
since the availability of reference antiserum pools ence of enteroviruses but also the changes in
has vastly reduced the number of tests required to predominant serotypes from one period to an-
identify an isolate. other,WI,90) and has been used recently to assess
In instances where an epidemic due to a single the impact of oral poliovirus vaccine on the circu-
serotype is in progress, serological surveys can be lation of nonpolio enteroviruses. (52) Isolation of
usefully incorporated into well-planned and spe- virus from an open lake swimming area served as
cifically targeted prospective or retrospective epi- confirmation of a coxsackievirus B5 epidemic at a
demiological studies and can provide timely guid- summer camp, (49) and provided an indication of
ance for physicians in making presumptive the extent of the infections.
diagnoses of current illnesses. Portable methods and apparatus for concentrat-
ing virus from sewage and from surface water in
the field have been developed. (147) These methods
have as their primary purpose the monitoring of
3.4. Virus Isolation from Surface Waters as an the viral content of drinking and recreational
Indicator of Community Infections waters so as to protect communities from water-
borne viral disease and to permit the safe recycling
The enteroviruses are excreted so regularly and of water.(4) An important by-product of this work
abundantly in feces that their presence in sewage can be utilization of the methods to provide a
can provide a great deal of information about the more accurate index of the kinds and amounts of
circulation of these viruses in a community. As enteroviruses present within the community.
3.5. Laboratory Methods (which yield coxsackievirus A21 isolates more

readily than specimens from the throat). Virus
Detailed descriptions of standard laboratory may be recovered from throat swabs taken during
principles and procedures for investigation of en- the first few days of illness (or of silent infection),
terovirus infections are available in reference and from rectal swabs or stools for several weeks.
books and texts.(68,69,98,111,130,131l Background infor- Most echoviruses are excreted for shorter periods
mation and details on development of procedures than the other enteroviruses.
utilizing monkeys as well as tissue cultures may be In fatal cases of suspected enteroviral etiology,
found in earlier editions of the American Public virus should be sought in the organ system af-
Health Association textbook (1956 and 1964). fected (e.g., in spinal cord and medulla in polio; in
Epidemiological knowledge of the enterovirus myocardium, endocardium, and pericardial fluid
group-with its numerous members, frequency of in cardiac illnesses), as well as in colon contents.
silent infection, and variability of clinical manifes- Not all agents recovered from feces or orophar-
tations when these do occur-must depend in ynx are enteroviruses. Others which might be
large part on investigators' ability to identify the recovered are reoviruses, adenoviruses, rhinovi-
viruses isolated and to communicate accurately ruses, and measles, mumps, rubella, and herpes
with others studying the same or similar enterovi- simplex viruses. Many of these agents produce
ruses. This in tum rests upon the establishment of peculiar cytopathic effect (CPE), which at once
a common nomenclature for the viruses and upon differentiates them from enteroviruses. Several
the development of standard reagents, both refer- evoke fatal encephalitis in newborn mice.
ence virus strains and type-specific antisera. Early If the virus laboratory has experienced person-
in studies of enteroviruses, it was recognized that nel, a presumptive diagnosis of enteroviral infec-
cooperative development of standard reagents was tion can often be made on the basis of the nature
requisite to progress in understanding of entero- of the associated illness (if any), the time of year
viral disease. (20) During the past 20 yr, there has when the specimen was obtained, the tissue cul-
followed a steadily broadening series of collabora- ture (or mouse) system in which the virus isolate
tive studies among working virologists around the grew, and the characteristic cytopathic effect ob-
world to develop such reagents, These develop- served in the cultures or the characteristic pathol-
ments have been reviewed recently. (84) At pres- ogy induced in the mice. There is often value in
ent, standardized equine antisera against 42 enter- reporting a presumptive identification without
oviruses are available, combined into eight waiting for specific typing of the isolate. Despite
lyophilized antiserum pools (A-H) (see below). the fact that specific antiviral therapy is lacking at
Use of these pools greatly facilitates the identifica- present, early recognition of probable enteroviral
tion of enterovirus isolates. In addition, equine infection can provide information for the manage-
antisera against 19 coxsackievirus A serotypes ment of a patient or of a community outbreak of
have been collaboratively evaluated, and are avail- similar illnesses, and may serve to contraindicate
able also in the form of seven lyophilized combina- administration of unnecessary or undesirable anti-
tion pools (J-P). biotic therapy and to assist in narrowing the scope
3.5.1. Virus Isolation and Identification. The of diagnostic tests undertaken during an outbreak
usual specimens are stools, rectal swabs, throat of compatible illnesses.
swabs, or throat washings. In addition, cerebro- Most of the common enterovirus serotypes
spinal fluid (CSF) yields virus frequently in cases which are cytopathogenic can be recovered by
of aseptic meningitis due to coxsackieviruses or inoculation of specimens into primary cultures of
echoviruses, but seldom if this syndrome is due to rhesus monkey kidney cells, but it is becoming
a poliovirus (nonparalytic poliomyelitis). Polio- increasingly clear that at least one human tissue
viruses, and some coxsackieviruses and echovi- culture system must also be included if recovery of
ruses, have been detected in blood specimens all possible types is being attempted. Tubes
taken very early in infection. Virus may also be seeded with two types of tissue cultures have been
isolated from vesicle fluids, urine, conjunctival found useful in primary isolation attempts.(99a) In
swabs (enterovirus 70), and nasal secretions addition, inocu~ation of newborn mice must be
used if one is to detect those coxsackieviruses of containing its homotypic antiserum. The first sets
group A which cannot be cultivated in cell cul- of these LBM pools (pools A-H) now are available
tures. Among the human cell cultures that have in lyophilized form from the Research Resources
been reported as most sensitive for a broad range Branch (RRB) , National Institute of Allergy and
of enteroviruses are WI-38 (a cell line from human Infectious Diseases, Bethesda, Maryland, or from
embryonic lung), HEK (primary human embryonic WHO Virus Reference Centers. By using the pools
kidney), and various local cell strains. For examin accordance with standardized directions, to-
ple, WI-38 cultures more readily support growth of gether with five monovalent antisera, 42 enterovi-
echovirus 30 isolates, as well as a number of other ruses which grow readily in cell cultures can be
echovirus serotypes I22 ,30,45,60); however, in initial correctly identified. 19H ) Standardized equine mon-
isolation of polioviruses and coxsackievirus B ovalent antisera against the mouse-grown types of
types, HEK cultures far surpassed either WI-38 or coxsackievirus group A are also available through
combined HeLa cell and monkey kidney cell cul- the RRB. These have also been combined into
ture systems. (22 ) The RU-1 strain of human em- additional sets of pools (J-P) , incorporating 19
bryonic lung fibroblast cells established by the coxsackievirus A antisera in a scheme parallel to
Respiratory Virology Unit of the Center for Dis- that described above, and are available in lyophi-
ease Control, Atlanta, Georgia, was found in com- lized form. However, it is prudent to conserve
parative studies to detect more echovirus strains these reagent pools; therefore, if an epidemic due
(91 % of the isolates vs. 60%) than did primary to a single serotype is in progress, use of the single
rhesus kidney cultures; however, 9% of the iso- monovalent hyperimmune serum to identify most
lates would have been missed if the simian cell isolates is indicated.
cultures had not been used. (48 ) HI and CF tests have also been used to identify
It may not be in the best interest of the commu- enterovirus serotypes. Only about one-third of
nity or of an individual patient to attempt to enteroviruses agglutinate erythrocytes, and this
identify the specific serotype for every enterovirus limits the usefulness of this test for routine use.
isolate. The decision to proceed with type identifi- Likewise, all enteroviruses cannot be identified by
cation should be made after weighing the specific the CF test. A brighter hope for rapid identifica-
need that would be served. At the present time, it tion of enterovirus isolates may rest with immuno-
is probably sufficient in many instances for the fluorescent staining of viral antigensya(i) A new
physician or health officer to know simply that an technique utilizes combination antiserum pools in
enterovirus has been isolated. conjunction with indirect immunofluorescence to
For most enteroviruses, specific identification of detect type-specific enteroviral antigens in cere-
the serotype rests with serum neutralization test- brospinal fluid leukocytes of patients with aseptic
ing, although hemagglutination inhibition (HI), meningitisym The results could be available
complement fixation (CF), immunofluorescence, within hours after procurement of the CSF. In
precipitin, and other antigen/antibody reactions addition to speed, this method has the advantage
may be used in some instances. While the isola- of associating the enteroviral isolate more closely
tion of an enterovirus is simple and relatively with the illness than would isolation from stool or
rapid, its specific identification may be slow and throat.
expensive, if only mono specific hyperimmune sera If a virus isolate cannot be identified, it may
are used. However, identification of isolates has represent a new enterovirus or a mixture of vi-
been considerably simplified by the development ruses.
of internationally standardized hyperimmune 3.5.2. Tests for Antibody. Testing for presence
equine antisera l91l which are now incorporated of type-specific antibody against enteroviruses is
into combination antiserum pools constituted in a feasible only (1) when a known enterovirus isolate
pattern proposed by Lim and Benyesh-Melnick m from the patient is available and confirmation of
in such a way that a given antiserum appears the infecting serotype is necessary, (2) when a
either in one pool, in two pools, or in three pools. clinical picture such as pleurodynia clearly impli-
An unknown enterovirus may be identified by its cates a small number of antigens (in this case,
pattern of neutralization by the pool or pools usually group B coxsackieviruses) against which
serum should be tested, (3) when an epidemic due velop homotypic CF antibody. The test has,
to a single serotype is in progress, or (4) when a however, been used successfully in the diagnosis
seroepidemiological survey is being conducted to of poliovirus infections.
determine the community or study group history N (native) and H (heated) complement-fixing
of experience with a particular serotype or group antigens of poliovirus are described below (Sec-
(e.g., polioviruses). Otherwise, for initial determi- tion 4). In the course of poliomyelitis infection, H
nation of a current infection in a patient or a antibodies form before N antibodies, and subse-
locality, virus isolation is far simpler, and is rec- quently the level of H antibodies declines first.
ommended. Early acute-stage sera thus contain H antibodies
For any purpose except a serological survey, only; 1-2 wk later, both Nand H antibodies are
paired serum specimens are required; the first present; in late convalescent sera, only N antibod-
sample must be taken as early as possible in the ies are present. Only first infection with poliovirus
course of the illness or infection, the second 3-4 produces strictly type-specific complement fixation
wk later. responses. Subsequent infections with heterotypic
The neutralization test is accurate and type-spe- polioviruses recall or induce antibodies, mostly
cific, and is at present the test commonly used for against the heat-stable antigenic components
most enteroviruses (for polioviruses, the comple- shared by all three types of poliovirus, i.e., against
ment fixation test has some advantages-see be- the poliovirus group antigen. Very high CF anti-
low). Acute and convalescent sera are usually body levels against a poliovirus are strongly
tested simultaneously, using various dilutions of suggestive of a recent infection.
serum against a constant amount of the specific After a coxsackievirus infection, patients may
virus. Serum titers are calculated on the basis of develop complement-fixing antibodies to a num-
the dilution of serum which neutralizes a given ber of both group A and group B agents, and
amount of virus, and a fourfold or greater rise in heterotypic echovirus CF antibody responses also
antibody titer is considered significant-indicative are common.
of an infection during the period covered. How- The HI test is relatively easy to perform and
ever, it should be noted that neutralizing antibody patients who become infected with an enterovirus
titers may already be high at the time of onset of which hem agglutinates do develop homotypic an-
clinical symptoms, making interpretation difficult; tibody, which may persist for years. They also
if neutralizing antibody titers are found to be may develop heterotypic antibody, making the test
equally high in both acute and convalescent speci- somewhat nonspecific. The major drawback to the
mens, the infection might have taken place either HI test, however, is that only about one-third of
recently or many years before, as neutralizing the known enteroviruses agglutinate erythrocytes;
antibody to any of the enteroviruses persists for even within a single serotype, some strains may
years if not for life. In addition to the homologous hemagglutinate while others do not.
antibody, antibodies against other enterovirus It is possible to detect and titrate serum anti-
types may appear transiently and at low levels. In body against enteroviruses, using the immunoflu-
poliovirus infections, neutralizing antibody also orescence technique. Infected coverslip cultures for
may be found in the urine. use as a source of antigen may be prepared and
Other serological tests which may be used in- kept frozen at - 20'C for at least 1 yr, making this
clude complement fixation (CF), hemagglutination test readily available for rapid diagnosis.m. 1all
inhibition (HI), immunofluorescence, and passive A new test, originally developed to screen for
hemagglutination. rises in antibody to rhinoviruses,'a;n has been
CF antibodies appear during the course of an found to be effective for detecting rises in anti-
infection, but may disappear or drop to a low level body titer to enteroviruses. This test, a passive
within a few months. For most enteroviruses, the hemagglutination test, relies on the use of a cou-
CF test has little value because of major hetero- pling reagent, chromic chloride, to attach proteins
typic cross-reactions among the enterovirus anti- to indicator erythrocytes. It has made possible the
gens, and because many individuals fail to de- hemagglutination of red blood cells by antigens
which otherwise do not demonstrate this property. in cells of human origin (embryonic human kid-
The technique has been utilized as a screening test ney, human diploid cell strains). In cesium chlo-
using paired sera collected during an epidemic of ride, enteroviruses have a density of 1.34 g1ml,
coxsackievirus B5. 01]) whereas rhinoviruses have a density of 1.4 g1ml.
Enteroviruses and some rhinoviruses can be stabi-
lized by magnesium chloride against thermal inac-
tivation.
4. Biological Characteristics of Virus
Affecting the Epidemiological Pattern 4.2. Reactions to Chemical and Physical Agents
Enteroviruses are resistant to all known anti-
4.1. General Properties
biotics and chemotherapeutic agents. Laboratory
Enteroviruses share the basic properties of Pi- disinfectants, such as 70% alcohol, 5% Lysol, or
cornaviridae including a genome of single- 1 % qua.ternary ammonium compounds (Roccal),
stranded RNA, small size (20-30 nm diameter), are ineffective. The viruses are insensitive to
lack of an envelope (Le., a "naked" nucleocapsid), ether, deoxycholate, and various detergents,
and insensitivity to ether and other lipid solvents, which destroy other viruses (arboviruses, myxovi-
indicating lack of essential lipids. The molecular ruses, etc.). Treatment with 0.3% formaldehyde,
weight of the nucleic acid is 25-2.8 million, con- 0.1 N HCI, or free residual chlorine at a level of
stituting about 30% of the particle mass. It has 0.3-0.5 ppm causes rapid inactivation, but the
been estimated that picornaviruses have 12 genes, presence of extraneous organic matter protects the
in contrast to 400 estimated for the large poxvi- virus from inactivationY42) Thus caution must be
ruses. The virus matures in the cytoplasm. Infec- exercised before carrying over laboratory findings
tive nucleic acid has been extracted from several on the chlorination of enteroviruses, often in puri-
enteroviruses and rhinoviruses. Because it is freed fied form, to chlorination under natural condi-
of the surface protein antigen, such RNA cannot tions. Enteroviruses are inhibited from propagat-
be neutralized by antiserum against the intact ing in cell cultures by 2-(a-hydroxyben-
virus. zyl)benzimidazole (HBB) , with the exception of
Enteroviruses and rhinoviruses differ in a num- group A coxsackieviruses 7, 11, 13, 16, and 18 and
ber of properties, but the most useful and reliable echoviruses 22 and 23.(140) Guanidine is also a
feature in distinguishing these two genera within potent inhibitor of polioviral (and other entero-
the Picornaviridae is sensitivity to acid: enterovi- viral) synthesis in cell cultures. However, viral
ruses are stable at acid pH (3-5) for 1-3 h, whereas progeny grown in the presence of guanidine be-
rhinoviruses are acid-labile. Rhinoviruses multiply come resistant to the drug, (89) and further passage
chiefly in the nose and throat, and can be re- results in selection of strains which are drug-
covered from these sites but only rarely from fecal dependent. (134)
specimens, while enteroviruses, inhabitants of the Exposure of these viruses to a temperature of
alimentary tract, may be isolated from the lower 500C destroys them rapidly. However, in the pres-
intestine or the throat. Enteroviruses grow readily ence of molar magnesium chloride, virtually no
in stationary cultures at 36-37"C, but initial growth detectable inactivation occurs in 1 h at 500C. (144)
of rhinoviruses in primary fetal cell cultures is Enteroviruses are stable at freezing temperatures
favored when cultures are incubated on roller for many years and remain viable for weeks at
drums at 33°C. Among the enteroviruses which are icebox temperatures WC) and for days at room
cytopathogenic (polioviruses, echoviruses, and temperature. Their inactivation at all temperatures
some coxsackieviruses), growth can usually be is inhibited by magnesium chloride.
obtained readily in primary cultures of human and Enteroviruses are rapidly inactivated by ultravi-
monkey kidney cells and in certain cell lines (such olet light and usually by drying, unless special
as HeLa or, for some serotypes, WI-38); in contrast, conditions are observed. Vital dyes (neutral red,
most rhinoviruses can only be recovered initially acridine orange, proflavine) when. incorporated
into the structure of these viruses render them of double-diffusion gel precipitation tests now
readily susceptible to visible light. (t28.145) indicates that strains of both types share a com-
mon antigen, and that, in addition, some strains
possess a second antigen relating them more clo-
4.3; Antigenic Characteristics
sely to one or the other of the prototype
Poliovirus types 1 and 2 share common anti- strains. (47) The reaction is not like that of the
gens. Intratypic strain differences are known for all classical prime relationship, but is similar to anti-
three poliovirus serotypes, and pronounced intra- genic variations described for echoviruses 4 and 9.
typic variation has been encountered among both For enteroviruses, there has been little docu-
coxsackie- and echoviruses. mentation of any long-term trends in antigenic
With some enteroviruses, antigenic variation alterations of serotypes like those seen with influ-
resulting in the appearance of prime strains is enza viruses. Such a trend may be suggested,
encountered. (79) The prime strain is poorly neu- however, by recent observations that strains of
tralized by antiserum to the originally character- coxsackievirus B5 isolated in 1973 from patients in
ized (prototype) strain, but it induces the produc- the United Kingdom are very different antigeni-
tion of antibody which neutralizes the prime cally from the prototype B5 virus (Faulkner strain),
strain and the prototype strain equally well. The isolated in 1952. Not only were wide differences
prime strains, however, share CF antigens with observed in immunodiffusion and neutralization
their prototypes. tests, but also RNA hybridization procedures
Another problem has been the difficulty of dem- showed current human strains to have 100% ho-
onstrating neutralization of certain strains. For mology with each other, but only 50% homology
example, as recognized soon after the discovery of with the prototype Faulkner strain,(JO) a difference
the enteroviruses, the prototype echovirus 4 strain of the same order as that found between different
(Pesascek) is poorly neutralized by homologous serotypes of poliovirus. In addition, a newly dis-
antisera. The Du Toit strain is much more sensi- covered enterovirus causing swine vesicular dis-
tive and is preferred for neutralization tests. The ease has been shown to be closely related antigen-
poor neutralization of the Pesascek strain was ically to human coxsackievirus B5. (9.10.43) In RNA
shown to be due to aggregation of viral particles; hybridization tests, the porcine virus showed
virus in nonneutralizable aggregates was found to about 50% homology with human strains. The
constitute up to 30% of untreated Pesascek stock serological relationship, together with evidence
preparations, but only 0.1% of Du Toit. With indicating that the virus has only recently infected
monodispersed virus obtained by filtration swine, has led to the suggestion that the swine
through Millipore membranes of npropriate po- virus may have originated rather recently, by
rosity, efficient neutralization of Pesascek strain transmission of a human B5 strain to the porcine
can be obtainedY46) This phenomenon still exists species. (43)
among the enteroviruses, for in a current example Associated with the above RNA genomic
successful neutralization of the Swedish strains of changes are changes in the polypeptide composi-
enterovirus 71 also depended on the use of mono- tion of the new coxsackievirus B5 isolates compared
dispersed virus. (Ha) to the 1952 prototype virus. Similarly, such differ-
A number of cross-relationships exist between ences exist in the swine viruses of 1966-1971 and
several enteroviruses; for example, coxsackievi- those of 1972-1973. In the same year, however, a
ruses A3 and A8; All and A15; A13 and A18; swine virus from France and a human isolate of
echoviruses 1 and 8; 12 and 29; 6 and 30; and coxsackievirus B5 have shown virtually identical
polioviruses 1 and 2 to a minor degree. The cross- pattems.(46al Further work is necessary to establish
reactions that have been previously observed be- the pathological and epidemiological significance
tween echovirus types 1 and 8, chiefly in the of these variations.
serum neutralization test, have been documented Complement-fixing antigens are known for each
in detail recently, along with antigenic diversity of of the three poliovirus serotypes. They may be
strains within each of these serotypes. Investiga- prepared from tissue culture or infected CNS.
tion of a number of strains of each type by means Inactivation of the virus by formalin, heat, or
ultraviolet light liberates a soluble complement- monkeys can also be infected by the oral route; in
fixing antigen. This antigen is cross-reactive and chimpanzees, the infection thus produced is us-
fixes complement with heterotypic poliomyelitis ually asymptomatic. The animals become intestinal
antibodies. A type-specific precipitin reaction oc- carriers of the virus; they also develop a viremia
curs when virus in sufficient concentration is used that is quenched by the appearance of antibodies in
with immune animal or convalescent human sera. the circulating blood. Unusual strains have been
Two type-specific antigens are contained in polio- transmitted to mice or chick embryos.
virus preparations and can be detected by precipi- Most strains can be grown in primary or contin-
tin and CF tests. They are called D and C, or Nand uous cell line cultures derived from a variety of
H. The D antigen occurs as a band in the more human tissues or from monkey kidney, testis, or
dense regions of a sucrose density gradient and muscle.
comprises most of the virus infectivity. The upper Coxsackieviruses are highly infective for new-
band containing the C antigen has little infectiv- born mice. Certain strains (BI-B6, A7, A9, A16)
ity. The virus in the D zone appears intact in also grow in monkey kidney cell culture. Some
electron micrographs and contains 20-25% RNA, group A strains grow in human amnion cells.
whereas that in the C zone is damaged and con- Coxsackieviruses AI, A5, A6, A19, and A22 have
tains little or no RNA. There is a direct relation- not yet been grown successfully in any cultures,
ship between the amount of D antigen, measured and must be cultivated in newborn mice. Chim-
by complement fixation, and the number of intact panzees and cynomolgus monkeys can be infected
physical particles of poliovirus as counted by elec- subclinically; virus appears in the blood and throat
tron microscopy. The two antigens are also known for short periods and is excreted in the feces for 2-
as Nand H (native and heated). Heat changes N 5 wk. Type AI4 produces poliomyelitis-like lesions
(or D) preparations from complete virus particles in adult mice and in monkeys, but in suckling
to empty particles when viewed in the electron mice this type produces only myositis. Type A7
microscope. strains produce paralysis and severe CNS lesions
Several coxsackieviruses and echoviruses agglu- in monkeys.(27.14~)
tinate human type 0 erythrocytes. The hemagglu- Group A viruses produce widespread myositis
tinins are associated with the infectious viral par- in the skeletal muscles of newborn mice, resulting
ticles: both are sedimented together by in flaccid paralysis without other observable le-
ultracentrifugation and are also adsorbed together sions. Group B viruses can produce a myositis
by red cells during hemagglutination. About one- which is more focal in distribution than that
third of the known enteroviruses have this prop- produced by viruses of group A, but they also give
erty, and antibodies against the virus can be rise to a necrotizing steatitis involving principally
measured by hemagglutination inhibition. (42.118) the maturing fetal fat lobules (interscapular pads,
cervical and cephalic pads, etc.) Encephalitis is
found at times; the animals die with paralysis of
4.4. Host Range in Vivo and in Vitro
the spastic type. Some B strains also produce
The host range of the enteroviruses varies pancreatitis, myocarditis, endocarditis, and hepa-
greatly from one type to the next, and even among titis in both suckling and adult mice. The corticos-
strains of the same type. They may readily be teroids may enhance the susceptibility of older
induced, by laboratory manipulation, to yield var- mice to infection of the pancreas. Normal adult
iants which have host ranges and tissue tropisms mice tolerate infections with group B coxsackievi-
different from those of certain wild strains; this ruses, but in mice subjected to sustained post-
has led to the development of attenuated poliovac- weaning undernutrition (marasmus) B3 virus pro-
cine strains. duces severe disease, including persistence of
Polioviruses have a very restricted host range infective virus in the heart, spleen, liver, and
among laboratory animals. Most strains will infect pancreas. Lymphoid tissues are markedly atrophic
only monkeys and chimpanzees. Infection is initi- in marasmic animals. Transfer of lymphoid cells
ated most readily by direct inoculation into the from normal mice immunized against the virus
brain or spinal cord. Chimpanzees and cynomolgus provides virus-infected marasmic mice with sig-
nificant protection against the severe sequelae. very precise quantification of infective virus, re-
These observations support the hypothesis that quired for many laboratory research studies of
lymphocyte-mediated defense mechanisms may enteroviruses. (sa)
play an important role in normal recovery from The factors underlying cell susceptibility to en-
primary viral infections. teroviruses are basic to understanding host sus-
In order to be included in the echovirus group, ceptibility to infection. Human cells possess a
prototype strains must fail to produce disease in receptor to poliovirus and can therefore be in-
suckling mice, in rabbits, or in monkeys. How- fected and killed by the virus. Rodent cells do not
ever, different strains can produce variants which possess the receptor and cannot be infected by
exhibit animal pathogenicity. A number of the polioviruses unless the viruses have been altered
echoviruses have produced inapparent infections by laboratory cultivation. But in human-rodent
in monkeys, with mild lesions in the CNS.(I49) In hybrid cells, possession of a human gene for the
the chimpanzee, no apparent illness is produced, poliovirus receptor was found to be sufficient to
but infection can be demonstrated by the presence enable the virus nucleic acid to enter the cell, and,
and persistence of virus in the throat and in the once this first step had been taken, the virus then
feces and by type-specific antibody responses.(S6) multiplied without the mediation of any further
Initially, echoviruses were distinguished from human gene products, the rodent genetic appara-
coxsackieviruses by their failure to produce patho- tus being sufficient for its needs. The human
logical changes in newborn mice, but echovirus 9 chromosome carrying the gene concerned with
can produce paralysis in newborn mice. Con- poliovirus reception was identified by making use
versely, strains of some coxsackievirus types (es- of human-rodent hybrid cells which differ in their
pecially A9) lack mouse pathogenicity and thus complement of human chromosomes. In these
resemble echoviruses. This variability in biological studies, it was found that some of the human
properties is the chief reason why new enterovi- chromosomes were shed after hybridization. Only
ruses are no longer being subclassified as echo- or when chromosome 19 was lost did the cells lose
coxsackieviruses. Although most of the common their susceptibility to poliovirus.(9") This implies
echoviruses can be isolated in primary monkey that chromosome 19 carries all the information
kidney cell cultures, strains of a number of the necessary for acceptance of poliovirus by a human
serotypes grow more readily in human cell cul- cell, and suggests that only a single gene codes for
tures (see Section 3.5). the receptor protein.
There are four new enteroviruses, types 68-71, Recent studies have been concerned with the
all of which grow in monkey kidney cell cultures. transfer of functional DNA from monkey cells to
Three of these are known to cause human disease hamster cells, after which poliovirus was able to
(types 68, 70, and 71). Enteroviruses 70 and 71 attach to the hamster cells. (86) The membrane
were isolated in human cell cultures and subse- alterations that allowed attachment of poliovirus
quently adapted to monkey kidney cultures (see were also associated with simian antigens that
Table 5 and Section 8.1.4 for details). appeared on the surface of the hamster cells. The
The growth of enteroviruses in monolayers of changes were present for several divisions of the
cultured cells is generally associated with a charac- rodent cells, but did not prove to be permanent,
teristic cytopathic effect (CPE). (lIS) Infected cells suggesting that the monkey DNA was not incor-
round up, show shrinkage and marked nuclear porated into the hamster cell chromosomes.
pyknosis, become refractile, and eventually degen-
erate and fall off the glass surface. In cell cultures
4.5. Replication of Enteroviruses
covered by fluid nutrient medium, virus may
spread via the fluid bathing the cells. Under agar The replication of poliovirus provides useful
overlay, which confines the spread of virus to a insights into its transmission, its in vivo and in
cell-to-adjoining-cell route, plaques of degenerat- vitro host range, and its relatedness to other entero-
ing cells are formed by various members of the viruses. The essential theme of viral replication is
enterovirus group in cultures of susceptible cells. that specific messenger RNA (mRNA) must be
Methods utilizing plaque formation have provided transcribed from the viral nucleic acid for success-
ful expansion and duplication of genetic informa- Comparison of the genomes of representative
tion. Once this is accomplished, viruses use cell polioviruses, coxsackieviruses of subgroups A and
components to translate the mRNA. In the replica- B, and echoviruses by RNA hybridization has
tion of poliovirus, all steps are independent of shown at least 5% of the genome to be shared by
host DNA and occur in the cell cytoplasm. all of the enteroviruses testedY57) In these recent
Polioviruses adsorb to cells at specific cell recep- studies, the polynucleotide sequence relationships
tor sites. This is evidenced by the fact that intact were consistent with the biological classification of
poliovirus infects only primate cells in culture, enteroviruses into subgroups (polioviruses,
whereas the isolated RNA will also infect nonpri- coxsackieviruses A and B, and echoviruses). In
mate cells (rabbit, guinea pig, chick) and complete general 30-50% of the nucleotide sequences were
one cycle of multiplication. Multiple cycles of infec- shared by different serotypes tested within each
tion are not observed in nonprimate cells because subgroup, whereas among the different groups
the resulting progeny possess protein coats and there was less than 20% homology. However, the
will again infect only primate cells. After attach- coxsackievirus B studied (B4) appeared to be more
ment, the virus particles are taken into the cell, closely related to echoviruses than to group A
and the viral RNA is uncoated. The single- coxsackieviruses, while polioviruses were only
stranded genomic RNA can then serve as its own distantly related to any of the other enteroviruses
messenger RNA. This messenger RNA is trans- tested.
lated, resulting in the formation of an enzyme, Other investigations into the mechanisms and
RNA polymerase, necessary for the formation of a the intermediate products of replication of entero-
replicative form, which is a double-stranded mole- viruses and of other picornaviruses have been
cule consisting of the parental RNA strand and a conducted. On the basis of some of these data, it
complementary strand, and also for the formation has been proposed that the picornavirus family
of inhibitors that tum off the synthesis of cellular could be divided into at least four major
RNA and protein. The number and nature of these subgroups: (1) the enteroviruses, (2) the rhinovi-
inhibitors are not known. Single-stranded viral ruses, (3) the cardioviruses (encephalomyocarditis,
RNA molecules, + -strands, are then synthesized EMC), and (4) foot-and-mouth disease viruses of
from the replicative form, first appearing as par- cattle. Several laboratories have been involved in
tially completed strands on the replicative inter- identifying the virus-specific polypeptides of
mediate. The newly synthesized +-strand RNA poliovirus and other picornaviruses and the post-
molecules perform any of the three following func- translational mechanisms by which they are pro-
tions: (1) serve as messenger RNA for synthesis of duced. Several lines of evidence suggest that the
structural proteins, (2) serve as template for con- picornaviral RNA possesses a single initiation site
tinued RNA replication, or (3) become encapsi- and that, once initiated, each ribosome completes
dated, resulting in mature progeny virions. The translation of the entire viral RNA. This property
synthesis of viral capsid proteins is initiated at has facilitated the genetic mapping of these vi-
about the same time as RNA synthesis. ruses. (13)
The entire poliovirus genome acts as its own The genetic map has been determined wholly or
mRNA and is translated to form a single large in part for EMC virus, rhinovirus, and poliovirus,
polypeptide which is subsequently cleaved to pro- and recently a comparative study was conducted
duce the various viral capsid polypeptides. Com- with these three viruses in terms of the genetic
pletion of encapsidation produces mature virus map of each, the molecular weights of the different
particles which are then released when the cell viral polypeptides, and the rates of cleavage of
undergoes lysis. several analogous polypeptides. (13) Previous work
Despite the relatively limited information on has shown that there are three main families of
which the establishment of the enterovirus group EMC virus-specific polypeptides. Translation of
was originally based and its subgroups were de- the EMC viral ribonucleic acid generates at least
fined, the validity of these groupings is being three primary products, termed polypeptides A, F,
borne out by current studies which utilize sophis- and C. Polypeptide A undergoes successive cleav-
ticated techniques of modem molecular virology. ages to produce the four major capSid polypep-
tides. Polypeptide F is stable, and polypeptide C learned about the molecular biology' of the virus.
cleaves to form polypeptide D, which in tum Although this knowledge did not contribute di-
cleaves to form polypeptide E. Comparison of rectly to the vaccine's success, it turned poliovirus
EMC virus with rhinovirus and poliovirus indi- into a useful model for studies in molecular biol-
cates that evolutionary pressures on these different ogy. Even if wild polioviruses were completely
members of the picornavirus family have resulted eradicated, and polio vaccines were 100% effec-
in extensive differences in antigenicity of the vi- tive, polioviruses would continue to be agents of
rions; furthermore, each profile had polypeptides great interest and usefulness to virologists. Be-
that were unique to that particular virus, and cause they have been so fully studied, and because
analogous cleavages proceeded at considerably they are small and relatively simple viruses, they
different rates for the different viruses studied. have served and will continue to serve as models
But, as judged by the results of this study, many for understanding the nature of viruses, and their
common features have been retained in the evolu- structure, function, replication, and genetics.
tion of these viruses, including the general mecha- Poliovirus may, for example, be the first animal
nism of synthesis and the size and genetic order of virus for which a complete genetic map will be
the three principal families of polypeptides. constructed.(2;l) As another example, at this writ-
Double neutralization of virus particles obtained ing, 20 yr after publication of the first papers on
from mixed infections has been observed. Us- attenuation of wild poliovirus for vaccine pur-
ually-and particularly for antigenically distinct poses,!a2.77.124l papers are appearing on the unin-
virus types such as influenza viruses A and B, or hibited translation of virus-specific messenger
polioviruses types 1 and 2-the doubly antigenic RNA under conditions where host cell translation
virus proved to be unstable on passage, suggest- is stopped. In such studies, cell-free protein-syn-
ing that the phenomenon could be explained by thesizing systems that initiate on endogenous
phenotypic mixing. Phenotypic mixing has also messenger RNA have been developed from unin-
been found to occur between an echovirus and a fected and poliovirus-infected human cells. Polio-
coxsackievirus. am Virus particles containing anti- virus double-stranded (replicative) RNA was found
gens of both viruses were obtained which on to be an inhibitor of protein synthesis in these
passage segregated into parental types. The phe- extracts, both of cell-directed and of virus-specific
notypically mixed particles may be regarded as protein synthesisym One may be certain that
having an additional surface antigen heterologous studies in this area 035J will continue to shed light
to the genetic core, or mosaic surface antigens on the molecular regulation of cellular as well as
composed of the two parental types. A single viral growth.
particle with two distinct genetic cores (one of
each virus) and mixed antigenic coats would also
be expected to behave like a phenotypic mixture,
i.e., be doubly neutralizable but on passage breed 5. Descriptive Epidemiology
the pure parental types. Recently, the protein of a
plant virus (cowpea chlorotic mottle virus) has
5.1. General Epidemiology of Enteroviruses
been shown to be able to encapsidate in vitro the
genome of poliovirus, to form a particle known as 5.1.1. Incidence and Prevalence. The epidemiol-
a pseudovirion. (5) When assayed in the presence ogical markers of the diseases associated with the
of DEAE-dextran to facilitate entrance into suscep- enteroviruses are based on the occurrence of a
tible human cells in cultures, the polio pseudovi- clinical syndrome sufficiently characteristic to be
rions were about 50 times more infectious than recognized, such as paralysis in poliomyelitis or
poliovirus RNA itself. This suggests that the en- the lesions of the hand, foot, and mouth syndrome
capsidation of the polio genome in a foreign coat of echovirus 16, or on the occurrence of an out-
protected the RNA from destruction by cellular break of aseptic meningitis or of an exanthem in
nucleases. which the causative enterovirus has been isolated.
In the course of work which led to the control of The epidemiological markers of the presence in the
poliomyelitis through vaccination, a great deal was community of infection due to enteroviruses in-
clude the prevalence of the virus in the stools of from 1081 to O. (data obtained from W. C. Cockburn
healthy persons or in the sewage serving the area, and S. G. Drozdov, WHO/1968 and reference 43a).
and the prevalence of antibody as detennined by Outbreaks of infection with coxsackieviruses
serological surveys. and echoviruses have occurred frequently in a
In considering enterovirus epidemiology, it is wide variety of places and years, and continue to
important to reemphasize that by far the most do so. A large number of strains of both groups of
common fonn of infection with any of these vi- viruses have been involved in such epidemics.
ruses is a mild or silent episode and that severe These outbreaks have been mostly localized to one
manifestations are rare. Paralytic poliomyelitis re- area, although one epidemic of echovirus 9 in the
mained an epidemiological enigma until this con- late 1950s had almost worldwide distribution.
cept was developed.o s,lSl) It must also be kept in With most nonpolio enteroviruses, the pattern of
mind that clinical features presented by infections infection for a specific serotype in a particular
with the different serotypes may be similar and locality resembles that of poliomyelitis: (1) There
that manifestations of infections with the same may be local serotypes which are endemic, con-
serotype may vary widely. stantly circulating among the few nonimmunes;
The pattern of incidence and prevalence, the age these are mostly very young children, since vir-
at the time of infection, and the nature of the host tually all of the older children and adults already
response are the consequences of a number of have protective antibody from previous infections.
interdependent variables whose common denomi- (2) Or specific serotypes may be completely absent
nator is probably the opportunity for exposure, from a particular locality or very limited in dis-
along with the hygienic level under which such semination for a number of years (see· examples
exposure occurs. These interdependent variables below); a population of susceptibles then builds
include geographic area, climate, and socioeco- up, and a wave of wide and rapid spread of the
nomic setting. virus may occur, reaching a large proportion of all
5.1.2. Epidemic and Endemic Behavior. In the age groups. Dissemination of different serotypes
prevaccine era, epidemics of poliomyelitis oc- may thus occur in waves, with one predominant
curred with great frequency in the economically type in an area succeeding another from one year
advanced countries of the world. In the United to the next or even within the same summer-fall
States, the first sizable outbreak was recognized in season.
Vennont in 1894 and involved 132 cases; it was by As an example of the above phenomenon, in the
far the largest number of cases ever reported in United Kingdom and the Republic of Ireland dur-
anyone year anywhere in the world. In the first ing 1960-1969, a number of echovirus types were
half of the twentieth century, recurrent outbreaks isolated sporadically and in relatively small num-
involved the "developed countries" of the world, bers,os2) In 1968, continuing into 1969, there was
such as the United States, Canada, Australia, and an epidemic of type 6 infections, and type 6 was
European and Scandinavian countries. by far the one most frequently recovered during
Great reductions in epidemic incidence occurred 1968 (about 40% of all echovirus isolates reported);
after the introduction of polio vaccine in 1955. In in 1969, echovirus type 9 also became epidemic,
the period 1951-1955, an average of almost 38,000 accounting for about 40% of the echovirus isolates
cases of poliomyelitis (approximately 16,000 paraly- in that year. In the latter epidemic, one-fourth to
tic) were reported annually in the United States; one-third of all the cases occurred in Scotland. In
from 1961 to 1965 the annual average was 570 cases 1971, however, about 60% of the echovirus isolates
(460 paralytic). After live attenuated vaccines were in the United Kingdom were echovirus type 4,
widely administered in the United States during which in previous years had been responsible for
1962-1963, even further reductions took place (see only about 5% of the echovirus reports. These
Section 5.2.3). Similar reductions from 1951-1955 to infections were mainly confined to northern and
1961-1965 followed vaccination in other countries: northwestern regions of England, and to Scotland
in the United Kingdom from 4381 to 322, in Aus- and Ireland. Significantly, in view of the limited
tralia from 2187 to 154, in Denmark from 1614 to 77, previous circulation of echovirus 4, a large share of
in Sweden from 1526 to 28, and in Czechoslovakia the isolations were from older children and young
adults. It should be noted that the infections ly distributed throughout the year. In temperate
selected for laboratory investigation may be biased climates, they are present at low levels in winter
toward significant illnesses; it seems probable that and spring, but are encountered far more com-
the younger children were also experiencing wide- monly during summer and fall. Some outbreaks of
spread infection but that overt illness more fre- enteroviral infection have continued from fall into
quently brought the older groups to clinical atten- winter months; winter outbreaks have been re-
tion. In 1971, echovirus 6 accounted for only 3% of corded, but they are rare.
all UK isolates; echovirus 9 accounted for 2%. Climate appears to be an important factor in the
During this period, coxsackievirus A9 was al- circulation and prevalence of enteroviruses. Even
most always the most frequent serotype reported within the climate range represented in the conti-
in the United Kingdom, constituting 35-55% of nental United States, healthy children in southern
the group A isolates. Coxsackievirus A16 was cities harbor a greater abundance of enteroviruses
frequently reported in most years, but tended and a wider variety of antigenic types than do
toward epidemic prevalence every 3 yr: peaks of those of comparable age in northern cities. Re-
dissemination were recorded in 1964, 1967, 1970, peated tests on the stools of 136 healthy preschool
and again in 1973. In 1970, about 57% of the children in Charleston, West Virginia, over a pe-
coxsackie A isolates were of the A16 type. Coxsack- riod of 29 months indicated that 90% of the
ieviruses B2, B3, B4, and B5 also appeared to be cytopathogenic enteroviruses were recovered dur-
somewhat cyclical in the United Kingdom, in pe- ing the summer and the autumn months and that
riods of 3-6 yr; B1 did not share this periodicity, the incidence was 3-6 times higher in the lower
and usually was isolated in lower numbers, al- socioeconomic than in the middle to upper middle
though an epidemic due to this virus occurred in class districts; 52% of the viruses recovered be-
1970; type B6 was rarely reported. longed to the echovirus group(79) (see Table 3). In
An example of very rapid succession of different areas farther south, such as Phoenix, Arizona, (79)
enterovirus serotypes in a small community has and Louisiana,!40) the prevalence of enteroviruses
been well documented.(J()!.15(l) In the course of among healthy children was more evenly distrib-
1968-1971, six outbreaks of febrile viral disease uted throughout the year but still markedly higher
with respiratory and gastrointestinal symptoms during the months of May to October. Subsequent
occurred in a Israeli kibbutz of about 450 mem- studies on enterovirus excretion rates in young
bers, and were differentiated by correlated clinical, children in Seattle, San Francisco, Minneapolis,
epidemiological, and laboratory study. In a single Buffalo, Atlanta, and Miami<37·41) have confirmed
summer there was an extensive outbreak of febrile and extended the earlier results: higher levels of
illnesses, characterized by respiratory and abdom- endemicity and longer periods of prevalence were
inal symptoms, which began in May 1970 and found in the southern cities.
continued without interruption until the begin- Among the Atlanta and Miami children studied
ning of August. During this period, 21 children in 1960-1963 and in the earlier investigations in
were ill on two occasions and six were sick three Charleston and Phoenix/ 79 ) average annual virus
times, with some of the episodes giving the clini- excretion rates were 7-14%, and far larger num-
cal impression of relapses in a disease caused by a bers of enterovirus serotypes were commonly
single agent. However, these illnesses were found prevalent than in northern cities. In the normal
to be due to successive and overlapping large population under study in the New York Virus
outbreaks of coxsackievirus B4 and echovirus 9 Watch Program,!63) only four to six serotypes of
infections, in which 43 persons were shown to cytopathogenic enteroviruses were prevalent at
have been infected by both viruses in sequence, at any given period, and the enterovirus isolation
intervals of 3-4 wk. Echovirus 16 was also found to rate in fecal specimens from young children (0-5 yr
be involved in a small number of the early ill- of age) was only 2.4%.
nesses. Among children living in warm climates and
5.1.3. Geographic Distribution and Climate. poor hygienic conditions, the incidence of infec-
Enteroviruses are found in all parts of the world. tion with one or more enterovirus serotypes may
In tropical and semitropical regions, they are wide- exceed 50%, and mixed infections are common. In
100
111 -----·2~14•
22• ..........-- \
/:.13
90
"
~: -,,<--~I
High Point
I/)
80 .... - .....
2S'-, 9• _ _ _ 5........... _. 5
z
0
~
70 ",--\ "" "
:) Alaska .- 18
..J 14
0
60
:E
:)
a:: 50 68
w •
I/)
40
~
<l: '-... Easton - 2
W 30
~
t:
I/) 20
0
a..
10 41 Conn.-5
2~:---- ---- -24: - - - - --- - 14: ---------:8 ---(-- -- - 13:

~
z
w
u 0
a:: 20 12 8 4 ~Ohio-I
w
a..
Age 4-10 11-20 21-30 31-40 41-72
Fig. 1. Results of neutralization tests with local Eskimo sera and coxsackieviruses
expressed in terms of percentages of sera positive against five coxsackievirus strains. The
serotypes represented are High Point (coxsackievirus A4), Alaska (coxsackievirus AID),
Easton-2 (coxsackievirus AI), Conn.-S (coxsackievirus BI), and Ohio-I (coxsackievirus B2).
The numerals at each point show the number of sera tested in the indicated age group.
From Banker and Melnick.(21
a study of infants in Karachi, Pakistan-almost all ces in temperate areas,<221 but they are less
of whom were less than 2 yr of age-approxi- frequent.
mately 80% of those tested yielded at least one In some isolated groups, such as certain Eskimo
enterovirus.(I071 Additional virus serotypes were communities,<21 the whole population may lack
recovered by mixing a portion of the original swab antibodies to some serotypes (see Fig. 1). In the
specimen with type-specific antiserum to block the survey depicted, not even the oldest persons, up
virus type or types previously isolated from the to 72 yr of age, had any serological evidence of
swab and then inoculating the mixture into tissue past infection with either coxsackievirus BI or
cultures. If an isolate was obtained, it was first coxsackievirus B2; coxsackievirus Al apparently
confirmed as a new type by retesting against had been present some years previously, and
antiserum to the previously recovered type or coxsackievirus A4 and AlO were currently present
types; if confirmed as new, the serotype was then or had been in the very recent past.
identified. Of 116 rectal swab specimens restudied On the other hand, a more recent study con-
for multiple virus isolation, approximately 45% ducted in the Accra area of Ghana, where polio
were positive for at least two different viruses, vaccination had not yet been introduced, indicated
14% for three viruses; and each of two infants had that infants and young children were experiencing
four different viruses in a single swab speci- widespread infections with all three types of
menY071 Mixed infections may also occur in chil- polioviruses/ H )(;) a pattern typical for a dense
dren living under good socioeconomic circumstan- popUlation living under poor hygienic conditions.
Even among children less than 3 yr old, 77% had served in the recurrence of specific types. With
antibody to poliovirus type 1, and only slightly each serotype analyzed, the number of reported
lower proportions to type 2 and to type 3; 80% isolations fluctuated greatly from year to year, and
were immune to all three types by the age of 6 yr. even larger fluctuations were observed for individ-
In the same children, coxsackievirus A9 antibody ual countries; e.g., of 154 coxsackievirus A9 infec-
developed at almost the same rate as poliovirus tions reported by Japan during the 4-yr period, all
antibodies, with 79% infected by 3 yr of age, and but eight were concentrated in 1967.
94% by the age of 6. Coxsackievirus B3, however, In this worldwide survey, which focused on
was less widespread, infecting only 52% of the virus isolations from sick persons, the clinical
children 4--6 yr old. manifestations usually included aseptic meningi-
The beginnings of a global picture of nonpolio tis, respiratory disease, skin eruptions, undiffer-
enterovirus prevalence have been drawn by As- entiated febrile illnesses, or gastroenteritis. Disease
saad and Cockburn,(1) who analyzed the reports of the central nervous system-commonly aseptic
received by WHO for the 4-yr period 1967-1970 meningitis-was associated with 24% of the
from laboratories around the world that participate coxsackievirus A infections (and with nearly 50% of
in the WHO reporting system (by 1970, 93 labora- those which were identified as A9 infections), with
tories in 33 countries). Because few tropical coun- 38% of the coxsackievirus B infections, and with
tries have yet joined the reporting scheme, chiefly 70% of the echovirus infections. The previously
temperate regions were represented in these re- recognized associations of specific syndromes to
ports. The reports used for this analysis included specific serotypes were also observed, e.g., Born-
almost 2300 coxsackievirus A isolates, more than holm disease (pleurodynia) and myocarditis associ-
5500 coxsackievirus B, and more than 8500 echovi- ated with coxsackieviruses B and hand, foot, and
ruses. These investigators were able to draw com- mouth disease with coxsackieviruses A. There were
parisons concerning infections by these agents also small numbers of cases of paralytic CNS dis-
despite the limitations implicit in the nature of the ease in association with many of the types reported
reports-particularly the underrepresentation of in each group.
coxsackievirus A isolates since relatively few labo- Irrespective of virus type, the largest number of
ratories now include mice in their isolation sys- cases of CNS disease were in children under 15 yr
tems. of age, while the largest number of cases of respi-
Most of the infections were in children under 15 ratory illness were in children under 5 yr of age. In
yr of age: 86% of the coxsackievirus A isolates coxsackievirus A infections, skin eruptions (in-
came from this age group, 78% of the coxsackievi- cluding hand, foot, and mouth disease) were seen
ruses B, and 77% of the echoviruses. With most of mostly in children under 5. A disproportionately
the A coxsackieviruses and with echovirus types 1, large share of the neurological illnesses was re-
3, 7, 11, 14, and 17, the number of isolates from ported in adults, and myalgia (Bornholm disease)
younger children (0-4 yr) was greater than or equal accompanying coxsackievirus B infections was also
to that for the 5- to 14-yr-old group. Echovirus disproportionately frequent in adults.
types 6 and 30, however, were recovered from the 5.1.4. Age and Sex. Children are the prime
older children far more frequently, and were ob- targets of these viruses and thus serve as the chief
tained from adults in considerable numbers; type vehicle for their spread. In warmer lands and in
4, 9, and 33 infections also extended into the older families living under unsanitary and poor socio-
age groups. economic conditions in temperate zones, children
Among the five group B coxsackieviruses under are infected very early in life, and more than 90%
study, B3 and B2 were the most frequently iso- may have already experienced infections with a
lated. Overall, most coxsackievirus B isolations number of the locally prevalent enteroviruses be-
were from children under 15 yr of age, but sub- fore the age of 5 yr. In such settings, paralytic
stantial numbers of adult infections were reported poliomyelitis is rarely recognized and epidemics
for each of these types. do not occur. When infection is delayed to older
No regular yearly pattern, worldwide, was ob- childhood and young adult life, the incidence of
Table 1. New York Virus Watch: Prevalence of Neutralizing Antibodies to Coxsackieviruses on

Entrance to Observation, in Subsequently Invaded and Control Households," by Age and Virus Type/)
Serum neutralizing antibodies by age (yr)
0--4 5-19 20+ All ages
Coxsackie- Number of Percent Number of Percent Number of Percent Number of Percent

virus type persons positive persons positive persons positive persons positive
A9 56 23 57 35 69 59 182 40
Bl 10 (20)" 2 (0) 14 14 26 15
B2 36 3 37 16 37 30 110 16
B3 14 14 14 36 20 40 48 40
B4 22 5 27 33 24 58 73 33
B5 33 3 53 11 62 24 148 15
All 171 14 190 24 226 41 587 27
U Control households were selected because no member had yielded the virus in question and because they were being observed
during the period of maximum incidence of infection with the specified virus. The members examined were selected for age
(preference given to children) and availability of paired or serial sera bracketing the desired period.
b From Kogan et al. (63) Used with permission.
, Parentheses are used for percentages based on ten or fewer observations.
paralytic poliomylitis rises, as does the frequency 5.1.5. Occurrence in Families and Closed Ecol-
of the more severe manifestations of the other ogical Units. Enterovirus infections are highly
enterovirus infections. communicable. Within a community, the viruses
The pattern of age distribution of the non polio generally spread horizontally via preschool chil-
enteroviruses can be defined by serological stud- dren, and are found more frequently in families of
ies. For example, an examination of antibodies to large size and lower socioeconomic level. How-
coxsackievirus A9 and coxsackievirus B1-BS was ever, once an agent has invaded a family, regard-
made in sera obtained from New York Virus less of family size or circumstances, non immune
Watch families(6~) upon entry into the program. family members readily become infected. In the
The results are shown in Table 1. Although com- New York Virus Watch Program, spread of
parison by age between virus types can only be coxsackieviruses to susceptible members of the
suggested on the basis of the relatively small household was high (76%), while that of echovi-
sample, it is clear that coxsackievirus B2, B4, and ruses was considerably lower (43% of the suscepti-
BS antibodies were infrequent in the youngest bles) (Table 2). In addition to infecting those
children at the beginning of the Virus Watch without prior type-specific antibody, coxsackievi-
observation period and that this relative vacuum ruses also spread to and reinfected one-half of the
in immunity was partially filled by subsequent siblings under the age of 10 yr who already had
outbreaks of infection with these viruses. specific antibody. Only one echovirus reinfection
For those enteroviruses on which data have was observed. The frequency of intrafamilial in-
been obtained, the patterns of exposure and fection may be related in part to the duration of
spread and of increasing development of antibod- virus excretion by the young index child; in the
ies along with increasing age are generally similar. New York Virus Watch, with a 2-wk interval
Sex appears to play no important role in infection, between routine collections, only 16% of those
although childhood paralytic poliomyelitis is twice infected with echoviruses yielded virus on more
as common in boys as in girls. than one occasion, while coxsackievirus excretion
Table 2. New York Virus Watch: Age Distribution of Infections"
Percent infected (number observed) by age in years
Virus group 0--1 2-5 6---9 10--19 Mothers Fathers All ages
Coxsackieb 74 (39) 85 (54) 88 (40) 67 (18) 78 (37) 47 (30) 76 (218)

Echo 43 (7) 68 (25) 58 (24) 22 (18) 24 (17) 24 (17) 43 (108)
" From Kogon et al. (63) Used with permission.

, The coxsackieviruses sought included only those which are cytopathogenic.
for more than 1 day was found in 44% of the slightly larger size, included more children 5-9 yr
infections, and excretion for more than a month of age, and included only three persons (two
was not uncommon. adults and one young child) who had antibody
Rapid and extensive spread also occurs in fami- prior to the epidemic. (The families escaping in-
ly-like close associations such as those in children's fection were by no means totally immune, but
institutions, in cabin groups in summer prior antibody was present in 13%, 14%, and 17%
camps,!49) and in the environment of a small of the children in the age groups 2-4, 5-9, and 10--
kibbutz.(101.15H) 19, respectively.) Of the persons observed to shed
Wide dissemination, in which overt illnesses virus, 47% reported possibly related mild febrile
represent only a "very small tip of a very large illnesses, few of which were serious enough to
iceberg" first "described for poliovirus infections, require medical attention; one father in an in-
has been repeatedly documented for a number of vaded family did develop aseptic meningitis, al-
enteroviruses. During an epidemic in which 149 most certainly due to echovirus 30, although virus
inhabitants of a city of 740,000 were hospitalized could not be isolated from his specimens. Thus on
with echovirus 9 disease, approximately 6% or the basis of the Virus Watch family experiences,
44,000 persons had an illness compatible with there must have been many thousands of echovi-
infection due to this agent. (m) Among families rus 30 infections in the Seattle area, more than half
which had been invaded by the virus, the rate of of which were completely without symptoms, dur-
inapparent or unrecognized infection (based on ing the period when 44 virologically confirmed
recovery of the virus) was 18%; however, among cases of echovirus 30 aseptic meningitis occurred
107 persons in families where no illness was ob- in Seattle. (141)
served, only one person yielded the virus from a In the normal middle-class families of the New
stool specimen. York Virus Watch Program,(3) all of the coxsack-
When outbreaks of aseptic meningitis and re- ievirus- and echovirus-associated illnesses ob-
lated illnesses due to echovirus type 30 began to served throughout the study period were mild,
spread along the Pacific Coast in 1968, the arrival and the largest number consisted of upper respira-
of the virus in the, Washington area coincided with tory disease with or without accompanying enteric
the initiation of the Seattle Virus Watch Program, illness, rash, or other signs and symptoms. Central
and extraordinary opportunities were available to nervous systems involvement, pleurodynia, peri-
observe infection and illness among the regularly carditis, and herpangina were not observed. In
studied Virus Watch families as related to the order to arrive at an estimate of the number of
community pattern of illness. (45) Sixty-four such illnesses attributable to the infection with which
families containing 291 members underwent con- they were temporally associated, allowance was
tinuing virological surveillance in this period. By made for illnesses "expected" had the observed
virus isolation and/or serology, infection was doc- concurrent infection not been present. For this
umented in 70 of 88 members (79%) of 18 families; correction, two types of controls were used: the
in the total observed Virus Watch population, the illness records of matched but virus-free controls
rate was 24%. The invaded families were of and the individual's own illness record before and
after the episode of viral infection. For the antibody to all three poliovirus types in women of
coxsackievirus infections, these corrected rates of childbearing age, passive immunity is transferred
attributable illnesses were 24% or 19% (depending from mother to offspring and many infants subse-
on which type of control is used), and for the quently experience their first poliovirus infections
echoviruses 9% or 18%. The observation of respi- while maternal antibodies still provide some pro-
ratory illness in association with coxsackievirus tection. In addition, the ratio of inapparent to
infections has numerous parallels in other studies, apparent infections is highest in infants and
particularly in relation to coxsackieviruses of young children, and paralytic disease is thus rela-
group B. A number of echovirus serotypes also tively rare despite the abundance of circulating
have been incriminated in respiratory or respira- virus. In the past, the rarity of clinical poliomyeli-
tory-enteric diseases. tis in the tropics had led many to believe that no
The mildness of the illnesses associated with poliovirus infections were present in such areas,
infection in the Virus Watch families is notewor- when in fact the reverse was true: polioviruses
thy. Many of the reports on which the more severe were highly endemic, but the infections were
disease associations were based have been derived largely asymptomatic.
from patient-centered or epidemic-centered inves- 5.2.1. Behavior in Temperate Zones and Devel-
tigations. As the authors indicate, the absence of oped Countries. In many areas of the temperate
more serious enteroviral disease in this study zones with better standards of community and
suggests either that, as with poliovirus infections, household hygiene, poliomyelitis during the first
the more severe syndromes are rare or that strains 50 or 60 yr of the twentieth century underwent a
infecting the Virus Watch families were of unu- transition from the endemic phase to one in which
sually low virulence. increasingly large and severe epidemics of the
5.1.6. Socioeconomic Setting. The close correla- paralytic disease occurred. The generally accepted
tion between low socioeconomic settings and the explanation, borne out by numerous studies, is
early acquisition of infection with the enterovi- that improved sanitation and hygiene reduced the
ruses has been repeatedly emphasized in both opportunities for infection among the very young.
tropical and temperate environments, and reflects Therefore, increasing numbers of persons encoun-
the general level of hygiene of the group. Fox(34) tered poliovirus for the first time in later child-
has predicted that, in parallel with the transition hood or in adult life, at ages when poliovirus
of poliomyelitis from endemic to epidemic, the infections are more likely to take the paralytic
frequency of severe disease associated with form. The delay in infection also resulted in a
coxsackievirus and echovirus infections may in- buildup of susceptibles in the population to a
crease as levels of hygiene and sanitation improve. point at which there was a "critical mass" suffi-
More individuals may escape infection as young cient to support wide and rapid circulation of the
children, only to experience more serious clinical viruses. Thus epidemics began to occur, some-
manifestations if they become infected in later times in an abrupt shift, sometimes after gradual
childhood or adulthood. increases in the annual case rates of "sporadic"
poliomyelitis. For example, in the United States
just before inactivated poliovaccine became gener-
5.2. Epidemiological Patterns of Poliomyelitis
ally available, the average annual number of cases
Poliomyelitis can be viewed as having three of paralytic poliomyelitis was approximately 21,-
major epidemiological phases: endemic, epidemic, 000. In epidemics the peak age incidence was in
and postvaccination. All of these coexist at the the 5- to 9~yr-olds and about one-third of the cases
present time, in different regions of the world. In and two-thirds of the deaths occurred in persons
some crowded, developing areas, chiefly in the over 15 yr of age. This was a marked change from
tropics, paralytic poliomyelitis continues to be a the pattern in the great 1916 epidemic, in which
disease of infancy (truly "infantile paralysis") that approximately 80% of cases were in children un-
is seen only sporadically. In these populations, der 5 yr of age.'H7 a l
virtually all children over 4 yr of age are already In the first half of the twentieth century, not
immune. With the almost universal presence of only was it the "advantaged" nations which expe-
rienced epidemic polio, it was also the socioecon- per 1000 live births, the incidence of poliomyelitis
omically advantaged sectors of the population can be expected to increase. Thus epidemic polio
within these nations that were most at risk. Even was a disease of affluent societies in the first half
within the same city, wider circulation of the wild of the twentieth century, and is now an unwel-
polioviruses in lower socioeconomic areas with come concomitant of improved living standards in
poorer sanitation and hygiene provided more chil- developing nations unless it is controlled by vacci-
dren with immunizing infections at an earlier age nation.
and reduced their chances of eventually develop- 5.2.3. Behavior in the Postvaccine Era. The
ing paralytic disease.<92.9fiJ The last outbreaks in postvaccine era for most countries in Europe,
the United States before polio vaccine became North America, and Oceania, and some countries
available included families living in good socioec- in other regions of the world, began after 1955
onomic conditions; the spread of the virus through when inactivated poliovirus vaccine was intro-
the community could be traced through young duced, and particularly after 1959 when live atten-
children who might or might not manifest illness; uated vaccines became available on a large scale.
however, a high incidence of paralytic cases oc- These areas experienced a marked reduction in the
curred among susceptible parents exposed to their incidence of poliomyelitis; rarely was a serious
virus-carrying children. (75.94.1 ()2) disease controlled so quickly and dramatically.
5.2.2. Behavior in Tropical Areas and Develop- In 1955, 17,364 cases of poliomyelitis were re-
ing Countries. This changing pattern of occurrence ported in the USSR, 27,343 in 23 other European
of paralytic poliomyelitis is now being seen in countries, and 31,582 in the United States, Can-
developing countries with rising levels of sanita- ada, Australia, and New Zealand-a total of over
tion, particularly in tropical and semitropical 76,000. In these same countries in 1967 only 1013
areas. Forty-five of 71 tropical and semitropical cases were recorded-a reduction of 99% in 12 yr.
countries reported an overall incidence of polio- Following the introduction of live poliovirus
myelitis in 1966 that was 3 times greater than the vaccine, during 1961-1965, the annual number of
average annual incidence for the period 1951-1955. paralytic cases in the United States decreased to
In such areas, if comprehensive and regular vacci- 465. In subsequent years, the rates averaged about
nation programs are not yet being carried out, 4G-50 cases per year, decreasing to 18 cases in
outbreaks of paralytic poliomyelitis continue to 1969. In 1970, however, 31 cases of paralytic po-
occur. For example, in Guinea, in equatorial Af- liomyelitis were reported, including 22 from an
rica, the average annual number of cases was two epidemic which occurred in Texas among unim-
in 1951-1955, ten in 1961-1965, 12 in 1969, 17 in munized persons. In 1971, only 17 scattered cases
1970, five in 1971, and then an outbreak occurred of paralytic poliomyelitis from 12 states were re-
in 1972 with a total of 74 cases during that year. In ported, the lowest number recorded since initia-
Niger, no cases were reported during 1951-1955; tion of surveillance reports in 1955; three cases
during 1961-1965, the number averaged ten an- were temporally related to travel outside the
nually; in subsequent years, an irregular but small United States. In 1972, 29 cases were reported,
increase in numbers took place until 1972, when but during 1973-1975, only 20 cases of paralytic
there were more than 420 cases. A similar trend is poliomyelitis occurred over the entire 3-year
seen in some Central and South American coun- period. 07,43a)
tries, and until vaccination programs are imple- Now, in the well-vaccinated areas of the world,
mented on a regular basis these countries should "postvaccine" epidemiological patterns of polio-
anticipate epidemics of paralytic poliomyelitis myelitis are emerging. These patterns differ from
such as those that occurred in the temperate coun- one country to another, and to some extent even
tries before the introduction of the vaccine. within the same country.
Payne"10) and others have shown that there a. Virus Isolation. In a few areas, where repeated
tends to be an inverse relationship between infant mass vaccination campaigns are conducted regu-
mortality rates and the incidence of clinical po- larly and are implemented so as to reach virtually
liomyelitis. Paul(IOS) pointed out that when the all young children, wild polioviruses are rarely
infant mortality rate in a country drops below 75 identified; almost all isolates now closely resemble
Table 3. Distribution of Enteroviruses Isolated from Healthy Children in Populations of Contrasting

Socioeconomic Levels during a Nonepidemic Period (1951-1953)a
Percent yielding viruses

Number of
Population group specimens tested Polioviruses Coxsackieviruses Echoviruses All enteroviruses
Charleston, W.Va.
Lower 597 2.3 2.3 3.7 8.4
Upper 1028 0.5 1.5 0.8 2.7
Phoenix, Ariz.
Lower 943 3.0 2.0 8.3 13.3
Upper 399 1.0 1.0 0.3 2.3
Total
Lower 1540 2.8 2.1 6.6 11.4
Upper 1427 0.6 1.3 0.6 2.6
a From Melnick."" Used with permission.
the vaccine strains and are generally presumed to occurrence for nonpolio enteric viruses in Japan
be vaccine progeny. Vaccine viruses are abun- were of the same order of magnitude as those
dantly excreted by the vaccinee, and infect unvac- found earlier in the U.S. cities, but the effect of
cinated contacts.'S2) The rare cases of poliomyeli- systematic widespread vaccination is clearly re-
tis which do appear may be due to imported wild flected in greatly reduced prevalence of polio-
viruses or may in some instances be vaccine asso- viruses. Most of the poliovirus isolates studied in
ciated (see Section 9). Results of recent studies, for Japan were vaccine-like in their properties and
example, suggest that wild polioviruses have been were considered to be vaccine virus progeny.'l:lS)
almost completely eradicated from Japan. Since b. Breadth of Immunity. In some field studies,
1964, infants in Japan between the ages of 3 children immunized previously with one strain of
months and 18 months have been vaccinated with type 3 vaccine virus were more susceptible to
two doses of trivalent live virus vaccine, in routine another vaccine strain of the same serotype (heter-
administration at local health centers over short ologous, but homotypic) than they were to the
periods in spring or autumn. Since 1962 a collabo- homologous strain.'591 The neutralizing antibody
rative study, conducted under sponsorship of the response was higher after administration of the
Ministry of Health and Welfare, has included ser- heterologous vaccine virus than after administra-
ological surveys for levels of antibody against tion of a second dose of the homologous strain.
polioviruses and virological studies for isolation The success of live poliovirus vaccination pro-
and identification of polioviruses from the feces of grams in many countries of the world has reduced
healthy children in periods when vaccine cam- substantially the wild poliovirus circulation in
paigns were not under way. Since no comparable these areas, so that there are now increasing num-
study is being carried out in the United States, bers of people whose immunological experience is
isolation from fecal specimens obtained 1962-1968 limited to a single vaccine strain of each type. This
from healthy children in Japan 2 months or more change in immunity status of populations has
after routine vaccination periods(139) are here brought a new question into focus. There is no
compared to American findings of more than a evidence as yet that the changed ecological situa-
decade earlier (in 1951-1953)'79) made in surveys tion is acting upon wild poliovirus populations as
of healthy preschool children in Charleston, West a selective mutational pressure toward wide anti-
Virginia, and Phoenix, Arizona, during the period genic divergence from the attenuated vaccine
prior to the development of polio vaccines. The strains, but such antigenic shifts are conceivable.
results are shown in Tables 3 and 4. The rates of If such shifts occur, and if they permit silent
Table 4. Poliovirus Isolation from Fecal Specimens from Healthy Children Collected Not Less Than 2
Months after the Routine Vaccinationa
Poliovirus isolated
Number of Number of Type Other

specimens cytopathogenic cytopathogenic
Year Time of specimen collection examined agents isolated b Number b 1 2 3 agentsb
1962 Late summer-early autumn 974 31 1 0 1 0 30

(3.2) (0.1) (3.1)

(2.6) (0.1) (2.5)
1964 Late summer-early autumn 2299 81 IJ 1 2 7 71

(3.5) (0.4) (3.1)
Late autumn-early winter 1803 18 17 4 11 2 1
(1.0) (0.9) (0.1)
1965 Late summer-early autumn 2069 174

(5.7)
1
(0.05)
.
0 1 0 173
(5.6)
(2.3) (0.06) (2.3)

(5.2) (0.2) (5.0)
(1.4) (0.3) (0.7)

(6.7) (6.7)
(1.1) (0.1) (1.0)

(7.6) (0.1) (7.4)
(2.0) (0.2) (1.8)
a From Takatsu et al.

(139)Used with permission.
b The figures in parentheses indicate the percentage of the total number of specimens examined.
circulation of heterologous wild strains to increase, discussed under control and prevention (Section
individuals who for some reason lack sufficient 9).
vaccine-induced immunity might be at risk to
paralytic poliomyelitis. In anticipation of such
problems, an appropriate subject for further inves- 6. Mechanisms and Route of Transmission
tigation is whether successive infections with two
different attenuated polioviruses of the same type Man is the only known reservoir for members of
could provide a "broadening" of alimentary tract the human enterovirus group, and close human
resistance to wild homotypic viruses. Other as- contact appears to be the primary avenue of
pects of vaccination including "social failure" are spread. For almost all of these agents, virus can be
recovered from the oropharynx and intestine of principal mode of spread to be person to person, an
individuals infected either clinically or subclini- oral-water-oral route is possible, as well as a
cally, and generally is shed for longer periods (up rectal-water-oral route.
to a month or more) in sto9ls than in secretions of An animal enterovirus, Nodamura, may be ar-
the upper alimentary tract. ',Thus fecal contamina- thropod borne. A strain of coxsackievirus A6,
tion (fingers, table utensils, foodstuffs, milk) is the originally obtained from mosquitos in Fiji, has
usual source of infections. However, droplets or been found to survive in mosquitos experimen-
aerosols from coughing or sneezing can also be a tally infected by injection or by feeding on viremic
source of direct or indirect contamination. mice, and a small number of transmissions to baby
Coxsackievirus A21 has been shown to be more mice by bite 'were obtained. The function of the
abundant in nasal secretions than in those from mosquito as a true vector was not demonstrated,
the throat and has been experimentally transmit- however, for virus did not multiply within the
ted from infected volunteers by airborne aerosols insect; in both fed and injected mosquitos, virus
produced by natural coughing. (24) Enterovirus 70, titers never exceeded the original level. (74)
the newly recognized agent of acute hemorrhagic
conjunctivitis,ooOJ has thus far been found almost
exclusively in conjunctival and throat specimens, 7. Pathogenesis and Immunity
although few fecal isolations have as yet been
attempted.
7.1. Pathogenesis
Warm weather favors the spread of virus by
increasing human contacts, the susceptibility of The portal of entry of enteroviruses is believed
the host, or the dissemination of the virus by to be the alimentary tract via the mouth. The
extrahuman sources. The viruses are most readily incubation period (defined as the time from expo-
spread within the family, and the extent of intra- sure to onset of disease) is usually between 7 and
familial infection appears to be closely related to 14 days, but may be 2-35 days. After initial and
duration of virus shedding, particularly by young continuing multiplication, probably in lymphoid
children. tissue of the pharynx and gut, viremia may occur
During periods of epidemic prevalence, in both and in tum lead to further virus proliferation in
rural and urban areas, house flies (Musca domes- the cells of the reticuloendothelial system, and
tica) and filth flies (Phormia regina, Phaenicia seri- finally to involvement of the target organs (spinal
cata, Sarcophaga species) may be found contami- cord and brain, meninges, myocardium, skin).
nated with enteroviruses and may act as Usually the virus is excreted in the stools for
mechanical carriers. The importance of flies in several weeks and is present in the pharynx 1-2
transmission is not easily evaluated, although it is wk postinfection in individuals having either clin-
important to note that poliovirus has been found ical or subclinical infection. Enteroviruses have
in food naturally contaminated by flies. As de- been isolated from feces, pharyngeal washings,
scribed in Section 3.4, enteroviruses also are pres- cerebrospinal fluid, heart, blood, the central nerv-
ent in urban sewage during periods when subclin- ous system, urine, and lesions of skin or mucous
ical or clinical disease is prevalent. Sewage may membrane.
serve as a source of contamination of flies or of Two or more enteroviruses may propagate si-
water supplies used for drinking or bathing, or multaneously in the alimentary tract,(07) but un-
through its use as fertilizer. Enteroviruses have der many circumstances multiplication of one vi-
been isolated frequently from sewage. Until re- rus may interfere with growth of the heterologous
cently, they had never been recovered from open type. Interference with the growth ("take") of live
recreational water not obviously contaminated by poliovaccine by other concurrent enterovirus in-
sewage. During an epidemic of coxsackievirus B5 fections is now well established.
infections in a boys' summer camp on Lake Cham- Pathogenesis has been studied more thoroughly
plain, the virus was isolated from water from the for poliomyelitis, the most serious disease caused
lake swimming area. (49) Although in this outbreak by any of the ·enteroviruses.(S.116) The status may
the clustering of infection in cabins suggests the be summarized as follows.
Poliovirus may be found in the blood of patients often affected. The cortex is virtually spared, with
with the abortive form ("minor illness") and can the exception of the motor cortex along the precen-
be detected several days before onset of clinical tral gyrus.
signs of CNS involvement in patients who develop Poliovirus does not multiply in muscle in vivo.
nonparalytic or paralytic poliomyelitis. In orally Its chief site of action is in the neuron, and the
infected monkeys and chimpanzees, viremia is changes which occur in peripheral nerves and
also regularly present in the preparalytic phase of voluntary muscles are secondary to destruction of
the disease. Antibodies to the virus appear early the nerve cell. Changes occur rapidly in nerve
in the natural infection and also early in orally cells, from mild chromatolysis to neuronophagia
infected experimental animals. They are usually and complete destruction. Cells which are not
present by the time paralysis appears. killed, but which lose their function temporarily as
These findings led to the view that the virus first a result of edema, may recover completely. Inflam-
multiplies in the tonsils, the lymph nodes of the mation occurs secondary to the attack on the nerve
neck, Peyer's patches, and the small intestine. The cells; the focal and perivascular infiltrations are
CNS may then be invaded by way of the circulat- chiefly lymphocytes, with some polymorphonu-
ing blood. In monkeys infected by the oral route, clear cells, plasma cells, and microglia. In addition
small amounts of antibody prevent the paralytic to pathological changes in the nervous system,
disease, whereas large amounts are necessary to hyperplasia and inflammatory lesions of lymph
prevent passage of the virus along nerve fibers. In nodes and of Peyer's patches and other lymph
man also, antibody in low titer in the form of ')'- follicles in the intestinal tract are frequently ob-
globulin may prevent paralysis if given before served; interstitial infiltration of the myocardium
exposure to the virus. with leukocytes is common but necrotizing myo-
In the experimental infection in monkeys, polio- carditis is rare.
virus can spread along axons of peripheral nerves
to the CNS, and there it continues to progress
7.2. Immunity
along the fibers of the lower motor neurons to
increasingly involve the spinal cord or the brain. Immunity is permanent to the poliovirus type
Neural spread may also occur in children who causing the infection. There may be a low degree
have inapparent infections at the time of tonsillec- of heterotypic resistance induced by infection,
tomy. In this situation, poliovirus present in the especially between type 1 and type 2 polioviruses.
oropharynx may enter nerve fibers exposed during This may account for the observation that second
surgery and spread to the brain, resulting in attacks of polio have most often involved types 1
bulbar paralysis. A similar mechanism of virus and 3.
spread along neural pathways may be responsible Passive immunity is transferred from mother to
for the rare instances of paralysis in a limb recently offspring. The maternal antibodies gradually dis-
injected with an irritating material during a period appear during the first 6 months of life. Passively
of high poliovirus prevalence. An alternative administered antibody lasts only 3-5 wk.
mechanism for the adverse effects of tonsillectomy Virus-neutralizing antibody forms within a few
has been suggested (see Section 7.2). days after exposure to the virus, often before the
Poliovirus invades certain types of nerve cells, onset of illness, and persists, apparently, for life.
and in the process of its intracellular multiplication Its formation early in the infection is a result of
it may damage or completely destroy these cells. viral multiplication in the intestinal tract and deep
The anterior hom cells of the spinal cord are most lymphatic structures before invasion of the nerv-
prominently involved, but in severe cases the ous system. As antibodies must be present in the
intermediate gray ganglia and even the posterior blood to prevent the dissemination of virus to the
hom and dorsal root ganglia are often affected. brain and are not effective after this has- already
Lesions are found as far forward as the hypothala- occurred, immunization is of value only if it pre-
mus and thalamus. In the brain, the reticular cedes the onset of symptoms referable to the
formation, the vestibular nuclei, the cerebellar nervous system.
vermis, and the deep cerebellar nuclei are most A decrease in resistance to poliovirus accompan-
ies removal of tonsils and adenoids. Preexisting the major, severe illness. Only about 1 % of infec-
secretory antibody levels in the nasopharynx de- tions result in recognized clinical illness.
crease sharply following operation (particularly in a. Abortive Poliomyelitis. Abortive poliomyelitis
young male children) without any change in anti- is the commonest form of the disease. The patient
body levels in serum. Local antibody levels remain has only the minor illness, characterized by fever,
low or absent for as long as 7 months. In seronega- malaise., drowsiness, headache, nausea, vomiting,
tive children, nasopharyngeal antibody response constipation, or sore throat in various combina-
to polio vaccine develops significantly later and to tions. The patient recovers in a few days. The
lower titers in children previously tonsillectomized diagnosis of abortive poliomyelitis cannot be
than in those with intact tonsils. Thus surgery of made with assurance, even during an epidemic,
this type may eliminate a valuable source of im- except when the virus is isolated or antibody
munocompetent tissue of importance in resistance development is measured.
to poliovirus. b. Nonparalytic Poliomyelitis (Aseptic Meningi-
Strains of coxsackievirus studied by cross-pro- tis). In addition to the above symptoms and signs,
tection tests in infant mice born of immunized the patient with the nonparalytic form presents
mothers show the same type-specificity as that stiffness and pain in the back and neck. The
observed in neutralization and CF tests. The im- disease lasts 2-10 days, and recovery is rapid and
munity conferred by mother's milk also is type- complete. In a small percentage of cases, the dis-
specific. In humans, a passive transfer of neutral- ease advances to paralysis. Poliovirus is only one
izing and complement-fixing antibodies from the of many viruses which produce aseptic meningi-
mother to the offspring also occurs. tis.
Circulating serum antibody against enterovi- c. Paralytic Poliomyelitis. In the absence of viro-
ruses is not the only source of protection against logical diagnosis, poliovirus must be suspected if
infection. The nature of the so-called local or disease occurs in persons associated with paralytic
cellular immunity, which is manifested by protec- patients, as paralysis is rare in other enterovirus
tion against intestinal reinfection after recovery infections. In poliomyelitis, the major illness,
from a natural infection or after immunization when it occurs, may follow the minor illness
with the live polio vaccine, has not been satisfac- described above, particularly in young children,
torily elucidated. Locally produced antibodies, or but it usually occurs without the antecedent first
perhaps interferon, are more likely to be responsi- phase. The predominating sign is flaccid paralysis
ble than are nonhumoral factors. Local or secretory resulting from lower motor neuron damage. How-
antibody is increasingly recognized as having an ever, incoordination secondary to brain stem inva-
important role in defense against enteroviral infec- sion and painful spasms of nonparalyzed muscles
tions. (104.105,121) may also occur. The amount of damage and de-
struction varies from case to case. Muscle involve-
ment is usually maximal within a few days after
the paralytic phase begins. The maximal recovery
8. Patterns of Host Response and Diagnosis usually occurs within 6 months, but it may take
longer.
8.1. Clinical Syndromes 8.1.2. Coxsackieviruses. Infection with a
coxsackievirus is suggested by the clinical mani-
8.1.1. Polioviruses. When an individual suscep- festations of herpangina, pleurodynia, aseptic
tible to infection is exposed to poliovirus, one of meningitis, summer minor illnesses of nonbacte-
the following responses may occur: (1) inapparent rial origin, or neonatal disease, particularly myo-
infection without symptoms, (2) mild (minor) ill- carditis. Virus is present in the CNS and heart
ness, (3) aseptic meningitis, (4) paralytic polio- muscle of fatal cases in the newborn. Coxsackievi-
myelitis. As the disease progresses, one response ruses may be responsible for myocardiopathies in
may merge with a more severe form, often result- adults more frequently than has been recognized.
ing in a biphasic course: a minor illness, followed a. Herpangina. Herpangina is caused chiefly by
first by a few days free of symptoms and then by group A types 2, 4, 5, 6, 8, 10 and is charac-
terized by an abrupt onset of fever and sore throat. difficulty, and vomiting with or without fever. In
There may be anorexia, dysphagia, vomiting, and severe cases, myocarditis and/or pericarditis may
abdominal pain. The pharynx is usually hyper- develop within the first 8 days of life. Cardiac and
emic, and a few (not more than 10-12) characteris- respiratory embarrassment are indicated by tachy-
tic tiny discrete vesicles with a red areola occur on cardia, dyspnea, cyanosis, and changes in the
the anterior pillars of the fauces, the posterior electrocardiogram. The clinical course may be rap-
pharynx, the palate, uvula, tonsils, or tongue. The idly fatal, or the patient may progress to complete
illness is self-limited, and occurs most frequently recovery. Myocarditis has also been caused by
in small children. some group A coxsackieviruses and echoviruses.
b. Summer Minor Illnesses. Coxsackieviruses are Recent reviews have dealt with neonatal infec-
often isolated from patients with acute febrile tions by enteroviruses and also with congenital
illnesses of short duration and without distinctive malformations in association with maternal entero-
features, occurring during the summer or fall. In virus infections (see above). In one large prospec-
young children, the illness may be accompanied tive study/II) enteroviral seroconversions of
by a rubelliform rash on the face, neck, and chest; women during their pregnancy were evaluated in
it is maculopapular, is not pruritic, and does not relation to anomalies in their infants and com-
desquamate. pared with matched controls. A higher rate of
c. Pleurodynia (Epidemic Myalgia, Bornholm Dis- infection (largely inapparent) was found in women
ease). Pleurodynia is generally caused by group B whose offspring were abnormal; there was sug-
viruses, rarely by echoviruses. Fever and chest gested evidence of an association between mater-
pain are almost invariably present together; they nal infections with coxsackieviruses B2 and B4 and
are usually abrupt in onset but are sometimes urogenital abnormalities, and between coxsackie-
preceded by malaise, headache, and anorexia. The virus A9 infection and defects of the digestive
chest pain may be located on either side or sub- system. Cardiovascular anomalies were associated
sternally, is intensified by movement, and may with maternal infections by coxsackieviruses B3
last from 2 days to 2 wk. Abdominal pain resulting and B4, and multiple infections with coxsackievi-
from involvement of the diaphragm occurs in ruses during pregnancy increased the likelihood of
approximately half of the cases; in children, this congenital heart disease in the infant.
often takes the place of chest pain and may be the f. Respiratory Infections. A number of enterovi-
chief complaint. The illness is self-limited and ruses have been associated with mild upper respi-
recovery is complete, although relapses are com- ratory infections; among these are coxsackievi-
mon. ruses AID, A21, A24, and B3; coxsackieviruses
d. Aseptic Meningitis and Mild Paresis. Aseptic have also been implicated in mild lower respira-
meningitis is caused by coxsackieviruses B1-B6, tory infections, particularly in young children.
A7, and A9 and by a number of echoviruses. There have been reports-although rare-of fatal
Fever, malaise, headache, nausea, and abdominal pneumonia caused by coxsackievirus A7, in which
pain are common early symptoms. Signs of men- the virus has· been isolated from the lung post-
ingeal irritation with stiffness of the neck or back mortem.
and vomiting may appear 1-2 days later. The g. Hand, Foot, and Mouth Disease. Hand, foot,
disease sometimes progresses to mild muscle and mouth disease has been associated particu-
weakness which is often confused clinically with larly with coxsackievirus A16, but A4, AS, A9, and
paralytic poliomyelitis. Patients almost always re- AID have also been implicated. Vesicular lesions
cover completely from nonpoliovirus paresis. appear, particularly on the palms and on the soles
e. Neonatal Disease. Neonatal infection caused of the feet, and small ulcers in the mouth. Virus
by group B coxsackieviruses may be acquired may be recovered not only from the stool and
transplacentally or more commonly in the birth pharyngeal secretions but also from vesicular
canal or as a contact infection in the newborn fluid. A combined syndrome also has been re-
nursery. The range of response is from inapparent ported, in which vesicular lesions and pneumonia
infection to severe, fatal disease. In the sympto- both are present.
matic infant, onset is marked by lethargy, feeding h. Myocardiopathy. Coxsackievirus B infections
Table 5. New Enterovirus Types
Illness in person yielding

Type Prototype strain Geographic origin prototype virus Investigator(s)"
68 Fermon California Lower respiratory illness Schieble et al. (129)
(pneumonia and
bronchiolitis)b
69 Toluca-l Mexico None c Rosen et al. (12()
70 J670/71 Japan and Singapore Acute hemorrhagic Kono et al.,'·4l Yin-Murphy
conjunctivitis (AHC)d and Lim, (155) Mirkovic et
al. (lO()
71 BrCr California Aseptic meningitise Schmid t et al. (132)
a Reference number is shown in parentheses.

, Prototype isolated from throat swabs.
C Prototype isolated from rectal swab.
d Prototype recovered from conjunctival swabs.

e Prototype virus recovered from stool; an identical strain was isolated from the brain of a fatal encephalitis case in the same local
outbreak of central nervous system disease, which occurred in California in 1970. Strains of the same serotype also have been isolated
from patients during an epidemic of aseptic meningitis and hand, foot, and mouth disease in Sweden;'·" other strains have been
identified in Australia. '61.)
are increasingly recognized as a cause of primary strikingly similar to that of rheumatic heart dis-
myocardial disease in adults as well as children. In ease. In experimental animals, the severity of acute
some series, up to 39% of persons infected with viral myocardiopathy is greatly increased by vig-
coxsackievirus B5 developed cardiac abnormali- orous exercise, hydrocortisone, alcohol consump-
ties. Coxsackieviruses of group A and echoviruses tion, pregnancy, and undernutrition and is greater
have also been implicated, but to a lesser degree. In in males than in females. In human illnesses, these
one series of patients with a clinical diagnosis of factors may similarly increase the severity of the
pericarditis (148 patients), myocarditis (92 pa- disease.
tients), or pleurodynia (19 patients), 27% had IgM 8.1.3. Echoviruses. Echoviruses 4, 6, 9, 11, 14,
antibody to one of the group B coxsackieviruses- 16, and 30 have been the ones repeatedly associ-
indicative of current or recent infection-as com- ated with aseptic meningitis; echovirus 3 also has
pared with 8% of the control group. <I3:J) been responsible for some outbreaks of this syn-
Evidence for a high degree of association of drome. Other types (including 2 and 5) have been
virus with disease has been obtained, usually at associated with aseptic meningitis only in spo-
autopsy, by demonstration of virus localized in the radic cases. With echoviruses 6 and 9, muscle
myocardium, endocardium, and pericardial fluid; weakness and mild transient paralysis have been
the presence of virus at the sites of pathological observed; echovirus 9 has been recovered in high
change has been demonstrated by immunoflu- titer from the medulla of a fatal case. Rash is a
orescence, peroxidase-labeled antibody, or ferri- common manifestation of infection with type 9
tin-labeled antibody. It has been estimated that (less frequently with type 4 and other types); the
about 5% of all symptomatic coxsackievirus infec- incidence is high in young children and decreases
tions induce heart disease. The virus may affect the with age. Conjunctivitis may also be present.
endocardium, pericardium, myocardium, or all Echo 16 has been responsible for outbreaks of
three. Acute myocardiopathies have been shown "Boston exanthem disease." Type 20 has been
to be caused by coxsackieviruses A4, A14, A16, associated with a febrile disease involving both
B1-B5, and others, and also by echovirus types 9 the respiratory and enteric tracts. Types 4, 18, and
and 22 and others. other echoviruses can produce infantile diarrhea,
Monkeys infected with coxsackievirus B4 de- and echo 4 has associated with vaginitis and
velop pancarditis, with a pathological picture cervicitis.
8.1.4. New Enterovirus Types. The new entero- problems, myalgia, encephalitis, Guillain-Barre
virus types are listed in Table 5. Among these, syndrome and ataxias, and hepatic disturbances.
enterovirus 70 is the cause of the most widespread A possible association of insulin-dependent, ab-
disease, acute hemorrhagic conjunctivitis (AHC), rupt-onset diabetes mellitus with group B cox sack-
which occurred in epidemics during 1971 in Japan, ievirus infections has been suggested in several
Singapore, and Morocco. These epidemics were recent reports concerning diabetic children, and
components of a pandemic involving tens of mil- also by studies in experimentally infected animals.
lions of people in Africa, Southeast Asia, Japan, For further information, the reader is referred to
India, and England during 1969-1971. The disease two recent experimental papers, (19,38) and a cur-
is most frequent in adults. Onset is sudden. AHC rent review.(25)
is an eye infection characterized by subconjuncti- In Tables 5-9 are listed the prototype strains of
val hemorrhage ranging from discrete petechiae to the known enteroviruses, together with the illness
large blotches of frank hemorrhage covering the (if any) in the person yielding the prototype virus.
bulbar conjunctiva. Corneal involvement, in the In Sections 8.1.1. to 8.1.5, above, have been listed
form of epithelial keratitis, may occur but is tran- the major clinical manifestations associated with
sient. Rarely, acute lumbar radiculomyelopathy enteroviruses, and the serotypes most frequently
has been reported. The incubation period is about associated with them. This listing of clinical syn-
24 h and recovery is complete within less than 10 dromes is not complete, as additional serotypes
days. The infectious agent is highly contagious have been sporadically associated with other rare
and spreads rapidly under unhygienic and syndromes. Further details concerning enteroviral
crowded conditions. diseases may be found in several recent reviews
Enterovirus 71, first recovered from the brain of on the role of nonpolio enteroviruses in human
a patient with fatal encephalitis in California, has disease, (62,98) viral myocardiopathies, (71) coxsack-
been isolated in other sporadic cases of meningitis ievirus infections of newborns/ 39l virus diseases
and encephalitis, and also from patients during an associated with cutaneous eruptions, (150) respira-
epidemic of aseptic meningitis and hand, foot, tory disease viruses/ 58 ) congenital malformations
and mouth disease in Sweden("a); other strains of associated with maternal viral infection, (6) and
enterovirus 71 have been identified in Australia. the possible role of viruses in diabetes melli-
Enterovirus 68 has been associated with pneu- tus. (25)
monia and bronchiolitis in children.
8.1.5. Miscellaneous Clinical Manifestations. In
8.2. Diagnosis
addition to the above, infections with nonpolio
enteroviruses have caused or have been closely In view of the wide range of host response to
associated with a number of signs and symptoms, any single enterovirus serotype, from the most
alone or in combination with other syndromes. common form-silent infection-to the severe di-
These include exanthems, upper and lower respi- seases which may occur, diagnosis must rest upon
ratory illness, diarrhea and other gastrointestinal virus isolation and identification and upon type-
Table 6. Polioviruses a

Type Prototype strain Geographic origin prototype virus Investigator(s)
1 Brunhilde Maryland Paralytic poliob Howe and Bodian

2 Lansing Michigan Fatal paralytic polioe Armstrong
3 Leon California Fatal paralytic polioe Kessel
a From Melnick and Wenner."8) Used with permission.

b Virus recovered from feces.
C Virus recovered from spinal cord.
Table 7. Coxsackieviruses Group A",b
Type Prototype strain Geographic origin Illness in person yielding prototype virus c Investigator
1 Tompkins Coxsackie, N.Y. Poliomyelitisrl Dalldorf

2 Fleetwood Delaware Poliomyelitisrl Dalldorf
3 Olson New York Aseptic meningitis Dalldorf
4 High Point North Carolina (Sewage of polio community) Melnick
5 Swartz New York Poliomyelitis Dalldorf
6 Gdula New York Aseptic meningitis Dalldorf
7 Parker New York Aseptic meningitis Dalldorf
8 Donovan New York Poliomyelitis Dalldorf
9 Bozek New York Aseptic meningitis Dalldorf
10 Kowalik New York Aseptic meningitis Dalldorf
11 Belgium-l Belgium Epidemic myalgia Cumen
12 Texas-12 Texas (Flies in polio community) Melnick
13 Flores Mexico None Sickles
14 G-14 South Africa None Gear
16 G-I0 South Africa None Gear
19 NIH-8663 Japan Guillain-Barre syndrome Huebner
20 IH-35 New York Infectious hepatitis Sickles
21 Kuykendall; Coe California Poliomyelitis/ mild respiratory disease e Lennette
22 Chulman New York Vomiting and diarrhea Sickles
24 Joseph South Africa None Gear
a From Melnick and Wenner."" Used with permission.

b Cross-reactivity has been observed between A3 and AB, A11 and A15, A13 and AlB.
C All isolates were from stools, except for prototypes of A4 and A12, which were isolated from sewage and flies, as indicated. Numerous
strains of each of these types were isolated from stools, also.

d When coxsackieviruses have been isolated from patients with paralytic poliomyelitis, the patient has often been found to have a dual
infection, the poliovirus presumably being responsible for the paralytic illness.
, The Coe virus was isolated from throat washings.
specific antibody response, as described in Section cially when some individuals are infected by both
3.5. Differential diagnosis can present even greater viruses, e.g., St. Louis encephalitis virus (SLE)
difficulties when a community is invaded simulta- and an enterovirus. For example, the distinction
neously by several interoviruses and by other between an aseptic meningitis or encephalitis due
viruses with similar symptomatology, and espe- to SLE and that due to an enterovirus often cannot
Table 8. Coxsackieviruses Group B"
Type Prototype strain Geographic origin Illness in person yielding prototype virus b Investigator
1 Conn-5 Connecticut Aseptic meningitis Melnick

2 Ohio-l Ohio Summer grippe Melnick
3 Nancy Connecticut Minor febrile illness Melnick
4 JVB New York Chest and abdominal pain Sickles
5 Faulkner Kentucky Mild paralytic disease with residual atrophy Steigman
6 Schmitt Philippine Islands None Hammon
a From Melnick and Wenner."" Used with permission.

b All isolates were from stools.
Table 9. Echoviruses",b

Type Prototype strain Geographic origin prototype virusC Investigator(s)
1 Farouk Egypt None Melnick

2 Cornelis Connecticut Aseptic meningitis Melnick
3 Morrisey Connecticut Aseptic meningitis Melnick
4 Pesascek Connecticut Aseptic meningitis Melnick
5 Noyce Maine Aseptic meningitis Melnick
6 D'Amori Rhode Island Aseptic meningitis Melnick
6' Cox Ohio None Ramos-Alvarez,
Sabin
6' Burgess Connecticut Aseptic meningitis Melnick
7 Wallace Ohio None Ramos-Alvarez,
Sabin
8 Bryson Ohio None Ramos-Alvarez,
Sabin
9 Hill Ohio None Ramos-Alvarez,
Sabin
11 Gregory Ohio None Ramos-Alvarez,
Sabin
12 Travis Philippine Islands None Hammon, Ludwig
13 Del Carmen Philippine Islands None Hammon, Ludwig
14 Tow Rhode Island Aseptic meningitis Melnick
15 CH 96-51 West Virginia None Ormsbee, Melnick
16 Harrington Massachusetts Aseptic meningitis Kibrick, Enders
17 CHHE-29 Mexico City None Ramos-Alvarez,
Sabin
18 Metcalf Ohio Diarrhea Ramos-Alvarez,
Sabin
19 Burke Ohio Diarrhea Ramos-Alvarez,
Sabin
20 JV-l Washington, D.C. Fever Rosen
21 Farina Massachusetts Aseptic meningitis Enders, Kibrick
22 Harris Ohio Diarrhea Sabin
23 Williamson Ohio Diarrhea Sabin
24 DeCamp Ohio Diarrhea Sabin
25 JV-4 Washington, D.C. Diarrhea Rosen
26 Coronel Philippine Islands None Hammon
27 Bacon Philippine Islands None HammoI)
29 JV-I0 Washington, D.C. None Rosen
30 Bastianni New York Aseptic meningitis Plager, Duncan,
Lennette
31 Caldwell Kansas Aseptic meningitis Wenner, Lennette,
von Magnus
32 PR-I0 Puerto Rico Aseptic meningitis Branche
33 Toluca-3 Mexico None Rosen, Kern
34 DN-19 d Texas Infantile diarrhea Melnick
a From Melnick and Wenner.<o" Used with permission.

• Types 1 and 8 share antigens, type 1 having the broader spectrum.
C All isolates were from stools.
d DN-19 antiserum partially neutralizes coxsackievirus A24, but A24 antiserum does not neutralize DN-19 virus, although it reacts with
the virus in CF and gel diffusion tests. Thus DN-19 should be considered a prime strain of coxsackievirus A24, rather than as a distinct
echovirus.
be made on clinical grounds; firm diagnosis of extensive use of the vaccine for almost 5 yr, there
singly infected patients, as well as of those with were still 2545 paralytic cases reported in the
dual enterovirus-SLE infections, can be made only United States.
by utilizing the virus laboratory. (1)2) In the fol- Oral vaccine (Sabin), containing live attenuated
lowing paragraphs, the most common clinical fea- virus, was licensed in the United States in 1961-
tures associated with enterovirus infections are 1962. It has a number of advantages over the
described. inactivated virus preparation: oral polio vaccine
In order to establish etiological association of an (OPV) simulates natural infection, which results in
enterovirus with disease, the following criteria can a state of resistance of the intestinal tract in addi-
be used: (1) There is a much higher rate of recov- tion to stimulating circulating antibody. The vac-
ery of virus from patients with the disease than cine is easily administered and immunity is
from healthy individuals of the same age and achieved rapidly, making it an effective means of
socioeconomic level living in the same area at the halting an epidemic.
same time. (2) Antibodies against the virus de- Viremia occurs regularly following ingestion of
velop during the course of the disease. If the type 2 oral vaccine. Free virus is usually present
clinical syndrome can be caused by other known between days 2 and 5 after vaccination, and virus
agents, then virological or serological evidence is bound to antibody for an additional few days.
must be negative for concurrent infection with Found virus is detected by acid treatment, which
such agents. (3) The virus is isolated in significant inactivates the antibody and liberates active virus.
concentration from body fluids or tissues mani- At first, oral polio vaccine was prepared in
festing lesions, e.g., from the CSF in cases of monkey kidney cell cultures(123); more recently,
aseptic meningitis. human diploid cell cultures have been used. The
vaccine can be stabilized by molar magnesium
chloride so that it can be stored without losing
potency for well over a year at 4°C and for at least a
9. Control and Prevention month at room temperature.
Because of the potential hazards (unknown viral
Both live and killed poliovirus vaccines have contaminants) presented by the use of monkey
been used widely in the past 20 yr. Formalinized kidney tissue for growth of vaccine virus, human
vaccine (Salk), (]26) which was prepared from virus diploid cell lines are now licensed for vaccine
grown in monkey kidney cultures, is no longer production. The most thoroughly studied human
available in the United States but continues to be diploid cell line is WI-38; this cell line has been
used in a few European countries. For primary found free of microbial contamination, and can be
immunization, four inoculations are required, the held in the frozen state until needed for vaccine
first three at 4-6 wk intervals and the fourth 6-12 production. Safety testing with such a cell line can
months later. A booster dose is necessary every 2- be far more complete than the tests that are possi-
3 yr subsequently to maintain immunity. It in- ble within the relatively brief life span of a stock of
duces humoral but not local (internal) antibody; primary cultures such as those from monkey kid-
hence poliovirus can still multiply in the gut and ney.
be a source of infection to others.
After the widespread use of killed vaccine, se-
9.1. Schedules of Oral Vaccine Administration
vere and paralytic poliomyelitis was greatly re-
duced in the Unite!i States from the 21,000 cases Trivalent oral polio vaccine replaced the monov-
annually seen in prevaccine years (until 1956). alent forms in the United States. The Committee
However, a few localized epidemics continued to on Infections of the American Academy of Pediat-
occur, the cases being concentrated in slum areas rics recommends that primary immunization for
among unvaccinated preschool children. Some infants begin at 2 months of age simultaneously
cases continued to occur even in the vaccinated; in with the first DPT inoculation. The second and
a study of several thousand paralytic cases, 17% third doses should be given at 2-month intervals
were in triply vaccinated children. In 1960, despite thereafter, and a fourth dose at It yr of age. A
trivalent vaccine booster is recommended for all plication of the vaccine virus. The inhibitor is
children entering elementary school. No further neutralizable by antibodies present in horse serum
boosters are presently recommended. The primary prepared against human y-globulin; the oral ad-
immunization schedule for children and adoles- ministration of this serum together with the vac-
cents consists of two doses of trivalent vaccine at cine virus increased the seroconversion and vac-
8-wk intervals followed by a third dose 6 months cine virus excretion rates.
to a year later. The World Health Organization has been ac-
Routine immunization for adults residing in the tively concerned with studies of enteroviruses for
continental United States is not felt to be necessary many years, and has taken a leading role in
because of the small risk of exposure. However, encouraging international collaboration in studies
adults who are at increased risk because of contact of poliomyelitis and of poliovirus vaccines. In
with a patient or who are anticipating travel to an 1969, WHO launched an international collabora-
endemic or epidemic area should be immunized. tive study to investigate the possible relation be-
Pregnancy is neither an indication for nor a con- tween cases of acute persisting spinal paralysis
traindication to required immunization. The pre- and live poliovirus vaccination. A uniform scheme
cautions mentioned below should be noted in for collection of epidemiological, clinical, and lab-
considering vaccination for persons known or sus- oratory information was developed in the 11 par-
pected to have immunoglobulin disorders, and for ticipating countries. Efforts are also being made to
those preparing to undergo immunosuppressive determine whether the strains isolated from po-
therapy. liomyelitis patients might be vaccine progeny
strains, or whether they resemble wild virus
strains concurrently circulating in the area.
9.2. Problems Associated with Oral Polio Vaccine
The classification of cases, in general closely
Live polio vaccine multiplies, infects, and thus following the pattern used in the Neurotropic Viral
immunizes. In the process, infectious progeny of Diseases Surveillance program of the U.S. Center
the vaccine virus are disseminated in the commu- for Disease Control, includes "recipient" vaccine-
nity. Although the viruses, particularly type 3, associated case (one in which illness begins 7-30
mutate in the course of their multiplication in days after receiving the vaccine), "contact" vac-
vaccinated children, only rare cases of paralytic cine-associated case (one in which the patient is
poliomyelitis have occurred in recipients of oral known to have been in contact with a vaccinee and
polio vaccine or their close contacts. To minimize becomes ill 7-60 days after the vaccinee received
the contact problem (Le., infecting a contact with the vaccine), "possible contact" case (no known
reverted virus progeny of greater neurovirulence contact with a vaccinee but occurring in an area
than the licensed vaccine), whole communities can and time of mass vaccination), and "no known
be given the vaccine at one time. contact" case (paralysis occurring with no known
A second potential limiting factor of the use of contact in an area where. intensive vaccination is
the oral vaccine is that of interference. The alimen- not in progress, or where routine vaccination can
tary tract of the child may be infected with another be given any time during the year). In an evalua-
enterovirus at the time the vaccine is fed. This can tion of the first 3 yr of the study, a coherent
interfere with the establishment of infection and picture is emerging, despite heterogeneity of in-
immunity and is an important problem in areas vestigation and reporting practices among the par-
where enterovirus infections are abundant, as in ticipating countries. However, direct calculation of
tropical and subtropical regions. A third problem, the risk of vaccination to recipients and their
in tropical areas, is related to an inhibitory sub- contacts cannot be made since this would require
stance present in the alimentary tract of infants data on both the number of doses actually received
that prevents multiplication of the vaccine virus. A and the number of susceptible (antibody-free)
recent WHO field study conducted in Africa con- people in contact with vaccinees. Nevertheless,
firms previous reports concerning this inhibitor, some estimate may be made of the occurrence of
which decreases implantation and/or limits multi- persistent paralysis in relation to vaccine, based
on rates per million doses distributed. In countries drugs who lack poliovirus antibodies be immu-
with fixed, short-period, mass vaccination cam- nized before therapy.
paigns, the highest rate of paralysis was found in
€Ontacts and possible contacts of those who re-
9.3. Current Status of Immunization for
ceived monovalent type 2 vaccine, and in recipi-
Poliomyelitis in the United States
ents of monovalent type 3 vaccine. Overall in this
group of countries, the rate was 2 cases in possible Following the introduction of live poliovirus
contacts per million doses distributed, 1 case per vaccine, during 1961-1965, the annual number of
million doses among recipients, and 0.8 case paralytic cases in the United States decreased to
among contacts per million doses. In these coun- 465, and in subsequent years the rates have ranged
tries, the risk was higher for unvaccinated children from 50 to as low as 6 in 1975.
in contact with infants vaccinated in short-period While the general trends established with the
campaigns. In the countries where vaccination is introduction of polio vaccines are overwhelmingly
offered throughout the year, the overall rates of favorable, the continuing need for thorough and
vaccine-associated cases were found to be lower- adequate vaccination programs cannot be overem-
0.18 per million doses for contacts, and 0.09 for phasized. Serological surveys as well as surveys of
recipients. The greatest risk in these areas was to vaccination status in the United States have re-
unvaccinated adults, usually those exposed to their vealed a downward trend since 1964 in the per-
own vaccinated children. It should be noted, how- centage of young children (1-4 yr of age) who have
ever, that in the absence of short-period mass vac- antibody to all three poliovirus types and in the
cination campaigns in the latter countries, "possi- percentage who have been fully vaccinated.
ble contact" cases could not be identified and that Whereas 87% of this age group had received a full
the year-round administration of vaccines in these course of vaccine in 1964, this declined to only
countries also tended to reduce the intensity with 67% in 1971. The problem of susceptibility is even
which all possible cases of paralytic polio were more pronounced among preschool children who
investigated. live in the inner city and other areas where the
One group of persons who should receive spe- environment is characterized by poverty and asso-
cial attention in evaluating cases that might be ciated deficiencies of health care; surveys in 1971
vaccine-associated are hypogammaglobulinemics. showed that only 40% of this population had been
In the United States for the period 1961-1971 fully vaccinated; in nonpoverty areas, only 68%
inclusive, there were 73 poliomyelitis cases among had received adequate immunization. With the
vaccine recipients and 37 cases among contacts. availability of effective vaccines and the success
Nearly 10% of these cases were shown to be in which has thus far been achieved, this lag in
persons with immunoglobulin disorders, an inci- immunity is unfortunate and steps should be
dence almost 10,000 times greater than in normal taken to rectify the situation.
persons. 05 ;]) It should be noted that poliomyelitis Both killed and live virus vaccines induce anti-
in such individuals develops in an atypical man- bodies and protect the CNS from subsequent inva-
ner, with an incubation period generally longer sion by wild virus. Low levels of antibody result-
than 28 days, a high rate of mortality after a long ing from killed vaccine have little effect in
chronic illness, and unusual lesions in the central preventing intestinal carriage of virus. However,
nervous system. In the hypogammaglobulinemic the alimentary tract develops a far greater degree
cases documented, reversion of the vaccine virus of resistance after live virus vaccine, which seems
to increased neurovirulence had not occurred. to be dependent on the extent of initial virus
Wyatt(l5;j) has suggested that all suspected cases of vaccine multiplication in the alimentary tract
vaccine-induced poliomyelitis be tested for im- rather than on serum antibody level.
mune globulin status; it also has been recom- y-Globulin can provide protection for a few
mended that only killed polio vaccine be given to weeks against the paralytic disease but does not
persons with immunoglobulin disorders and that prevent subclinical infection. The dose is about
persons to be treated with immunosuppressive 0.14 mlflb intramuscularly. y-Globulin is effective
only if given shortly before infection; it is of no ask for it, and were from the same population
value after clinical symptoms of the disease are sector in both years. Immunization histories ob-
apparent. tained in 1968 showed that the sole polio vaccina-
tion experience of many children, even those of
school age, consisted of the single series of mono-
9.4. "Social Failures" of Vaccine Administration
valent vaccines they had received during the 1962
In most countries in which polio vaccine is mass campaign. Three paralytic poliomyelitis cases
widely used, circulation of wild polioviruses has occurred in the Houston area in late 1968 and early
been suppressed, but these viruses have not been 1%9, all in nonvaccinated infants less than 1 yr of
eliminated. In the United States, virulent wild age, from the low-income group.
polioviruses have been detected in sewage(44) and Similarly, gaps in immunity have been de-
also, unfortunately, in paralyzed children.(S7) In scribed in children of other U.S. communities and
contrast to the prevaccine epidemic phase of po- in other well-vaccinated countries. (51) In the
liomyelitis in the United States (in which older United Kingdom, only 49% of 75 nursery school
groups were chiefly affected), the postvaccine era children surveyed in one district of Glasgow had
is marked by the young age of the poliO victims, antibody to all three types of poliovirus; 54% of
who mostly are un immunized infants and pre- the children with a history of immunization lacked
school children, often those in "inner city" or other triple immunity. (114) Marked decline of antibody
poverty areas. Thus in some parts of this country titers to low levels has been documented in some
vaccmation has not established sufficient "herd follow-up studies of individual vaccinees, (14,70)
immunity" of the general population to constitute but studies in other areas and groups have shown
a solid barrier blocking circulation of wild viruses high antibody prevalence among young children
and thereby indirectly protecting even unvaccin- in some localities(51) and persistence of antibod-
ated susceptibles. Instead, it has reduced wild ies, although at low titers, 8-10 yr after vaccina-
virus circulation sufficiently to minimize the early tion. 022 ,127) Where antibodies persist, there may
natural infections that might otherwise have im- well be reinforcement of immunity by exposure to
munized these same disadvantaged children. Chil- circulating virus, either wild or vaccine strains,
dren of higher socioeconomic groups are no longer within the community.
unprotected because almost all are fully vaccinated Most evaluations of current immune status have
in infancy: these advantaged children now become focused on children or on those previously vacci-
victims of polio in only extraordinary circumstan- nated in their early childhood. There now is some
ces, such as refusal of vaccination because of reason for concern that the immune status of the
religious beliefs.(65,14S) But in the absence of in- general population could be tending toward haz-
tensive efforts to provide early and complete vacci- ard in the postvaccine era, contrary to the hopes
nation for infants and young children of lower that older persons would be protected by the
socioeconomic groups, large numbers of such chil- barrier of herd immunity and by indirect immuni-
dren are not now receiving adequate vaccination, zation through spread of attenuated virus from
are growing up susceptible, and are at risk to vaccinees. There have been some reports of vac-
paralytic poliomyelitis should they encounter wild cine-associated cases of poliomyelitis in adult con-
polioviruses. The magnitude of hazard that can tacts, particularly the parents, of young vaccinees.
exist is indicated in Fig. 2, in which the percent- Poliovirus antibody prevalence and levels found in
ages of children lacking antibody in various age sera from persons of all age groups in Tecumseh,
groups are shown both for 1963, shortly after a Michigan, indicate several problems in this re-
large community-wide vaccination program had gard. (103) Disturbing proportions of children were
been conducted, and for 1968, after 5 yr in which susceptible to at least one poliovirus type, and
there had been no widely publicized mass cam- significantly more 5- to 9-yr-olds were susceptible
paign. The children studied were from low-income in 1971 (40%) than in 1966 (25%). Fewer suscepti-
families to whom polio vaccine is freely available' bles were found in those between 10 and 29 yr of
provided that they attend public health clinics and age, but in those 30 yr of age and older there was
100
1963 PER CENT SUSCEPTIBILITY
90
80
70
60
SO
40
30
20
1&.1
...I 10
CD
..
~
0
..
G..
1&.1 0-2 3-8 9-11 12- 23
U ~--------------------~.~ ~.~------------------------------------
CI)
:::» MONTHS YEARS
CI)
~
Z 100
1&.1
1968 PER CENT SUSCEPTIBILITY
U 90
II:
1&.1
G.. 80
70
60
SO
40
30
20
10
0
•
t;ii,;i{:l,)';J ". OF AGE GROUP SINGL.Y SUSCEPTIBL.E (MISSING I ANTIBODY TYPE)
iiiiilili i i1i!iii ". OF AGE GROUP DOUBL.Y SUSCEPTIBLE (MISSING 2 ANTIBODY TYPES)
% OF AGE GROUP TRIPL.Y SUSCEPTIBL.E (MISSING 3 ANTIBODY TYPES)

Fig. 2. Percentage of each age group in low-income Houston families, in 1963 and in 1968, who
were susceptible to one or more types of poliovirus, as measured by lack of type-specific
antibody. From Melnick et al. (87)
seen a progressive increase in susceptibles with individuals with passage of time after vaccination.
age, up to 60%, and antibody titers were very low Both of these situations can and should be moni-
when found. The greater protection among those tored by periodic serological surveys to detect
10-29 yr old may reflect sources of immunization situations of risk before poliomyelitis epidemics
that are not necessarily continuing with the same reappear. Such epidemics would be even more
intensity at the present time: immunization by tragic than those of the 1940-1950 era, for now the
broadly circulating wild poliovirus in their prevac- means of prevention are readily at hand. A resurg-
cine childhood, special attention as priority vacci- ence of paralytic poliomyelitis now would reflect
nees during the periods of enhanced emphasis not "vaccine failures" but social failures. The cen-
immediately after the inactivated and then the live tral-city poverty areas depend chiefly on the public
vaccine became available, and indirect immuniza- sector both for health care delivery and for devel-
tion or boostering by spread of vaccine virus from opment of community awareness of what care is
their own young children. The decreased antibody available, when and how it can be obtained, and
in the older groups probably reflects not only why it is needed. Cross-cultural failures of com-
smaller numbers who have ever received vaccine munication contribute significantly to these seri-
but also longer periods of time since either natu- ous deficits. Some successes in overcoming these
rally acquired or vaccine-induced immunity has problems of health care delivery seem to be com-
been reinforced by reexposure to circulating virus. ing in community-based, decentralized immuniza-
Persons with low antibody titers may, without tion and surveillance programs with substantial
developing paralytic disease, nonetheless excrete support and assistance from the larger commu-
virus and act as a source of infection for suscepti- nity.(54J
ble persons. Current immunization surveys indi-
cate that, in 1973, 40% of the preschool children in
the United States lacked full protection against
9.5. Nonspecific Control Measures
poliomyelitis. If the trend continues or increases
for less solid immunity among children, the way It is not possible to list rules for the prevention
could become open for introduction and wide of poliomyelitis other than vaccination. Quaran-
circulation of wild polioviruses in the general tine either of patients or of exposed family or
population, ~ith outbreaks in which paralytic po- intimate contacts is ineffective in controlling the
liomyelitis could once again become prevalent spread of the disease. This is understandable in
among nonimmune adolescents and adultsY54) view of the large number of inapparent and there-
Lack of serum antibody may not indicate com- fore unrecognized infections that occur during an
plete lack of protection against clinical illness. epidemic.
Antibody may be present but at low levels unde- During epidemic periods, children with fever
tectable by commonly used testing methods, or should be given bed rest. Undue exercise or fa-
local secretory antibodies may afford protection in tigue should be avoided, especially if there is any
the absence of detectable circulating antibodyyo4J suspicion of involvement of the nervous system.
However, serum antibodies do contribute to the Elective nose and throat operations and dental
prevention of viremia, and therefore minimize the extractions should be avoided. Children should
possibility of invasion of the central nervous sys- not travel unnecessarily to or from epidemic areas.
tem (see Section 7). It is thus misleading to assume Food and human excrement should be protected
that protection is present when serum antibody from flies. Once the poliovirus type responsible
cannot be demonstrated. for the epidemic is determined, type-specific mon-
Thus at least two factors contribute to the devel- ovalent oral polio vaccine should be administered
opment of deficiencies in the immune status of to susceptible persons in the population.
populations: (1) failure to obtain proper vaccina- Patients with poliomyelitis can be admitted to
tion, which can lead to the developmen.t of pockets general hospitals provided that the hospital regu-
of susceptibles even within a "well-vaccinated" lations are followed. All pharyngeal and bowel
community, and (2) decline of antibody levels in discharges are considered infectious.
9.6. Control of Other Enterovirus Infections be achieved in the face of interference by other
enteroviruses or by inhibitors which limit vaccine
For the nonpolio enteroviruses, no specific con-
effectiveness. The epidemiologist must recognize
trol measures are known. Avoidance of contact
that the major determinants of poliomyelitis infec-
with patients exhibiting acute febrile illness, espe- tion and disease are now not the result of natural
cially those with a rash, is advisable for very infection but depend on the public health immu-
young children. Members of institutional staffs nization practices of the country and the degree to
responsible for caring for infants should be tested
which effective and long-lasting immunity has
to determine whether they are carriers of enterovi-
been induced in all segments of the population.
ruses. This is particularly important during out-
Monitoring to ensure that levels of immunity re-
breaks of diarrheal disease among infants.
main sufficient should not consist merely of
awaiting the occurrence of clinical cases alone but
should be determined by periodic serum surveys
10. Unresolved Problems to determine the distribution and level of antibody
in the population.
Although many of the unresolved problems con- Development of vaccines for selected nonpolio
cerning the enteroviruses are described or implied enteroviruses is technically possible. It may be
in the foregoing presentation, this section is in- wise to look toward having such vaccines available
cluded to emphasize their importance to persons for certain of these agents, particularly coxsackie-
concerned with public health and epidemiology, virus of the B group, which have a recognized role
who may be ideally situated to contribute in myocarditis of infants and which may well
uniquely to a number of the problems which still prove, if the proper studies are conducted, to be
await solutions. responsible for a significant share of adult cardio-
Answers are needed to the "social failures" of vascular disorders. Such vaccines may not appear
vaccine delivery; to the epidemiological conse- to be required for widespread use in any entire
quences of a highly successful polio vaccine pro- population but could be important for specifically
gram for one segment of the population while targeted groups at high risk.
another segment is placed at higher risk by reduc-
tion of natural infection at an early age; to the
present and potential problems of viruses in ACKNOWLEDGMENT
drinking and recreational water, and the need for
public awareness and support of new water treat- The able assistance of Miss Verle Rennick in the
ment methods which would permit recycling of preparation of this chapter is gratefully acknowl-
this limited and dwindling resource; to the possi- edged.
ble association of enteroviruses with diseases of
unknown etiology, such as diabetes; and to the
possibility that infections with nonpolio enterovi- 11. References
ruses might undergo a shift in age incidence,
involving a consequent increase in severity of the 1. ASSAAD, F., AND COCKBURN, W. c., Four-year study
illnesses which they cause, in parallel with that of WHO virus reports on enteroviruses other than
which took place with the polioviruses in the late poliovirus, Bull. WHO 46:329-336 (1972).
nineteenth and early twentieth centuries. 2. BANKER, D. D., AND MELNICK, J. L., Isolation of
Coxsackie virus (C virus) from North Alaskan Eski-
Despite the availability of effective vaccines,
mos, Am. J. Hyg. 54:383--390 (1951).
poliomyelitis can be expected to be an increasing
3. BERG, G. (ed.), Transmission of Viruses by the Water
problem in developing countries in tropical areas Route, Wiley, New York, 1967.
as well as in low socioeconomic groups of devel- 4. BERG, G., BODILY, H., LENNETTE, E. H., MELNICK, J.
oped countries. Even in countries where vaccine is L., AND METCALF, T. G. (eds.), Viruses in Water,
being widely introduced, there remains the ques- American Public Health Association, Washington,
tion of how successful "takes" of the vaccine can D.C., 1976.
5. BLACK, D. R, CONNELL, C. J., AND MERIGAN, T. c., 18. CLARKE, N. A., AND KABLER, P. W., Human enteric
Structure and infectivity of picornaviral RNA en- viruses in sewage, Health Lab. Sci. 1:44-49 (1964).
capsidated by cowpea chlorotic mottle virus pro- 19. COLEMAN, T. J., GAMBLE, D. R., AND TAYLOR, K.
tein, J. Virol. 12:1209-1215 (1973). W., Diabetes in mice after Coxsackie B4 virus infec-
6. BLATTNER, R. J., WILLIAMSON, A. P., AND HEYS, F. tion, Br. Med. J. 3:25-27 (1973).
M., Role of viruses in the etiology of congenital 20. Committee on the ECHO viruses, Enteric cytopath-
malformations, Prog. Med. Viral. 15:1-41 (1973). ogenic human orphan (ECHO) viruses, Science
6a. BLOMBERG, J., LYCKE, E., AHLFORS, K., JOHNSSON, 122:1187-1188 (1955).
T., WOLONTIS, S., AND VON ZEIPEL, G., New entero- 21. Committee on the Enteroviruses, National Founda-
virus type associated with epidemic of aseptic mention for Infantile ParalysiS, The enteroviruses, Am. J.
ingitis and/or hand, foot, and mouth disease, Lancet Public Health 47:1556-1566 (1957).
ii:112 (1974). 22. COONEY, M. K., HALL, C. E., AND Fox, J. P., The
7. BLOOM, H. H., MACK, W. N., KRUEGER, B. J., AND Seattle Virus Watch. III. Evaluation of isolation
MALLMANN, W. 1., Identification of enteroviruses methods and summary of infections detected by
in sewage, J. Infect. Dis. 105:61-68 (1959). virus isolations, Am. J. Epidemiol. 96:286-305 (1972).
8. BODIAN, D., AND HORSTMANN, D. M., Polioviruses, 23. COOPER, P. D., STEINER-PRYOR, A., AND WRIGHT, P.
in: Viral and Rickettsial Infections of Man, 4th ed. (F. J., A proposed regulator for poliovirus: The eques-
1. HORSFALL, JR., AND I. TAMM, eds.), pp. 430-473, tron, Intervirology 1:1-10 (1973).
Lippincott, Philadelphia, 1965. 24. COUCH, R B., DOUGLAS, R. G., JR., LINDGREN, K. M.,
9. BROWN, F., TALBOT, P., AND BURROWS, R, Antigenic GERONE, P. J., AND KNIGHT, V., Airborne transmis-
differences between isolates of swine vesicular dis- sion of respiratory infection with coxsackievirus A
ease virus and their relationship to Coxsackie B5 type 21, Am. J. Epidemiol. 91:78-86 (1970).
virus, Nature (London) 245:315-316 (1973). 25. CRAIGHEAD, J. E., The role of viruses in the patho-
10. BROWN, F., AND WILD, F., Variation in the coxsack- genesis of pancreatic disease and diabetes mellitus,
ievirus type B5 and its possible role in the etiology Prog. Med. Viral. 19:161-214 (1975).
of swine vesicular disease, Intervirology 3:125-128 26. CURNEN, E. c., SHAW, E. W., AND MELNICK, J. 1.,
(1974). Disease resembling nonparalytic poliomyelitis asso-
11. BROWN, G. c., AND KARUNAS, R S., Relationship of ciated with a virus pathogenic for infant mice, J.
congenital anomalies and maternal infection with Am. Med. Assoc. 141:894-901 (1949).
selected enteroviruses, Am. J. Epidemiol. 95:207-217 27. DALLDORF, G., Neuropathogenicity of group A
(1972). Coxsackie viruses, J. Exp. Med. 106:69-76 (1957).
12. BROWN, G. c., AND O'LEARY, T. P., Fluorescent 28. DALLDORF, G., AND MELNICK, J. 1., Coxsackievi-
antibody responses of cases and contacts of hand, ruses, in: Viral and Rickettsial Infections of Man, 4th
foot, and mouth disease, Infect. Immun. 9:1098-1101 ed. (F. 1. HORSFALL, JR., AND I. TAMM, eQ.s.), pp.
(1974). 474-512, Lippincott, Philadelphia, 1965.
13. BUTTERWORTH, B. E., A comparison of the virus- 29. DALLDORF, G., SICKLES, G. M., PLAGER, H., AND
specific polypeptides of encephalomyocarditis vi- GIFFORD, R., A virus recovered from the feces of
rus, human rhinovirus-lA, and poliovirus, Virology "poliomyelitis" patients pathogenic for suckling
56:439-453 (1973). mice, J. Exp. Med. 89:567-582 (1949).
14. CABASSO, V. J., NOZELL, H., RUEGSEGGER, J. M., AND 30. DUNCAN, I. B. R, A comparative study of 63 strains
Cox, H. R., Poliovirus antibody three years after of echovirus type 30, Arch. Virusf9rsch 25:93-104
oral trivalent vaccine (Sabin strain), J. Pedial. (1968).
68:199-203 (1966). 31. ENDERS, J. F., WELLER, T. H., AND ROBBINS, F. c.,
15. CAVERLY, C. S., Notes of an epidemic of acute Cultivation of the Lansing strain of poliomyelitis
anterior poliomyelitis, J. Am. Med. Assoc. 26:1-5 virus in cultures of various human embryonic tis-
(1896). sues, Science 109:85-87 (1949).
16. CELMA, M. 1., AND EHRENFELD, E., Effect of polio- 32. ENDERS, J. F., WELLER, T. H., AND ROBBINS, F. c.,
virus double-stranded RNA on viral and host-cell Alteration in pathogenicity for monkeys of Brun-
protein synthesis, Proc. Natl. Acad. Sci. USA hilde strain of poliomyelitis virus following cultiva-
7l:2440-2444 (1974). tion in human tissues, Fed. Proc. 11:467 (1952).
17. Center for Disease Control, Reported morbidity and 33. FAULK, W. P., VYAS, G. N., PHILLIPS, C. A., FUDEN-
mortality in the United States, 1973, in: Morbidity BERG, H. H., AND CHISM, K., Passive hemagglutina-
and Mortality Weekly Report, Annual Supplement, tion test for anti-rhinovirus antibodies, Nature (Lon-
1973, Vol. 22, No. 53 (July 15, 1974). don) New BioI. 231:101-104 (1971).
34. Fox, J. P., Epidemiological aspects of coxsackie and AND YOHN, D. S., Comparative studies on patterns
echo virus infections in tropical areas, in: Proceedings of family infections with polioviruses and ECHO
of the 7th International Congresses on Tropical Medicine virus type 1 on an American military base in the
and Malaria, Vol. 3, pp. 212-213, 1964. Philippines, Am. J. Public Health 47:802-811 (1957).
35. Fox, J. P., Family-based epidemiologic studies, the 46a. HARRIS, T. J. R., AND BROWN, F., Correlation of
Second Wade Hampton Frost Lecture, Am. J. Epide- polypeptide composition with antigenic variation
miol. 99:16~179 (1974). in the swine vesicular disease and coxsackie B5
36. Fox, J. P., HALL, C. E., COONEY, M. K., LUCE, R. E., viruses, Nature (London) 258:758-760 (1975).
AND KRONMAL, R. A., The Seattle Virus Watch. II. 47. HARRIS, 1. F., HAYNES, R. E., CRAMBLETT, H. G.,
Objectives, study population and its observation, CONANT, R. M., AND JENKINS, G. R., Antigenic anal-
data processing and summary of illnesses, Am. J.. ysis of echoviruses 1 and 8, J. Infect. Dis. 127:63-68
Epidemiol. 96:270-285 (1972). (1973).
37. FROESCHLE, J. E., FEORINO, P. M., AND GELFAND, H. 48. HATCH, M. H., AND MARCHETTI, G. E., Isolation of
M., A continuing surveillance of enterovirus infec- echoviruses with human embryonic lung fibroblast
tion in healthy children in six United States cities. cells, App!. Microbiol. 22:736-737 (1971).
II. Surveillance enterovirus isolates 1960-1963 and 49. HAWLEY, H. B., MORIN, D. P., GERAGHTY, M. E.,
comparison with enterovirus isolates from cases of TOMKOW, J., AND PHILLIPS, C. A., Coxsackievirus B
acute central nervous system disease, Am. J. Epide- epidemic at a boys' summer camp: Isolation of virus
miol. 83:45~69 (1966). from swimming water, J. Am. Med. Assoc. 226:33-36
38. GAMBLE, D. R., TAYLOR, K. W., AND CUMMING, H., (1973).
Coxsackie viruses and diabetes ~ellitus, Br. Med. J. 50. HONIG, E. I., MELNICK, J. 1., ISACSON, P., PARR, R.,
4:260-262 (1973). MYERS, I. 1., AND WALTON, M., An epidemiological
39. GEAR, J. H. S., AND MEASROCH, V., Coxsackievirus study of enteric virus infections: Poliomyelitis,
infections of the newborn, Prog. Med. Virol. 15:42- Coxsackie, and orphan (ECHO) viruses isolated
62 (1973). from normal children in two socio-economic
40. GELFAND, H. M., Fox, J. P., AND LEBLANC, D. R., groups, J. Exp. Med. 103:247-262 (1956).
The enteric viral flora of a population of normal 51. HORSTMANN, D. M., Need for monitoring vacci-
children in southern Louisiana, Am. J. Trop. Med. nated populations for immunity levels, Prog. Med.
6:521-531 (1957). Virol. 16:21~240 (1973).
41. GELFAND, H. M., HOLGUIN, A. H., MARCHETTI, G.. 52. HORSTMANN, D. M., EMMONS, J., GIMPEL, 1., SUB-
E., AND FEORINO, P. M., A continuing surveillance RAHMANYAN, T., AND RIORDAN, J. T., Enterovirus
of enterovirus infections in healthy children in six
surveillance following a community-wide oral
United States cities. I. Viruses isolated during 1960
poliovirus vaccination program: A seven-year
and 1961, Am. J. Hyg. 78:358-375 (1963). study, Am. J. Epidemiol. 97:173-186 (1973).
42. GOLDFIELD, M. S., SRIHONGSE, S., AND Fox, J. P.,
53. HSIUNG, G. D., Diagnostic Virology: An Illustrated
Hemagglutinins associated with certain human en-
Handbook, 2nd ed., Yale University Press, New
teric viruses, Proc. Soc. Exp. BioI. Med. 96:788-791
Haven, 1973.
(1957).
54. IMPERATO, P. J., PINCUS, 1., HWA, C. 1., AND
43. GRAVES, J. H., Serological relationship of swine vesi-
CHAVES, A. D., The control of measles in New York
cular disease virus and coxsackie B5 virus, Nature
City, Bull. N.Y. Acad. Med. 2nd Ser. 50:602-619
(London) 245:314-315 (1973).
(1974).
43a. GREGG, M. B., Poliomyelitis in the United States
since 1955. Presented at American Academy of Pe- 55. International Poliomyelitis Conferences: Poliomye-
diatrics, Evanston, Illinois, August 11-12, 1975. litis: Papers and discussions presented at the First
through Fifth International Poliomyelitis Confer-
44. GRINSTEIN, S., MELNICK, J. 1., AND WALLIS, c., Vi-
rus isolations from sewage and from a stream receiv- ences (M. FISHBEIN, ed.), Lippincott, Philadelphia,
1949, 1952, 1955, 1958, 1961.
ing effluents of sewage treatment plants, Bull. WHO
42:291-296 (1970). 56. ITOH, H., AND MELNICK, J. 1., The infection of
45. HALL, C. E., COONEY, M. K., AND Fox, J. P., The chimpanzees with ECHO viruses, J. Exp. Med.
Seattle Virus Watch Program. I. Infection and illness 106:677-688 (1957).
experience of Virus Watch families during a commu- 57. ITOH, H., AND MELNICK, J. 1., Double infections of
nity-wide epidemic of echovirus type 30 aseptic single cells with ECHO 7 and Coxsackie A9 viruses,
meningitis, Am. J. Public Health 60:1456-1465 (1970). J. Exp. Med. 109:393-406 (1959).
46. HAMMON, W. McD., LUDWIG, E. H., SATHER, G., 58. JACKSON, G. G., AND MULDOON, R. 1., Viruses
causing common respiratory infections in man, J. eds.), pp. 1-65, American Public Health Association,
Infect. Dis. 127:328-408 (1973). New York, 1969.
59. JANDA, Z., ADAM, E., AND VONKA, V., Properties of 69. LENNETTE, E. H., MELNICK, J. L., AND MAGOFFIN, R
a new type 3 attenuated poliovirus. VI. Alimentary L., Clinical virology: Introduction to methods, in:
tract resistance in children fed previously with type Manual of Clinical Microbiology, 2nd ed. (E. H.
3 Sabin vaccine to reinfection with homologous and LENNETTE, E. H. SPAULDING, AND J. P. TRUANT,
heterologous type 3 attenuated poliovirus, Arch. eds.), pp. 667-677, American Society for Microbiol-
Virusforsch. 20:87-98 (1967). ogy, Washington, D.C., 1974.
60. KAPLAN, G. J., CLARK, P. S., BENDER, T. R., FELTZ, 70. LEPOW, M. L., NANKERVIS, G. A., AND ROBBINS, F.
E. T., LIST-YOUNG, B., NEVIUS, S. E., AND CHIN, T. c., Immunity of school children two years after oral
D. Y., Echovirus type 30 meningitis and related poliomyelitis vaccination, J. Am. Med. Assoc.
febrile illness: Epidemiologic study of an outbreak 202:121-125 (1967).
in an Eskimo community, Am. J. Epidemiol. 92:257- 71. LERNER, A. M., AND WILSON, F. M., Virus myocar-
265 (1970). diopathy, Prog. Med. Viro!' 15:63-91 (1973).
61. KELLY, S., WINSSER, J., AND WINKELSTEIN, W., JR., 72. LIM, K. A., AND BENYESH-MELNICK, M., Typing of
Poliomyelitis and other enteric viruses in sewage, viruses by combinations of antiserum pools: Appli-
Am. J. Public Health 47:72-77 (1957). cation to typing of enteroviruses (Coxsackie and
61a. KENNETT, M. L., BIRCH, C. J., LEWIS, F. A., YUNG, echo), J. Immunol. 84:309-317 (1960).
A. P., LOCARNINI, S. A., AND GUST, I. D., Enterovi- 73. LUND, E., HEDSTROM, C.-E., AND STRANNEGA.RD, 0.,
rus type 71 infection in Melbourne, Bull. WHO A comparison between virus isolations from sewage
51:609-615 (1974). and from fecal specimens from patients, Am. J. Epi-
62. KIBRICK, S., Current status of Coxsackie and ECHO demiol. 84:282-286 (1966).
viruses in human disease, Prog. Med. Virol. 6:27-70 74. MAGUIRE, T., The laboratory transmission of
(1964). Coxsackie A6 virus by mosquitoes, J. Hyg. 68:625-
63. KOGON, A., SPIGLAND, I., FROTHINGHAM, T. E., 630 (1970).
ELVEBACK, L., WILLIAMS, c., HALL, C. E., AND Fox, 75. MCCARROLL, J. R, MELNICK, J. L., AND HORST-
J. P., The Virus Watch Program: A continuing MANN, D. M., Spread of poliomyelitis infection in
surveillance of viral infections in metropolitan New nursery schools, Am. J. Public Health 45:1541-1550
York families. VII. Observations on viral excretion, (1955).
seroimmunity, intrafamilial spread and illness asso- 76. MELNICK, J. L., Poliomyelitis virus in urban sewage
ciation in coxsackievirus and echovirus infections, in epidemic and in non-epidemic times, Am. J.
Am. J. Epidemiol. 89:51-61 (1969). Hyg. 45:240-253 (1947).
64. KONO, R., SASAGAWA, A., ISHII, K., SUGIURA, S., 77. MELNICK, J. L., Variation in poliomyelitis virus on
OCHI, M., MATSUMIYA, H., UCHIDA, Y., KAMEYAMA, serial passage through tissue culture, Cold Spring
K., KANEKO, M., AND SAKURAI, N., Pandemic of Harbor Symp. Quant. Bioi. 18:278-279 (1953).
new type of conjunctivitis, Lancet, i:1191-1194 78. MELNICK, J. L., Application of tissue culture meth-
(1972). ods to epidemiological studies of poliomyelitis, Am.
65. KRAUS, G., Details of poliomyelitis outbreak, N. J. Public Health 44:571-580 (1954).
Eng!. J. Med. 288:1357-1358 (1973). 79. MELNICK, J. L., Echo viruses, in: Cellular Biology,
66. LAMB, G. A., CHIN, T. D. Y., AND SCARCE, L. E., Nucleic Acids and Viruses, Special Publication of the
Isolations of enteric viruses from sewage and river New York Academy of Sciences, Vol. 5, pp. 365-381
water in a metropolitan area, Am. J. Hyg. 80:320-327 (1957).
(1964). 80. MELNICK, J. L., Advances in the study of the entero-
67. LANDSTEINER, K., AND POPPER, E., Ubertragung der viruses, Prog. Med. Virol. 1:59-105 (1958).
Poliomyelitis acuta auf Affen, Z. Immunitatsforsch., 81. MELNICK, J. L., Echoviruses, in: Viral and Rickettsial
Orig., 2:377-390 (1909). Infections of Man, 4th ed. (F. L. HORSFALL, JR., AND
67a. LAVINDER, C. H., FREEMAN, A. W., AND FROST, W. I. TAMM, eds.), pp. 513-545, Lippincott, Philadel-
H., Epidemiologic studies of poliomyelitis in New phia, 1965.
York City and northeastern United States during 82. MELNICK, J. L., Enteroviruses: Vaccines, epidemiol-
the year 1916, Public Health Bull. No. 91, July, 309 p. ogy, diagnosis, and classification, CRC Crit. Rev.
(1918). c/in. Lab. Sci. 1:87-118 (1970).
68. LENNETTE, E. H., General principles underlying lab- 83. MELNICK, J. L. Periodic serological surveillance, in:
oratory diagnosis of viral and rickettsial infections, Serological Epidemiology (J. R PAUL AND C. WHITE,
in: Diagnostic Procedures for Viral and Rickettsial Infec- eds.), pp. 143-154, Academic Press, New York,
tions, 4th ed. (E. H. LENNETTE AND N. J. SCHMIDT, 1973.
84. MELNICK, J. 1., Reference materials in virology: The 97. MELNICK, J. 1., SHAW, E. W., AND CURNEN, E. c., A
enterovirus example, in: Proceedings of the Interna- virus from patients diagnosed as non-paralytic po-
.tional Conference on Standardization of Diagnostic liomyelitis or aseptic meningitis, Proc. Soc. Exp .
• Materials, pp. 213-235, CDC Monograph, Center for Bioi. Med. 71:344-349 (1949) .
Disease Control, Atlanta, Ga., 1974. 98. MELNICK, J. 1., AND WENNER, H. A., Enteroviruses,
85. MELNICK, J. 1., AND AGREN, K., Poliomyelitis and in: Diagnostic Procedures for Viral and Rickettsial
Coxsackie viruses isolated from normal infants in Infections, 4th ed. (E. H. LENNETTE AND N. l
Egypt, Proc. Soc. Exp. Bioi. Med. 81:621~24 (1952). SCHMIDT,eds.), pp. 52~2, American Public
86. MELNICK, J. 1., BOYD, A. 1., AND BUTEL, J. S., DNA Health Association, New York, 1969.
transfer and virus-cell relationships, in: Viruses, 98a. MELNICK, J. 1., et al. (Study Group on Picornaviri-
Evolution and Cancer (E. KURSTAK AND K. MARAMO- dae, Vertebrate Virus Subcommittee, International
ROSCH, eds.), pp. 31-54, Academic Press, New Committee on Taxonomy of Viruses), Picornaviri-
York,1974. dae, Intervirology 4:303-316 (1974).
87. MELNICK, J. 1., BURKHARDT, M., TABER, 1. H., AND 99. MILLER, D. A., MILLER, O. J., VAITHILINGAM, G. D.,
ERCKMAN, P. N., Developing gap in immunity to HASHMI, S., TANTRAVAHI, R., MEDRANO, 1., AND
poliomyelitis in an urban area, J. Am. Med. Assoc. GREEN, H., Human chromosome 19 carries a ·polio-
209:1181-1185 (1969). virus receptor gene, Cell 1:167-173 (1974).
88. MELNICK, J. 1., COCKBURN, W. c., DALLDORF, G., 99a. MILLER, D. G., GABRIELSON, M. 0., AND HORST-
GARD, S., GEAR, J. H. S., HAMMON, W. McD., MANN, D. M., Clinical virology and viral surveil-
KAPLAN, M. M., NAGLER, F. P., OKER-BLOM, N., lance in a pediatric group practice: The use of
RHODES, A. J., SABIN, A. B., VERLINDE, J. D., AND double-seeded tissue culture tubes for primary
VON MAGNUS, H., Picornavirus group, Virology virus isolation, Am. J. Epidemio/' 88:24>-256 (1968).
19:114-116 (1963). 100. MIRKOVIc, R R., KONO, R., YIN-MuRPHY, M., So-
89. MELNICK, J. 1., CROWTHER, D., AND BARRERA-ORO, HIER, R, SCHMIDT, N. J., AND MELNICK, J. 1., Entero-
J., Rapid development of drug-resistant mutants of virus type 70: the etiologic agent of pandemic acute
poliovirus, Science 134:557 (1%1). haemorrhagic conjunctivitis, Bull. WHO 49:341-346
90. MELNICK, J. 1., EMMONS, J., COFFEY, J. H., AND (1973).
SCHOOF, H., Seasonal distribution of Coxsackie vi- 101. NISHMI, M., AND YODFAT, Y., Successive overlap-
ruses in urban sewage and flies, Am. J. Hyg. 59:164- ping outbreaks of a febrile illness associated with
184 (1954). coxsackie virus type B4 and echo virus type 9 in a
91. MELNICK, J. L., AND HAMPIL, B., WHO collaborative kibbutz, Isr. J. Med. Sci. 9:89>-899 (1973).
studies on enterovirus reference antisera: Fourth 102. NOLAN, J. P., WILMER, B. J., AND MELNICK, J. 1.,
report, Bull. WHO 48:381-3% (1973). Poliomyelitis: Its highly invasive nature and narrow
92. MELNICK, J. 1., AND LEDINKO, N., Social serology: stream of infection in a community of high socioeco-
Antibody levels in a normal young population dur- nomic level, N. Engl. J. Med. 253:94>-954 (1955).
ing an epidemic of poliomyelitis, Am. J. Hyg. 103. OBERHOFER, T. R., BROWN, G. c., AND MONTO, A. S.,
54:354-382 (1951). Seroimmunity to poliomyelitis in an American com-
93. MELNICK, J. 1., AND LEDINKO, N., Development of munity, Am. J. Epidemiol., 101:333-339 (1975).
neutralizing antibodies against the three types of 104. OGRA, P. 1., AND KARZON, D. T., Formation and
poliomyelitis virus during an epidemic period: The function of poliovirus antibody in different tissues,
ratio of inapparent infection to clinical poliomyeli- Prog. Med. Virol. 13:156-193 (1971).
tis, Am. J. Hyg. 58:207-222 (1953). 105. OGRA, P. 1., OGRA, S. S., AL-NAKEEB, S., AND
94. MELNICK, J. 1., MCCARROLL, J. R, AND HORST- COPPOLA, P. R., Local antibody response to experi-
MANN, D. M., A winter outbreak of poliomyelitis in mental poliovirus infection in the central nervous
New York City: The complement-fixation test as an system of rhesus monkeys, Infect. Immun. 8:931-937
aid in rapid diagnosis, Am. J. Hyg. 63:9>-114 (1956). (1973).
95. MELNICK, J. 1., P,.UL, J. R, AND WALTON, M., 106. PACSA, S., AND WERBLINSKA, J., Natural immunity of
Serologic epidemiology of poliomyelitis, Am. J. Pub- Ghanaian children to polio and coxsackieviruses:
lic Health 45:429-437 (1955). Brief report, Arch. Gesamte Virusforsch. 33:192-193
96. MELNICK, J. 1., RENNICK, V., HAMPIL, B., SCHMIDT, (1971).
N. J., AND Ho, H. H., Lyophilized combination 107. PARKS, W. P., QUEIROGA, 1. T., AND MELNICK, J. 1.,
pools of enterovirus equine antisera: Preparation Studies of infantile diarrhea in Karachi, Pakistan. II.
and test procedures for the identification of field Multiple virus isolations from rectal swabs, Am. J.
strains of 42 enteroviruses, Bull. WHO 48:263-268 Epidemial. 85:469-478 (1%7).
(1973). 108. PAUL, J. R, Endemic and epidemic trends of po-
liomyelitis in Central and South America, Bull WHO 121. ROSSEN, R D., KASEL, J. A., AND COUCH, R B., The
19:747-758 (1958). secretory immune system: Its relation to respiratory
109. PAUL, J. R, Development and use of serum surveys viral infection, Prog. Med. Virol. 13:194-238 (1971).
in epidemiology, in: Serological Epidemiology 0. R. 122. ROUSSEAU, W. E., NOBLE, G. R., TEGTMEIER, G. E.,
PAUL AND C. WHITE, eds.), pp. 1-13, Academic JORDAN, M. c., AND CHIN, T. D. Y., Persistence of
Press, New York, 1973. poliovirus neutralizing antibodies eight years after
109a. PAUL, J. R., A History of Poliomyelitis, Yale Univer- immunization with live, attenuated-virus vaccine,
sity Press, New Haven, 1971. N. Engl. J. Med. 289:1357-1359 (1973).
110. PAYNE, A. M.-M., Poliomyelitis as a world problem, 123. SABIN, A. B., Oral poliovirus vaccine, J. Am. Med.
Papers and discussions presented at the Third Inter- Assoc. 194:872-876 (1965).
national Poliomyelitis Conference, pp. 393-400, Lip- 124. SABIN, A. B., HENNESSEN, W. A., AND WINSSER, J.,
pincott, Philadelphia, 1955. Studies on variants of poliomyelitis virus. I. Experi-
111. PHILLIPS, C. A., Enteroviruses, in: Manual of Clini- mental segregation and properties of avirulent var-
cal Microbiology, 2nd ed. (E. H. LENNETTE, E. H. iants of three immunologic types, J. Exp. Med.
SPAULDING, AND J. P. TRUANT, eds.), pp. 723--727, 99:551-576 (1954).
American Society for Microbiology, Washington, 125. SABIN, A. B., KRUMBIEGEL, E. R, AND WIGAND, R,
D.C., 1974. ECHO type 9 virus disease: Virologically controlled
112. PHILLIPS, C. A., MELNICK, J. L., BARRETT, F. F., clinical and epidemiologic observations during 1957
BEHBEHANI, A. M., AND RIGGS, S., Dual virus infec- epidemic in Milwaukee with notes on concurrent
tions: Simultaneous enteroviral disease and St. similar diseases associated with Coxsackie and other
Louis encephalitis, J. Am. Med. Assoc. 197:169-172 ECHO viruses, Am. J. Dis. Child. 96:197-219 (1958).
(1966). 126. SALK, J. E., Poliomyelitis: control, in: Viral and
113. RAMOS-ALVAREZ, M., AND SABIN, A. B., Character- Rickettsial Infections of Man, 3rd ed. (T. M. RIVERS
istics of poliomyelitis and other enteric viruses AND F. L. HORSFALL, JR., eds.), pp. 499-518, lippin-
recovered in tissue culture from healthy American cott, Philadelphia, 1959.
children, Proc. Soc. Exp. BioI. Med. 87:655-661 127. SANDERS, D. Y., AND CRAMBLETT, H. G., Antibody
(1954). titers to polioviruses in patients ten years after
114. REID, D., BELL, E. J., AND GRIST, N. R, Poliomyeli- immunization with Sabin vaccine, J. Pediat. 84:406-
tis: A gap in immunity? Lancet, pp. 899-900 (Oct. 408 (1974).
20, 1973). 128. SCHAFFER, F. L., Binding of proflavine by and
115. REISSIG, M., HOWES, D. W., AND MELNICK, J. L., photo inactivation of poliovirus propagated in the
Sequence of morphological changes in epithelial cell presence of the dye, Virology 18:412-425 (1962).
cultures infected with poliovirus, J. Exp. Med. 129. SCHIEBLE, J. H., Fox, V. L., AND LENNETTE, E. H., A
104:289-304 (1956). probable new human picornavirus associated with
116. RIVERS, T. M., AND HORSFALL, F. L., JR., (eds.), Viral respiratory disease, Am. J. Epidemiol. 85:297-310
and Rickettsial Infections of Man, 3rd ed., Lippincott, (1967).
Philadelphia, 1959. 130. SCHMIDT, N. J., Tissue culture technics for diagnos-
117. ROBBINS, F. c., ENDERS, J. F., WELLER, T. H., AND tic virology, in: Diagnostic Procedures for Viral and
FLORENTINO, G. L., Studies on the cultivation of Rickettsial Infections, 4th ed. (E. H. LENNETTE AND
poliomyelitis viruses in tissue culture. V. The direct N. J. SCHMIDT, eds.), pp. 79-178, American Public
isolation and serologic identification of virus strains Health Association, New York, 1969.
in tissue culture from patients with nonparalytic 131. SCHMIDT, N. J., AND LENNETTE, E. H., Advances in
and paralytic poliomyelitis, Am. J. Hyg. 54:286-293 the serodiagnosis of viral infections, Prog. Med.
(1951). Virol. 15:244-308 (1973).
118. ROSEN, L., AND KERN, J. K., Hemagglutination and 132. SCHMIDT, N. J., LENNETTE, E. H., AND Ho, H. H.,
hemagglutination-inhibition with coxsackie B vi- An apparently new enterovirus isolated from pa-
ruses, Proc. Soc. Exp. BioI. Med. 107:626-628 (1961). tients with disease of the central nervous system, J.
119. ROSEN, L., MELNICK, J. L., SCHMIDT, N. J., AND Infect. Dis. 129:304-309 (1974).
WENNER, H. A., Subclassification of enteroviruses 133. SCHMIDT, N. J., MAGOFFIN, R L., AND LENNETTE, E.
and echovirus type 34, Arch. Gesamte Virusforsch. H., Association of group B coxsackieviruses with
30:89-92 (1970). cases of pericarditis, myocarditis, or pleurodynia by
120. ROSEN, L., SCHMIDT, N. J., AND KERN, J., Toluca-I, a demonstration immunoglobulin M antibody, Infect.
newly recognized enterovirus, Arch. Gesamte Virus- Immun. 8:341-348 (1973).
forsch. 40:132-136 (1973). 134. SERGIESCU, D., HORODNICEANU, F., AND AUBERT-
COMBIESCU, A., The use of inhibitors in the study of 145. WALLIS, c., AND MELNICK, J. 1., Photodynamic
picornavirus genetics, Prog. Med. Viral. 14:123-199 inactivation of enteroviruses, J. Bacterial. 89:41-46
(1972). (1965).
135. SMITH, A. E., Picornaviruses still useful as model 146. WALLIS, c., AND MELNICK, J. 1., Virus aggregation
systems, Nature (London) 250:100-101(1974). as the cause of the non-neutralizable persistent
136. SOMMERVILLE, R. G., Rapid diagnosis of viral infec- fraction, J. Viral. 1:478-488 (1967).
tions by immunofluorescent staining of viral anti- 147. WALLIS, c., HOMMA, A., AND MELNICK, J. 1., A
gens in leukocytes and macrophages, Prog. Med. portable virus concentrator for testing water in the
Viral. 10:398-414 (1968). field, Water Res. 6:1249-1256 (1972).
137. TABER, L. H., MIRKOVIC, R. R., ADAM, V., ELLIS, S. 148. WEINSTEIN, 1., Poliomyelitis-A persistent prob-
S., Yow, M. D., AND MELNICK, J. L., Rapid diagnosis lem, N. Engl. J. Med. 288:370-372 (1973).
of enterovirus meningitis by immunofluorescent 149. WENNER, H. A., The ECHO viruses, Ann. N.Y.
staining of CSF leukocytes, Intervirology 1:127-134 Acad. Sci. 101:398-412 (1962).
(1973). 150. WENNER, H. A., Virus diseases associated with
138. TAGAYA, I., NAKAO, c., HARA, M., AND YAMADERA, cutaneous eruptions, Prog. Med. Viral. 16:269-336
S., Characterization of poliovirus isolates in Japan (1973).
after the mass vaccination with live oral poliomyeli- 151. WICKMAN, I., Studien liber Poliomyelitis acuta; zu-
tis vaccine (Sabin), Bull. WHO 48:547-554 (1973). gleich ein Beitrag zur Kenntnis der Myelitis acuta,
139. TAKATSU, T., TAGAYA, I., AND HIRAYAMA, M., Po- 1905 (English translation, Nervous and Mental Dis-
liomyelitis in Japan during the period 1962-68 after ease Monograph Series, No. 16, Karger, Berlin,
the introduction of mass vaccination with Sabin vac- 1913).
cine, Bull. WHO 49:129-137 (1973). 152. World Health Organization, WHO Weekly Epide-
140. TAMM, I., AND EGGERS, H. J., Differences in the miological Records, during the 1960s and 1970s.
selective virus-inhibitory action of 2-(a-hydroxy- 153. WYATT, H. V., Hypothesis: Poliomyelitis in hypo-
benzyl)-benzimidazole and guanidine' HCl, Virol- gammaglobulinemics, J. Infect. Dis. 128:802-806
ogy 18:439-447 (1962). (1973).
141. TORPHY, D. E., RAY, C. G., THOMPSON, R. S., AND 154. WYATT, H. V., The immunity gap and vaccination
Fox, J. P., An epidemic of aseptic meningitis due to against poliomyelitis, Lancet, i:784-785 (Apr. 27,
echovirus type 30: Epidemiological features and 1974).
clinical laboratory findings, Am. J. Public Health 155. YIN-MuRPHY, M., AND LIM, K. H., Picornavirus
60:1447-1455 (1970). epidemic conjunctivitis in Singapore, Lancet ii:857-
142. TRASK, J. D., MELNICK, J. 1., AND WENNER, H. A., 858 (1972).
Chlorination of human, monkey-adapted and 156. YODFAT, Y., AND NISHMI, M., Epidemiologic and
mouse strains of poliomyelitis virus, Am. J. Hyg. clinical observations in six outbreaks of viral dis-
41:30-40 (1945). ease in a kibbutz, 1968-1971, Am. J. Epidemiol.
143. VOROSHILOVA, M. K., AND CHUMAKOV, M. P., Po- 97:415-423 (1973).
liomyelitis-like properties of AB-IV-Coxsackie A7 157. YOUNG, N. A., Polioviruses, coxsackieviruses, and
group of viruses, Prog. Med. Viral. 2:106-170 (1959). echoviruses: Comparison of the genomes by RNA
144. WALLIS, c., AND MELNICK, J. 1., Cationic stabiliza- hybridization, J. Viral. 11:832-839 (1973).
tion-A new property of enteroviruses, Virology
16:683-700 (1961).
CHAPTER 9
Epstein-Barr Virus
Alfred S. Evans and James C. Niederman
1. Introduction of the liver and spleen.(12(;) As this description

antedated by some 30-50 yr the recognition of the
Epstein-Barr virus (EBV), a member of the herpes hematological changes and the discovery of heter-
group of viruses, is the cause of heterophil-posi- ophil antibody, it is uncertain whether this can be
tive infectious mononucleosis, of some heterophil- accepted as true infectious mononucleosis. How-
negative cases, and of occasional cases of tonsillitis ever, his description of this type of febrile syn-
and pharyngitis in childhood. Rarely, it may prodrome in older children and young adults seems
duce involvement of the central nervous system. best to fit this diagnosis. There is little doubt
This virus is strongly implicated as having a causal about the classical description of the disease made
relationship to African Burkitt lymphoma and to by Sprunt and Evans, from Johns Hopkins, in
nasopharyngeal cancer. High antibody titers are 1920.(139) They described the disorder in young
also present in 40-50% of cases of Hodgkin's adults as we now know it, named the disease
disease, sarcoidosis; and systemic lupus erythe- "infectious mononucleosis," and reported in detail
matosus. the hematological changes. This description was
This chapter will deal with the epidemiology of followed rapidly by similar reports from other
EB virus infections and the epidemiology of infec- workers.m.22.9n.1(8) A definitive presentation of
tious mononucleosis. It will also mention the rela- hematological changes was made by Downey and
tionship of high antibody titers to certain chronic McKinlay in 1923.(28) The next major development
and malignant diseases, but the major discussion was the discovery in 1932 of the heterophil anti-
of Burkitt lymphoma and of nasopharyngeal cancer body by Drs. John R. Paul and William W. Bunnell
will be found in later chapters of this book. of Yale University.(1211 Their report was based on
an accidental observation while studying the oc-
currence of heterophil antibodies in rheumatic
fever. This search had been initiated because of
2. History the clinical similarity of rheumatic fever and serum
sickness and because of the work of Davidsohn(24)
In 1889, Emil Pfeiffer of Wiesbaden, Germany, describing the presence of heterophil antibodies in
described a condition called Driisenfieber (glandu- serum sickness. Among the control subjects for
lar fever), characterized by fever, adenopathy, rheumatic fever patients was one who had infec-
mild sore throat, and in severe cases enlargement tious mononucleosis and was found to have a
much higher heterophil antibody titer than pres-
Alfred S. Evans and James C. Niederman . Depart- ent in any other condition. Paul and Bunnell then
ment of Epidemiology and Public Health, Yale University continued these observations in three additional
School of Medicine, New Haven, Connecticut cases of infectious mononucleosis and utilized 275
209
210 Chapter 9 • Epstein-Barr Virus
controls for comparison. Their paper also describes phocytes on a feeder layer, and fluorescent anti-
what they believed to be a false-positive hetero- body techniques to identify an agent were unsuc-
phil antibody occurring in a patient with aplastic cessful.(31) Epidemiologically, the key events
leukemia. A review of the details of this case(4J) during this time were the observations of Hoag-
reveqls that the heterophil antibody occurred land, who suggested that the disease might be
about 20 days after the administration of several transmitted by kissing(79) and that the incubation
units of blood and therefore this patient may period was of the order of 30--49 days.(S])
represent the first case of transfusion infectious Early in 1968, evidence first appeared that EB
mononucleosis. Soon after the discovery of the virus was the cause of infectious mononucleo-
presence of heterophil antibodies, Davidsohn and sis. m.ll4) This virus, isolated by Epstein, Barr,
Walker(23) reported on the use of guinea pig and Achong from a culture of African Burkitt
kidney and of beef cells to absorb serum prior to tumor tissue, was found to be a new member of
heterophil testing in order to increase the specific- the herpes group of viruses.(33) While working
ity of the test. Both of these procedures have with this agent, a technician in the Henles' labora-
withstood the test of time well and still constitute tory in Philadelphia developed infectious mono-
one of the major criteria of diagnosis. Regular nucleosis. Her serum, which lacked antibody sev-
alterations in various liver function tests during eral months prior to disease, developed EBV
acute infectious mononucleosis were recognized in antibody during illness, and her lymphocytes,
several laboratories in the late 1940s and which had failed to be cultivated successfully hith-
1950s,m.J;.s(;) even though only 5% of patients erto, now grew well in tissue culture and were
had clinical jaundice. This was followed by the shown to contain EB viral antigen.(72l This seren-
discovery of alterations in serum glutamic oxala- dipitous observation was rapidly confirmed and
cetic transaminase (SGOT) and other hepatic en- extended at that time by the Henles in conjunction
zymes during the course of disease.(6.131.15S) with Niederman and McCollum of Yale(ll4) and
Search for the etiological agent of infectious later in several other prospective studies carried
mononucleosis began in the 1920s, but met little out by the Yale team(50.llJ.132) and in one English
success until 1942 when Wising(15(;) reported the study. ()48) Subsequent investigations established
successful transmission of classical infectious the presence and persistence of EB virus in the
mononucleosis to a female medical student volun- throat during and after acute infectious mononu-
teer who received 250 ml of blood hom a patient ill cleo sis, (19.59.1
(I;jj the occurrence of EBV -specific
with the acute disease. This successful experiment IgM/4.66.1l4a.133) and the reproduction of some fea-
was not reproducible by Wising in several other tures of mononucleosis by inoculation of EB virus
attempts, nor by Bang/ 3) who carried out a simi- into monkeys. ((35.154) Fuller details of the history
lar set of volunteer experiments. In 1947 and again of infectious mononucleosis have been published
in 1950, additional efforts of this sort were carried elsewhere. (](;.4;)1
out at Yale University using whole blood, serum,
or throat washings. The results provided sugges-
tive but inconclusive evidence of transmis-
sion.(34,36) A third effort with questionable success
3. Methodology
was reported from Yale University in 1965.012)
Subsequent EBV antibody tests on the sera from
3.1. Mortality Data
these last experiments in 1968 revealed that all vol-
unteers had actually been immune to infection Infectious mononucleosis is rarely a fatal dis-
prior to the experiment as indicated by the pres- ease; only about 50 fatalities have been re-
ence of antibody.ow portedY9) Examination of autopsy records or of
Repeated attempts in the 1950s to isolate an international indexes of causes of death would
infectious agent from the throat or blood of pa- therefore give little indication of the occurrence of
tients with infectious mononucleosis using several the disease even though its pathological features
tissue culture systems, long-term cultures of lym- are quite characteristic.
Chapter 9 • Epstein-Barr Virus 211
3.2. Morbidity Data the serum has been preabsorbed with guinea pig
kidney in the sheep and horse red cell tests, or that
Infectious mononucleosis is not a reportable
the beef hemolysin test has been used. In a test
disease in most states and in most countries.
performed in this way, an elevated titer quite
Exceptions are the state of Connecticut, where it
accurately reflects the occurrence of infectious
has been reportable since 1948/21l and the U.S.
mononucleosis even in the absence of clinical and
armed forces, which collect hospitalization data on
hematological data and has been utilized as an
all diseases.(41l Unless strong emphasis is placed
indicator of infectious mononucleosis in sera sent
on the need for fulfilling clinical, hematological,
to hospitals and state laboratories.(~8) The major
and serological criteria for diagnosis before report-
limitation of this approach is the extent to which
ing, the reliability of morbidity data from these
physicians have sent sera from suspected cases to
sources must be seriously questioned. This re-
the diagnostic laboratory for analysis. The increas-
quirement is emphasized by the fact that even for
ing use of simple laboratory kits for identifying
the 15--25 age group-where the disease has its
heterophil antibody elevations in the physician's
highest incidence, its most characteristic clinical
office probably results in much less utilization of
features, and the highest frequency of elevated
state and hospital laboratories so that morbidity
heterophil antibody tests-only one-third of the
data from these sources may greatly underestimate
serum samples sent to a state laboratory for diag-
the occurrence of the disease. Thus, utilization of
nosis of suspected cases were heterophil antibody
positive. (~8) the heterophil antibody as an epidemiological tool
to identify the acute illness has high reliability and
In order to collect morbidity data, special sur-
specificity but low sensitivity. Heterophil-positive
veys of selected populations for infectious mono-
cases diagnosed in the Connecticut State Public
nucleosis have been carried out in college infirma-
Health Laboratory alone represented 74.5% of all
ries/ 50,113,132) community medical care groupS/69)
the reported cases in the state in 1972.
general practitioners' offices/ 83 ) and by physicians
Since the discovery of EB virus as the cause of
and laboratories serving defined communi-
infectious mononucleosis in 1968, many serologi-
ties.(38,68) The Center for Disease Control also pe-
cal surveys in different countries have been made
riodically publishes a Surveillance Report on infec-
for the presence of antibody to this virus in sera
tious mononucleosis based on data derived from 19
colleges,08) collected from healthy persons, usually employing
the indirect immunofluorescence test(70) for viral
The problems of data derived from such surveys
capsid antigen. This antibody persists for many
are related to the extent to which the numerator or
years, perhaps for life.<m,[14) These studies yield
case report reflects the proper diagnosis and
prevalence data on prior EBV infection but give no
whether adequate surveillance has been carried
direct indication of the occurrence of clinical infec-
out with respect to the denominator-the popula-
tious mononucleosis.
tion at risk.
The most accurate information on the incidence
of both EBV infections and clinical infectious mo-
3.3. Serological Surveys nonucleosis has come from prospective'seroepide-
miological studies of defined populations with
Up to 1968, when the causal association of EB close clinical surveillance for the occurrence of
virus to infectious mononucleosis was discovered, suspected cases of infectious mononucleosis and
the heterophil antibody constituted the only serol- other illnesses. Sera taken at the start of the
ogical approach to diagnosis and survey work. observation period are tested to define the number
Because this is an IgM-type antibody and is tran- of susceptibles, i.e" those lacking EBV antibody;
sient in nature, it can be used as a serological tool samples showing seroconversion at the end of the
only for incidence data-i.e., during the acute observation period will identify the total EBV
illness, and as an essential diagnostic feature. (14 ) infection rate; those collected during interim ill-
The specificity of a properly performed quantita- nesses and tested for EBV and heterophil antibod-
tive heterophil antibody test is high provided that ies will delineate the number and spectrum of
clinical illnesses, such as infectious mononucleo- oped. Five antibody methods based on immuno-
sis, associated with EBV infection. fluorescence have been used. First, for
epidemiological purposes the indirect immunoflu-
orescence test of the Henles'70) for viral capsid
antigen has been widely employed in serological
surveys as a reliable indicator of susceptibility and
3.4.1. EBV Isolation. The virus cannot be grown immunity to infectious mononucleosis. However,
in the usual tissue cultures employed for other it has not proved very useful as a diagnostic test
herpesviruses. The currently available isolation for infectious mononucleosis because antibody is
technique is tedious, difficult, and usually con- usually present by the time the patient seeks
fined. to research laboratories. It is based on the medical care and rises in titer are detectable in
ability of EB virus to transform uninfected human only 15-20% of cases. Second, antibody to "early
leukocytes into continuous cell lines and the iden- antigen" is also identified by immunofluorescence
tification of this effect as due to EBV.09,103) Leu- techniques(74.76) and its presence is indicative of
kocytes derived from the cord of newborn infants recent or active infection. Unfortunately from a
or from persons lacking EBV antibody are em- diagnostic standpoint it is demonstrable only in
ployed to ensure absence of EBV antigen in the about 75% of patients with infectious mononu-
lymphocytes. Throat washings or other materials cleosis(77); it also occurs in the sera from patients
to be tested are usually filtered to remove debris with Burkitt lymphoma and nasopharyngeal can-
and bacteria, then added to the leukocytes, and cer. Third, antibodies to Epstein-Barr virus associ-
placed on a placental fibroblast feeder layer. If EBV ated nuclear antigen (EBNA) are detectable by an
is present, evidence of transformation is indicated immunofluorescence technique based on fixation
by an abrupt increase in the total number of cells, of complement; these usually arise only 1 or more
the production of acid, growth of cells in clumps, months after onset of infectious mononucleosis
and the development of the capacity to be subcul- and after primary infections and probably persist
tured indefinitely. Usually, transformation occurs for life. (73) Their late appearance impairs their use-
30-90 days after addition of the throat washing. fulness in routine diagnosis. Fourth, there is an
The presence of EBV nuclear antigen can be indirect immunofluorescence test for EBV-specific
demonstrated in acetone-fixed smears of trans- IgM antibody, and this is the most useful procedure
formed cord cells using an indirect complement for the diagnosis of heterophil-negative infectious
fixation fluorescence technique,(29) but viral cap- mononucleosis(29,114a.133); however, in its present
sid antigen (VeA) cannot be demonstrated by form this test is technically difficult to perform and
ordinary immunofluorescence methods, presum- interpret, and it is thus not currently available in
ably because the virus does not mature sufficiently diagnostic laboratories. Finally, a membrane fluo-
in such cells. EBV-transformed leukocytes may rescence test has been developed by Klein et
also be grown further in culture to prepare a ai. (88.89.90) Other antibody tests include complement
complement-fixing antigen as a means of identifi- fixation using either the virus(l) or soluble anti-
cation; however, this is a laborious method. More gens,<57l neutralization tests based on contact inhi-
sensitive methods of antigen detection, chemical bition, (78.105) and immunodiffusion tests. (16 )
means of enhancing the rapidity of viral multipli- 3.4.3. Heterophil Antibody Tests. Three general
cation to shorten the long observation time, or methods are employed to test for heterophil anti-
discovery of a more sensitive cell line will be body: (1) the classic Paul-Bunnell test021l using
needed before viral isolation will be practical in sheep or horse red cells after absorption of the
the diagnostic laboratory. Recently, Robinson and serum with guinea pig kidney as developed by
Millet 129a) have demonstrated that DNA stimula- Davidsohn and Walker(23); (2) the beef cell hemo-
tion occurs early in EBV infected cord cells and can lysin test of Bailey and Raffel(2) adapted for diag-
be detected by increased uptake of radioactive- nostic use by Mason, (98) which does not require
labeled thymidine. absorption of sera with guinea pig kidney because
3.4.2. EBV Antibody. A wide variety of tech- beef cell hemolysins are absent or at very low titers
niques to measure EBV antibody have been devel- in normal sera; and (3) the enzyme test of
Wollner,(57) in which red cell receptors for heter- have made characterization of the physical and
ophil antibody are specifically removed by treat- chemical properties of EBV very difficult. Alllym-
ment with papain or a similar enzyme. Recent phocytes in continuous cultures established from
evidence suggests that heterophil antibody titers infectious mononucleosis blood or Burkitt lym-
may reach diagnostic levels even after mild or phoma biopsies contain the EBV genome as dem-
asymptomatic EBV infections provided that serial onstrated by DNA hybridization or EBV nucleic
specimens are tested over a month or so by the acid (EBNA) tests, but only 1-3% have demonstra-
horse cell differential test. (52) The test may be ble viral capsid antigen(1I5·129.160); cell clones
useful in childhood EBV infections, which are grown from such cultures show a similar low
often mild. Most state and large diagnostic labora- percent of complete virus. (99.159) One line of cells
tories employ either the Davidsohn differential from Burkitt lymphoma, the P3J line of Pulver-
absorption test or the beef cell hemolysin test; the taft,(28) and its cloned derivative, the HR1K,
former, using horse cells, is more sensitive, and produce more extracellular virus than other lines.
heterophil antibody to this antigen often persists Another line derived from EBV-infected marmoset
at diagnostic levels for as long as a year or SO.(52.93) cells by Miller and Lipman (02 ) releases about 1000
The beef hemolysin antibody is more specific but times more transforming virus but about the same
disappears in 3 months or less; it is perhaps the number of viral particles as HR1K. It should be
most reliable test to diagnose infectious mononu- useful in viral characterization.
cleosis during the acute illness. Some of the biological properties of EBV are
A number of commercial testing kits for the important epidemiologically. The capacity for per-
diagnosis of infectious mononucleosis in the phy- sistence of a lytic infection in the throat provides a
sician's office are now available. Most are slide source of potential transmission; the low yield of
agglutination tests; usually performed at a single extracellular virus may bear on the need for inti-
dilution and commonly based on the agglutination mate, oral contact, perhaps with transfer of in-
of formalinized horse cells. Some of these employ fected cells, for transmission in young adults. The
guinea pig kidney to remove nonspecific agglutin- reasons for the higher efficiency of transmission of
ins from the serum prior to testing. Other tests EBV infection in young"children than in adults are
employ papain-treated red cells in the agglutina- unknown but might include the production of
tion test. Such tests are useful if carried out by more infectious virus in the pharynx of children,
trained personnel using fresh material; they more intense exposure, or spread by a fecal-oral
should be used for corroboration of clinical and route in settings with poor hygiene.
hematological findings, and if doubt exists should The capacity for persistence and latency of EBV
be confirmed by a standard quantitative test. in a nonproductive form sets the stage for later
reactivation under conditions of immunosuppres-
sion (malaria, therapeutic immunosuppression in
4. Biological Characteristics of the Agent renal transplants, etc.). African Burkitt lymphoma
and nasopharyngeal cancer may be expressions of
this reactivation. The long-term persistence of EBV
4.1. The Virus
in lymphocytes is of importance epidemiologically
Epstein-Barr virus is a distinctive member of the in the transmission of infection during blood
herpes group of viruses. On electron microscopy, transfusions to susceptible recipients. Of great
EBV appears similar to other herpes-group vi- importance is the capacity of EBV to transform
ruses. (33) Currently, two laboratory strains of EBV uninfected primate lymphocytes, inducing in them
have been identified,(06) but the sophisticated the potential for unlimited proliferation, a prop-
techniques needed to differentiate strain differ- erty termed "immortalization" by Miller/ IOO ) and
ences as small as exist between herpes types I and the lymphocytes that result are termed "I-lympho-
II are not yet available. The virus has been culti- cytes." The EBV-transformed and infected cells
vated only in suspension cultures of primate lym- appear to be B-type lymphocytes. (118,119) Viral in-
phocytes, and most cultures yield only small duction of new antigens (or unmasking of preex-
amounts of extracellular virus. These limitations isting ones) such as the membrane antigen of
Table 1. Summary of 11 Prospective Studies of EB Virus Infection in

Children and Young Adults u
Subsequent rate per 100lyr
EBV antibody Clinical infectious

status at start Number Percent EBV infection mononucleosis·
With antibody 3733 70.7 0 0

Without antibody 1547 29.3 16.4 7.1
Total 5280 100 4.6 2.0
a From ten studies carried out by Yale investigators and one by an English team"''''
• Clinical infectious mononucleosis was recognized in 47% of those infected with EBY.
Klein et ai. (88) may have immunological conse- antibody and no other viral antibody has been
quences in the development of new antibodies, in demonstrated during heterophil-positive infec-
a graft-vs.-host response, or in mixed lymphocyte tious mononucleosis. The occurrence of some het-
type reactions with uninvolved lymphocytes. erophil-negative cases of infectious mononucleosis
A better understanding of the dynamics and due to EBV has also been noted in prospective
effects of EBV activity at molecular and cellular studies. (50.65) Other mono-like syndromes are due
levels ("molecular epidemiology") and of the re- to cytomegalovirus and other agents.
sponses of the host to them under varied condi- EBV-specific antibody of the IgM class has been
tions of age, concomitant infection, immune sta- demonstrated during acute infectious mononu-
tus, and genetic constitution will be needed before cleosis and found to disappear during convales-
the full spectrum of clinical response is known._ cence, thus indicating that this is a primary re-
sponse to EBV infection. (4.29.66.133) Both the IgG
and IgM EBV-specific antibodies of infectious
4.2. Proof of Causation of Infectious mononucleosis are distinct from the heterophil
Mononucleosis antibody.
The causation of heterophil-positive infectious The virological evidence consists of the appear-
mononucleosis by EBV has been established be- ance of EBV in the oropharynx and in the circulat-
yond any reasonable doubt. The proof is based on ing lymphocytes of patients with acute infectious
seroepidemiological and virological evidence and mononucleosis. The agent has been regularly dem-
also on partial success in the experimental trans- onstrated in the pharynx of over 80% of patients
mission of infection to monkeys and man. during the acute illness. (19.59.103.125) It persists for
Seroepidemiological investigations have repeat- many months, and in several cases has persisted
edly shown that antibody to EBV of the IgG type for as long as a year or so. A chronic carrier state
has been consistently absent in sera taken prior to may exist. EBV has been regularly demonstrated in
the onset of infectious mononucleosis, regularly lymphocyte cultures from patients with acute in-
appears during illness, and persists for years fectious mononucleosis, where it may persist in a
thereafter. (50.65.114.132.148) The presence of this anti- latent form for years and may be a source of
body indicates immunity to clinical infectious transfusion mononucleosis.(58.75) EBV has not yet
mononucleosis, and its absence indicates suscepti- been demonstrated in fresh lymphocytes from pa-
bility to the disease. Table 1 summarizes 11 pro- tients with infectious mononucleosis: whether this
spective studies involving over 5000 children and is due to small amounts of virus, insensitive meth-
young adults in support of this relationship. No ods, existence in altered form, the destruction of
other virus has been found that induces a similar EBV-infected B cells by T lymphocytes, or other
PERCENT POSITIVE
10 20 30 40 50 60 70 80 90 100
BARBADOS
UGANDA
INDONESIA
Fig. 1. EBV antibody prevalence at
age 4--6 yr in different populations. MEXICO
Adapted from A. S. Evans, New dis- HAWAII

coveries in infectious mononucleo-
BRAZIL
sis, Mod. Med. 1: 18-24 (1974).
FRANCE
SWEDEN
ENGLAND
CONN.
reasons is currently unknown. * The appearance and Recent studies with this virus in humans have
persistence of EBV in the oropharynx following been very limited because of concern for the onco-
mild or asymptomatic infections provides a large genicity of EBV, Grace et al. (61l repeatedly inocu-
pool of healthy carriers capable of transmitting lated partially purified EBV into a terminal cancer
infection through appropriate exposure. patient who lacked prior antibody; both EBV and
Efforts to transmit infectious mononucleosis to heterophil antibodies developed, Inoculation of
volunteers using blood, throat washings, or stools EBV-infected lymphocytes into gibbons has re-
from acutely ill patients were made prior to the sulted in an exudative tonsillitis and the appear-
discovery of EBV in 1968; the results were largely ance of EBV antibodyY54) Shope and Miller(135)
inconclusive or unsuccessful, probably because of have induced transient EBV and heterophil anti-
the presence of prior immunity in those inocu- body in squirrel monkeys inoculated with virus-
lated. However, there are a few exceptions. Wis- transformed leukocytes. The current evidence of
ing(156l successfully transmitted the full-blown successful transmission of infectious mononucleo-
disease to a female volunteer by transfusion. Ev- sis to monkeys must be regarded as incomplete at
ans(37) and Taylor(145) reported suggestive evi- this time.
dence of successful transmission by inoculation of In summary, the results of seroepidemiological,
pooled sera from patients with acute infectious virological, and transmission studies in man and
mononucleosis into patients with acute leukemia as monkeys indicate that EBV is the cause of hetero-
a therapeutic effort to induce a remission; the phil-positive infectious mononucleosis.
young age of this group probably meant that some
were susceptible because they had not been previ-
ously exposed. About 50 other experiments in hu-
mans were equivocal or unsuccessful.(3,34,36,112) 5. Descriptive Epidemiology
Similarly, earlier efforts to induce infectious mon-
onucleosis in monkeys were not rewarding.(49,137) 5.1. Prevalence and Incidence
The prevalence of antibody to EBV has been
* EBV nuclear antigen has recently been found in B
lymphocytes separated from the blood of 4 acute cases determined in many countries and in many age
[Klein, G., Svedmyr, E" Jondal, M., and Persson, P, groupS,(42) Fig, 1 indicates the percentage of chil-
0., EBV-determined nuclear antigen (EBNA)-positive dren in several areas of the world with EBV anti-
cells in the peripheral blood of infectious mononucleo- bo~y. In developing and tropical areas, most chil-
sis patients, Int. J. Cancer, 17:21-26 (1976)], dren have been infected by age 6 yr. Because
NO PERCENT WITH ANTIBODY

TESTED 1----:-:o=--::-:20~3::::0;:::..:..:,4~O-:..::5~O~60~7,,:,0:=.:8::::0:...:.,,9-=O-.I:-::Oc=-lO
MILITARY RECRUITS
COLOMBIA 303 100W.6I
ARGENTINA 120 ~~~~~~~~~~~~]9!8~~

UNITED STATES 484
Fig. 2. EBV antibody prev-
COLLEGE FRESHMEN
alence in young adults in dif-
THAILAND* 145 ,:,:,:,:,:,:,:,:,:,:,:,:,:,:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::,:::::,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:100,:,:,:,:,1
ferent populations. x Student
PHILIPPINES 122 :':::::':':':':':':";'=::::"""""":':"':':"""":"""",,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:::,:,:,:,:,:,:,:,:,:,:,:,:, 82 nurses. Adapted from A. S.
1401 :::::::::::,:,:,:,:,:,:,:,:,:::,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,;:,:,:::,:,:""t 63 Evans, New discoveries in
U.S.' WEST POINT
infectious mononucleosis,
U.S.' YALE GIRLS ('70) 139 :,:,:,:,:,:,:,:,:,:,:,:,:,:,:::::::,:::,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,: 60 Mod. Med. 1: 1S-24 (1974).
ENGLAND' 5 COLLEGES ('70) 1437
u.s., YALE BOYS ('68)
NEW .ZEALAND ('69) 50 ::::::::::,:::,:,:,:,:,:,:,:,:::::::::,:::i,:,:,:,:,:,:':':':':':':';'~ 48
U.S.' SMITH GIRLS ('60) 87 :::,:,:,:::::,:::::,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:,:, 38
U.S.' YALE BOYS 1'58-'63) 424 :::::,:::::,:::::::::::::::::,:,:a 26
infections with EBV are usually mild and asympto- freshman student nurses in Thailand had anti-
matic in young children, it is not likely that body.
infectious mononucleosis would be recognized as The incidence of clinical infectious mononucleosis is
a clinical entity in such countries. The few charac- about 48 per 100,000 in the state of Connecticut,
teristic and heterophil-positive cases that do occur where the disease is reportable, (21) 45 per 100,000
may be so diluted out as to be unnoticed. The according to a recent community survey in At-
prevalence of EBV antibody in young adults living lanta, Georgia, of heterophil-positive cases/68 )
in different parts of the world is depicted in Fig. 2. and 200 per 100,000 in Olmstead County, Minne-
A similar socioeconomic pattern exists. It is only sota, where patients are largely handled by the
when a significant percentage of the population Mayo Clinic.'69) Use of the rate of 48 per 100,000
reaches ages 15-25 before exposure to and infec- in Connecticut in 1972 as generally representative
tion with EBV that infectious mononucleosis would make infectious mononucleosis one of
emerges as an important clinical entity. This delay the commonest infectious diseases in the United
in exposure is largely limited to nations with high States based on diseases summarized in the 1972
economic and hygienic levels and to middle and Center for Disease Control Annual Report and
upper socioeconomic classes in any country. The listed in Table 2. Data from the CDC Surveillance
most susceptible college group tested thus far were Report of 19 U.S. colleges place the incidence of
entering freshman students at Yale University in infectious mononucleosis in this age group during
the period 1958-1963, when nearly 75% were at 1971-1972 at 840 per 100,000(18) for college stu-
risk to infectious mononucleosis because they dents, with a range of 485-1256.
lacked antibody; coincident with programs that Hospitalization rates for infectious mononucleosis
broadened admission to include students with in the armed forces range from 148 to 250 per
widely differing socioeconomic backgrounds, 100,000.(41) In the navy and marine corps, where
among them many minority groups, the suscepti- comparative data are available, it ranks as the fifth
bles decreased to 40-50%. In contrast, under 20% commonest infectious disease and the fourth com-
of undergraduate students at the University of monest cause of days lost.
Philippines lacked EBV antibody and all of 145 The most accurate measure of EBV infection and
Table 2. Estimated Number of Cases of the third year, and 30.8% in the fourth college
Infectious Mononucleosis Compared to Notifiable year.(65) Over the 4-yr period, 45".9% of suscepti-
Infectious Diseases in 1972 U
ble cadets were infected with EBV and 26.4% of
these were known to have clinical infectious mo-
Number of reported nonucleosis; others may have been ill but did not
Diseases cases
report to the clinic for treatment.
Gonorrhea 767,215
Chickenpox 164,114
Infectious mononucleosis b 97,550 5.2. Epidemic Behavior
Syphilis 91,149
Mumps 74,215
True epidemics of infectious mononucleosis that
Infectious hepatitis 54,074 fulfill appropriate diagnostic criteria have not oc-
curred in modem times.(38,82) Earlier, many pur-
a From Annual Supplement, Reported incidence of notifi~ble ported epidemics were described, of which the
diseases in the United States, 1972, CDC Morbidity and Mortal-
ity, Vol. 21 (1973).
most impressive are those described by West in
• Based on rate of 48 per 100,000 in Connecticut (1972), where the United States in 1896,(155) by Moir in the
infectious mononucleosis is reportable, and U.S. population of Falkland Islands in 1930,(107) and by Carlson et al.
203.2 million.
in Wisconsin in 1926. (15) More recent and sugges-
tive outbreaks have been described from an Emer-
gency Medical Hospital(641 and from Oxford, Eng-
disease has been obtained in prospective serologi- land, reported by Hobson et al. (83)
cal and clinical studies, where the number of The high incidence in military camps during
susceptibles, the infection (seroconversion) rate, World War II probably reflects the rapid turnover
and the clinical attack rate can be critically de- of large numbers of men.(46.149,153) Some reported
fined. Comparative data are available from three hospital "outbreaks" are suggestive of a true out-
prospective investigations of freshman students: at break(64,83) but in general do not fully meet diag-
Yale University,(l321 at five English colleges and nostic criteria. On a hypothetical basis, the early
universities,(48) and at the U.S. Military Acad- acquisition of immunity to infectious mononu-
emy at West Poillt, New York.(65) As depicted in cleosis by mild and inapparent infections with
Table 3, the incidence rate of EBV infection was EBV in childhood and the probable route of trans-
strikingly similar in all three settings: 12-13% of mission via intimate oral contact in young adults
susceptible students were infected with EBV during weigh heavily against the occurrence of "epidemic
the freshman year, and of those with known EBV infectious mononucleosis."
infection 27.7-74.0% developed clinical infectious The high prevalence rates of EBV antibody in
mononucleosis. At the U.S. Military Academy, children in developing countries,<42) in nurser-
where a prospective investigation was carried on ies,<t24) and in orphanages(147) suggest that EBV
in a single cohort of freshmen over 4 yr, the EBV spreads effectively in young children under cir-
infection rate in susceptible cadets was 12.4% in cumstances of crowding and poor hygiene to reach
the first year, 24.4% in the second year, 15.1% in almost all susceptibles. However, the contagious-
Table 3. EBV Infection Rates During Freshman Year and Percent Clinically Expressed in Different
Colleges
Percent clinical
Infection rate in infectious
Place Number in study Percent susceptible susceptibles (%) mononucleosis
u.s. Military Academy'651 1401 36 12.3 27.7

Five English schools(1481 1487 43 12.0 59.1
Yale University(132) 355 49 13.1 74.0
ness of infectious mononucleosis has been noto- versity of the Philippines not a single case was
riously low in young adult populations; secondary recorded among 5000 admissions to the college
cases have been rare in roommates of index infirmary, wher.e laboratory facilities existed(47);
cases/ 37 ,65,79) in college dormitories/ 37,45,132) and EBV antibody determinations in this college popu-
aboard ship,022) The low contagiousness in col- lation revealed a very high level of prior immu-
lege populations has been confirmed in recent nity. In a recent study, the prevalence of EBV
studies employing the status of EBV antibody as a antibody had been found to vary in young adults
marker of susceptibility and of infection. Among entering the U.S. Military Academy from different
susceptible and exposed roommates of Yale fresh- areas of the United States.(65) The highest rate of
men with infectious mononucleosis, no evidence of 81.5% was found in cadets resident for 6 yr or
increased risk was found over the susceptible pop- more in the East South Central States and the
ulation as a whole(132); however, there tended to be lowest prevalence rate of 51.9% in the West North
some aggregation of cases in social clusters in dor- Central States. As admission to the Academy is
mitories. In a more critical analysis of this issue at based on competitive academic, athletic, and
the U.S. Military Academy over a period of 4 yr, no achievement values rather than on any social or
evidence of increased spread of EBV infection to economic considerations, a broad range of back-
susceptible roommates exposed to an index case grounds would be expected.
was detected as compared with susceptible room-
mates not so exposed.(65) Transmission of infection
did not occur in a Polaris submarine in which two 5.4. Temporal Distribution
cases of infectious mononucleosis occurred. (142) In There is no clear-cut evidence of yearly fluctua-
a family setting, about 10% of exposed and suscep- tions in the incidence of infectious mononucleosis,
tible members will develop EBV infection. m .85,15!) although appropriate morbidity data are not avail-
This low level of contagiousness of EBV infec- able to determine this accurately. Since 1948 in
tion in older children and in young adults of the Connecticut, a yearly increase in incidence has
-same sex may be related to a high level of existing been noted from 3.9 cases per 100,000 initially to
immunity and to the need for intimate oral con- 46.7 in 1967(21); this probably reflects increased
tact. The rate of infection among susceptible per- reporting rather than actual changes in incidence.
sons who are known to have had intimate oral In one Swedish hospital where the same popula-
contact with patients having infectious mononu- tion was served and the same diagnostic criteria
cleosis or with established pharyngeal carriers of were presumably applied over a period from 1940
EBV has not yet been defined; it may well be high. to 1957, the hospitalization rate increased from 12
cases per year in 1940-1942 to 110 per year in 1955-
1957,044) Caution must be observed in interpret-
ing hospital data in which there is no defined
Infection with EBV is world wide. Antibody to denominator. No changes in the incidence rates of
EBV has been demonstrated in every population infectious mononucleosis were noted at Yale Uni-
thus far tested, including very isolated tribes in versity over a 5-yr period, (50) or in a careful study
Brazil, (11) Alaska, (147) and other remote areas(57) with a defined population base in Rochester, Min-
where measles and influenza antibody are often nesota, over the period 1950-1969.(69)
lacking. Infection occurs earlier in life in develop- Earlier studies of college students at the U.S.
ing countries. Military Academy(82) and at the University of
Clinical infectious mononucleosis occurs in those Wisconsin(37) showed a peak in February, some
hygienic and socioeconomic areas where exposure 4-6 wk after Christmas vacation, presumably due
to and infection with EBV are delayed until older to increased exposure at these times. However, no
childhood and young adult life. This includes clear-cut seasonal pattern has been seen in the
Australia, Canada, England, many European CDC Surveillance Reports from 19 colleges and
countries, New Zealand, Scandinavian countries, universities,08) In a recent community study in
and the United States. (42) In contrast, at the Uni- Atlanta, Georgia/ 68 ) two peaks were found, one
in early fall and a larger one in later winter and vated antibody titers in sera from suspected cases
early spring; but in Rochester, Minnesota,(9) no sent in for heterophil testingY8) The peak fre-
seasonal peak was observed. quency was in the 20-24 age group, in which 29.6%
of the sera were positive. Some cases occurred at
the extremes of age: 11.9% of the sera from sus-
5.5. Age pected cases were positive in the 5-9 age group and
The acquisition of EBV antibody by age is shown 5.8% in the 65-69 age group.
in Fig. 3 for three different geographic areas. Anti- The age pattern described is that of developed
body occurs early in life in economically underde- countries. In developing countries, the age distri-
veloped countries, often reaching close to 100% bution will be shifted downward because of the
immunity by age 10. In contrast, clinical infectious small number of children escaping infection until
mononucleosis is clearly a disease of older children an age when the host response is that of recogniz-
and young adults in economically developed coun- able infectious mononucleosis. In Sao Paulo, Bra-
tries, with its highest incidence in the 15- to 25-yr- zil, for example, examination of records of the
old age group. This has been true of data based on public health laboratory and several hospitals re-
hospitalized cases in the United States, (55,68,(;9.95,110) vealed only three fully confirmed cases, all in
France, (138) and Denmark/ 146l on heterophil-posi- patients under the age of 10 yr. (48) In this setting,
tive cases identified in state public health laborato- over 90% of the popUlation have EBV antibody by
ries,<25.38.109) and on recent community surveys in age 10.(17)
which the population at risk can be defined. (68,69)
In results from the Atlanta community survey
based on 575 heterophil-positive cases, the highest
5.6. Sex
rate of 345.2 per 100,000 occurred in the 15-19 age
group and the next highest, 122.8, in the 20-24 age No difference in EBV antibody prevalence rates
group; 27 heterophil-positive cases occurred in the by sex have been noted in population surveys.
5-9 age group, and four in the 0-4 age group. Infectious mononucleosis occurs equally in both
Figure 4 shows the distribution of cases in this sexes, although girls appear to develop the disease
study. A similar age distribution was observed in earlier than boys,((;8,69) with a peak occurring in
the Wisconsin State laboratory data based on ele- girls at age 16 and boys at age 18 (see Fig. 4).
,..o
g 100 0-._._ ..0-,-,-'-0-._.-0
j:
z ,/
~
,/
~ 80 /
w 0/'
a:
o
u.
w 60
Fig. 3. Acquisition of EBV antibody by age in 3 >
i=
different areas. Data derived in part from refs. 42 Ul
NO. TESTED
and 84. ~ 40 .-e Conn. 1701

I- Hawaii (Oahu) 304
z (;--1>
w <>,~ Barbados 248
o
ffi
Q.
20
4 8 12 16 20 24
AGE (YEARS)
50 _MALE
--- FEMALE
40
C/) 30
w
C/)
« Fig. 4. Cases of infectious mononucleosis, by age
u 20 and sex, metropolitan Atlanta, Georgia, 1968.
10
~~~~~~~'~-~/~~~~~~~~~~~~~
o 2 4 6 8 1012 14 1618 2022 24 26 28 30 32 34 36+
AGE (YEARS)
5.7. Race partially borne out by subsequent studies. Analy-

ses of sera from the Cleveland family study(27,71l
EBV infection occurs in all ethnic groups; no
produced evidence of several cases in three of
evidence of differential susceptibility has been
seven families. There appeared to be a paucity of
found.
EBV infections in the 6-12 yr age group in this
Infectious mononucleosis in developed countries
setting, with higher rates observed in children
has been rare in blacks, but this probably reflects
under 6 and over 12. Among 75 Canadian families,
socioeconomic levels and earlier acquisition of Joncas and Mitnyan(85) identified 67 persons lack-
infection rather than any difference in susceptibil-
ing EBV antibody; in follow-up over approximately
ity. The incidence of the disease in whites in
2 yr, only 10.5% of these susceptible persons devel-
Atlanta, Georgia, was 30 times higher than in
oped EBV antibody. In Sweden, Wahren et al. 0511
blacks. (68) Antibody prevalence to EBV among
found EBV antibody increases in seven of 21 mem-
entering black cadets at the U.S. Military Academy
bers exposed to an index case; six of the 21 contacts
was 85% as compared with 65% among
lacked EBV antibody initially and three of these
whites.(65) In an analysis of prevalence rates
. .. (84)
H awall, seroconverted.
among different ethnic groups In
The high rates of infectious mononucleosis in
higher rates were observed in Hawaiians and
college and military settings have already been
Filipinos than in Caucasians of the same age.
noted. However, during the early recruit training
However, socioeconomic levels, hygienic habits,
period in the armed forces infectious mononucleo-
and varying cultural practices in the home cannot
sis is not a common disease, unlike adenovirus,
be separated from the ethnic backgrounds.
Mycoplasma pneumoniae, and other respiratory in-
fections. This is probably due both to a high level
5.8. Occupation of preexisting immunity among recruits and to the
long incubation period of infectious mononucleo-
Infectious mononucleosis is a disease of the sis, so that cases usually develop after the end of
college student and of the white-collar the usual training period and after dispersal of
worker/ 55 ,!!O) especially young doctors and recruits to other military assignments. The former
nurses. It is these groups that are apt to escape point is supported by the finding of an antibody
infection until young adult life because of a higher prevalence rate of 85% in entering marine recruits
socioeconomic level and/or hygienic standards. at Parris Island,(94) and of 93% in army recruits at
Fort Jackson, South Carolina.(511 Among the ma-
5.9. Occurrence in Different Settings rine recruits at Parris Island whose sera lacked
antibody, the infection rate was 18.5 per 1000 over
Pfeiffer's(126) original cases suggested that the the 16-wk training period; in those returning from
disease had a familial pattern, and this has been a 13-month overseas assignment, the EBV infec-
tion rate was estimated at 23.8 per 1000. Among 5.11. Other Factors
the 34 Fort Jackson recruits lacking EBV antibody,
three recruits developed EBV antibody during the Little is known of the role of nutritional and
16 wk of basic and advanced training, (51) a rate of genetic factors in relation either to EBV infections
88 per 1000 recruits. or to infectious mononucleosis. However, it is
recognized that ABO blood groups are not corre-
lated with susceptibility to infection or to clinical
5.10. Socioeconomic Factors disease. (65.132) The relation to HL-A antigens has
not been critically explored. It seems possible that
Socioeconomic settings influence the incidence genetic control of the immune response might play
of both EBV infection and infectious mononucleo- a role in the severity of clinical illness, in the
sis but in opposite directions. Low socioeconomic persistence of virus, and in possible oncogenic
groups have high rates of EBV infection early in sequelae.
life but little clinical infectious mononucleosis;
high socioeconomic groups have low levels of EBV
infection early in life but a high rate of clinical
disease which occurs in the 15- to 25-yr-old group. 6. Mechanism and Route of Transmission
Two examples illustrate their effect on infection
rates. At the U.S. Military Academy at West Point, The major route of transmission of infectious
the EBV antibody prevalence rate was 77.1% in mononucleosis in young adults is probably
cadets coming from families earning under $6000 through intimate oral contact in kissing with the
and only 58.6% among those from families with exchange of saliva and perhaps of infected cells, as
incomes of over $30,000.(65) In New Haven, the first suggested by Hoagland in 1955. (79) This con-
antibody prevalence among first graders in three cept is supported by three types of circumstantial
schools serving a low socioeconomic group was evidence. First, close personal contact without
84.8% and in three schools serving a high socioec- kissing as in roommates of infected patients(132) or
onomic group it was 37.8%.(36) A second serum in such confining environments as a destroyer(122)
sample collected from these same children 4-5 yr or a Polaris submarine rarely leads to secondary
later revealed an EBV seroconversion rate of 50% cases!l42); this has been true even when the ex-
among susceptible children from lower socioeco- posed roommate is known to lack EBV antibody
nomic areas and only 2.4% in susceptible children and is followed closely over 2 months for the
in the higher socioeconomic group. appearance of antibody or of clinical symp-
toms.(65) Second, a history of intimate oral contact
within the appropriate incubation period is com-
Table 4. Recovery of EBV from Oropharyngeal mon in young adults developing infectious mo-
Excretions of 32 Patients with Infectious nonucleosis(79) and occurs statistically more fre-
Mononucleosis quently than in healthy controls or patients with
acute respiratory infections.(37) Third, the pres-
Throat washings
ence of EBV has been demonstrated in the pharynx
Days
after Number Number Percent during acute illness and during convalescence for
onset tested positive positive periods of many months (Table 4).09.59.103) In
addition, cross-sectional studies of presumably
0-6 5 1 20.0 healthy adults also have shown EBV pharyngeal
7-14 20 15 75.0 excretion in 15-20% of young adults. (59.143) One
1'>-21 8 5 62.5 investigation found a leukocyte transforming fac-
22-28 10 6 60.0 tor, presumably EBV, in the throats of 18% of 368
29-60 13 8 61.5 patients attending an outpatient clinic. (20) Trans-
61-150 12 11 91.7
mission of EBV infection may also occur via the
>150 19 6 31.6
transfusions, usually without illness. (58.75.150)
Total 87 52 59.7 This prolonged carrier state in persons lacking
EBV antibody after clinical infectious mononucleo-
sis and presumably also following inapparent EBV prolonged periods and as indicated in Table 4 is
infection may serve as the principal source of regularly recovered several months after clinical
exposure in young adults. The long duration of illness. In six of 19 patients, the agent was still
virus excretion may explain the difficulties in present over 5 months after disease had occurred
tracing transmission of disease from case to case. and in one case was detected 16 months after
Virus excretion occurs in the presence of circulat- onset. No special clinical characteristics have as
ing antibody, which suggests that humoral anti- yet been identified in those cases associated with
body does not have a major role in the regulation prolonged oropharyngeal virus shedding.
of oropharyngeal shedding. Clearly, identification Prior to the onset of definite symptoms in young
of the specific oropharyngeal cells which produce adults, there is frequently a history of ill-defined
infectious virus remains an important area for complaints, such as malaise and easy fatigue. It
further investigation. has been suggested that an early, abortive infec-
The mechanism of transmission accounting for tion of this type may occur in children without
the rapid and high rate of acquisition of EBV subsequent development of classical infectious
antibody in nurseries and in young children in mononucleosisY7) In an analysis of 100 presumed
low socioeconomic circumstances<I24.147) is not heterophil-negative cases of infectious mononu-
definitely known. Presumably transfer of infected cleosis involving the 0-9 yr age group studied in
saliva on fingers, toys, and other inanimate objects England/ 8") the incubation period was shorter
in settings of poor hygiene can account for much than for adults and estimated at 4-10 days.
of the spread of infection. Perhaps more cell-free The pathogenesis of infectious mononucleosis is
virus is released in childhood infections. It is not intriguing not only because the self-limited clinical
known if EBV occurs in urine or feces and could be disease is manifested primarily in young adults
important epidemiologically. but also because of the suspected oncogenicity of
From a practical standpoint, the low contagious- the virus and its relationship to Mrican Burkitt
ness of the disease in young adults eliminates the lymphoma and to nasopharyngeal carcinoma. An
need for strict isolation procedures. understanding of what immunological mecha-
nisms tum infectious mononucleosis on and what
tum it off is important in this context.
7. Pathogenesis and Immunity Transient depression of delayed hypersensitivity
has been described during acute infectious mo-
The incubation period of infectious mononu- nonucleosis, (10."2) and depressed T-cell stimula-
cleosis is 4-7 wk("7.81J in college students. This tion(134) by phytohemagglutinin has been re-
estimate is based on well-defined, often single corded. Recently, profound alterations in cell-
contacts between an index case and a member of mediated immunity were demonstrated by intra-
the opposite sex involving intimate oral contact. dermal skin tests, in vitro lymphocyte stimulation,
Studies of the recovery of EBV from oropharyn- and enumeration of absolute numbers of periph-
geal secretions of patients with infectious mono- eral blood T and B cells. (97) Lymphocyte respon-
nucleosis have revealed that virus shedding occurs siveness to a variety of mitogens and antigens was
during the acute illness and from several weeks to found to be depressed during the first weeks of
many months after onset of the syndrome, but the illness. Serial studies of the interaction of T- and
type of cells involved is unknown. Transformation B-cell populations during acute disease indicated
of umbilical cord leukocytes into continuous cell that peripheral blood B cells increase during the
lines has been the assay system used for demon- first week of illness and return to normal levels
stration of the virus, and this transformation has several weeks later. In contrast, T cells reach peak
been neutralized by sera containing EBV antibody, values during the second week of disease and
but not affected by sera lacking this antibodyyo:lI remain elevated for approximately 5 wk. (97)
In addition, transformed leukocytes acquire EBV Recent investigations indicate that both T and B
genome, demonstrated by nucleic acid hybridiza- cells may be transformed into atypical lympho-
tion, and express EBV-associated antigens. The cytes characteristic of this disease. (31."0.97) These
virus has been detected in throat washings for observations suggest that B cells may be trans-
PERSISTENT
LYTIC INFECTION !
- - ENTRY VIA MOUTH ___ ~ LOCAL LYMPHATICS
---ISORE THROATI
r=-:-:-::-~-'---'
AB~~VR~AL ~c----LlVER EE--_BLjOOD~:pHLEN:~ES ----~ON~~~~~~CTIVE

TESTS INFECTION
j
(UNEXPRESSED)
INFECTION OF -------,1
'B' LYMPHOCYTES ~
I CHRON~
IN MATURE
IHETEROPHILEI c rNEO-AN+rIGENSl NON-PRODUCTIVE +
LYMPHS I I CARRIER
AND OTHER MALARIA
: + : STATE
j,
ANTIBODIES
(ANA, ANTI- i)
:
L._ ---t----J
T CELLS :
MIXED LYMPHOCYTE
REACTION
EXPRESSION
BLAST
~
FORMATION
~S MALIGNANCY
ANERGy_IATYPICAL LYMPHSI
~
LYSIS
IINFECTIOUS MONOI
1
IBURKITT LYMPHOMAI
PRODUCTIVE CYCLE NONPRODUCTIVE CYCLE
Fig. 5. Hypothetical pathogenesis of EBV infection.
formed by infection with EBV and T cells may be pouring of atypical lymphocytes with T-cell char-
transformed as an immunological response to the acteristics. In. support of the presence of a new
viral antigen itself or to altered antigens on the membrane antigen, lymphocytes from patients
surface of the B.cells. with acute infectious mononucleosis have been
A version of pathogenesis incorporating our found to cause stimulation of convalescent leuko-
current understanding of the role of EBV is pre- cytes from the same persons.(7.87) During' the
sented in Fig. 5.(44) EBV appears to enter the acute illness, the activated T cells may cause the
oropharynx in young adults, and multiplies lo- destruction of EBV-infected B cells, as has been
cally, producing a lytic and persistent infec- shown in vitro and in other viral systems. ((;7.97.14(1)
tion.(32) It then enters the bloodstream and possi- This destruction may account for the inability to
bly the gut, although the latter has not yet been demonstrate EBV or its genome in fresh lympho-
established. Lymphocytes of the B type are in- cytes from patients with acute infectious mononu-
fected and a long-term carrier state is established; cleosis. That not all B lymphocytes are destroyed is
some of these transformed B cells contribute to the shown by the presence of a sufficient number of
atypical lymphocytosis early in disease. ((;0.97> infected cells to initiate a long-term culture of
There may also be an immunological response of T EBV-infected B lymphocytes, perhaps through sec-
cells to B cells whose membrane has been altered ondary infection of other B cells in vitro when
by an EBV-induced antigen. This results in T-cell immunological inhibitors in the serum are re-
proliferation,(50) transformation, and a major out- moved. (32) The mechanism of heterophil produc-
tion is still unexplained, but knowledge that its adenopathy, accompanied by splenomegaly in
appearance is most common in EBV infections of 50% and hepatomegaly in 10%. The pharyngitis is
young adults(42) and that the degree of expression often associated with a whitish or a gray/green
and release of EBV in vitro varies in lymphocytes exudate having an offensive odor. The eyelids may
from donors of different ages suggests avenues of be swollen, and petechiae occur on the hard palate
investigation. For example, EBV-infected fetal in 25% of cases.
lymphocytes do not have demonstrable. VCA anti- Abnormalities of liver function tests are a regu-
gen but do contain EBV nuclear antigen by the lar feature of infectious mononucleosis, and clini-
EBNA test<tOI.129) and complement-fixing anti- cally recognizable jaundice occurs in 5% of cases.
gen,o°I.I04) In lymphocytes from adults and from Rarer manifestations include a variety of central
marmosets, EBV may mature more fully, resulting nervous system syndromes (encephalitis; menin-
in release of EBV antigens to other lymphocytes. goencephalitis, Guillain-Barre syndrome), pneu-
Heterophil antibody may occur in response to monitis and pneumonia, thrombocytopenic pur-
membrane-induced antigens of EBV expressing pura, myocarditis, and nephritis.(39.82) The major
themselves more fully in lymphocytes of young complications include splenic rupture and airway
adults than in those of younger children or in fetal obstruction from exudative pharyngotonsillitis.
lymphocytes. About 50 deaths have been reported due mostly to
While the presence of antibGdy to the viral central respiratory failure. An immunological defi-
capsid antigen of EBV has been shown to indicate cit, especially in cell-mediated immunity, may be
protection against infectious mononucleosis and involved, as suggested by the recent report of two
its absence indicates susceptibility,<44.50.65.113.132) deaths in a family.(5)
the actual antibody providing immunity is proba- The frequency with which EBV infections are
bly the neutralizing antibody for which tests have expressed as clinical illness in young adults has
recently been developed. (78,105) One attack of infec- varied in different populations. In a recent study of
tious mononucleosis confers a high degree of dura- a cohort of U.S. Military Academy cadets over a 4-
ble immunity to subsequent attacks of clinical yr period, only 26.4% of 201 infected with this
infectious mononucleosis. (16.50,105) Presumably agent developed heterophil-positive clinical infec-
subclinical or inapparent EBV infections also confer tious mononucleosis.(65) The apparent:inapparent
lasting immunity. One fairly well-documented case EBV infection ratio in different years ranged from
of clinical recurrence has been reported(9) and a 1:1 to 1:2.6 in this population. Comparison of the
resurgent anamnestic heterophil response after infrequency of clinically expressed infectious mo-
fectious mononucleosis has also been noted in pa- nonucleosis in freshman students in three different
tients subsequently developing a respiratory infec- settings is presented in Table 3. The reasons for the
tion.(8,80) Reinfection with or without clinical differences are not known but may relate to the
illness has not yet been fully documented by appro- motivation to seek medical care, physical fitness, or
priate heterophil and EBV antibody tests. concern about the effect of hospitalization on aca-
demic and school activities.
The relationships between clinical features and
S. Patterns of Host Response antibody levels in a typical heterophile-positive
case in an 18-year-old student are shown in Fig. 6.
Following a prodromal period associated with fa-
8.1. Clinical Features
tigue, fever, and headache over several days, the
When infection with EBV occurs in childhood, a onset of sore throat, cervical adenopathy, and recur-
mild, nonspecific illness or an inapparent infection rent fever developed during the second week.
may develop, both of which are associated with Characteristic blood changes were present on the
the appearance and persistence of antibody to third day after onset, and the patient's lymphocytes
EBV. If exposure and primary infection are de- contained EB virus-associated complement-fixing
layed until adolescence or young adulthood, the antigens (EBNA) in a nuclear location. The hetero-
characteristic clinical picture usually occurs. This phile antibody titer was negative on the first day of
consists of fever, pharyngitis, and cervical lymph- symptoms, rose to 1:14 after guinea pig absorption
OF FATIGUE
104
SORE THROAT
EDEMA OF
EYELIDS
l TO
INFIRMARY
103
CLINICAL
102
ONSET
6/Y/72 101
8ETTER ..... SCHOOL
100
99
Fig. 6. The relation between

WBC 26.5 12.2
clinical and laboratory features of
LYMPHS + M 28 38 45 15
infectious mononucleosis in an
ATYPICAL 27 27 30 38
IS-year-old male.
HETEROPHILE NEG 1-14 Mono Spol + 1-896
EBV - IGG <1-5 <1-5 1'80 1-320 80
EBV - IGM 0 0 1-2.5 1-10
EBV IN THROAT 0 + +
LYMPHOCYTE
GROWTH
+ (SHOWN TO CONTAIN E8V)
5 10 15 20
DAY OF DISEASE
two days later, and then increased to 1:896 on the bodies to EBV-associated nuclear antigen (EBNA)
15th day. In contrast, Epstein-Barr VeA antibodies usually arise 1 month or more after illness and
of IgG type, undetectable on the third day of ill- probably persist for life. (73) EBV-specific IgM an-
ness, were present on the 8th day and rose to a level tibodies are demonstrable in 85% of cases during
of 1:320 by the second week. EBV-specific IgM anti- acute illness. Figure 7 depicts the course of EBV-
bodies were demonstrable on the 8th day at a titer specific IgG and IgM antibodies during the course
of 1:2.5, which then increased to 1:10 by the 15th of illness. IgG antibodies persist for years, perhaps
day. for life; IgM antibodies usually disappear in 3-6
No direct correlation has been found between months. At present, there is no practical and rapid
the levels of Epstein-Barr VeA and heterophil EBV antibody test for the diagnosis of infectious
antibodies, nor between YeA, early antigen, and mononucleosis.
EBNA antibody levels and the severity of clinical The main reliance in diagnosis must be placed
symptoms and hematological changes.m.77.1l4l on the heterophil antibodies which are of the IgM
type. Methods in most common use are the sheep
and horse cell agglutination tests after absorption
S.2. Diagnosis
of the serum with guinea pig kidney to remove
The diagnosis of infectious mononucleosis is Forssman antibody, and the beef cell hemolysin
based on a typical clinical picture with the triad of test, which does not require absorption. The ap-
fever, sore throat, and cervical lymphadenopathy, pearance and persistence of these tests during acute
the occurrence of at least 50% lymphocytosis with and convalescent infectious mononucleosis are
at least 10% atypical lymphocytes, and the appear- shown in Fig. 8. The beef hemolysin test is the most
ance of heterophil antibodies. The presence of specific but has a short duration; the horse cell test
antibodies to EBV is an absolute requirement in is the most sensitive and most persistent, with
doubtful or heterophil-negative cases. Antibody to positive tests present for a year or more in 75%.(52)
viral capsid antigen is usually present at the time The appearance and persistence of antibody to
the physician first sees the patient, and only 15- horse cells have been found to follow mild and
20% of patients will show a subsequent rise in subclinical episodes of infectious mononucleosis
titer; antibodies to early antigen appear later but provided that sera are collected over a long enough
are present in only 75% of typical cases.(77) Anti- time. This test may be useful in childhood infec-
100
90
~I
.' I I
edge. If intimate oral contact represents the major
route of spread in young adults, there seems little
likelihood of interdicting this practice or of pre-
I I I venting salivary transfer. If poor hygienic condi-
-
80
on
"I 70
I I I tions promote the spread of EBV infections in
young children, then improvement in hygienic
I I I and socioeconomic circumstances might reduce
I
I&J
> 60 their incidence. Unfortunately, control of spread at
~
(/)
0
50 I I this time when infection is largely mild and
n. asymptomatic might simply delay exposure to later
~
z
I&J
40
30
I i I childhood and young adult life when the majority
of EBV infections are expressed as clinical infec-
u tious mononucleosis.
It:
I&J
n. 20
I I The high degree of protection against infectious
mononucleosis provided by natural infection with
10
I EBV suggests that a vaccine capable of evoking
@
0 similar humoral, cell-mediated, and local immun-
0
ity might be highly effective. An attenuated live
vaccine administered orally would be the most
. PRE I 2 3 4'6 7-9 10-12 13·18 ~19 desirable. However, the apparent limitation of
NUMBER OF MONTHS AFTER viral multiplication in vitro to primate lymphocyte
ONSET OF ILLNESS suspension cultures and the low yield of infectious
Fig. 7. Appearance and duration of IgG and IgM anti-
bodies specific for Epstein-Barr virus during infectious
mononucleosis. From ref. (52).
100 I
tions with EBV, which are often heterophil nega-
tive by other tests or when inadequately followed.
90 I I
HORSE RBe
Development of EBV antibody has also been 80 I I
shown in cases where the clinical and hematologi- I
cal characteristics are those of infectious mononu- 70
cleosis but the heterophil antibody remains per- 60
I
sistently negative.<5o.114aJ These heterophil-
negative, EBV antibody positive cases appear to be 50
common in infants and children, but are rare in
40
adults. Infection with cytomegalovirus (CMV) may
also produce a clinical picture of heterophil-nega- 30
tive mononucleosis that is hard to distinguish
from classical infectious mononucleosis; however, 20
it usually occurs at a later age and adenopathy and o
10 ®
exudative pharyngitis are rare.<91J
o
9. Control and Prevention PRE 2 3 4-6 7-9 10-1213-18 ~19

NUMBER OF MONTHS AFTER
Attempts to control infectious mononucleosis ONSET OF ILLNESS
and EBV infections by interrupting the presumed Fig. 8. Persistence of heterophile antibodies during in-
chain of transmission seem neither realistic nor fectious mononucleosis. RBC = red blood cells. From ref.
perhaps desirable in light of our current knowl- (52).
virus released are formidable technical obstacles at rized in Table 5. While EBV is well established as
present. the cause of heterophil-positive infectious mono-
If an effective vaccine were available, it might nucleosis and "turns on" the immunological events
best be given on entrance to high school to permit that are involved in the pathogenesis of the clinical
natural infection with little clinical illness to occur disease, we have little information as to what
before that and then to prevent clinical illness in "turns off" the lymphoproliferative cycle and
the young adult. It would be useful only in devel- makes the disease a benign, self-limited one.
oped countries with a high incidence of infectious The persistence of EBV in circulating lymph\)-
mononucleosis. cytes following infection and the presence of a
The oncogenic and transforming potential of small number of "atypical lymphocytes" in healthy
EBV poses a serious question of risk for use of a persons suggest that the proliferative process is
vaccine. The numerous problems associated with not fully "turned off" but held under careful con-
long-term surveillance for possible complications trol and immunological surveillance; the continued
would be considerable, but these risks in devel- presence of anti-VCA, anti-EBNA, complement-
oped countries may not be great. The association fixing, and other viral antibodies supports the
between EBV and cancer is evident primarily in concept of continued antigenic stimulation. Viral
Burkitt lymphoma in Africa and in nasopharyngeal excretion in the pharynx certainly continues long
carcinoma (NPC) patients of Chinese descent in after infection, perhaps intermittently for life, but
the Far East. In these settings, clinical infectious the cells supporting this multiplication are pres-
mononucleosis is too rare a disease to merit vacci- ently unknown. There is also the existing paradox
nation. Furthermore, tumor development is asso- that neither EBV nor viral genome has been dem-
ciated with malaria in African Burkitt lymphoma onstrated in fresh lymphocytes during infectious
and immunogenetic susceptibility to NPC in mononucleosis except in overwhelming and fatal
Chinese. In the absence of malaria and genetic infections; whether this is due to extremely small
susceptibility, as in the United States, both of numbers of infected cells or represents viral multi-
these tumors are very rare. Such considerations plication in secluded cells outside the circulation is
suggest that if the technical problems of viral unknown (see footnote on p. 215). The source of the
attenuation and vaccine production can be over- heterophil antibody and the variety of other non-
come, oncogenicity would be a hazard of negligi- viral antibodies that appear during the course of
ble magnitude in the United States· and other infectious mononucleosis remains a mystery;
countries where clinical infectious mononucleosis whether these antibodies appear in milder EBV
is a common and disabling disease. infections in smaller amounts and at a later time is
not known, but very recent evidence suggests this
may be so. A simple EBV-specific antibody test is
10. Unsolved Problems
needed in the diagnostic laboratory to confirm pre-
The problems that remained to be solved con- sumably heterophil-negative cases. An explanation
cerning the nature of EBV infections are summa- is lacking for the observation that a more severe
Table 5. Unsolved Questions in EBV
1. What turns infectious mononucleosis off and makes it a self-limited disease?

2. What cell supports pharyngeal multiplication of EBV?
3. Why can't EBV be demonstrated in lymphocytes in acute infectious mononucleosis?
4. Where does heterophil antibody originate?
5. Can a practical EBV antibody test be developed for diagnostic use?
6. What causes different responses to EBV at different ages?
7. Is an infectious mononucleosis vaccine possible?
8. Does EBV cause cancer?
9. Why are EBV antibody titers high in some chronic diseases?
10. What accounts for the geographic distribution of Burkitt lymphoma and nasopharyngeal cancer?
clinical response to EBV infection occurs when ex- 8. BENDER, C. E., Interpretation of hematologic and
posure is delayed until older childhood and young serologic findings in the diagnosis of infectious
adult life, similar to the more frequent occurrence mononucleosis, Ann. Intern. Med. 49:852-865 (1958).
of jaundice and paralysis in hepatitis and poliom- 9. BENDER, C. E., Recurrent mononucleosis, J. Am.
yelitis infections in adults. If the clinical syndrome Med. Assoc. 182:954-956 (1962).
10. BENTZON, J. W., The effect of certain infectious
of infectious mononucleosis is primarily an immu-
diseases on tuberculin allergy, Tubercle 34:34-41
nological response of T cells to EBV-induced neoan- (1953).
tigens on the B-cell membrane, then one can specu- 11. BLACK, F. 1., EVANS, A. 5., HENLE, G., LIEBHABER,
late that induction of membrane antigens occurs H., AND WOODALL, J. P., Prevalence of antibody
more commonly in lymphocytes from mature indi- against viruses in the Tiriyo, an isolated Amazon
viduals in which more complete virus is formed tribe, Am. J. Epidemiol. 91:430-438 (1970).
than in lymphocytes from young children; this idea 12. BLOEDORN, W. A., AND HOUGHTON, J. E., The oc-
is supported by the failure of EBV-infected cord currence of abnormal leucocytes in the blood in
cells to produce viral capsid or membrane antigens. acute infections, Arch. Intern. Med. 27:315-325
(1921).
The possibility of a vaccine has already been dis-
13. BROWN, J. W., CLIFFORD, J. E., SIMS, J. 1., AND
cussed, and the relation of EBV to cancer is ex-
WHITE, E., Liver function during infectious mono-
plored in other chapters of this book. Infectious nucleosis, Am. J. Med. 6:321-328 (1949).
mononucleosis continues to be an important model 14. CABOT, R. c., The lymphocytosis of infection, Am.
for studying the immunological and virological J. Med. Sci. 145:335-339 (1913).
events involved in a persistent and possibly neo- 15. CARLSON, G. W., BROOKS, E. H., AND MARSHALL, V.
plastic infection. F., Acute glandular fever: Recent epidemic, report
of cases, Wis. Med. J. 25:176-178 (1926).
16. CARTER, R. 1., AND PENMAN, H. G., The early
history of infectious mononucleosis and its relation
11. References to "glandular fever," in: Infectious Mononucleosis,
(R. 1. CARTER AND H. G. PENMAN, eds.), Blackwell,
1. ARMSTRONG, D., HENLE, G., AND HENLE, W., Com- Oxford, 1969.
plement-fixation tests with ce:J lines derived from 17. CARVALHO, R. P. 5., EVANS, A. 5., FROST, P., DALL-
Burkitt's lymphoma and acute leukemias, J. Bacte- DORF, G., CAMARGO, M. E., AND JARMA, M., EBV
riol. 91:1257-1262 (1966). infection in Brazil. I. Occurrence in normal persons,
2. BAILEY, G. H., AND RAFFEL,S., Hemolytic antibodies in lymphomas and in leukemias, Int. J. Cancer
for sheep and ox erythrocytes in infectious mononu- 11:191-201 (1973).
cleosis, J. c/in. Invest. 14:228-244 (1935). 18. Center for Disease Control, Infectious Mononucleo-
3. BANATVALA, J. E., BEST, J. M., AND WALLER, D. K., sis Surveillance, November 1972.
Epstein-Barr virus-specific IgM in infectious mono- 19. CHANG, R. 5., AND GOLDEN, H. D., Transformation
nucleosis, Burkitt lymphoma, and nasopharyngeal of human leucocytes by throat washings from infec-
carcinoma, Lancet 1:1205-1208 (1972). tious mononucleosis patients, Nature (London)
4 .. BANG, J., Forsoeg paa at overfoere mononucleosis 234:359-360 (1971).
infectiosa til mennesket, Ugeshkr. Laeg. 105:499-504 20. CHANG, R. 5., LEWIS, J. P., AND ABILDGAARD, C. F.,
(1943). Excretors of leucocyte-transforming agents among a
5. BAR, R. 5., DELoR, L CLAUSEN, K. P., HURTUBISE, human population, N. Eng/. J. Med. 289:1328-1329
P., HENLE, W., AND HEWETSON, J. F., Fatal infec- (1973).
tious mononucleosis in a family, N. Eng/. J. Med. 21. CHRISTINE, B. W., Infectious mononucleosis, Conn.
290:363-367 (1974). Health Bull. 82:115-119 (1%8).
6. BARONDESS, J. A., AND ERLE, H., Serum alkaline 22. CROSS, J. G., Conditions simulating an acute leuke-
phosphatase activity in hepatitis of infectious mon- mia (acute benign leukemia), Minn. Med. 5:579-581
onucleosis, Am. J. Med. 29:43-54 (1960). (1922).
7. BAUSCHER, J. c., AND SMITH, R. T., Studies of 23. DAVIDSOHN, I., AND WALKER, P. H., The nature of
Epstein-Barr virus-host-relationship: Autochthon- the heterophilic antibodies in infectious mononu-
ous and allogeneic lymphocyte stimulation by lym- cleosis, Am. J. c/in. Pathol. 5:455-465 (1935).
phoblast cell lines in mixed cell culture, c/in. Immu- 24. DAVIDSOHN, I., Heterophile antibodies in serum
no/. Immunopatho/. 1:270-281 (1973). sickness, J. Immunol. 16:259-273 (1929).
25. DAVIDSOHN, R. J. L., A survey of infectious mono- 43. EVANS, A. 5., The history of infectious mononucleo-
nucleosis in the North-East Regional Hospital Board sis, Am. J. Med. Sci. 267:189-195 (1974).
area of Scotland, 1960--9, f. Hyg. 68:393-400 (1970). 44. EVANS, A. 5., Commentary. EB virus, infectious
26. DIEHL, V., HENLE, G., HENLE, W., AND KOHN, G., mononucleosis and cancer: The closing of the web,
Demonstration of a herpes group virus in cultures Yale J. BioI. Med. 47:113-122 (1974).
of peripheral leukocytes from. patients with infec- 45. EVANS, A. 5., AND ROBINTON, E. D., An epidemio-
tious mononucleosis,]. Virol. 2:663-669 (1968). logic study of infectious mononucleosis in a New
27. DINGLE, J. H., BADGER, G. F., AND JORDAN, W. 5., England college, N. Engl. J. Med. 242:492-496 (1950).
JR., Illness in the Home: A Study of 25,000 Illnesses in 46. EVANS, A. 5., AND PAUL, J. R., Infectious mononu-
a Group of Cleveland families, The Press of We5item cleosis, in: Preventive Medicine in World War II, Vol.
Reserve, Cleveland, 1964. V: Communicable Diseases (J. B. COATES, JR., ed.),
28. DOWNEY, H., AND McKINLAY, C A., Acute lym- Office of the Surgeon General, Department of the
phadenosis compared with acute lymphatic leuke- Army, Washington, D.C, 1960.
mia, Arch. Intern. Med. 32:82-112 (1923). 47. EVANS, A. 5., AND CAMPOS, L. E., Acute respiratory
29. EDWARDS, J. M. B., AND MCSWIGGAN, D. A., Studies diseases in students at the University of the Philip-
on the diagnostic value of an immunofluorescence pines, Bull. WHO 45:103-112 (1971).
test for EB virus specific IgM, Clin. Pathol. 27:647- 48. EVANS, A. 5., CARVALHO, R. P. 5., AND GROSSMAN,
651 (1974). L., EBV infections in Brazil. III. Infectious mononu-
30. ELLENBOGEN, C, AND REINARZ, J. A., The Epstein- cleosis, unpublished (1974).
Barr virus and its relationship to infectious mono- 49. EVANS, A. 5., EVANS, B. K., AND STURTZ, V., Stand-
nucleosis in air force recruits, Mil. Med. 140:371-373 ards for hepatic and hematologic tests in monkeys:
(1974). Observations during experiments with hepatitis
31. ENBERG, R. N., EBERLE, B. J., AND WILLIAMS, R. C, and mononucleosis, Proc. Soc. Exp. BioI. Med.
Peripheral blood T and B cells in infectious mono- 82:437-440 (1953).
nucleosis,]. Infect. Dis. 130:104-111 (1974). 50. EVANS, A. 5., NIEDERMAN, J. C, AND McCOLLUM,
32. EpSTEIN, M. A., AND ACHONG, B. G., Various forms R. W., Seroepidemiological studies of infectious
of Epstein-Barr virus infection in man: Established mononucleosis with EB virus, N. Engl. J. Med.
facts and a general concept, Lancet 2:836-839 (1973). 279:1121-1127 (1968).
33. EpSTEIN, M. A., ACHONG, B. G., AND BARR, Y. M., 51. EVANS, A. 5., JENSEN, R., NIEDERMAN, J. C, AND
Virus particles in cultured lymphoblasts from Burk- WALLACE, D. K., Studies of EBV antibody in Fort
itt's lymphoma, Lancet 1:702-703 (1964). Jackson military recruits, unpublished data (1974).
34. EVANS, A. 5., Experimental attempts to transmit 52. EVANS, A. 5., NIEDERMAN, J. C, CENABRE, L. C,
infectious mononucleosis to man, Yale J. BioI. Med. WEST, B., AND RICHARDS, V., A., A prospective eval-
20:19-26 (1947). uation of heterophile and Epstein-Barr virus-specific
35. EVANS, A. 5., Liver function tests in infectious IgM antibody tests in clinical and subclinical infec-
mononucleosis, J. Clin. Invest. 27:106-110 (1948). tious mononucleosis: Specificity and sensitivity of
36. EVANS, A. 5., Further experimental attempts to the tests and persistence of antibody, J. Inf. Dis.
transmit infectious mononucleosis to man, J. Clin. 132:546-554 (1975).
Invest. 29:508-512 (1950). 53. FILATOV, N. F., Semiotik and Diagnostik de Kinder-
37. EVANS, A. 5., Infectious mononucleosis in Univer- krankheiten, Verlag von Ferdinand Enke, Stuttgart,
sity of Wisconsin students: Report of a five-year 1892.
investigation, Am. ]. Hyg. 71:342-362 (1960). 54. FILATOV, N. F., Lektuse ob ostrikh infektsion Nikh
38. EVANS, A. 5., Infectious mononucleosis: Observa- Lolieznyak (Lectures on acute infectious diseases of
tions from a public health laboratory, Yale ]. BioI. children), Moscow, U Deitel, 1885. Cited by Wis-
Med. 34:261-276 (1961/1962). ing, P. J., Acta Med. Scand. Suppl. 133:1-102 (1942).
39. EVANS, A. 5., Complications of infectious mononu- 55. GARDNER, H. T., AND PAUL, J. R., Infectious mono-
cleosis: Recognition and management, Hasp. Med. nucleosis at the New Haven Hospital, 1921-46,
3:2~25, 28-33 (1967). Yale ]. BioI. Med. 19:839-853 (1947).
40. EVANS, A. 5., Infectious mononucleosis: Recent de- 56. GERBER, P., AND DEAL, D. R., Epstein-Barr virus-
velopments, G.P. 60:127-134 (1969). induced viral and soluble complement-fixing anti-
41. EVANS, A. 5., Infectious mononucleosis in the gens in Burkitt lymphoma cell cultures, Proc. Soc.
armed forces, Mil. Med. 135:300--304 (1970). Exp. BioI. Med. 134:748-751 (1970).
42. EVANS, A. 5., New discoveries in infectious mono- 57. GERBER, P., AND ROSENBLUM, E. N., The incidence
nucleosis, Mod. Med. 1:18-24 (1974) of complement-fixing antibodies to herpes simplex
and herpes-like viruses in man and rhesus mon- 72. HENLE, G., HENLE, W., AND DIEHL, V., Relation of
keys, Proc. Soc. Exp. BioI. Med. 128:541-546 (1968). Burkitt's tumor-associated herpes-type virus to in-
58. GERBER, P., PURCELL, R H., ROSENBLUM, E. N., AND fectious mononucleosis, Proc. Natl. Acad. Sci. USA
WALSH, J. H., Association of EB-virus infection 59:94-101 (1968).
with the post-perfusion syndrome, Lancet 1:593-596 73. HENLE, G., HENLE, W., AND HORWITZ, C. A., Anti-
(1969). bodies to Epstein-Barr virus-associated nuclear an-
59. GERBER, P., GOLDSTEIN, 1. 1., LUCAS, S., NONOY- tigen in infectious mononucleosis, J. Infect. Dis.
AMA, M., AND PERLIN, E., Oral excretion of Epstein- 130:231-239 (1974).
Barr viruses by healthy subjects and patients with 74. HENLE, G., HENLE, W., AND KLEIN, G., Demonstra-
infectious mononucleosis, Lancet 2:988-989 (1972). tion of two distinct components in the early antigen
60. GIULANO, V. J., JASIN, H. E., AND ZIFF, M., The complex of Epstein-Barr virus-infected cells, Int. J.
nature of the atypical lymphocyte in infectious Cancer 8:272-282 (1971).
mononucleosis, Clin. Immunol. Immunopathol. 3:90- 75. HENLE, W., HENLE, G., HARRISON, F. S., JOYNER, C.
98 (1974). R, KLEMOLA, E., PALOHEIMO, J., SCRIBA, M., AND
61. GRACE, J. T., BLAKESLEE, J., AND JONES, R., Induc- VON ESSEN, F., Antibody responses to the Epstein-
tion of infectious mononucleosis in man by the Barr virus and cytomegaloviruses after open-heart
herpes-type virus (HTV) in Burkitt lymphoma cells and other surgery, N. Engl. J. Med. 282:1068-1074
in tissue culture, Proc. Am. Assoc. Cancer Res. 10:31 (1968).
(1969). 76. HENLE, W., HENLE, G., PEARSON, G., SCRIBA, M.,
62. HAIDER, S., COUTINHO, M. D., AND EMOND, R T. D., WAUBKE, R, AND ZAJAC, B. A., Differential reactivity
Tuberculin anergy and infectious mononucleosis, of human serums and with early antigens induced
Lancet 2:74 (1973). by Epstein-Barr virus, Science 169:188-190 (1970).
63. HAINEBACH, J., II. Beitrag zur Aetiologie des Pfeif- 77. HENLE, W., HENLE, G., NIEDERMAN, J. c., HALTIA,
fer'schen Driisenfiebers. Deutsche Med. Wochenschr. K., AND KLEMOLA, E., Antibodies to early antigens
26:419-420 (1899). induced by Epstein-Barr virus in infectious mono-
64. HALCROW, J. P. A., OWEN, 1. M., AND ROGER, N. nucleosis, J. Infect. Dis. 124:58-67 (1971).
0., Infectious mononucleosis with an account of an 78. HEWETSON, J. F., ROCHI, G., HENLE, W., AND
epidemic in E.M.S. hospital, Br. Med. J. 2:443-447 HENLE, G., Neutralizing antibodies to Epstein-Barr
(1943). virus in healthy populations and patients with
65. HALLEE, T. J., EVANS, A. S., NIEDERMAN, J. c., infectious mononucleosis, J. Infect. Dis. 128:283-389
BROOKS, C. M., AND VOEGTLY, J. H., Infectious (1973).
mononucleosis at the U.S. Military Academy. A 79. HOAGLAND, R. J., The transmission of infectious
prospective study of a single class over four years, mononucleosis, Am. J. Med. Sci. 229:262-272 (1955).
Yale J. BioI. Med. 47:182-195 (1974). 80. HOAGLAND, R J., Resurgent heterophil-antibody
66. HAMPAR, B., Hsu, K. c., MARTOS, 1. M., AND reaction after infectious mononucleosis, N. Engl. J.
WALKER, J. 1., Serologic evidence that a herpes-type Med. 269:1307-1308 (1963).
virus is the etiologic agent of heterophile-positive 81. HOAGLAND, R. J., The incubation period of infec-
infectious mononucleosis, Proc. Nat!. Acad. Sci. tious mononucleosis, Am. J. Public Health 54:1699-
USA 68:1407-1411 (1971). 1705 (1964).
67. HARDY, D. A., AND STEEL, C. M., Cytotoxic poten- 82. HOAGLAND~ R, Infectious Mononucleosis, Grune and
tial of lymphocytes stimulated with autochthonous Stratton, New York, 1967.
lymphoid cell lines, Experentia 27:1336-1338 (1971). 83. HOBSON, F. G., LAWSON, B., AND WIGFIELD, M.,
68. HEATH, C. W., BRODSKY, A. 1., AND POTOLSKY, A. Glandular fever, a field study, Br. Med. J. 1:845-852
I., Infectious mononucleosis in a general popula- (1958).
tion, Am. J. Epidemiol. 95:46-52 (1972). 84. JENNINGS, E., Prevalence of EB virus antibody in
69. HENKE, C. E., KURLAND, 1. T., AND ELVEBACK, 1. Hawaii, M.D. thesis, Yale University School of
R, Infectious mononucleosis in Rochester, Minn., Medicine, 1973.
1950 through 1969, Am. J. Epidemiol. 98:483-490 85. JONCAS, J., AND MITNYAN, c., Serological response
(1973). of the EBV antibodies in pediatric cases of infec-
70. HENLE, G., AND HENLE, W., Immunofluorescence in tious mononucleosis and in their contacts, Can.
cells derived from Burkitt's lymphoma, J. Bacteriol. Med. Assoc. J. 102:1260-1263 (1970).
91:1248-1256 (1966). 86. JORDAN, W. S., AND ALBRIGHT, R. W., Liver func-
71. HENLE, G., AND HENLE, W., Observations on child- tion tests in infectious mononucleosis, J. Lab. Clin.
hood infections with Epstein-Barr virus, J. Infect. Med. 35:688-698 (1950).
Dis. 121:303-310 (1970). 87. JUNGE, U., DEINHARDT, F., AND HOEKSTRA, J., Stim-
ulation of peripheral lymphocytes by allogeneic and secondary clones of several Burkitt lymphoma cell
autochthonous mononucleosis lymphocyte cell li- lines, Cancer Res. 30:2870-2875 (1970).
nes, J. Immunol. 106:1306-1315 (1971). 100. MILLER, G., The oncogenicity of Epstein-Barr virus,
88. KLEIN, G., KLEIN, E., CLIFFORD, P., AND STERNS- J. Infect. Dis. 130:187-205 (1974).
WARD, G., Search for tumor specific immune reac- 101. MILLER, G., AND HESTON, L., Expression of Epstein-
tors in Burkitt lymphoma patients by the membrane Barr viral capsid, complement fixing and nuclear
immunofluorescence reaction, Proc. Natl. Acad. Sci. antigens in stationary and exponential phase cul-
USA 55:1628-1635 (1966). tures, Yale J. Bioi. Med. 47:123-135 (1974).
89. KLEIN, G., LINDAHL, T., JONDAL, M., LEIBOLB, W., 102. MILLER, G., AND LIPMAN, M., Release of infectious
MENEZES, J., NILSSON, K., AND SUNDSTROM, c., Con- Epstein-Barr virus by transformed marmoset leuco-
tinuous lymphoid cell lines with characteristics of B cytes, Proc. Nat!. Acad. Sci. USA 70:190-194 (1973).
cells (bone-marrow-derived) lacking the Epstein- 103. MILLER, G., NIEDERMAN, J. c., AND ANDREWS, L. L.,
Barr virus genome, and derived from three human Prolonged oropharyngeal excretion of Epstein-Barr
lymphomas, Proc. Natl. Acad. Sci. USA 71:3283-3286 virus after infectious mononucleosis, N. Engl. J.
(1974). Med. 288:229-232 (1973).
90. KLEIN, G., DIEHL, V., HENLE, G., HENLE, W., PEAR- 104. MILLER, G., MILLER, M. H., AND STITT, D., Epstein-
SON, G., AND NIEDERMAN, J. c., Relations between Barr viral antigen in single cell clones of two human
Epstein-Barr viral and cell membrane immunoflu- leucocytic lines, J. Virol. 6:699-701 (1970).
orescence in Burkitt tumor cells. II. Comparison of 105. MILLER, G., NIEDERMAN~ J. c., AND STITT, D. A.,
cells and sera from patients with Burkitt's lym- Infectious mononucleosis: Appearance of neutraliz-
phoma and infectious mononucleosis, J. Exp. Med. ing antibody to Epstein-Barr virus measured by
128:1021-1030 (1968). inhibition of formation of lymphoblastoid cell lines,
91. KLEMOLA, E., HENLE, G., HENLE, W., AND VON J. Infect. Dis. 125:403-406 (1972).
ESSEN, R., Infectious mononucleosis-like disease 106. MILLER, G., ROBINSON, J., HESTON, L., AND LIPMAN,
with negative heterophil agglutination test: Clinical M., Differences between laboratory strains of Ep-
features in relation to Epstein-Barr virus and cyto- stein-Barr virus based on immortalization, abortive
megalovirus antibodies, J. Infect. Dis. 121:608-614 infection and interference, Proc. Natl. Acad. Sci.
(1970). USA 71:4006-4010 (1974).
92. LANG, D. J., AND HANSHAW, J. B., Cytomegalovirus 107. MOIR, J. I., Glandular fever in the Falkland Islands,
infection and the postperfusion syndrome: Recogni- Br. Med. J. 2:822-823 (1930).
tion of primary infection in four patients, N. Engl. J. 108. MORSE, P. F., Glandular fever, J. Am. Med. Assoc.
77:1403-1404 (1921).
Med. 280:1145-1149 (1969).
109. NEWALL, K. W., The reported incidence of glandu-
93. LEE, C. L., DAVIDSOHN, I., AND SLABY, R., Horse
lar fever, and analysis of a report of the Public
agglutinins in infectious mononucleosis, Am. J.
Health Laboratory Service, J. c/in. Pathol. 10:20-22
Clin. Pathol. 49:3-11 (1968). (1957).
94. LEHANE, D. E., A seroepidemiologic study of infec- 110. NIEDERMAN, J. c., Infectious mononucleosis at the
tious mononucleosis: The development of EB virus Yale-New Haven Medical Center, 1946-1955, Yale J.
antibody in a military population, J. Am. Med. Bioi. Med. 28:629-643 (1956).
Assoc. 212:2240-2242(1970). 111. NIEDERMAN, J. c., The presence of EBV antibody in
95. LIEBOWITZ, S., Infectious Mononucleosis, Grune and sera from volunteers in infectious mononucleosis
Stratton, New York, 1953. transmission attempts prior to inoculation, unpub-
96. LONGCOPE, W. T., Infectious mononucleosis (glan- lished work (1969).
dular fever), with a report of ten cases, Am. J. Med. 112. NIEDERMAN, J. c., AND SCOTT, R. B., Studies on
Sci. 164:781-807 (1922). infectious mononucleosis: Attempts to transmit the
97. MANGI, R., NIEDERMAN, J. c., KELLEHER, J. E., disease to human volunteers, Yale J. BioI. Med. 38:1-
DWYER, J. M., EVANS, A. S., AND KANTOR, F. S., 10 (1965).
Depression of cell-mediated immunity during acute 113. NIEDERMAN, J. c., EVANS, A. S., MCCOLLUM, R. W.,
infectious mononucleosis, N. Engl. J. Med. AND SUBRAHMANYAN, L., Prevalence, incidence and
291:1149-1153 (1974). persistence of EB virus antibody in young adults,
98. MASON, K. L., An ox cell hemolysin test for the N. Engl. J. Med. 282:361-365 (1970).
diagnosis of infectious mononucleosis, J. Hyg. 114. NIEDERMAN, J. c., MCCOLLUM, R. W., HENLE, G.,
49:471-481 (1951). AND HENLE, W., Infectious mononucleosis: Clinical
99. MAURER, B. A., IMAMURA, T., AND WILBERT, S. M., manifestations in relation to EB virus antibodies, J.
Incidence of EB virus containing cells in primary and Am. Med. Assoc. 203:205-209 (1968).
114a. NIKOSKELAINEN, J., LEIKOLA, J., AND KLEMOLA, E., tion of an Epstein-Barr virus (EBV) associated com-
IgM antibodies specific for Epstein-Barr virus in plement-fixing antigen in producer and non-pro-
infectious mononucleosis without heterophile an- ducer lymphoblastoid cell lines, Int. J. Cancer
tibodies, Br. Med. J. 4:72-75 (1974). 11:499-520 (1973).
115. NONOYAMA, M., AND PAGANO, J. S., Homology 129a. ROBINSON, J., AND MILLER, G., Assay for Epstein-
between Epstein-Barr virus DNA and viral DNA Barr virus based on stimulation of DNA synthesis
from Burkitt's lymphoma and nasopharyngeal carci- in mixed leukocytes from human umbilical cord
noma determined by DNA-DNA reassociation ki- blood, J. Virol., 15:1065-1072 (1975).
netics, Nature (London) 242:44-47 (1973). 130. ROCCHI, G., HEWETSON, J., AND HENLE, W., Specific
116. OLD, 1. J., CLIFFORD, P., BOYSE, E. A., DEHARVEN, neutralizing antibodies in Epstein-Barr virus associ-
E., GEERING, G., OETTGEN, H. F., AND WILLIAMSON, ated diseases, Int. J. Cancer 11:637-647 (1973).
B., Precipitating antibody in human serum to an 131. ROSALKI, S. B., LWYNN, J. T., AND VERNEY, P. T.,
antigen present in cultured Burkitt lymphoma cells, Transaminase and liver function studies in infec-
Proc. Nail. Acad. Sci. USA 56:1699-1704 (1966). tious mononucleosis, Br. Med. J. 1:929-932 (1960).
117. PAGANO, J. S., The Epstein-Barr viral genome and its 132. SAWYER, R. N., EVANS, A. S., NIEDERMAN, J. C,
interactions with human Iymphoblastoid cells arid AND MCCOLLUM, R. W., Prospective studies of a
chromosomes, in: Viruses, Evolution and Cancer (K. group of Yale University freshmen. I. OccuITence of
MARAMOROSCH AND E. KURSTAK, eds.), Academic infectious mononucleosis, J. Infect. Dis. 123:263-269
Press, New York, 1974. (1971).
118. PATTENGALE, P. K., GERBER, P., AND SMITH, R. W., 133. SCHMITZ, H., AND SCHERER, M., IgM antibodies to
Selective transformation of B lymphocytes by EB vi- Epstein-Barr virus in infectious mononucleosis,
rus, Lancet 2:1153-1155 (1973). Arch. Gesamte Virusforsch. 37:332-339 (1972).
119. PATTENGALE, P. K., GERBER, P., AND SMITH, R. W., 134. SHELDON, P. J., HEMSTED, E. H., HOLBOROW, E. J.,
B-cell characteristics of human peripheral and cord AND PAPAMICHAEL, M., Thymic origin of atypical
blood lymphocytes transformed by Epstein-Barr vi- lymphocytes in infectious mononucleosis, Lancet
rus, J. Nail. Cancer Inst. 52:1081-1086 (1974). 2:1153-1155 (1973).
120. PATTENGALE, P. K., SMITH, R. W., AND PERLIN, E., 135. SHOPE, T., AND MILLER, G" Epstein-BaIT virus,
Atypical lymphocytes in acute infectious mononu- heterophile responses in squirrel monkeys inocu-
cleosis, N. Engl. J. Med. 291:1145-1148 (1974). lated with virus-transformed autologous leucocytes,
121. PAUL, J. R., AND BUNNELL, W. W., The presence of J. Exp. Med. 137:140-147 (1973).
heterophile antibodies in infectious mononucleosis, 136. SHOPE, T., EVANS, A. S., AND HORSTMANN, D. M.,
Am. J. Med. Sci. 183:91-104 (1932). Seroconversion rates of EBV antibody in New Haven
122. PAUL, 0., Mononucleosis on board a destroyer, school children by socio-economic level, unpub-
U.S. Naval Med. Bull. 44:614-617 (1945). lished studies (1973).
123. PEARSON, G., DEWEY, F., KLEIN, G., HENLE, G., AND 137. SOHIER, R., LEPINE, P., AND SAUTTER, V., Re-
HENLE, W., Relation between neutralization of Ep- cherches sur la transmission experimentale de la
stein-Barr virus and antibodies to cell membrane mononucleose au singe et a I'homme, Ann. Inst.
antigens induced by the virus, J. Natl. Cancer Inst. Pasteur 65:50-62 (1940).
45:989-995 (1970). 138. SOHIER, R., La Mononucleose Infectieuse, Masson et
124. PEREIRA, M. S., BLAKE, J. M., AND MACRAE, A. D., Cie, Paris, 1943.
EB virus antibody at different ages, Br. Med. J. 139. SPRUNT, T. P., AND EVANS, F. A., Mononuclear leu-
4:526-527'(1969). cocytosis in reaction to acute infections (in infectious
125. PEREIRA, M. S., FIELD, A. M., BLAKE, J. M., RODG- mononucleosis), Bull. Johns Hopkins Hosp. 31:410-
ERS, F. G., BAILEY, 1. A., AND DAVIES, J. R., Evi- 417 (1920).
dence for oral excretion of E. B. virus in infectious 140. STEEL, eM., AND LING, N. R., Immunopathology
mononucleosis, Lancet 1:710-711 (1972). of infectious mononucleosis, Lancet 2:861-862
126. PFEIFFER, E., DRUSENFIEBER, Jahrb. Kinderheilk. (1973).
29:257-264 (1889). 141. STEVENSON, E. M. K., AND BROWN, T. G., Infectious
127. POPE, J. H., HORNE, M. K., AND WETTERS, E. J., mononucleosis: Preliminary investigation of a se-
Significance of a complement-fixing antigen associ- ries of cases, Glasgow Med. J. 140:139-150 (1943).
ated with herpes-like virus and detected in the Raji 142. STORRIE, M. C, SAWYER, R. N., SPHAR, R. 1., AND
cell line, Nature (London) 228:186-187 (1969). EVANS, A. S., Seroepidemiological studies of Polaris
128. PULVERTAFT, R. J. X., Cytology of Burkitt's tumor submarine crews. II. Infectious mononucleosis, Mili-
(African lymphoma), .Lancet 1:238-240 (1964). tary Med. 141:30-33 (1976).
129. REED MAN, B. M., AND KLEIN, G., Cellular localiza- 143. STRAUCH, B., ANDREWS, 1., MILLER, G., AND SIEGEL,
N., Oropharyngeal excretion of Epstein-Barr virus 155. WEST, J. P., An epidemic of glandular fever, Arch.
by renal transplant recipients and other patients Pediat. 13:889-900 (1896).
treated with immunosuppressant drugs, Lancet 156. WISING, P. J., A study of infectious mononucleosis
1:234--237 (1974). (Pfeiffer's disease) from the etiological point of
144. STROM, J., Infectious mononucleosis-Is the inci- view, Acta Med. Scand. Suppl. 133:1-102 (1942).
dence increasing? Acta Med. Scand. 168:35-39 157. WOLLNER, D., Ueber die serologische Diagnose del'
(1960). infektiosen Mononukleose nach Paul-Bunnell mit
145. TAYLOR, A. W., Effects of glandular fever in acute nativen and fermentierten Hammel Erythrocyten. 2,
leukemia, Br. Med. J. 1:589-593 (1953). Immunitat Forsch. 112:290-308 (1955).
146. THOMSEN, S., Studier over Mononucleosis Infectiosa, 158. WROBLEWSKI, F., Increasing clinical significance of
Munksgaard, Copenhagen, 1942. alterations in enzymes in body fluids, Ann. Intern.
147. TISCHENDORF, P., BALAGTAS, R. c., DEINHARDT, F., Med. 50:62-93 (1959).
KNOSPE, W. H., MAYNARD, J. E., NOBLE, G. R., AND 159. ZAJAC, B. A., AND KOHN, G., Epstein-Barr virus
SHRAMEK, G. J., Development and persistence of antigens, marker chromosomes, and interferon pro-
immunity to Epstein-Barr virus in man, J. Infect. duction in clones derived from cultured Burkitt
Dis. 122:401-409 (1970). tumor cells, J. Natl. Cancer Inst. 45:399-406 (1970).
148. University Health Physicians and P.H.1.S. Labora- 160. ZUR HAUSEN, H. H., CLIFFORD, P., HENLE, G.,
tories, A joint investigation: Infectious mononu- HENLE, W., KLEIN, G., SANTESSON, 1., AND
cleosis and its relationship to EB virus antibody, Br. SCHULTE-HoLTHAUSEN, H., EB-virus DNA in biop-
Med. J. 4:643-646 (1971). sies of Burkitt tumors and anaplastic carcinomas of
149. VANDERMEER, R, LUTTERLOH, C. H., AND PILOT, J., the nasopharynx, Nature (London) 228:1056-1057
Infectious mononucleosis: An analysis of 26 clinical (1970).
and 340 subclinical cases, Am. J. Med. Sci. 210:765- 161. ZUR HAUSEN, H., DORRmR, K., EGGER, H., SCHULTE-
774 (1945). HOLTHAUSEN, H., AND WOLF, H., Attempts to detect
150. VIROLAINEN, M., ANDERSON, 1. c., LALLA, M., AND virus-specific DNA in human tumors. II. Nucleic
VON ESSEN, R., T-lymphocyte proliferation in mono- acid hybridizations with complementary RNA of
nucleosis, c/in. Immunol. Immunopathol. 2:114-120 human herpes group viruses, Int. J. Cancer 13:657-
(1973). 664 (1974).
151. WAHREN, B., ESPMARK, A., LANTORP, K., AND STER-
NER, G., EBV antibodies in family contacts of pa-
tients with infectious mononucleosis, Proc. Soc.
Exp. BioI. Med. 133:934-939 (1970). 12. Suggested Reading
152. WALTERS, M. K., AND POPE, J. H., Studies of the EB
virus-related antigens of human leucocyte cell lines, CARTER, R. 1., AND PENMAN, H. G. (eds.), Infectious
Int. J. Cancer 8:32-40 (1971). Mononucleosis, Blackwell, Oxford, 1969.
153. WECHSLER, H. F., ROSENBLUM, A. H., AND SILLS, C. EVANS, A. S., New discoveries in infectious mononucleo-
T., Infectious mononucleosis: Report of an epidemic sis, Mod. Med. 1:18-24 (1974).
in an army post, Ann. Intern. Med. 25:113-133, 236- GLADE, P. R (ed.), Infectious Mononucleosis, Lippincott,
265 (1946). Philadelphia, 1973.
154. WERNER, J., HAFF, R F., HENLE, G., HENLE, W., HOAGLAND, R, Infectious Mononucleosis, Grune and
AND PINTO, C. A., Responses of gibbons to inocula- Stratton, New York, 1967.
tion of Epstein-Barr virus, J. Infect. Dis. 126:678--681 KLEIN, G., The Epstein-Barr Virus in Herpesviruses (A. S.
(1972). Kaplan, ed.), Academic Press, New York, 1973.
CHAPTER 10
Viral Hepatitis
Robert W. McCollum
1. Introduction account for all illnesses currently diagnosed as

viral hepatitis on the basis of viruses A and B
Evidence of acute inflammation of the liver may be alone. However, additional specific types have not
observed in association with infections due to a yet been identified either virologically or epide-
number of different viruses, e.g., members of the miologically.
herpesvirus group, yellow fever virus, coxsackie-
viruses, and mumps virus. The term viral hepatitis,
however, is usually reserved for those infections 2. Historical Background
due to either of two agents currently designated as
hepatitis A virus (HAV) and hepatitis B virus (HBV),
The earliest descriptions of hepatitis (epidemic
respectively associated with viral hepatitis type A
jaundice) are usually attributed to Hippocrates.
and viral hepatitis type B. These terms are now
More detailed observations were not recorded un-
widely accepted as replacements for the multitude
til the seventeenth and eighteenth centuries, when
of previous designations, the most common of
outbreaks of jaundice were noted particularly in
which were infectious hepatitis (type A) and serum
hepatitis (type B). The clinical manifestations of association with military campaigns. The infec-
tious character of the disease was not recognized
these infections are sufficiently similar that until
or widely accepted until the early part of the
recently the differential diagnosis of the individual
twentieth century. Efforts to identify specific bac-
c(!.se rested almost entirely on epidemiological in-
terial, leptospiral, and other possible etiological
formation or inference. Several specific serological
agents repeatedly met with total failure or spu-
tests for type B are now available and are widely
rious findings and ultimate lack of confirmation.
used for both diagnostic and epidemiological
By the beginning of World War II, however, suffi-
studies. Recent reports indicate that similar tests
cient evidence had been accumulated to support
may soon become available for the diagnosis and
the probable existence of at least two distinct types
study of viral hepatitis type A.
of hepatitis, both of viral etiology but with appar-
In spite of, or perhaps even to some extent
ently different epidemiological features. The mili-
because of, the spectacularly rapid developments
tary significance of hepatitis stimulated an in-
during the past few years, the total viral hepatitis
~reased emphasis on research efforts, particularly
picture is still somewhat confusing. There is a
10 England and the United States, beginning in
growing suspicion that it may not be possible to
the early 1940s. Repeated failures in attempts to
Robert W. McCoUum . Department of Epidemiology find susceptible experimental animals or other
and Public Health, Yale University School of Medicine, laboratory methods for isolation and propagation
New Haven, Connecticut of the etiological agents led to the initiation of
235
236 Chapter 10 • Viral Hepatitis
controlled human transmission studies which the laboratory propagation of hepatitis A virus
firmly established the basic etiological and epide- (HAV) and the development of serological meth-
miological distinctions between type A (infectious) ods for measuring specific antibodies(20,29,34a)
and type B (serum) hepatitis, the lack of cross- have opened the way for more definitive studies of
immunity, and the broad clinical spectrum of viral hepatitis type A.
manifestations of infection.
After World War II, hepatitis, presumed. to be
mostly type B, followed in the wake of widespread
civilian applications of developments in blood 3. Methodology Involved in Epidemiological
banking technology and plasma fractionation Analysis
which had been stimulated in large part by mili-
tary medical needs. In addition, both sporadic 3.1. Mortality
cases and common-source outbreaks of hepatitis,
presumed to be mostly type A, were recognized The mortality of viral hepatitis is usually very
and reported with increasing frequency in many low, so that it serves as a poor indicator of disease
countries. The rising incidence appeared to be incidence. Furthermore, the special features at-
following a pattern previously noted in Scandina- tending a higher mortality such as older age,
vian countries. This recognition of viral hepatitis concomitant disease, and immunosuppression
as a major worldwide medical and public health make death rates unrepresentative of the usual
problem served as a continuing stimulus for re- epidemiological features. Further, there are prob-
search directed particularly at virological and ser- lems in differential diagnosis and in the rubrics
ological methods for diagnosis and study. The employed under the International Classification of
rapidly developing tissue culture technology of the Disease.
1950s disappointingly failed to provide the antici-
pated answers to long-standing questions about
3.2. Morbidity
hepatitis viruses. However, limited human trans-
mission studies, particularly those of Krugman Although some designation for viral hepatitis is
and his associates, continued to add significantly included in the lists of notifiable diseases for more
to our knowledge of the natural behavior of viral than 125 countries, type A and type B are still not
hepatitis, including measures for its control and officially reported separately in most of them.
certain characteristics of the viruses. A landmark Even in those which provide for this distinction,
finding was the first clear demonstration of non- the figures are available for only a few years at
parenteral transmission of hepatitis B virus.(35) most and their reliability is likely to be relatively
A new era in viral hepatitis research and under- poor. Indeed, overall reporting of viral hepatitis
standing was opened with the discovery of Aus- from the public health viewpoint is so widely
tralia antigen (now designated hepatitis B surface variable in both practice and efficiency that strict
antigen, HBsAg) by Blumberg et al. (7.9) and the comparisons of data from different geographic
subsequent recognition by Prince(57) and oth- areas or political units are likely to be unrewarding
ers(22,24,51) of its specific relationship to type B or even misleading. Only about one-third of the
viral hepatitis. This single discovery has provided countries report cases by age and sex.
the essential key to many long-standing hepatitis While the limitations of both morbidity and
riddles and served to stimulate an intensive world- mortality reporting are widely recognized, various
wide research effort which continues to add to our patterns and trends can be discerned which are
knowledge of the clinical and epidemiological be- probably fair and reasonable indicators of the
havior of HBV and the complexity of its antigenic overall collective behavior of hepatitis. Data de-
structure. Some of the subsequent findings have rived from hospital discharge diagnoses or from
already led to significant specific control measures intensive surveys of limited population groups
in relation to parenteral transmission of type B, may provide useful information and answers to
particularly by blood transfusion. specific questions, but they are unlikely to be
Recent confirmation(62) of earlier reports(17) of representative of the hepatitis problem in general.
Chapter 10 • Viral Hepatitis 237
3.3. Serological Surveys covered, the corresponding antigens can be

indicated.
The discovery in serum of the 20-nm Australia
antigen particles by Blumberg et al. (7) and recog- HBs Ag is ordinarily detectable in the serum for
nition of their specific relationship to type B hepa- a relatively brief time (a few days to a few weeks)
titiS(57) provided the first basis for seroepidemiol- during the late incubation period and acute phase
ogical studies of viral hepatitis. It also offered the of illness. It also occurs in the absence of clinical
first clues leading to the identification and com- manifestation of infection. In some instances anti-
plexity of ·the hepatitis B virus itself, probably a genemia persists for much longer periods, and
42-nm spherical structure first described by Dane with varying frequency a chronic, presumably
et al. (6) in electron micrographs showing their lifetime, carrier state may ensue. Results of serol-
clear association with Australia antigen particles. ogical surveys for this antigen are therefore likely
The Dane particle is double shelled, with core to reflect little more than the prevalence of persist-
and surface components having specific antigenic ent carriers. Another limiting factor related to most
properties. The surface component is antigenically of the earlier large-scale serological surveys which
related to the 20-nm spherical and tubular" Aus- have been reported is the relatively low level of
tralia" particles, which appear to :r;.epresent excess sensitivity of the methods used, i.e., agar gel
surface component production. The surface struc- diffusion or counterelectrophoresis. The subse-
ture itself is complex, being made up of both quently developed and much more sensitive meth-
group-specific (a) and subtype-specific determi- ods, such as passive hemagglutination and ra-
nants with different alphabetic designations (d, y; dioimmunoassay, have not yet been widely used
w, r). for comparable survey studies.
In an attempt to bring some order into the Infection with hepatitis B virus is followed by
complexity of terminology of the hepatitis B virus, the development of specific antibodies against
the Committee on Viral Hepatitis of the National HBs Ag (anti-HBs), but the relatively low levels
Research Council-National Academy of Sciences observed and the limited duration of detectability
suggested the following system of nomenclature as measured by currently available methods have
and abbreviations in 197404b ): tended to restrict their value as epidemiological
HBs Ag: The hepatitis B antigen found on the markers for serological surveys. However, the
surface of the Dane particle and on the combination or simultaneous testing for HB. Ag
unattached 20-nm particles. and anti-HBs probably provides the most accurate
HBc Ag; The hepatitis B antigen found within reflection of a population's prior hepatitis B expe-
the core of the Dane particle. rience.
Dane particle: A current term for the 42-nm Since HBc Ag is still not readily available as a
particle containing HBc Ag in its core and reagent for routine testing to detect anti-HBc,
HBs Ag on its surface. large-scale serological surveys have not been un-
dertaken. However, limited studies of serial serum
HBV: Reserved for hepatitis B virus. The Dane
specimens obtained during the course of hepatitis
particle may tum out to be HBV.
B virus infections have revealed the regular ap-
HBs AgJadr: Hepatitis B surface antigen mani- pearance of anti-HBc usually at or close to the time
festing the group-specific determinant, a, of clinical symptoms or biochemical evidence of
and subtype-specific determinants d and r. hepatocellular damage. (3]) These antibodies ap-
All recognized subtypes are to be indicated pear to fall to low or undetectable levels fairly
to the right of the slash. rapidly in most instances. Indeed, it has been
Anti-HBs: Antibody to hepatitis B surface an- suggested that their persistence may be an indica-
tigen. If the sub typic reactivity is known, tor of continuing viral replication.
the appropriate antigenic determinants are Several antigens have been reported in associa-
to be indicated to the right of a slash. tion with hepatitis A infections. The serum anti-
Anti-HBc: Antibody to hepatitis B core antigen described by Del Prete et al. (8) and desig-
gen. If more than one core antigen is dis- nated as EHAA or Milan antigen has subsequently
been found to be an abnormal f3-lipoprotein, (81) gens and antibodies associated with hepatitis vi-
perhaps a result of hepatocellular damage but not rus A, at the present time limitations of materials
likely to be related to hepatitis A virus specifically. impose severe restrictions on their availability and
Two different reports of fecal antigens,(20,21) pre- application.
sumably viral particles or subunits, are still under Similarly, at the moment the limited methods
intensive investigation. However, the 27-nm par- and relative scarcity of suitable reagents available
ticles described by Feinstone et al. (20) appear to be to most investigators also restrict studies con-
serologically related to both experimental and nat- cerned with the detection and measurement of
urally occurring type 'A infections. Their method HBc Ag and anti-HBc. These were originally dem-
for detecting both antigen and antibody was im- onstrated by immunoelectronmicroscopy(3) and
munoelectronmicroscopy, which does not lend it- subsequently by immunofluorescence, comple-
self readily to serological surveys. It would appear ment fixation, counterelectrophoresis, and ra-
likely that simpler and more feasible methods will dioimmunoassay. Comparisons and details of
be forthcoming. Indeed, Hilleman et al. (29) have methods have been reviewed by Purcell et al. (63)
described both immune adherence and comple- In marked contrast, there are numerous methods
ment fixation techniques for measuring antibodies readily and routinely available for the detection
against an antigen derived from marmosets in- and measurement of HBs Ag and anti-HBs.
fected with HAY. Presumably this antigen is HBs Ag was first detected by a method using
closely related to at least one of the fecal antigens. agar gel immunodiffusion (AGD). Although con-
sidered to be a relatively insensitive method as
compared to techniques developed during the past
3.4. Laboratory Methods 5 yr, AGD is still the only method which provides
A variety of biochemical tests which are indica- the high degree of specificity needed for reference
tive of hepatocellular damage with varying degrees purposes and for the identity of new HBs Ag
of specificity are routinely used as the basis for subtypes. A variety of tests employing techniques
both the diagnosis and the clinical management of of counterelectrophoresis (CEP) or complement
viral hepatitis. With the exception of well-defined fixation (CF) have been found to be more sensitive
instances of common-source or limited-contact than AGD and are still widely used for diagnosis
spread, these tests have not proved to be useful for and screening. However, they are being rapidly
epidemiological studies. replaced in favor of more sensitive red cell agglu-
The long, frustrating search for suitable methods tination (RCA) tests employing antibody-coated
for the laboratory isolation and propagation of stabilized human or fowl(3 ) erythrocytes and ra-
human hepatitis viruses is still far from being dioimmunoassay (RIA) methods utilizing 125I-Ia-
satisfactorily resolved. The recent recognition that beled anti-HBs.(43,87) Reagents for both RCA and
certain species of marmosets are susceptible to RIA tests are commercially available. While RIA is
type A and that chimpanzees and possibly rhesus the more sensitive and objective method of the
monkeys respond to type B represents a major step two, it requires expensive equipment and the
toward finding reasonable and realistic substitutes reagents have a relatively short shelf life.
for the human. However, the scarcity of chimpan- AGD, CEP, and CF methods may also be used to
zees and marmosets and the relative insensitivity detect anti-HBs, but they are all relatively insensi-
of rhesus monkeys impose severe limitations on tive and likely to yield positive results only with
their use. The intensive search for sensitive and sera from individuals who have been repeatedly
feasible tissue culture systems continues to be exposed to HBs Ag. Reagents for both an agglutin-
unrewarding and unpromising. ation test employing HBs Ag coated erythro-
For practical purposes, both diagnostic and epi- cytes(86) and a radioimmunoprecipitation (RIP)
demiological studies of hepatitis are dominated by test(41 a ) have been found to be highly sensitive for
serological methods related to HBY. Although detecting anti-HBs in research evaluations during
there have been several significant developments the past few years. In consideration of their antici-
in methods related to the detection of both anti- pated extensive use for epidemiological and diag-
nostic studies, it is hoped that reference and Although little is known about the possible
working reagents for one or both methods will transmission or maintenance of hepatitis virus
soon be commercially available. among nonhuman primates under natural condi-
tions, it is doubtful that such potential reservoirs
are of major importance in relation to human
infection with either type. While long-term or
4. Biological Characteristics of the Human chronic carriers of HBV are not uncommon and are
Hepatitis Viruses epidemiologically important, carriers of HAV must
be relatively uncommon and of little epidemiologi-
Until recently, relatively little was known about cal significance.
the physicochemical or biological characterization Little else is currently known about the biologi-
of the human hepatitis viruses. Indeed, their pre- cal characteristics and behavior of HAV. It has
cise classification among viruses is still unsettled. been suggested that the recently demonstrated 27-
On the basis of epidemiological observations nm particle in acute-phase type A hepatitis stool
and limited "inactivation" attempts carried out specimens(20) is a parvovirus and that one of the
during human transmission studies, both virus A presumably similar agents isolated in marmo-
and virus B have long been assumed to be unu- sets(29) belongs to the enterovirus group. It is also
sually hardy agents, highly resistant to chlorina- 27 nm in diameter and appears to possess charac-
tion, disinfectants, heat, and ultraviolet irradia- teristics previously ascribed to HA V. The specific
tion, especially in the presence of serum proteins. relationship between these agents is still far from
No in vitro organ, tissue, or cell culture tech- being settled conclusively, but their specific asso-
nique has yet been demonstrated to support the ciations with viral hepatitis type A appear to be
growth of human hepatitis viruses in continuous clear-cut on the basis of serological tests using
laboratory passage. The animal host range for both paired serum specimens from well-documented
hepatitis A and B viruses (HAV and HBV) was experimental or epidemic-related infections. In
thought to be restricted to man until 1961, when keeping with the long-held presumption of a sin-
Hillis(30) reported an unusual outbreak of hepati- gle type A virus, distinct from type B, these agents
tis, presumably type A, among handlers of newly may well prove to be identical, and it is almost
imported young chimpanzees. Since then, there certain that neither bears any direct serological
have been numerous reports of similar episodes relationship to HBV.
among handlers or close contacts of several nonhu- Hepatitis B virus is antigenically complex. A
man primates (including woolly monkeys, gib- number of closely related but distinct subtypes
bons, Celebes apes, and gorillas) presumably in- have now been defined on the basis of antigenic
fected in nature or in the process of capture, sub determinants carried on the surfaces of both
collective holding, shipment, and conditioning the 20-nm and Dane particles. In addition to a
prior to sale. However, previous and subsequent common group-specific antigen, a, these particles
attempts to infect such animals experimentally met carry one of each of at least two independent
with apparent total failure or yielded inconsistent "allelic" sets of antigens d and y(42) and wand
results until 1967, when Deinhardt et al. (17) re- r.(5) These allow for the clear definition of at least
ported successful isolation and serial transmission four genotypes of HBV with the surface antigen
of a human hepatitis virus, presumably type A, in combinations adw, adr, ayw, and ayr. It is likely
marmosets. This finding was subsequently con- that a number of additional antigenic determi-
firmed and extended by others. (47) Since then, nants still awaiting full definition and accept-
there have been reports of transmission of type B ance(42a) will provide means for further character-
in chimpanzees(58) and in rhesus monkeys.(45) In izing variants of HBV.
all instances, the infections appear to be mild and In 1972, Magnius and Espmark(46a) described
are usually detectable only on the basis of bioch- the discovery of an antigen/antibody system, des-
emical and serological tests or histopathological ignated "e/anti-e," found to be associated only
examinations of liver tissue biopsies. with HBs Ag positive sera. However, this antigen
is not believed to be carried on or be a part of the teric infection spread primarily by the fecal-oral
surface components of HBV. The "e" system itself route. Most well-delineated epidemics, both large
now appears to be a heterogeneous one. Its origins and small, can be accounted for by this mode of
and specific relationships with HBV infections are transmission, related either to close personal con-
yet to be fully explained. tact or to common-source food or water contami-
nation. However, the majority of cases reported as
type A do not fit neatly into this epidemic pattern,
and such sporadic cases are frequently assumed to
5. Descriptive Epidemiology be linked to anicteric or unrecognized asympto-
matic infections.
Until a few years ago, it was generally accepted 5.1.1. Geographic Distribution. Hepatitis A vi-
that viral hepatitis type A was far more common rus is believed to have a worldwide distribution.
than type B, that it was usually spread by the This is an assumption previously based on clinical
fecal-oral route while type B was limited to paren- diagnoses, but there appears to be no logical
teral transmission, and that almost all sporadic reason to expect that a more limited distribution
cases were likely to be type A. On this basis, will be found when appropriate virological and
officially reported incidence figures were assumed serological tests are available for more definitive
to be sufficiently weighted with type A to be survey purposes. Although reported rates of de-
representative of the distribution and epidemiol- crease vary conSiderably from country to country,
ogical 'behavior of this type. In light of findings this may represent a reflection of age-related infec-
based on the use of recently developed serological tion rates rather than relative overall levels of
tests, these old concepts have been subjected to infection.
reconsideration. They are still under study and 5.1.2. Temporal Patterns. Hepatitis infections
subject to further revision, in relation to both type occur sporadically and in epidemic clusters
A and type B. throughout the year in both tropical and temperate
Reported annual figures of overall hepatitis inci- climates. In the latter regions, an autumn-winter
dence vary from less than 10 per 100,000 in some, seasonal peak has been observed, largely related to
mostly tropical, countries in which reporting is the younger age groupS(751 as well as a longer 6-10
probably poor to greater than 200 per 100,000 in yr cycle or periodicity of incidence. Both of these
several other countries (especially eastern Europe) cyclical patterns were regular features of reported
where special reporting systems have been in hepatitis occurrence in the United States between
effect for some 20 yr. At the moment, it is impossi- 1952 and 1970. Since then, seasonal variation has
ble to state with any degree of certainty what the essentially disappeared and annual incidence ap-
true proportionate distribution between A and B is pears to have become stabilized. In Denmark,
in any of these countries. On the basis of limited where peak incidence rates of over 500 per 100,000
reports, it is fair to say that type B may account for were observed in the mid-1940s, there has been a
50% or more of acute "nonepidemic" hepatitis steady decline from 1955 to virtual disappearance
cases. Until such time as more reliable diagnostic over the next 15 yr.
and reporting practices become commonly ac- 5.1.3. Age and Sex. Although all age groups are
cepted, descriptions of presumed differential gen- susceptible, type A hepatitis has long been con-
eral epidemiological features of types A and B will sidered to be predominantly an infection of chil-
be of questionable significance. With this reserva- dren, with the highest rate among preschool and
tion clearly stated, the epidemiological patterns of school-age groups and the lowest rates among
hepatitis type A and type B will be considered older adults, a presumably highly immune group.
separately. The major fluctuations between epidemic and non-
epidemic years have been noted to occur in these
younger age groupS/441 whereas rates among the
5.1. Viral Hepatitis Type A
older age groups remain relatively unchanged
Viral hepatitis type A has long been considered from year to year. These patterns have been
to represent a secondary manifestation of an en- changing in the United States during recent years
and are subject to clearer definition on the basis of problems in future studies, the World Health Or-
specific diagnostic classification. It is likely, how- ganization has made available standardized in-
ever, that the shift in reported peak age of inci- terim working reagents.
dence of hepatitis, particularly among males, to 5.2.1. Geographic Distribution. On the basis of
the 15-24 yr age group can be accounted for largely extensive serological surveys for HBs Ag and more
by type B, not type A, infections associated with limited antibody surveys, HBV is now known to
illici t drug use. (25al have penetrated and persisted throughout the
There is no convincing evidence that a sex world, even among remote and insular popula-
differential exists for virus A infections, but re- tions. Antigen carrier (prevalence) rates vary wide-
ported sex· specific rates are usually slightly higher ly from less than 0.1 % to 20% or greater among
for males than for females, especially in the older otherwise presumably healthy individuals. Al-
age groups. In common-source epidemics, age and though the reported carrier rates appear to be
sex patterns will vary widely according to the higher in tropical zones than in most temperate
composition of the popUlation exposed. For exam- areas, carrier frequencies per se may not provide
ple, raw shellfish associated epidemics occur al- very accurate or meaningful indicators of total
most entirely among adults, and particularly HBV activity or infection rates.
males, reflecting the age and sex distribution of 5.2.2. Temporal Distribution. There has never
this eating preference. been any evidence to suggest a seasonal preference
5.1.4. Occupation. There are no specific occupa- for HBV transmission or its clinical manifestations.
tional associations except for handlers of certain Indeed, there has never been any reason to suspect
recently imported primates in zoos or laborato- seasonal variation, and the recently observed flat-
ries/ 28al health professionals (including hospital tening of seasonal peaks previously observed in
personnelo21 and staff members of institutions for overall viral hepatitis reporting in the United
retarded children), government military personnel, States has been attributed in part to an increasing
and missionaries(l4al assigned to highly endemic proportion of type B. No long-term cycles in the
areas. temporal distribution of type B infection have
been observed or suspected. However, there has
been a relatively steady rise in reported cases of
5.2. Viral Hepatitis Type B
type B in the United States since 1966, in parallel
For a quarter of a century, from the mid-1940s with the increasing problem of illicit parenteral
until the late 1960s, hepatitis B virus (HBV) was drug use.
widely presumed to be totally dependent on par- 5.2.3. Age. HBs Ag carrier rates have been ob-
enteral routes of transmission with limited distri- served to increase directly with age in all popula-
bution patterns determined largely by modern tions studied, but with a decline among older age
medical practices and procedures, except for cases groupS,C74·761 suggesting the possibility that the
associated with tattooing(691 and with shared carrier state is self-limited in duration in some
equipment in illicit drug use. (711 Epidemics as individuals. True age patterns of infection with
such were unknown outside these restrictive HBV remain largely undetermined. On the basis of
bounds. With the discovery of hepatitis B surface limited antibody (anti-HBs) surveys/14.77I there is
antigen (HBs Ag), its clear association with HBV sufficient evidence to suggest that the older ac-
infection, and the widespread application of rap- cepted age patterns, based on clinically diagnosed
idly improving and more sensitive methods for its cases, are totally unreliable indicators of true age-
detection, the epidemiological behavior of HBV is related infection patterns. The preponderance of
being subjected to a thorough and continuing adult cases is probably a combined reflection of
reinvestigation and revision. Widely variable and increased clinical recognition (more severe host
changing laboratory methods and study designs response) and perhaps a greater likelihood of par-
(or lack thereof) have often made for difficulty in enteral infection by blood transfusion containing a
strict comparisons between results obtained by more massive dose of the infecting agent. In any
different investigators at different times and in event, almost universally type B hepatitis has been
different places. To help minimize some of these considered to be an adult infection as contrasted to
the higher incidence of type A among young situations providing intimate or close personal
children. contact, although the exact modes and mecha-
5.2.4. Sex. HBs Ag carrier rates are higher nisms for transmission are not clearly defined or
among males than females in most reported stud- readily demonstrated. HBV has been found to be
ies,o°,25) Similarly, the reported incidence of type endemic in large institutions for mentally re-
B viral hepatitis usually reveals an excess among tarded, where antigen carrier and antibody preval-
males, although variation~ have been observed in ence rates are extremely high.(72) Secondary infec-
relation to age and presumed mode of transmis- tion rates among household contacts of index
sion (e.g., higher among females of childbearing hepatitis B cases and antigen carriers are also high,
age in transfusion recipients; higher among teen- although clinical manifestations are relatively in-
age and young adult males in relation to illicit frequent as compared to observations for type A in
drug use). similar settings. (49,82) Extremely high carrier and
5.2.5. Race. There is at present insufficient evi- illness rates have been observed among both pa-
dence for making distinctions concerning suscep- tients and staff of hemodialysis units. These have
tibility or epidemiological behavior of HBV on the been explained on the basis of a combination of
basis of race. Such variations as have been ob- factors including risk associated with blood usage,
served among different racial or ethnic groups apparatus design, and sterilization methods and
have usually been attributed to environmental or with immunological deficits among patients re-
other factors. Recent studies revealing marked var- lated to their basic illnesses or induced artificially
iations in antigen prevalence rates among blood for medical or organ transplantation reasons.
donors of different ethnic groups in New York Both antigen and antibody prevalence studies
point to the likelihood thaf factors other than among different populations have continued to
socioeconomic ones are significant determinants. support the original expectations that the preval-
5.2.6. Occupation. Increased risks of hepatitis ence rates are higher (and rise at earlier ages)
related to occupation have been found among among the lower socioeconomic groups in patterns
health professionals, hospital and other (especially consonant with those observed for other common
staff members of hemodialysis units), among labo- infectious diseases in which crowding and lack of
ratory workers handling blood, among certain in- sanitation contribute to spread. Nutrition per se
stitutional employees (e.g., caretakers of mentally has not been studied carefully in relation to either
retarded), and recently among commercial proces- infection or illness patterns.
sors of human plasma.(]2,28,41,5fi,80) In most of these There has been considerable controversy over
instances, it has been presumed that the increased the role of genetic factors in relation to HBV
risk largely represents an increased exposure to infection, clinical response, and development of
contaminated blood and blood products, with in- the carrier state since Blumberg first proposed a
fection occurring by accidental inoculation or pos- genetic hypothesis for his observed distribution of
sibly by aerosol or oral routes. Australia antigen (HBs Ag) among insular popula-
Although ordinarily not classified as an occupations. The question, still far from settled, is a
tional category, members of the "hippie" culture subject of continued study.(8.54.851
and drug-using groups run a high risk of hepati-
tis, probably A as well as B and perhaps yet
unknown types. Not uncommonly, individuals
suffer multiple episodes of jaundice. It is generally 6. Mechanisms and Routes of Transmission
assumed that the risk is largely associated with the
sharing of equipment for parenteral drug use, but
the life-style and communal living arrangements
often adopted by such individuals may well foster Of the earliest-recognized distinguishing fea-
other mechanisms of transmission as well. tures between type A and type B viral hepatitis,
5.2.7 Special Settings and Association. There is mechanisms and routes of transmission appeared
now abundant evidence that HBV infection is to be among the most specific. On the basis of
readily transmitted by nonparenteral means in prior epidemiological observations and controlled
transmission studies in the early 1940s, type A assumed to be equally as effective in virus excre-
seemed to behave in a fashion typical of known tion and transmission as are those with icterus.
enteric diseases, i.e., transmission by the fecal- Although it has frequently been proposed that
oral' route by way of contaminated food and water hepatitis A virus might be spread by the respira-
or by direct close personal contact. Numerous tory route/ 33 ' there is as yet no convincing exper-
small and large epidemics have been well docu- imentaland little suggestive epidemiological evi-
mented as due to contamination of various foods, dence(Ja' to support this as an important
usually uncooked, or water, including individual mechanism of spread.
wells, streams, or community supplies. Not un- No biological vectors are known for HAV. Dur-
commonly, secondary epidemic waves occur due ing the past two decades, a number of well-
to spread by close contact, particularly within studied shellfish-associated outbreaks of hepati-
households. The largest water-borne epidemic re- tiS(64.65) have clearly pointed to oysters and clams
ported was one which occurred in New Delhi(47a, harvested from sewage contaminated waters as
when a temporary diversion in the course of the effective hepatitis virus filters and vehicles for
river resulted in massive sewage contamination of transmission when eaten raw. Perhaps the most
the water supply. More than 30,000 cases of pre- widely publicized such epidemic was the one first
sumed hepatitis type A followed the event after an recognized in New Jersey in 1961, which resulted
appropriate incubation period in spite of increased in cases scattered over a wide area and led to the
chlorination sufficient to inactivate most known closing of Raritan Bay for clam harvesting. How-
pathogens. More recently, an outbreak of hepatitis ever, there is no evidence to suggest that shellfish
which caused cancellation of most of a college act as biological hosts or reservoirs for either
football team's entire fall schedule was traced to a hepatitis A or B virus.
contaminated water line at the practice field. (48a'
That the fecal-oral route may not be exclusive has
been suggested by findings related to a food-borne 6.2. Viral Hepatitis Type B
epidemic among Navy flight personnel who had The early experimental human hepatitis trans-
consumed potato salad prepared with mayonnaise mission studies of the 1940s which clearly defined
presumably contaminated with urine by a dis- two distinct etiological agents also led to an epide-
turbed mess hall worker with anicteric hepati- miological misunderstanding that prevailed for
tis. (33a' more than 20 years, i.e., the concept that HBV was
Various levels of endemicity and epidemicity of transmitted only via the blood and was infective
type A hepatitis have been commonly observed in exclusively by the parenteral route. For these rea-
institutional settings, especially those providing sons, the perpetuation of hepatitis type B was felt
care for the mentally subnormal, in which personal to be largely dependent on therapeutic and pre-
hygiene and environmental sanitation problems ventive health measures involving needles and
cannot be adequately monitored and controlled. syringes, blood, and blood products. Indeed, the
Since the infection is usually mild and anicteric in earliest-recorded and well-documented epidemic
young children, the problem may be apparent only of what retrospectively must represent type B
among susceptible adult employees. In addition to occurred in Germany among shipyard workers
the fecal-oral route, parenteral transmission can who were vaccinated against smallpox usinggly-
occur since there is a viremia during the latter half cerinated human lymph.(4(;) Beginning in the
of the incubation period and the early acute phase 1930s, hepatitis was recognized as a risk associated
of illness, an interval roughly paralleling fecal with the use of pooled human convalescent serum
excretion of infective virus.(4()) However, paren- to prevent diseases such as measles(38) and
teral transmission is generally thought to be of no mumps. W) The largest recorded epidemic oc-
more than minor importance in the spread of curred in 1942, when more than 45,000 U.S. mili-
HAV. There is as yet little evidence(72' in support tary personnel developed type B hepatitis follow-
of the existence of prolonged or chronic carrier ing inoculation with live-attenuated yellow fever
states for hepatitis virus A infections. Individuals virus vaccine which contained "normal" human
with anicteric and asymptomatic infections are serum as a stabilizer. (53)
The risk of hepatitis transmission in association tions concerning the presence or absence of
with the transfusion of whole blood or pooled HBs Ag in urine, feces, saliva, and other body
human plasma, first recognized during World War secretions, all of which may be contaminated to
II, became a major postwar civilian problem with some degree with blood at one time or another.
the increasing therapeutic and prophylactic use of However, the mere presence of detectable antigen
blood and blood products. A number of plasma does not necessarily serve as a certain marker of
protein fractions, pi,\rticularly fibrinogen and an- infectivity. An HBs Ag inhibitor has been demon-
tihemophilic factor, were found to carry a high strated in human feces and intestinal mucosa.(55)
frequency of virus B contamination and a high risk The possibility of sexual or venereal transmis-
of infection. sion has been a subject of intense interest for a
Transmission has also been associated with a number of investigators in recent years and has
variety of medical, surgical, and dental instru- resulted in several reports which present various
ments contaminated with blood or serum and observations and speculations(2.21a.2Ba.52a) concern-
inadequately cleansed and sterilized between ing a wide range of sexual activities but no clear-
uses. Aside from medical procedures, parenteral cut convincing evidence of a precise route or
transmission has been associated with tattoo mechanism of transmission.
needles and injection equipment shared among Although a variety of epidemiological and labo-
illicit drug users. Indeed, the latter mode of trans- ratory observations appear to support the proba-
mission may have accounted for a major share of bility of various nonparenteral routes of transmis-
recognized type B infections during the past dec- sion for HBV, the matter is still far from settled
ade, and is likely to remain so until laboratory methods
The failure to demonstrate nonparenteral trans- are available for testing and proving infectivity.
mission of HBV in the volunteer studies of the Perinatal transmission of HBV infection has
1940s was probably due in large part to the lack of been studied intensively since the advent of
sufficiently sensitive biochemical and specific ser- HBs Ag testing.(4.4B.66.67) Only a small proportion
ological tests for the detection of anicteric infec- of babies born to asymptomatic HBs Ag carrier
tions. Methods for measuring serum levels of mothers are found to be antigen positive at birth,
transaminase, which are extremely sensitive indi- suggesting that HB, Ag does not readily cross the
cators of hepatocellular damage, had been devel- placenta. Some become antigen positive much
oped and carefully evaluated by the mid-1960s, later, possibly as a result of infection during partu-
when Krugman et al. (35) attempted oral transmis- rition, nursing, or other close postnatal contact
sion of HBV by feeding serum already known to with the carrier mother. In contrast, children born
be infective by the parenteral route. None of the of women who develop acute hepatitis B infection
resulting infections would have been recognized during pregnancy or within 2 months post partum
without the benefit of serial serum enzyme deter- run an increasing risk of biochemical and serologi-
minations over a period of several months. In a cal evidence of neonatal infection in relation to the
later study, testing of the same serum specimens time of recognition of maternal infection.(66) Some
for the presence of HBs Ag provided additional of these infants develop chronic subclinical hepati-
evidence.(22) Subsequently, the demonstration of tis and antigenemia. Their ultimate fate and infec-
HBs Ag in association with sporadic and contact tivity remain to be determined.
cases of hepatitis clearly unrelated to possible 6.2.1. Vectors and Reservoirs. No nonhuman
parenteral transmission pointed to the need to natural reservoirs of HBV have been defined, al-
seek further evidence in support of specific non- though it is possible that infectious cycles may
parenteral routes. Family clustering of asympto- occur among chimpanzees and perhaps other
matic carriers of HBs Ag(7.6B.79) suggests the im- lower primates.
portance of the household setting without defining It has long been suspected that mosquitos and
the mechanism of transmission. While the possi- other bloodsucking insects might act as nature's
bility of fecal-oral spread has not been disproved, parenteral transmitters of HBV. A number of in-
it is still far from having been established. There vestigators have reported demonstrating HBs Ag
are many published claims and some contradic- in pools of wild-caught mosquitos, in both tropical
and temperate regions,U),)9,52,HOl but such findings lin). (73) The recent electron microscopic demon-
may be a reflection of the number of human stration of specific binding of antibody molecules
antigen carriers serving blood meals at a given in convalescent serum to fecal particles presumed
time and place, Artificial mosquito feeding experi- to represent HA V, (20) the demonstrated protective
ments have so far provided no evidence in support effect of convalescent serum in neutralization of
of biological transmission, Le" antigen persistence infectivity of HAV in marmosets/ 471 and the de-
or replication, but this would not rule out the velopment of complement fixation and immune
possibility of mechanical transmission in the adherence antibodies(:14a,H2a) offer convincing evi-
course of interrupted and consecutive feedings, dence of specific immune response to HAV. To
Other bloodsucking insects have not been looked date, there have been no reports of studies dem-
at in sufficient detaiL onstrating cell-mediated immunity in type A hep-
atitis.
So far, there is neither conclusive evidence of a
7. Pathogenesis and Immunity multiplicity of either specific antigens or subtypes
of HA V nor any reason to believe that this virus
will prove to be simpler than HBV in its antigenic
structure.
In the limited controlled transmission studies of
hepatitis A virus (HA V) carried out in the 1940s
and 1950s,<4o.84) it was demonstrated that fecal 7.2. Viral Hepatitis Type B
excretion of infective virus began approximately The primary site of replication of HBV is un-
two-thirds of the way in the incubation period, known. The regular early appearance in the serum
Le., from about the twenty-fifth day after oral of large quantities of HBs Ag, long before any
infection in one series. The specific cells or tissue biochemical or other evidence of hepatocellular
sites of this early viral replication are still un- damage, would suggest that the site might well be
known. It may be suspected that the primary site some cells other than hepatocytes or that these
of infection is in the intestine or some other cells are relatively undamaged by the viral replica-
nonhepatic site since there is no clinical or bio- tion process. Recent limited studies of experimen-
chemical evidence of hepatocellular damage at that tally infected chimpanzees have revealed evidence
early stage of infection. Indeed, it appears that of HBV core components in hepatocytes only 2 wk
fecal infectivity subsides rapidly with the occur- after parenteral infection. Humoral immune re-
rence of jaundice and peak serum transaminase sponses are readily demonstrable in virtually all
levels, both of which are closely related to rising HBV infections. The appearance of anti-HBc"IJ.:J8 1
serum IgM and thymol turbidity levels. The tem- in close association with liver dysfunction (during
poral association of these events suggests that the the period of HBs antigenemia and long before
pathogenesis of liver damage may be due to an detectable anti-HBs appears) suggests the possibil-
immune mechanism rather than simply hepatocyte ity of an immune mechanism in the production of
destruction by virus replication. Circulating anti- hepatocellular damage. Evidence is just beginning
gen/antibody complexes specific for virus A have to accumulate strongly supporting the view that
not been demonstrated, nor have extrahepatic cell-mediated immunity may playa significant role
manifestations of infections suggested their pres- in determining the clinical response and outcome
ence in specific tissue sites. of HBV infections. Although the mechanism for
Application of recently developed serological persistence of antigenemia, particularly in the ab-
methods should provide for rapid advancement of sence of apparent hepatic damage, is still far from
our previously very limited knowledge concerning fully explained, defects in cell-mediated immunity
specific HA V antibodies. Previously their exis- and/or other forms of immunodeficiency are likely
tence was assumed on the basis of apparently solid to be Significant factors.
immunity to experimental reinfection(27,351 and Extrahepatic symptoms and lesions are not un-
the protection afforded by even very small doses of common in association with HBV infection. A
pooled human immune serum globulin (y-globu- transient "serum sickness" syndrome may appear
well in advance of hepatic symptoms(3a) in rela- istics are frequently noted. The onset of type A is
tion to circulating antigen/antibody complexes. likely to be relatively more abrupt and febrile than
Such complexes have also been demonstrated in that for type B, in which it tends to be more
association with vascular lesions of HBs Ag serum insidious with low or absent fever. The onset of
positive cases of polyarteritis nodosa(24al and ne- type B hepatitis not uncommonly follows a serum-
phrosis or glomerulonephritis.(]]al sickness-like prodrome of urticaria, pruritis, and}
or arthritis. The total duration of illness varies
widely from a few weeks to a few months, with
type B tending to be more prolonged.
8. Patterns of Host Response
The diagnosis of acute hepatitis rested primarily 8.2. Laboratory Diagnosis

on the occurrence of jaundice until the 1940s,
when the first controlled human transmission In addition to these clinical differences, certain
studies and extensive application of biochemical laboratory tests may be helpful in differentiating
and histological methods confirmed the common between type A and type B hepatitis. The general
occurrence of anicteric and asymptomatic infec- patterns of serum transaminase elevation, e.g.,
tions. Since the latter are still ordinarily unrecog- steepness of rise and duration, differ in conso-
nized and undiagnosed as viral hepatitis, their nance with the abrupt (type A) and insidious (type
frequency and relative epidemiological importance B) patterns of onset of symptoms. Serum thymol
remain matters for speculation. turbidity is elevated consistently and early in both
The spectrum of acute clinical manifestations of icteric and anicteric infections with virus A. It
infection appears to be similar for both type A and usually remains normal in anicteric virus B infec-
type B. It ranges from mild to fatal, the distributions.(39)
tion according to severity being dependent on a Undoubtedly the most helpful and specific labo-
number of host factors, as yet poorly defined, and ratory method for differential diagnosis is one of
possibly on variations in virulence of the agents. the serological tests for the presence of hepatitis B
In the past, it has been widely accepted that HBV surface antigen, HBs Ag (see Section 3.3). Except
infections tend to be more severe than those due for the possibility of a carrier state, a positive test
to HAV. This may well prove to be true, but such is indicative of acute infection with hepatitis B
beliefs must now be reconsidered in the light of virus. The duration of detectable antigenemia is
better differential diagnosis and clinical classifica- variable, but it usually appears well in advance of
tion. The vast majority of symptomatic infections symptoms and persists throughout most of the
due to either virus will be followed by complete period of acute illness or elevated serum transami-
recovery. A small proportion will continue into nase levels. However, its detectability may be
one or another form of unresolved chronic liver fleeting, so failure to find HBs Ag does not neces-
disease. A much smaller proportion of acute infec- sarily rule out type B hepatitis. With appropriately
tions will result in massive hepatic necrosis, coma, spaced paired or serial serum specimens, antibody
and death. conversion (either anti-HBc or anti-HB" or both)
may be detected.

Fever, malaise, fatigue, headache, anorexia,
nausea, vomiting, and abdominal pain are com- 9. Control and Prevention
mon and usual features of variable severity associ-
ated with acute hepatitis of either type. However, There is currently no approved vaccine for the
when large numbers of cases have been well prevention of either type A or type B hepatitis,
documented and grouped as either type A or type although recent developments toward this goal, at
B for comparison, useful differentiating character- least in the case of. type B, would suggest that
agents for active immunization may become avail- velopment of tests to identify carriers and/or in-
able in the near future. fected blood in order to reduce the risk of trans-
mission, and (3) the use of pooled human immune
globulin for passive immunization of those at risk
9.1. Type A (or mixed directly with blood prior to transfusion
in order to "neutralize" the virus in vitro).
Since transmission of type A hepatitis virus is
The first of these approaches produced encour-
primarily associated with close personal contact
aging results from time to time, but no proven,
and fecal contamination of food or water, those
practical, readily applicable methods were forth-
measures of personal hygiene and environmental
coming after more than two decades of effort.
sanitation which apply to control of other enteric
Until the discovery of HBs Ag and its widespread
infections are generally effective in limiting the
use in blood-donor screening procedures, little
spread of infection. The identification of common-
. progress was made in the second approach. Al-
source outbreaks will often lead to recognition of
though markedly differing degrees of risk were
the vehicle of transmission, but usually too late for
found among different donor populations, particu-
the institution of corrective measures to be benefi-
larly "commercial" or paid donors vs. volunteer or
cial except as they may be effective in preventing
family donors,<2a) relatively little heed was paid to
similar outbreaks in the future.
the observation for almost two decades. This asso-
Pooled human immune serum globulin (16%
ciation was confirmed and extended to include
solution, 0.01-0.10 ml1kg body weight) is highly
non-type-B posttransfusion hepatitis as well in a
effective in preventing or attenuating type A virus
recent study. (67a) Since the introduction of federal
infection among contacts of cases and among per-
regulations in the United States mandating the
sons regularly exposed to or preparing to enter
testing of all donor blood for HBs Ag and the
known endemic settings,<34) e.g., institutional
subsequent introduction of extremely sensitive
employees, military and other travelers, or long-
screening methods such as radioimmunoassay,<43J
term visitors to recognized areas of high risk. The
the possibility of almost complete elimination of
smaller dose is appropriate and effective when
transfusion-associated type B hepatitis has become
given during the early incubation period. The
a realistic goal. Pretesting and the use of only
larger amounts are usually given in anticipation of
HBs Ag negative units for the preparation of
risk of infection, the total single dose being pro-
pooled plasma fractions or for other specialized
portional to the expected duration of risk (e.g.,
blood components should further reduce the risk
1.0--2.0 ml/month for adults). In instances of more
of HBV transmission in therapeutic and prophy-
extended continuing exposure, injections may be
lactic medical procedures.
repeated two or three times at intervals of 4-6
Results of numerous prospective and variably
months. A primary aim in the use of immune
controlled posttransfusion studies of the value of
globulin under such circumstances is that infection
pooled human immune globulin in the prevention
and active immunity will develop under the cover
of viral hepatitis type B have been characterized
of this temporary passive protection.
by inconsistency, perhaps at least partially ex-
plained by variations in infecting dose and in
specific antibody content of the different globulin
9.2. Type B
preparations tested. In a limited series of direct
From the earliest recognition of blood as a vehi- hepatitis B virus parenteral challenge studies,
cle for transmission of type B hepatitis, three main Krugman et al. (37) found a specific globulin prepa-
approaches to control have been pursued: (1) the ration containing a high level of anti-HBs Ag to be
development of methods for the routine phYSical about 70% effective. Soulier et al. (70) have also
and/or chemical treatment of all blood, plasma, reported protection afforded by specific hepatitis B
and pooled plasma protein fractions which would Ag immune globulin given to 27 individuals dur-
render them noninfective without diminishing or ing the first week after exposure to HBs Ag posi-
altering their therapeutic effectiveness, (2) the de- tive blood (19 after transfusion, eight after acci-
dental inoculation). Similar preparations are the chimpanzee, provides at least one alternative
currently under evaluation in the prevention of to the human for safety testing. It also provides an
hepatitis following transfusion or accidental inoc- experimental model for exploring further the ques-
ulation with materials known to contain HBs Ag. If tion of cross-immunity between the various anti-
the results bear out early expectations, specific genic subtypes of HBV(501 studies.
preparations of hepatitis B immune human globu-
lin should become available, but until they do
standard globulin preparations are likely to con-
tinue to be used empirically in large doses when 10. Unresolved Problems
there has been a reasonable suspicion of parenteral
exposure to HBV, particularly among laboratory In spite of rapid and continuing progress in our
and medical personnel. total understanding of viral hepatitis during the
Recent studies have provided evidence of the past several years, many questions remain unre-
efficacy of passive immunization under conditions solved. The seemingly endless search for suscepti-
of presumed nonparenteral transmission of HBV. ble experimental animals has finally led to positive
A large-scale controlled study of U.S. military answers for both type A and type B viruses, but
personnel in Korea, an area of high hepatitis the answers are less than totally satisfactory be-
incidence, indicated that a 5-ml dose of "stand- cause of the relative scarcity of both chimpanzees
ard" ,,-globulin provided significant protection for and marmosets. It now appears doubtful that less
6 months against both type Band non-BYbl exotic or more readily available species will be
Szmuness et al. (781 compared the protective effect found to be equally acceptable substitutes. Identi-
of standard and a special hepatitis B immune fication of feasible cell culture systems for the
globulin in prospective study of children newly regular isolation and propagation of both virus A
admitted to three institutions in which HBV was and virus B still represents a major challenge for
known to be endemic. Both appeared to be about both diagnostic and epidemiological studies as
equally, but far from completely, protective. No well as approaches to further development of rou-
chronic antigen carriers were observed among the tine serological reagents and ultimately vaccines,
globulin recipients as compared to un immunized either inactivated or live attenuated strains. Read-
children, among whom this outcome was com- ily available and reliable virus isolation and serol-
mon. ogical methods are needed to fill in large gaps in
A series of active immunization studies(361 has our epidemiological understanding of hepatitis
evolved from observations made by Krugman and and especially to clarify the meaning and impor-
his associates. They found that injection of heat- tance of several suggested nonparenteral mecha-
inactivated serum determined to be rich in HBs Ag nisms of transmission of HBV.
stimulated specific antibodies which appeared to In addition to the more practical considerations
be protective in subsequent challenge experiments. of their usefulness in diagnostic and epidemiolog-
Additional evidence of the protective effect of anti- ical studies, it is becoming more and more appar-
HBs has been derived from comparative studies of ent that immune responses are likely to play sig-
transfusion recipients with and without preexisting nificant roles in the pathogenesis of both type A
anti-HBs.(1) It does not appear that antibody to the and type B viral hepatitis. Immune complexes
core antigen of HBV is protective. To the contrary, involving HBs Ag have also been demonstrated in
its persistence at high levels appears to be associ- association with certain nonhepatic diseases, e.g.,
at~d with the chronic carrier state.(321 polyarteritis nodosa, glomerulonephritis, and ne-
At the present time, it is likely that the best phrosis, but their etiological significance and tem-
prospect for a safe and effective vaccine against poral relationships are not yet resolved. Still far
hepatitis B virus infection will be one based on from satisfactorily answered are the roles of immu-
some method of purification of HBs Ag followed nodeficiency and immunosuppression in the de-
by an inactivation procedure to safeguard against velopment of persistent HBs Ag-and presumably
any residual infective HBV particles. The availabil- HBV-carriers.
ity of a sensitive susceptible experimental animal, Last but not least, progress in defining the
respective roles of viruses A and B has revealed a antigen (Australia antigen) in Down's syndrome,
previously unrecognized problem related to other leukemia and hepatitis, Ann. Intern. Med. 66:924-931
types of hepatitis, probably large and complex, (1967).
perhaps not even of viral etiology. 10. BLUMBERG, B. S., SUTNICK, A. I., LONDON, W. T.,
AND MELARTIN, L., Sex distribution of Australia
antigen, Arch. Intern. Med. 130:227-231 (1972).
11. BROTMAN, B., PRINCE, A. M., AND GODFREY, H. R.,
11. References Role of arthropods in transmission of hepatitis-B
virus in the tropics, Lancet 1:1305-1308 (1973).
1. AACH, R. D., ALTER, H. J., HOLLINGER, F. B., HOL- 11a. BRZOSKO, W. J., KRAWCZYNSKI, K., NAZAREWICZ, T.,
LAND; P. V., LANDER, J. J., MELNICK, J. L., AND MORZYCKA, M., AND NOWOSLAWSKI, A., Glomerulo-
WEILER, J. M., Risk of transfusing blood containing nephritis associated with hepatitis-B surface anti-
antibody to hepatitis-B surface antigen, Lancet 2:190- gen immune complexes in children, Lancet 2:477-
193 (1974). 482 (1974).
1a. AACH, R. D., EVANS, J., AND LOSEE, J., An epidemic 12. BYRNE, E. B., Viral hepatitis: An occupational hazard
of infectious hepatitis possibly due to airborne of medical personnel: Experience of the Yale-New
transmission, Am. ,. Epidemio/' 87:99-109 (1968). Haven Hospital, 1952-1965, J. Am. Med. Assoc.
lb. A Cooperative Study: Prophylactic gamma globulin 195:362-364 (1966).
for prevention of endemic hepatitis: Effects of U.S. 13. CAYZER, I., DANE, D. S., CAMERON, C. H., AND
gamma globulin upon the incidence of viral hepati- DENNINGS, J. V., A rapid hemagglutination test for
tis and other infectious diseases in U.s. soldiers hepatitis B antigen, Lancet 1:947-949 (1974).
abroad, Arch. Intern. Med. 128:723-738 (1971). 14. CHERUBIN, C. E., PURCELL, R. H., LANDER, J. J.,
2. ADAM, E., HOLLINGER, F. B., MELNICK, J. L., MCGINN, T. G., AND CONE, L. A., Acquisition of
DUENAS, A., AND RAWLS, W., Type B hepatitis anti- antibody to hepatitis B antigen in three socioecon-
gen and antibodies among prostitutes and nuns, ,. omically different medical populations, Lancet 2:149-
Infect. Dis. 129(3):317-321 (1974). 151 (1972).
2a. ALLEN, J. G., AND SAYMAN, W. H., Serum hepatitis 14a. CLINE, A. L., MOSLEY, J. W., AND SCOVEL, F. G.,
from transfusions of blood, J. Am. Med. Assoc. Viral hepatitis among American missionaries
180:1079-1085 (1962). abroad: A preliminary study, J. Am. Med. Assoc.
3. ALMEIDA, J. D., RUBINSTEIN, D., AND STOTT, D. J., 199:551-553 (1967).
New antigen-antibody system in Australia antigen 14b. Committee on Viral Hepatitis of the NAS/NRC: No-
positive hepatitis, Lancet 2:1225-1227 (1971). menclature of antigens associated with viral hepati-
3a. ALPERT, E., ISSELBACHER, K. J., AND SCHUR, P. H., tis type B, Intervirology 2:134-135 (1974).
The pathogenesis of arthritis associated with viral 15. CROSS, G. F., WAUGH, M., FERRIS, A. A., GUST, 1. D.,
hepatitis, N. Eng/. J. Med. 285:185-189 (1971). AND KALDOR, J., Virus-like particles associated with
4. AZIZ, M. A., KHAN, G., KHANUM, T., AND SIDDIQUI, a faecal antigen from hepatitis patients and with
A.-R., Transplacental and postnatal transmission of Australia antigen, Aust. ,. Exp. BioI. Med. Sci. 49:1-9
hepatitis associated antigen, ,. Infect. Dis. 127:110- (1971).
112 (1973). 16. DANE, D. S., CAMERON, C. H., AND BRIGGS, M.,
5. BANCROFT, W. H., MUNDON, F. K., AND RUSSELL, P. Virus-like particles in serum of patients with Aus-
K., Detection of additional antigenic determinants of tralia-antigen-associated hepatitis, Lancet 1:695-698
hepatitis B antigen,!. ImmunoI. 109:842-848 (1972). (1970).
6. BEESON, P. B., CHESNEY, G., AND McFARLAN, A. M., 17. DEINHARDT, F., HOLMES, A. W., CAPPS, R. B., AND
Hepatitis following injection of mumps convalescent POPPER, H., Studies on the transmission of human
plasma, Lancet 1:814-815 (1974). viral hepatitis to marmoset monkeys. 1. Transmission
7. BLUMBERG, B. S., ALTER, H. J., AND VISNICH, S., A of disease, serial passage and description of liver
"new" antigen in leukemia sera, J. Am. Med. Assoc. lesions, ,. Exp. Med. 125:673-687 (1967).
191:541-546 (1965). 18. DEL PRETE,S., CONSTANTINO, D., DOGLIA, M., AND
8. BLUMBERG, B. S., FRIEDLANDER, J. S., WOODSIDE, A., GRAZIINA, A., Detection of a new serum-antigen in
SUTNICK, A. I., AND LONDON, W. T., Hepatitis and three epidemics of short-incubation hepatitis, Lancet
Australia antigen: Autosomal recessive inheritance 2:579-581 (1970).
of susceptibility to infection in humans, Proc. Nat!. 19. DICK, S. J., TAMBURRO, C. H., AND LEEVY, C. M.,
Acad. Sci. USA 62:1108-1115 (1969). Hepatitis B antigen in urban-caught mosquitoes, ,.
9. BLUMBERG, B. S., GERSTLEY, B. J. 5., HUNGERFORD, D. Am. Med. Assoc. 229:1627-1629 (1974).
A., LONDON, W. T., AND SUTNICK, A. I., A serum 20. FEIN STONE, S. M., KAPIKIAN, A. Z., AND PURCELL, R.
H., Hepatitis A: Detection by immune electron mi- 30. HILLIS, W. D., An outbreak of infectious hepatitis
croscopy of a viruslike antigen associated with acute among chimpanzee handlers at a United States Air
illness, Science 182:1026-1028 (1973). Force base, Am. J. Hyg. 73:316-328 (1961).
21. FERRIS, A A., KALDOR, J., AND GUST, 1. D., Faecal 31. HOOFNAGLE, J. H., GERETY, R. J., AND BARKER, L. F.,
antigen in viral hepatitis, Lancet 2:243--244 (1970). Antibody to hepatitis B core in man. Lancet 2:869-
21a. FULFORD, K. W. M., DANE, D. S., CATTERALL, RD., 873 (1973).
WOOF, R, AND DENNING, J. V., Australia antigen 32. HOOFNAGLE, J. H., GERETY, R. J., NI, L. Y., AND
and antibody among patients attending a clinic for BARKER, L. F., Antibody to hepatitis B core antigen:
sexually transmitted d.iseases, Lancet 1:1470-1473 A sensitive indicator of hepatitis B virus replication,
(1973). N. Engl. J. Med. 290:1336-1340 (1974).
22. GILES, J. P., MCCOLLUM, R W., BERNDTSON, L. W., 33. IpSEN, J., DONOVAN, W. R., AND JAMES, G., Sociol-
JR., AND KRUGMAN, S., Viral hepatitis: Relationship ogic factors in the spread of epidemic hepatitis in a
of the AustraliaiSH antigen to the Willowbrook MS-2 rural school district, J. Hyg. 50:457-470 (1952).
strain, N. Engl. J. Med. 281:119-121 (1969). 33a. JOSEPH, P. R., MILLAR, J. D., HENDERSON, D. A.,
23. GINSBERG, A L., CONRAD, M. E., BANCROFT, W. H., NAUMANN, R D., BAGLEY, C. S., SCHLANG, H. A.,
LONG, C. M., AND OVERBY, L. R., Prevention of AND SHAW, G. A., An outbreak of hepatitis traced to
endemic HAA-positive hepatitis with gamma globu- food contamination, N. Eng/. J. Med. 273:18S-194
lin: Use of a simple radioimmune assay to detect (1965).
HAA, N. Eng/. J. Med. 286:562-566 (1972). 34. KRUGMAN, S., The clinical use of gamma globulin, N.
24. GOCKE, D. J., AND KAVEY, N. B., Hepatitis antigen: Eng/. J. Med. 269:195-201 (1963).
Correlation with disease and infectivity of blood 34a. KRUGMAN, S., FRIEDMAN, H., AND LATTIMER, c.,
donors, Lancet 1:1056-1059 (1969). Viral hepatitis, type a: Identification by specific
24a. GOCKE, D. J., Hsu, K., MORGAN, c., BOMBARDIERI, complement-fixation and immune adherence tests,
S., LOCKSHIN, M., AND CHRISTIAN, C. L., Associa- N. Engl. J. Med. 292:1141-1143 (1975).
tion between polyarteritis. and Australia antigen, 35. KRUGMAN, S., GILES, J. P., AND HAMMOND, J., Infec-
Lancet 2:1149-1153 (1970). tious hepatitis: Evidence for two distinctive clinical,
25. GOODMAN, M., WAINRIGHT, R L., WEIR, H. F., AND epidemiological and immunological types of infec-
GALL, J. c., JR., A sex difference in the carrier state tion, J. Am. Med. Assoc. 200:365-373 (1967).
of Australia (hepatitis-associated) antigen, Pediatrics 36. KRUGMAN, S., GILES, J. P., AND HAMMOND, J., Viral
48:907-913 (1971). hepatitis type B (MS-2 strain): Studies on active
25a. GREGG, M. B., The changing epidemiology of viral immunization, J. Am. Med. Assoc. 217:41-45 (1971).
hepatitis in the United States, Am. J. Dis. Child. 37. KRUGMAN, S., GILES, J. P., AND HAMMOND, J., Viral
123:350-354 (1972). hepatitis type B (MS-2 strain): Prevention with spe-
26. GROB, P. J., AND JEMELKA, H. 1., Fecal SH-antigen in cific hepatitis B immune serum globulin, J. Am. Med.
acute hepatitis, Am. J. Dis. Child. 123:400-401 (1972). Assoc. 218:1665-1670 (1971).
27. HAVENS, W. P., JR., Immunity in experimentally 38. KRUGMAN, S., HOOFNAGLE, J. H., GERETY, R. J.,
induced infectious hepatitis, J. Exp. Med. 84:403--406 KAPLAN, P. M., AND GERIN, J. L., Viral hepatitis,
(1946). type B: DNA polymerase activity and antibody to
28. HAYASHI, S. J., NAKAMURA, R. M., AND GIORGI, E. hepatitis B core antigen, N. Engl. J. Med. 290:1331-
A, Problems of prevention and detection of hepatitis 1335 (1974).
in personnel of hospital hemodialysis units, J. Oc- 39. KRUGMAN, S., AND WARD, R., Viral hepatitis, in:
cup. Med. 13:38S-392 (1971). Infectious Diseases of Children and Adults, 5th ed., pp.
28a. HEATHCOTE, J., GATEAU, P., AND SHERLOCK, S., Role 76-95, Mosby, St. Louis, 1973.
of hepatitis-B antigen carriers in non-parenteral 40. KRUGMAN, S., WARD, R., AND GILES, J. P., The
transmission of the hepatitis-B virus, Lancet 2:370- natural history of infectious hepatitis, Am. J. Med.
372 (1974). 32(5):717-728 (1962).
28b. Hepatitis Surveillence Report: Sub-human Primate- 41. KUH, c., AND WARD, W. E., Occupational virus
Associated Hepatitis, Center for Disease Control, hepatitis: An apparent hazard for medical personnel,
pp. 10-14, U.S. Department of Health, Education, J. Am. Med. Assoc. 143:631-635 (1950).
and Welfare, Atlanta, Ga., No. 34 (September 1971). 41a. LANDER, J. J., ALTER, H. J., AND PURCELL, R H.,
29. HILLEMAN, M. R., PROVOST, P. J., MILLER, W. J., et aI., Frequency of antibody to hepatitis associated anti-
Immune adherence and complement-fixatton tests for gen as measured by a new radioimmunoassay tech-
human hepatitis A: Diagnostic and epidemiologic in- nique, J. Immunol. 106:1166-1171 (1971).
vestigations, Proc. Int. Assoc. BioI. Stand. 270(1):93--98 42. LE BOUVIER, G. L., The heterogeneity of Australia
(1975). antigen, J. Infect. Dis. 123:671-675 (1971).
42a. LE BouvmR, G. 1., AND WILLIAMS, A., Serotypes of and P. M. Hoff, eds.), pp. 411-462, Government
hepatitis B antigen (HBs Ag): The problem of "new" Printing Office, Washington, D.C., 1960.
determinants as exemplified by "t," Am. J. Med. Sci. 54. PETRAKIS, N., Genetic predisposition to hepatitiS, in:
270(1):165-171 (1975). Hepatitis and Blood Transfusion (G. Vyas, H. Perkins,
43. LING, C. M., AND OVERBY, 1. R., Prevalence of and R. Schmid, eds.), pp. 89-93, Grune and Stratton,
hepatitis B virus antigen as revealed by direct ra- New York, 1972.
dioimmune assay with ! 251-antibody, J. Immunol. 55. PIAZZA, M., 01 STASIO, G., MAIO, G., AND MARZANO,
109:834-841 (1972). 1., Hepatitis B antigen inhibitor in human feces and
44. LOBEL, H. 0., AND McCOLLUM, R. W., Some obser- intestinal mucosa, Br. Med. J. 2:334-337 (1973).
vations on the ecology of infectious hepatitis, Bull. 56. POLAKOFF, S., Decrease in the incidence of hepatitis
WHO 32:675-682 (1965). in dialysis units associated with prevention pro-
45. LONDON, W. T., ALTER, H. J., LANDER, J., AND grammes, Br. Med. J. 4:751-754 (1974).
PURCELL, R. H., Serial transmission in rhesus mon- 57. PRINCE, A. M., An antigen detected in the blood
keys of an agent related to hepatitis B antigen, J. during the incubation period of serum hepatitis,
Infect. Dis. 125:382-389 (1972). Proc. Natl. Acad. Sci. USA 60:814-821 (1968).
46. LURMAN, A, Eine Icterusepidemie, Ber!' Klin. Woch- 58. PRINCE, A. M., Use of chimpanzees as a model for
enschr. 22:20-23 (1885). the study of hepatitis B virus infection, in: Medical
46a. MAGNIUS,1. 0., AND ESPMARK, J. A, New specifici- Primatology (E. 1. GOLDSMITH AND J. MOOR-JAN-
ties in Australia antigen positive sera distinct from KOWSKI, eds.), pp. 97-109, Karger, Basel, 1972.
the Le Bouvier determinants, J. Immunol. 109:1017- 59. PRINCE, A M., BROTMAN, B., GRADY, G. F., KUHNS,
1021 (1972). W. J., HAZZI, c., LEVINE, R. W., AND MILLIAN, S. J.,
47. MAscoLI, C. C., ITIENSOHN, O. 1., VILLAREJOS, V. Long incubation post-transfusion hepatitis without
M., PROVOST, P., AND HILLEMAN, M., Recovery of serological evidence of exposure to hepatitis B virus,
hepatitis agents in the marmoset from human cases Lancet 2:241-246 (1974).
occurring in Costa Rica, Proc. Soc. Exp. Bioi. Med. 60. PRINCE, A. M., METSELAAR, D., KAPUKo, G. W.,
142:276-282 (1973). MUKWAYA, 1. G., LING, C. M., AND OVERBY, L. R.,
47a. MELNICK, J. 1., A water-borne urban epidemic of Hepatitis B antigen in wild-caught mosquitoes in
hepatitis, in: Hepatitis Frontiers (F. W. Hartman, Africa, Lancet 2:247-250 (1972).
ed.), pp. 211-225, Little, Brown, Boston, 1957. 61. PROPERT, S. A., Hepatitis after prophylactic serum,
48. MERRILL, D. A., DUBOIS, R. S., AND KOHLER, P. F., Br. Med. J. 2:677-678 (1938).
Neonatal onset of the hepatitis-associated-antigen 62. PROVOST, P. J., ITIENSOHN, O. L., VILLAREJOS, V. M.,
carrier state, N. Engl. J. Med. 287:1280-1282 (1972). ARGUEDAS, J., AND HILLEMAN, M. R., Etiologic rela-
48a. MORSE, 1. J., BRYAN, J. A., HURLEY, J. P., MuRPHY, tionship of marmoset-propagated CR 326 hepatitis A
J. F., O'BRmN, T. F., AND WACKER, W. E., The Holy virus to hepatitis in man, Proc. Soc. Exp. Bioi. Med.
Cross College football team hepatitis outbreak, J. 142:1257-1267 (1973).
Am. Med. Assoc. 219:706-708 (1972). 62a. PROVOST, P. J., ITIENSOHN, O. 1., VILLAREJOS, V.
49. MOSLEY, J. W., The epidemiology of viral hepatitis: M., AND HILLEMAN, M. R., A specific complement-
An overview, Am. J. Med. Sci., 270(1):253--270 (1975). fixation test for human hepatitis A employing CR
50. MURPHY, B. 1., MAYNARD, J. E., AND LE BouvmR, G. 326 virus antigen: Diagnosis and epidemiology,
1., Viral subtypes and cross-protection in hepatitis B Proc. Soc. Exp. Bioi. Med. 148:962-969 (1975).
virus infections of chimpanzees, Intervirology 3:37S- 63. PURCELL, R. H., GERIN, J. 1., ALMEIDA, J. B., AND
381 (1973). HOLLAND, P., Radioimmunoassay for the detection
of the core of the Dane particle and antibody to it,
51. OKOCHI, K., AND MURAKAMI, S., Observations on
Intervirology 2:231-243 (1973/1974).
Australia antigen in Japanese, Vox Sang. 15:374-385
64. Roos, B., Hepatitepidemi spridd genom ostron,
(1968).
Svenska Lakart 53:989-1003 (1956).
52. PAPAEVANGEWU, G., AND KOUREA-KREMASTINOU, T., 65. RUDDY, S. J., JOHNSON, R. F., AND MOSLEY, J. W., An
Role of mosquitoes in transmission of hepatitis B epidemic of clam-associated hepatitis, J. Am. Med.
virus infection, J. Infect. Dis. 130:7S-80 (1974). Assoc. 208:649-655 (1968).
52a. PAPAEVANGELOU, G., TRICHOPOULOS, D., KREMAs- 66. SCHWEITZER, 1. L., DUNN, A E. G., PETERS, R. 1.,
TINOU, T., AND PAPOUTSAKIS, G., Prevalence of AND SPEARS, R., Viral hepatitis B in neonates and
hepatitis B antigen and antibody in prostitutes, Br. infants, Am. J. Med. 55:762-771 (1973).
Med. J. 2:256-258 (1974). 67. SCHWEITZER, 1. L., AND SPEARS, R. L., Hepatitis-
53. PAUL, J. R., AND GARDNER, H. T., Viral hepatitis, in: associated antigen (Australia antigen) in mothers
Preventive Medicine in World War II, Vol. 5 (E. C. Hoff and infants, N. Eng!. J. Med. 283:570-572 (1970).
67a. SEEFF,1. B., ZIMMERMAN, H. J., WRIGHT, E. c., AND 77. SZMUNESS, W., PRINCE, A. M., ETLING, G. F., AND
McCOLLUM, R. W., VA cooperative study of post- PICK, R., Development and distribution of hemag-
transfusion hepatitis, 1969-1974: Incidence and char- glutinating antibody against the hepatitis B antigen
acteristics of hepatitis and responsible risk factors, in institutionalized populations, J. Infect. Dis.
Am. J. Med. Sci. 270(1):355-362 (1975). 126:498-506 (1972).
68. SINGLETON, J. W., KOHLER, P. F., AND MERRILL, D. 78. SZMUNESS, W., PRINCE, A. M., GOODMAN, M.,
A., Infectivity risk of household contact with chronic EHRICH, c., PICK, R., AND ANSARI, M., Hepatitis B
carriers of hepatitis B antigen, Gastroenterology immune serum globulin in prevention of nonparen-
64:172 (1973). terally transmitted hepatitis B, N. Engl. J. Med.
69. SMITH, B. F., Occurrence of hepatitis in recently 290:701-706 (1974).
tattooed service personnel, J. Am. Med. Assoc. 79. SZMUNESS, W., PRINCE, A. M., HIRSCH, R. 1., AND
144:1074-1076 (1950). BROTMAN, B., Family dustering of hepatitis B infec-
tion, N. Engl. J. Med. 289:1162-1166 (1973).
70. SOULffiR, J.-P., BLATIX, c., COUROUCE, A. M., BENA-
80. TAYLOR, J. S., SHMUNES, E., AND HOLMES, A. W.,
MON, P., AMOUCH, P., AND DROUET, J., Prevention of
Hepatitis B in plasma fractionation workers: A seroe-
virus B hepatitis (SH hepatitis), Amer~ J. Dis. Child.
pidemiologic study, J. Am. Med. Assoc. 230:850-853
123:429-435 (1972).
(1974).
71. STEIGMAN, F., HYMAN, S., AND GOLDBLOOM, R., Infec-
81. TAYLOR, P. E., ALMEIDA, J. D., ZUCKERMAN, A. J.,
tious hepatitis (homologous serum type) in drug ad-
AND LEACH, J. M., Relationship of Milan antigen to
dicts, Gastroenterology 15:642-645 (1950).
abnormal serum lipoprotein, Am. J. Dis. Child.
72. STOKES, J., JR., BERK, J. E., MALAMUT, 1. 1., MILES, E. 123:329-331 (1972).
D., BARONDESS, J. A., BASHE, W. J., WOLMAN, I. J., 82. VILLAREJOS, V. M., GUTIERREZ, A., AND PELON, W.,
FARQUHAR, J. D., BEVAN, B., DRUMMOND, R. J., MAY-
Identification of a type B hepatitis epidemic in Costa
COCK, W. D' A., AND CAPPS,. R. B., The carrier state in
Rica: Comparative analysis of two outbreaks of viral
viral hepatitis, J. Am. Med. Assoc. 154:1059-1065 hepatitis, Am. J. Epidemiol. 96:372-378 (1972).
(1954).
83. VILLAREJOS, V. M., VISONA, K. A., GUTffiRREZ, A.,
73. STOKES, J., JR., AND NEEFE, J. R., The prevention and AND RODRIGUEZ, A., Role of saliva, urine and feces in
attenuation of infectious hepatitis by gamma globu- the transmission of type B hepatitis, N. Engl. J. Med.
lin, J. Am. Med. Assoc. 127:144-145 (1945). 291:1375-1378 (1974).
74. SZMUNESS, W., HIRSCH, R. L., PRINCE, A. M., LEV- 84. VOEGT, H., Zur Aetiologie der Hepatitis epidemica,
INE, R. W., HARLEY, E. J., AND IKRAM, H., Hepatitis Munchen Med. Wechenschr. 89:76-79 (1942).
B surface antigen in blood donors: Further observa- 85. VYAS, G. N., Evidence against recessive inheritance
tions, J. Infect. Dis. 131:111-118 (1975). of susceptibility to the chronic carrier state for hepa-
75. SZMUNESS, W., AND PRINCE, A. M., Epidemiologic titis B antigen, Science 248:159-160 (1974).
patterns of viral hepatitis in Eastern Europe in the 86. VYAS, G. N., AND SCHULMAN, N. R., Hemagglutina-
light of recent findings concerning the serum hepati- tion assay for antigen and antibody associated with
tis antigen, J. Infect. Dis. 123:200-212 (1971). viral hepatitis, Science 170:332-333 (1970).
76. SZMUNESS, W., PRINCE, A. M., BROTMAN, B., AND 87. WALSH, J. H., YALLOW, R., AND BERSON, S. D.,
HIRSCH, R. 1., Hepatitis B antigen and antibody in Detection of Australia antigen and antibody by
blood donors: An epidemiologic study, J. Infect. Dis. means of radioimmunoassay techniques, J. Infect.
127:17-25 (1973). Dis. 121:550-554 (1970).
CHAPTER 11
Epidemiology of
Herpes Simplex
Viruses 1 and 2
Andre J. Nahmias and William E. Josey
1. Introduction and Social Significance exposure to either virus (primary infections) may
often be subclinical, they tend to be more severe than
Herpes simplex viruses (HSV) are among the most infections occurring in individuals previously ex-
common infectious agents of man. There are at posed to HSV-l and/or HSV-2. The clinical mani-
least two distinct serotypes (HSV-l and HSV-2), festations of either virus may also be more severe
which have different modes of transmission. HSV- in certain types of hosts, e.g., the newborn or
1 is transmitted chiefly via a nongenital route, immunocompromised patient, and with involve-
whereas HSV-2 is most often transmitted vener- ment of certain sites, e.g., the central nervous sys-
eally or from a mother's genital infection to the tem.
newborn. The mode of spread of each of the two Although not ubiquitous in all populations
virus types is reflected by its relative prevalence at studied, infection with these viruses represents a
different ages and by its pattern of clinical distri- socially significant problem for which no effective
bution within the host. Thus HSV-l infections vaccine is yet available. HSV-2 infection is becom-
occur most frequently during childhood and using appreciated as a common venereal disease in
ually affect body sites above the waist. HSV-2 several countries, and more cases of neonatal HSV
infections, on the other hand, occur most often infections with fatal or severe sequelae are being
during adolescence and young adulthood and in- recognized. HSV infections of the central nervous
volve body sites below the waist, primarily the system are also often fatal or debilitating, and
genitals. Most infections in newborns are also ocular infections may endanger normal vision.
caused by HSV-2. Recurrent HSV infections are very common and
Although infections in individuals without prior are often physically or psychologically distressing.
With the greater usage of immunosuppressive and
cytotoxic drugs, iatrogenic HSV infections of vary-
Andre J. Nahmias and William E. Josey . Depart- ing clinical severity are more commonly recog-
ments of Pediatrics, and Gynecology and Obstetrics, Em- nized. Because of incompleteness of information,
ory University School of Medicine, Atlanta, Georgia the total impact of the relation of herpes simplex
253
254 Chapter 11 • Epidemiology of HSV-l and HSV-2
viruses to human cancers, abortions, birth defects, latter part of that century, a further distinction was
and chronic neurological diseases cannot be ascer- made on the basis of cytopathological differences
tained at present. between infections of the pox and herpes groups.
In the early part of the twentieth century, herpes
zoster was differentiated on clinical and epidemiol-
ogical grounds from "herpes febrilis" and "herpes
2. Evolutionary and Historical Background genitalis." This distinction was further supported
by the studies of Gruter and other European work-
Herpes simplex viruses belong to a family of ers who showed that specimens obtained from zos-
DNA viruses which includes more than 60 other ter lesions could not be transmitted to the rabbit
viruses affecting a wide range of species from cornea, in contrast to those obtained from the other
fungi to man.(44) The other human viruses are two herpetic conditions. Around 1920, a German
cytomegalovirus (CMV), varicella-zoster virus physician, Lipschutz, maintained that, although
(VZV), and Epstein-Barr virus (EBV). All of these biologically related, herpes febrilis and herpes gen-
viruses have the capacity to persist in their natural italis are etiologically different; however, this idea
host, either in neural tissues, e.g., HSV and VZV, was not confirmed until recent years.
or in nonneural tissues, e.g., CMV and EBV. The Over the next 40 yr, the experimental host range
high prevalence in primitive societies of antibod- of herpes simplex viruses was widened to include
ies to the human herpesviruses, in contrast to the other laboratory animals, chick embryos, and ulti-
low prevalence of antibodies to other nonpersis- mately cell cultures. The clinical spectrum of HSV
tent viruses,<7l emphasizes the survival advantage infections was augmented to include gingivosto-
conveyed by viral persistence and suggests an matitis, encephalitis, keratitis, Kaposi's varicelli-
early origin for viruses in the herpes family. form eruption, and neonatal disease. It also be-
Many of the vertebrate herpesviruses have very came appreciated that HSV infections could recur
similar clinicoepidemiological patterns, such as in the face of demonstrable levels of serum anti-
venereal transmission and the ability to cause bodies.
encephalitis, keratitis, skin or genital lesions, and In the early 1960s, Schneweis w51 in West Ger-
disseminated neonatal disease. (4]) Despite the many and Plummet 53 ) in England found anti-
presence of common antigens among many of the genic differences among HSV strains. By 1967,
herpesviruses and other common phenotypic Nahmias and Dowdle(3H) had demonstrated that
expression, such as intranuclear inclusiens in the the large majority of genital and newborn infec-
infected cell, genetic similarities have been dem- tions are caused by HSV-2 and that most nongeni-
onstrated with current technology only between tal infections are caused by HSV -1, relating these
HSV-1 and H5V-2.(44) It therefore appears that clinical findings with the usual mode of transmis-
one of these viruses evolved from the other; how- sion of the two virus types. The application of
ever, the origin of the herpes simplex viruses from modern biochemical and immunological technol-
progenitors in lower species remains to be ascer- ogy, together with the broadening clinicopathol-
tained. ogical and epidemiological observations in more
The term herpes (epe7rtv = to creep) has been recent times, has provided new approaches to
used since the earliest epoch of Greek medicine to laboratory diagnosis, prevention, and therapy.(421
include spreading cutaneous lesions of varied
etiology.(3H) The "herpetic eruptions which ap-
pear about the mouth at the crisis of simple
fevers" were first described around A.D. 100 by a 3. Methodology Involved in Epidemiological
Roman physician, Herodotus. About 1600 yr later, Analysis
herpes of the genital tract in both men and women
was first reported by a French physician, Astruc.
3.1. Mortality
By the nineteenth century, the generally accepted
use of the term herpes was restricted to certain Herpes simplex virus infections are not reported
diseases associated with vesicular eruptions; by the in the United States, other than for the few fatal
Chapter 11 • Epidemiology of HSV-l and HSV-2 255
cases of HSV encephalitis (around 20 a year) which tions. This is because inapparent infections in
are reported to the Center for Disease Control. these two sites are common and clinically manifest
Mortality from HSV infection occurs primarily in infections are more easily misdiagnosed. Skin her-
three types of hosts: fetuses and newborns, older petic infections may also be confused clinically
individuals with encephalitis, and those who are with other entities. Infections of other sites, such
compromised by immunological or skin defects or as the central nervous system, cervix, and urethra,
by severe malnutrition. The mortality rate is still as well as cases of eczema herpeticum, require
ill-defined, but several series suggest a minimum laboratory aids for diagnosis.
case fatality rate of 30% in infected newborns(47) 3.2.2. Virological. Three types of virological ap-
and in older individuals with encephalitis.(83) proaches have been employed. One is to detect
infectious virus in clinically suspect herpetic con-
ditions. A second is to demonstrate infectious
3.2. Morbidity virus in clinically inapparent cases. The most re-
An attempt is being made in some European cent has been to detect latent virus in the sensory
countries, such as Great Britain, to report genital ganglia of human cadavers, usually from trige-
herpes, based primarily on clinical findings. Other minal or sacral ganglia.(3,4) Only the more recent
than a recent effort by the Center for Disease studies have provided information on whether
Control to obtain reports of cases of neonatal HSV-1 or HSV-2 was specifically involved, since
herpes occurring in the United States, and the few virus typing has only recently become avail-
cases of HSV encephalitis reported every year to able. (3(;)
this agency, no official health records are avail- 3.2.3. Cytohistopathological. Papanicolaou
able. screening of cervicovaginal smears for cervical
Any estimate of the true extent of HSV-1 and cancer has offered another approach to determine
HSV-2 infections must take into consideration (1) the relative frequency of genital herpes in different
the method of diagnosis, (2) the occurrence of female populations, since cellular changes associ-
inapparent infections, particularly of the mouth ated with herpesviruses can be demonstrated in
and urogenital areas, and (3) the facts that HSV-1 such smears!50l This method is about two-thirds
and HSV-2 can infect the same individual at dif- as sensitive as viral isolation and has been found
ferent times and even concomitantly and that to be highly specific for genital HSV infection. We
HSV -1 and/or HSV -2 infection can be primary or do not believe it possible to differentiate HSV-2
recurrent in the same individual. It is therefore and HSV-1 infections, or to distinguish between
important to keep in mind the following possible primary and recurrent infections by cytological
circumstances in anyone individual within a methods.
study popUlation: (1) no evidence of infection with Histological examination of biopsy or autopsy
either HSV-1 or HSV-2, (2) a primary HSV-1 or specimens may be helpful in cases of neonatal
HSV-2 infection but without recurrences with HSV infection or HSV encephalitis. However, it
either virus, (3) a recurrent infection with one HSV should be appreciated that other viral infections
type only, (4) a recurrent infection with one HSV and some noninfectious conditions may also pro-
type and a first infection with the other type, or (5) duce intranuclear inclusions.
recurrent infections with both HSV-1 and HSV-2.
Information on prevalence rates is derived from
clinical, virological, and cytohistopathological ob- 3.3. Serological Surveys
servations and by serological surveys in various Most serological surveys, until relatively re-
populations in different parts of the world. cently, employed methods which did not differen-
3.2.1. Clinical. Clinical surveys without labora- tiate antibodies to HSV-1 and HSV-2. In addition,
tory support will be accurate to different degrees, complement fixation tests used in some studies are
particularly when the information is obtained ret- not as sensitive as neutralization assays to detect
rospectively. Surveys on the prevalence of cold HSV antibodies!74) In general, neutralizing anti-
sores or herpetic keratitis are likely to be more bodies tend to persist for longer periods than
reliable than those on genital or intraoral infec- complement-fixing antibodies. The serological
tests currently in use for differentiating HSV-l and ability of HSV-l and HSV-2 to grow in certain
HSV -2 antibodies have many technological prob- tissue culture cells or to produce plaques of differ-
lems, due primarily to the presence of common ent size.(36) However, serological typing methods
antigens in the two viruses. ((;6) The difficulty is are more finite than these biological assays, which
much less with primary HSV -1 or HSV -2 infec- could yield erroneous virus typing results, particu-
tions than it is in case of individuals who have larly if the virus has been passaged many times in
been infected with both virus types. Even mi- the laboratory.
croadapted serological tests to differentiate HSV HSV can also be demonstrated in vesicular fluid,
antibodies are either too cumbersome or too non- biopsy, or autopsy specimens by the use of elec-
specific at present for the ready performance of tron microscopic techniques, which would reveal
very large serological surveys. The detection of enveloped or nonenveloped virus particles. The
HSV-2 antibodies in children between the ages of morphological appearance of HSV by this tech-
6 months and 10 yr can be employed to provide nique cannot be distinguished from that of other
evidence of a clinically undiagnosed HSV-2 peri- herpesviruses, such as cytomegalovirus or vari-
natally acquired infection. The presence of HSV cella-zoster virus. The virus can be distinguished
antibodies in the IgM serum fraction of infants as HSV by the use of HSV antibodies labeled
below 6 months of age has recently been used for specifically with ferritin or horseradish peroxi-
this purpose.(471 dase.
More recently, it has been possible to demon-
strate HSV in sensory ganglia obtained from hu-
3.4. Laboratory Diagnosis man cadavers. (3,4) Two methods have usually
3.4.1. Virological Methods. Clinical specimens been employed. The first consists of placing the
for virus isolation should be processed as rapidly ganglion explants in culture and observing cyto-
as possible or frozen at -7CJ'C until processed. It is pathic effect in fibroblastic cells growing from
better to keep the specimen for a few hours at 4°C supporting cells or after supernates of the ganglion
icebox temperature than in the -15"C freezing cultures are transferred to susceptible tissue cul-
compartment. The recent development of a trans- ture cells. Another method is to cocultivate the
port medium (Leibovitz-Emory) has facilitated the ganglion cells with susceptible cells. With either
shipment of clinical specimens, since the swab method, infectious virus is detectable no earlier
with which the specimen is obtained, when placed than 8 days and as long as 40 days after incubation
in this medium, can be stored and shipped at of the ganglion cultures.
ambient temperature. (39) 3.4.2. Morphological Aids. The intranuclear in-
Virus can be isolated readily in a number of clusions and multinucleated giant cells that are
tissue culture systems, and an almost pathogno- seen in Papanicolaou-stained smears of cells, fixed
monic cytopathic effect can be detected as rapidly in 90% alcohol and obtained by scraping the base
as in a bacterial culture (usually within 1-3 days). of herpetic vesicles or ulcers of the skin or mouth
Specific identification of HSV and its antigenic or by scraping the conjuctiva or cornea, are charac-
types can then be obtained by neutralization or teristic of herpesviruses, including HSV and
immunofluorescence techniques. (45) The latter VZV.(SO) The intranuclear inclusions are less read-
technique can be used for rapid identification and ily apparent in Wright- or Giemsa-stained smears.
direct typing of HSV in clinical specimens. Immu- In most instances, there is little difficulty in differ-
nofluorescence tests are particularly helpful for the entiating clinically between HSV and VZV infec-
diagnosis of HSV in brain biopsies of patients tion. The inclusions in urinary cells may make it
with encephalitis and are currently under study for difficult, however, to distinguish HSV from CMV
the detection of HSV antigens in CSF leukocytes. infection. Papanicolaou smears of the cervix are
Embryonated eggs and labora!:ory animals such particUlarly helpful in detecting subclinical her-
as mice or rabbits can be used for initial isolation petic cervicitis in women. Biopsy or autopsy mate-
of HSV; however, these assays are more laborious rial should be preferably fixed in Bouin's fixative
than tissue culture methods. HSV typing can be rather than formalin in order to enhance the dem-
done also in embryonated eggs (HSV-2 produces onstration of the characteristic inclusions and
larger pocks than HCV-l) or by differences in the giant cells.
3.4.3. Serological Tests and Assays of Cell-Me- in recent reviews/42.48.621 which include those as-
diated Immunity. Many serological assays can be pects related to the clinicoepidemiological behav-
used to demonstrate HSV antibodies, including ior of the viruses and host responses..
neutralization, complement fixation, passive hem- Herpes simplex viruses consist of four major
agglutination, complement-mediated cytolytic, components-a centrally located core surrounded
and indirect immunofluorescence tests. The HSV by three concentric structures: the capsid, the
antibody type (types 1 and/or 2) can be determined tegument, and the envelope. The core contains
by more specialized serological procedures, such DNA coiled around proteins arranged in the form
as microneutralization, kinetic neutralization, of a barbell. The icosahedral capsid contains 162
multiplicity analysis, and inhibition passive hem- capsomeres and measures around 100 nm. Be-
agglutination tests.(541 A primary infection is sug- tween the capsid and the envelope is the tegu-
gested by the finding of a fourfold or greater rise ment, composed of fibrillous material. The enve-
in titer between the acute and the convalescent lope, derived from nuclear and occasionally other
serum, obtained 1 wk or more later. Since such a cell membranes, confers on the complete virus
titer rise may be observed with recurrent infec- particle a diameter of 15(}-200 nm. The lipid com-
tions, particularly in individuals with certain can- position of the envelope makes the virus particu-
cers or those receiving certain cytotoxic drugs, the larly susceptible to ether and other lipid solvents.
distinction between primary and recurrent infec- The proteins on the envelope of the virus are
tion is occasionally difficult. very similar to those found on the membranes of
Indirect immunofluorescence and radioimmu- infected cells, so that immune mechanisms could
nological methods have been developed recently to operate not only on the virus itself but also on cells
detect HSV antibodies in the IgM, IgG, IgA classes infected by the virus. Antibodies alone, for in-
of immunoglobulins.(42,471 Thus IgM HSV anti- stance, are incapable of inhibiting cell-to-cell
bodies can be used to diagnose neonatal herpes in spread of the virus; together with complement or
patients with no characteristic findings in the eye, with mononuclear cells (K cells), antibodies can
throat, or skin. Such IgM antibodies usually ap- lyse HSV -infected cells in vitro. There are at least
pear within 1-4 wk after birth and persist for at 49 proteins specified by the virus, of which about
least 6 months. The detection of IgM or IgA 33 are found in the virion. Variations of the
antibodies in the serum of older individuals un- proteins within strains of either type of HSV may
fortunately cannot be used to differentiate a pri- influence immune responses and serodiagnosis.
mary from a recurrent HSV infection, since such The DNAs of HSV-1 and HSV-2 are linear, dou-
antibodies can occasionally be found when infec- ble-stranded molecules, 99 ± 5 million daltons in
tion is recurrent. molecular weight. About half of the HSV-1 and
In vitro assays for cell-mediated immunity to HSV-2 DNA sequences are homologous. In vitro, it
HSV are still in the research stage but may be is possible to infect cells with "naked" DNA free
potentially useful in diagnosis or in the demon- of virus proteins and to demonstrate defective
stration of individuals more prone to HSV recur- DNA in some strains of HSV, of possible relevance
rences.(52,58,76,82) Positive skin tests of delayed hy- to the oncogenic potential of HSV. Recent studies
persensitivity can be elicited with inactivated HSV on temperature-sensitive mutants and genetic re-
preparations that correlate well with the presence combination between HSV-1 and HSV-2 are allow-
of serum neutralization antibodies. (84) Such HSV ing the development of genetic maps and the
skin test materials are not currently available definition of genes responsible for specific viral
clinically. functions.
The different lability of HSV-1 and HSV-2 to
high temperature exposure (HSV -2 is more labile
at 39"C than HSV-1) and their different suscepti-
4. Biological Characteristics of HSV-l and bility to certain antiviral agents may potentially
HSV-2 affect pathogenesis and therapy. For instance, fe-
ver is well appreciated to reactivate HSV-1 recurr-
Detailed information on the basic structure and ences but may not be as effective in reactivating
characteristics of HSV-1 and HSV-2 can be found HSV-2. The viruses are also labile to low pH, so
258 Chapterll • Epidemiology of HSV-l and HSV-2
that they are infrequently recovered from the gas- ing the overall infection rate, as determined by
trointestinal tract. Although HSV may survive for various clinical or laboratory surveys, and those
some time in skin scabs from patients with eczema rela ted to particular clinical entities.
herpeticum, it is unlikely that either HSV-1 or
HSV-2 would remain infectious for any duration
outside the human body. 5.1. General Epidemiology
HSV-1 and HSV-2 have a wide in vitro and in The major epidemiological determinants of HSV
vivo host spectrum, being capable of infecting infections are age, socioeconomic level, and geo-
large numbers of cell cultures of human or animal graphic area. In case of HSV-2 infections, the
origin and a great number of experimental ani- degree of sexual exposure is particular important.
mals, from mice to monkeys. Variability in the in The interdependency of these variables causes
vitro or in vivo behavior of the two virus types, some overlap in the following discussion.
however, can be demonstrated in some of these 5.1.1. Incidence and Prevalence. A high preval-
systems. In humans, either HSV type appears to ence rate of HSV infection has been found in
be capable of infecting any body site, if it can be virological or serological studies of healthy indi-
transmitted to that site by external or internal viduals. In 1953, Buddingh et al. (8) reported on
spread. In the case of neurological involvement in the recovery of HSV from the mouth of 20% of
older individuals, it appears, however, that the asymptomatic children 7 months to 2 yr of age, 9%
increased chance of meningitis with HSV-2 and of of children 3-14 yr of age, and 2.4% of adolescents
encephalitis with HSV-1 may be related to differ- and adults. This high isolation rate has been
ences in the mode of viral spread-HSV-2 via the questioned, because the technique used at that
blood to the meninges and HSV -1 neurogenically time for identifying HSV was chorioallantoic
to the brain. membrane inoculation, which might yield non-
As noted earlier, all herpesviruses have the specific lesions.(72) By use of tissue culture meth-
capacity to persist throughout the host's lifetime, ods, the isolation rate in asymptomatic children
providing this group of viruses a great survival has been found by later workers to be around
advantage. In the case of HSV, it has been appre- 1 %(21.27) and that in adults to be between 0.75
ciated that recrudescences occur in individuals and 5% .(18.28.72) In studies of adults with serum
with circulating HSV antibodies. Although the HSV antibodies, serial samplings indicated that
possibility of low-level virus multiplication around HSV could be recovered from oral secretions in up
the site of involvement cannot be completely ruled to 50% in the absence of clinicallesions,03.19) In a
out as a possible mechanism for viral persistence, children's home, 32% of the children with serum
the best evidence at present favors latency of the HSV antibodies were found to shed oral virus
virus in a noninfectious form in the sensory gan- periodically, and most were asymptomatic,oll
glia. This conclusion is supported by a great Virological studies of HSV-2 in pregnant women
amount of experimental data in mice, rabbits, and of lower socioeconomic status have revealed geni-
humans. Although infectious virus cannot be tal viral excretion rates of 1:75 to 1:250.(24) Rates of
demonstrated in sensory ganglia, with the use of genital isolation of HSV-2 of as high as 12% have
special cultivation methods of the ganglia (noted been recorded in prostitutes.(14) Intermittent
in Section 3.4) infectious virus can be reactivated asymptomatic genital excretion of HSV-2 has been
within several days or weeks. The various types of observed in some women.(9) The duration of
HSV-cell interactions (produdive infection, la- virus shedding and the frequency of virus isola-
tency, and transformation) are further detailed in tion from the cervix varied from individual to
Chapter 23. individual. In asymptomatic males attending a VA
hospital, HSV was isolated from the urethra, pros-
tate, or epididymis of 15% of the ~tudy groupYOl
5. Descriptive Epidemiology These high rates of asymptomatic urogenital HSV
infections have yet to be confirmed.
The epidemiological characteristics of herpes Preliminary observations on approximately 80
simplex viruses can be divided into those reflect- trigeminal ganglia obtained from cadavers of
adults have revealed 55% to contain latent HSV- pediatric wards housing 37 children below 2 yr of
V 3 ) Close to 20% of 21 sacral ganglia were found age, 17 of the infants developed, over a I-month
to contain latent HSV-2.(4) These rates are only period, manifest forms of HSV infections. All of
slightly less than those expected from serological the affected infants had gingivostomatitis, but in
studies in similar population groups. three cases this was also associated with herpetic
Antibody surveys have also established a high keratitis or skin involvement.
prevalence of infection with HSV. While early Outbreaks of herpetic stomatitis have been de-
surveys did not differentiate between HSV-l and scribed in orphanage nurseries and children's
HSV-2 antibodies, they are consistent with HSV homes. Within a I-month period, the attack rate of
antibody prevalence rates in adult populations of the clinically apparent primary infections was
50% to close to 100%, depending on socioeco- around 80%.(20,25) The attack rate in another insti-
nomic status. Later differential antibody surveys tution for young infants over an 11-month period
confirmed these observations and in addition in- was found to be 56%.(1) Although these studies
dicated prevalence rates of 10--70% for HSV-2, would imply that HSV spreads very readily in
depending on sexual activity and socioeconomic closed populations, another report demonstrated
level. (38.59-6]) that only 10% of susceptible children developed
The incidence of HSV (presumably HSV-l) in- HSV infections over a 6-yr period. (11)
fections has been measured largely in childrens' Several clusters of an unusual form of cutaneous
institutions through repeated bleedings and/or HSV ("herpes gladiatorum") have also been re-
viral isolations over time. In one 6-yr study in a ported. (55,68,81) Person-to-person spread from the
children's home, Cesario et al. (1]) found that, of close body contact associated with wrestling has
the 70 initially seronegative children, eight or been observed repeatedly. Underlying skin condi-
11.4% experienced a primary infection while in tions or mat bums increase the susceptibility of
the home, of whom six had an associated illness. the wrestlers to this type of skin infection.
In an earlier Australian study in a home for chil- 5.1.3. Geographic Distribution. HSV infections
dren, all under 3 yr of age, Anderson and Hamil- are worldwide, as attested by the finding of
ton(l) found that 29 of 43 seronegative children antibodies to both HSV types in sera from all over
(67.4%) developed HSV antibodies over a l-yr the world, including remote islands and isolated
period, of whom 20 had an associated illness. primitive populations. For example, studies of
5.1.2. Epidemic Behavior. Epidemics of diseases remote and primitive Indian tribes in Brazil have
associated with HSV have not been described. demonstrated that sera from nearly all of the Tiriyo
This is in large part because HSV infections, tribe have HSV neutralizing antibodies; this is in
unlike varicella, are very often asymptomatic. contrast to the low incidence or even absence of
However, clusters of cases in various environ- antibodies to respiratory-transmitted infections,
ments have been reported. Scott(67) and Juretic(25) such as influenza and measles. m This observation
have reviewed such clusters in families, in hospi- was extended in a subsequent study of nine tribes
tals, and in various closed populations. At least 17 on the periphery of the Amazon Basin in which
families have been described in which two or the proportion of sera positive for HSV antibodies
more family members were found to be infected was higher than in New Haven, Connecticut, and
over a short period of time. The source of the other urban areas of the United States for each age
infection was ascribed to adults with recurrent group.
labial infections or children with primary oral Surveys for HSV-2 antibodies in healthy
infections. women, made in pursuit of a relationship between
Hospital outbreaks of eczema herpeticum or of this virus and cervical cancer, have revealed wide
gingivostomatitis have been described in England geographic and socioeconomic variations. (61)The
and in Yugoslavia. (27,56) In the contact outbreak of prevalence of HSV-2 antibodies in sera from
eczema herpeticum, four patients developed the women over 40 yr old has ranged from 9% in one
infection in succession within 8 days. In addition, U.S. community to 77% in Uganda.
some of the nurses caring for the patients devel- 5.1.4. Temporal Distribution. One report indi-
oped herpetic lesions on their hands. In crowded cates that herpetic skin infections are more com-
mon in the summertime.<'5) Otherwise, no clear- oping genital herpes. The most striking observa-
cut yearly or seasonal pattern of infection has been tions are the high prevalence rates of HSV-2 anti-
demonstrated for either HSV-1 or HSV-2. How- bodies of close to 70% in prostitutes(14) and the
ever, such variations in infection rate might occur low frequency of 3% in chaste women.(38)
and go unrecognized because of the need for 5.1.9. Occurrence in Different Settings. HSV-1
laboratory-based studies to identify the infection. is transmitted by personal contact, so that settings
5.1.5. Age. Herpetic infections, most often due with close and prolonged exposure such as fami-
to HSV-2, occur in newborns as a consequence lies, nurseries, and orphanages can result in a
usually of maternal genital infection.(4H,47) There- higher rate of infection. Reactivation of HSV-1
after, during childhood, primary HSV-1 infections infections is seen on hospital wards in patients
are most common and are reflected clinically as having a variety of febrile illnesses or various
herpetic gingivostomatitis, and less often as infec- cancers or being treated with immunosuppres-
tions of the over skin, and central nervous system. sants, and on ski slopes after ultraviolet exposure.
Recurren t HSV -1 infections appear to be less fre- HSV-2 infections occur most commonly in set-
quent in children than in older individuals. tings associated with sexual activity and sexual
HSV -2 infections and their clinical manifesta- promiscuity. It is not uncommon to find HSV-2
tions occur mainly after 14 yr of age, when vener- infections in association with other venereal di-
eal exposure becomes a mechanism of spread. Two seases. (24,431
seroepidemiological studies, conducted in lower 5.1.10. Socioeconomic. 'The higher frequency of
socioeconomic populations, (38,59) demonstrated HSV infections in lower socioeconomic groups
essentially similar age patterns in the distribution was well established in earlier antibody sur-
of HSV-1 and HSV-2 antibodies. There was a veys.(8,2(;.74) While these did not differentiate type
sharp rise of HSV -1 antibodies between the ages 1 and type 2 antibodies, the conclusions seem
of 1 and 5 yr, at which time approximately half the valid. Similar findings for HSV -1 have been seen
children already demonstrated such antibodies. in more recent work; for HSV-2 the association
The frequency of HSV-1 antibodies thereafter rose between socioeconomic level and sexual activity
gradually to reach around 90% by adulthood. On has made interpretation more difficult, but the
the other hand, HSV-2 antibodies were not de- evidence is in the same direction.(38,(l0i Among
tected until around 14 yr of age and peaked to 20- upper social classes, HSV -2 antibodies are ac-
35% by 35 yr of age. By use of virological or quired later, and up to 50% of young adults may
cytological methods, the peak age for detecting lack antibodies to either HSV type; the pattern is
genital HSV infections has been found to be be- similar to that observed with EBV antibodies in
tween 20 and 29 yr of age.(40,50,51) different socioeconomic groups (see Chapter 9).
5.1.6. Sex. No sex difference in susceptibility to 5.1.11. Other Factors. Some but not all studies
HSV infections has been demonstrated, if expo- indicate that certain forms of immunosuppression
sure patterns are kept in mind. increase the reactivation of HSV infections. (2,30,33)
5.1.7. Race. A higher frequency of HSV-1 and However, immunosuppression clearly in~reases
HSV-2 antibodies has been found in black popula- the severity and chronicity of the infection. Severe
tions than in white populations.(5,60,74) This most malnutrition does not appear to alter susceptibil-
likely reflects socioeconomic levels and sexual ac- ity, instead increasing markedly the severity of a
tivities rather than any differences in susceptibil- herpetic infection.(6) Recent immunogenetic stud-
ity or host response. ies point to a higher frequency of HL-A1 antigens
5.1.8. Occupation. An occupational risk has in individuals with frequent recurrences than in
been noted in three groups. The first group the general population.«l4)
includes medical or dental personnel, who are at
higher risk of developing herpetic paronychia. (63)
5.2. Epidemiological Aspects of Specific Clinical
A second group is comprised of college wrestlers,
Entities
who have been noted in several studies to have a
propensity to acquire "herpes gladiatorum," a 5.2.1. Genital Infections. Surveys of genital her-
special form of skin herpes.(55,68,81l A third group petic infections have been conducted most com-
includes prostitutes, who are at high risk of devel- monly in venereal disease clinics. As far back as
1880, the rates were found to be 7% in women and oral herpetic infections can occur in adolescence
1 % in men attending a VD clinic in Hamburg; and adulthood and that the virus has been associ-
approximately similar rates have been observed ated with about 10% of respiratory illnesses in
recently in VD clinics in the United States, Eng- student populations. (W.18)
land, and Sweden.(24.43) These observations would 5.2.3. Labial Herpes. A positive history of re-
not support the recent popular concept that vener- current herpes labialis was recorded in 38% of
eal herpes is on the rise and might be explained by 1800 students attending professional schools at the
the increasing awareness and recognition of this University of Pennsylvania.(71) Among the stu-
entity. However, it is still possible that a true dents susceptible to recurrences, new lesions oc-
increase is occurring in certain segments of the curred once a month in 5%, at intervals of 2-11
general population who have become more prom- months in 34%, and once a year or less often in
iscuous in recent years. Of interest has been the 61 %. Recurrent herpes labialis was also noted to
finding that the ratio of genital herpes to gonor- occur 3 times as frequently in a group of febrile
rhea in these clinics was one case of herpes to five patients as in a group of nonfebrile controlsY9)
to ten of gonorrhea.(43) Such information might This study corroborated the older findings that up
permit a rough estimate of the number of cases of to a half of individuals treated with fever therapy
genital herpes in the United States. Thus, with experienced reactivation of a herpetic infection,
about 2 million cases of gonorrhea a year, one mostly on the lips. The Perinatal Study of the
might expect around 200,000 cases of genital National Institutes of Health found 1 % of pregnant
herpes. women to have labial herpes at some time during
By use of cytological methods for the detection pregnancy. Another study in the United States
of genital HSV infections, rates have varied from indicates that about 1 % of nursery personnel had
0.03% to 3.3%, depending on the population stud- recurrent labial herpes within any 1 wk.<l7)
ied. (50) The highest rates were in women attend- 5.2.4. Herpetic Keratitis. About 5% of individu-
ing VD clinics (around 3%). Comparative studies als attending an ophthalmology clinic were noted
by the same group of workers revealed the rate in to have herpetic ocular disease.(2:l) Close to half of
indigent women to be 0.31% and in private pa- the patients would be expected to have at least one
tients to be 0.2%.(511 In two different hospitals for recurrence of herpetic keratitis within a 2-yr pe-
indigent patients, the rates were 3 times higher in riod.
pregnant women than in nonpregnant 5.2.5. Herpes of the Skin. The prevalence rate of
women. (49.51) The median age for the detection of herpetic skin infections was found to be around
673 cases of genital herpes in our hospital was 1 % of 7495 persons over 7 yr of age in the county
found to be 22 yr. of Skaraborg in Sweden.(22) This investigation,
5.2.2. Oral Infections. The most thorough study performed during a mass X-ray survey of the
of primary herpetic oral infection was performed lungs, showed little variation in rates according to
by Juretic in Yugoslavia.(25) This worker found age or sex. Another Swedish study found that 2%
that, over a 10-yr period, about 13% of 18,730 of men and 1.5% of women attending a dermatol-
children attending outpatient clinics had clinical ogy clinic in Gothenburg over a 6-yr period had
evidence of oral herpes. No cases were recorded in clinical evidence of HSV skin infectionY51 Of
the first 6 months of life. The frequency distribu- interest in that study was the observation of sea-
tion of the total number of cases over the next age sonal variations, in that the highest rates were
periods was as follows: 6-12 months, 12%; 1-2 yr, observed during summer months.
35%; 2-3 yr, 23%; 4--5 yr, 11%; 5-6 yr, 8%. 5.2.6. Respiratory Infections. In a 6-yr study
Thereafter, cases continued to be observed at low involving 293 students attending a health clinic,
frequency. No significant sex differences or sea- 142 (11.5%) with respiratory illnesses were found
sonal variations were observed. These age distri- with oral HSV, while only 11 (1.1%) of asympto-
butions correspond well with those noted in South matic students shed virusY81 Most of the respira-
Africa in the severely malnourished children with tory illnesses were associated with primary HSV
fatal disseminated HSV infections whose initial infections. This study provided strong support for
site of infection was intraoral herpes.<';) It should the much-debated issue of the role of HSV in
also be reemphasized that symptomatic primary causing respiratory illnesses. 03 ,w,28.31,32.72)
5.2.7. Neurological Infections. According to period for HSV encephalitis has been more diffi-
limited reports from the Center for Disease Con- cult to define, but appears to be longer. The
trol, HSV encephalitis is associated with a higher duration of lesions and/or infectious virus is us-
case-fatality rate than encephalitis caused by other ually longer with a primary infection, particularly
viruses. Rough estimates of at least 1000 cases during pregnancy, lasting in such cases for as long
occurring a year in the United States have been as 3 months.(24) Virus does not usually persist
made.(S3) No estimate is available of the incidence over 2 wk in case of recurrent infections.
of the benign meningitis most often associated The major source of virus to the newborn is the
with HSV-2 genital infections. mother's HSV-2 (and occasionally HSV-l) genital
5.2.8. Neonatal Herpes. In a recent review of infection around the time of delivery. (46,47) The
neonatal herpetic infections,(47) we noted that the virus is acquired by an ascending infection, if
number of cases observed over the past 4 yr was membranes are ruptured, or on passage of the
equal to that reported in the literature over the infant through the infected birth canal. The acqui-
previous 36 yr. This may reflect increased aware- sition of virus by the newborn from a nonmaternal
ness of this entity, which has been found to occur source is poorly documented.
in over 25 countries in the world. An alternative Detailed information on the mode of spread of
explanation is the coincidence of this increase with many types of HSV -1 nongenital infections is not
that possibly occurring with genital HSV infec- available. Cases have been observed in which
tions. On the basis of the number of cases ob- virus spread occurred via kissing or from body
served in two hospitals for indigent patients, an contact associated with wrestling.(55,68,SIl Spread
estimate of the minimum number of cases of by saliva is best exemplified by the cases of
neonatal herpes in the United States is 120 per herpetic paronychia in medical or dental personnel
year. (46) who handle the infected oral cavity of patients or
contaminated tracheal catheters. (63) Spread via air
droplets of via infected skin squames has not been
well documented. HSV-l appears to have varying
6. Mechanisms and Routes of Transmission degrees of communicability, as suggested by sur-
veys in closed populations.o,1l,20,25) HSV-l has
There are not known animal vectors for the been demonstrated on occasion to be transmitted
transmission of herpes simplex viruses. Although by oral-genital contact or by autoinoculation of
a few cases of HSV-l or HSV-2Iaboratory-acquired oral virus to the genitals.
infections have occurred, the major mode of The venereal transmission of genital HSV infec-
spread appears to be by close personal contact. tion was postulated during the nineteenth and
The source of virus is an individual with a sub- early twentieth centuries. Thereafter, despite a few
clinical or clinically inapparent primary or recur- case reports substantiating such transmission, the
rent infection. It is also possible for an individual venereal route of spread was not accepted gener-
to autoinfect himself. Exogenous reinfection in ally, most likely as a result of the lack of apprecia-
humans with the same virus type has been diffi- tion of subclinical genital infections. The advent of
cult to document. However, this possibility is HSV type differentiation has provided more con-
supported by the ability to infect the skin of an clusive evidence of venereal transmission, The risk
individual with vesicular fluid obtained from of developing genital HSV in female contacts of
some other body site, and to reinfect at the same males with penile herpes is around 60-80%,<4(),(;(1l
site various experimental animals. (36,42) The recent although the risk has not been defined in terms of
recognition of antigenic and protein differences single exposure. The risk of males developing
among strains within HSV-l and HSV_2«;2,69) genital HSV from contact with infected female
should provide markers to test this mechanism in partners has not been systematically studied, al-
humans. though many such cases have been observed. It is
The incu1;>ation period for either primary HSV-l still unclear whether males are infectious to their
or HSV-2 infection ranges from 2 to 20 days, with sexual contacts in between episodes of clinically
an average of around 6 days. The incubation evident penile infections. Homosexual· transmis-
sion between males has been reported, resulting damage. Thus the clinical spectrum may differ,
in HSV -2 perianal lesions. (24) Similar transmis- depending on which organ sites are involved and
sion in female homosexuals, although likely to the amount of cellular damage in these organs.
occur, has not yet been described. The transmis- In the noncompromised host, recovery of virus
sion of HSV-2 by oral-genital contact, causing from the blood or peripheral leukocytes has been
intraoral HSV-2 infections, has also been ob- infrequent. (12) It is therefore not clear at present
served. whether virus affects areas other than the local site
HSV-2 infections of genital sites may occasion- and regional lymph nodes. However, the recovery
ally involve neighboring areas, such as the peri- of HSV -2 from peripheral blood leukocytes and
neum, thighs, or buttocks either by autoinoccula- from the cerebrospinal fluid of patients with men-
tion or by contact with infected partners. ingitis suggests that blood dissemination may oc-
Recurrences in these sites can occur independent cur more commonly than has been appreciated in
of, or together with, recurrences at genital sites. In the past.021 Several human and experimental ani-
addition, HSV-2 infections of the hands have been mal observations suggest that HSV may spread
acquired by medical personnel from contact with neurogenically when encephalitis occurs in other-
infected patients. wise normal individuals. Viral spread from super-
ficial areas of skin to deeper layers may be pre-
vented by the meshwork of connective tissue
fibers, because of size factors, and by the possible
7. Pathogenesis and Immunity effects of the negative electrical charge on the virus
of acid mucopolysaccharides in connective tis-
Primary HSV-1 or HSV-2 infections are often suesY51 The pathogenesis of the deeper ocular
clinically inapparent in both children and older manifestations associated with HSV has been at-
individuals, partly because the more common pri- tributed either to direct viral involvement or to a
mary sites of infection, such as the mouth or hypersensitivity reactionYSl
cervix, are not readily visible. Primary infections, The pathogenesis of the disseminated forms of
when clinically manifest, tend to be more severe neonatal herpes, occurring in infants without tran-
(fever, more extensive lesions of longer duration, splacental antibodies, appears to be similar to that
constitutional signs, and local adenopathy) than in of primary herpes in the severely malnourished
individuals with prior antibodies to either or both child, although the brain is involved much more
HSV-1 or HSV-2. often in the newborn.(4f;,471 Direct neurogenic
Primary HSV infections are particularly severe spread to the brain, and possibly to the retina,
in certain types of patients, including severely appears to occur also in newborns.
malnourished children and those with associated In individuals with a primary HSV infection,
measles, patients with severe bums or chronic humoral antibodies usually can be detected within
skin disorders such as eczema, individuals receiv- 1-3 weeks by a variety of neutralization, com-
ing immunosuppressive therapy, patients with plement' fixation, complement-mediated cytolysis,
cancers, particularly of the lymphohematopoietic antibody-mediated mononuclear cell cytolysis, or
organs, and children with certain forms of im- passive hemagglutination tests. With special serol-
mune deficiency, such as the Wiskott-Aldrich syn- ogical methods, it is also possible to demonstrate
dromeyo,33.421 In stich individuals, as in the new- an early rise of IgM antibodies to HSV, followed
born, the virus may disseminate to internal by IgA and IgG antibodies.(18,421 In the newborn,
organs. The pathogenesis of primary HSV infec- IgM antibodies to HSV can be detected within 1-4
tion has been defined most thorough!y in severely wk after birth and are present for 6 or more
malnourished childrenyn In such cases, as a re- months.(471
sult of the initial replication of virus at the portal In addition to the humoral responses, various
of entry, there is a primary viremia resulting in assays of cellular immunity in vitro have demon-
involvement of certain susceptible organ sites. A strated a cell-mediated response within 1-2 wk
secondary viremia then ensues with further dis- after onset of infection in both man and experi-
semination to visceral organs and more extensive mental animals.(4S,7(;) Individuals with serum neu-
Table 1. Clinical Spectrum of Infections Caused by Herpes Simplex Viruses 1 and 2 in Newborns and
Older Persons and the Type Isolated from Different Sites and Clinical Conditionsu
Number of individuals with HSV type
Type 1 Type 2 Total
I. Usually mild to moderately severe (persons over 1 month of age)

A. Urogenital infections
1. Females (cervix, vulva, vagina, urethra) 272 (5 C ) 306
2. Males (penis, urethra) 187 (l d ) 193
B. Nongenital infections
1. Gingivostomatitis or asymptomatic (mouth) 131 3 (Ie) 134
2. Herpes labialis (lips) 84 0 84
3. Keratitis and/or conjunctivitis (cornea and/or conjunctiva) 28 1 29
4. Dermatitis
a. Skin above waist 84 (Ie) 3 87
b. Skin below waist 4 W,l e) 72 W,lf) 76
c. Hands or arms 13 (If) 11 (2f ,l e) 24
C. Latent infections (trigeminal or thoracic ganglia) 21 (F) 0 21
(sacral ganglia) o 5 5
II. Usually severe to fatal (persons over 1 month of age)
A. Meningoencephalitis (brain, spinal cord, CSF) 86 2 88
B. Multiple sclerosis (brain) o 1 1
C. Eczema herpeticum (skin, lungs) 11 0 11
D. Generalized disease (visceral organs) 2 Ih 3
III. Newborns-localized or generalized infection (skin, eyes, brain, 36 74 110
CSF, visceral organs)
Total 540 632 1172
a Typing is done by microneutralization or direct immunofluorescence tests.

b Simultaneous isolation of similar HSV type from mouth.
, Simultaneous isolation of type 2 HSV from cervix or vulva and type 1 HSV from lip or mouth.
d Simultaneous isolation of type 2 HSV from penile lesion and type 1 HSV from eye.
e Simultaneous isolation of same HSV type from genitals.
f Laboratory- or hospital-acquired infection.
• Simultaneous isolation of type 2 HSV from sacral ganglia.
h Isolated also from brain.
tralization antibodies will usually also demonstrate adult mice.(34,77J Since any virus circulating in the
a delayed hypersensitivity skin test response to blood would be affected greatly by the ability of
HSVantigens.(B4J reticuloendothelial cells in the liver or other organs
It is yet unclear as to which of these humoral or to inactivate the virus or allow its multiplication
cellular factors operate in curtailing the virus in a and further spread, it is likely that macrophages
primary infection or in a newborn without tran- playa central role in neonatal HSV infection and
splacental antibodies. In experimental animals, it probably also in primary HSV infections of older
has been demonstrated that a depression of either individuals.
T-lymphocytes or macrophages leads to increased Although HSV-l or HSV-2 infections in individ-
mortality.m.B5) It has been noted that HSV multi- uals with prior HSV-l and/or HSV-2 infections
plies in phytohemagglutinin-stimulated lympho- tend to be less severe clinically than primary
cytes and that the virus also multiplies better in infections, in compromised hosts such infections
the macrophages of newborn mice than in those of tend to be more extensive and chronic.(30,33J HSV
encephalitis, which was formerly believed to occur type is most likely to occur in anyone body site,
only in association with a primary infection, has the other HSV type can occasionally infect similar
now been documented in individuals with prior sites.
HSV infection. (2 ) Similarly, although newborns
with transplacental HSV antibodies were origi-
8.1. Mouth and Respiratory and Gastrointestinal
nally believed to be protected from acquiring HSV
Tracts
infections, several cases of neonatal herpetic dis-
ease, including fatalities, have been recorded in The mouth is the most common site of primary
such infants.(46) HSV-1 infection. Children are most often affected,
In recurrent HSV infections, all individuals ap- but oral infections may also occur in older individ-
pear to possess neutralizing antibodies in varying uals. The spectrum of oral infections ranges in the
titers, and usually these do not rise after a recurr- noncompromised individuals from inapparent in-
ence. It appears, however, that clinically apparent fection to severe gingivostomatitis with extensive
or inapparent recurrences might be necessary to ulcerations of the mouth, tongue, and gums, cervi-
maintain the neutralizing titer to constant levels in cal adenopathy, and fever, sometimes necessitat-
the serum. There are also individuals with fre- ing hospitalization for fluid and electrolyte resto-
quent herpetic recurrences who possess persistent ration. The patient may occasionally infect himself
levels of IgG, IgA, and IgM antibodies to HSV in at other body sites, such as the face, fingers, or
their serum and who may demonstrate a signifi- genitals. In the newborn or compromised host,
cant boost in titers to antibodies in the various and infrequently in the apparently normal indi-
classes after a recurrence.(42) vidual, oral infection may extend to involve the
Individuals with recurrences also demonstrate esophagus or lungs, and may disseminate to in-
positive responses in a variety of in vitro cell- volve the liver and other visceral organs or the
mediated assays. (48.58,82) Preliminary data suggest brain.
that depression in certain lymphokines, e.g., ma- Because of the common presence of HSV in the
crophage inhibitory factor, interferon, or leukocyte mouth of asymptomatic individuals, it has been
inhibitory factor, may correlate with increased difficult to ascertain the etiological role of HSV in
predilection to HSV recurrences. (52,58,82) upper respiratory infections, such as rhinitis,
In vitro studies indicate that both nonspecific pharyngotonsillitis, and laryngitis, and the role of
and specific mechanisms are involved in stopping the virus as a cause of recurrent lesions inside the
the cell-to-cell spread of HSV, since neutralizing mouth. However, recent data suggest strongly that
antibodies alone cannot prevent this type of viral HSV is etiologically related to these clinical mani-
spread.(29) In addition, in vitro observations indi- festationsys,79}
cate that neutralizing antibodies are unable to The large majority of cases of oral herpetic
inactivate large amounts of extracellular virus and infections are caused by HSV-l. However, HSV-2
may operate together with complement or with has been found to cause infections, with or with-
non immune mononuclear cells (K cells) in lysing out clinically manifest lesions, as a consequence of
HSV -infected cells. (73.75) fellatio (Table 1).
8.2. Lips
8. Patterns of Host Response Labial herpes is the most common form of
recrudescence with HSV-1. The lesions, which are
Table 1 presents our most recent findings on single or multiple, may involve the mucocuta-
close to 1200 individuals in whom HSV-1 and/or neous junction, at or around the same site with
HSV-2 has been isolated from a variety of body every recurrence. Occasionally, the herpetic le-
sites. The occurrence in some individuals of si- sions may affect both sides and may be accompan-
multaneous infections of different sites by HSV-1 ied by involvement of other body sites. The lips
and HSV-2 can be noted from the table. It is may also be infrequently involved during a pri-
important to emphasize that, although one HSV mary infection. Extensive local spread or persist-
ence of the lesions for long periods may occur in waist are caused by HSV-1, reflecting the different
compromised individuals. modes of acquisition of the two virus types. Her-
petic lesions of the hand or fingers can result from
infection with either virus type.
8.3. Eyes
The spectrum of ocular involvement includes 8.5. Urogenital Tract
conjunctivitis, keratitis (superficial and stromal),
cataracts, iridocyclitis, and. panuveitis. Although The term "herpes progenitalis" should be dis-
the more superficial ocular lesions in children and carded, since in women genital infections occur
adults are usually associated with HSV-1, a few more commonly on the cervix than on the external
cases of HSV-2 infection have been recognized. In genitals, and in either symptomatic or asympto-
the newborn, the ocular lesions may be caused by matic males the virus may be cultured not only
either HSV-1 or HSV-2. The ill effects of cortico- from the penis but also from the urethra, prostate,
steroids in ocular herpes are worth reemphasizing and seminal vesicles.(J()·241 Although HSV has
here. been implicated as an occasional cause of urethri-
tis, prostatitis, and cystitis, its exact role in these
diseases remains to be elucidated. Cerebrospinal
8.4. Skin fluid pleocytosis in the presence or absence of
meningeal signs, radiculitis, and myelitis have
HSV vesicles on the skin are usually localized, been occasionally observed in association with
may assume a zosteriform distribution in some genital herpetic infections,021
instances, and may result from either a primary or
a recrudescent infection. In the compromised indi-
vidual, the skin lesions may be more extensive 8.6. Nervous System
and chronic. In individuals with atopic eczema or
with other dermatoses (e.g., Darier's disease), The neurological manifestations associated with
HSV infection can be more generalized and in- HSV infection, including encephalitis, meningitis,
volve both affected and nonaffected areas of the radiculitis, and myelitis, have been recently re-
underlying skin \ondition, resulting in Kaposi's viewed. (12) The association of a particular neurol-
varicelliform eruption or eczema herpeticum. (5(;) ogical manifestation with HSV-1 or with HSV-2
Occasional recurrences of this entity have been appears to depend on (1) the host, i.e., whether
described, and mortality may ensue from viral newborn or older individual, and whether com-
dissemination to vital organs or from bacterial promised or uncompromised, and (2) the preval-
superinfection. ence of a particular HSV type at various ages and
Traumatic herpes occurs in areas of skin abra- in different socioeconomic groups. Since HSV-1 is
sions, bums, or puncture wounds. Laboratory the viral type that has been recovered in all but
HSV-lor HSV -2 infections have occasionally re- two cases of herpetic encephalitis (Table I), the
sulted from such skin breaks in the hand (Table 1). possibility exists that the two HSV types differ
Herpetic paronychia occurring in medical, nurs- also in their ability to spread neurogenically or via
ing, or dental personnel and the skin infections the blood to the brain. Further study is needed to
occurring in wrestlers-herpes gladiatorum-have substantiate the role of HSV in chronic CNS dis-
been cited earlier. HSV infection of severe bums ease, psychiatric disorders, and Bell's palsy.
may be fatal, as it may lead to pneumonia and
viral involvement of other vital organs. HSV infec-
8.7. Fetus and Newborn
tions may also be associated on occasion with the
allergic manifestations of erythema multi- A wide spectrum of clinical manifestations has
forme.(70) been observed with HSV infections in the new-
In general, skin lesions below the waist (Table 1) born, which appears to be similar whether HSV-1
are caused by HSV-2, often in association with or HSV -2 is the causal agent. (4(;.47) The most se-
genital infection, whereas skin lesions above the vere form is the disseminated disease with in-
volvement of the liver and other visceral organs, serious question as to the possible immunopathol-
including frequently the brain. HSV encephalitis, ogy which could ensue from their administration.
which can occur without evidence of viral blood At present, therefore, efforts are being made to
dissemination to visceral organs, is also associated isolate virus envelope glycoproteins.
with.a poor prognosis. Localized involvement of Another major problem is the lack of finite
the eyes, skin, and/or mouth may occur. Although information regarding the immune responses to
fatality is rare in such cases, some of the infants HSV.(48) Nevertheless, in contrast to the situation
have been found with neurological and/or ocular for the other human herpesviruses (CMV, EBV,
sequelae. In contrast to cytomegalovirus infec- and VZV), there are an abundant number of ex-
tions, subclinical HSV infections of the newborn perimental animal models and of immunological
are very infrequent. assays which could be employed to evaluate pro-
The association of maternal genital herpetic in- spective HSV vaccines.
fection with abortions, stillbirths, and premature 9.1.2. Passive Immunization. It has been found
delivery has been reported.(4(;·47) Even though the in experimental animals that HSV antibodies will
virus has been recovered from abortus material, prevent infection if administered prior to virus
the possibility exists that the fetus was contami- inoculation. The effect is negligible, however, if
nated on passage through the mother's infected antibodies are administered 1 or more days after
genital tract, as exemplified by two of our recent virus inoculation. Hyperimmune HSV serum is
cases. The role of HSV in congenital malforma- not currently available for human use. However,
tions, suggested by the finding in some cases of the protection afforded by y-globulin, which con-
microcephaly or chorioretinitis soon after birth, tains a relatively high titer of HSV antibodies, has
also awaits more conclusive evidence. been inconsistent in a very small number of new-
borns exposed to maternal genital HSV infection at
delivery. Although newborns can become infected
despite the presence in their serum of transplacen-
9. Control and Prevention tally transmitted antibodies, it has not been deter-
mined whether these failures represent the rule
rather than the exception.
Although there are several potential methods
Other potentially beneficial approaches still re-
which might be used in the control of HSV infec-
quiring clinical evaluation for individuals at spe-
tions, most have little scientific validation. These
cial risk, such as newborns, include interferon or
can be grouped into (1) prevention of the initial
substances which might enhance immunity, such
infection in an individual and (2) reducing the
as BCG and transfer factor.
source of virus transmissible to others.
9.1.3. Interruption of Transmission. An ap-
proach in this direction has been made toward
protecting newborns from acquiring HSV from
9.1. Prevention of the Initial Infection
their mother's genital infection around the time of
9.1.1. Active Immunization. There are great, al- delivery. Although the risk of the infant acquiring
though not insurmountable, problems associated the infection under these circumstances is not fully
with the development of effective HSV vaccines. established (around 40-50% in a relatively small
The potential. oncogenicity of HSV imposes a re- number of cases), cesarean section pErformed prior
striction as to the type of immunogen which could to or within 4 h of rupture of membranes appears
be employed in humans. Attenuated or inactivated to be most usually protective on the basis of
viruses would still contain the viral DNA genome, presently limited information. (47)
which might be oncogenic. Thus, until the onco- The use of condoms or vaginal jellies to prevent
genic component of the viral DNA is identified transmission of genital infections has not yet been
and mutants free of this portion are produced, the evaluated. Individuals might abstain from sexual
only option available is to work with viral proteins contact with partners with obvious lesions. Simi-
free of DNA. Although cell membrane prepara- larly, close contact with individuals with nongeni-
tions of infected cells could be employed, there is tal lesions, on the lips or skin, might be avoided.
The problem, however, is that many times the chemicals toward this goal. The other strategy
genital or nongenital infections are asymptomatic. would be to enhance immune responses, so as to
The use of gloves by medical or dental personnel abort propagation at the external sites and hence
when handling oral catheters or the mouth of curb transmissibility. Several such regimens, e.g.,
patients might prevent acquisition of herpetic pa- BCG, transfer factor, and levamizole, are under
ronychia. Similarly, isolation of patients with se- current evaluation.
vere herpetic involvement, such as patients with
eczema herpeticum, or of newborns with HSV
infections, might prevent transmission to other
hospitalized patients or to attending personnel. It 10. Unresolved Problems
has not yet been determined whether hospital
personnel with herpetic lesions, most usually cold 10.1. Reporting
sores, should abstain from patient care. A system for national reporting of certain forms
of HSV infections, such as genital, ocular, and
9.2. Reducing the Source of Virus Transmissible neonatal infections should be established, and
to Others reporting of HSV infections of the nervous system
should be improved.
There are two main approaches toward reducing
the source of virus in one individual which would
be transmissible to his or her contacts. The first is 10.2. Virological Aspects
to reduce the duration of the lesions in primary or Virological aspects include (1) improving knowl-
recurrent infections and hence of transmissible edge of the natural variants within each of the
virus. This approach requires some effective HSV types and their clinicoepidemiological corre-
method of treatment, administered either topically lates; (2) identification and purification of HSV
or systemically. proteins which might be type specific, hence use-
The only proven effective regimen is the use of a ful for seroepidemiological studies, and of virus-
topical antiviral drug e.g., iododeoxyuridine (IOU) specified proteins which might be employed as
or adenine arabinoside (ara-A), in case of herpetic vaccines; and (3) further understanding of the
keratitis. None of the other regimens has as yet basic mechanisms involved with latency.
been conclusively demonstrated with the aid of
control studies in humans to be effective. Further-
more, there is some theoretical risk with some 10.3. Host Factors
regimens, e.g., use of neutral red or proflavine
Information needs to be expanded on the ge-
followed by light, since photodynamically inacti-
netic and immune factors which might be associ-
vated HSV has been shown to be oncogenic in
ated with the severity or the frequency of recur-
vitro. (57) An interhospital controlled study to eval-
rences with HSV infection in certain individuals.
uate the effectiveness of systemically administered
ara-A is currently under way for cases of severe
HSV infections-newborn herpes, HSV encephali- 10.4. Control and Prevention
tis, and HSV in the compromised host. However,
it is unlikely that treatment would be used for the Further evaluation in the laboratory and in hu-
milder infections in the foreseeable future. mans of the various possible approaches listed in
The other approach is to decrease the frequency Section 9 is required.
of recurrences or prevent them completely, since a
recurrent infection is an important source of virus
to others. Two strategies could be employed here. ACKNOWLEDGMENTS
One would be to find some way to maintain the
virus in its latent state in the ganglia. The current This work was supported by grants from the
availability of models with human ganglia in cul- National Foundation and the National Institutes of
ture permits experimentation with a variety of Health.
11. References tonsillitis in University of Wisconsin students, J. Am.

Med. Assoc. 190:699-708 (1964).
17. FRANCIS, D. P., HERRMANN, K 1., MAcMAHON, J. R.,
1. ANDERSON, S. G., AND HAMILTON, J., The epidemiol- et aI., Nosocomial and maternaIIy acquired herpesvi-
ogy of primary herpes simplex infection, Med. J. Aust. rus hominis infections. A report of four fatal cases in
1:308-311 (1949). neonates, Am. J. Dis. Child. 129(8):889-93, Aug. 1975.
2. ASTON, D. 1., COHEN, A., AND SPINDLER, M., Herpes- 18. GLEZEN, W. P., FERNALD, G. W., AND LOHR, J. A,
virus hominis infection in patients with certain mye- Acute respiratory disease of university students with
loproliferative and lymphoproliferative disorders, Br. special reference to the etiologic role of herpesvirus
Med. J. 4:462-465 (1972). hominis, Am. J. Epidemio!. 101:111-121 (1975).
3. BARINGER, J. R., AND SWOVELAND, P., Recovery of 19. GREENBERG, M. S., BRIGHTMAN, V. J., AND SHIP, I. I.,
herpes simplex virus from human trigeminal gan- Clinical and laboratory differentiation of recurrent
glions, N. Engl. J. Med. 288:648-650 (1973). intraoral herpes simplex virus infections following
4. BARINGER, J. R., Recovery of herpes simplex virus fever, J. Dent. Res. 48:385-391 (1969).
from human sacral ganglions, N. Eng!. J. Med. 20. HALE, B. D., RENDTORFF, R. c., WALKER, L. C., AND
291:828-830 (1974). ROBERTS, A. N., Epidemic herpetic stomatitis in an
5. BECKER, W.B., The epidemiology of herpesvirus in- orphanage nursery, J. Am. Med. Assoc. 183:1068-1072
fection in three racial communities in Cape Town, S. (1963).
Afr. Med. J. 40:109-111 (1966). 21. HAYNES, R. E., AzIMI, P. H., AND CRAMBLETT, H. G.,
6. BECKER, W.B., KIPPS, A., AND M~ENZIE, D., Dissem- Fatal herpesvirus hominis (herpes simplex virus) in-
inated herpes simplex virus infection: Its pathogen- fections in children-Clinical, pathologic and virol-
esis based on virological and pathological studies in ogic characteristics, J. Am. Med. Assoc. 206:312-319
33 cases, Am. J. Dis. Child. 115:1-8 (1968). (1968).
7. BLACK, F. 1., Infectious diseases in primitive socie- 22. HELLGREN, 1., The prevalence of some skin diseases
ties, Science 187:515-518 (1975). and joint diseases in total populations in different
8. BUODINGH, G. J., SCHRUM, D. I., LANIER, J. c., AND areas of Sweden, Proc. North. Dermatol. Soc., pp. 155-
GUIDRY, D. J., Studies of the natural history of herpes 162 (1962).
simplex infections, Pediatrics 11:595-610 (1953). 23. HOWARD, G. M., AND KAUFMAN, H. E., Herpes sim-
9. CENTIFANTO, Y. M., HILDEBRANDT, R. J., HELD, B., plex keratitis, Arch. Ophthalmol. 67:373-387 (1962).
AND KAUFMAN, H. E., Relationship of herpes simplex 24. JOSEY, W. E., NAHMIAS, A. J., AND NAIB, Z. M., The
genital infection and carcinoma of the cervix: Popula- epidemiology of type 2 (genital) herpes simplex virus
tion studies, Am. J. Obstet. Gynecol. 110:690-692 infection, Obstet. Gynecol. Surv. Supple. 27:295-302
(1971). (1972).
10. CENTIFANTO, Y. M., DRYLIE, D. M., DEARDOURFF, S. 25. JURETIC, M., Natural history of herpetiC infection,
L., AND KAUFMAN, H., Herpesvirus type 2 in the male Helv. Paediat. Acta. 21:35£r.368 (1966).
genitourinary tract, Science 178:318-319 (1972). 26. KIBRICK, S., AND GOODING, G. W., Pathogenesis of
11. CESARIO, T. c., POLAND, J. D., AND WULFF, H., Six infection with herpes simplex virus with special refer-
years experience with herpes simplex virus in a chil- ence to nervous tissue, in: Slow, Latent, and Temperate
dren's home, Am. J. Epidemiol. 90:416-422 (1969). Virus Infections, NINDB Monograph No.2, pp. 143-
12. CRAIG, C. P., AND NAHMIAS, A., Different patterns of 154 (1%5).
neurologic involvement with herpes simplex virus 27. KLOENE, W., BANG, F. B., CHAKRABORTY, S. M.,
types 1 and 2: Isolation of herpes simplex virus type 2 COOPER, M. R., KULEMANN, H., OTA, M., AND SHAH,
from the buffy coat of two adults with meningitis, J. K .V., A two-year respiratory virus survey in four
Infect. Dis. 127:365-372 (1973). villages in West Bengal, India, Am. J. Epidemiol.
13. DOUGLAS, R. G., JR., AND COUCH, R. B., A prospective 92:307-320 (1970).
study of chronic herpes simplex virus infection and 28. LINDGREN, K M., DOUGLAS, R. G., JR., AND COUCH, R.
recurrent herpes labialis in humans, J. Immunol. B., Significance of herpesvirus hominis in respiratory
104:289-295 (1970). secretions of man, N. Eng!. J. Med. 278:517-523 (1968).
14. DUENAS, A., ADAM, E., MELNICK, J. L., AND RAWLS, 29. LODMELL, D. 1., NIWA, A, HAYASHI, K, AND NOT-
W. E., Herpesvirus type 2 in a prostitute population, KINS, A, Prevention of cell-to-cell spread of herpes
Am. J. Epidemiol. 95:483-489 (1972). simplex virus by leukocytes, J. Exp. Med. 137:70£r.720
15. ElLARD, U., AND HELLGREN, L., Herpes simplex: A (1973).
statistical and clinical investigation based on 669 pa- 30. LOGAN, W. S., TINDALL, J. P., AND ELSON, M. 1.,
tients, Dermatologica 130:101-106 (1965). Chronic cutaneous herpes simplex, Arch. Dermatol.
16. EVANS, A. S., AND DICK, E. C., Acute pharyngitis and 103:60£r.614 (1971).
270 Chapter 11 • Epidemiology of HSV-1 and HSV-2
31. MOGABGAB, W. J., Acute respiratory illnesses in uni- 46. NAHMIAS, A. AND VISINTINE, A., Perinatal herpes
versity (1962-1966), military and industrial (1962- simplex virus infection, in: Perinatal Infections (J. RE-
1963) populations, Am. Rev. Resp. Dis. 98:359-379 MINGTON AND G. KLEIN, eds.), in press.
(1968). 47. NAHMIAS, A. J., VISINTINE, A. M., REIMER, C. B., DEL
32. MUFSON, M. A., WEBB, P. A., AND KENNEDY, H., BUONO, 1., SHORE, S. L., AND STARR, S. E., Herpes
Etiology of upper respiratory tract illnesses among simplex virus infection of the fetus and newborn, in:
civilian adults, J. Am. Med. Assoc. 195:1-7 (1966). Symposium on Infection of the Fetus and Newborn Infant
33. MULLER, S. A., HERRMANN, E. c., JR., AND WINKEL- (5. KRUGMAN AND A. GERSHON, eds.), in press.
MANN, R. K., Herpes simplex infections in hemato- 48. NAHMIAS, A., SHORE, S. L., KOHL,S., STARR, S. E.,
logic malignancies, Am. ). Med. 52:102-114 (1972). AND ASHMAN, R. B., Immunology of herpes simplex
34. NAHMIAS, A., KIBRICK, 5., AND ROSAN, R. c., Viral- virus infection, Cancer Res. 36:836-844 (1976).
leukocyte interrelationships. 1. Multiplication of a 49. NAIB, Z. M., NAHMIAS, A. J., JOSEY, W. E., AND KRA-
DNA virus-herpes simplex-in human leukocyte MER, J., Genital herpetic infection: Association with
cultures, J. Immunol. 93:69-74 (1964). cervical dysplasia and carcinoma, Cancer 23:940-945
35. NAHMIAS, A. J., AND KIBRICK, 5., Inhibitory effect of (1969).
heparin on herpes simplex virus, J. Bacteriol. 87:1060- 50. NAIB, Z. M., NAHMIAS, A. J., JOSEY, W. E., AND ZAKI,
1066 (1964). S. A., Relation of cytohistopathology of genital her-
36. NAHMIAS, A. J., AND DOWDLE, W. R., Antigenic and pesvirus infection to cervical anaplasia, Cancer Res.
biologic differences in herpesvirus hominis, Prog. 33:1452-1463 (1973).
Med. Virol. 10:110-159 (1968). 51. NG. A. B., REAGAN, J. W., AND YEN, S. 5., Herpes
37. NAHMIAS, A. J., HIRSCH, M.S., KRAMER, J. H., AND genitalis-Clinical and cytopathologic experience
MURPHY, F., Effect of antithymocyte serum on herpes- with 256 patients, Obstet. Gynecol. 36:645--651 (1970).
virus hominis (type 1) infection in adult mice, Proc. 52. O'REILLY, R. J., AND LOPEZ, c., Cyclic deficiency of
Soc. Exp. BioI. Med. 132:696-698 (1969). lymphokine production in patients with recurrent
38. NAHMIAS, A. J., JOSEY, W. E. , NAIB, Z. M., LuCE, c., herpes labialis or progenitalis, Fed. Proc. 34:947
AND DUFFEY, c., Antibodies to herpesvirus hominis (1975).
types 1 and 2 in humans. 1. Patients with genital 53. PLUMMER, G./Serological comparison of the herpesvi-
herpetic infections, Am. J. Epidemiol. 91:539-546 ruses, Br. J. Exp. Pathol. 45:135--141 (1964).
(1970). 54. PLUMMER, G., A review of the identification and titra-
39. NAHMIAS, A. WICKLIFFE, c., PIPKIN, J., LEIBOVITZ, A., tion of antibodies to herpes simplex viruses type 1
AND HUTTON, R., Transport media for herpes simplex and type 2 in human sera, Cancer Res. 33:1469-1476
virus types 1 and 2, Appl. Microbiol. 22:451-454 (1971). (1973).
40. NAHMIAS, A. J., DOWDLE, W. R., NAIB, Z. M., JOSEY, 55. PORTER, P. 5., AND BAUGHMAN, R. D., Epidemiology
W. E. MCCLONE, D., AND DOMESCIK, G., Genital of herpes simplex among wrestlers, J. Am. Med. Assoc.
infection with type 2 herpesvirus hominis-A com- 194:998-1000 (1965).
monly occurring venereal disease, Br. J. Vener. Dis. 56. PUGH, R. C. B., DUDGEON, J. A., AND BODIAN, M.,
45:294-298 (1969). Kaposi's varicelliform eruption (eczema herpeticum)
41. NAHMIAS, A. J., Herpesviruses from fish to man-A with typical and atypical visceral necrosis, J. Pathol.
search for pathobiologic unity, Pathobiol. Annu. Bacterial. 69:67-80 (1955).
2:153--182 (1972). 57. RAPP, F., Herpesviruses and cancer, Adv. Cancer Res.
42. NAHMIAS, A. J., AND ROIZMAN, B., Infection with 19:265--302 (1974).
herpes simplex viruses 1 and 2, N. Engl. J. Med. 58. RASMUSSEN, L. E., JORDAN, G. W., STEVENS, D. A.,
289:667-674, 719-725, 781-789 (1973). AND MERGIN, T. c., Lymphocyte interferon produc-
43. NAHMIAS, A. J., VON REYN, C. F., JOSEY, W. E., NAm, tion and transformation after herpes simplex infec-
Z. M., AND HUTTON, R., Genital herpes simplex virus tions in humans, J. Immunol. 112:728-736 (1974).
infection and gonorrhoea-Association and analo- 59. RAWLS, W. E., IWAMOTO, K., ADAM, E., AND MELNICK,
gies, Br. J. Vener. Dis. 49:306-309 (1973). J. L., Measurement of antibodies to herpesvirus types
44. NAHMIAS, A. J., The evolution (evovirology) of her- 1 and 2 in human sera, J. Immunol. 104:599-606 (1970).
pesviruses, in: Viruses, Evolution and Cancer (E. KUR- 60. RAWLS, W. E., GARDNER, H. L., FLANDERS, R. W.,
STAK AND K. MARAMOROSCH, eds.), pp. 605--624, Aca- LOWRY, S. P., KAUFMAN, R. H., AND MELNICK, J. L.,
demic Press, New York, 1974. Genital herpes in two social groups, Am. J. Obstet.
45. NAHMIAS, A. J., SHORE, S. L., AND DEL BUONO, 1., Gynecol. 110:682-689 (1971).
Diagnosis by immunofluorescence of human viral in- 61. RAWLS, W. E., ADAM, E., AND MELNICK, J. L., Geo-
fectionswith emphasis on herpes simplex viruses, in: graphical variation in the association of antibodies to
Viral Immunodiagnosis (E. KURSTAK AND R. MORISSET, herpesvirus type 2 and carcinoma of the cervix, in:
eds.), pp. 157-172, Academic Press, New York, 1974. Oncogenesis and Herpesviruses (P. M. BIGGS, G. DE
Chapter 11 • Epidemiology of HSV-1 and HSV-2 271
TIm, AND L. N. PAYNE, eds.), pp. 424-427, Scientific A., AND NAHMIAS, A., Stimulation of human lympho-
Publication No.2, International Agency for Research cytes by herpes simplex virus antigens, Infect. Immun.
on Cancer, Lyon, 1972. 11:109-112 (1975).
62. ROIZMAN, B., AND FURLONG, D., The replication of 77. STEVENS, J. G., AND COOK, M. L., Restriction of herpes
herpesviruses, in: Comprehensive Virology, Vol. 3, (H. simplex virus by macrophages. An analysis of the
FRAENKEL-CONRAT AND R. R. WAGNER, eds.), pp. 229- cell-virus interaction, J. Exp. Med. 133:19--38 (1971).
403, Plenum, New York, London (1974). 78. SWYERS, J. S., LAUSCH, R. N., AND KAUFMAN, H. E.,
63. ROSATO, F. E., ROSATO, E. F., AND PLOTKIN, S. A., Corneal hypersensitivity to herpes simplex, Br. J.
Herpetic paronychia-An occupational hazard of Ophthalmol. 51:843--846 (1%7).
medical personnel, N. Eng!. J. Med. 283:804-805 79. WEATHERS, D. R., AND GRIFFIN, J. W., Intraoral ulcer-
(1970). ations of reCUITent herpes simplex and recurrent
64. RUSSELL, A. S., AND SCHLANT, J., HLA transplantation aphthae: Two distinct clinical entities, J. Am. Dent.
antigens in subjects susceptible to recrudescent Assoc. 81:81--87 (1970).
herpes labialis, in press. 80. WENTWORTH, B. B., AND ALEXANDER, E. R., Seroepi-
65. SCHNEWEIS, K. E., Serologische Untersuchungen zur demiology of infections due to members of the her-
Typendifferenzierung des Herpesvirus hominis, Z. pesvirus group, Am. J. Epidemio!. 94:496-507 (1971).
Immunitaetsforsch. Exp. Ther. 124:24-48 (1962). 81. WHEELER, C. E., JR., AND CABANISS, W. H., JR., Epi-
66. SCHNEWEIS, K. E., AND NAHMIAS, A. J., Antigens of demic cutaneous herpes simplex in wrestlers (herpes
herpes simplex virus types 1 and 2-Immunodiffu- gladiatorum), J. Am. Med. Assoc. 194:993--997 (1965).
sion and inhibition passive hemagglutination stud- 82. WILTON, J. M., IVANYI, L., AND LEHNER, T., Cell-
ies, Z. Immunitaetsforsch. Exp. Klin. Immunol. 141:471- mediated immunity in herpesvirus hominis infec-
487 (1971). tions, Br. Med. J. 1:723--726 (1972).
67. SCOTT, T F. McN., Epidemiology of herpetic infec- 83. Workshop on the treatment and prevention of herpes
tions, Am. J. Ophthalmo!. 43:134--146 (1957). simplex virus infections, J. Infect. Dis. 127:117-119
68. SELLING, B., AND KIBRICK, S., An outbreak of herpes (1973).
simplex among wrestlers (herpes gladiatorum), N. 84. YAMAMOTO, Y., A re-evaluation of the skin test of
Eng!. J. Med. 270:979--982 (1964). herpes simplex virus, Jpn. J. Microbio!. 10:67-77
69. SETH, P., RAWLS, W. E., DUFF, R., RAPP, F., ADAM, E., (1966).
AND MELNICK, J. L., Antigenic differences between 85. ZISMAN, B., HIRSCH, M. S., AND ALLISON, A. c.,
isolates of herpesvirus type 2, Intervirology 3:1-14 Selective effects of anti-macrophage serum, silica and
(1974). anti-lymphocyte serum on pathogenesis of herpes vi-
70. SHELLEY, W. B., Herpes simplex virus as a cause of rus infection of young adult mice, J. Immuno!.
erythema multiforme, J. Am. Med. Assoc. 201:153--156 104:1155-1159 (1970).
(1967).
71. SHIP, I. I., MORRIS, A. L., DUROCHER, R. T., AND
BURKET, L. W., Recurrent aphthous ulcerations and
recurrent herpes labialis in a professional school stu- 12. Suggested Reading
dent population. IV. Twelve month study of natural
disease patterns, Oral Surg. 14:30--39 (1961). JUEL-JENSEN, B. E., AND MACCALLUM, F. 0., Herpes Sim-
72. SHERIDAN, P. J., AND HERRMANN, E. C.,JR., Intraoral plex, Varicella and Zoster: Clinical Manifestations and
lesions of adults associated with herpes simplex vi- Treatment, Lippincott, Philadelphia, 1972.
rus, Oral Surg. 32:390--397 (1971). KAPLAN, A. S. (ed.), The Herpesviruses, Academic Press,
73. SHORE, S. L., NAHMIAS, A. J., STARR, S. E., WOOD, P. New York, 1973.
A., AND McFARLIN, D. E., Detection of cell-depend- NAHMIAS, A., AND ROIZMAN, B., Infection with herpes
ent cytotoxic antibody to cells infected with herpes simplex viruses 1 and 2, N. Engl. J. Med. 289:667-674,
simplex virus, Nature (London) 251:350--352 (1974). 719-725, 781-789 (1973).
74. SMITH, I. W., PEUTHERER, J. F., AND MACCALLUM, F. NAHMIAS, A. J., The evolution (evovirology) of herpesvi-
0., The incidence of herpesvirus hominis antibody in ruses, in: Viruses, Evolution and Cancer (E. KURSTAK AND
the population, J. Hyg. 65:395-408 (1%7). K. MARAMOROSCH, eds.), pp. 605-622, Academic Press,
75. SMITH, J. W., ADAM, E., MELNICK, J. L., AND RAWLS, New York, 1974.
W. E., Use of the slCr release test to demonstrate ROIZMAN, B., AND FURLONG, D., The replication of her-
patterns of antibody response in humans to herpesvi- pesviruses, in: Comprehensive Virology, Vol. 3, (H.
rus types 1 and 2, J. Immunol. 109:554-564 (1972). FRAENKEL-CONRAT AND R. R. WAGNER, eds.), pp. 229-
76. STARR, S. E., KARATE LA, S. A., SHORE, S. L., DUFFEY, 403, Plenum, New York, 1974.
CHAPTER 12
Influenza Viruses
Fred M. Davenport
1. Introduction antigenically distinct. However, within type, both

surface antigens exhibit differences which confer
Epidemic influenza remains the last great uncon- identity and similarities which indicate lineage. In
trolled plague of mankind. Epidemics of influenza succeeding epidemic years, variation of each oc-
A and influenza B recur with monotonous fre- curs independently. When changes appear to take
quency, and each quietly but relentlessly exacts place gradually and are of such an extent that
its death toll. Periodically worldwide pandemics sharing of antigenic components is as readily dis-
levy larger and more conspicuous liens. Vaccines cernible as are differences, the process is referred
developed for control of influenza have been to as antigenic drift. At long intervals abrupt
shown to be highly effective when applied to changes occur, yielding variants antigenically so
selected segments of the general population, but to unique that serological relationships to strains
date they have not been employed on a scale large formerly prevalent are difficult to recognize. That
enough to determine whether their use can inter- event is referred to as antigenic shift. Recognition
rupt nationwide epidemic spread. The primary of shifting among the hemagglutinins and neura-
strategy for partial containment of influenza has minidases of type A viruses has permitted defini-
been to concentrate effort on prevention of lethal tion of subtypes or families of strains. Nomencla-
outcomes by vaccination of persons known to be ture of the subtypes has evolved over time.
at high risk. However, intensified efforts in educa- Common synonyms for currently recognized pro-
tion of the medical profession and the public totypes are swine, A/swine/31, Afswinellowa/31
concerning the importance of immunization (Hsw1N1); PR8, Ac/PRl8/34, AfPRl8/34 (HONl);
against influenza and development of mechanisms FM1, A t /FMJl/47, A/FMJl/47 (H1N1); A2 /Singaporei
for overcoming chronic vaccine shortages and mal- 1157, AfSingaporell157 (H2N2); AfHong Kongll168
distributions will be required in order to achieve a (H3N2). The term A prime has been used with
significant degree of control. (641 reference to At strains and Asian to A2 isolates. For
Vaccine efficacy is conditioned by closeness of completeness, strain designations identify sero-
fit of vaccine-induced antibody to the surface type, host of origin, geographic origin, strain
antigens of influenza viruses, i.e., hemagglutinin number, year of isolation, and, in parentheses,
and neuraminidase. Type A and B viruses are numerical indices of the antigenic character of
viral hemagglutinin (H) and neuraminidase (N)
Fred M. Davenport Department of Epidemiology, subtype. Unless otherwise specified, the host of
School of Public Health, The University of Michigan, origin is man. Type B strains undergo antigenic
Ann Arbor, Michigan drift but to date have not exhibited antigenic shift.
273
274 Chapter 12 • Influenza Viruses
2. Historical Background until swinelike strains evolved as the virus respon-

sible for the record-breaking pandemic of
Hirsch in a chronological survey of influenza 1918. (2,27,66,77,97,102) Swinelike strains remained in
lists 299 epidemics occurring between 1173 and epidemic prevalence until 1928, when type Au
1875, an incidence of one outbreak every 2.4 strains emerged. (26)
yr. (55,112) Differences in extent and severity of The modem annals of influenza have been com-
episodes were clearly recognized. Some exhibited piled by mapping of viral prevalences and charac-
a low attack rate and limited distribution. Others, terization of the antigenic composition of isolates.
such as the first pandemic (recorded in 1580), The virus of swine influenza was isolated in ferrets
struck much of the globe with a high incidence. by Shope in 1931yoll In 1933, Smith et al. (lOS)
Epidemics and pandemics were encountered more reported isolation of a virus from human cases
frequently in the eighteenth and nineteenth centu- occurring in England. Francis(4()) and Burnet<(;)
ries than in preceding ones. That difference is confirmed their findings in the next outbreaks
thought to be due to changes in size and distribu- experienced in the New World and in Australia.
tion of the world's population and to changes in On comparison of the early isolates of influenza
travel and commerce rather than to changes in Au, it became clear that they were not identical
viruses or in fashions of reporting. East to west antigenically, and minor antigenic variations con-
spread of pandemics was repeatedly documented, tinued to be observed during the remainder of the
although progression in the opposite direction was period of prevalence of Au subtype strains. (71)
less commonly observed. Clinical and epidemiol- This period was abruptly terminated when what
ogical descriptions of influenza have remained later became known as A prime strains first ap-
remarkably similar over this period, lending cred- peared in Australia during the winter of 1946. By
ence to the authenticity of the chronicle. the succeeding winter in the northern hemisphere
In recent years, results of seroepidemiological (1947), A prime strains had become the dominant
studies have permitted reconstruction of part of prevailing form.(49) They constituted a major anti-
the historic antigenic experience of mankind. Such genic shift away from the set of antigens that had
a reconstruction is possible because the major characterized their predecessors, and as time went
antigens of the strains of first infection of child- on exhibited minor antigenic changes within the
hood impress an indelible orientation upon the set that came to be recognized as those defining
antibody-forming mechanism so that throughout the Al subtype.(60l In 1957, strains of ~ or Asian
life, on subsequent exposure to related strains, the subtype of influenza viruses first appeared in the
level of primary antibody is reinforced. Persistence Kweichow Province of Central China and emerged
of antibody response to strains of first infection from the mainland via Hong Kong. (67,SO) Antigen-
has been called' "the doctrine of original antigenic ically these strains were also only remotely related
sin."(45) Since, as will be seen, the initial anti- to their predecessors. As they became the domi-
genic experience of different cohorts of the popu- nant prevailing form in this and succeeding years,
lation is sharply different, one can obtain a serol- minor antigenic changes in the composition of the
ogical recapitulation of a population's past isolates of subsequent epidemics were observed.
experience with the different antigens of influenza In 1968, from an unknown source in China, Hong
viruses by determining currently the pattern of age Kong was again the scene of emergence of a new
distribution of antibody oriented to different pro- subtype of strains, and antigenic variation within
totype strains.(27) this new subtype has occurred since.(1I)·9S)
By use of that technique, the serological evi- From the epidemiological events and serological
dence obtained identifies a period of prior preval- findings, a pattern of behavior of influenza A
ence of NEquif2/63-like viruses believed to have viruses has developed. At intervals of 10--15 yr, a
taken place between 1874 and 1889.(2S) The great different family or subtype of strains emerges from
pandemic of 1889-1890 has been related to the first an unknown source and site, generally resulting in
appearance of ~ Asianlike strains which were the occurrence of a pandemic characterized by
succeeded in tum by the first appearance of Hong high attack rates and rapid spread in a population
Kong-like viruses in 1902. (24,31,52,72,73,74.75.76,84,lIS) relatively devoid of antibodies to the major anti-
The latter strains persisted in epidemic prevalence gens of the emergent virus. In subsequent years,
Chapter 12 • Influenza Viruses 275
lesser outbreaks occur through recurrence of from another suspect case. Principally because the
strains of the same subtype. These appear to virus could be implicated as the etiological agent
undergo minor antigenic change or drift as anti- involved in an institutional outbreak of influenza
body levels oriented to the set of antigens which and because a high frequency of antibody was
characterize that subtype become progressively noted in the general population, the authors used
built up in the population. At saturation levels, a the designation "type e influenza virus" in re-
major antigenic shift occurs and the sequence of porting their observations. Since that time, spo-
events is repeated. Recycling of major antigenic radic cases and local small outbreaks have been
viral components seems to have occurred as the identified in various countries. Recent findings
resurgence in 1957 of Asian antigens once domi- suggest that antigenic change among type e
nant in the virus involved in the pandemic of strains has occurred over time, but in this in-
1889--1890 and as the resurgence in 1968 of the stance, too, the degree of change does not warrant
Hong Kong antigens formerly emphasized in separation into subtypesYB)
strains prevalent in 1902. Recycling of the 1918 However, the validity of the designation "influ-
pandemic swine strain occurred in 1976. The recon- enza e" has been questioned. Hirst(5(i) demon-
structed succession of strains is summarized in Ta- strated that the erythrocyte receptor of type e
ble 1. Other reconstructions have been proposed by virus was qualitatively different from that of type
Masurel and by Marine.(73,75,76) A and B viruses. Melnick(79) cites structural differ-
Type B influenza virus was first isolated in 1940 ences, suggesting the need for taxonomic separa-
by Francis, (42) who also demonstrated serologi- tion of type e from true influenza viruses. Ken-
cally that a related virus had been involved in the dat<63) was unable to detect neuraminidase on
epidemic of 1936. Antigenic drift among strains type e virus, yet that enzyme constitutes an im-
isolated in subsequent years has been widely portant surface component of A and B strains. It
recognized, but the degree of change has not yet seems not unlikely that influenza e virus will be.
been great enough to permit recognition and des- reclassified.
ignation of distinct subtypes. (9(;) The frequency of
epidemics is less than that for influenza A, and
severe pandemics have not been recognized.
A virus isolated by Taylotll11 in 1947 from a
3. Epidemiological Methodology
patient suspected to have influenza was found to
be unrelated antigenically to type A or B viruses. 3.1. Mortality Data
In 1950, Francis et al. (47) isolated an identical virus William Farr introduced the concept of "excess
mortality" in describing the epidemic that swept
through London in 1847. He defined it as the
number of deaths observed over and above the
Table 1. Hypothetical and Factual Summary of number expected for the particular season and
Periods of Past Prevalences of Influenza A Viruses place where the epidemic occurred, and found that
of Epidemiological Importance in Man these excess deaths were ascribed not only to
influenza but also to pneumonia, bronchitis, other
Prototype Prevalence
respiratory diseases, and many nonrespiratory di-
Equi/2lMiami/63-like 1874-1889a seases as well. Excess total mortality still provides
A,/Japan/305l57-like 1890-1901 a the most accurate measure of the impact of an
A,/Hong Kongl68-like 1902-1917" influenza epidemic on a population. However,
NSwine/1976/31-like 1918-1928a during mild or moderate epidemics, the total
Ao/PRl8/34 1929-a (1933-1943°) number of excess deaths may exceed the expel;:ted
A,/FMJl/47 1947-1957b number only slightly, and the statistical proce-
A,/Japan/305/57 1957-1968b dures required to evaluate their significance be-
~/Hong Kongl68 1968-b come complex. The most sensitive index for meas-
NNew Jersey/8/76 1976° uring severity and extent of influenza epidemics is
a Serological recapitulation.
the record of excess deaths due to influenza and
• Virus isolation. pneumonia. (69)
For monitoring current epidemics in the United distributions. Seasonal mortality curves with ex-
States, weekly reports on the total number of pected limits have been constructed by computers
deaths and deaths due to influenza-pneumonia are using data supplied by each country for the pre-
received by the Center for Disease Control (CDC), ceding 5-10 yr. Charts are drawn to different scales
Atlanta, Georgia, via postcards sent from the Vital to facilitate immediate comparison of influenza
Statistics Offices of 121 large cities whose popula- activity in reporting countries, irrespective of large
tions comprise about one-third of the total U.s. variation in the numbers of events reported. The
population. Deaths are listed by place of occurr- system provides a week-to-week record of deaths
ence and include those of persons whose residence from. acute respiratory disease in countries where
may have been elsewhere. Since reports consist of weekly returns are available and a retrospective
a count of death certificates filed each week, the analysis of the disease pattern in collaborating
tabulation may include some deaths which oc- countries. As in earlier studies, excess mortality
curred in preceding weeks. Notorious lags in re- from respiratory disease was found more useful in
porting accompany holidays. Pneumonia and in- epidemiological studies than excess total
fluenza deaths for each city and region and an deaths.(31 The WHO collaborative study will be
expected number for the country as a whole are continued for a number of years. It is hoped that
published in Table IV of the Morbidity and Mor- systematic collection of data in epidemic and non-
tality Weekly Report (MMWR). Because fatal out- epidemic periods will provide a firm basis for
come follows the onset of illness by a variable numerical estimation of the intensity of different
period and because it takes time for reports to get epidemics of influenza occurring in these coun-
to local officials, perception of excess mortality . tries and these climates. Such information will
occurs between 3 and 5 wk after clinical disease is contribute greatly to knowledge of the global im-
noted to be widespreadY,391 pact of influenza and will point up the existence of
In addition to the tabulation, charts of pneu- regional and temporal differences.
monia-influenza deaths are prepared by plotting
the weekly number of reported deaths in relation
to a curve of expectancy calculated to identify an 3.2. Morbidity Data
epidemic threshold which takes into account sea- Morbidity data are not reported regularly or
sonal variation and long-term trends.(99) Charts systematically. During the influenza season, the
are constructed with data received from all 121 CDC may conduct periodic telephone surveys with
cities and from each of nine geographic subdivi- state epidemiologists in all 50 states. Information
sions of the United States. By inspection of the is requested on school and industrial absenteeism
latter, information on timing and relative impact and on closed schools or colleges. While influenza
of the epidemic in different regions may be ob- is not a nationally reportable disease, 25 states
tained. Despite limitations in accuracy of report- currently report cases of influenza or influenzalike
ing, these data provide the best readily available disease to CDC and publish them in their own
evidence on extent and severity of an epidemic in state morbidity reports. Since 1972, additional in-
the country as a whole. Findings are published formation has been sought on the level of emer-
promptly in the MMWR and are summarized at gency room visits to large community hospitals in
least annually in the Influenza-Respiratory Disease major cities and on the findings in 60 cooperating
Surveillance Report of the CDC. virus diagnostic laboratories; 44 states participate
Until recently, data on excess mortality compa- in the expanded program on a weekly basis. The
rable to those developed for the United States were data provide a rapid general assessment of influ-
available only from England and Wales, and from enza activity throughout the United States and are
Canada. Since 1970, however, the World Health epitomized at appropriate intervals in the MMWR
Organization (WHO) has conducted a collabora- and CDC Surveillance Bulletins.
tive study on use of excess mortality from respira- For the past 12 yr, the National Health Survey
tory disease as a method for assessing the impact has collected data on occurrence of influenzalike
of influenza epidemics upon 13 countries selected illness experienced in 800 households interviewed
to encompass different climates and geographic each week. The data can be used to provide a
crude retrospective estimate of the overall attack Serological sampling has also proved useful for
rate experienced during epidemic years as meas- rapid identification of the serotype of influenza
ured against the self-reported background of diag- virus causing an outbreak. Specimens are drawn at
noses during nonepidemic years. (lIlO) one point in time from convalescents and from
Mass media provide timely news on occurrence subjects of the same age who are in the early acute
of influenza outbreaks, but lack of uniformity of phase of illness. For each group of subjects, geo-
data collection precludes accurate analysis. All in metric mean antibody titers are then ascertained
all, the information available on morbidity due to with type A and B strains. If, for example, the
influenza is highly unsatisfactory and unreliable outbreak is caused by type A virus, geometric
unless carefully designed special studies are con- mean type B antibody levels in both sets of sera
ducted. should be approximately equivalent while type A
geometric mean antibody titers of convalescents
will be the higher. A conventional Student's t test
of mean log titers will establish the significance of
3.3. Serological Surveys any difference noted. As few as ten sera in each set
The determination of influenza antibody pat- will frequently suffice to establish etiology.(S)
terns in population groups was begun as early as
1935, shortly after the discovery of the virus. These
early studies employed the neutralization test,
which is cumbersome and expensive for mass 3.4.1. Isolation. The isolation of influenza virus
application. The hemagglutination inhibition (HI) is important early in the course of an epidemic in
test is now most commonly used. It is economical, order to identify and characterize the antigenic
reflects long-lasting antibody, has high strain composition of the prevailing strain. Throat swabs
specificity, and is adaptable to the microtiter sys- or garglings are obtained from patients within the
tem for testing. The complement fixation (CF) test first 3 or 4 days of onset of fever. Usually no more
is group specific as commonly employed and be- than a dozen specimens are needed to determine
cause it reflects antibody of shorter duration can the cause of an outbreak. Inoculation of primary
be used to identify more recent outbreaks. Anti- rhesus monkey kidney cell cultures and of 10- to
body to neuraminidase has now been introduced ll-day-old embryonated eggs is recommended be-
to population surveys to yield additional data on cause influenza B strains are more readily isolated
protection levels of immunity. The neutralization in monkey kidney cells while eggs are often more
test has the highest strain specificity and is em- sensitive for isolation of influenza A viruses. In
ployed for special studies. practice, however, most laboratories rely on one or
As previously described, serological surveys the other culture system, accepting the possibility
have proven useful for developing information that the yield of isolates may be reduced thereby.
about the antigenic composition of strains of influ- Reports on isolation of influenza C strains have
enza A prevalent before 1933. Serological surveil- specified 7-day-old eggs. For successful egg inocu-
lance of the incidence of influenza A and influenza lation, the amniotic route is required. Egg harvests
B in defined populations has had limited use, but are tested for hemagglutination with guinea pig or
the findings have made important contributions to human type 0 erythrocytes and with chicken
our knowledge of the epidemiology of influenza. erythrocytes. Tissue culture tubes are tested for
In 1957, the fact that sera of persons less than 70 yr hemadsorption with guinea pig cells, and, if posi-
of age were devoid of Asian antibody provided a tive, the supernate of companion tubes can be
unique opportunity to obtain serological age-spe- tested for hemagglutination.
cific infection rates, to compare them with age- Identification of isolates as type A or B strains is
specific clinical attack rates, and to follow the first readily accomplished by complement fixation (CF)
and second waves of the epidemic curve as using standardized reagents. Type C antisera
depicted by excess pneumonia-influenza should be used only if the isolate exhibits the
deaths.cs4.116) The results of these studies will be unique cellular affinity characteristic of such
presented in Section 5. strains, i.e., capacity to agglutinate chicken cells at
4°C but not at room temperature and inability to lated protein. The lipid and protein layers com-
agglutinate guinea pig cells at either temperature. prise the viral envelope. Between RNP strands, a
HI tests are also used for identification of isolates. third nonglycosylated protein of uncertain func-
Here it is important to effect the removal of non- tion is found. Spikes are of two types. One con-
specific inhibitors from test antisera by treatment tains viral hemagglutinin and the other viral neur-
with receptor destroying enzyme (RDE) or trypsin aminidase. The ratio is at least 2:1.(981
and potassium periodate. Hemadsorption inhibi- These morphological structures have been iso-
tion may be employed if culture tubes fail to yield lated and characterized by physical and chemical
an adequate titer of hemagglutinin. Test antisera procedures. The hemagglutinin is a glycoprotein
should be prepared using the most recently iso- consisting of two polypeptides-HAl and H~
lated type A and B strains available. (;10,32) held together by disulfide bonds. Two HA mole-
By use of a battery of sera prepared against cules (HAl plus H~) form the hemagglutinin
present and earlier prototype isolates, one can spike. HAl components are presumably located at
establish by cross-HI or strain-specific CF tests a the tip of the spikes, and they alone account for
quantitative expression of the antigenic relation- antigenic specificity of hemagglutinins. They also
ships of current strains to their predecessors. The are responsible for viral attachment to cell recep-
principal antibody being measured in such tests is tors. The latter are mucoproteins which are cleaved
that directed against viral hemagglutinin. Viral by viral neuraminidase, yielding sialic acid. Viral
neuraminidase, the minor surface antigen, is at neuraminidase consists of one or two kinds of
times responsible for detectable low-level cross- polypeptides joined in a tetramer to form the other
reactions, but these can be eliminated by use of glycoprotein spike. Antigenic distinction of spikes
monospecific antisera. For completeness, the anti- is conferred by differences in their amino acid
genic characteristics of both surface antigens composition, which is most readily reflected by
should be established.(3S) differences in peptide maps of the appropriate
3.4.2. Serological Tests. Serodiagnosis of influ- components of different strains. The nucleocapsid
enza is most commonly employed in large-scale supplies genetic information. It is believed to exist
epidemiological studies. Paired sera drawn 2-3 wk not as a continuous strand but as eight different-
apart are used. The CF and HI tests are approxi- sized pieces capable of rearrangement. This capac-
mately equal in sensitivity, but use of either alone ity may provide the virus an unusual flexibility for
may result in missing as much as 15% of infec- genetic expression. Small internal protein(s) asso-
tions. Therefore, paired negative sera should be ciated with the RNP strand may function as virion
tested by the other technique. Use of "soluble" CF polymerase(s). (6S,90a)
antigen will often, but not always, distinguish
between antibody response to vaccination and that
due to infection, since a rise in antibody level
above 1/s is uncommon following vaccination. Re-
5.1. Incidence and Prevalence Date
cently a single radial diffusion test has been devel-
oped which may prove to be well suited for field 5.1.1. Mortality and Morbidity. By use of excess
investigations, but to date experience is lim- mortality due to influenza and pneumonia as an
ited. (94) index/ fi9 ) Collins(l2) compiled an impressive re-
cord of influenza-associated mortality extending
from 1887 through 1956 (Fig. 1). Over the period of
4. Biological Characteristics of the Virus reporting, the intervals and sites have changed.
Mter decades of quiescence, the pandemic of
Influenza virions are spherical particles 100 nm 1889-1890 erupted unexpectedly. The death toll of
in diameter. The surface contains approximately 1891-1892 was even greater, and sharp large peaks
550 spikelike structures embedded in a lipid coat. of excess mortality recurred as "trailer" epidemics
Beneath is a nonglycosylated protein membrane through 1908. Relative quiescence again ensued
enclosing the twisted and coiled RNP strand, until 1915, when moderately severe epidemics
which consists of RNA and another nonglycosy- reappeared. These failed to be predictive of the
JAN.1892 740 500

500
JAN.
z 400 MASSACHUSETTS: BY MONTHS, 1887-1898 400
0
j: 300 300
FEB.
~ 200 200
:)
CL 100 100
0
CL o- o
gq. -100 ~~~~~~~~~~~~~~~~~~~~~~~~~~-IOO
0 300
~
II:
200
....
CL
100 1'00
.... 0 0
=
I-
-100 1909 1910 -100
%
l-
800 4799: OCT. 16,1918 131Z:
800
e 700 700
.... FEB.II,19Z0
0
..J
600 600
e:) 35 LARGE CITIES: BY MONTHS, JAN., 1910-AUG., 1918;
500 500
BY WEEKS, SEPT., 1918-DEC., 1921
z 400 400
z
e FEB. 300
II)
300 26
II)
.... 200 200
u
)(
100 100
.... 0 0
-100
1910 1911 191Z 1913 1914 191!! 1916 1917 1918 1919 1920 19Z1
z 500 90 REPRESENTATIVE CITIES: BY WEEKS, 1922-1933 500

~ 400
l- 400 JAN.9
e 300
..J 300
:)
CL 200 200
0
CL 100 100
0 0
0 0
q,
0
-100 -100
~
II:
....IL
.... 400 90 REPRESENTATIVE CITIES: BY WEEKS, 1934-1942; 400
I-
e 300 56 CITIES, 1943-1945
DEC.Z9
300
II:
%
200 200
e 100 100
I-
.... 0 0
0
..J -100 -100
e 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 194!!
:)
z
z
e
II) 300 56 CITIES: BY WEEKS, 1946-1950; 62 CITIES, 1951-1956
II)
.... 200
u
.... 100 FEB. II
)(
0
-100
1946 1947 1948 1949 1950 19!!1 19!!Z 19!!3
Fig. 1. Excess annual death rate in Massachusetts and in representative U.S. cities, 1887-1956.
catastrophic pandemic of 1918-1919, in which matic heart disease, especially those with mitral
globally over 20 million lives were lost. Subse- stenosis, (b) other cardiovascular disorders such as
quently, moderately severe outbreaks recurred arteriosclerotic heart disease and hypertension,
through the early 1940s, but thereafter excess mor- especially those with evidence of frank or incipient
t~lity declined conspicuously. cardiac insufficiency, (c) chronic bronchopulmon-
Another way of presenting the available data is ary disease, e.g., chronic asthma, chronic bronchi-
in terms of monthly pneumonia-influenza death tis, bronchiectasis, pulmonary fibrosis, pulmonary
rates and bar graphs of total excess death and of emphysema, and pulmonary tuberculosis, (d) dia-
excess pneumonia-influenza death rates observed betes mellitus, and (e) Addison's disease; (2) preg-
during epidemic periods. Fig. 2 summarizes infor- nant women; and (3) persons in older age groups,
mation accumulated since 1934, a period wherein those over 45 and particularly those over 65 yr of
the identity of the causal viruses is known. (7) age. Subsequent advisory committees have deleted
Here, too, the influenza-associated death experi- the category of pregnancy, since excess mortality
ence, qS judged by monthly pneumonia-influenza in pregnancy, while apparent in epidemics occur-
death rates, appears to have declined gradually, ring through 1931, was not discernible in less
reaching fairly stable levels by 1944. In the past 40 severe epidemics encountered in later years. The
yr, 20 epidemics of influenza A and eight of influ- present system of registration and coding of
enza B have been identified. Influenza B is clearly deaths would preclude establishing such an asso-
less frequent and less lethal than influenza A. ciation without special study, since an influenza-
Nevertheless, the impact of the 1936 epide~ic of pneumonia death is coded as due to influenza and
influenza B was outstanding. Over the entire pe- pneumonia regardless of whether pregnancy was
riod of record, 54 epidemics occurred in the 87 yr noted or not. (371
elapsed since 1887. 5.1.3. Incidence. Current usage tends to restrict
The occurrence of excess deaths from influenza the term pandemic influenza to episodes of spread
and pneumonia above the expected baseline is of a known or presumed major antigenic variant in
shown in Fig. 3 for 121 cities for 1971-1974 and for a popUlation relatively devoid of antibody ori-
nine regions of the United States for 1973-1974. ented to the novel strain. The literature on the
The slight peak excess mortality seen in reports incidence of influenza is enormous and in part
received from all cities for the fifteenth week of contradictory. Discrepancies may be due in part to
1974 stands in marked contrast to high peaks of variability in cr:iteria used for reporting and in part
mortality observed in 1972 and 1973. The Middle to actual differences in the experience of the sev-
Atlantic region reported heaviest involvement in eral populations because of disparities in innate or
1974.(91 acquired characteristics or in relative exposures.
5.1.2. High-Risk Categories. Detailed analysis The statements that follow are believed to repre-
of mortality data by criteria which describe the sent the average expectancy.
kinds of persons most likely to suffer a fatal Data accumulated by household surveys in
outcome has led to identification of certain "high- 1889-1890, 1918, 1957, and 1968 indicate that an
risk groups," i.e., persons classified as being at incidence of from 20 to 40% can be anticipated
increased risk of death during the course of an during the first wave of a new pandemic. Subse-
influenza epidemic.(191 From these findings and quent events cannot be summarized so simply. For
from clinical and laboratory data on influenza- unknown reasons, second waves at a short interval
associated deaths,<371 the Surgeon General's Advi- have been observed in certain pandemics and not
sory Committee on Influenza (USPHS) initiated in others. The rate of decline of intensity of epi-
the policy in 1962 that special emphasis should be demics during revisitations of strains of the same
given to protecting such persons in campaigns for general antigenic character is also somewhat varia-
better control of influenzaY51 They can readily be ble and irregular, as may be inferred by inspection
identified as (1) persons of all ages who suffer of mortality curves in Fi~s. 1 and 2. Toward the
from chronic debilitating disease, e.g., chronic end of the period of prevalence of some major
cardiovascular, pulmonary, renal, or metabolic variants, incidence may ultimately decline to as
disorders, in particular, patients with (a) rheu- little as 2-5%.
., 300
:J:
:.
~
~8 200
~~
-'0
10.-
;!:a:
,101
elL 100
Z
~
~
101
f ,
0 ,934" 35 "36 I '37 "38 "39 I '40 "41 "42 "43 "44 "45 "46 "47 "48 "49 ''50 "51 "52 "53 "54 "55 \ 6 "57 "58 "59 "60 "6. "62 "63 "64 "65 "66' '670.'68"69 "70' '71 "72 "73 "74' '75 I
50.. TYPE A -EPIDEMICS
A A A A A A, A, A, A, A, A. A. A. A. A. A. HI< HK HK A.
40'
., 30~ WALL CAUSES

:J: 20
PNEUMONIA- INFLUENZA
!C
1010 Id
00
.,q 0
:::8 '35 - - '40 - - '45 - 'SO '55 '60 '65 -'70 - '75
. ~l TYPE B-EPIDEMICS
:; 30
."." ~
t- 20
.: . . . . 0 I I I I I ~ I • I I I ~ I I \iJ I I I ~. I ~ I I I j;l I I I I I I I • I
1934 '35 '36 '37 '38 '39 «> '41 '42 '43 '44 '45 '46 '47 '48 '49 'SO '5. '52 '53 '54 '55 '56 '57 "58 '59 '60 '6. '62 '63 '64 '65 '66 '67 '68 '69 '70 '7. '72 '73 '74 '75
Fig. 2. Pneumonia-influenza death rates by month and excess mortality during epidemic periods, United States, 1934-1973. From Epidemiology
Program, Center for Disease Control.
i
~
•
iii
f
<:
~.
m
~
00
....
N
00
N
1,600
ALL CITIES 1
~
- - - EPIDEMIC THRESHOLD
1,400 EXPECTEQ NUMBER •
1,200
II>
f
<::
~OOO If
~
800
600
400
200"""'" " ' ( " ' ( " " ' t " " " " - " " " " " " " " " " " "" " , 1 " , 1 " , 1 " " " " " , 1 " " ,,,,,,,, ••••• , . 1 " " " , ( " , 1 " , ( " , ( " " " , !",(",(".(",!,."""",(
WEEK NO. 40 44 48 52 4 8 12 16 20 24 28 32 36 40 44 48 52 4 8 12 16 20 24 28 32 36 40 4448 52 4 8 12 16 20 24 28 32 36
WK. ENDED 9 6 4 I 29 26 25 22 20 17 15 12 9 7 4 2 30 27 24 24 21 19 16 14 II 8 6 3 I 29 26 23 23 20 18 15 13 10 7
MONTH 0 N D .' ~ M A M J J A SON D 1 J F M A M J J A SON D J F M A M J J A S
197111972 1972 1973 197311974
150
W. N. CENTRAL 300-1 E. N. CENTRAL 200 NEW ENGLAND
10 CITIES 20 CITIES 14 CITIES
125 175
250
150
100 200
125
75' 150 100
50
25
25
o ' , ." I " II , , , ! 1 , " " ' , " " ' , , " " II " , I I II ! , , "rI
O'"",! rI , I , " , , , t' I , , , " ! , , ! , , , ! , ! " , ! ! I ! ! I 'II I! 0 ' ! , , ! , I ! I, I ! " I ,1, ! , " , , , " ' I , , , ! " If
II' " I , ! , , , ' " rI
WEEK NO. 40 44 48 52 4 8 12 16 20 24 28 32 40 44 48 52 4 8 12 '16 20 24 28 32 40 44 48 52 4 8 12 16 20 24 28 32 36
197311974 197311974 197311974
175
125. MOUNTAIN E. S. CENTRAL MIDDLE ATLANTIC
9 CITIES 8 CITIES 350 20 CITIES
ISO
I
100
300
125
250
75 100
2'
7
50
25
0
WEEK NO.
200 .. PACIFIC 200-4 W S. CENTRAL SOUTH ATLANTIC

175' 16 CITIES 12 CITIES 225112 CITIES
175
200
150 ISO
175
125 125 ISO
100
75
50
25
0 '" !:' '!~' '!!.It!~' " ..'" 'A"!~":1' '~b"24 '28"~2 0' I ' ..
'.,!. r)~! "l!' '.22." '}" '.l" !.!o" !2.It..!.!.' !.:.~' '..!.!.' '':':' t.:.~
wEEK NO
Fig. 3. Pneumonia-influenza deaths in 121 U.S. cities.

!Ii
~
•
~
f
rt-.)
QO
~
5.2. Epidemic Behavior appeared first near the French battlefields in Au-
gust, although there had been widespread scat-
Dissemination of influenza occurs in several
tered episodes during the preceding year. The
forms. Infection may smolder in a population
source of emergence of influenza Ao strains on or
without clinical recognition, being manifest only
about 1928 is unknown. Ai strains were isolated in
by a 5--10% rate of titer increase discernible in
Australia in the winter of 1946 before their intro-
serum samples collected to span interepidemic
duction to North America early in 1947 followed
periods. (341 Introductions of novel serotypes of
by widespread extension in Europe during 1949.
virus, as occurred in 1957 and 1968, may be
The 1957 Asian pandemic had its origin in Kwei-
followed by several months of sporadic widely
chow Province, China, and, after extending wi-
scattered small outbreaks of characteristic disease,
dely, broke out at Hong Kong shortly thereafter.
indicating that widespread seeding of a country
The 1968 pandemic of Hong Kong influenza
has preceded the subsequent epidemic explo-
erupted via the same city, presumably from the
sion.(671 At other times, prior seeding is not
Chinese mainland. It would appear from the re-
detected and sharp outbreaks promptly follow im-
cord to date that while the behavior of influenza
portation with rapid but irregular spread over a
remains unpredictable it would be prudent to
region.
expect and prepare for a severe pandemic of influ-
Once an outbreak begins, the epidemic behavior
enza every 10-15 yr, followed by trailing epidem-
of influenza in any given locale is quite character-
ics of lesser intensity until the next burst of major
istic. Early cases are obscured by the background
activity initiates another characteristic sequence.
of noninfluenzal disease. Suddenly the observer is
confronted with an upsurge of patients exhibiting
a precipitous onset of illness with fever, chills,
aches, hacking nonproductive cough, and prostra-
tion, despite the absence of prominent physical Major outbreaks of influenza A tend to recur at
findings in the respiratory tract. Uncomplicated 2-3 yr intervals and of influenza B at 4-7 yr
recovery begins after 3-7 days of illness. The attack intervals. Either or both serotypes may exhibit
rate is high. The peak of the epidemic curve for yearly endemicity.(201 In the temperate zones,
areas of metropolitan size is often reached in 3-4 epidemics commonly occur during the period from
wk, while the epidemic course may be essentially early autumn to late spring, but there have been
complete in an additional 3-4 wk. This time scale instances wherein they begin or extend during the
is compressed for smaller geographic areas and warm seasons. In the tropics, epidemics tend to
expanded for larger ones. The clinical severity of cluster in the rainy season, but pandemic influ-
disease, the high attack rate, and the steepness of enza may be experienced at other times when
the ascending limb of the epidemic curve are invasion occurs from the northern or southern
unique features of influenza which account for the hemisphere. Influenza C has been recognized in
fact that epidemic influenza remains the one respi- sporadic cases or in small institutional outbreaks
ratory disease of modem times capable of closing among children. The majority of type C infections
schools and factories and embarrassing or disrupt- are submerged in the viral smog that accompanies
ing essential community services. the early years of life.
5.3. Geographic Distribution 5.5. Age

Most epidemic strains of influenza A and influ- The highest incidence in a primary epidemic of
enza B extend globally. The origin of pandemics influenza A is generally encountered in the 5- to
remains obscure. Earlier literature suggests that 14-yr-old group, frequently 5--9. A decline occurs
Turkestan or eastern Russia was an endemic to about 20-25 yr, followed by a moderate but
source for westward spread of the major epidemics distinct rise to about age 30-35. Those are the
of man. The pandemic of 1889-1890 possibly arose years of heaviest household exposure to school-
in China. The severe pandemic strain of 1918 aged children. Thereafter the attack rate tends to
decline slowly and somewhat progressively, bot- marked antigenic drift would tend to restore the
toming out at about 10%. In secondary and subse- CUIVe of age incidence toward that seen in primary
quent waves, the highest age-specific attack rate invasion.
tends to shift to older cohorts, reflecting persist- The data with respect to incidence and age
ence of acquired resistance in the age group most distribution of influenza B are fewer in number. In
heavily involved at the first visitation as well as 1937 an attack rate of 30-40% was noted in several
the apparent capacity of the virus to pick off the communities in California.(4!) The age incidence
vulnerables spared during the first wave. Fig. 4 CUIVe was not unlike that seen in primary influ-
illustrates these patterns with data collected from enza A outbreaks.
Tecumseh, Michigan, in 1957 and 1960.(54) The Solov'ev in an extensive review of influenza
CUIVe shown for 1957 is that of the first wave of morbidity presents limited data indicating that age
Asian influenza, while the CUIVe for 1960 reflects distribution of cases of influenza B is not dissimi-
the third exposure of the population. The overall lar to that of influenza A. (119) In a comparison of
attack rate in the first wave of 1957 was 23.0% and the age distribution of pneumonia cases notified
in 1960 it was 17.3%, yet the age group in which in Glasgow during an epidemic of influenza A in
the median case .occurred in 1957 was 10-14 while 1950-1951 and of influenza B in 1952, some excess
in 1960 it was 30-34. Since the likelihood of fatal of cases was noted in the 0-5 and 60+ yr age
outcome increases with age, the findings help' to groups during the A outbreak, but on the whole
explain why the case fatality rate may rise in the CUIVes were remarkably similar.(7) The results
certain secondary epidemics. It is noteworthy that of several sUIVeys carried out in the United States
antigenic composition of the 1960 virus was vir- in 1961-1962 emphasized the high attack rate of
tually indistinguishable from that of 1957, and that influenza B in school-aged children, with a pro-
the inteIVal between the second wave of 1958 and gressive slow decline after age 20.0 4 ) In a small
the 1960 outbreak was less than 24 months. It sUIVey conducted in 1966, the decline after age 20
seems likely that both factors may have contrib- was described as more abrupt. (13) Present infor-
uted heavily to persistence of immunity in 1960 of mation on the unusually light influenza B epi-
those young people involved in the first two demic of 1974 indicates that attack rates were high
waves of Asian influenza. One would expect that in affected schools but that industrial absenteeism
the occurrence of a longer inteIVal between out- was not noticeably increased. The picture that
breaks and the advent of viruses exhibiting a emerges from the scant data available is that the
40 -/9!l7
0---0/960
35
30
I--
z
~25 t
i,,
a:: t \
.... o
t b
\
Fig. 4. Incidence by age of Asian influenza in Tecum- 1l.20
seh, Michigan, in 1957 and in 1960. From Hennessy et .... , '
D-
-0
" \
\
I--
,
0" "0' II,
al. (54) ~ 15 ....0_-0....
10
'" ,\
0
• (/) ! ·111
'j' •'l' III
OJ • ., •
6.,
III ,• on 'I'
III
•
co
~ •on
I I
i
I
0 10
~ ~ 0
OJ
I
on
OJ ~
I I
0 on
on on
AGE
attack rate of influenza B can simulate that of fatality rate drops abruptly and is maintained at
influenza A but in general the incidence is lower, low levels until age 35. From age 35 to age 60 a
especially in adults. In either disease, an impor- slow rise occurs, but at age 60 the slope of the
tant component of the lowered incidence found in curve rises abruptly and dramatically. In 1918, a
adults is, as in the case of other respiratory infec- high mortality occurred in the 2G-40 yr age group,
tions contracted in childhood, that of acquired especially males, converting the usual V-shaped
immunity. The relative sparing of adults by influ- respiratory mortality curve to a distinctive W-
enza B is also consonant with the lesser degree of shaped one.(44) This change has been cited as a
antigenic drifting that has been observed among characteristic of "pandemic" influenza and has
type B strains. been interpreted to indicate that the virus of the
The high incidence in school-aged children is 1918 pandemic was more pneumotropic and there-
undoubtedly related to the fact that schools pro- fore more virulent than strains encountered before
vide an environment extremely favorable for trans- or since. However, the change is also conceived to
mission of respiratory pathogens. Daily assembly be the result of excess physiological or environ-
of a large mass of susceptibles who are intermit- mental stresses contributing to pneumonia rather
tently partitioned in different classrooms with clo- than a selective viral effect. (4(;) The data cited on
sed ventilation systems provides ideal tinder for the age distribution of influenza-associated deaths
conflagration once the spark of infliction is intro- relate largely to those associated with influenza A
duced. In 1957, the opening of schools was or with influenza of unknown etiology. As seen in
promptly followed by an epidemic upsurge of Figs. 1 and 2, the mortality associated with influ-
Asian influenza after a summer of seeding of virus enza B is less pronounced, a finding consistent
dispersed by focal outbreaks. In Japan the epi- with the impression that the attack rate of influ-
demic peaked first in May while schools were in enza B in adults is lower than that of influenza A.
session, abated in July as vacations began, but The magnitude of the death toll varies enormously
peaked again after schools were reopened in Sep- from epidemic to epidemic and from place to
tember. (51) The ordinary seasonal incidence of place. At present, there is no objective way to
influenza in temperate and troDical zones seems in measure, either in the field or in the laboratory,
large part due to climatic factors that determine the virulence of a strain of influenza virus. If
their customary school schedules. The effects of influenza-pneumonia deaths are counted, impor-
crowding are also discernible in institutions other tant contributing factors are probably type and
than schools. High attack rates on shipboard have distribution of bacterial pathogens prevalent in
been repeatedly observed, and epidemic disper- different populations. In recent years, these factors
sions through offices, industries, college dormito- are almost never under surveillance. Age composi-
ries, hospitals, and other institutions are familiar tion of different populations is obviously another
occurrences. However, the possible effect of sea- important variable. So too is the proportion of the
sonal climatic changes on physiological host resist- popUlation already handicapped by chronic dis-
ance or on survivorship of the virus in transit ease, a circumstance of special importance when
between hosts cannot be dismissed. It is known total excess mortality is being tabulated, since as is
that influenza virus remains infectious for a longer evident from Fig. 2 the bulk of excess mortality
period of time in cold, moist atmospheres. No encountered in influenza epidemics is attributed
convincing evidence for differences in attack rates on death certificates to other causes. Conditions
in rural vs. urban communities exists, although that indirectly influence magnitude of the attack
instances of escape by isolated communities have rate such as crowding, effects of climate on behav-
been recorded. ior, and history of past experience with influenza,
As mentioned earlier, mortality is conditioned etc., also influence total impact as judged by mortal-
not only by the presence of chronic debilitating ity.
disease but also by age. The curve of age distribu-
tion of influenza-pneumonia deaths emphasizes 5.6. Other Factors
the vulnerability of subjects at the extremes of the Presumably, the natural susceptibility of both
span of life. After the first year of life, the case sexes to influenza is equal. Nevertheless, on one
study the attack rate was found to be higher in occurs in enclosed spaces, as evidenced by find-
women than in men if the household contained ings with sentinel animals(48.93) or by measures
children and adolescents. On the other hand, men that promote air sterilization. (78) Unfortunately,
exhibited a higher rate than women in households precise information is lacking concerning the rela-
not containing subjects under 20 yr of age. The tive importance of any of the mechanisms of
findings were attributed to differences in expo- transmission known to be involved.
sures, women being more prone to acquire infec-
tion from their children and men from contacts
outside the home.(S4) Natural susceptibility of all
races is apparently equal. Attack rates in different
racial components of a population may be condi-
7.1. Pathogenesis
tioned by popUlation density, access to medical
services, or prior exposures. Differences in attack A more detailed description of the author's
rates in various socioeconomic groups probably views on pathogenesis and immunity has been
reflect the effects of crowding. It has been shown published previously.(2!) Briefly it is postulated
that the attack rate in households increases as size that virus lodges first in the upper respiratory tract
of the household increases. (S4) Occupational data as a result of inhalation of infected droplets dis-
have not been collected systematically in this charged into the air during talking, sneezing, and
country. In the USSR, the highest level of morbid- coughing. The viral hemagglutinin makes a spe-
ity is observed in those branches of industry cific combination with the complementary molec-
where contact between people in the course of ular configuration of heat-stable mucoproteins de-
production is greatest.(I]9) In the United States, tectable as a inhibitors in respiratory secretions.
incidence among doctors, nurses, and schoolteach- Viral neuraminidase then rapidly lowers the vis-
ers is said to be high in pandemics and their cosity of surface mucus, converting this material to
involvement to occur early in the course of an a watery fluid and simultaneously laying bare cell
outbreak. surface receptors. Liquifaction of mucus prevents
viral extrusion by ciliary action and promotes
spread of virus to dependent portions of the respi-
6. Transmission ratory tract. Next, penetration of virus in vacuoles
or by intake of RNA from particles disrupted at the
At the height of illness, respiratory secretions surface initiates viral reproduction. Finally, release
commonly contain 1 million or more infectious of newly synthesized virus is facilitated by neura-
viral particles per milliliter. One 50% human in- minidase activity and a new cycle of adsorption,
fectious dose is comprised of as few as 320 50% penetration, synthesis, and release is begun. By
tissue culture infectious doses when certain lines analogy to observations in ferrets and mice, peak
of virus are given to volunteers by nasal instilla- pulmonary virus titers in man are probably
tion.(17) Presumably a tenth of that number, or reached within 24 h, remain at their fastigium for
less, would be required for infection if virus were an additional 48 h, and then at 72 h decline almost
aerosolized to yield droplets small enough to reach as abruptly as they rose. The decline is accompan-
the alveoli, i.e., 1-5 Ilm. Clearly the large amount ied, at least in mice, by the development of high
of virus available for distribution from patients levels of interferon in pulmonary tissue.(S8) The
and the relatively small amount needed to bring incubation period in volunteer studies may be as
down susceptibles are factors that help to explain short as 24 h. Under conditions of natural expo-
the ready and rapid spread of influenza observed sure in isolated communities, 48 h is a common
on the ascending limb of the epidemic curve. In interval between contact with a single source and
nature, virus is easily transmitted by direct con- development of symptomatic cases.
tact, by large droplet infection, or by articles The early stage of release of virus from infected
freshly contaminated by discharges from the nose cells is not accompanied by visible manifestations
and throat of infected persons. Further, true air- of cell injury. Later, necrosis and desquamation of
borne transmission via droplet nuclei undoubtedly respiratory epithelium occur, which may extend to
the basement membrane. Intracellular spaces are vated vaccine subcutaneously was followed by
distended with edema fluid and hemorrhagic ex- enhanced nasal antibody titer levels.(43) Fazekas
travasation. Cellular exudate is scanty. The naso- de St. Groth and Donnelley<38) showed that the
pharynx, trachea, bronchi, and bronchioles are best correlate with protection was the antibody
involved to a variable extent in different cases. titer of respiratory secretions rather than 'of serum.
Injury and reaction to it are focally distributed in Kasel et al. lfi2 ) demonstrated that 11 5 IgA secre-
both lungs. In fatal cases, degree and extent of tory antibody levels were enhanced by administra-
pathological change increase distally. In the special tion of inactivated vaccines either by the naso-
case of influenza virus pneumonia, fixed alveolar pharyngeal route or subcutaneously, although
cells show cytopathic changes accompanied by titers tended to be higher after direct application.
necrosis, capillary thrombosis, capillary hemor- In volunteer studies, Couch et al. (1m found that
rhage, and focal leukocytic exudate. In some cases, the presence of serum antibody alone was associ-
hyaline membranes are seen. Pneumonia is most ated with a reduction in the frequency of infec-
commonly due to superimposed bacterial infection. When both serum and nasal secretion anti-
tion, with the majority of fatal cases being associ- body were present, a still further reduction in
ated with coagulase-positive staphylococci. Recov- frequency of infection occurred. The sole individ-
ery is marked by epithelial hyperplasia and ual who possessed nasal secretion antibody but no
regeneration effected by proliferation from the serum antibody became infected, possibly because
basal cell layers. (83) the distribution of nasal antibody tends to be
Probably distribution of virus is generally lim- restricted to the site of vaccine application. IliS)
ited to the respiratory tract. Attempts to demon- Protection against natural disease by respiratory
strate viremia in antibody-free natural cases application of vaccine via aerosol has given irregu-
proved negative in 1957.(8Il However, isolation of lar results.(l14) At present, the common view is
virus from the blood of volunteers has been re- that secretory antibody constitutes the first line of
ported once.(I07) In addition, virus--presumably natural defense, and the role of serum antibody is
bloodbome-has been found in the urine of chil- called into play when the inflammatory response
dren.o 17l Finally, Oseasohn et al. (88) report isola- results in diffusion of 7 5 IgA and plasma constitu-
tion of virus from extrapulmonary tissues obtained ents of 19 5 IgM to areas of viral invasion. In man,
at autopsy from a few patients with fatal Asian the protective effect of serum antibody on the lung
influenza. Baron and Isaacs(4) failed to find inter- may be as important as that seen in ferrets.
feron in extracts prepared with lungs of patients The duration of immunity following natural in-
who died of influenza virus pneumonia. That fection is not known exactly. The results of com-
circumstance would favor survival of virus and munity studies in Tecumseh demonstrate that re-
foster dissemination by leukocytes.(21l sistance to Asian influenza was present 2 yr after
the original assault.'54) FryI50) found that immun-
ity against Asian influenza lasted at least 4 yr.
7.2. Immunity Pickles et al. (89) came to the same conclusion with
respect to previous experience with influenza A.
Resistance to influenza infection is a complex During a 3-yr period, Hall et al. IS:!) observed only
phenomenon. Human respiratory secretions con- a 2% and a 12% serological reinfection rate against
tain a nonspecific humoral factor called f3 inhibi- influenza A and influenza B, respectively, in Seat-
tor. This heat-labile proteinaceous substance is tle Virus Watch families. The prevailing view is
capable of inactivating in vitro the infectivity of that postinfection immunity measured by failure
low concentrations of influenza viruses.(II) Fran- to exhibit disease lasts for several years after a
cis(43) demonstrated in 1941 that nasal secretions previous attack, although subclinical reinfection
contain specific neutralizing antibody and that probably occurs after a much shorter interval.
plasma antibody can diffuse across mucous mem- However, under conditions of heavy exposure,
branes to appear in respiratory secretions. The clinical recurrence did affect a significant propor-
ratio of serum vs. nasal neutralizing activity was tion of children after an interval as short as 2
found to be about 10:1. Administration of inacti- yr. The narrow specificity and rapid decline in
antibody response of children would correlate for sibilant coarse rales heard best over larger
with a less durable immunityyo3) bronchi in about one-third of patients. When the
patient experiences prostration, as is frequently
the case, an apathetic appearance is characteristic.
8. Patterns of Host Response The leukocyte count generally is normal, but about
one-third of the patients exhibit leukopenia with a
8.1. Clinical Features relative increase in lymphocytes. Convalescence
ordinarily begins on or about the fourth day, and
The consequences of infection with influenza most patients are back to full activity within a
viruses extend from a totally asymptomatic state to week to 10 days. However, many experience pro-
fatal outcome despite heroic therapeutic efforts. longed lassitude or sense of debility and persistent
Estimates of subclinical infection rates derived cough. The clinical picture in children ordinarily
from clinical and serological studies indicate that tends to be milder and difficult to recognize.
for every febrile patient exhibiting symptoms Croup and bronchiolitis may precipitate hospitali-
compatible with influenza there is another subject zation, but the true incidence of these manifesta-
who denies illness or has at best a trivial experi- tions is unknown.
ence self-diagnosed as a common cold. (54.92) De- The most dreaded complication of influenza is
spite the range of symptoms in individual pa- pneumonia. Pneumonia should be suspected if
tients, clinical descriptions of influenza remain fever persists beyond the fourth or fifth day or
remarkably constant from year to year and ob- recurs abruptly after convalescence appears to
server to ~bserver. This seeming paradox probably have begun. It has been estimated that 80% of the
relates to the fact that physicians tend to reserve pneumonias represent secondary bacterial infec-
the clinical diagnosis of influenza for classical tion. The clinical picture, physical findings, and
cases and diagnostic specimens are usually not laboratory data are markedly influenced by the
processed for minor illnesses. The spectrum of type of bacterial invader, with staphylococci being
clinical response is described in meticulous detail the most lethal. Pure viral pneumonia may account
elsewhere. (46,1118) The patient most likely to be for up to 20-25% of influenza-associated pneu-
recognized clinically as suffering influenza is one monias, and it may be suspected when pneumonia
who 1-4 days after exposure (average 48 h) experi- is observed to occur in synchrony with influenza
ences an abrupt onset with chills, fever, headache, rather than after an interval. In viral pneumonia
malaise, backache, and nasal symptoms of sneez- few bacteria are seen on smear, and no significant
ing and mild discharge. Hacking nonproductive pathogens are obtained on culture. Sputum is
cough is characteristic. At first, except for cough, scant but bloody. Cyanosis and tachypnea are
the severity of constitutional symptoms far out- extreme, yet despite evidence of poor air exchange
weighs in importance to the patient the severity of pulmonary findings are diffuse rather than lobar.
respiratory symptoms. In the next 24 h, fever Rheumatic heart disease with mitral stenosis and!
reaches a substantial plateau and respiratory or insufficiency has been identified as an impor-
symptoms become more prominent. Obstructed tant predisposing factor. Bacterial pneumonias are
nostrils, hoarseness, dry or sore throat, and sub- more commonly seen in subjects bearing the addi-
sternal soreness may be pronounced and trouble- tional diagnosis of chronic pulmonary disease,
some cough persists. Retroorbital aching and pho- chronic cardiac disease, or pregnancy.
tophobia are less common complaints. Anorexia,
nausea, or vomiting may accompany fever, but
diarrhea is not characteristic. Gastrointestinal 8.2. Diagnosis
symptoms are more common in children. Fever The clinical diagnosis of influenza presents little
persists on the average for 3 days and may exhibit problem in severe cases during epidemic or pan-
a diphasic course. Physical signs are few and not demic periods. The consistency of the clinical
pathognomonic. Watery eyes, flushed face, and ~spects from outbreak to outbreak, the large num-
reddening of nasopharyngeal membranes are fre- bers of persons presenting with similar features,
quent findings. The chest is generally clear except and the tendency of influenza viruses to dominate
over other causes of respiratory morbiditY during country has failed to cause a discernible decrease
such periods make the diagnosis easy and quite in the number of influenza-associated deaths. (68)
reliable. In sporadic and isolated cases, these clini- More effective educational programs for vaccine
cal signs and symptoms are not characteristic utilization in high-risk subjects are clearly needed.
enough to permit bedside recognition of influenza A large amount of the vaccine available in any
virus as the cause. Many other viruses can produce given year is used in industry because of the
acute upper respiratory disease with similar find- conviction many industrial physicians have that
ings. Reliance must be placed on laboratory diag- vaccination minimizes economic loss due to ab-
nosis. This is based on isolation of the virus from senteeism-related production setbacksYIOl Expan-
the nasopharynx and/or the demonstration of an sion of the volume used in this sector could
antibody rise between acute and convalescent probably be carried out quite efficiently, because
specimens. These techniques are outlined in Sec- industry provides a suitable milieu for vaccination
tion 3.4 of this chapter. campaigns. The potential savings are enormous.
For example, Kavet (39) estimates that the indirect
costs (loss of earnings and production deficits) of
9. Control Measures the 1968-1969 epidemic of Hong Kong influenza
totaled $3,242,926,000.
Prevention of the nationwide spread of influ- Use of vaccine for protection of strategic com-
enza has never been accomplished. The task is munity services is recommended in years of antic-
formidable but theoretically not impossible. Suffi- ipated high incidence. Doctors, nurses, school-
cient epidemiological data are available to direct teachers, firemen, policemen, transportation
immunization concepts. It seems likely that an workers, etc., have been identified as appropriate
essential requirement for effective control would priority groups. It is believed that use of vaccine
be vaccination of school-aged children, since at all for this purpose is sporadic and not well sup-
times the attack rate in this cohort remains high ported. Somewhere between 20 and 50 million
and their role in transmission important.(6D The doses of vaccine would be needed to protect
demonstration that vaccination of schoolchildren against economic losses and for defense of stra-
confers a Significant degree of protection on the tegic services.
rest of the community recommends adoption of As coverage of more and more of the population
this practice.(82) The development of nonreacto- is extended, at some point the condition would be
genic vaccines favors that approach.(25) However, reached where the effects of herd immunity would
extensive educational efforts would be required become contributory. At present, there are no data
before large-scale vaccination of schoolchildren that permit prediction of the level of coverage
could be accomplished. It is estimated that in the required to gain that advantage. Nevertheless, it is
United States 60 million doses would be required clear that the number of schoolchildren, high-risk
for coverage of this cohort. persons, industrial employees, and employees in
Vaccination of schoolchildren would not be ex- strategic community services sums to about 75%
pected to offer complete protection for persons at of our population, a level once-but no longer-
high risk of death during influenza epidemics, and believed capable of containing the spread of mea-
for direct protection of these individuals an addi- sles virus. The maximal amount of influenza virus
tional 40 million doses would be needed. At best, vaccine previously produced in the United States
only about 25% of high-risk persons receive influ- was about 50 million doses. (87) In recent years, the
enza virus vaccine, even in years of high promo- annual interpandemic volume has been about 20
tional activity. That low level of coverage is condi- million doses. In 1976 the National Influenza Im-
tioned by recurrent vaccine shortages and more munization Program will attempt to distribute
importantly by perceptions of the public and of 200 million doses of influenza vaccine at no cost.
physicians concerning risk of influenza and the Because of these considerations, the Surgeon
merits of vaccination.(9D Hence it is not surpris- General's Advisory Committee on Influenza made
ing that the use of influenza virus vaccine in this the recommendation in 1962 that in practice first
priority on use of vaccine be given to prevention 10. Unresolved Problems

of deaths in high-risk groups. This recommenda-
tion has been retained by subsequent groups ad- At this point in time, the most striking of
visory to the United States Public Health Service, unresolved problems in the study of influenza
and was widely adopted abroad. However, imple- relate to the questions--where does the virus come
mentation of the recommendation remains unsat- from, and where does it go between epidemics
isfactory due to failure to develop effective proce- and pandemics? There are data to support the
dures for augmenting vaccine supplies and concept that between epidemics virus continues to
directing their distribution and utilization.(33) be transmitted at a low frequency without causing
This failure is distressing because the record of recognized influenza and without reaching a level
vaccine effectiveness demonstrates that in most of virus shedding sufficient to permit virus isola-
years a high degree of protection follows its use. tion. (34.39.53) Presumably, antigenic drift occurs
For example, in seven vaccine trials carried out by during this relatively quiescent phase. Pandemic
the Commission on Influenza in the interval 1943- strains have been postulated to erupt from animal
1969, the range of protection was 80-90% effec- or avian reservoirs, to arise by recombination of
tiveness. In an additional five trials, the protection strains derived from human and subhuman
level was about 70%. Clearly vaccination confers sources, or to reappear when their nucleic acids
an important benefit to the recipient. This sub- have been reactivated by unknown forces acting
ject has been reviewed in detail else- on their reservoir in the human host. (39.109) Con-
where. (22.23.46.108,110) ceivably, recycling of antigens involved in strains
Live virus vaccines have been used extensively of prior pandemics and sharing of antigens among
in the USSR with results comparable to those strains isolated from different species could come
achieved in other countries with killed vaccines. about not by recent genetic interaction but by
They are under active investigation in Great Brit- genetic limitations imposed by the requirement
ain and in the United States. (5,29,36,57,70,85,86.104.113) that surface components of mutants must form a
Theoretically their use might produce a superior functioning limiting viral membrane.(30 In con-
degree of local immunity. Since they do not re- trast to the plethora of ideas relating to evolution
quire concentration in order to attain an antibody- of pandemic strains, there is a dearth of ideas
stimulating dose, the supply of vaccine rapidly relevant to the astonishing phenomenon that once
available might be markedly enhanced. However, a new subtype of viruses emerges, members of the
there are difficulties in regularly producing a suffi- old subtype abruptly cease to circulate, even
ciently attenuating yet antigenic strain. Francis though susceptibles remain available in the popu-
and Maassab(46) have provided the most complete lation. A satisfactory answer to these unresolved
discussion of the Russian experience. problems must explain disappearances as well as
Until recently, it could be said that vaccination appearances. Intriguing though these questions
provided the sole proven means for prevention of are, there is no assurance that their solution will
influenza. At present, brief mention must be made result in better control of influenza. To that end
of two other approaches. Solov'ev(106) describes the immediate objective is to enhance immuniza-
the use of exogenous interferon for protection, but tion capabilities.(64)
widespread application of the procedure described
seems impractical. Amantadine hydrochloride has
been found effective for prevention of Asian influ- 11. References
enza but is ineffective against influenza B. The
1. ANDERSON, T., GRIST, N. R., LANDSMAN, J. B., LAID-
therapeutic benefit of amantadine is at best slight. LAW, S.1. A., AND WEIR, 1. B. L., An epidemic of
The expense and duration of drug administration influenza due to virus B, Br. Med. J. 1:7-11 (1953).
militate against its widespread application, but 2. ANDREWES, C. H., LAIDLAW, P. P., AND SMITH, W.,
consideration of use seems justified for high-risk Influenza: Observations on the antibody content of
persons exposed without vaccine protection, espe- human sera, Br. J. Exp. Pathol. 16:566-582 (1935).
cially as household contacts. (59) 3. ASSAAD, F., COCKBURN, W. c., AND SUNDARESAN, T.
K., Use of excess mortality from respiratory diseases 20. DAVENPORT, F. M., Recent advances in prevention
in the study of influenza, Bull. WHO 49:219-233 of influenza by vaccination, Mod. Med. 26:115-122
(1973). (1958).
4. BARON, S., AND ISAACS, A., Absence of interferon in 21. DAVENPORT, F. M., Pathogenesis of influenza, Con-
lungs from fatal cases of pneumonia, Br. Med.]. 1:18- ference on Airborne Infection, Bacteriol. Rev.
20 (1962). 25:294-300 (1961).
5. BEARE, A. S., Methods of obtaining viruses suitable 22. DAVENPORT, F. M., Killed influenza virus vaccines:
for live influenza vaccines and their potential effi- Present status, suggested use, desirable develop-
cacy in man, in: Proceedings of the Symposium on ments, in: Proceedings: International Conference on
Live Influenza Vaccine, pp. 21-29, Yugoslav Acad- the Application of Vaccines Against Viral, Rickettsial
emy of Sciences and Arts, Zagreb, 1971. and Bacterial Diseases of Man, Pan American Health
6. BURNET, F. M., Influenza virus isolated from an Organization-World Health Organization, Wash-
Australian epidemic, Med. ]. Aust. 2:651-653 (1935). ington, D.C., December 14-18, 1970, pp. 85-95,
7. Center for Disease Control, Influenza-Respiratory PAHO Scientific Publication No. 226, 1971.
Disease Surveillance, Report No. 88, p. 8, January 23. DAVENPORT, F. M., Control of influenza, Sympos-
1973.
ium on Influenza, Med. ]. Aust. Spec. Suppl. 1:33-38
8. Center for Disease Control, Influenza-Respiratory
(1973).
Disease Surveillance, Report No. 89, p. 22, February
24. DAVENPORT, F. M., AND HENNESSY, A. V., The
1974.
clinical epidemiology of Asian influenza, Ann. In-
9. Center for Disease Control, Morbidity and Mortality
tern. Med. 49:493-501 (1958).
Weekly Report 23, No. 18, p. 167, May 4, 1974.
25. DAVENPORT, F. M., HENNESSY, A. V., BRANDON, F.
10. CHANG, W. K., National influenza experience in
M., WEBStER, R. G., BARRETT, C. D., AND LEASE, G.
Hong Kong, Bull. WHO 41:349-351 (1968).
0., Comparisons of serologic and febrile responses
11. CHU, C. M., The action of normal mouse serum on
in humans to vaccination with influenza A viruses
influenza virus,]. Gen. Microbiol. 5:739-757 (1951).
or their hemagglutinins, J. Lab. Clin. Med. 63:5-13
12. COLLINS, S. D., Influenza in the United States 1887-
(1964).
1956 Public Health Monograph No. 48, Government
26. DAVENPORT, F. M., HENNESSY, A. V., DRESCHER, J.,
Printing Office, Washington, D.C., 1957.
MULDER, J., AND FRANCIS, T., JR., Further observa-
13. Communicable Disease Center, Influenza-Respira-
tions on the relevance of serologic recapitulations of
tory Disease Surveillance ReprJrt No. 82, p. 6, June
human infection with influenza virus,]. Exp. Med.
30,1966.
120:1087-1097 (1964),
14. Communicable Disease Center, Influenza Surveil-
27. DAVENPORT, F. M., HENNESSY, A. V., AND FRANCIS,
lance, Report No. 72, p. 10, May 31, 1962.
T., JR., Epidemiologic and immunologic signifi-
15. Communicable Disease Center, Influenza Surveil-
cance of age distribution of antibody to antigenic
lance, Report No. 72, Supplement, May 31, 1962.
variants of influenza virus,]. Exp. Med. 98:641-656
16. COUCH, R. B., DOUGLAS, R. G., ROSSEN, R., AND
(1953).
KASEL, J. A., Role of secretory antibody in influ-
28. DAVENPORT, F. M., HENNESSY, A. V., AND MINUSE,
enza, in: The Secretory Immunologic System (D. H.
E., Further observations on the significance of Ai
DAYfON, JR., P. A. SMALL, JR., R. M. CHANOCK, H.
Equine-2163 antibodies in man, J. Exp. Med.
E. KAUFMAN, AND T. B. TOMASI, eds.), pp. 93-112,
126:1049-1061 (1967).
National Institute of Child Health and Develop-
ment, Government Printing Office, Washington, 29. DAVENPORT, F. M., HENNESSY, A. V., MINUSE, E.,
D.C., 1969. MAASSAB, H. F., ANDERSON, G. R., MITCHELL, J. R.,
17. COUCH, R. B., KASEL, J. A., GERIN, J. 1., SC~LMAN, HEFFELFINGER, J. C., AND BARRETT, C. D., JR., Pilot
J. 1., AND KILBOURNE, E. D., Induction of partial studies on mono- and bivalent live attenuated influ-
immunity to influenza by a neuraminidase-specific enza virus vaccines, in: Proceedings of the Sympos-
vaccine,]. Infect. Dis. 129:411-420 (1974). ium on Live Influenza Vaccine, pp. 105-113, Yugoslav
18. CZEKALOWSKI, J. W., AND PRASAD, A. K., Studies on Academy of Sciences and Arts, Zagreb, 1971.
influenza virus. I. Antigenic variation in influenza 30. DAVENPORT, F. M., AND MINUSE, E., Influenza vi-
virus type C, Arch. Gesamte Virusforsch. 42:215-227 ruses, in: Diagnostic Procedures for Viral and Rickett-
(1973). sial Diseases, 3rd ed. (E. H. LENNETTE AND N. J.
19. DAUER, C. c., AND SERFLING, R. E., Mortality from SCHMIDT, eds.), pp. 455-469, American Public
influenza 1957-1958 and 1959-1960, International Health Association, Inc., New York, 1964.
Conference on Asian Influenza, Am. Rev. Resp. Dis. 31. DAVENPORT, F. M., MINUSE, E., HENNESSY, A. V.,
83(2): Part 2, 15-26 (1961). AND FRANCIS, T., JR., Interpretations of influenza
antibody patterns of man, Bull. WHO 41:453-460 E., Identification of another epidemic respiratory
(1969). disease, Science 112:495-497 (1950).
32. DAVENPORT, F. M., AND MONTO, A. S., Practical 48. FRANCIS, T., JR., SALK, J. E., PEARSON, H. E., AND
considerations in the diagnosis of myxovirus infec- BROWN, P. N., Protective effect of vaccination
tions, Am. J. Clin. Pathol. 57:777-782 (1972). against induced influenza A, J. Clin. Invest. 24:536-
33. DAVIS, D. J., Problems of allocation and distribution 546 (1945).
of influenza vaccines, International Conference on 49. FRANCIS, T., JR., SALK, J. E., AND QUILLIGAN, J. J.,
Asian Influenza, Am. Rev. Resp. Dis. 83(2): Part 2, JR., Experience with vaccination against influenza
168-170 (1961). in the spring of 1947, Am. J. Public Health 37:1013-
34. DINGLE, J. H., BADGER, G. F., AND JORDON, W. S., 1016 (1947).
JR., Illness in the Home, p. 174, The Press of Western 50. FRY, J., 1961 influenza pattern, Br. Med. f. 1:745-746
Reserve University, Cleveland, 1964. (1961).
35. DOWDLE, W. R., COLEMAN, M. T., HALL, E. c., AND 51. FUKUMI, H., Summary report on the Asian influ-
KNEZ, V., Properties of the Hong Kong influenza enza epidemic in Japan 1957, Bull. WHO 20:187-198
virus. 2. Antigenic relationship of the Hong Kong (1959).
virus hemagglutinin to that of other human influ- 52. FUKUMI, H., Interpretation of influenza antibody
enza A viruses, Bull. WHO 41:419-424 (1969). patterns in man, Bull. WHO 41:469-473 (1969).
36. EDWARDS, E. A., MAMMEN, R. E., ROSENBAUM, M. 53. HALL, C. E., COONEY, M. K., AND Fox, J. P., The
J., PECKINPAUGH, R. 0., MITCHELL, J. R., MAASSAB, Seattle virus watch, Am. J. Epidemiol. 98:365-380
H. F., MINUSE, E., HENNESSY, A. V., AND DAVEN- (1973).
PORT, F. M., Live influenza vaccine studies in 54. HENNESSY, A. V., DAVENPORT, F. M., HORTON, R. J.
human vol~nteers, in: International Symposium on M., NAPIER, J. A., AND FRANCIS, T., JR., Asian
Influenza Vaccines for Men and Horses, London, 1972 influenza: Occurrence and recurrence, a community
(F. T. PERKINS, London, AND R. H. REGAMEY, Ge- and family study, Mil. Med. 129:38-50 (1964).
neva, eds.), pp. 289-294, 39th Symp., Ser. Immuno- 55. HIRSCH, A., Handbook of Geographical and Historical
bioI. Standard., Vol. 20, 1973. Pathology, Vol. 1, pp. 7-17, translated from the
37. EICKHOFF, T. c., SHERMAN, I. 1., AND SERFLING, R. second German edition by CHARLES CREIGHTON,
E., Observations on excess mortality associated New Sydenham Society, London, 1883.
with epidemic influenza, f. Am. Med. Assoc. 56. HIRST, G. K., The relationship of the receptors of a
176:104--110 (1961). new strain of virus to those of the mumps-NDV-
38. FAZEKAS DE ST. GROTH, S., AND DONNELLEY, M., influenza group, f. Exp. Med. 91:177-184 (1950).
The protective value of active immunization, Aust. 57. HOBSON, D., BEARE, A. S., AND GARDNER, A. W.,
f. Exp. Bioi. Med. Sci. 28:61-75 (1950). Haemagglutination-inhibiting serum antibody
titres as an index of the response of volunteers to
39. Fox, J. P., AND KILBOURNE, E. D., Epidemiology of
intranasal infection with live attenuated strains of
influenza, Summary of Influenza Workshop IV, f.
influenza virus, in: Proceedings of the Symposium on
Infect. Dis. 128:361-386 (1973).
Live Influenza Vaccine, pp. 73-84, Yugoslav Acad-
40. FRANCIS, T., JR., Transmission of influenza by a emy of Sciences and Arts, Zagreb, 1971.
filterable virus, Science 80:457-459 (1934). 58. ISAACS, A., AND HITCHCOCK, G., Role of interferon
41. FRANCIS, T., JR., Epidemiological studies in influ- in recovery from virus infections, Lancet 2:69-71
enza, Am. J. Public Health 27:211-225 (1937). (1960).
42. FRANCIS, T., JR., A new type of virus from epidemic 59. JACKSON, G. G., STANLEY, E. D., AND MULDOON, R.
influenza, Science 92:405-408 (1940). 1., Prospects for the control of viral diseases with
43. FRANCIS, T., JR., Factors conditioning resistance to chemical substances, PAHO Sci. Pub. 226:588-601
epidemic influenza, Harvey Lect. Ser. 37:69-99 (1970).
(1941). 60. JENSEN, K. E., AND FRANCIS, T., JR., The antigenic
44. FRANCIS, T., JR., Influenza: The newe acquayant- composition of influenza virus measured by anti-
ance, Ann. Intern. Med. 39:203-221 (1953). body-absorption, J. Exp. Med. 98:619-639 (1953).
45. FRANCIS, T., JR., On the doctrine of original anti- 61. JORDON, W. S., JR., DENNY, F. W., JR., BADGER, G.
genic sin, Proc. Am. Phil. Soc. 104:572-578 (1960). F., CURTIN, c., DINGLE, J. H., OSEASOHN, R., AND
46. FRANCIS, T., JR., AND MAASSAB, H. F., in: Viral and STEVENS, D. A., A study of illness in a group of
Rickettsial Infections of Man, 4th ed. (F. 1. HORSFALL, Cl.!!veland families. XVII. Occurrence of Asian influ-
JR., AND I. TAMM, eds.), pp. 689-740, Lippincott, enza, Am. f. Hyg. 68:190-212 (1958).
Philadelphia, 1965. 62. KASEL, J. A., HORNE, E. B., FULK, R. V., TOGO, Y.,
47. FRANCIS, T., JR., QUILLIGAN, J. J., JR., AND MINUSE, HUBER, M., AND HORNICK, R. B., Antibody re-
sponses in nasal secretions and serum of elderly 78. McLEAN, R. 1., General discussion, International
persons following local or parenteral administration Conference on Asian Influenza, Am. Rev. Resp. Dis.
of inactivated influenza virus vaccine, ]. Immunol. 83(2): Part 2, 36-38 (1961).
102:555-562 (1969). 79. MELNICK, J. 1., Classification and nomenclature of
63. KENDAL, A. P., A new receptor destroying enzyme animal viruses 1971, Prog. Med. Virol. 13:462-484
in influenza C, in: Symposium ot! Neuraminidase, (1971).
Behring Institute Mitteilungen, pp. 18-34, Vol. 55, Mar- 80. MEYER, H. M., JR., HILLEMAN, M. R., MIESSE, M. 1.,
burg, 1974. CRAWFORD, 1. P., AND BANKHEAD, A. S., New anti-
64. KILBOURNE, E. D., CHANOCK, R. M., CHOPPIN, P. genic variant in Far East influenza epidemic, 1957,
W., DAVE!'IPORT, F. M., Fox, J. P., GREGG, M. B., Proc. Soc. Exp. Bioi. Med. 95:609--616 (1957).
JACKSON, G. G., AND PARKMAN, P. D., Influenza 81. MINUSE, E., WILLIS, P. W., III, AND DAVENPORT, F.
vaccines-Summary of Influenza Workshop V, J. M., An attempt to demonstrate viremia in cases of
Infect. Dis. 129:750-771 (1974). Asian influenza, ]. Lab. Clin. Med. 59:1016--1019
65. KILBOURNE, E. D., CHOPPIN, P. W., SCHUUE, 1. T., (1962).
SCHOLTISSEK, c., AND BUCHER, D. 1., Summary of 82. MONTO, A. S., DAVENPORT, F. M., NAPIER, J. A.,
Workshop I,]. Infect. Dis. 125:447-455 (1972). AND F~CIS, T., JR., Effect of vaccination of a
66. LAIDLAW, P. P., Epidemic influenza: A virus dis- school-age population upon the course of an A2
ease, Lancet 1:1118-1124 (1935). Hong Kong influenza epidemic, Bull. WHO 41:537-
67. LANGMUIR, A. D., Epidemiology of As!an influenza, 542 (1969).
Am. Rev. Resp. Dis. 83(2): Part 2,2-9 (1%1). 83. MULDER, J., AND HERS, J. F. P., Influenza, pp. 9--204,
68. LANGMUIR, A. D., HENDERSON, D. A., AND SER- Wolters-Noordhoff, Groningen, the Netherlands,
FLING, R. E., The epidemiological basis for control 1972.
of influenza, Am. ]. Public Health 54:563--571 (1964). 84. MULDER, J., AND MASUREL, N., Pre-epidemic anti-
69. LANGMUIR, A. D., AND HOUSWORTH, J., A critical body against the 1957 strain of Asiatic influenza in
.evaluation of influenza surveillance, Bull. WHO the serum of older persons living in the Nether-
41:393-398 (1969). lands, Lancet 1:810-814 (1958).
70. MACKENZIE, J. S., The use of temperature-sensitive 85. MURPHY, B. R., CHALHUB, E. G., NUSINOFF, S. R.,
mutants in live virus vaccines, in: Proceedings of the AND CHANOCK, R. M., Temperature-sensitive mu-
Symposium on Live Influenza Vaccine, pp. 35-41, tants of influenza virus. II. Attenuation of ts recom-
Yugoslav Academy of Sciences and Arts, Zagreb, binants for man, J. Infect. Dis. 126:170-178 (1972).
1971. 86. MURPHY, B. R., CHALHUB, E. G., NUSINOFF, S. R.,
71. MAGILL, T. P., AND FRANCIS, T., JR., Antigenic KASEL, J., AND CHANOCK, R. M., Attenuation of ts
differences in strains of human influenza virus, recombinants for man. III. Further characterization
Proc. Soc. Exp. BioI. Med. 35:463-466 (1936). of ts-l (E) influenza A recombinant (HaN.) virus in
72. MARINE, W. M., AND WORKMAN, W. M., Hong man,]. Infect. Dis. 128:479-487 (1973).
Kong influenza immunologic recapitulation, Am. ]. 87. MURRAY, R., Production and testing in the USA of
Epidemiol. 901:406-415 (1969). influenza virus vaccine made from the Hong Kong
73. MARINE, W. M., WORKMAN, W. M., AND WEBSTER, variant in 1968-69, Bull. WHO 41:495-496 (1969).
R. G., Immunological interrelationships of Hong 88. OSEASOHN, R., ADELSON, 1., AND KAJI, M., Clinico-
Kong, Asian and Equi-2 influenza viruses in man, pathologic study of thirty-three fatal cases of Asian
Bull. WHO 41:475-482 (1969). influenza, N. Engl. J. Med. 260:509--518 (1959).
74. MASUREL, N., Relation between Hong Kong virus 89. PICKLES, W. N., BURNET, F. M., AND McARTHUR,
and former A. isolates and the A/Equi/2 virus in N., Epidemic respiratory infection in a rural popu-
human sera collected before 1957, Lancet 1:907-910 lation with special reference to the influenza A
(1969). epidemics of 1933, 1936--7 and 1943-4, ]. Hyg.
75. MASUREL, N., Serological characteristics of a "new" 45:469-479 (1947).
serotype of influenza A virus: The Hong Kong 90. PLUMMER, N., Essential industry and its role in an
strain, Bull. WHO 41:461-468 (1969). influenza epidemic, International Conference on
76. MASUREL, N., AND MARINE, W. M., Recycling of Asian Influenza, Am. Rev. Resp. Dis. 83(2): Part 2,
Asian and Hong Kong influenza A virus hemagglu- 211-214 (1961).
tinins in man, Am. ]. Epidemiol. 97:44-49 (1973). 90a. PONS, M. W., A reexamination of influenza single-
77. MASUREL, N., AND MULDER, J., Studies on the and double-stranded RNA's by gel electrophoresis,
content of haemagglutinin-inhibiting antibody for Virology 69:789--792 (1976).
swine influenza virus, A. Verk. Inst. Prevo Geneesk. 91. ROSENSTOCK, 1. M., Public acceptance of influenza
52:1 (1962). vaccination programs, International Conference on
Asian Influenza, Am. Rev. Resp. Dis. 83(2): Part 2, 106. SOLOv'EV, V. D., The results of controlled observa-
171-174 (1961). tions on the prophylaxis of influenza with inter-
92. SALK, J. E., MENKE, W. J., AND FRANCIS, T., JR., A feron, Bull. WHO 41:683-688 (1969).
clinical, epidemiological and immunological evalua- 107. STANLEY, E. D., AND JACKSON, G. G., Viremia in
tion of vaccination against epidemic influenza, Am. Asian influenza, Trans. Assoc. Am. Phys. 79:376-387
]. Public Health 42:57-93 (1945). (1966).
93. SALK, J. E., PEARSON, H. E., BROWN, P. N., AND 108. STUART-HARRIS, C. H., Influenza and Other Virus
FRANCIS. T., JR., Protective effect of vaccination Infections of the Respiratory Tract, pp. &-21, Williams
against induced influenza B; J. c/in. Invest. 24:547- and Wilkins, Baltimore, 1965.
553 (1945). 109. STUART-HARRIS, SIR CHARLES H., Pandemic influ-
94. SCHILD, G. c., HENRy-AYMARD, M., AND PEREIRA, enza: An unresolved problem in prevention, J.
H. G., A quantitative, single-radial-diffusion test Infect. Dis. 122:10&-115 (1970).
for immunological studies with influenza virus, ]. 110. STUART-HARRIS, SIR CHARLES H., Control of influ-
Gen. Virol. 16:231-236 (1972). enza, lack of knowledge versus lack of application
95. SCHILD, G. c., HENRy-AYMARD, M., PEREIRA, M.S., of knowledge, Arch. Environ. Health 21:276-284
CHAKRAVERTY, P., DOWDLE, W., COLEMAN, M., AND (1970).
CHANG, W. K., Antigenic variation in current hu- 111. TAYLOR, R. M., A further note on 1233 ("influenza
man type A influenza viruses: Antigenic character- C") virus, Arch. Gesamte Virusforsch. 4:485-500
istics of the variants and their geographic distribu- (1951).
tion, Bull. WHO 48:269-278 (1973). 112. THOMSON, D., AND THOMSON, R., Influenza, Ann.
96. SCHILD, G. c., PEREIRA, M.S., CHAKRAVERTY, P., Pickett-Thomson Res. Lab. 9:4 (1933).
COLEMAN, M. T., DOWDLE, W. R, AND CHANG, W. 113. TYRRELL, D. A. J., AND BEARE, A. 5., Live influenza
K., Antigenic variants of influenza B virus, Br. Med. virus vaccines: An interim report, PAHO Sci. Pub.
J. 4:127-131 (1973). 226:96-100 (1971).
97. SCHILD, G. c., AND STUART-HARRIS, C. H., Serol- 114. WALDMAN, R. H., BOND, J. 0., LEVITT, L. P.,
ogic epidemiological studies with influenza A vi- HARTWIG, E. c., PRATHER, E. c., BARATTA, R. L.,
ruses, J. Hyg. 63:479-490 (1965). NEILL, J. 5., AND SMALL, P. A., JR., An evaluation of
98. SCHULZE, 1. T., The structure of influenza virus: A influenza immunization: Influence of route of ad-
model based on the morphology and composition of ministration and vaccine strain, Bull. WHO 41:543-
subviral particles, Virology 47:181-196 (1972). 548 (1969).
99. SERFLING, R E., Methods for current statistical anal- 115. WALDMAN, R. H., SMALL, P. A., JR., AND ROWE, D.
ysis of excess pneumonia-influenza deaths, Public S., Utilization of the secretory immunologic system
Health Rep. (USA) 78:494-506 (1963). for protection against disease, in: The Secretory
100. SHARRAR, R. G., National influenza experience in Immunologic System (D. H. DAYTON, JR., P. A.
the U.s.A.; 196&-69, Bull. WHO 41:361-366 (1969). SMALL, JR., R. M. CHANOCK, H. E. KAUFMAN, AND
101. SHOPE, R. E., Swine influenza. III. Filtration experi- T. B. TOMASI, eds.), pp. 129-147, National Institute
ments and etiology, J. Exp. Med. 54:373-385 (1931). of Child Health and Development, Government
102. SHOPE, R. E., The incidence of neutralizing antibod- Printing Office, Washington, D.C., 1969.
ies for swine influenza virus on the sera of human 116. WIDELOCK, D., KLEIN,S., PElZER, L. R., AND SIMO-
beings of different ages, J. Exp. Med. 63:669-684 NOVIC, 0., A laboratory analysis of 1957-1958 influ-
(1936). enza outbreak in New York City. II. A seroepide-
103. SIGEL, M. M., KITTS, A. W., LIGHT, A. B., AND miological study, Am. J. Public Health 49:847-856
HENLE, W., The recurrence of influenza A prime in (1959).
a boarding school after 2 years, J. Immunol. 64:33-38 117. ZAKSTELSKAYA, L. Y., Recovery of the virus from the
(1950). urine of patients with epidemic influenza, Gupp:
104. SLEPUSHKIN, A. N., SCHILD, G. c., BEARE, A. 5., OKUDR Trans. Ob'jed. Sess. Inst. AMN SSSR, Mos-
CHINN,S., FREESTONE, D., HALL, T., AND TYRRELL, cow, 72 (1953).
D. A. J., Antineuraminidase antibody and resist- 118. ZAKSTELSKA]A, L. Y., EVSTIGNEEVA, N. A., ISACH-
ance to vaccination with live influenza A2 Hong ENKO, V. A., SHENDEROVITCH, S. P., AND EFIMOVA,
Kong vaccines, in: Proceedings of the Symposium on V. A., Influenza in the USSR: New antigenic variant
Live Influenza Vaccine, pp. 85-92, Yugoslav Acad- A2/Hong Kong/1/68 and its possible precursors, Am.
emy of Sciences and Arts, Zagreb, 1971. J. Epidemiol. 90:400-405 (1969).
105. SMrrH, W., ANDREWES, C. H., AND LAIDLAW, P. P., 119. ZHDANOV, V. M., SOLOVEV, V. D., AND EpSHTEIN, F.
A virus obtained from influenza patients, Lancet G., The Study of Influenza: Epidemiology, pp. 64&-
2:66-68 (1933). 732, Russian Scientific Translation Program, Divi-
sion of General Medical Sciences, National Insti- FRANCIS, T., JR., AND MAASSAB, H. F., in: Viral and
tl.\tes of Health, Bethesda, Md., 1960. Rickettsial Infections of Man, 4th ed. (F. L. HORSFALL,
JR., AND I. TAMM, eds.), pp. 689-740, Lippincott,
Philadelphia, 1965.
HOYLE, L., The Influenza Viruses, Springer-Verlag, New
12. Suggested Reading York,1968.
KILBOURNE, E. D., The Influenza Viruses and Influenza,
Academic Press, New York, 1975.
Fox, J. P., AND KILBOURNE, E. D., Epidemiology of STUART-HARRIS, C. H., Influenza and Other Virus Infections
influenza, Summary of Influenza Workshop N, J. of the Respiratory Tract, Williams and Wilkins, Balti-
Infect. Dis. 128:361-386 (1973). more, 1965.
CHAPTER 13
Measles
Francis L. Black
1. Introduction may reach 10% or more in unfavorable circum-

stances, and worldwide it is estimated(38) that
In 1948, Kenneth Maxcy(6S) wrote in a chapter on measles accounted for 1 % of all deaths in a typical
epidemiology, "The simplest of all infectious dis- prevaccine year.
eases is measles." That was before the virus had
been isolated or any serological test had become
available, but the statement is true now, more 2. Historical Background
than 25 yr later, as it was then. This relative
simplicity makes measles an ideal model for the The writings of Abu Becr, known by his home-
study of infectious disease epidemiology. Babbott town name as Rhazes, provide our earliest de-
and Gordon(S) reviewed our knowledge of mea- scription of measles. Rhazes lived in the tenth
sles epidemiology as of 1954. Much has been century, but he quoted other authors on measles
clarified since. from as far back as Al Yehudi, who lived in the
Measles is a relatively distinct disease both clin- seventh century.* Rhazes looked on measles as a
ically and etiologically. The confusion that has relatively severe disease and considered it "more
sometimes occurred between measles and other to be dreaded than smallpox." It is curious, then,
exanthems, especially rubella and scarletina, can that measles had not been described earlier; small-
usually be avoided except in sporadic atypical pox had been accurately described by Galen in the
cases. A macular exanthem is the most prominent second century A.D.
sign of measles in the Caucasian race, but the Hasbah, the Arabic word for measles, which
enanthem, referred to as Koplik spots, is more Rhazes used, seems to be reasonably specific,
specifically characteristic. Respiratory tract in- although other exanthems were doubtless con-
volvement which peaks with the onset of rash, but fused. This word carries much the same connota-
which may be complicated by secondary invaders, tion as the English word "eruption." The precision
probably causes most of the mortality. The central of this name in Arabic is in contrast to classic
nervous system is regularly involved to a minor Greek, which had no specific word, and Latin,
degree, and frank encephalitis, which seems to be which came to use the descriptive terms rubeola
immunologically mediated, occasionally follows as and morbilla only during the Middle Ages. The
a delayed manifestation of the disease. Mortality is Teutonic languages have a common root word,
low when the underlying health is good, but it
• Some confusion has appeared in recent literature
Francis L. Black . Department of Epidemiology and through the fact that the first century after the Hegira
Public Health, Yale Univer~ity School of Medicine, New has been mistaken for the first century of the Christian
Haven, Connecticut era in dating Al Yehudi's life.
297
298 Chapter 13 • Measles
mazer, which became masern in German and mis- Work on the epidemiology of measles continued
lingar in Icelandic, as well as "measles" in English. in the twentieth century because this was ob-
The divergence of the Teutonic words suggests viously a good model for the development of
considerable antiquity for the original recognition epidemic theory, but there were more false starts
of the disease in northern Europe. than constructive discoveries, and the picture be-
Measles requires a human population of several came quite confused until 1954. In that year End-
hundred thousand persons if it is to find a suffi- ers and Peebles(371 isolated the virus and demon-
cient supply of new susceptibles to permit contin- strated immune reactions by neutralization and
uance of the virus.(20l Populations of this size did complement fixation tests. The serological tests
not exist prior to development of the Middle proved to be of immense value in delineating the
Eastern river valley civilizations. Therefore, mea- epidemiology of natural measles. The isolated vi-
sles, as we now know it, must have arisen since rus was attenuated to provide a vaccine whose use
that time, possibly by adaptation of rinderpest or fundamentally changed the epidemiological pat-
canine distemper viruses to man. This puts the tern of this disease wherever it has been exten-
appearance of the disease after 2500 B.C. The sively used. These products of Enders' and Pee-
linguistic evidence suggests that it was much later bles' work are part of our modern understanding
than that. There were massive epidemics in the of this disease and will be described in subse-
Roman Empire starting in 165 and in 251 A.D., and quent sections of this chapter.
two similar epidemics in China in 162 and 310.
McNeill(67) suggests that each of these represented
virg~n-soil outbreaks of smallpox and measles.
Historical records suggest that smallpox came first 3. Methodology Involved in Epidemiological
in the West and measles first in the East. Analysis
Rhazes recognized the seasonal nature of mea-
sles epidemics but seems not to have considered 3.1. Sources of Mortality Data
the disease infectious. Rather, he believed it a
necessary part of growing up. Sydenham/ 881 the Measles mortality rates are tabulated in the
first to describe measles in northern Europe, ap- World Health Statistics Annual, WHO, Geneva,
pears to have considered it infectious, but the first and by various national vital statistics publications
clear demonstration of this may be attributed to as, for instance, the Vital and Health Statistics
Home/ 53 ) who, in 1758, attempted a procedure published by the National Center for Disease Con-
with measles analogous to variolation smallpox. trol (CDC) of the United States. Mortality rates are
In 1846, Peter Panum went to the Faroe Islands affected by intercurrent problems such as malnu-
to give help during a measles epidemic. While trition and the age at which measles is contracted,
there he carried out an extraordinarily fruitful so they do not give an accurate picture of measles
investigation which led him to conclude that the incidence. Sometimes, however, where case re-
source of this disease was solely through conta- porting is very poor, mortality data may offer a
gion. He was also able to define the 14-day incu- better picture of changes in incidence than those
bation period and to show that infection conveyed available from reported cases.
lifetime immunity. (75) Hirsch(52) then ·built on
Panum's work to reach the conclusion that an
epidemic persisted "so long as there are found
susceptible individuals affording the poison a soil The reporting of measles cases to public health
adapted to its reproduction, whilst it perishes if authorities is mandatory in most sociologically
there be no ground to reproduce itself." A very advanced countries. However, measles is so com-
modern concept of the epidemic cycle involving monly regarded as a routine part of childhood that
input of new births and output of immunes to reporting is notoriously incomplete. Confusion
maintain a fluctuating population of susceptibles with other exanthems is also a problem, but this is
within stable limits was formulated by Hamer in usually important only in interepidemic periods,
1906.(48) when measles cases are few. Under these circum-
Chapter 13 • Measles 299
stances, falsely diagnosed cases may make up a Figures on reported cases for the nineteenth
significant proportion of the total. On the basis of century are available from a few European ci-
serological studies(24) and observations made dur- ties,l83) but, for the most part, reporting was
ing acute epidemics,l33) we may reasonably as- initiated only near the beginning of the twentieth
sume that essentially everyone contracts measles century, when quarantine was in vogue for the
unless vaccinated and that practically no one has control of infectious diseases. Prior to that time,
the disease more than once. Because of this inevit- there are numerous descriptions of epidemics of
ability of measles, the effectiveness of reporting measles but little information on routine inci-
may be estimated, over longer periods of time, by dence. Currently, measles is a reportable disease
determining the ratio between reported cases and in many countries, and the WHO Weekly Epide-
number·of births (minus infant deaths). The effi- miologic Reports tabulate these data. In the United
ciency of reporting may be quite variable. For States, the Weekly Morbidity and Mortality Re-
instance, in the United States, reporting of cases in ports of the CDC provide a current tabulation of
schoolchildren during the school year is usually reported cases.
more complete than reporting during the summer
or reporting of cases in preschool children. Never-
theless, reporting is usually sufficiently consistent
in anyone administrative area that epidemics are Serological methods have been of immense value
well defined and major differences in age distribu- in confirming and sharpening the precision of the
tion are clearly discernible. reported incidence of measles and in deciphering
1024
/.
.~.
512
.,,-,,- ..... ....--- ..

•••• )(........ 0 ........
256 • ""tk·· / X...."
,'<iii' / 'III"...
.! ,.' .~
"~
i '\
I" /
128
/
I
• •
,l f '-'"
:
• I
/ " ' ............. .
:
y. I .........·x··· ........... .
! / c. F.
: I
16 ! I
! I
: I
8 : p
: I
: I
4
iI
:/
.,,~
".. 2 3 5 10 40 100 365 1000
Day after rash onset
II 12 13 15 20 50
Days after vaccination
Fig. 1. Measles antibody titers in serum relative to time after infection with vaccine (HI) or wild virus (neutralization
and complement fixation).
patterns of incidence where there has been no Untreated infected tissue culture fluid may be
reporting .. Several tests are available: complement used as antigen, but treatment by ether and deter-
fixation, neutralization, hemagglutination inhibi- gent or ultrasonics increases the hemagglutinin
tion (HI), and hemolysis inhibition.(211 All give titer. The virus has no neuraminidase, and the test
similar results with serum from normal persons may be carried out at 37"C with less trouble from
(Fig. 1). Antibodies are not found in persons nonspecific reactions than at lower temperatures.
unexposed to the virus except for maternal anti-
bodies during the first year of life. Complement
fixation titers in immune persons are only slightly 4. Biological Characteristics of the Virus
less stable over extended periods of time than
titers measured by other methods. Hemolysis in- Measles virus is morphologically a member of
hibition titers may be slightly elevated relative to the paramyxovirus group, but it lacks neuramini-
titers obtained by other tests in certain specific dase and its hemagglutinin reacts with cells of Old
diseases. The hemagglutination inhibition test is World monkeys only. Curiously, human and
the most generally useful in epidemiological work chimpanzee erythrocytes are not agglutinated. The
because the test is sensitive, the titers are stable, virus has a large single-stranded RNA genome and
and the procedure is not time-consuming. synthesizes shorter complementary RNAs during
The serological reactions to measles are remarka- replication. The fact that the measles virus genome
bly specific, being unmodified by any other is comprised of a single molecule provides a par-
known human infection. Wherever these antibod- tial explanation for the fact that strain variation is
ies have been found, there has always been a not observed. The covalent links between cistrons
history of measles activity in the community, and would make recombination much more compli-
persons with antibody are resistant to infection cated than in influenza virus with its multiseg-
with wild or attenuated virus. Cross-reactions do men ted genome.
occur with canine distemper and with rinderpest, Measles virus is labile. Half the infectivity is lost
but humans exposed to these viruses do not be- every 2 h at 37"C even in favorable medium. It is
come naturally infected. inactivated by pH below 5, by proteolytic en-
Antibody titers induced by measles infection are zymes, and by strong light. It does not survive
unusually stable. (241 There may be a slow decline drying on a surface except when lyophilized.(IS)
in titer, but thi-s is scarcely more than that attribut- These properties mean that it has a short survival
able to the generalized reduction in antibody titer time on contaminated fomites. The acid sensitivity
associated with aging. Measles antibody titers in also means that it does not infect through the
nearly everyone who has had the disease remain stomach or lower alimentary tract and is not dis-
readily detectable for life (Fig. 1). Whether this seminated in the feces. However, the virus sur-
antibody titer stability indicates persistence of vives drying in micro droplets in the air relatively
latent virus remains unanswered. well. (551 In a droplet the virus would not be
mechanically crushed by surface tension, as it is
3.4. Laboratory Methods the last stage of drying on a flat surface. It is thus
able to spread effectively as an aerosol.
Technical details of laboratory methods have
been published elsewhere.(21,571 The hemagglutin-
ation inhibition test is the only test that has
unusual features. For this test, sera must be 5. Descriptive Epidemiology
treated with kaolin, or the y-globulin must be
5.1. Incidence
separated by ammonium sulfate precipitation, to
free it of nonspecific inhibitors. Old World mon- Reported measles cases in the United States
key erythrocytes must be used for the test; red prior to the introduction of vaccine numbered
cells from the genus Cercopithecus are usually pre- between 200,000 and 400,000 per annum, or
ferred. Antibody to these cells is removed from slightly less than 10% of the number of infants
serum by extraction with packed erythrocytes. entering the population. In localities where mea-
120 Reported Cases - 1972-1973
'\
110 6
100 rn ,, ,, ----- 1972

,,
UJ 5
rn ,, -1973
l3rn 90 « ,
u 4 ,,
5 80 u.
0
,,,
,
\,
\
,,
~ 70 rn 3
0
Z
,,
, \,
\
~ 60
«
rn 2
,,
\
,
~ 50 ::>
rn
5 40 0
J:
I-
i= 30
20 J FMAMJ JASOND
10
OL-----~--~~----~--~~~~==~~~~--~~--~~--~~~~~~~~=
1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973
Fig. 2. Measles cases reported by mouth to the U.s. National Center for Disease Control since the first vaccine was
licensed and interview surveillance was instituted in 1963.
sles reporting received close attention, however, week in any very large population even when the
the number of reported cases was about half the epidemic cycle is at a low point. In economically
number of births and direct questioning of parents advanced countries, measles epidemics are closely
raised this to 80% or more. Even this is a low tied to the school year, building to a peak in the
estimate because serological tests indicated that by late spring and ceasing abruptly after the summer
age 18 at least 98% of the popUlation had had recess has begun. This pattern, however, is only
experience with measles antigen. In fact, it ap- slightly different from that which prevailed in the
pears, therefore, that in the United States, as in all same countries before schooling became generally
but the most isolated comers of the world, the true available. Sydenham(881 describes an epidemic
incidence of measles was essentially equal to the that reached its peak in London in late March of
number of surviving children. 1670, and Schutz(83J provided data to demonstrate
Since the vaccine was introduced, the number of that March was the month of peak incidence in
reported cases has fallen to about one-tenth the Hamburg in the early nineteenth century.
former value (Fig. 2). We are left uncertain, how- Much work has been done to devise mathemati-
ever, whether this means that the number of cases cal formulas that will describe the sequence of
has been reduced to 10% or 1% of the natural measles epidemics and identify the parameters
incidence. With cases occurring less frequently, that control their course. With minor modifica-
each case generates more interest and, coupled tions, these formulas, developed from data on
with intensified surveillance efforts, much better measles incidence, describe the epidemic pattern
reporting is likely to result. On the other hand, of any acute infectious disease. In the case of
most measles is occurring in persons who were not measles, one may start with the two premises (1)
vaccinated and these are the persons least likely to that all persons are equally susceptible initially and
receive medical attention. (2) that when a susceptible is infected he re-
mains infectious for a limited period and then,
through death or acquired immunity, withdraws
5.2. Epidemic Behavior from any further participation in the epidemic cycle.
In populous parts of the world, measles causes Following the pioneering work of Hamer(48)
epidemics every 2-5 yr and each epidemic lasts 3-4 and Soper, (86) Bailey<6) and Bartlett(7-9) and others
months. A few cases are usually reported each have used measles as a model for definition of the
i~
~~
II)
~
4000
6000
( . ) 2 0 0 0 .
~ oooo~ C j
~ ::~~\
2000
n
r \
III
II h'~
\
A
i\
~ ,A\ A
i\
~~ •.wLL...._LVlL\.c..L\.&A.ti.oi&..•A.L\'.A.ll_.L
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
YEARS
Fig. 3. Actual and model measles epidemic curves. (A) Curve derived from the
deterministic model. (B) Curve derived from the stochastic model. (C) Actual curve
for Baltimore, Maryland, 1900-1920. Curves are redrawn to a common scale from the
work of Bartlett,(7) Griffiths/'B) and Hedrick.(50)
parameters that control cyclical epidemics and for curves based on this model show a remarkable
development of mathematical formulas to predict resemblance to actual measles epidemic curves
their course. (Fig. 3B,q. Bartlett's equation has been used to
It is evident that over a short period of time the predict that measles endemicity would exhibit
number of people infected will be dependent on breaks in continuity in any community with an
the number susceptible, as well as on the number average of fewer than 100 cases per week. Actual
who are already infected and capable of spreading observations(8,S) are in agreement with this; an
the disease. The number susceptible is continu- average of 80 cases in North America and of over
ously modified by new births in the community 106 in England was required for continuity. In
and by removal of susceptibles through infection. island popUlations where introductions are fewer
Since the number infected in one round depends and breaks in continuity more obvious, the critical
on the number infected in the previous round, it is value was between 260 and 320.(20)
relatively easy to develop formulas that will pre- The equation also predicts that the average in-
dict a cyclical oscillation in the epidemic pa.ttem, terval between epidemics will become shorter with
as in Fig. 3A. The epidemic waves in these simple increa:sing community size. This, too, confirms
models, however, are always subject to damping field observations. Griffiths(4B) has used the for-
and gradually approach a steady state. To get a mula to predict that vaccination of half the suscep-
more accurate picture of the way epidemics come tibles in a community will have only a minor effect
and go, it is necessary to recognize the role played on the peak measles incidence during an epidemic
by chance. but will result in increased intervals between epi-
When an epidemic is in the ebb phase, the demics.
number of cases may be quite small and the Even this model does not take into account a
number of new contacts highly variable. Using number of factors that modify natural outbreaks,
computer technology, Bartlett(7) selected values such as the effect of uneven distribution of per-
for the number of new cases in each round ran- sons within a community, seasonal variations in
domly from pools of possible numbers. Epidemic habits and virus stability, and the fact that the
disease is not transmissible during the early part from one community to another in proportion of
of the incubation period. If these added factors can persons infected at specific ages and proportion of
be incorporated into the formula, we may be the whole community susceptible to infection. In a
better able to predict the course measles incidence North American city, young children spend much
will follow in the present situation of extensive but time isolated at home, but when they enter school
incomplete vaccination programs. the number of contacts rises greatly. Most measles
(prior to vaccination campaigns) occurs in the
elementary school grades in these communities.
5.3. Geographic Distribution Overall, up to 15% of the total population is
Measles occurs regularly in every land,except in susceptible. On the other hand, in less developed
very remote and isolated areas. Strains of virus countries, young susceptible and infected children
from different countries are indistinguishable, and are commonly carried about by their mothers in
antibody in sera from diverse populations shows the course of their daily chores, greatly increasing
identical specificity. Nevertheless, the epidemic the number of contacts. Most measles occurs in
patterns, average age at the time of infection, and children under 4 yr of age, and the proportion of
the mortality vary considerably from one area to the total population susceptible may be less than
another (Fig. 4). 5%. When the number of close contacts is raised to
The average number of infective persons in a a very high level, as in military recruits, epidemics
community will bear a constant relationship to the of measles have occurred where less than 2% were
community size, if indeed all members are eventu- susceptible.
ally infected. However, there may be differences A characteristic of the epidemic curve noted by
" 100 A ",;/1 ._._.....-~-.-. __ -x

~o ."r New Haven __ x- - -
.
~'
Co I
IEgypt / ./ 1957 .....,k' - - -Iceland
..
80 " 1963. __ -- 1950-57
/"x-
(l:
j///
I
Fig. 4. Cumulative reported age-specific

...o"
u 60!
measles incidence (A) and age-specific per-
cent positive by serological test (B) in devel- /-
ae
.
"
oped, underdeveloped, thinly populated, and 40:

'
//
, x/
isolated areas. Egypt and Casablanca are typ- .~
; I • REPORTED CASES
ical of the pattern observed in populous "
:::I
20:: / /
underdeveloped areas. New Haven is charac- E
teristic of developed countries. In Iceland, the U
:::I
:;......../
population is relatively dispersed. St. Helena
.
I
B
....._._........~._New ._._._0
100 Haven 1957_._ 0 .0
is representative of an isolated population, >
rr~ P--·-·St. Helena 1963
which last experienced a measles epidemic ~ Casc bl anco,' I
r
'iii I
12-13 yrs prior to the time the sera were o 80
i: ..
Q.." 1954,$1
collected. The two methods of determining p'P .
."'-"
e.9
the age-specific attack rate give similar results
(f).!:! 60 x
except that in Iceland a significant part of the "''0
population escaped measles altogether and o~
ae.. zi ~,/
't
/ II .x----.. .
x- --i;.;iand 1949
the proportion immune did not reach more 40 I x.-x-"'"
than 60% even in the older age brackets. .~ >.
-.0
.2 ! j Vl~
! I
SEROLOGICALLY
E 20 ~x, POSITIVE
J I / i
:::I
U
~~~.~o.jG---~----~----~----~--~
5 10 15 20 25 39
Age (years)
20
.£c 15
!en
Fig. 5. Relation between average duration of mea-
sles epidemics and dispersity of population in areas
o
.~ 10 with about 2000--4000 new susceptible children per
"0
year. The ordinate plot of the inverse root of the
....,o
'Q.
number of new susceptibles introduced annually
c per square kilometer represents the mean distance
·2 between new susceptible persons.
e::>
o
b~--~----~2~--~3~---4~---75----~6~--~7~
Hamer(481 is that it has momentum. The more dry season of Rhazes' Persia(lI or modern Sahe-
intense the peak of the epidemic, the farther the lian Africa, (68) and thus explain the relatively high
epidemic will proceed below the equilibrium state incidence of measles during these seasons. How-
before it subsides. In isolated communities, where ever, it may equally well be that humans tend to
introductions of measles are few, a large number congregate most in these inclement seasons and
of susceptibles accumulate in the interepidemic that the more important effect of climate is indi-
period. This may lead to a very intense epidemic rect, through its effect on human habits.
peak, and before the epidemic subsides nearly
every susceptible person in the community will
become infected. When measles was first intro- 5.5. Age
duced to Greenland in 1951, all but five individu- Maternal antibody usually confers solid protec-
als in a susceptible population of more than 4000 tion to infants against measles for 6 months, and
were infected within 6 wk.(33) the disease may be modified by marginal levels of
Another factor affecting the number of persons maternal antibody remaining during the latter part
infected by each index case is simple population of the first year. Beyond the first birthday, all ages
density. In Greenland, the population was con- seem to be equally susceptible to infection, and
fined to a few coastal towns, making the probabil- the age at which measles is most commonly con-
ity of contact high. If, however, the population is tracted depends again on human habits rather
disperse, the probability of virus transmission is than on the nature of the virus.
reduced. This effect may be observed by compar- Measles mortality is highest in the very young
ing the duration of epidemics in various islands of and very old. This may be demonstrated with data
comparable population but different area (Fig. 5). from France collected by Celers(30) or with data
from two virgin-soil epidemics in the Arctic,
where all ages were infected (Table 1). It is not
always possible to dissociate direct effects of mea-
Dejong and Winkler(551 found that measles vi- sles virus from the effect of secondary bacterial
rus was most stable when the relative humidity invaders in determining this mortality, but in the
was below 40%. There was a second optimum 1951 Greenland epidemic a third of the deaths
above 80% humidity. The favorable effect of dry occurred in the period before the appearance of
air on virus would enhance spread in dry heated rash, when secondary infections probably had
homes in the northern winter, as well as in the hot little effect, and these early deaths were distrib-
Table 1. Measles Mortality by Age Group: tality is not limited to inexperienced peoples but
Percent of Cases also occurs in parts of West Africa and Central
America and occurred in Victorian Britain, where
Age France" Greenland, 1951' UngavaC the disease had long been known (Table 2).
Since 1951, data have become available from
<1 0.111 2.8 23.0
!
several virgin-soil epidemics. These figures indi-
1-2 0.054 1.5
cate that, in the absence of medical assistance, the
}
2-4 0.013 1.7
5--9 0.007 0.0 mortality was very high indeed but that emer-
gency medical aid could reduce the death rate
10-14 0.044 } 2.9
considerably. Where, as in Greenland, there was a
}
15--19
20-39
0.175
0.8
} 6.4 well-organized medical service, the mortality was
40-59 2.2 less than 1%. Even this rate, however, is high
60+ 13.3 20.0 relative to that in developed areas with good
medical services, where measles mortality is us-
a Data from Celers. (30)
b Data from Christensen et al. (33) ually about 0.02%. It is difficult to determine what
C Data from Peart and Nagler."·) part of the effect of medical care works on the
primary measles infection and what part on sec-
ondary invaders. In the best-characterized Green-
uted by age in the same manner as the total. land epidemic, deaths occurred before onset of
Contrary to popular opinion, young adults were rash in 0.6% of the cases. These deaths were
not more severely affected than children in the presumably due directly to the virus and they
Arctic epidemics. would have to be reduced to attain the lower
mortality rates observed elsewhere.
5.6. Sex Measles vaccine virus causes a mild form of
disease with all the primary symptoms of natural
No difference has been noted between the sexes measles but in reduced frequency and reduced
in either the incidence or the severity of measles. severity. It therefore provides a model with which
Antibody titers in women, however, are margin- host response to measles virus may be tested
ally higher than in men. under controlled conditions. Reactions to vaccine
in Micronesians, who had not been exposed to
natural measles for 20-30 yr, were not significantly
5.7. Race
different from reactions in other races.(29) How-
It is commonly believed that measles is a more ever, in four Amazon tribes which showed no
severe disease in races which have had limited serological evidence of ever having had experience
prior experience with it. For example, popular with measles, the vaccine produced an average
theory has it that the Polynesians and American maximum fever O.SOC higher than that which had
Indians are more severely affected than the Cauca- been observed in several cosmopolitan popula-
sian, Mongolian, and Negro races. This assump- tions.(23.92) This difference in febrile response may
tion has been based on the very high mortality not seem large but is the same as that achieved by
that occurred during measles epidemics when the giving 'Y-globulin with the less attenuated (Ed-
virus first reached these communities. In fact, monston) vaccine strains. The Indian tribes live
however, it 'is based on very few data: specific under conditions that are very different from those
numbers are nowhere available for measles deaths of the comparison groups, and it is by no means
in any virgin-soil epidemic prior to 1951. clear that the differences in the reactions are at-
Severe breakdown of the social organization tributable to race. Malnutrition is believed to be
may occur during virgin-soil epidemics because so the cause of the severe reactions in Africa/ 7m but
large a part of the whole population is affected at the Indian tribes were well nourished as indicated
one time, and this disruption may have greatly by body weight, by hair root diameter, and by
increased the mortality resulting from a moderate tabulation of available foodstuffs.
primary disease. Furthermore, high measles mor- At this time, it seems probable that racial differ-
Table 2. Measles Mortality Rates
Number of Percent Medical care

Place Year cases mortality Reference available
Endemic measles
Glasgow, Scotland 1908 22,000 4.8 (31)
Chile 1960 93,625 2.3 (79)
Rural Guatemala 1960-1963 206 6.8 (43)
Upper Volta 1963-1964 5,701 2.9 (68)
England and Wales 1961 764,000 0.020 (4)
Epidemic measles
Caucasian
Faroe Islands 1846 6,000 1.3 (75)
Iceland 1882 5,500 4.5 (52)
Iceland 1947-1956 21,091 0.12 (62)
Oceanic
Hawaii 1848 150,000 27 (47)
Fiji 1873 115,000 26 (35)
Samoa 1911 36,000 7.4 (52)
Warburton Range, 1961 206 3.0 (89)
Australia
Amerindians
Yagan, Argentina 1884 50 (28)
Julianahaab, Greenland 1951 4,320 1.8 (33) +
Ungava, Canada 1952 900 7.0 (78)
Baffin Island, Canada 1952 900 2.0 (78) +
Xingu, Brazil 1954 298 27 (73)
Xingu, Brazil 1954 356 9.6 (73) +
Jacobshaven, Greenland 1959 1,178 0.3 (11) +
Several towns, Greenland 1962 10,722 0.5 (12) +
Yanomama, Venezuela 1968 170 18 (72) +
ences in response to measles do exist but that The several factors represented in Table 3 all
these differences are only a partial explanation of showed significant correlation with measles his-
the high mortality rates that have been observed tory. However, these differences are of rather
in isolated populations. modest magnitude in comparison to the effects of
the same factors in other infections. In the first
school grade, most of the observed differences are
5.8. Occupation
attributable to incidence of infection during the
As has been observed in Section 5.2, occupa- preschool years. Within a few years of entering
tions and institutions do not ordinarily affect the school, nearly all of these children will have con-
nearly 100% incidence mte ultimately observed tracted measles regardless of family setting.
with measles. They do affect the age at which Gathering large numbers of recruits together
measles is usually contracted and the rapidity of increases the opportunities for measles transmis-
its spread by isolating or congregating susceptible sion, both by congregating them and by contin-
individuals. ually introducing new susceptibles. Measles epi-
demics were a major problem in the Civil War,
significant in World War I, minor in World War II,
5.9. Social Setting
and of little consequence in the U.S. forces since
Family size and circumstance exert a clear influ- that time (Table 4). These changes seem to reflect
ence on the age at which measles is contracted. (22) changes in the rural-urban distribution and in
Table 3. Social Characteristics Relative to Measles History"
Number of Residential Father's

Number siblings neighborhood b education"
Positive history 388 2.75 2.31 11.0

Negative history 168 1.98 3.54 12.5
a Children in the first school grade in New Haven, Connecticut, 1962, with serologically confirmed histories.
b Myers"''' 6-point scale: 1 the most and 6 the least favored.
, Average years of schooling.
school district size, which have reduced the num- supplement. Morley(70) noted a clinical correlation
ber of persons growing up in very small communi- between severe measles and kwashiorkor in West
ties, rather than any change in the military. The Africa and by means of a mail poll found that
changes in national social structure have resulted severe measles was more common in areas where
in a highly immune population at the time of kwashiorkor was relatively frequent.
induction. For example, in 1962, at least 98.8% of
the entering U.S. recruit population had antibody.
Nevertheless, 0.1 % of the military population de-
veloped measles annually,09l 6. Transmission
5.10. Socioeconomic Factors Proof that the transmission of measles is an

unusually efficient process lies in the evidence
Socioeconomic factors are related to many of the presented above: that it spreads very rapidly and
other factors described above and hence often reduces the susceptible proportion of a population
show a correlation to age at which measles infec- to extremely low levels. The chief mechanism of
tion occurs. This correlation, however, is weak transmission is clearly via aerosol. The fact that the
when compared to the effects observed with many most infectious stage of the disease is associated
other virus infections. The weakness of the associ- with sneezing and coughing doubtless increases
ation seems to be characteristic of viruses spread the amount of virus put into suspension.
by the respiratory route, which is little affected by Measles virus grows in tissues throughout the
standard hygienic practices. body, but the mucosal cells of the respiratory tract
are the main source of disseminated virus. In-
fected cells are not rapidly killed but continue to
5.11. Nutrition
release virus for several days. Adjacent cells are
It is generally believed that malnutrition may
increase the severity of measles substantially, but
controlled tests of this correlation are almost im- Table 4. Measles Rates in the U.S. Armed Forces
possible to obtain. Scrimshaw et al. (84) noted that
measles mortality in young children living in one Cases
Guatemalan village was reduced from 1% to 0.3% per 1000
per annum when the children were offered a man-yr Deaths
protein-rich dietary supplement. The rate stayed
Civil War 32.2 2.0
near 0.7% in a control village not offered the
Spanish-American War 26.1 0.32
supplement. However, since only 27% of the chil- World War I 23.8 0.57
dren who had the extra protein available to them World War II 4.7 0.004
actually took it regularly, it would appear that the Vietnam War, 1966 0.9
observed change was not entirely due to the food
often fused into syncytia and these may slough off. 7. Pathogenesis and Immunity
Whether inside sloughed cells or free, the virus is
delivered directly to the respiratory and urinary Although commonly classed as an exanthem,
excretions in a form that is readily put into aero- measles involves many body tissues. The lym-
sol. Virus excretion from the respiratory tract is phatic and mucosal epithelial cells are most promi-
reduced promptly on development of antibodies, a nently involved during the period when virus is
process that is synchronous with appearance of the multiplying.
rash, but the urine remains infectious a few days Infection with measles virus is followed by an
longer. (45) How often urine is the source of infec- incubation period that usually lasts 10-12 days.
tion is not clear, but the possibility of infection via This incubation period is longer in older persons,
the urine a few days after appearance of rash must and in adults may last as long as 3 wk. Failure to
be recognized. recognize the extended period in older persons has
In the early 1950s, Papp(7(i) conducted a series of sometimes invalidated quarantine precautions .
trials with measles to "prove" that the conjunctiva . This happened in the 1951 Greenland epi-
is the natural portal of entry. She found that a high demic. (33) Administration of virus by injection,
proportion of subjects were infected when secre- whether wild virus strains as used by Home(5;J) or
tions from measles patients were dropped into the vaccine virus as in current immunization practice,
eyes of susceptible children. Also, the proportion shortens the incubation period by 2 or 3 days.
of children infected, when they were put in the Differences in the size of the infecting dose also
same room as children with active cases, was have an effect on the duration of this period,'(iC;)
reduced if the susceptible subjects were protected but it is doubtful that large inocula are commonly
with goggles. She did not try administering the encountered in nature.
virus by other routes. However, experiments with The only evidence of disease during the incuba-
vaccine virus have not confirmed these conclu- tion period is a decreasing leukocyte count, espe-
sions: vaccine virus did not infect when dropped cially eosinophils and lymphocytesY4.2(;) Berg and
in the eye or when swabbed on the buccal mu- Rosenthal(!5) showed that the virus is capable of
cosaY5) On the other hand, vaccine virus growing in leukocytes. It is possible that this
dropped into the nose infected half the recipients. leukopenia is a direct result of virus action.
Vaccine virus. given as an aerosol fine enough to With the onset of the prodromal period, virus
reach the lower respiratory tract infected nearly appears in the tears, nasal secretions, throat, and
100%.'59 ) It is uncertain whether the more viru- urine. Little is known of the sequence and relative
lent wild virus used by Papp infected the conjunc- titer of virus in these fluids. Isolation of virus from
tiva more efficiently than the vaccine strain or natural sources has never been an easy procedure
whether the virus she administered drained because of the narrow tissue specificity of wild
through the lacrimal duct into the respiratory tract. virus and the fact that the early stages of disease
The fact that aerosols are important in measles are difficult to identify. The virus is doubtless
transmission does not mean that other mecha- widespread in the body during the prodrome; it
nisms are not operative. The lability of the virus, may be isolated from the blood at this time, and
however, would make indirect mechanisms ineffi- giant cells have been found in the lymph nodes,
cient. There is no significant vector of measles tonsils, and appendix. Neutrophil counts decline,
virus and no animal reservoir. Old World primates lymphocyte counts remain depressed, and eosino-
may be infected naturally or experimentally, but phils practically disappear during this period. Hy-
they usually get a mild disease.(27) Animals persensitivity reactions to a wide variety of anti-
caught in the wild are free of measles antibody gens are suppressed during the prodromal period.
unless they have lived in close proximity to hu- This effect may be nearly complete for a few days
mans or have been held in cages with large num- before and after onset of rash. Normal reactions to
bers of other animals.(l7) Unlike the situation dermal antigens return slowly, with some anergy
with yellow fever, the monkey does not serve to being demonstrable for about 1 month.(5!) It is
maintain measles endemicity. tempting to attribute this anergy to the destruction
of lymphocytes; measles virus has been shown to gives an adequate picture of measles immunity.
grow in vitro in both T- and B-like lymphocyte cell Cellular immunity is probably involved in elimi-
lines(4Ia) but T cells uniquely exhibit surface nating foci of infected cells,
binding sites for measles virus. (91) As discussed Free virus is quickly cleared from the blood with
in the next section, the electroencephalogram may the appearance of antibody but remains detectable
be abnormal during the prodromal period. in the leukocytes for 1 or 2 days longer. Lympho-
Koplik spots appear on the oral membranes and cyte and eosinophil counts return to the normal
sometimes on other mucosal surfaces toward the range quickly, The neutrophils remain depressed
end of the prodromal period. These seem to be a for a day or two and then recover their numbers
direct manifestation of virus pathology and cells in gradually,
the spots have been shown to contain virus nu- Like the Koplik spots, cells in the macules of the
cleocapsid. (87) rash contain nucleocapsidlike structures, (87! The
With the appearance of rash, both IgG and IgM two lesions show similar pathological changes ex-
antibodies become detectable by neutralization or cept that there are more inflammatory cells in the
hemagglutination inhibition tests. IgM antibody skin lesions. It seems probable that Koplik spots
titers do not greatly exceed the IgG even in the and rash are basically similar but that under the
early stages. Peak IgM titers are reached at about skin the lesions are not visible until an immunol-
10 days after rash, and they become undetectable ogical reaction with virus antigen on the surface of
again by about 30 days.(82) IgG titers reach a peak the cells of the capillary endothelium causes dila-
at about 30 days, fall two- to fourfold during the tion and extravasation. The synchrony between
ensuing 6 months, and then remain very nearly the appearance of rash and of circulating measles
stationary for life. Little is known of IgA antibody antibody is striking (Fig. 6) and suggestive of an
or cellular responses. Both are part of the immune etiological relationship. However, it is quite possi-
response to measles, (13,90) and it seems probable ble that cellular immunity, too, appears at this
that they play important roles in natural protec- time and that it, rather than antibody, causes the
tion. Despite the fact that circulating globulins rash.
passively administered will confer protection, it Once infectious measles virus is cleared from the
cannot be assumed that circulating antibody titer body, within a few days of the rash, it does not
(/)
0::
w
~
~1024 :
~ 512
o
"o
~ . o
00
.! :e!: : .: ! I
o o
~ 256
: •• 0 00
••• I
.
o 000
o
~
o
128 Ii !- • • 00
o
00 0
o
0
0 0
Fig, 6. Measles CF antibody ti- (!)

ters in Greenlanders relative to ~ 64 :1 •••
the time of onset of measles ~
~ 32
rash, Data from Bech."O) I-
~ 16
:2
~ 8
0..
:2
o() 4 .1
.-
< 4·· !h!!!'
-4 0 6 12 18 24 30 36 42 48 54 60
DAYS FROM ONSET OF RASH
reappear. No instance has been reported where may be responsible for many of the symptoms/ 58 )
new cases of measles have been attributed to but it seems probable that direct virus involve-
contact with persons who had had measles in the ment of the CNS precedes the immune response.
past. Nevertheless, the presence of measles virus As with measles virus in the skin prior to develop-
antigens and recoverable virus in the brain of ment of antibody, the virus in the brain seems to
patients with subacute sclerosing panencephalitis cause no symptom that is distinguishable from the
indicates that the virus may occasionally persist in general effects of the prodromal disease. The dam-
the body for long periods. The stability of anti- age accompanying the immune reaction to virus-
body titers throughout life further suggests that a containing tissues may be amplified if it exposes
continuing source of antigenic stimulation is the sequestered brain antigens and thus induces an
rule, not the exception. autoimmune response.
A high proportion of children with measles
encephalitis are left with sequelae, and there is
some evidence that even neurological involvement
8. Patterns of Host Response too mild to be diagnosed as encephalitis may leave
residua in many children.(4(),74)
The usual pattern of host response to infection 8.1.2. Subacute Sclerosing Panencephalitis
with measles has been described in Section 7. (SSPE). SSPE is a rare, slow, neurological disease
There are also certain rarer and more serious forms of older children that is accompanied by high
the disease may take. measles antibody titers in blood and CSF. Measles
IgM antibody is commonly demonstrable in the
serum. Children suffering from SSPE usually give
8.1. Clinical Features of Unusllal Forms
a history of measles infection some years previ-
8.1.1. Encephalitis. The incidence of measles 0usly. The primary infection commonly has oc-
encephalitis is about one in 2000 measles cases in curred before the second birthday. Reported cases
the more developed countries of the world, when in the United States show a concentration in boys
the denominator is corrected for underreporting of from rural parts of the southeastern states.(36) The
uncomplicated cases. Geographic variations in this geographic disproportion may, however, be an
rate are not of sufficient magnitude to be visible artifact of survey procedures.
against the varied background of different report- A virus can often be isolated from affected tissue
ing efficiencies. Increasing age is accompanied by by cocultivation of brain cells with a cell line that
an increasing proportion of measles patients af- is competent to replicate measles.(54) These SSPE
fected by encephalitis, and encephalitis occurs 2 or strains frequently differ from ordinary measles
3 times as frequently with measles in children over virus in host specificity, but there has been no
10 as in those under 5.(44) Onset may be from 1 to consistent pattern to these differences. Several
15 days after appearance of rash, but there is a SSPE strains have been compared to a measles
rather sharp peak frequency on the sixth day. strain with respect to antigenicity and no differ-
Measles encephalitis is probably not a distinct ences were found. Payne and Baublis(17) reported
disease but rather the visible peak of a process that five SSPE strains were all neutralized less
common to nearly all infections with wild measles effectively than one measles strain regardless of
virus. Abnormal electroencephalograms have been whether SSPE or measles antiserum was used in
reported in most acute-stage measles cases(42) and the test, but they could isolate an SSPE-like strain
in all prodromal stage cases(74) examined in one from their measles stock after a single selective
report. The virus has never been isolated from the passage in the presence of antiserum.
brain in measles encephalitis. Adams(2) has re- It is difficult to reconcile the idea of a distinct
ported finding inclusion bodies in the majority of SSPE agent with the epidemiology of the disease.
cases coming to autopsy, but it is not certain that The antigenic similarity probably means that in-
these inclusions are actually composed of virus fection with either SSPE or measles virus would
material. The timing and pathology of measles confer immunity to the other. This means the
encephalitis suggest that immunological reaction SSPE agent could oniy move in those few persons
who have no history of measles. If distribution of during the first week of rash will show a signifi-
SSPE virus were this restricted, the cases would cant increase in titer even when collected only a
probably be more distinctly clustered in time and few days apart. Reexposure of immune persons to
space than they are. the virus does not usually produce a boost in titer,
Rather, each SSPE strain may represent a sepa- and no serologically related virus is known to
rate variant of measles virus. The question then is infect man. Laboratory-confirmed diagnoses have
whether the variants arise during the primary very high reliability, and this fact makes measles
period of measles infection and determine the an ideal model for the study of detailed points in
neurological involvement or whether they only infectious disease epidemiology.
appear secondarily as a result of selective pres-
sures in the immune host, or even during the
protracted and selective manipulations that are
required to rescue the virus from nervous tissue. 9. Control and Prevention
In any case, the development of SSPE strains
might be attributable to host-related factors-im- Quarantine has been tried and has proven futile
munological deficiency that allowed modified vi- in the prevention of measles, except as a tempo-
rus to persist or a physiological anomaly that rary expedient in small isolated popUlations when
allowed virus to penetrate the nervous system. The used to gain time until vaccine can be adminis-
fact that most SSPE follows measles at a very early tered.
age implies that host factors are important. A more A killed vaccine against measles was found
detailed presentation of SSPE is given in Chapter effective in conferring temporary protection, but a
24. hypersensitive state sometimes followed this im-
munization, in which infection with either wild or
attenuated live measles virus caused unusual and
8.2. Diagnosis possibly serious disease. (41) This vaccine has been
8.2.1. Clinical. In the absence of modifying fac- withdrawn.
tors, such as 'Y-globulin prophylaxis or vaccines, Early forms of the live attenuated vaccine caused
the majority of measles infections follow a typical considerable reaction, (57) and there was reluctance
course that is quite distinctive. Koplik spots are to use them, especially in mass campaigns. 'Y-
particularly useful because they appear early and Globulin was commonly given in a separate site at
are not seen in other exanthems. The prodromal the same time as the early vaccine virus strains to
period is longer and associated with more fever reduce the reaction. This procedure has now been
than the rubella prodrome. Catarrhal symptoms almost entirely replaced by use of newer "further
are more prominent than in roseola or scarletina. attenuated" vaccine strains which cause a reaction
The rash is more macular than that of scarletina, comparable to typhoid vaccine. ((;()) Little or no
and, unlike in roseola, fever persists with rash. virus is excreted by vaccinees, and secondary
Lymphadenopathy is not characteristic as with spread to contacts is not a mechanism that in-
rubella or scarletina. creases vaccine coverage as with live poliovirus
In compilation of measles statistics, the reliabil- vaccine. The vaccine can be safely and effectively
ity of positive case reports is higher than that for administered in combination with other vaccine
most other infectious disease. Problems may occur viruses such as rubella, mumps, yellow fever, and
when vaccine use has reduced the number of new smallpox.
measles infections to a low level and atypical cases To confer immunity comparable to that con-
make up a large part of the remainder, but failure ferred by the natural disease, a vaccine must give
to report typical cases represents a greater prob- lifelong protection. Obviously, we cannot yet
lem. know if the vaccines meet this standard. The
8.2.2. Laboratory. Diagnosis by virus isolation antibody titers which they induce are lower than
is difficult, but serological techniques are useful. those induced by natural measles infection, but in
Appearance of humoral antibody is sufficiently most studies the titers have been equally stable.
rapid and regular that paired specimens collected We do know that a large proportion of vaccine
recipients are protected for at least 10 yr. (63) One as by less well-publicized immunization
careful study by Krugman,W) however, showed campaigns.
continuously declining titers in a group of vacci- 2. Accumulation of susceptible individuals
nated children who were protected from subse- through vaccine omission at a rate that is
quent exposure to measles virus. greater than their removal by natural dis-
Herd immunity to measles has been elusive. ease. Although the proportion susceptible
Reduction of cases by vaccination reduces the in the younger age groups is well below
number of persons naturally immunized; immuni- that of the prevaccine era, more and more
zation programs can never be 100% effective; and susceptible persons are moving into the
persons missed in successive years accumulate in upper school grades.
the population until epidemics are again possible. 3. Vaccine failures and possibly reversion to
The problems of vaccine distribution and effec- susceptibility with waning vaccine-in-
tiveness are discussed in the next section. With duced immunity. The importance of this
regard to control and prevention, it is only neces- third factor is not known.
sary to state that the measles vaccine is unusually
In 1973, most measles cases occurred in children
effective but vaccination of one person will not
who had never been vaccinated. Getting vaccine to
help another unvaccinated person.
all the poor of the central cities has proven an
especially difficult task. If a vaccination program
reaches 80% of those needing it, and the critical
10. Unresolved Problems level of susceptibles in the prevaccination popUla-
tion were 10%, as in New Haven during the 1950s,
10.1. Vaccine Distribution then the residual number of susceptible children
would be reduced, initially, to 2.0%. This would
The most pressing problem in measles control is
stop most virus spread. However, if the program
the increased incidence of disease that has held
continued 80% effective, 20% of each new age
since 1969, when the effect of the vaccination
program was most apparent.(H9) When the vaccine cohort would remain susceptible, and the critical
proportion would again be reached in the schools
came to be used in mass vaccination programs, the
in a few years. The total number of cases would be
number of reported cases plunged in spite of
reduced in proportion to vaccine usage, but epi-
greatly improved reporting. The number of cases
demics would occur. Even if less than 10% of the
in the United States fell from a probable actual
population were left unvaccinated, these unpro-
average of more than 4 million per year before
tected persons would not remain sequestered in
1967 to something close to the officially reported
their hoines but, as they grew up, would move
number of 22,000 in 1968. In areas where intensive
into large congregations, where, as we have seen,
vaccination campaigns were carried out, it could
less than 2% susceptible may provide fuel for an
be shown that the disease was eliminated except
epidemic. A vaccination program will have to be
for a small number of imported cases and even
extraordinarily thorough and the protection it af-
smaller number of secondary infections. (SIl It took
fords exceptionally solid if herd immunity to mea-
only a short extrapolation of this curve to indicate
sles is to be maintained.
that eradication would soon be achieved.(S5)
Naturally acquired measles immunity has been
In fact, the number of measles cases in the
demonstrated to be durable for life. We cannot
United States increased to 75,000 in 1971 and has
know whether vaccine-induced immunity will be
remained elevated in subsequent years. This in-
equally effective until it either fails or does in fact
crease is attributable to three factors:
persist through a normal life span. In a 1970
1. Slackening enthusiasm for the job of main- measles epidemic in St. Louis, Cherry et al. (32)
taining immunity rates in children being reported that 44% of 10,000 cases occurred in
added by birth to the pool of susceptibles. persons with a history of vaccination. This seems
This is reflected by vacillation in govern- an extraordinarily large number to attribute to
ment funding of vaccine programs as well technical errors in vaccination, although it may
have been less than 5% of all vaccine recipients. whereas the titer of nonspecifically transferred
Cherry et al. suggest that many of these cases antibodies in the CSF was usually 1/320 or less of
occurred in persons in whom the vaccine "took" the serum titer, measles titers in the CSF might be
but whose immunity waned. They cite certain 1/10 the serum titer. Recent studies(34.9()) have also
bizarre symptoms in this epidemic as reminiscent suggested that the lymphocyte response to measles
of the syndrome seen in persons who had had is suppressed in MS patients. Measles virus has
aberrant immune stimulation from killed measles been isolated from the brain of an MS patient on
vaccine. It seems probable that problems with the one occasion/ 391 but so have other viruses, and
vaccine-induced immunity will involve only a the significance of the isolation is hard to evaluate.
small proportion of all those vaccinated, but this On the basis of the immunological data, it is
might still be a large number of persons. Only clear that some specific relationship exists between
time and more investigation will determine their measles and a large proportion of MS cases. Stud-
magnitude. ies on migrants from areas of high to low MS
incidence indicate that the precipitating event in
MS occurs in adolescence. If we consider the
10.2. Unusual Reactions Following Killed Vaccine simplest possibility, that the event may be infec-
A problem which has been avoided in recent tion with measles, this would represent measles
years, but not eliminated, is that of the unusual infection unusually late in life, instead of unu-
and severe reactions which may accompany mea- sually early, as in SSPE. Unusually late measles is
sles infection in persons who have received killed compatible with the geographic distribution of
vaccine. These may include local reaction to subse- MS, which shows higher rates in northerly eco-
quently administered live vaccine(491 and severe nomically advanced countries. This is not to say
systemic reactions to wild virus.(41l The killed that there are not other factors involved in the
vaccine has been removed from the market, and etiology of this disease. It is quite clear that there
the fact that reports of this unusual response have are predisposing genetic factors, because there is
become uncommon suggests that the period of an unusual proportion of MS patients with the
sensitization is temporary. The underlying mecha- HL-A3 and -A7 tissue antigens. It is also quite
nism, however, remains poorly understood. It is clear that there is an autoimmune mechanism,
clear that this reaction reflects an immunological because antimyelin antibodies can be demon-
imbalance. Bellanti et al. (13) have shown that the strated. Much more work is needed before anyone
killed vaccine gives rise to little secretory anti- theory of the relation between measles and MS can
body, but these differences at the mucosal·surface be proven.
hardly explain the systemic reaction.
10.3. Measles and Multiple Sclerosis 11. References

A third unsolved problem is the relation of 1. ABu BECR, M., A Discourse on the Smallpox and Measles
measles to multiple sclerosis (MS). Adams and (trans. R. Mead), J. Brindley, London, 1748.
Imagawa(3) noted that the average measles anti- 2. ADAMS, J. M., Clinical pathology of measles enceph-
body titer in serum from MS patients was 1.4 alitis and sequelae, Neurology 18:52-56 (1968).
times higher than in controls. This difference is 3. ADAMS, J. M., AND IMAGAWA, D. T., Measles anti-
small, but it has been confirmed in many subse- bodies in multiple sclerosis, Proc. Soc. Exp. BioI.
quent studies. Even more striking than the serum Med. 111:562-566 (1962).
4. BABBOlT, F. 1., GALBRAITH, N. S., McDONALD, J. c.,
data, measles antibody was present in the CSF of
SHAW, A., AND ZUCKERMAN, A. J., Deaths from
70% of the patients and none of the controls. At
measles in England and Wales in 1961, Mon. Bull.
first, it seemed possible that the CSF antibody Minist. Health Public Health Lab. Servo 22:167-175
represented material that had leaked nonspecifi- (1963).
cally from the serum as a result of disease-induced 5. BABBOlT, F. 1., AND GORDON, J. E., Modem measles,
damage, but Salmi et al. (80) have shown that, Am. J. Med. Sci. 228:334-361 (1954).
6. BAILEY, N. T. J., The Mathematical Theory of Epidem- antibodies in residents of Tahiti and their stability in
ics, Griffin, London, 1957. the absence of re-exposure, J. Immunol. 88:725-731
7. BARTLEtT, M. S., Deterministic and stochastic (1962).
models for recurrent epidemics, Third Berkeley Symp. 25. BLACK, F. 1., AND SHERIDAN, S. R., Studies on
Math. Stat. Prob. 4:81-109 (1956). attenuated measles-virus vaccine. IV. Administration
8. BARTLEtT, M. S., Measles periodicity and community of vaccine by several routes, N. Eng!. J. Med. 263:166-
size, J. R. Stat. Soc. Ser. A 120:40-70 (1957). 170 (1960).
9. BARTLEtT, M. S., The critical community size for 26. BLACK, F. 1., AND SHERIDAN, S. R., Blood leukocyte
measles in the United States, J. R. Stat. Soc. Ser. A response to live measles vaccine, Am. J. Dis. Child.
123:37-44 (1960). 113:301-304 (1967).
10. BECH, V., Studies on the development of comple- 27. BLAKE, F. c., AND TRASK, J. D., Studies on measles.
ment fixing antibodies in measles patients, J. Immu- II. Symptomatology and pathology in monkeys ex-
nolo 83:267-275 (1959). perimentally infected, J. Exp. Med. 33:413-422 (1921).
11. BECH, V., Measles epidemics in Greenland, Am. J. 28. BRIDGES, E. 1., Uttermost Part of the Earth, Dutton,
Dis. Child. 103:252-253 (1962). New York, 1949.
12. BECH, V., The measles epidemic in Greenland, Arch. 29. BROWN, P., BASRIGHT, M., AND GAJDUSEK, D. c.,
Gesamte Virusforsch. 16:53-56 (1965). Response to live attenuated measles vaccine in sus-
13. BELLANTI, J. A, SANGA, R. 1., KLUTINIS, B., BRANDT, ceptible island populations in Micronesia, Am. J.
B., AND ARTENSTEIN, M. S., Antibody responses in Epidemiol. 82:115-122 (1965).
serum and nasal secretion of children immunized 30. CELERS, J., Problemes de sante publique poses par la
with inactivated and attenuated measles virus vac- rougeole dans les pay favorises, Arch. Gesamte Virus-
tines, N. Engl. J. Med. 280:62S-633 (1969). forsch. 16:5-18 (1965).
14. BENJAMIN, B., AND WARD, S. M., Leukocyte response 31. CHALMERS, A K., The Health of Glasgow 1818-1925,
to measles, Am. J. Dis. Child. 44:921-963 (1932). Bell and Bain, Glasgow, 1930.
15. BERG, R. B., AND ROSENTHAL, M. S., Propagation of 32. CHERRY, J. D., FEIGIN, R. D., LOBES, 1. A., JR.,
measles virus in suspensions of human and monkey HINTHORN, D. R., SHACKLEFORD, P. G., SHIRLEY, R.
leukocytes, Proc. Soc. Exp. Bio!. Med. 106:581-585 H., LINs, R. D., AND CHOI, S. C., Urban measles in
(1961). the vaccine era: A clinical, epidemiologic and serol-
16. BERTRAMS, J., AND KUWERT, E., H-LA antigen segre- ogic study, J. Pediat. 81:217-230 (1972).
gation analysis in multiple sclerosis, Lancet ii:43-44 33. CHRISTENSEN, P. E., HENNING, S., BANG, H. 0.,
(1974). ANDERSEN, V., JORDAL, B., AND JENSEN, 0., An
17. BHAtT, P. N., BRANDT, C. D., WEISS, R. A., Fox, J. epidemic of measles in southern Greenland, 1951.
P., AND SHAFFER, M. F., Viral infections of monkeys Measles in virgin soil. II. The epidemic proper, Acta
in their natural habitat in southern India, Am. J. Med. Scand. 144:430-449 (1952).
Trop. Med. Hyg. 15:561-566 (1966). 34. CIONGOLl, A. K., PLATZ, P., DUPONT, B., SVEJGAARD,
18. BLACK, F. 1., Growth and stability of measles virus, A., FOG, T., AND JERSLID, c., Lack of antigen re-
Virology 7:184-192 (1959). sponse to myxoviruses in mUltiple sclerosis, Lancet
19. BLACK, F. 1., A nationwide survey of United States ii:1147 (1973).
military recruits, 1962. III. Measles and mumps anti- 35. CORNEY, B. G., The behavior of certain epidemic
bodies, Am. J. Hyg. 80:304-307 (1964). diseases in natives of Polynesia with especial refer-
20. BLACK, F. 1., Measles endemicity in insular popula- ence to the Fiji Islands, Trans. Epidemiol. Soc. London
tions: Critical community size and its evolutionary (n.s.) 3:76-95 (1884).
implication, Theor. Bioi. 11:207-211 (1965). 36. DETELS, R., BRODY, J. A., McNEW, J., AND EDGAR, A
21. BLACK, F. 1., Measles, in: Manual of Clinical Microbi- H., Further epidemiological studies of sub-acute
ology, 2nd ed. (E. H. LENNETTE AND J. P. TRUANT, sclerosing panencephalitis, Lancet ii:11-14 (1973).
eds.), American Society of Microbiology, Bethesda, 37. ENDERS, J. F., AND PEEBLES, T. C., Propagation in
Md., 1974. tissue cultures of cytophathogenic agents from pa-
22. BLACK, F. 1., AND DAVIS, D. E. M., Measles and tients with measles, Proc. Soc. Exp. Bioi. Med.
readiness for reading and learning. II. New Haven 86:277-286 (1954).
Study, Am. J. Epidemiol. 88:337-344 (1968). 38. FENNER, F., The Impact of Civilization on the Biology of
23. BLACK, F. L., HmRHOLZER, W., WOODALL, J. P., AND Man (S. V. BOYDEN, ed.), University of Toronto
PINHEIRO, F., Intensified reactions to measles vaccine Press, Toronto, 1970.
in unexposed populations of American Indians,· J. 39. FmLD, E. J., COWSHALL, S., NARANG, H. K., AND
Infect. Dis. 124:306-317 (197l). BELL, T. M., Viruses in multiple sclerosis, Lancet
24. BLACK, F. 1., AND ROSEN, 1., Patterns of measles ii:280-281 (1972).
40. Fox, J. P., BLACK, F. L., AND KOGON, A., Measles and measles virus in air, Nature (London) 201:1054-1055
readiness for reading and learning. V. Evaluative (1964).
comparison of the studies and overall conclusions, 56. KATZ, S. L., AND ENDERS, J. F., Measles virus, in:
Am. J. Epidemiol. 88:168--175 (1969). Diagnostic Procedures for Viral and Rickettsial Infec-
41. FULGINITI, V. A., ELLER, J. J., DOWNIE, A. W., AND tions, 4th ed. (E. H. LENNETTE AND N. J. SCHMIDT,
KEMPE, C. H., Altered reactivity to measles virus: eds.), American Public Health Association, New
Atypical measles in children previously immunized York,1969.
with inactivated measles virus vaccines, J. Am. Med. 57. KATZ, S. L., KEMPE, C. H., BLACK, F. L., LEPOW, M.
Assoc. 202:1075-1080 (1967). L., KRUGMAN, S., HAGGERTY, R. J., AND ENDERS, J. F.,
41a. GALLAGHER, M., AND FLANAGAN, T. D., Growth of Studies on an attenuated measles-virus vaccine. VIII.
measles in continuous lymphoid cell lines, Fed. General summary and evaluation of the results of
Proc. 34:948 (1975). vaccination, N. Engl. J. Med. 273:180-184 (1960).
42. GIBBS, F. A., GIBBS, E. L., CARPENTER, P. R., AND 58. KOPROWSKI, H., The role of hyperergy in measles
SPIES, H. W., Electroencephalographic abnormality encephalitis, Am. J. Dis. Child. 103:273-278 (1962).
in "uncomplicated" childhood diseases, ]. Am. Med. 59. KRESS, S., SCHLUEDERBERG, A. E., HORNICK, R B.,
Assoc. 171:1050-1055 (1959). MORSE, L. J., COLE, J. L., SLATER, E. A., AND
43. GORDON, J. E., JANSSEN, A. A. J., AND ASCOLI, W., MCCRUMB, F. R, Studies with live attenuated mea-
Measles in rural Guatemala, J. Pedial. 66:779-786 sles-virus vaccine. II. Clinical and immunological
(1965). response of children in an open community, Am. ].
44. GREENBERG, M., PELLITTERI, 0., AND EISENSTEIN, D. Dis. Child. 101:701-707 (1961).
T., Measles encephalitis. 1. Prophylactic effect of 60. KRUGMAN, S., GILES, J. P., JACOBS, A. M., AND
gamma globulin, J. Pedial. 46:642-{'47 (1955). FRIEDMAN, H., Studies with a further attenuated live
45. GRESSER, I., AND KATZ, S. L., Isolation of measles measles-virus vaccine, Pediatrics 66:471-488 (1965).
virus from urine, N. Engl. J. Med. 263:452-454 (1960). 61. KRUGMAN, S., Present status of measles and rubella
46. GRIFFITHS, D. A., The effect of measles vaccination immunization in the United States: A medical prog-
on the incidence of measles in the community, J. R. ress report, J. Pedial. 78:1-16 (1971).
Stat. Soc. Ser. A 136:441-449 (1973). 62. Landlaekni, Heilbrigdisskyslur (Public Health in Ice-
47. GULICK, L. H., On the climate, diseases and materia land), Rikisprentsmidjan Gutenberg, Reykjavik, 1950,
medica of the Sandwich (Hawaiian) Islands, N.Y. J. 1957.
Med. 14:169-211 (1855). 63. LEPOW, M. L., AND NANKERVIS, G. A., Eight-year
48. HAMER, W. H., The Milroy lectures on epidemic serological evaluation of Edmonston live measles
disease in England-The evidence of variability and vaccine, J. Pedial. 75:407-411 (1969).
persistency of type, Lancet 1:733-739 (1906). 64. LUMSDEN, C. E., in: Multiple Sclerosis: A Reappraisal,
2nd ed., Williams and Wilkins, Baltimore, 1972.
49. HARRIS, R. W., ISACSON, P., AND KARZON, D. T.,
65. MAXCY, K. F., Principles and methods of epidemiol-
Vaccine induced hypersensitivity: Reactions to live
ogy, in: Viral and Rickettsial Infections of Man (T. M.
measles and mumps vaccine in prior recipients of
RIVERS, ed.), Lippincott, Philadelphia, 1948.
inactivated measles vaccine, J. Pedial. 74:552-563
66. MCCRUMB, F. R, KRESS, S., SAUNDERS, E., SNYDER,
(1969).
M. J., AND SCHLUEDERBERG, A. E., Studies ~ith live
50. HEDRICK, A. W., Monthly estimates of the child
attenuated measles vaccine. I. Clinical and immunol-
population susceptible to measles 1900-1931, Am. J.
ogical responses in institutionalized children, Am. ].
Hyg. 17:613-636 (1933). Dis. Child. 101:689-700 (1961).
51. HELMS, S., AND HELMS, P., Tuberculin sensitivity 67. McNEILL, W. H., Plagues and Peoples:' A Natural
during measles, Acta Tuberc. Scand. 35:166-171
History of Infectious Diseases, Doubleday, New York
(1956).
(in press).
52. HIRSCH, A., Handbook of Geographical and Historical 68. MEYER, H. M., Mass vaccination against measles in
Pathology, Vol. 1, pp. 154-170, New Sydenham Soci- Upper Volta, Arch. Gesamte Virusforsch. 16:243-245
ety, London, 1883. (1965).
53. HOME, F., Medical Facts and Experiments, A. Millar, 69. Measles-United States, first 36 weeks, 1973, Morbid-
London, 1759. ity Mortality Weekly Rep. 22:310 (1973).
54. HORTA-BARBOSA, L., FUCCILO, D. A., HAMILTON, R, 70. MORLEY, D., The severe measles of West Africa, Proc.
TRAUB, R, LEY, A., AND SEVER, J. L., Some character- R. Soc. Med. 57:846-849 (1969).
istics of SSPE measles virus, Proc. Soc. Exp. BioI. 71. MYERS, J. M., Assimilation to the ecological and
Med. 134:17-21 (1970). social systems of a community, Am. Sociol. Rev.
55. DEJONG, J. G., AND WINKLER, K. 0., Survival of 15:367-370 (1950).
72. NEEL, J. V., CENTERWALL, W. R., CHAGNON, N. A., 82. SCHLUEDERBERG, A. E., Immune globulins in human
AND CASEY, H. 1., Notes on the effects of measles in viral infections, Nature (London) 205:1232-1233
virgin-soil population of South American Indians, (1965).
Am. J. Epidemiol. 91:418--429 (1970). 83. SCHUTZ, F., Die Epidemiologie der Masern, Gustav
73. NUTELs, N., Medical problems of newly contacted Fisher, Jena, 1925.
Indian groups, PAHO Sci. Pub. 165:68-76 (1968). 84. SCRIMSHAW, N. S., SOLOMON, J. B., BRUCH, H. A.,
74. PAMPIGLIONE, G., Prodromal phase of measles: Some AND GORDON, J. E., Studies of diarrheal disease in
neurophysiological studies, Br. Med. J. ii:1296-1300 Central America. VIII. Measles, diarrhea and nutri-
(1964). tional deficiency in Guatemala, Am. J. Trap. Med.
75. PANUM, P. 1., Observations Made During the Epidemic 15:625-631 (1966).
of Measles on the Faroe Islands in the Year 1846, 85. SENCER, D. J., DULL, H. B., AND LANGMUIR, A. D.,
American Publishing Association, New York, 1940. Epidemiologic basis for eradication of measles in
76. PAPP, K., Experiences prouvant que la voie 1967, Public Health Rep. 82:1253-1256 (1967).
d'infection de la rougeole est la contamination de la 86. SOPER, H. E., The interpretation of periodicity in
muqueuse conjonctivale, Rev. Immunol. 20:27-36 disease prevalence, J. R. Stat. Soc. Ser. A 92:34-61
(1956). (1929).
77. PAYNE, F. E., AND BAUBLIS, J. V., Decreased reactivity 87. SURINGA, D. W. R., BANK, 1. J., AND ACKERMAN, A.
of SSPE strains of measles virus with antibody, J. B., Role of measles in skin lesions and Koplik spots,
Infect. Dis. 127:505-511 (1973). N. Engl. J. Med. 283:1139-1142 (1970).
78. PEART, A. F. W., AND NAGLER, F. P., Measles in the 88. SYDENHAM, T., The Works of Thomas Sydenham, Vol.
Canadian Arctic 1952, Can. J. Public Health 45:146- 2, pp. 250-251, Sydenham Society, London, 1922.
157 (1954).
89. TOOTH, J. S. H., AND LEWIS, I. c., Measles epidemic
79. RISTORI, c., BOCCARDO, H., BORGONO, J. M., AND
in a primitive isolated community, Med. J. Aust.
ARMIJO, R., Medical importance of measles in Chile,
1:182-186 (1963).
Am. J. Dis. Child. 103:236-241 (1962).
80. SALMI, A. A., NORRBY, E., AND PANELIUS, M., Identi- 90. UTERMOHLEN, V., AND ZABRISKIE, J. B., A suppres-
sion of cellular immunity in patients with multiple
fication of different measles virus-specific antibodies
sclerosis, J. Exp. Med. 138:1591-1596 (1973).
in the serum and cerebro-spinal fluid from patients
with sub-acute sclerosing panencephalitis and multi- 91. VALDIMARSSON, H., AGNARSDOTIIR, G., AND LACH-
ple sclerosis, Infect. Immun. 6:248-254 (1972). MANN, P. J., Measles virus receptor on human T
81. SCHAFFNER, W., SCHLUEDERBERG, A. E., AND BYRNE, lymphocytes, Nature (London) 225:554-556 (1975).
E. B., Clinical epidemiology of sporadic measles in a 92. VIERA, J. P. B., JR., Vacinadio dos indios Surui
highly immunized population, N. Eng/. J. Med. contra 0 sarapo, Rev. Assoc. Med. Brazil 16:183-186
279:783-789 (1968). (1968).
CHAPTER 14
Mumps
Harry A. Feldman
1. Introduction summarized as follows(65):

Knowledge of mumps has developed within 3
Mumps is an acute communicable disease of chil- periods. The first was concemed chiefly with
dren and young adults caused by a single strain of the study of frank epidemics, and established
a myxovirus. Epidemiologically mumps has played both the communicability of the condition and
an important role in armies during mobilization, its wide distribution. Hirsch's collection of
resulting in widespread morbidity. In addition to some 150 epidemics, occurring between 1714
producing the well-known syndrome of parotitis, and 1859, showed the disease to be prevalent
it also is the most common cause of meningoence- from Iceland to Egypt, and from Alaska to Poly-
nesia. Accumulated evidence from outbreaks in
phalitis; additional manifestations include orchi-
the first half of the 19th century demonstrated
tis, mastitis, oophoritis, and pancreatitis. another epidemiologic feature of mumps, its
predilection for prisons, orphanages, boarding
schools, garrisons, and ships. The second gen-
2. Historical Background eral advance was concemed with better defini-
tion of the clinical features of mumps, credit for
which goes in large part to a brilliant line of
An outbreak of mumps or epidemic parotitis
French army surgeons. The third era was initi-
probably was described by Hippocrates in the fifth ated with the production of mumps experimen-
century B.C. as an illness accompanied by swelling tally and the recognition of the specific infec-
near the ear and painful enlargement of the testes, tious agent.
either unilaterally or bilaterally. Hamilton in 1790
not only emphasized the importance of orchitis as Gordon and Heeren,<47> reviewing the epide-
a manifestation of the disease but also thought miology of mumps in anticipation of America's
that some patients had symptoms related to the becoming involved in World WarII, quoted Haven
central nervous system. This was recognized early Emerson that in World War I, as a cause of days
in the present century. lost from active duty, mumps was the most impor-
But until relatively recently mumps was viewed, tant disease to affect the American army in France.
primarily, as an illness which affected armies dur- Similarly, Surgeon General Parran of the Public
ing times of mobilization. Its history has been Health Service said that mumps was exceeded only
by venereal disease as a disabling acute infection
of recruits.
Harry A. Feldman . Department of Preventive Medi- In their landmark report of the successful trans-
cine, State University of New York, Upstate Medical mission of mumps from patients to rhesus mon-
Center, Syracuse, New York keys in 1934, Johnson and Goodpasture(65) clearly
317
318 Chapter 14 • Mumps
demonstrated that mumps was caused by a filtra- titers, but are detectable for longer periods than
ble virus present in saliva. With the development are those induced by the S antigen. Antibodies for
of specific serological techniques, it soon became the S antigen are measurable by complement fixa-
evident that mumps was a generalized disease tion (CF) and do not seem to relate to protection.
with a particular proclivity for glandular tissues Several varieties of antibodies-CF, hemagglutina-
such as the parotids, ovaries, testes, and pancreas, tion inhibition (HI), and neutralization (N)-are
but on occasion the central nervous system, myo- induced by the V antigen and are indicative of
cardium, and kidneys. Furthermore, 30-40% of immunity. Delayed hypersensitivity with positive
people were found to be immune apparently as the skin reactions also develops in those who have
result of asymptomatic infections. When coupled had mumps or have received either inactivated or
with underreporting (only about 12% are re- live virus vaccines.
corded), the gathering of precise epidemiological Immunity follows both clinically apparent and
data becomes obviously very difficult. inapparent infections. Second infections can occur,
Cultivation of mumps virus in the developing but their rate is unknown and their clinical expres-
chick embryo was described by Habel(50J in 1945, sion and complications are infrequent.
and an experimental vaccine produced in 1946(5oaJ
was used in humans in 195V 50b ) A live mumps
virus vaccine has been used in Russia since the 4. Methodology Involved in Epidemiological
early 1960s.(1111 Successful trials of a live atten- Analysis
uated mumps virus vaccine in the United States by
Weibel et al. <l25al led to its licensure in December
4.1. Sources of Data
1967.
In view of the frequency with which clinically
asymptomatic and undiagnosed cases of mumps
3. The Agent occur and the fact that most cases are not reported,
all epidemiological data are somewhat suspect. It
Myxovirus parotiditis, the cause of epidemic comes as no surprise that much of the information
parotitis, is a member of the same group which on incidence, prevalence, complications, and fatal-
includes the influenza, parainfluenza, and New- ities is drawn from military sources where epi-
castle disease viruses. It is an RNA virus with a demics have been almost a tradition. These will be
nucleoprotein core (S antigen) surrounded by a dealt with subsequently.
lipid-containing outer membrane which is suscep- In recent years the source of the most useful data
tible to ether and chloroform. The outer surface has been the Epidemiology Program of the Center
contains a neuraminidase and a hemagglutinin (V for Disease Control (CDC), which instituted a
antigen) and induces protective antibodies. There mumps surveillance program in January 1968,<211
is only one serotype. Readily destroyed by heat, when, coincidentally with the licensing of atten-
the virus also is inactivated by 0.2% formalin, uated live virus mumps vaccine, mumps was rein-
ultraviolet light, and other agents. stated as a notifiable disease. First .put on the
Mumps virus is found only in man, but has notifiable list in 1922, it had been removed in
been adapted to monkeys, chick embryos, and 1950, although some states, with variable effec-
tissue cultures. Newcastle disease and parainflu- tiveness, had continued their own reporting sys-
enza viruses, but not influenza, produce antibod- tems. A second CDC report(22) was issued in
ies which cross-react with mumps virus. Antibod- September 1972 and a third(23) in October 1974.
ies to the various components of mumps virus Mumps also is recorded in the Morbidity and
appear at different rates and time intervals. Those Mortality Weekly Reports (MMWR) which are
to the S antigen are apparent by the seventh day published by CDC and summarized annually.
after the onset of illness and reach their peak All incidence and prevalence data err on the low
within about 2 wk. Antibodies to the V antigen side, for several reasons: at least some reported
appear somewhat slower, requiring 2-3 wk for cases of aseptic meningitis and encephalitis are
detection and another week or two for maximum related to mumps, subclinical cases of mumps are
Chapter 14 • Mumps 319
frequent, and underreporting is common. Aside early stage of infection, whereas the reverse sug-
from the CDC data, many individual local and gests convalescence or later.
state health departments continue to provide in- 4.3.4. Skin Test. The antigen for the skin test,
formation for their areas. Other useful information originally produced from mumps-infected monkey
has been provided from military experiences, parotid, usually is now made from infected chick
especially those in World War I and World embryos. It is difficult to standardize but generally
War II. (47,48,74,89) contains a defined amount of HA or CF antigen.
Reactions are of the delayed type. A minimum of
10 mm of erythema usually is required for a
4.2, Serological Surveys "positive," but some authors insist on a larger area.
A number of serological surveys utilizing the Positive reactions are assumed to indicate immun-
method(s) available at a particular time have been ity, but variable results have been reported. Skin
reported. For these purposes, CF, HI and N tech- tests probably do not induce antibody responses
niques, as well as skin tests, were em- except as a secondary response. Probably useful for
ployed. oo.I1 ,57.60,68.83.85.98) the study of cell-mediated immunity, mumps virus
skin tests are of relatively minor value in the esti-
mation of resistance to infection.
4.3.5. Hemagglutination Inhibition (HI). Lev-
Henle(55) recently reviewed the laboratory pro- ens and Enders(82) found allantoic fluid from in-
cedures available for the study of patients and fected chick embryos to agglutinate fowl erythro-
popUlations for mumps. cytes which were inhibited by both human and
4.3.1. Virus Isolation. The virus was first trans- monkey convalescent sera. This reaction, similar
mitted to monkeys by Johnson and Goodpas- in all respects to that produced by influenza vi-
ture,(65) but Habel(50) adapted it to developing ruses, has been evaluated by several investigators
chick embryos from infected monkey parotid tis- and correlates quite well with CF tests. A variety
sue and found both CF and skin test antigens to be of red cells can be used and antibodies seem to
produced. Henle and McDougall(58) transmitted persist, but clear end points are sometimes diffi-
the virus directly to chick embryos with spinal cult to achieve.
fluid from a human patient. Later, Levens and
Enders(82) demonstrated hem agglutinins in the
amniotic fluids of such infected eggs. Virus has 5. Descriptive Epidemiology
been isolated from saliva, blood, spinal fluid, and
parotids, but this is not often attempted since
5.1. Incidence and Prevalence
several effective serological techniques are avail-
able. During 1974/20> 59,128 cases of mumps were
4.3.2. Neutralization (N). Neutralizing antibod- reported in the United States, as opposed to 69,612
ies have been detected in serum-virus mixtures during the preceding year and a 5-yr median of
inoculated into embryonated eggs or tissue cul- 88,380. The cases reported to CDC in 1974 repre-
tures. The latter generally are used, with the end sented a disease incidence of 29.0 per 100,000, the
point being taken as the demonstration of cyto- lowest in the history of mumps surveillance. The
pathic effects (CPE) , hemadsorption, or interfer- rates of reported cases of mumps, by month, in the
ence. Titers as low as 1:2 are accepted as indicative United States from 1922 to 1973 are depicted in
of specific immunity. Fig. 1. The highest number of cases was recorded
4.3.3. Complement Fixation (CF). Two antigens in 1964, with 212,932 reported and a rate of about
are used for complement fixation, (55) each supply- 250 per 100,000. Since the licensure of mumps
ing somewhat different information. Antibodies to vaccine in December 1967, there has been a steady
S (soluble) antigen appear early, while those to V decrease in reported cases to well below 75,000.
(viral) antigen appear in convalescence and persist The significance of this is not yet certain, but the
for many years. Thus a positive test with the fact that in the 5 yr preceding vaccine introduction
former and negative with the latter indicate an no year had fewer than 114,000 reported cases
260
z 240
2I- 220
:3 200
~ 180
~ 160
8 140 Fig. 1. Reported cases of mumps,
0, 120
8... 100 United States, 1922-1973. From
Center for Disease Control. (23)
ffi
a..
80
CI)
w
~ 40
u 20
O~~~~~~-U __~~L-~~~-U_ _~~~~~
1922 '26 '30 '34 '38 '42 '46 '50 '54 '58 '62 '66 '70 '74
YEAR
suggests that the decrease is associated with vac- 1973. Some 2.5 cases of mumps encephalitis were
cine utilization. reported for every 1000 cases of mumps, and there
The incidence of mumps encephalitis and of were some 1.6--3.8 fatalities pet 10,000 cases of
mumps deaths is compared in Fig. 2 with the reported mumps.
incidence of reported mumps for the years 1960- As mentioned in Section 4.1, the number of
reported cases of mumps falls far short of the
actual number. This underreporting occurs be-
300,000 MUMPS cause a patient with mumps must first seek medi-
cal care by a physician, which often does not
happen with milder cases, and the physician must
properly diagnose and report the case; the latter
~50,OOO often falls short of attainment by the busy physi-
!;{ cian. Furthermore, even if all cases were recog-
w nized and reported, the total picture of mumps
Cl
Cl infection would be grossly underestimated because
z of the predominance of mild and subclinical cases.
« 1,000
CI)
w An example of the magnitude of these errors is
~ 500 illustrated by a seroepidemiological study of 126
u cases and 233 contacts carried out by Levitt et
u..
o al. (831 in Florida. Based on their data, they esti-
a: mated the yearly incidence rate to be 19.5 per 1000
w
~ 100 or about 10 times the national surveillance figure
~ MUMPS DEATHS based on reported cases alone. Of the 126 cases
z
identified, only 27% resulted in a visit to a physi-
cian and only 6% were actually reported. In addi-
tion to the clinical cases, serological tests revealed
that 25% of the family contacts had had inapparent
infections. From 14 to 46% of family contacts
1960 '62 '64 '66 '68 '70 '72
develop secondary clinical cases, the rate varying
Fig. 2. Reported cases of mumps (1960-1973), mumps with the age of the contact. No serological evi-
encephalitis (1960-1971), and mumps-associated deaths dence of reinfection was found in reexposed adults
(1960-1971), United States. From Center for Disease Con- by the complement fixation or hemagglutination
trol. (23) inhibition tests.
5.2. Survey Data needed because they did not always agree. Varia-
bility between different lots of commercial skin
Several types of population surveys have been test antigens has been found when compared to
carried out to determine the patterns of suscepti- serum neutralization tests. (12.105) The results of the
bility and immunity within a community. These skin test may not accurately reflect susceptibility
have used questionnaire and interview data, skin or immunity, whereas the presence of neutralizing
tests, and various laboratory determinations of antibody is a reliable indicator of immunityY2.13)
mumps antibody (complement fixation, hemag- The neutralization test should be carried out prior
glutination inhibition, and neutralization). to skin testing, for it may result in an anamnestic
Questionnaire data were used by Harris et response. (105)
al. (52) to define the incidence of mumps among Antibody surveys of healthy populations have
various members of the health profession and been widely employed to indicate the past experi-
general university faculty members. By age, high- ence of a community with mumps and the number
est attack rates occurred in the 20-29 yr old group, of remaining susceptibles (i.e., lacking antibody).
by profession among pediatricians; the lowest at- The CF test has been a fairly good indicator of
tack rates were in those over 50 yr of age and immunity to mumps.(8) The results of surveys
among the general university faculty. An inverse employing various tests are summarized in Table
relationship was found between the student's age 1. The first nationwide recruit study of Liao and
and the frequency of mumps in the teacher. Benenson(85) in 1951 revealed antibody at levels of
Household surveys conducted in Buffalo, New 1:8 or more by the CF test in 53.8% of the recruits
York, also by Harris et al.,<53) indicated that the tested. By history, 70% had a clinical history of
peak incidence of cases was at 7 yr and that 74% mumps (51% prior to age 10). Among the 29%
had experienced mumps by age 10. Some investi- who had no prior history of mumps, 39% had
gators feel that a history of mumps is not a reliable positive CF tests. In a second study of 2400 U.S.
indicator of immunity.(H8) recruits by Black(1O) in 1962, 76% had HI antibody
Using skin and complement fixation tests, Henle in the 1:10 dilution; in a third study of 1385
et al. (57) carried out an early study of 1800 resi- Brazilian recruits, by Niederman et al. (98) in 1964,
dents in the Philadelphia area. Among persons 83% were positive in the 1:10 dilution.
with a past history of mumps, 70-80% had posi- Wide variations were found in antibody preval-
tive skin or CF tests. While not an absolute crite- ence in serum collections from the WHO Serum
rion, fewer than 2% of persons with CF or skin Bank at Yale University retrospectively tested by
test reactivity acquired mumps; both tests were Black and Houghton,<l1) which included individu-
Table 1. Results of Serological Surveys for Mumps Antibody
Type of population Number Titer Percent

tested Country Year bled tested Test used "positive" immune a Reference
Army recruits United States 1951 2625 CF 1:8 54 (85)

Army recruits United States 1962 2400 HI 1:10 76 (10)
Army recruits United States 1962 2400 HI 1:20 47 (10)
Army recruits Brazil 1964 1385 HI 1:10 83 (98)
Rural Iceland 1962,1965 384 HI 1:20 73 (11)
First grade New Haven, 1964,1965 419 HI 1:20 52 (11)
Connecticut
Eskimos Point Barrow, Alaska 1949 97 HI 1:20 14 (11)
Aleutian Islanders St. Paul Island, Alaska 1968 195 N 1:4 12 (87)
Aleutian Islanders St. George Island, 1963 57 CF 1:4 7 (103a)
Alaska
Medical students United States 1971(?) 59 N 1:2 88 (12)
a Based on antibody tests and rounded off to nearest whole numbers.

als from Iceland and from New Haven, Connecti- and the 10-14 yr age group (91%). The subclinical
cut, Eskimos, and several island groups. Overall in rates were 16 and 6%, respectively, in these age
the 5-9 yr age group the percentages with mumps groups; in ten persons over age 60 who had been
antibody were 0% Point Barrow, 15% Tahiti, 55% exposed in 1907 or before, no clinical cases occurred
Cape Verde Islands, 79% Iceland, 52% New Ha- but six subclinical reinfections were identified. In
ven, Connecticut, and 74% Bahamas. The lowest a third island outbreak on St. Paul Island in 1967-
prevalence rates were found in Point Barrow, 1968 preillness sera indicated that 88% of residents
Alaska, where no one had antibody until age 15 or were susceptible. A mumps vaccination program
more. A good correlation was found between a was promptly initiated in part of the population.
history of mumps and a relatively high HI titer. Among the nonvaccinated persons lacking anti-
The titers declined slowly, about twofold per dec- body, mumps subsequently infected 59% and clin-
ade. In another remote island off Alaska, st. Paul, ical mumps occurred in 35%. While a similar
a virgin-soil population was identified in which attack rate occurred in vaccinees, the vaccination
only 12% of the residents had neutralizing anti- may have prevented the exhaustion of the pool of
body, and on St. George only 7% were positive. susceptibles. These studies show a high conta-
This contrasts with U.S. medical students, of giousness of mumps in susceptible populations
whom 88% had neutralizing antibody.o2) similar to that of influenza and rubella in open and
susceptible groups but of lower contagiousness
than in measles and chickenpox.
5.3. Epidemic Behavior and Contagiousness
The term epidemic parotitis reflects the capacity of 5.4. Geographic Distribution
mumps virus to result in outbreaks, even though it
Except for very isolated island groups and re-
fails to indicate that infection is always general-
mote villages, mumps occurs throughout the
ized rather than localized to the parotid gland.
world. In the United States variations in the inci-
Outbreaks of mumps occur periodically at inter-
dence of reported cases occur from year to year
vals from 2-3 to 7 yr. Local outbreaks are common
within most states and from one region to another
wherever there are large aggregates of children
within a given year. Urban centers are capable of
and young adults in close contact. This includes
supporting the virus endemically with sporadic
military barracks, institutions, and boarding
outbreaks in schools and other institutions,
schools.
whereas it tends to die out in rural areas until
The contagiousness of mumps can be judged by
enough susceptibles have accumulated. Some 80-
outbreaks in virgin populations. Three isolated
90% of city residents may acquire mumps infec-
island groups off Alaska have been. studied in this
tion by age 16, whereas only 10-20% are infected
regard. On St. Lawrence and adjacent islands
by this age in relatively remote communities.(29)
where no prior outbreak of mumps was known, a
In a study of a large military outbreak in 1917-1918
mumps outbreak occurred in 1957. Sixty-five per-
involving over 1000 cases, only 15% occurred in
cent of the 561 resident Eskimos had clinical
soldiers from cities as opposed to 85% from rural
mumps over a 6-month period; the clinical attack areas. (129)
rates were highest in the 5-9 and 10-14 yr age
Gordon and Heeren(47) concluded that mumps
groups, where the incidence was 86 and 87%,
is quite endemic within urban populations, but of
respectively, in two villagesyOl) A second island
somewhat irregular incidence. They thought that
outbreak in a virgin population occurred on St.
epidemics were unusual except among crowded
George Island in 1965; no known exposure to
close populations, although some Scandinavian
mumps had been recorded since 1907 and 93% of
data suggested that increased prevalence occurred
57 preepidemic sera obtained in 1963 lacked anti-
at approximately 7-8 yr intervals.
body. (103a) During the outbreak, 56% of the 212
native residents had clinical mumps and 20% had
subclinical infections, as revealed by serological 5.5. Temporal Distribution
tests; again the highest incidence of clinical In the north temperate zone, mumps seems to
mumps occurred in the 5-9 yr age group (74%) occur more often in the winter and spring than at
other times of the year, especially the summer. period. Mumps-associated deaths in 158 cases
Cases may be seen in any month, but March and from 1966 to 1971 were distributed by age as
April have the greatest number of outbreaks. follows: 38% over age 40, 22.2% age 5--9 yr, and
There are no seasonal increases in tropical areas. 19% age 0-4 yr.
5.6. Age 5.7. Sex

In the United States, more than 50% of reported Males and females are affected equally, most
cases occur in the 5--9 yr age group and 90% in often at about age 6.(21) In one survey, males were
children 14 yr of age or younger. Cases in adoles- found to have a history of mumps more commonly
cents and adults have a peak age distribution later than females. (53)
than with measles or rubella. The cumulative age
frequency is shown in Fig. 3. In Massachusetts,
Gordon and Heeren(47) reported almost 90% of 5.8. Race and Occupation
reported cases were in children under age 15 yr. A
Race per se appears to exert no effect, although
household survey by interview carried out in Buf-
blacks tend to have higher rates at an earlier age
falo, New York,<53) indicated that 10% of those
than whites.(53) Occupation also does not seem to
less than 5 yr of age and 33% of those 5--9 yr had
play any role except that those susceptible adults
had mumps previously. The peak age of recorded
who deal with young children are more likely to
cases was 7 yr, but 74% were experienced by age
acquire infections.
10 and only 5% after age 20.
Mumps encephalitis is most common in the 5--9
yr age group. Of 163 reported cases in the United
5.9. Occurrence in Different Settings
States in 1972,44.2% of the patients were age 5--9,
16.6% age 0-4, and 16.0% age 10--14. The remain- Outbreaks are common in families, schools, in-
der of cases were scattered throughout all other stitutions, and especially the military, where
age groups. A similar age distribution was seen in mumps can be a major cause of morbidity among
76 cases of aseptic meningitis reported in the same recruit populations.
100
90
... 80
z
w 70
u
a::
~ 60
w
>50
i=
S 40
::::l
:E 30
::::l
U
20
10
O~~~~-r~~~----~----~~-----r------~----~
<1 1 2 34 56 7 8 910 14 19 24 29 30+
AGE
Fig. 3. Reported cases of mumps, cumulative percent by age. From Center for Disease
Control.(22)
5.9.1. In the Family. As with so many other u.s. Army. The average number of days lost from
diseases, the young school-age child most often duty by a patient during World War II was 18.
introduces mumps into the home, then it spreads Since the disease was primarily one of recruits, it
to other susceptible siblings and adults. In house- was relatively infrequent after they arrived over-
holds with more than one child, the younger seas.(74)
sibling acquires the disease at an earlier age. McGuinness and Gall(89) summarized the U.S.
5.9.2. In Military Personnel. Wesselhoeft and Army's experience during 1943. They, like others,
Walcott(29) reviewed the military importance of believed that mumps was not likely to repeat the
mumps and its potential control. They reported World War I experience because of "the tremen-
that the U.S. Army had had major epidemics dous increase in travel during the past 25 years
during the Civil War and again in World War I, and the resultant decrease in isolation in rural
but not in the Spanish-American War; nor did areas, where many persons formerly reached adult
mumps assume great prominence during World life without exposure to the usual communicable
War II. Both the army and navy were affected diseases." In this paper, they described an epi-
during World War I, and epidemics were so severe demic at Camp McCoy, Wisconsin, in which 1378
that training and embarkation schedules were dis- mumps patients were admitted to the station hos-
rupted. From 1917 through 1919, there were 231,- pital between November 22, 1942, and June 23,
490 cases in the U.S. Army. There were 168,519 1943. This outbreak progressed at a fairly slow
cases during 1918 alone, with 8020 men being rate, but one company had 19% of its 194 mem-
counted among the "noneffective" at anyone bers ill with mumps at some time during the 16
time. The seasonal nature of mumps was illus- wk between the first and last cases. The maximum
trated by the occurrence of 70% of these cases in number ill in anyone week was 2.5%. This
the winter and spring. The total noneffective days epidemic was unique for several reasons. It
for the army during World War I was 3,884,147, seemed to move slowly through the camp, which
making mumps third in incidence after venereal was not a recruit training center. The peak inci-
disease and influenza. dence for the entire camp was late, occurring in the
Kneelar,· "74) has emphasized the lower inci- seventeenth week, at which time there were 194
dence of mumps in the U.S. Army in World War II cases. Because this was a wartime publication, no
as compared with World War I: in World War I information as to strength or number of individuals
there were 237,000 cases of mumps, but only at risk was provided. One of the conclusions of the
103,055 were reported during World War II from a authors is that the men who came from the rural
much larger force. Others have made similar ob- areas of the South and Southwest were predomi-
servations. Gordon and Kilham(481 analyzed these nantly those affected.
military experiences somewhat differently but also The prevalence of mumps antibody in military
concluded that the admission rates for mumps recruits has already been presented and is summa-
(U.S. Army) per 1000 strength were higher in rized in Table 1.
World War I than in World War II, with a ratio of 5.9.3. Hospitals and Institutions. Outbreaks
about 11:1. In Europe, the difference was almost 16 also occur in hospitals and other institutions. Spar-
times greater. Nonetheless, mumps was more fre- ling(l13) has described an outbreak in an Alaskan
quent than rubella, measles, meningococcal infec- hospital in which an asymptomatic infection in a
tions, diphtheria, and scarlet fever. nurse was the probable source.
Mumps has been the most frequent communica-
ble disease of childhood diagnosed in military
5.10. Other Factors
personnel but has had a very low mortality. It was
estimated that the case fatality rate during World Socioeconomic factors play little role in inci-
War I was 0.08%, when mumps represented the dence except that the impoverished tend to live
primary reason for hospital admission. Deaths under more crowded conditions (if in cities) and
generally were due to secondary infections such as thus acquire the infection at earlier ages. Other
pneumonia. During all of World War II, only five factors which may play significant roles in other
deaths were attributed to mumps in the entire diseases such as nutritional levels and genetics do
not seem to be of any consequence in relation to lished. About a week or more after the onset of
mU1l1ps except for the usual increased risks for parotitis, orchitis may occur in as many as one-
those who either have abnormal immunological third of postpubertal males. Other complications
systems or are being "immunosuppressed" for may make their appearance at this time or, occa-
therapeutic purposes. sionally, seriatim.
Mumps is generally considered to be less conta-
gious than measles or chickenpox, which may
explain why children escape into adult life without
6. Mechanisms and Routes of Transmission having been immunized by naturally acquired
virus. As many as one-third of mumps infections
are totally asymptomatic, but the reasons for this
There are no known animal reservoirs or insect are unknown. One would anticipate, if this were
vectors of mumps virus. The route of transmission because of the acquisition of markedly attenuated
is by infected droplets containing live virus which viruses, that they would not be readily transmissi-
is being secreted in the throat or from the salivary ble. Such does not seem to be the case. In sympto-
glands. Presumably infection could be transmitted matic infections, the clinical severity varies
during mouth-to-mouth resuscitation. The period greatly, and, in fact, even a rare death may occur.
of infectiousness of mumps ranges from about 3 Parotitis is unilateral in at least 25% of cases. (77)
days prior to the onset of clinical mumps to about Estimates of the frequency of central nervous sys-
the fourth day of active disease. Transmission by tem involvement differ, depending greatly on the
persons with inapparent infections is also an im- frequency with which spinal fluids were exam-
portant source of spread of mumps virus. Long- ined.
term human carriers are unknown so that a contin- Kilham(70) first isolated mumps virus from the
uing source of both acutely infected persons and bloodstream, and also from milk. (72) The latter
susceptible contacts is needed to maintain the had been obtained at the beginning of lactation 3
virus in a community. days after the delivery of an infant to a 23-yr-old
woman with parotitis of 2 days duration; two of
her other children had had mumps during the
7. Pathogenesis and Immunity preceding 3 wk. The infant remained symptom
free, while the mother had an eightfold rise in
antibodies during the following 3 wk. The baby
The usual sources of mumps virus are saliva and never developed antibodies, but was not breast
respiratory secretions. After an incubation period fed. Virus could not be isolated from the placenta.
of 16-18 days, a viremia follows which persists for This virus, after egg passage, was inoculated into
3-5 days; several days later, parotid swelling may two lactating monkeys, one of whom developed
appear. The virus is acquired through the respira- parotitis and a rise in antibodies. Virus was not
tory tract, following which the available evidence isolated from its milk. Its infant failed to develop
indicates there is local multiplication in both up- antibodies and never became ill. In the other,
per respiratory tract and the regional lymph nodes. mumps virus appeared in the milk 6 days after
Virus seems to be present in saliva for about 7-10 inoculation and persisted for 9 days, but no paro-
days (about one-third before and about two-thirds tid swelling, signs of breast infection, or fever was
after the appearance of symptoms). During the noted. There was a maternal rise in antibodies,
viremic stage, virus may be disseminated widely but the infant developed none. Kilham concluded
to the meninges and glands such as the salivary, that the virus probably multiplies in the lactating
testes, pancreas, ovaries, and sometimes thyroid breast.
and mammaries. It has been isolated from saliva, Utz et al. Cl21l inoculated ultracentrifugates of
blood, urine, stool, and spinal fluid. Viruria is urine from 13 mumps patients into monkey kidney
frequent, lasting about 10 days, sometimes longer, tissue cultures and obtained isolates 3 times as
after the onset of symptoms. Whether urine serves often as from simple urine dilutions. Isolates were
as a means of transmission has not been estab- made from all specimens as early as the first and
up until the fourteenth day of illness. No patient 8. Patterns of Host Response

had orchitis, and in seven viruria could be de-
tected after there was no longer clinical parotitis.
B.1. Common Clinical Features
Subsequently, Utz and Szwed020 ) expanded these
investigations to a larger group and demonstrated Mumps virus infections are generalized, but
viruria not only often (80% of specimens collected produce no symptoms in about one-third of in-
during the first 5 days) but also as late as 15 days fected individuals. The wide range of responses in
after the onset of illness. In another study,(19) those with clinical disease reflects the attraction of
they found that 15 of 20 young servicemen with glandular and nerve tissue for the virus. The most
mumps had viruria at some time, usually within common signs are fever and swelling of the paro-
the first 5 days of illness. Twelve of 55 specimens tid glands, either unilaterally or bilaterally. The
were positive on the eleventh through the twenty- sublingual and submaxillaries also may be in-
fifth days; the five from patients with orchitis all volved. With these signs may appear simultane-
were positive. Abnormal renal function was de- ously or in any sequence pancreatitis, oophoritis,
tected at some time in each individual: 17 had mastitis, myocarditis, meningoencephalitis, cran-
abnormal creatinine clearances, 15 abnormal PSP ial nerve involvement (especially the eighth
excretion, eight microscopic hematuria, and four nerve), and, in adult males, epididymo-orchitis.
proteinuria, and all had at least one abnormal The occurrence of virus in urine and abnormal
Fishberg test. Generalized edema and/or hyperten- renal function suggests that it produces an infec-
sion was not detected in any, and all had negative tion of the kidney. In some instances, parotitis
cultures and normal renal function by the end of may be absent and one or more of the other
the study. It was concluded that renal involve- complications occur. Kilham,'71) for example,
ment, when it occurs, is mild. found 13 of 25 patients with mumps meningoence-
Virus has been found in saliva as long as 7 days phalitis to have no clinical parotitis, and he also
before the appearance of parotitis(36) and for 3 was able to isolate virus from cerebrospinal fluid
days subsequently. Henle earlier had made a simi- as late as the sixth day of disease. Not infrequently
lar observation following the inoculation of egg mumps virus has been found in the saliva of
passage virus into volunteers. patients in the absence of evident enlargement of
Antibodies for mumps are transmitted across the salivary glands.
the placenta. (38.62) Since approximately 80% of Various complications often are reported as in-
adults have antibodies, most infants are immune dividual cases so that their rates cannot be calcu-
for about 6 months. This can be detected by CF, lated. Rarely have attempts been made to estimate
HI, or N tests, which probably accounts for the their incidence in closed or limited populations.
rarity of the clinical disease in young infants. All of the studies performed in the army during
Interferon is produced during mumps infec- World War I and most during World War II were
tions, with the highest titers being detected within based on clinical findings without stipport from
the first 3 days. Levels in saliva parallel those in serological tests or the isolation of viruses. One
serum. (24 ) Interferon has been reported in spinal study in which rates could be calculated is that of
fluid. Philip et al.,OOl) who investigated a virgin-soil
Second attacks of mumps are assumed to oc- epidemic of mumps among 561 Eskimos living on
cur,<77l but their rate is unknown. One reason for St. Lawrence Island in the Bering Sea (see Table 2).
this is that the substantial proportion of asympto- The outbreak already has been mentioned in Sec-
matic infections makes a prior history of mumps tion 5.3. The villages were visited after the epi-
an unreliable indicator of past infection; another demic had begun, but 57 cases were available for
reason is that parotitis may be caused by other examination. Members of each household were
agents. In general, one attack, whether sympto- interviewed, and the records of the village nurse
matic or asymptomatic, is assumed to induce life- were reviewed. Orchitis was age related, increas-
long immunity. Clinically expressed reinfections, ing sharply at puberty: the youngest patient was a
if they do occur, probably account for well below boy of 9 and the oldest a man of 51. Of 205 males
5 % of all cases.
Table 2. Incidence of Infection and Clinical Disease in a Virgin-Soil

Outbreak of Mumps in 561 Residents of St. Lawrence Island, Bering Seaa
Feature Number Percent
1. Mumps infection b 460 82

2. a. Males 30cr 53
With clinical mumps 205 67
Without clinical mumps 95" 20
b. Females 261" 47
c. Both sexes 561 100
Total infection rateC 85
3. Clinical mumps 363" 65
a. With salivary gland swelling 344 95
b. With stiffness of neck 40 11
c. With scrotal swelling (males) 52 25
d. With swelling of breasts (females) 24 15
a The data for this table are derived from Philip e/ al. (lOll
b Based on serological data.
, An additional 3% had disease without antibodies.
d Of total population of 561.
with mumps, 52 had orchitis, 37% of them bilater- were exposed to mumps during pregnancy. Serol-
ally. Among 158 female patients, 15% had mastitis, ogical follow-up some 10 yr later of 12 children
which increased in incidence with puberty. The whose mothers had mumps during pregnancy re-
youngest was a girl of 12 and the oldest a woman vealed the absence of neutralizing antibody but
of 61. Amont the female patients 15 yr of age or the presence of positive skin tests in many of the
older, 31% had mastitis. In a few instances there children w ; this suggests the possibility that infec-
were swelling and tenderness over the thyroid tion in utero fails to induce humoral antibodies but
area and a few women had lower abdominal pain, does activate cell-mediated responses.
suggestive of oophoritis. Stiffness of the neck was
reported by 40 patients, sometimes with delirium,
vomiting, and high fever, but all recovered. Of 8.2. Involvement of the Central Nervous System
four deaths noted during the outbreak, three ap-
parently were unrelated to mumps and the fourth Mumps can cause aseptic meningitis, menin-
death was that of a 10-month-old girl 2 days after goencephalitis, and encephalitis. It is one of the
the appearance of parotitis. Since no one was in most important causes of these syndromes in the
attendance, the cause of her death could not be United States. Of 824 cases of aseptic meningitis
determined. Of additional interest were the in military personnel in the period 1941-1952,
women who were in the first trimester of preg- Adair et al. (2) found 12% associated with mumps
nancy; four aborted. Fifteen were in their second virus. In 4073 cases of aseptic meningitis reported
or third trimester, but they had neither stillbirths to the Center for Disease Control (CDC) in 1971,
nor miscarriages. Three of the four who aborted 2.2% were associate.d with mumps and 15% with
were among eight women with clinical mumps. In enteroviruses.(23) Other data from 407 cases in
contrast, only one of 12 women with inapparent Cleveland revealed a relationship to mumps in
mumps aborted. No congenital malformations 7.8%(80) and from 511 cases in Los Angeles an
were detected in the 17 infants whose mothers association in 8.2%(78) Altered encephalograms
are uncommon during mumps parotitis,<45) sug- 8.4. Orchitis and Sterility
gesting that the meninges rather than the brain is
the more common site of involvement. Since orchitis frequently occurs during mumps,
Epidemiological and clinical investigations of there has been a great deal of interest in whether
mumps meningoencephalitis have been made by a or not this results in residual difficulties such as
number of investigators. (6,66,84,91,114) In Toronto sterility. At least half of orchitis cases resolve
mumps accounted for 8.7% of 43 patients diag- completely and most are unilateral. (77) The follow-
nosed as having meningoencephalitis in 1963.(9U ups of World War I and II cases failed to demon-
Boys are more commonly affected than girls; the strate impotence and sterility to be important
ratio is 3:1. Parotitis may be absent in 25-50% of consequences of mumps infection. By history, or-
patients with this syndrome. chitis occurred in 4.9% of 2000 males ag0 14-43,
Mumps is the most common cause of viral and among those over 13 yr of age the frequency
encephalitis in the United States. It accounted for increased to 19%(27); the disease was unilateral in
35.9% of the cases reported to CDC in 1967, 20.3% two-thirds and bilateral in one-third. Atrophy oc-
in 1971, and 12.5% in 1972. (23 ) Most patients recurred in one-third of the orchitis cases. Sperm
cover without sequelae. Of 11 surviving patients counts for 49 males with histories of mumps orchi-
from an outbreak in Guam in 1947-1948, eight were tis and for 91 without such histories revealed little
without sequelae when examined 10 yr later002 ); difference; only one instance of lack of sperm was
the remaining three were without complaints but found among those who had a history of mumps
minimal neurological changes were detected. Iso- and none in controls. Testicular atrophy did not
lated fatal cases of encephalitis have been reported appear to be an important factor in sperm produc-
by a number of investigators(28,29,1l0) and the CDC tion qualitatively or quantitatively. These studies
recorded 63 deaths from 1963 through 1972.(23) The suggest that mumps is not an important cause of
Guillain-Barre syndrome(44,93) and a variety of rare sterility in the male population. About 28 cases of
central nervous system complications have been neoplasm of the testes have been reported follow-
described. (7-9.26,51.66,90,92,110,117) ing the atrophy of mumps orchitis. (69) One case of
Deafness is an important residual complication breast cancer 36 yr after atrophic mumps orchitis
of mumps infection and may occur unattended by also has been recorded.(97)
meningitis or encephalitisy03,123) Some hearing
loss was found in 4.4% of 298 mumps patients in a
military epidemic in Finland who were evaluated 8.5. Mumps and Diabetes
audiometrically,(23) An incidence rate of about
one per 200,000 persons was calculated. In the While some single instances of diabetes have oc-
United States this would be equivalent to 1100 curred in children following mumps infec-
cases annually. tion/ 25 ,39,61,67,73,94) a causal relationship has yet to
be demonstrated. In Erie County, New York, a 7-
yr periodicity of childhood diabetes was found
over a 25-yr observation period. (lI5) Allowing a 3-
8.3. Involvement of the Heart
yr lag time, mumps had a similar periodicity.
Higher antibody level to coxsackieviruses, espe-
As it does in other acute infections, myocarditis cially type B4, have been found in insulin-depend-
may occur during mumps(31,79,104,1l6) and some in- ent diabetics of 3 months' duration or more than
vestigators have suggested that intrauterine infec- in control groupS.(4OJ There was a seasonal pattern
tion may lead to endocardial fibroelasto- consistent with coxsackievirus B4 infections, but
SiS. 132 ,43,99,106,107,109,122l The relationship to the latter not with other viruses.(411 These results have not
syndrome has been based on correlations among been confirmed in a subsequent study.(59l The
the syndrome, positive mumps skin tests, circulat- relationship of both mumps and coxsackievirus
ing antibody, and a history of maternal exposure to infections to diabetes is thus contradictory and
mumps. The evidence is conflicting, and more inconclusive, and the solution must await proper
studies are needed before the issue can be settled. prospective studies.
8.6. Other Complications thusiasm for a general immunization program.

The one exception perhaps was the military,
A variety of other acute and delayed complica- where mumps always has seemed to produce
tions have been reported following mumps infec- problems, especially in times of general mobiliza-
tion. These include arthritis in adults/5.17.46.112.11B)
tion. Yet the various complications-such as orchi-
with an incidence of 0.44% among 1334 patients tis with testicular atrophy, CNS involvement with
during an outbreak in Paris in 1923--1924.07) Vi- permanent damage especially to the eighth nerve,
ruria is common in mumps infection, and this may myocarditis of clinical significance, potential tera-
be accompanied by abnormal renal function togenesis, pancreatitis, and perhaps a relation
tests/" 9l and rarely by nephritis,l4.64.86.96) which
with the onset if not the induction of diabetes-
is sometimes fatal. (4,64) Hematological complica- led some to believe that its control by vaccine was
tions are rare but include a leukemoid reaction(42) warranted. Enders foresaw this earlyCl3) and re-
and paroxysmal cold hemoglobinuria.(24) No evi- ported in 1946 that the mumps virus which he had
dence of a relationship to leukemia was found in adapted to the monkey when passed continuously
children of mothers who had mumps during preg- in chick embryos lost its virulence for the monkey
nancyY) Holowach et al. (63) described a case of
and probably for man. After 25 passages no paroti-
congenital chorioretinitis in a 6-month-old infant tis was produced in the monkey, but immunity
whose mother had been infected by mumps in the followed the apparently subclinical infection. CF
latter part of the first trimester, and these authors and HI antibodies were induced when the virus
feel on review of the literature that mumps infec- was sprayed into the mouth and throat, but im-
tion at this time could affect the fetus. In a pro- munity followed irregularly. In one experiment
spective study of 19 mumps infections among 4930 there was a suggestion that single egg passage
pregnant women,(75) no evidence of any fetal virus (less attenuated) might do better.
abnormalities or of endocardial fibroelastosis was Henle et al. (56) used formalin-inactivated mumps
found. virus as a vaccine and gave this to a number of
The possible relationship of mumps and other children. Neutralizing antibodies were formed fol-
viruses to multiple sclerosis has been studied, but lowing multiple doses, and there was evidence of
no differences in skin reactivity to viral antigens clinical protection, although the occurrence of sub-
were found in 20 patients compared to con- clinical disease was not altered. Deinhardt and
trols,o°B) Of 43 patients with multiple sclerosis Shramek(27) reviewed this problem extensively and
tested, immunoglobulin M mumps-specific anti- stated that immunization was a worthwhile goal
body was present in the serum of two patients and but that killed antigens were inadequate inducers
measles-specific IgM in four patients; none of the of long-range protection. They felt that attenuated
serum samples from 43 patients with other neurol- vaccines should be the objective, and, in fact, one
ogical diseases or from 43 healthy controls con- was already being tested at that time.
tained mumps IgM antibody but one of the former
Penttinen et al. (toO) related the experiences of
had measles IgM antibody.(95) The significance of
the Finnish military forces, in which inactivated
these findings is not clear, but one explanation is
mumps vaccine (formalin-treated allantoic fluid)
that persistent IgM antibody may reflect persist-
has been used routinely since 1960. Among some
ence of the virus.
200,000 servicemen who had received two injec-
tions of vaccine following induction, the only
reactions encountered were small and localized.
The seroconversion rate by CF varied between 73
and 92%, depending on the year. From 1955 to
9. Control and Prevention
1959 the rate for mumps in these forces was 31 per
1000, whereas from 1961 to 1966 it was 1.9 per
Long viewed as a disease primarily of child- 1000, or a reduction of 94%. Until immunization
hood, often inapparent, usually mild, and leaving was put into routine effect, the military was con-
only infrequent, inconsequential complications, tributing about 10% of all the cases reported in
mumps understandably failed to induce great en- Finland. This, too, decreased tenfold with vaccine
usage. Penttinen et al. also found that even during and administration considerably and increases pa-
the vaccination period mumps occurred most often tient acceptance.
in the first month of service, before immunization Lerner<81) reviewed the status of mumps vac-
could be completed. It was about twice as frequent cine and concluded with the recommendation that
in those from rural areas as in those from urban it be administered to all children over 1 yr of age
centers. Overall, orchitis was 25 times less fre- and to susceptible adults. The latter would be
quent among the vaccinated than among the non- those with a negative history for clinical mumps or
vaccinated. The authors also pointed out that dur- a negative skin test, although the author acknowl-
ing World War II mumps occurred at the rate of edges that the best measure of immunity is the
25(}-'300 per 1000 men in the Finnish army. level of serum neutralizing antibodies. Because the
Buynak and Hilleman(5 ) have described the vaccine is derived from chick cells, those allergic to
attenuated mumps virus vaccine licensed in the egg proteins should not be inoculated. Like other
United States in December 1967 and made avail- live virus vaccines, it probably should not be
able for general use soon thereafter. Initiated in administered to those who are receiving immuno-
1963, the virus is grown in both embryonated suppressive therapy. In this instance or during
chicken eggs and tissue cultures of chick embryos. pregnancy, the recommendation is for inactivated
It stores well lyophilized and is rehydrated just vaccine to be used, although the response may be
prior to use. Following clinical trials in thousands irregular and inadequate. Lerner also agrees that
of susceptible children and adults, it was con- the skin test may not be entirely reliable.
cluded that about 97% of the children and about Brunell et al. (4) studied 20 children with paro-
93% of adults are converted from seronegative to tid swelling who had received single doses of live
seropositive by a single dose of the vaccine. Pro- attenuated mumps virus vaccine in any of four
tection from natural infection is of the order of different offices during a 4-yr period. The diagno-
95%. In follow-up studies, the same group dem- sis of mumps was confirmed in only eight of the
onstrated that neutralizing antibodies persist for at 17 from whom serological specimens were avail-
least 6 yr with concomitant protective immun- able. Diagnoses in the other nine children re-
ity.(J25) Ennis et al.(35) in a careful study of this mained obscure. The authors point out that while
vaccine found no clinical reactions as the result of most individuals who receive the vaccine develop
its administration. While N, HI, and CF antibod- antibodies the occasional one who fails to do so
ies were formed, virus could not be isolated from may still get mumps if exposed to the disease at
the blood, urine, or saliva of its recipients. Anti- some future time.
body titers were somewhat lower than after natu- Several cases that might represent complications
ral infection, but 1 yr later neutralizing antibodies of mumps immunization have been reported.
still could be detected. Among these are one each of hemolytic-uremic
Subsequently, Buynak et al. (6) demonstrated syndrome/ 30 ) possible deafness/ 54 ) and encepha-
that mumps virus could be administered com- lopathy with convulsions,<37) and one of the Guil-
bined with live measles and rubella virus vaccines lain-Barre type following combined mumps-ru-
without altering the immunological responses to bella vaccine.(49) The last began only 2 days after
any. Smorodintsev et al. (111a) did the same with administration of live attenuated vaccine and was
their vaccine strains and also believed the results followed by complete recovery. Reactions are re-
to be as good as when each was used alone. The corded regularly in the Mumps Surveillance Re-
American trivalent vaccine was subsequently ports of the Center for Disease Control.
tested by Krugman et al. (76) in 40 susceptible Yamauchi et alY31l administered vaccine to five
infants and found to be well tolerated and to women (three susceptible and two immune) 7-10
induce the usual immunological responses. Com- days prior to the scheduled termination of their
bined live measles and mumps vaccine was tested pregnancies with hypertonic saline. Mumps virus
also by Weibel et al. (26 ) in children under 7 yr of was recovered from the placentas of two of the
age with a 99% response to the measles and 96% three seronegative women but not from fetal tis-
to the mumps antigens. The use of vaccines in sues. The suggestion was made that the vaccine be
combination simplifies the problems of supply given with caution to postpubertal females.
Preparatory to the licensing of vaccine, mumps Soon after mumps vaccine was licensed, the
was again reinstituted as a notifiable disease. CDC state of Massachusetts initiated the first full-scale
Mumps Surveillance Reports, No. 1 (January immunization program early in 1969. During its
1968),<21) No. 2 (September 1972),(22) and the first 2 yr, the concentration was on schoolchildren
most recent, unnumbered (October 1974),<23) con- aged 5-14 yr, but in 1971 the program was broad-
tain listings of vaccine usage, complications, cases ened to include preschool children. The most re-
reported, and eradication programs. The last recent summary of cases reported in the state of
port indicates that recorded mumps incidence is Massachusetts (1968-1973) is illustrated in Fig. 4.
now at the lowest level since surveillance began. There was a remarkable drop in the number of
Further, the number of encephalitis cases reported reported cases coincident with the institution of
annually since 1968 has been lower than in prior the program. The modest increase in 1973 remains
years, accounting in 1972 for only 12.5% of all to be explained.
encephalitides. In children less than 15 yr old, Witte and Karchmer,(30) in a surveillance study
males have encephalitis 3 times more often than meant to serve as a background for the use of
females but this difference is not carried into vaccine, found that the incidence of mumps has no
adulthood. Deaths, too, have declined steadily apparent cyclical pattern and varies markedly from
since 1968; there is no sex predominance, but 38% year to year. It is most frequent, as has been
are of persons over 40 yr old. noted, in the early school years; while cases are
The U.S. Immunization Survey (CDC, 1973) only slightly more prevalent in males than in
found(23) that 28.9% of individuals 1-13 yr. of age females, encephalitis seems to occur excessively in
had received mumps vaccine and that 18 million males (some 70% of the total). Witte and Karchmer
doses of mumps-containing vaccine had been dis- rightfully emphasize the importance of maintain-
tributed by the end of 1973. As with other live ing surveillance in order to determine the effec-
virus vaccines, failures may be expected in about tiveness and the best possible utilization of vac-
5% of recipients. Complications, mostly involving cine and any complications which might follow its
the central nervous system, have been reported in use.
24 persons within 2 months of vaccination. Almost A recent report<95a) from CDC summarizes the
all have recovered fully; some cases were probably status of mumps prevalence, complications, and
caused by other agents. Surveillance for possible vaccine utilization in the United States. The 1974
vaccine-induced complications is continuing, but U.S. Immunization Survey is quoted to the effect
at this writing the problem does not appear to that 39% of 1- to 9-yr-olds had received mumps
excessively serious. vaccine, a marked increase over 1973. Generally
11,000 1,100,000
10,000 1,000,000 0
W
9,000 \ 900,000 a:
u.. W
8,000
\CASES 800,000
01-
(I)
\ (1)-
\
\ w2
7,000 \
\ 700,000 (1)-
Fig. 4. Reported cases of mumps and
cumulative doses of mumps vaccine
(I)
w 6,000
\
,
\
\ 600,000 00
w«
O~
(I)
administered, Massachusetts, 1968- « 5,000
\
\ >w
U \
\ -2
500,000 1--
1973. From Center for Disease Con- ~" «u
400,000 ..JU
trol.(23) 4,000
"", , :::l«
3,000
", 300,000 ~>
...
:::l(l)
UO-
2,000 ...... ... 200,000 :E
1,000 _ .,..------
.............. ... 100,000
:::l
:E
0 0
1968 1969 1970 1971 1972 1973
speaking, vaccine reactions continue to be brief nant women and the immunologic response of their
and mild. Nonetheless, energetic public health offspring, N. Engl. J. Med. 286:1379-1382 (1972).
support for mumps vaccine utilization is still lack- 2. ADAIR, C. V., GAULD, R. L., AND SMADEL, J. E.,
ing. Its increased use may be expected as a by- Aseptic meningitis, a disease of diverse etiology:
product of the general availability of the measles- Clinical and etiologic studies on 854 cases, Ann.
Intern. Med. 39:675---704 (1953).
rubella-mumps vaccine combination. This is at-
3. ADELSTEIN, A. M., AND DONOVAN, J. W., Malignant
tractive not only because of the resultant decreased disease in children whose mothers had chickenpox,
cost but also because of the reduction in required mumps, or rubella in pregnancy, Br. Med. J. 4:629-
inoculations. 631 (1972).
4. ANDERSON, D. M., AND HUTCHINSON, D. N., Renal
damage and virus infection, Br. Med. J. 3:680-681
10. Unresolved Problems (1968).
5. ApPELBAUM, E., KOHN, J., STEINMAN, R. E., AND
SHEARN, M. A., Mumps arthritis, Arch. Intern. Med.
That complete solutions for biological problems 90:217-223 (1952).
represent unachievable goals generally is accepted; 6. AZIMI, P. H., CRAMBLETT, H. G., AND HAYNES, R.
mumps certainly is no exception to this rule. A E., Mumps meningoencephalitis in children, J. Am.
large list of unresolved issues could be constructed Med. Assoc. 207:509-512 (1969).
rather readily, but much of it would serve little 7. BALFOUR, H. H., JR., HABLE, K. A., CARLSON, G. S.,
purpose now that apparently effective vaccines are ISENBERG, J. N., AND SIEM, R. A., Mumps associated
available and in ever-widening use. with coma or exanthems: A clinical study including
Among the problems which seem most impor- an instance of dual mumps and varicella infection,
Clin. Pediat. 11:88-92 (1972).
tant at this time are
8. BEAL, D. D., AND NAUNTON, R. F., Mumps hearing
1. Will live virus vaccine administered in loss: A case report, Laryngoscope 76:1786-1791
childhood prevent mumps and its compli- (1966).
9. BEARDWELL, A., Facial palsy due to the mumps
cations in adulthood, especially orchitis,
virus, Br. J. Clin. Pract. 23:37-38 (1969).
partial or total deafness, central nervous
10. BLACK, F. L., A nationwide serum survey of United
system disease, and, possibly, fetal terato- States military recruits, 1962. III. Measles and
genesis? These will require continuing sur- mumps antibodies, Am. J. Hyg. 80:304-307 (1964).
veillance based on sound epidemiological 11. BLACK, F. L., AND HOUGHTON, W. J., The signifi-
principles and aided by the application of cance of mumps hemagglutinin inhibition titers in
specific laboratory procedures. normal populations, Am. J. Epidemiol. 85:101-107
2. What is the meaning of reactivity to (1967).
mumps skin test antigen(s)? May this be 12. BRICKMAN, A., AND BRUNELL, P. A., Susceptibility
acquired from infections other than with of medical students to mumps: Comparison of
this virus? Does it have a meaningful role serum neutralizing antibody and skin test, Pediat-
rics 48:447-450 (1972).
in any disease state, including endocardial
13. BRUNELL, P. A., BRICKMAN, A., O'HARE, D., AND
fibroelastosis? Would purified antigens STEINBERG, S., Ineffectiveness of isolation of pa-
help to sort out the answers to these ques- tients as a method of preventing the spread of
tions? mumps: Failure of the mumps skin-test antigen to
3. Is mumps virus infection a cause of either predict immune status, N. Eng!. J. Med. 279:1357-
(or both) juvenile- or adult-onset diabetes? 1361 (1968).
Can any such relationship be determined by 14. BRUNELL, P. A., BRICKMAN, A., STEINBERG, S., AND
other than prospective studies following ALLEN, E., Parotitis in children who had previously
natural or vaccine infections? received mumps vaccine, Pediatrics 50:441-444
(1972).
15. BUYNAK, E. B., AND HILLEMAN, M. R., Live atten-
11. References uated mumps virus vaccine. 1. Vaccine develop-
ment, Proc. Soc. Exp. Bio!. Med. 123:768-775 (1966).
1. AASE, J. M., NOREN, G. R., REDDY, D. V., AND ST. 16. BUYNAK, E. B., WEIBEL, R. E., WHITMAN, J. E., JR.,
GEME, J. W., JR., Mumps-virus infection in preg- STOKES, J., JR., AND HILLEMAN, M. R., Combined
live measles, mumps, and rubella virus vaccines, J. H. M., JR., BROWN, E. R., HOBBINS, T. E., AND
Am. Med. Assoc. 207:2259-2262 (1969). BIEHUSEN, F. c., Clinical studies with virulent and
17. CARANASOS, G. J., AND FELKER, J. R., Mumps arthri- attenuated mumps viruses, Am. J. Epidemiol.
tis, Arch. Intern. Med. 119:394-398 (1967). 89:176-183 (1969).
18. Center for Disease Control: Morbidity and Mortality 36. ENNIS, F. A., AND JACKSON, D., Isolation of virus
Weekly Report, Annual Supplement, Summary during the incubation period of mumps infection, J.
1972, Vol. 21 (No. 53), p. 4, July 1973. Pediat. 72:536-537 (1968).
19. Center for Disease Control: Morbidity and Mortality 37. Epidemiological Bulletin, Health and Welfare, Can-
Weekly Report, Vol. 22 (Nos. 51/52), December ada, Vol. 18 (No.1), p. 10, January 1974.
1973. 38. FLORMAN, A. 1., SCHICK, B., AND SCALETTAR, H. E.,
20. Center for Disease Control: Morbidity and Mortality Placental transmission of mumps and streptococcus
Weekly Report, Vol. 23 (No. 53), pp. 2, 3, December MG antibodies, Proc. Soc. Exp. BioI. Med. 78:126-
1974. 128 (1951).
21. Center for Disease Control: Mumps Surveillance, 39. FREEMAN, A. G., Mumps followed by diabetes (let-
Report No.1, January 1968. ter to the editor), Lancet 2:96 (1962).
22. Center for Disease Control: Mumps Surveillance, 40. GAMBLE, D. R., KINSLEY, M. 1., FITZGERALD, M. G.,
Report No.2, September 1972. BOLTON, R., AND TAYLOR, K. W., Viral antibodies in
23. Center for Disease Control: Mumps Surveillance, diabetes mellitus, Br. Med. J. 3:627-630 (1969).
January 1972-June 1974, issued October 1974. 41. GAMBLE, D. R., AND TAYLOR, K. W., Seasonal inci-
24. COLLEY, E. W., Paroxysmal cold haemoglobinuria dence of diabetes mellitus, Br. Med. J. 3:631-633
after mumps, Br. Med. J. 1:1552-1553 (1964). (1969).
25. DACOU-VOUTETAKIS, c., CONSTANTINIDIS, M., Mos- 42. GARCIA, R., AND RASCH, C. A., Leukemoid reaction
CHOS, A., VLACHOU, c., AND MATSANIOTIS, N., to mumps virus, N. Eng/. J. Med. 271:251-252 (1964).
Diabetes mellitus following mumps: Insulin re- 43. GERSONY, W. M., KATZ, S. 1., AND NADAS, A. S.,
serve, Am. J. Dis. Child. 127:89~91 (1974). Endocardial fibroelastosis and the mumps virus,
26. DAVIS, 1. E., HARMS, A. c., AND CHIN, T. D. Y., Pediatrics 37:430--434 (1966).
Transient cortical blindness and cerebellar ataxia 44. GHOSH, S., Guillain-BaITe syndrome complicating
associated with mumps, Arch. Ophthalmol. 85:366- mumps, Lancet 1:895 (1967).
368 (1971). 45. GIBBS, F. A., GIBBS, E. 1., SPIES, H. W., AND
27. DEINHARDT, F., AND SHRAMEK, G. J., Immunization CARPENTER, P. R., Common types of childhood
against mumps, in: Progress in Medical Virology, encephalitis: Electroencephalographic and clinical
Vol. 11, pp. 126-153, Karger, New York, 1969. relationships, ftrch. Neural. 10:1-11 (1964).
28. DONOHUE, W. 1., The pathology of mumps enceph- 46. GOLD, H. E.1 BOXERBAUM, B., AND LESLIE, H. J., JR.,
alitis: With report of a fatal case, J. Pediat. 19:42-52 Mumps arthritis, Am. J. Dis. Child. 116:547-548
(1941). (1968).
29. DONOHUE, W. 1., PLAYFAIR, F. D., AND WHITAKER, 47. GORDON, J. E., AND HEEREN, R. H., The epidemiol-
1., Mumps encephalitis, J. Pediat. 47:395--412 (1955). ogy of mumps, Am. J. Med. Sci. 200:412-428 (1940).
30. DosIK, H., AND TRICARICO, F., Haemolytic-uraemic
48. GORDON, J. E., AND KILHAM, 1., Ten years in the
syndrome following mumps vaccination, Lancet
epidemiology of mumps, Am. J. Med. Sci. 218:338-
1:247 (1970).
359 (1949).
31. Editorial, Mumps of the heart, Br. Med. J. 5481:187-
49. GUNDERMAN, J. R., Guillain-Barre syndrome: Oc-
188 (1966).
currence following combined mumps-rubella vac-
32. Editorial, Mumps and the endocardium, N. Engl. J.
cine, Am. J. Dis. Child. 125:834-835 (1973).
Med. 275:393 (1966).
33. ENDERS, J. F., LEVENS, J. H., STOKES, J., JR., MARIS, 50. HABEL, K., Cultivation of mumps virus in the
E. P., AND BERENBERG, W., Attenuation of virulence developing chick embryo and its application to
with retention of antigenicity of mumps virus after studies of immunity to mumps in man, Public
passage in the embryonated egg, J. Immunol. Health Rep. 60:201-212 (1945).
54:28~291 (1946). 50a. HABEL, K., Preparation of mumps vaccine and
34. ENNIS, F. A., Immunity to mumps in an institu- immunization of monkeys against experimental
tional epidemic: Correlation of insusceptibility to mumps infection, Public Health Rep. 61:1655-1664
mumps with serum plaque neutralizing and hemag- (1946).
glutination-inhibiting antibodies, J. Infect. Dis. 50b. HABEL, K., Vaccination of human beings against
119:654-657 (1969). mumps; vaccine administered at the start of an
35. ENNIS, F. A., DOUGLAS, R. D., Hopps, H. E., MEYER, epidemic. I. Incidence and severity of mumps in
vaccinated and control groups, Am. J. Hyg. 54:295- 65. JOHNSON, C. D., AND GOODPASTURE, E. W., An
311 (1951). investigation of the etiology of mumps, J. Exp. Med.
51. HARBERT, F., AND YOUNG, I. M., Sudden deafness 59:1-19 (1934).
with complete recovery. Arch. Otolaryngol. 79:459- 66. JOHNSTONE, J. A., Ross, C. A. c., AND DUNN, M.,
471 (1964). Meningitis and encephalitis associated with mumps
52. HARRIS, R. W., KEHRER, A. F., AND ISACSON, P., infection: A 10-year survey, Arch. Dis. Child.
Relationship of occupation to risk of clinical mumps 47:647-651 (1972).
in adults, Am. J. Epidemiol. 89:264-270 (1969). 67. KAHANA, D., AND BERANT, M., Diabetes in an
53. HARRIS, R. W., TU~BULL, C. D., ISACSON, P., infant following inapparent mumps, c/in. Pediat.
KARZON, D. T., AND WINKELSTEIN, W., JR., Mumps 6:124-125 (1967).
in a northeast metropolitan community. I. Epide- 68. KALTER, S. S., AND PRmR, J. E., Immunity to
miology of clinical mumps, Am. J. Epidemiol. mumps among physicians, Am. J. Med. Sd. 229:161-
88:224-233 (1968). 164 (1955).
54. HEALY, C. E., Mumps vaccine and nerve deafness 69. KAUFMAN, J. J., AND BRUCE, P. T., Testicular atro-
(letter to the editor), Am. J. Dis. Child. 123:612 phy following mumps: A cause of testis tumour? Br.
(1972). J. Urol. 35:65-69 (1963).
55. HENLE, W., Mumps virus, in: Diagnostic Procedures 70. KILHAM, 1., Isolation of mumps virus from the
for Viral and Rickettsial Infections, 4th ed. (E. H. blood of a patient, Proc. Soc. Exp. BioI. Med. 69:99-
LENNETTE AND N. J. SCHMIDT, eds.), pp. 457-482, 100 (1948).
American Public Health Association, Inc., New 71. KILHAM, .1., Mumps meningoencephalitis with and
York,1969. without parotitis, Am. J. Dis. Child. 78:324-333
56. HENLE, W., CRAWFORD, M. N., HENLE, G., TABIO, (1949).
H. F., DEINHARDT, F., CHABAU, A. G., AND OLSHIN, 72. KILHAM, 1., Mumps virus in human milk and in
I. J., Studies on the prevention of mumps. VII. milk of infected monkey, J. Am. Med. Assoc.
Evaluation of dosage schedules for inactivated 146:1231-1232 (1951).
mumps vaccine, J. Immunol. 83:17-28 (1959). 73. KING, R. C., Mumps followed by diabetes (letter to
57. HENLE, G., HENLE, W., BURGOON, J. S., BASHE, W. the editor), Lancet 2:1055 (1962).
J., JR., AND STOKES, J., JR., Studies on the preven- 74. KNEELAND, Y., JR., Mumps, in: Internal Medicine in
tion of mumps. I. The determination of susceptibil- World War II, Vol. II, 0. B. COATES, JR., ed. in chief,
ity, J. Immunol. 66:535-549 (1951). and W. P. HAVENS, JR., ed. for internal medicine),
58. HENLE, G., AND McDOUGALL, C. L., Mumps men- pp. 35-38, Office of the Surgeon General, Depart-
ingo-encephalitis: Isolation in chick embryos of ment of the Army, Washington, D.C., 1963.
virus from spinal fluid of a patient, Proc. Soc. Exp. 75. KORONES, S. B., TODARO, J., ROANE, J. A., AND
BioI. Med. 66:209-211 (1947). SEVER, J. 1., Maternal virus infection after the first
59. HmRHOIZER, J. C., AND FARRIS, W. A., Follow-up of trimester of pregnancy and status of offspring to 4
children infected in a coxsackievirus B-3 and B-4 years of age in a predominantly Negro population,
outbreak: No evidence of diabetes mellitus, J. In- J. Pediat. 77:245-251 (1970).
fect. Dis. 129:741-746 (1974). 76. KRUGMAN, S., MURmL, G., AND FONTANA, V. J.,
60. HILDES, J. A., WILT, J. c., PARKER, W. L., STACKIW,
Combined live measles, mumps, rubella vaccine:
W., AND DELAAT, A., Surveys of respiratory virus
Immunological response, Am. J. Dis. Child. 121:380-
antibodies in an Arctic Indian population, Can.
381 (1971).
Med. Assoc. J. 93:1015-1018 (1965).
77. KRUGMAN, S., AND WARD, R., eds., Mumps (epi-
61. HINDEN, E., Mumps followed by diabetes, Lancet
demic parotitis), in: Infectious Diseases of Children
1:1381 (1962).
62. HODES, D., AND BRUNELL, P. A., Mumps antibody:
and Adults, pp. 150-162, Mosby, St. Louis, 1973.
Placental transfer and disappearance during the first 78. LENNETTE, E. H., MAGOFFIN, R. 1., AND KNOUF, E.
year of life, Pediatrics 45:99-101 (1970). G., Viral central nervous system disease, J. Am. Med.
63. HOLOWACH, J., THURSTON, D. 1., AND BECKER, B., Assoc. 179:687-695 (1962).
Congenital defEICts in infants following mumps dur- 79. LEONIDAS, J. c., ATHANASIADES, T., AND ZOUM-
ing pregnancy: A review of the literature and a BOULAKIS, D., Mumps myocarditis: Case report, J.
report of chorioretinitis due to fetal infection, J. Pediat. 68:650-653 (1%6).
Pediat. 50:689-694 (1957). 80. LEPOW, M. 1., CARVER, D. H., WRIGHT, H. T., JR.,
64. HUGHES, W. T., STEIGMAN, A. J., AND DELONG, H. WOODS, W. A., AND ROBBINS, F. c., A clinical,
F., Some implications of fatal nephritis associated epidemiologic and laboratory investigation of asep-
with mumps, Am. J. Dis. Child. 111:297-301 (1966). tic meningitis during the four-year period, 1955-58.
I. Observations concerning etiology and epidemiol- BENNETT, A. D., Current status of mumps in the
ogy, N. Engl. J. Med. 266:1181-1187 (1962). United States, J. Infect. Dis. 132:106-108 (1975).
81. LERNER, A. M., Guide to immunization against 96. MONTEIRO, G. E., AND LILLICRAP, C. A., Case of
mumps, J. Infect. Dis. 122:116-121 (1970). mumps nephritis, Br. Med. J. 4:721-722 (1967).
82. LEVENS, J. H., AND ENDERS, J. F., The hemoagglu- 97. NICOLlS, G. 1., SABETGHADAM, R., Hsu, C. C. S.,
tinative properties of amniotic fluid from embryon- SOHVAL, A. R, AND GABRILOVE, J. 1., Breast cancer
ated eggs infected with mumps virus, Science after mumps orchitis, J. Am. Med. Assoc. 223:1032-
102:117-120 (1945). 1033 (1973).
83. LEVITT, 1. P., MAHONEY, D. H., JR., CASEY, H. 1.,' 98. NIEDERMAN, J. c., HENDERSON, J. R, OPTON, E. M.,
AND BOND, J. 0., Mumps in a general population: A BLACK, F. 1., AND SKVRNOVA, K., A nationwide
sero-epidemiologic study, Am. J. Dis. Child. serum survey of Brazilian military recruits, 1964. II.
120:134-138 (1970). Antibody patterns with arboviruses, polioviruses,
84. LEVITT, 1. P., RICH, T. A., KINDE, S. W., LEWIS, A. measles and mumps, Am. J. Epidemiol. 86:319-329
1., GATES, E. H., AND BOND, J. 0., Central nervous (1967).
system mumps: A review of 64 cases, Neurology 99. NOREN, G. R., ADAMS, P., JR., AND ANDERSON, R
20:829-834 (1970). c., Positive skin reactivity to mumps virus antigen
85. LlAo, S. J., AND BENENSON, A. S. Immunity status of in endocardial fibroelastosis, J. Pediat. 62:604-606
military recruits in 1951 in the United States. II. (1963).
Results of mumps complement-fixation tests, Am. J. 100. PENTTINEN, K., CANTELL, K., SOMER, P., AND POI-
Hyg. 59:273--281 (1954). KOLAINEN, A., Mumps vaccination in the Finnish
86. MASSON, A. M., AND NICKERSON, G. H., Mumps defense forces, Am. J. Epidemiol. 88:234-244 (1968).
with nephritis, Can. Med. Assoc. J. 97:866-867 101. PHILIP, R. N., REINHARD, K. R., AND LACKMAN, D.
(1967). B., Observations on a mumps epidemic in a "vir-
87. MAYNARD, J. E., SHRAMEK, G., NOBLE, G. R, DE IN- gin" population, Am. J. Hyg. 69:91-111 (1959).
HARDT, F., AND CLARK, P., Use of attenuated live 102. PIEPER, S. J. 1., JR., AND KURLAND, 1. T., Sequelae
mumps virus vaccine during a "virgin soil" epi- of Japanese B and mumps encephalitis: Recent fol-
demic of mumps on St. Paul Island, Alaska, Am. J. low-up of patients affected in 1947-1948 epidemic
Epidemiol. 92:301-306 (1970). on Guam, Am. J. Trop. Med. Hyg. 7:481-490 (1958).
88. MCCRAE, W. M., Diabetes mellitus following 103. PRASAD, 1. N., Complete bilateral deafness follow-
mumps, Lancet 1:1300--1301 (1963). ing mumps, J. Laryngol. 77:809-811 (1963).
89. McGUINNESS, A. c., AND GALL, E. A., Mumps at 103a. REED, D., BROWN, G., MERRICK, R., SEVER, J., AND
army camps in 1943, War Med. 5:95-104 (1944). FELTZ, E., A mumps epidemic on St. George Island,
90. McKAIG, C. B., AND WOLTMAN, H. W., Neurologic Alaska, J. Am. Med. Assoc. 199:967-971 (1967).
complications of epidemic parotitis: Report of a case 104. ROBERTS, W. c., AND Fox, S. M., III. Mumps of the
of parotitic myelitis, Arch. Neurol. Psychiat. 31:794- heart: Clinical and pathologic features, Circulation
808 (1934). 32:342-345 (1965).
91. McLEAN, D. M., BACH, R D., LARKE, R. P. B., AND
105. ST. GEME, J. W., JR., Susceptibility of medical stu-
McNAUGHTON, G. A., Mumps meningoencephali-
dents to mumps: Dubious value of currently avail-
tis, Toronto, 1963, Can. Med. Assoc. J. 90:458--462
able skin test antigens (letter to the editor), Pediatrics
(1964).
49:314-315 (1972).
92. MEDNICK, J. P., AND LEONARDS, R., An unusual
central nervous system complication of mumps, 106. ST. GEME, J. W., JR., NOREN, G. R., AND ADAMS, P.,
Calif. Med. 101:42-43 (1964). JR., Proposed embryopathic relation between
93. MELNICK, S. c., AND FLEWETT, T. H., Role of infec- mumps virus and primary endocardial fibroelasto-
tion in the GuiIlain-Barre syndrome, J. Neurol. Neu- sis, N. Eng!. J. Med. 275:339-347 (1966).
rosurg. Psychiat. 27:395-407 (1964). 107. ST. GEME, J. W., JR., PERALTA, H., FARIAS, E.,
94. MESSARITAKIS, J., KARABULA, c., KATTAMIS, c., AND DAVIS, C. W. c., AND NOREN, G. R., Experimental
MATSANIOTIS, N., Diabetes following mumps in gestational mumps virus infection and endocardial
sibs, Arch. Dis. Child. 46:561-562 (1971). fibroelastosis, Pediatrics 48:821-826 (1971).
95. MILLAR, J. H. D., FRASER, K. B., HAIRE, M., CON- 108. SEVER, J. 1., AND KURTZKE, J. F., Delayed dermal
NOLLY, J. H., SHIRO DARIA, P. V., AND HADDEN, D. hypersensitivity to measles and mumps antigens
S. M., Immunoglobulin M specific for measles and among multiple sclerosis and control patients, Neu-
mumps in multiple sclerosis, Br. Med. J. 2:378-380 rology, 19:113--115 (1969).
(1971). 109. SHONE, J. D., ARMAS, S. M., MANNING, J. A., AND
95a. MODLIN, J. F., ORENSTEIN, W. A., AND BRANDLING- KEITH, J. D., The mumps antigen skin test in
endocardial fibroelastosis, Pediatrics 37:423-429 122. VOSBURGH, J. B., DmHL, A. M., LIU, c., LAUER, R.
(1966). M., AND FABIYI, A., Relationship of mumps to
110. SILVERMAN, A. c., Mumps complicated by a pre- endocardial fibroelastosis: Complement-fixation,
ceding myelitis, N. Engl. J. Med. 241:262-266 (1949). hemagglutination-inhibition and intradermal skin
111. SMORODINTSEV, A. A., LUZIANINA, T. Y., AND MIK- tests for mumps in children with and without
UTSKAYA, B. A., Data on the efficiency of live endocardial fibroelastosis, Am. J. Dis. Child. 109:69-
mumps vaccine from chick embryo cell cultures, 73 (1965).
Acta Viral. 9:240-247 (1965). 123. VUORI, M., LAHIKAINEN, E. A., AND PELTONEN, T.,
IlIa. SMORODINTSEV, A. A., NASIBOV, M. N., AND JA- Perceptive deafness in connection with mumps: A
KOVLEVA, N. V., Experience with live rubella virus study of 298 servicemen suffering from mumps,
vaccine combined with live vaccines against mea- Acta Oto-Iaryngol. 55:231-236 (1962).
sles and mumps, Bull. WHO 42:283--289 (1970).
124. WADDELL, D. J., WILBUR, J. R., AND MERIGAN, T. c.,
112. SOLEM, J. H., Mumps arthritis without parotitis,
Interferon production in human mumps infections,
Scand. J. Infect. Dis. 3:173--175 (1971).
Proc. Soc. Exp. Bioi. Med. 127:320-324 (1968).
113. SPARLING, D., Transmission of mumps (letter to the
editor), N. Engl. J. Med. 280:276 (1969). 125. WEIBEL, R. E., BUYNAK, E. B., STOKES, J., JR., AND
114. STRUSSBERG, S., WINTER, S., FRmDMAN, A., BEND- HILLEMAN, M. R, Persistence of immunity follow-
ERLY, A., KAHANA, D., AND FREUNDLICH, E., Notes ing monovalent and combined live measles,
on mumps meningoencephalitis: Some features of mumps, and rubella virus vaccines, Pediatrics
199 cases in children, Clin. Pediat. 8:373--374 (1969). 51:467-475 (1973).
115. SULTZ, H. A., HART, B. A., ZmLEZNY, M., AND 125a. WEIBEL, R. E., STOKES, J., JR., BUYNAK, E. B.,
SCHLESINGER, E. R, Mumps and childhood diabetes: WHITMAN, J., AND HILLEMAN, M. R., Live atten-
An epidemiologic association, 1974 American Public uated mumps-virus vaccine. 3. Clinical and serol-
Health Association Annual Meeting, Program and ogic aspects in a field evaluation, N. Engl. J. Med.
Abstracts, p. 116, October 20-24, 1974. 276:245-251 (1967).
116. THOMPSON, W. M., JR., AND NOLAN, T. B., Atrio- 126. WEIBEL, R E., VILLAREJOS, V. M., HERNANDEZ, C.
ventricular dissociation associated with Adams- G., STOKES, J., JR., BUYNAK, E. B., AND HILLEMAN,
Stokes syndrome presumably due to mumps myo- M. R., Combined live measles-mumps virus vac-
carditis, J. Pediat. 68:601-607 (1966). cine, Arch. Dis. Child. 48:532-536 (1973).
117. TIMMONS, G. D., AND JOHNSON, K. P., Aqueductal 127. WERNER, C. A., Mumps orchitis and testicular atro-
stenosis and hydrocephalus after mumps encephali- phy. I. Occurrence, Ann. Intern. Med. 32:1066--1074
tis, N. Engl. J. Med. 283:1505-1507 (1970). (1950).
118. TRACEY, J. P., AND RIGGENBACH, R. D., Mumps
128. WERNER, C. A., Mumps orchitis and testicular atro-
arthritis associated with positive latex fixation reac-
phy. II. A factor in male sterility, Ann. Intern. Med.
tion, Southern Med. J. 63:1122, 1126 (1970).
32:1075-1086 (1950).
119. UTZ, J. P., HOUK, V. N., AND ALLING, D. W.,
Clinical and laboratory studies of mumps. IV. Viru- 129. WESSELHOEFf, c., AND WALCOTT, C. F., Mumps as a
ria and abnormal renal function, N. Engl. J. Med. military disease and its control, War Med. 2:213--222
270:1283--1286 (1964). (1942).
120. UTZ, J. P., AND SZWED, C. F., Mumps. III. Compari- 130. WITTE, J. J., AND KARCHMER, A. W., Surveillance of
son of methods for detection of viruria, Proc. Soc. mumps in the United States as background for use
Exp. Bioi. Med. 110:841-844 (1962). of vaccine, Public Health Rep. 83:95-100 (1968).
121. UTZ, J. P., SZWED, C. F., AND KASEL, J. A., Clinical 131. YAMAUCHI, T., WILSON, c., AND ST. GEME, J. W.,
and laboratory studies of mumps. II. Detection and JR., Transmission of live, attenuated mumps virus
duration of excretion of virus in urine, Proc. Soc. to the human placenta, N. Engl. J. Med. 290:710-712
Exp. Bioi. Med. 99:259-261 (1958). (1974).
CHAPTER 15
The Parainfluenza
Viruses
w. Paul Glezen, Frank A. Loda, and Floyd W. Denny
1. Introduction Cincinnati; this virus, recovered from children

with croup, was designated originally as the
The parainfluenza viruses are species of the para- "croup-associated" or CA virus. Two additional
myxovirus family. (3.43) They are exceeded only by parainfluenza strains were identified in 1958 by
respiratory syncytial virus as important causes of their ability to adsorb guinea pig erythrocytes onto
lower respiratory disease in young children, and infected rhesus monkey kidney cells in culture. ( 1)
they commonly reinfect older children and adults Because these viruses, first designated "HA-1"
to produce upper respiratory illnesses. There is and "HA-2" or hemadsorption 1 and 2, shared
considerable diversity in both epidemiological and many biological properties with CA virus while
clinical manifestations of infections due to the being antigenically distinct, they were reclassified
parainfluenza viruses. Parainfluenza virus type 1 as parainfluenza viruses: type 1 (HA-2), type 2
(Para 1) is the principal cause of croup (laryngo- (CA), and type 3 (HA-1).(4) Type 4 was first
tracheobronchitis) in children, and parainfluenza isolated in 1960.(45) During the same period, these
virus type 3 (Para 3) is second only to RS virus as a viruses were compared with isolates obtained
cause of pneumonia and bronchiolitis in infants from animals. The Sendai virus/ 54 ) recovered
less than 6 months of age. Parainfluenza virus type from rodents, was found to share antigens with
2 (Para 2) resembles type 1 in clinical manifesta- type 1 and is classified as a subtype of this
tions, but serious illnesses occur less frequently; strain.(w.17l In 1959 a hemadsorbing virus,(771
infections with parainfluenza virus type 4 (Para 4) antigenically similar to Para 3 virus, (t) was re-
are detected infrequently and associated illnesses covered from cattle with "shipping fever." A sim-
are usually inconsequential. ian virus, SV5/ 42l has been shown to be related to
Para 2 virus. (41.92)
2. History
3. Methodology Involved in Epidemiological
Chanock(9) reported the first isolation of a para-
Analysis
influenza virus from human sources in 1956 in
w. Paul Glezen, Frank A. Loda, and Floyd W. Denny
. Department of Pediatrics, School of Medicine, Univer- Limited mortality data are available and consist
sity of North Carolina, Chapel Hill, North Carolina of sporadic case reports/ 2 •96 ) the failure to identify
337
338 Chapter 15 • The Parainfluenza Viruses
more fatal cases may be a result of the lability of spectrum of disease due to these agents. Mild
these viruses in postmortem specimens. Most illnesses occurring within families have been de-
deaths due to parainfluenza virus infections are scribed in both the United States(29) and Great
probably related to Para 3 virus infections in Britain.(5,38)
young infants, but even in this age group mortal- The role of parainfluenza viruses as etiological
ity is not documented with sufficient frequency to agents in respiratory illnesses of adults has been
allow a reasonable estimate of the mortality rate in investigated, also .08,25,31.34,64,68,83,93) These studies
the general population. Mortality data do not re- have reported sampling of patients with acute
flect the occurrence of these agents or the amount respiratory disease in hospitals, military services,
of morbidity that they cause. university student health services, and industrial
medical facilities. The ability of parainfluenza vi-
ruses to infect volunteers has been demonstrated
3.2. Sources of Morbidity Data in studies in both the United States(48,76,81.86) and
Official morbidity reports do not include acute Great Britain.(85,87,88) There also have been studies
respiratory infections; furthermore, laboratory di- of the role of respiratory pathogens including the
agnosis is required to establish the diagnosis of a parainfluenza viruses in asthmatic children(60l
parainfluenza virus infection. Morbidity data, and in patients with chronic bronchitis.(82) Evi-
therefore, are based on special research studies of dence of infections with paramyxoviruses has
the etiology of respiratory disease in various com- been obtained in all areas of the world(55,67,84,91l
munities around the world. including tropical climates(6,52.66,7lJ and isolated
Standardized techniques have been employed communities. (8,59)
by reliable investigators to provide some estimate
of the impact of parainfluenza viruses as causes of
acute respiratory disease in diverse populations. 3.3. Serological Surveys
Most studies have been cross-sectional studies of In an effort to delineate the importance of the
the etiology of either illnesses of hospitalized pa- parainfluenza viruses as etiological agents of res-
tients or epidemics in closed populations. These piratory disease, numerous serological studies
studies provide a limited view of the total morbid- have been conducted. Such serological surveys
ity resulting from infections with these viruses. frequently have sought to determine if the pattern
Five investigations of the etiology of acute respira- of occurrences of parainfluenza virus infection is
tory disease conducted over extended periods of similar in special population groups to that re-
time and involving large popUlations merit special ported elsewhere. Such studies have been useful
mention because of the broader perspective which in demonstrating the ubiquity of these agents and
they provide. These five studies in Washington, the relative similarity of age at acquisition of
D.C/uO) Chapel Hill, North Carolina/ 26 .28 ) Tec- antibody in various areas of the world. (8,55,6(;,(;7,84)
umseh, Michigan/ 65 ) Seattle, Washington/ l9l Many community studies have utilized both serol-
and Great Britain(J5) have differed in methods of ogical and isolation data but have relied heavily on
patient selection, types of illnesses surveyed, and serological data to de.termine the frequency of
ages of the subjects, but taken together they con- infection within the population.o 8,19,33,64.!l5) Care
stitute an extensive survey of respiratory illness should be taken in the interpretation of studies
over an extended time period in widely diverse which rely solely on the measurement of hemag-
geographic environments and socioeconomic glutination inhibition or complement fixation an-
groups. Numerous other studies have focused on tibodies because cross-reactions are frequent
the occurrence of respiratory illness in specialized among the paramyxovirus group, which includes
population groups. Children seen on the wards mump virus as well as the parainfluenza viruses.
and in the clinics of hospitals have been studied
extensively hoth in North America and in Great
Britain.(23,36,37,4o,61,73,97) Studies of uncomplicated 3.4. Laboratory Methods
respiratory disease in institutionalized chil- Most studies have utilized primary monkey kid-
dren, (3,12.35,47) day care groups, (57) and schoolchil- ney tissue culture for isolation of parainfluenza
dren(80) have contributed information about the viruses from clinical specimens; this is the most
Chapter 15 • The Parainfluenza Viruses 339
practical system for isolation, although human may reinfect older children who have circulating
embryonic tissues may be used. Infection is de- antibodies.(12) Excretion of virus may be pro-
tected usually by adding guinea pig erythrocytes, longed up to 1 month or longer, even with the
which will adsorb to infected tissue culture cells. second or third infection. (30.57.56) Epidemiological
This property is useful for identification of isolates, evidence suggests that reinfected children are in-
which is accomplished by inhibition of hemad- fectious for their contacts. (12)
sorption with monospecific antisera raised in labo- The incubation period is short and the virus
ratory animals.(43) Rapid identification can be ac- spreads rapidly to a high percentage of persons in
complished by use of fluorescent-tagged antisera closed populations, which indicates that the virus
for the major hemadsorbing viruses including par- possesses a high degree of infectiousness. Adult
ainfluenza virus types 1, 2, and 3.(23) Antibody in volunteers with preexisting antibody were in-
serum and nasal secretions can be measured by fected with as little as 1500 TCID5o .(88) More than
neutralization, hemagglutination inhibition, and half of the volunteers infected with the virus
complement fixationY3) All of the serological tests developed signs and symptoms of an upper respi-
have been adapted to micro titer techniques. (95) ratory illness.
The end point of titers of neutralizing antibodies to
parainfluenza viruses can be detected by hemad-
sorption; type 3 can be adapted readily to produce 5. Descriptive Epidemiology
recognizable cytopathic effect in continuous cell
lines, and the observation of cytopathology also can
5.1. Incidence-Prevalence Data
be used as an end point in neutralization tests.
5.1.1. Serological Surveys. Available evidence
supports strongly the view that parainfluenza vi-
ruses are ubiquitous viruses that infect most indi-
4. Biological Characteristics of Virus viduals during childhood. Serological surveys
Affecting the Epidemiological Pattern have uniformly demonstrated that 90-100% of
children have antibodies to Para 3 virus by age 5
The parainfluenza viruses are RNA-containing yr.(8,33,66) Antibodies to types 1 and 2 do not
viruses consisting of a lipoprotein envelope with develop as rapidly or as universally as do antibod-
hemagglutinin spikes surrounding the nucleocap- ies to Para 3 virus or respiratory syncytial virus;
sid. (43) The viruses are ether sensitive and acid however, 74% of the children over 5 yr of age
labile. They apparently are antigenically stable. tested in Washington, D.C., possessed antibody
Para 3 virus remains infectious in an aerosol for against Para 1 virus and 59% possessed antibody
periods greater than 1 h.(3) Studies have shown against Para 2 virus.(72) Similar data have been
that 10% of virus particles aerosolized are infec- obtained in serological surveys in a wide variety of
tious after 1 h in 20% relative humidity. No geographic areas. (8,33,55,59,66. 71)
systematic studies of the stability of other parain- 5.1.2. Association of Para 1 and 2 Viruses with
fluenza viruses in aerosol have been reported, but Illnesses. Studies of lower respiratory disease have
Para 1 virus has been isolated from air samples shown the highest isolation rates of parainfluenza
obtained in the vicinity of infected children. (2 ) virus types 1 and 2 to be between 4 months and 5
The biological characteristic of parainfluenza vi- yr of age.(lU.28) The rate for lower respiratory
ruses which seems to be the most important deter- disease associated with type 1 virus infections in
minant of their success as respiratory pathogens is the Chapel Hill pediatric practice was 17 per 1000
their ability to replicate in the respiratory epithe- children per year for children under 4 yr of
lium without deeper invasion. The virus is ex- age,(28,26) Lower respiratory disease after that age
truded from the cell membrane without immedi- was relatively uncommon. (68,83)
ately destroying the cell, which allows continued Studies of outbreaks of Para 1 and 2 viruses in
release of particles from a single cell. (43) Further- d~y care centers and in families suggest a high
more, Para 3 virus may infect the mucosa of attack rate in young antibody-negative children.
infants in the presence of maternally derived cir- An outbreak of Para 1 virus infections in a resi-
culating antibodies(1o.23.28.69) and also frequently dential home in Washington, D.C., resulted in the
development of neutralizing antibody in 65% of 90% of the children with neutralizing antibody
the children without prior antibody. (12) In studies titers between 1:8 and 1:32 were reinfected while
at the same home for children in Washington, only one-third of those with higher antibody lev-
D.C., 21 of 49 residents without antibody were els were reinfected. (12) In contrast, the studies
infected during a Para 2 outbreak.(47J In two other focused on school-age children(80) and young
outbreaks of Para 2 virus infection, one in a day adults 08 ,34,641 have revealed a relatively low rate of
care center in Chapel Hm 571 and the other in a isolation of parainfluenza viruses, although infec-
children's home in Kansas City, Kansas/ 351 the tions by these agents are well documented in
infection rates were 79% and 65%, respectively, in adults.
antibody-negative children. Most illnesses in both 5.1.4. Para 4 Virus Infections. Para 4 virus has
studies were afebrile and involved the upper res- not been isolated frequently, but serological sur-
piratory tract. These results suggest that Para 1 and veys indicate that infection may be com-
2 viruses are less effective than Para 3 virus in monY4.49,87) Most of these infections are consid-
spreading through a susceptible population.(12) ered to be asymptomatic, but isolation of the virus
5.1.3. Association of Para 3 Virus with Illness. may be missed in some ill children because of the
Para 3 virus infections have been detected in all technical problems in identifying the virus in
studies of hospitalized children with acute lower tissue culture. (241
respiratory disease/7,lO,61,7o,971 and this virus is
now recognized to be second only to RS virus as a
cause of bronchiolitis and pneumonia in in-
fants. 05 ,23,26,28,691 Few studies of open populations
have had denominator data to allow calculation of 5.2.1. Para 1 and 2 Viruses. The longest contin-
attack rates. In Chapel Hill, studies of children uous observation of the epidemic behavior of Para
with lower respiratory disease presenting to a 1 virus has been at the Children's Hospital of the
pediatric practice from 1966 to 1971 showed that 15 District of Columbia. From the initiation of the
children per 1000 per year were infected with Para studies in 1957 until 1961, the virus was en-
3 virus each year for the first 3 yr of life.(26,281 demicYOl Beginning in 1962, sharp epidemics of
A small group of infants in Chapel Hill were Para 1 virus began to occur every 2 yr in the
followed longitudinally through the first 2 yr of autumn of even-numbered years. now) A similar
life, and 21 of 62 (34%) developed respiratory pattern was noted in Great Britain between 1962
illnesses associated with Para 3 virus infection; six and 1972.(J5) In Chapel Hill, epidemics of Para 1
of the 21 had evidence of involvement of the lower virus have occurred every 2 yr since 1964, syn-
respiratory tract. (25) Of 15 children infected dur- chronously with these other epidemics.(2m Epi-
ing the first year of life, four were reinfected demics of Para 1 virus occurring in the fall of even-
during the second year; 66% of the total had numbered years after 1962 have been described in
neutralizing antibodies at the end of 2 yr, indicat- other reports as weI1.(36.37,4o.(H1 Evidence suggests
ing that mild or inapparent infections occurred in that the epidemic occurrence of Para 1 virus at
a number equal to the number of those presenting these times was not limited to a few communities
with illness. but occurred over a wide geographic area. In
Studies in Seattle in a prepaid group health care contrast, in other longitudinal studies, including
program have reported isolation rates of Para 3 those in Tecumseh/ 651 Para 1 virus occurred in
virus considerably lower than those observed in the endemic pattern seen in Washington, D.C.,
the Chapel Hill pediatric practice, but in the pa- prior to 1962. A more irregular pattern of epidemic
tients with paired serum specimens a high per- occurrence was noted in Seattle, where Para 1
centage showed antibody rises to this virusY91 virus epidemics were associated with increased
In closed populations such as children's homes incidence of croup during the winters of 1966--
and nurseries, infections with Para 3 virus were 1967, 1967-1968, and 1970--1971. 091 The evidence
frequent. (3,12) The investigations at Junior Village suggests that Para 1 virus can, at different times
in Washington, D.C., showed that all infants and at different places, assume different patterns
without preexisting antibodies were infected and of occurrence varying from an endemic pattern
over several years to sharp epidemics associated and this could explain the ability of parents to
with a marked increase in the incidence of croup. transmit infection to their infants.
Continued surveillance over time in different areas
will be necessary before a predominant pattern can
be established, if indeed such a pattern does exist. 5.3. Geographic Distribution
Para 2 virus would appear to be nearly as Available evidence indicates that parainfluenza
ubiquitous as Para 1 virus on the basis of serologi- viruses are found throughout the world and in all
cal surveys, but it is not associated as frequently areas cause illness in young children. There is
with severe clinical disease as is Para 1 virus. remarkable similarity of serological and isolation
Because many studies depend on the isolation of data obtained from tropical, (6,66) temper-
the agent from lower respiratory disease to estab- ate,02,33,84) and arcticl 59 ) climates.
lish the presence of the virus in the community,
there is less information on the occurrence of Para
2 virus. The available data suggest that it occurs in 5.4. Temporal Distribution
a sporadic epidemic pattern, often disappearing
Parainfluenza viruses can be isolated in any
from the community for fairly long periods of month of the year, in both temperate(lO,26) and
time. In Chapel Hill, Para 2 virus epidemics oc- tropical climates. (6,52,71) The most common time
curred in the fall of the odd-numbered years, the
for the occurrence of epidemics of Para 1 virus has
years in which Para 1 virus was absent from the been during the fall months of the year.(7,15,19,26,36)
population.(26) A similar pattern occurred in
A similar occurrence in the fall has been noted for
Washington, D.C.m In Great Britain(5 ) and in Para 2 virus in studies in Chapel Hill, (26) and
Tecumseh(65) Para 2 virus tended to occur in well-
Washington, D.c.,m while studies in Tecum-
defined, but somewhat erratic, epidemic patterns, seh(66) showed a peak occurrence of Para 2 virus
while in the Seattle surveillance studies(9) it was
in the winter.
rarely identified. In surveillance studies of young
Para 3 virus infections occur endemically
children with minor respiratory illness, Para 2
throughout the year. During the first 7 yr of
virus has had a distinct epidemic pattern with studies at the Children's Hospital of the District of
high attack rates in small, defined popula-
tions. (35,47,57) Columbia, infections with Para 3 virus were asso-
ciated with respiratory illness in 70 of 81
5.2.2. Para 3 Virus. Infections with Para 3 virus
months. (0) A similar endemicity was noted in
have been invariably endemic in nature, occurring
studies in the Chapel Hill pediatric practice, where
in all seasons of the year.(7,26) Small outbreaks
this virus was associated with lower respiratory
have been noted, but there has been no predict- illness in 63 of 91 months.(26)
able periodicity in their occurrence. Most major
respiratory viruses have caused relatively discrete
epidemics, but outbreaks of Para 3 virus have
5.5. Age Distribution
occurred concurrently when other viruses were
epidemic. (26) This virus has been prevalent in 5.5.1. Para 1 and 2 Viruses. Maternal antibody
Chapel Hill during RS virus, influenza virus, or apparently prevents severe disease in very young
Para 1 virus epidemics. infants infected with either Para 1 or 2 virus. Data
The high reinfection rate of Para 3 virus allows it from studies of lower respiratory disease show few
to spread in populations containing majorities of cases of severe disease in infants under 4 months
people with previous experience with the virus. of age.(6,15,19,23,28,97) After 4 months of age, there is
Observations in Chapel Hill of families with a rise in the number of cases of croup and other
child under 2 yr of age showed that Para 3 virus lower respiratory diseases. (28) This high incidence
infected these infants regardless of family constel- continues until approximately age 6 yr. After a
lation while RS virus infections were more likely child reaches school age, there is a much lower
to occur in infants with an older sibling who incidence of lower respiratory symptomatology,
might bring the virus into the home.(25) A latent and lower respiratory illnesses in individuals in-
state of infection in adults has been suggested, (30) fected by Para 1 and 2 viruses are distinctly unu-
sual in adolescents(26) and adults/ 68 ,83) although There were insufficient numbers of cases of Para 2
they have been reported. (93) virus infections to analyze. Para 3 virus had ident-
Studies of milder illness have shown a similar ical rates of lower respiratory illness in males and
age distribution. Infection and minor clinical ill- females.(26) The, attack rates for lower respiratory
ness has been demonstrated more frequently in illnesses due to Para 3 virus infections in the
younger children than in adolescents and Chapel Hill pediatric practice were 12 and 11 per
adults.(5,29,65) Infections do occur in older individ- 1000 children per year for boys and girls under 6 yr
uals/ 15,18,34,38,64,65) most of which presumably rep- of age.
resent recurrent infections in individuals with an-
tibody. The studies conducted in Tecumseh(65)
showed serological evidence of frequent infections 5.7. Race and Occupation
in young adults in the age groups who would be No differences in infection rates or in the conse-
likely to be the parents of young children. In quences of infection with parainfluenza viruses
family studies infection in adults occurred concur- have been noted in different racial or occupational
rently with illness in their children, but attack groups.
rates in adults were distinctly lower than those in
younger family members. (5,29)
5.5.2. Para 3 Virus. Initial infections with Para 3 5.8. Occurrence in Special Epidemiological
virus occur early in life. Several investigators have Settings
noted that, like RS virus, Para 3 virus infections
often occur in the first months of life when infants The frequencies of infections with parainfluenza
still possess circulating antibodies derived from viruses are greater in studies of young children
their mothers. 00,15,23,28,69) In the studies of lower hospitalized with lower respiratory disease(69) or
respiratory disease in the Chapel Hill pediatric in children's homes(3,12.35,47) or day care facili-
group practice, the age-specific attack rate for Para ties.(57) Infections associated with respiratory dis-
3 disease paralleled that for RS virus. (28) The ease occur but are usually mild or inapparent in
average annual attack rate for the period from 1966 school-age children/ 80 ) university students/ 18 ,34)
to 1971 was 15 lower respiratory illnesses per 1000 military recruits/ 64 ,93) and adults. (29,31,38,68,83)
children per year for children under 3 yr of Nosocomial infections with respiratory viruses
age.(26) After the first 3 yr of life, the incidence of may occur readily if susceptible infants are not
lower respiratory illnesses associated with this kept isolated from children with respiratory dis-
virus falls off considerably, but studies in other ease. Mufson(70) reported infections with Para 3
populations indicate that reinfections are common virus in 18% of infants who were well or infected
in older children and adults but usually are not with some other respiratory pathogen at the time
associated with evidence of lower tract involve- of admission to Cook County Children's Hospital.
ment.02,18,29,31,34)
5.9. Socioeconomic Factors

5.6. Sex There is some evidence to suggest that infants
The increased frequency of croup in males has from low-income families are more likely to be
long been recognized. (75) Studies in the Chapel hospitalized with bronchiolitis or pneumonia in
Hill pediatric practice demonstrated infection rates the first months of life than are infants from
for Para 1 virus of 1.8 lower respiratory illnesses middle-income families. (22) RS virus and Para 3
per 100 boys compared to 1.1 per 100 girls.(28) virus are frequent etiological agents of these ill-
This sex difference disappeared after age 6 yr. A nesses. There may be many factors involved in
similar predominance of serious illness in young this situation. The decision to hospitalize an infant
males has been noted in other studies of lower may be based on the social milieu in which the
respiratory disease. (58) The available information child lives and not necessarily on the severity of
suggests that the rates of infection in young boys the presenting signs and symptoms; however,
and girls are the same but that the clinical mani- some evidence suggests that young infants in low-
festations of infection are more severe in boys. (26) income families do have more severe illnesses and
this may result from exposures to relatively large inflammatory response of glottic tissues(96) which
inocula at an earlier age. Unlike Para 3 virus, there is evident from the serious clinical manifestation
does not appear to be any difference in severity of (croup) of infections with these viruses.
disease due to Para 1 and 2 viruses in children of Because infection with Para 3 virus may occur
different socioeconomic groups. (26) early in life in the presence of maternal antibody,
the possibility of an immunopathological process
must be considered similar to that proposed for RS
6. Mechanisms and Routes of Transmission virus disease. Gardnet 23 ) has noted the similarity
of the clinical manifestations of infections with
these two viruses in early infancy, and the need
Transmission of parainfluenza viruses is by di-
for learning more about the pathogenesis. Al-
rect person-to-person contact or large droplet
though it is well accepted that infection with Para
spread. These viruses do not persist long in the
3 virus may occur in the presence of low levels of
environment, but Para 1 virus has been recovered
from air samples collected in the vicinity of in- maternal antibody, there is no direct evidence that
fected patients and from 1 to 10% of Para 3 virus maternal antibody will enhance the pathogenicity
particles in aerosols may be viable after 1 h.(63) of the host/viral interaction. Experimental studies
Adult volunteers who have had prior natural in- in hamsters have not demonstrated enhanced vir-
ulence in the presence of passive antibody. (27) In
fection have been reinfected experimentally by
inoculation of the upper airway with a coarse fact, the pulmonary infiltrations were less in ani-
aerosol and/or nasal drops. (48,88) The high rate of mals with passive antibody than those w,thout;
however, animals whose primary infection oc-
infection early in life coupled with the frequency
curred with passive antibody had significantly
of reinfection suggests that the virus spreads read-
greater infiltrate at the time of reinfection. This
ily, that reinfected persons may be infectious, and
that a relatively small inoculum is necessary to suggests that passive antibody may dampen some
part or parts of the immune response to the
produce an infection.
primary infection, which allows for development
There is little evidence of animal reservoirs for
human disease and no evidence of vector spread. of more disease at the time of reinfection. Studies
have demonstrated that the primary antibody re-
The Sendai virus is a rodent strain of Para 1 virus,
sponse to infection is decreased by passive anti-
but there is no evidence that it is related to disease
in humans.(43) SV5, a simian virus related to Para body, but it is unknown whether other parameters
2 virus, has been reported to cause human infec- such as surface antibody production and cellular
tions on rare occasions(41.92); reports of human immune response are affected. Viremia has been
reported both with primary infection(78) and with
infections must be reviewed critically because this
reinfection. (30,46) It is difficult to determine the
virus often contaminates monkey kidney tissue
cultures.(42) A virus which is antigenically similar consequences of this because clinical and patho-
logical evidence of infection has been noted only
to human Para 3 virus has been isolated from
several animals but particularly cattle(77) and in the respiratory tract. Viremia with reinfection
sheep. (39) Bovine parainfluenza virus type 3 is at was reported to have occurred in the presence of
circulating antibodies; more work is necessary to
least one of the agents commonly associated with
determine the factors inherent in these observa-
an economically important disease of cattle usually
called "shipping fever,"(79) but there is no evi- tions.
dence of spread between cattle and man.
7.2. Immunity
Studies with Para 1 virus(81) and Para 2 vi-
ruS(86) have revealed that immunity is better cor-
related with the presence of nasal antibody than
7.1. Pathogenesis
with the level of serum antibody. The protective
Little is known about the pathogenesis of infec- immune response to Para 3 virus infection in
tions with Para 1 and 2 viruses. Pathological stud- humans has not been established. Clinical studies
ies have noted the predilection for the marked have shown that the risk of reinfection is inversely
related to the level of circulating antibodies,(J2) respiratory disease (Table 1). The most characteris-
but the relationship to surface antibody or cellular tic and clinically important syndrome associated
immunity is unknown. Although reinfection is with infections with Para 1 and 2 viruses is croup
common, the consequences of subsequent infec- or laryngotracheobronchitis. Para 1 virus was iso-
tions seem to be negligible. Lower respiratory lated from 20% of patients with croup in studies in
involvement with reinfection is unusual, and mild the Chapel Hill pediatric practice.(28) Para 2 virus
upper respiratory symptoms are the rule. is much less frequently associated with croup than
Studies in calves infected with Para 3 virus Para 1 virusyo.26) Mortality has been reported
indicate that maternal antibody derived from co- with both of these agents but is rare.(6.23,73,92)
lostrum is protective.(20) Calves are usually pro- Studies in ambulatory populations suggest that
tected for 10-23 wk after birth if allowed to suckle. most initial infections with Para 1 virus result in
Inactivated vaccines injected parenterally have febrile upper respiratory illness, while initial in-
provided some protection against natural and ex- fections with Para 2 virus result in somewhat less
perimental challenge, but attenuated viruses inoc- severe upper respiratory illnesses with a high
ulated intranasally provide better protection.(32) proportion being afebrile.(35.57) Reinfection with
There is some evidence that hyperimmunization of either of these agents is associated with upper
dams with inactivated vaccines to increase anti- respiratory symptoms indistinguishable from
body titers in colostrum will decrease the morbid- those due to other viruses. (29)
ity of their offspring.(53) The clinical manifestations of infections with
In summary, studies of bovine disease and ex- Para 3 virus are varied. In studies in the Chapel
perimental infections of hamsters do not support Hill pediatric practice of children presenting with
the hypothesis that passive antibody may contrib- lower respiratory disease, the diagnosis varied
ute to the pathogenesis of disease in early life. The with age(26); infants under 1 yr of age were likely
data suggest that passively acquired antibody may to present with bronchiolitis or pneumonia while
provide at least partial protection. children from 6 to 18 months might develop croup.
Older children usually were diagnosed as having
tracheobronchitis. In general, though, it should be
8. Patterns of Host Response stated that there was no consistent clinical presen-
tation of Para 3 virus infection.
Prospective studies of children indicate that pri-
8.1. Clinical Manifestations
mary infection with Para 3 virus is usually symp-
Primary infections with parainfluenza viruses tomatic but often mild.(57) In children followed for
are usually symptomatic, but the clinical manifes- the first 2 yr of life, about one-third of primary
tations may range from an afebrile upper respira- infections involved the lower respiratory tract, but
tory illness to severe and life-threatening lower only 5% of primary infections resulted in lower
Table 1. Parainfluenza Viruses: Serotypes and Associated Clinical and Epidemiological

Manifestations
Major
Human clinical Peak age Sex Antigenically related
serotype syndrome (months) predominance Periodicity" animal strains
1 Croup 6-24 Male Epidemic (fall) Sendai virus (rodents)

2 Croup 6-24 Male Epidemic (fall) Simian virus 5 (SV5)
3 Pneumonia 0--6 None Endemic Bovine Para 3 virus
Bronchioli tis
4 URI Unknown Unknown Endemic None
a Peak season in parentheses.

respiratory illnesses for which families sought begun to develop effective vaccines. Most early
medical care.(25) Frequency of reinfection-both efforts involved the use of formalin-inactivated,
symptomatic and asymptomatic-decreased with parenterally administered vaccines grown in em-
age (and experience with the virus). Reinfection bryonated hens' eggsY4.22,44,50l These prepara-
was symptomatic among young children at Junior tions were given either as a monovalent prepara-
Village 20% of the time,<12l but this frequency is tion,<2lJ as a trivalent parainfluenza vaccine, or as
probably higher than that in open populations; the a multivalent vaccine including other respiratory
circumstances of living conditions in this nursery pathogens. Most preparations were aqueous sus-
could have resulted in a greater inoculum than pensions, but one alum-adsorbed egg-grown para-
would occur ordinarily. The incidence of reinfec- influenza type 3 vaccine was tested.(21l One group
tion in adult populations is difficult to determine employed a monkey kidney grown, formalin-
because of the cross-reactions that may occur by killed, alum-precipitated parainfluenza vaccine
serological testing-particularly if the HI or CF test given both as a trivalent parainfluenza vaccine and
is used. The viruses have been isolated rarely from as a multivalent respiratory vaccine.(90) A high
asymptomatic adults. (25) proportion of subjects developed serum antibody
rises with parenterally administered, formalin-in-
8.2. Diagnosis activated vaccines-particularly antibody-negative
individuals. Antibody rises occurred in a smaller
Clinical diagnosis of the etiology of sporadic proportion of individuals with preexisting anti-
episodes of acute respiratory disease is difficult; body, either passively acquired maternal antibody
however, infections with parainfluenza viruses or antibody secondary to natural infectionY9) All
may be suspected by combining the clinical mani- studies uniformly failed to show evidence of pro-
festations with known epidemiological pat- tection even in individuals with good serum anti-
terns.(26) As noted in Section 5.2.1, Para 1 virus
body responses. There was no evidence of more
infections have produced predictable epidemics of severe disease in the individuals given the triva-
croup in the autumn of even-numbered years in lent aqueous parainfluenza vaccine, an important
widely scattered geographic areas observed for finding in view of the fact that infants given alum-
periods up to 10 yr. Croup is most common in precipitated respiratory syncytial virus vaccine
boys between 6 months and 3 yr of age. With had more severe illness than expected when they
knowledge of the patterns of parainfluenza virus were naturally infected.(50,50a)
infections provided by regional laboratories, it The demonstration that protective immunity is
may be possible to predict the occurrence of epi-
more closely related to the level of secretory nasal
demics of Para 1 or 2 virus infections and therefore antibody than to serum antibody, (BLB6) and the
establish an estimate of the etiology of respiratory actual worsening of disease seen with inactivated
illnesses-particularly when they present with a respiratory syncytial virus vaccine, has led to a
major clinical manifestation such as croup. Para 3 reevaluation of the use of parenteral respiratory
virus infections are much less predictable, but this vaccines. Efforts have focused on use of attenuated
etiology should be considered for infants less than live vaccines given intranasally. Initial trials of a
6 months of age with bronchiolitis or pneumonia temperature-sensitive Para 1 mutant in animals
occurring at times other than during RS virus were promising,<74) but an attenuated strain suit-
epidemics.(26) Although RS virus associated bron-
able for use in humans has not been developed. It
chiolitis has been more common in male infants, has been shown that aerosol inoculation of an
lower respiratory illnesses associated with Para 3 inactivated Para 2 vaccine will safely stimulate
virus have had an even sex distribution. nasal secretory antibody in adults. (94) The effec-
tiveness of this method of vaccine administration
has not been tested further.
9. Control and Prevention Based on Epidemiological data suggest that the most im-
Epidemiological Data portant age group to immunize against parainflu-
enza viruses types 1 and 2 is children over 4
As soon as the clinical importance of the parain- months of age. This contrasts with Para 3 and
fluenza viruses was demonstrated, efforts were respiratory syncytial viruses, which cause signifi-
cant illness between 1 and 3 months of age, and 5. BANATVALA, J. E., ANDERSON, T. B., AND REISS, B. B.,
which would require immunization in early in- Parainfluenza infections in the community, Br. Med.
fancy. J. 1:537-540 (February 1964).
For bovine parainfluenza type 3 infections, both 6. BISNO, A L., BARRATT, N. P., SWANSTON, W. H.,
AND SPENCE, L. P., An outbreak of acute respiratory
inactivated and attenuated vaccines administered
disease in Trinidad associated with parainfluenza
parenterally and intranasally have been used in
viruses, Am. J. Epidemiol. 91:68 (1970).
calves. (32) The results are not consistent, but it
7. BRANDT, C. D., KIM, H. W., CHANOCK, R. M., AND
would appear that attenuated strains given intra- PARROTT, R. S., Parainfluenza virus epidemiology,
nasally are more effective. Evidence suggests that in Pediat. Res. 8:422 (1974).
calves vaccine-induced antibody is associated with 8. BROWN, P. K., AND TAYLOR-RoBINSON, D., Respira-
protection and does not cause more severe disease. tory virus antibodies in sera of persons living in
However, until more is known about the patho- isolated communities, Bull. WHO 34:895-900 (1966).
genesis of human parainfluenza disease, care must 9. CHANOCK, R. M., Association of a new type of
be exercised in the use of any vaccine-particu- cytopathogenic myxovirus with infantile croup, J.
Exp. Med. 104:555 (1956).
larly in infants.
10. CHANOCK, R. M., AND PARROTT, R. H., Acute respi-
ratory disease in infancy and childhood: Present
understanding and prospects for prevention, Pediat-
10. Unresolved Problems rics 36:21 (1965).
11. CHANOCK, R. M., PARROTT, R. H., COOK, K., AN-
The clinical spectrum of illness, age incidence, DREWS, B. E., BELL, J. A., REICHELDERFER, T., KAPI-
KlAN, A. Z., MASTROTA, F. M., AND HUEBNER, R. J.,
and ubiquity of parainfluenza virus infections has
Newly recognized myxoviruses from children with
been demonstrated (Table 1). There remains some
respiratory disease, N. Engl. J. Med. 258:207 (1958).
question about the epidemic patterns associated 12. CHANOCK, R. M., PARROTT, R. H., JOHNSON, K. M.,
with types 1 and 2 which can be clarified by KAPIKIAN, A. Z., AND BELL, J. A, Myxoviruses:
further observations over time. The most impor- Parainfluenza, Am. Rev. Resp. Dis. 88:152 (1963).
tant needs at the present time are for more intense 13. CHANOCK, R. M., WONG, D. c., HUEBNER, R. J., AND
study of the pathogenesis of disease-especially BELL, J. A, Serologic response in individuals in-
that associated with type 3-and a better under- fected with parainfluenza viruses, Am. J. Pub. Health
standing of the total immune response to all para- 50:1858 (1960).
influenza viruses in order to facilitate the develop- 14. CHIN, J., MAGOFFIN, R. L., SHEARER, L. A, SCHffiBLE,
J. H., AND LENNETTE, E. H., Field evaluation of a
ment of effective vaccines.
respiratory syncytial virus vaccine and a trivalent
parainfluenza virus vaccine in a pediatric popula-
tion, Am. J. Epidemiol. 89:449 (1969).
15. CLARRE, S. K. R., Parainfluenza virus infections,
11. References Postgrad. Med. J. 49:792 (1973).
16. COOK, M. K., ANDREWS, B. E., Fox, H. H., TURNER,
1. ABINANTI, F. R., CHANOCK, R. M., COOK, M. K., H. c., JAMES, W. D., AND CHANOCK, R. M., Anti-
WONG, D., AND WARFffiLD, M., Relationship of hu- genic relationships among the "newer" myxoviruses
man and bovine strains of myxovirus parainfluenza (parainfluenza), Am. J. Hyg. 69:250-264 (1959).
3, Proc. Soc. Exp. Bioi. Med. 106:466-469 (1961). 17. COOK, M. K., AND CHANOCK, R. M., In vivo antigenic
2. AHERNE, W., BIRD, T., COURT, S. D. M., GARDNER, P. studies of parainfluenza viruses, Am. J. Hyg. 77:150-
S., AND McQUILLEN, J., Pathological changes in virus 159 (1963).
infections of the lower respiratory tract in children, J. 18. EVANS, A. S., AND DICK, E. c., Acute pharyngitis
Clin. Pathol. 23:7-18 (1970). and tonsillitis in University of Wisconsin students, J.
3. AITKEN,.C. J. D., MOFFAT, M. A J., AND SUTHER- Am. Med. Assoc. 190:699 (1964).
LAND, J. A. W., Respiratory illness and viral infection 19. Foy, H. M., COONEY, M. K., MALETZKY, A J., AND
in an Edinburgh nursery, J. Hyg. 65:25-36 (1967). GRAYSTON, J. T., Incidence and etiology' of pneu-
4. AN DREWES, C. H., BANG, M. B., CHANOCK, R. M., monia, croup and bronchiolitis in preschool children
AND ZHDANOV, B. M., Parainfluenza viruses 1, 2 and belonging to a prepaid medical care group over a
3: Suggested names for recently described myxovi- four-year period, Am. J. Epidemiol. 97:80 (1973).
ruses, Virology 8:129-130 (May 1959). 20. FRANK, G. H., AND MARSHALL, R. G., Parainfluenza 3
virus infection of cattle, J. Am. Vel. Med. Assoc. tory pathogens in New York and New Orleans fami-
163:858-860 (1973). lies, Am. J. Epidemiol. 94:367 (1971).
21. FULGINITI, V. A., SIEBER, O. F., JOHN, T. J., ASKIN, 34. HAMRE, D., CONNELLY, A. P., AND PROCKNOW, J. J.,
P., AND UMLANT, H. J., JR., Parainfluenza virus Virologic studies of acute respiratory disease in
immunization. II. The influence of age and maternal young adults. IV. Virus isolations during four years
antibody upon successful immunization with an of surveillance, Am. J. Epidemiol. 83:238 (1966).
alum-adsorbed parainfluenza type 3 vaccine, Pedial. 35. HARRIS, D. J., WULFF, H., RAY, C. G., POLAND, J. D.,
Res. 1:50--58 (1967). CHIN, T. D. Y., AND WENNER, H. A., Viruses and
22. FULGINITI, V. A., ELLER, J. J., SIEBER, O. F., JOYNER, disease. II. An outbreak of parainfluenza type 2 in a
J. W., MINAMITANI, M., AND MEIKLEJOHN, G., Respi- children's home, Am. J. Epidemiol. 87:419 (1968).
ratory virus immunization. I. A field trial of two 36. HERRMANN, E. c., AND HABLE, K. A., Experiences in
inactivated respiratory virus vaccines; an aqueous laboratory diagnosis of parainfluenza viruses in rou-
trivalent parainfluenza virus vaccine and an alum- tine medical practice, Mayo Clin. Proc. 45:177 (1970).
precipitated respiratory syncytial virus vaccine, Am. 37. HOLZEL, A., PARKER, L., PATTERSON, W. H., CART-
J. Epidemiol. 89:435 (1969). MEL, D., WHITE, L. L. R., PURDY, R., THOMPSON, K.
23. GARDNER, P. S., MCQUILLIN, J., MCGUCKIN, R., AND M., AND TOBIN, J., Virus isolations from throats of
DITCHBURN, R. K., Observations on clinical and children admitted to hospital with respiratory and
immunofluorescent diagnosis of parainfluenza virus other diseases, Br. Med. J. 1:614 (1965).
infections, Br. Med. J. 2:7-12 (1971). 38. HOPE-SIMPSON, R. E., AND HIGGINS, P. G., A respira-
24. GARDNER, S. D., The isolation of parainfluenza 4 tory virus study in Great Britain: Review and evalua-
subtypes A and B in England and serological studies tion, Prog. Med. Viral. 11:354 (1969).
of their prevalence, J. Hyg. 67:54&-550 (1969). 39. HORE, D. E., STEVENSON, R. G., GILMOUR, N. J. L.,
25. GLEZEN, W. P., Unpublished data. V ANTISIS, J. T., AND THOMPSON, D. A., Isolation of
26. GLEZEN, W. P., AND DENNY, F. W., Epidemiology of parainfluenza virus from the lungs and nasal pas-
acute lower respiratory disease in children, N. Engl. sages of sheep showing respiratory disease, J. Camp.
J. Med. 288:498-505 (1973). Palhol. 78:259-265 (1968).
27. GLEZEN, W. P., AND FERNALD, G. W., Effect of 40. HORTSMANN, D. M., AND HSIUNG, G. D., Myxovirus
passive antibody on experimental infection with par- infections and respiratory illnesses in children, Clin.
ainfluenza virus type 3 (para 3), Pedial. Res. 8:425 Pedial. 2:378 (1963).
(1974). 41. HSIUNG, G. D., ISACSON, P., AND TUCKER, G., Studies
28. GLEZEN, W. P., LODA, F. A., CLYDE, W. A., JR., of parainfluenza viruses. II. Serologic interrelation-
SENIOR, R. J., SHEAFFER, C. I., CONLEY, W. G., AND ships in humans, Yale J. BioI. Med. 35:534-544 (1963).
DENNY, F. W., Epidemiologic patterns of acute lower 42. HULL, R. N., MINNER, J. R., AND SMITH, J. W., New
respiratory disease of children in a pediatric group agents recovered from tissue cultures of monkey
practice, J. Pedial. 78:397 (1971). kidney cells, Am. J. Hyg. 63:204-215 (1956).
29. GLEZEN, W. P., WULFF, H., LAMB, G. A., RAY, C. G., 43. JACKSON, G. G., AND MULDOON, R. L., Viruses caus-
CHIN, T. D. Y., AND WENNER, H. A., Patterns of ing common respiratory infections in man. II. Enter-
virus infections in families with acute respiratory oviruses and paramyxoviruses, J. Infeci. Dis. 128:387-
illnesses, Am. J. Epidemiol. 86:350 (1967). 469 (1973).
30. GROSS, P. A., GREEN, R. H., AND CURNEN, M. C. M., 44. JENSEN, K. E., PEELER, B. E., AND DULWORTH, W. G.,
Persistent infection with parainfluenza type 3 virus Immunizations against parainfluenza infections, J.
in man, Am. Rev. Resp. Dis. 108:894-898 (1973). Immunol. 89:216-226 (1962).
31. GWALTNEY, J. M., JR., HENDLEY, J. 0., SIMON, G., 45. JOHNSON, K. M., CHANOCK, R. M., COOK, M. K., AND
AND JORDAN, W. S., Rhinovirus infections in an HUEBNER, R. J., Studies of a new human hemadsorp-
industrial population. I. The OCCUITence of illness, N. tion virus. I. Isolation, properties and characteriza-
Engl. J. Med. 275:1261-1268 (1966). tion, Am. J. Hyg. 71:81-92 (1960).
32. GUTEKUNST, D. E., PATON, 1. M., AND VOLANCE, F. J., 46. JOHNSON, D. P., AND GREEN, R. H., Viremia during
Parainfluenza 3 vaccine in cattle: Comparative effi- parainfluenza type 3 virus infection of hamsters,
cacy of intranasal and intramuscular routes, J. Am. Proc. Soc. Exp. BioI. Med. 144:74&-748 (1973).
Vel. Med. Assoc. 155:1879-1885 (1969). 47. KAPIKIAN, A. Z., BELL, J. A., MASTROTA, F. M.,
33. HALL, C. E., BRANDT, C. D., FROTHINGHAM, T. E., HUEBNER, R. J., WONG, D. c., AND CHANOCK, R. M.,
SPIGLAND, I., COONEY, M. K., AND Fox, J. P., The An outbreak of parainfluenza 2 (croup-associated)
Virus Watch Program: A continuing surveillance of virus infection, J. Am. Med. Assoc. 183:324 (1963).
viral infections in metropolitan New York families. 48. KAPIKIAN, A. Z., CHANOCK, R. M., REICHELDERFER,
IX. A comparison of infections with several respira- T. E., WARD, T. G., HUEBNER, R. J., AND BELL, J. A.,
Inoculation of human volunteers with parainfluenza 62. McLEAN, D. M., BANNATYNE, R. M., AND GIBAN, K.,
virus type 3, J. Am. Med. Assoc. 178:537-541 (1961). Myxovirus dissemination by air, Can. Med. Assoc. J.
49. KILLGORE, G. E., AND DOWDLE, W. R., Antigenic 96:1449 (1967).
characterization of parainfluenza 4A and 4B by the 03. MILLER, W. S., AND ARTENSTEIN, M. S., Aerosol
hemagglutination-inhibition test and distribution of stability of three acute respiratory disease viruses,
HI antibody in human sera, Am. J. Epidemiol. 91:308- Proc. Soc. Exp. BioI. Med. 125:222-227 (1967).
316 (1970). 64. MOGABGAB, W. J., Acute respiratory illnesses in uni-
50. KIM, H. W., CANCHOLA, J. G., VARGOSKO, A J., versity (1962-1966), military and industrial (1962-
ARROBIO, J. 0., DE MEIO, J. L., AND PARROTT, R. H., 1963) populations, Am. Rev. Resp. Dis. 98:359 (1968).
Immunogenicity of inactivated parainfluenza type 1, 65. MONTO, A S., The Tecumseh study of respiratory
type 2, and type 3 vaccines in infants, J. Am. Med. illness. V. Patterns of infection with the parainflu-
Assoc. 196:819 (1966). enza viruses, Am. J. Epidemiol. 97:338-348 (1973).
51. KIM, H. W., VARGOSKO, E. J., CHANOCK, R. M., AND 66. MONTO, A. S., AND JOHNSON, K. M., Respiratory
PARROTT, R. H., Parainfluenza 2 (CA) virus: Etiologic infections in the American tropics, Am. J. Trop. Med.
association with croup, Pediatrics 28:614-621 (1961). Hyg. 17:867-874 (1968).
52. KLOENE, W., BANG, F. B., CHAKRABORTY, S. M., 67. MONOZENKO, M. A., BANYSHEVA, A. E., TEMOFEYEVA,
COOPER, M. R., KULEMANN, H., OTA, M., AND SHAH, G. A., BYSTOYAKAVA, L. V., AND KALINNIKOVA, O.
K. V., A two-year respiratory virus survey in four N., Diagnostic value of the complement fixation
villages in West Bengal, India, Am. J. Epidemiol. reaction in viral respiratory infections of infants,
92:307 (1970). Acta Virol. 7:534-541 (1963).
53. KOLAR, J. R., JR., SHECHMEISTER, 1. L., AND STRACK, 1. 68. MUFSON, M. A., CHANG, V., GILL, V., WOOD, S. c.,
E., Field experiments with formalin-killed-virus vac- ROMAN SKY, M. J., AND CHANOCK, R. M., The role of
cine against infectious bovine rhinotracheitis, bovine viruses, mycoplasmas and bacteria in acute pneu-
viral diarrhea, and parainfluenza-3, Am. J. Vet. Res. monia in civilian adults, Am. J. Epidemiol. 86:526
34:1469-1471 (1973). (1967).
54. KUROYA, M., AND ISHIDA, N., Newborn virus pneu- 69. MUFSON, M. A., KRAUSE, H. E., MOCEGA, H. E., AND
monitis (type Sendai). II. Isolation of a new virus DAWSON, F. W., Viruses, Mycoplasma pneumoniae
possessing hemagglutinin activity, Yokohoma Med. and bacteria associated with lower respiratory tract
Bull. 4:217-233 (1953). disease among infants, Am. J. Epidemiol. 91:192-202
55. LAPLACA, M., AND MOSCOVICI, c., Distribution of (1970).
parainfluenza antibodies in different groups of pop- 70. MUFSON, M. A., MOCEGA, H. E., AND KRAUSE, H. E.,
ulation, J. Immunol. 88:72 (1962). Acquisition of parainfluenza 3 virus infection by
56. LODA, F. A., COLLIER, A. M., AND GLEZEN, W. P., hospitalized children. 1. Frequencies, rates, and tem-
Unpublished observations. poral data, J. Infect. Dis. 128:141-147 (1973).
LODA, F. A, GLEZEN, W. P., AND CLYDE, W. A.,
71. OLSON, L. c., LEXOMBOON, U., SITHISARN, P., AND
57.
Respiratory disease in group day care, Pediatrics
NOYES, H. E., The etiology of respiratory tract infec-
49:428 (1972).
tions in a tropical country, Am. J. Epidemiol. 97:34
58. MALETZKY, A. J., COONEY, M. K., LUCE, R., KENNY,
(1973).
G. E., AND GRAYSTON, J. T., Epidemiology of viral
72. PARROTT, R. H., VARGOSKO, A. J., KIM, H. W., BELL,
and mycoplasmal agents associated with childhood
J. A, AND CHANOCK, R. M., III. Myxoviruses: Parain-
lower respiratory illness in a civilian population, J.
fluenza, Am. J. Publ. Health 52:907-917 (1962).
Pediat. 78:407-414 (1971).
73. PEREIRA, M. S., AND FISHER, O. D., An outbreak of
59. MAYNARD, J. E., FELTZ, E. T., WULFF, H., FORTUINE,
R., POLAND, J. D., AND CHIN, T. D. Y., Surveillance acute laryngotracheobronchitis associated with para-
of respiratory virus infections among Alaskan Es- influenza 2 virus, Lancet 2:790 (1960).
kimo children, J. Am. Med. Assoc. 200:927 (1967). 74. POTASH, 1., LEES, R., GREENBERGER, J. 1., HOYRUP,
60. MciNTOSH, K., ELLIS, E. F., HOFFMAN, L. S., LYBASS, A, DENNEY, 1. D., AND CHANOCK, R. M., A mutant
T. G., ELLER, J. J., AND FULGINITI, V. A, The associa- of parainfluenza type 1 virus with decreased capacity
tion of viral and bacterial respiratory infections with for growth at 38C and 39C, J. Infect. Dis. 121:640-647
exacerbations of wheezing in young asthmatic chil- (1970).
dren, J. Pediat. 82:578 (1973). 75. RABE, E. F., Infectious croup. II. "Virus" croup,
61. McLEAN, D. M., BACH, R., LAVKE, R. P. B., AND Pediatrics 2:415 (1948).
McNAUGHTON, G. A., Myxoviruses associated with 76. REICHELDERFER, T. E., CHANOCK, R. M., CRAIGHEAD,
acute laryngotracheobronchitis in Toronto, 1962- J. E., HUEBNER, R. J., WARD, T. J., TURNER, H. c.,
1963, Can. Med. Assoc. J. 89:1257 (1963). AND JAMES, W. D., Infection of human volunteers
with type 2 hemadsorption virus, Science 128:779-780 virus vaccines. VIII. Field evaluation of trivalent
(1958). parainfluenza virus vaccine among preschool chil-
77. REISINGER, R. c., HEDDLESTON, K. 1., AND MANTHEI, dren in families, 1967-1968, Am. Rev. Resp. Dis.
C. A., A myxovirus SF-4 associated with shipping 99:526 (1969).
fever of cattle, J. Am. Vet. Med. Assoc. 135:147-152 91. VIHMA, 1., Surveillance of acute viral respiratory
(1959). diseases in children, Acta Paediat. Scand. Suppl. 192:1
78. ROCCHI, G., ARANGRO-RuIZ, G., GIANNINI, V., JE- (1969).
MOLO, A. M., ANDREONI, G., AND ARCHETTI, I., 92. VON EULER, 1. V., KANTOR, F. S., AND HSIUNG, G.
Detection of viremia in acute respiratory disease of D., Studies of parainfluenza viruses. I. Clinical,
man, Acta Virol. 14:405-407 (1970). pathological and virological observations, Yale f. BioI.
79. ROSNER, S. F., Bovine parainfluenza type 3 virus Med. 35:523 (1963).
infection and pasteurellosis, J. Am. Vet. Med. Assoc. 93. WENZEL, R. P., MCCORMICK, D. P., AND BEAM, W.
159:1375-1381 (1971). E., JR., Parainfluenza pneumonia in adults, J. Am.
80. SALIBA, G. S., GLEZEN, W. P., AND CHIN, T. D. Y., Med. Assoc. 221:294 (1972).
Etiologic studies of acute respiratory illness among 94. WIGLEY, F. M., FRUCHTMAN, M. H., AND WALDMAN,
children attending public schools, Am. Rev. Resp. R. H., Aerosol immunization of humans with inacti-
Dis. 95:592 (1967). vated parainfluenza type 2 vaccine, N. Engl. J. Med.
81. SMITH, C. B., PURCELL, R. H., BELLANTI, J. A., AND 283:1250 (1970).
CHANOCK, R. M., Protective effect of antibody to 95. WULFF, H., SOEKEN, J., POLAND, J. D., AND CHIN, T.
parainfluenza type 1 virus, N. Engl. f. Med. 275:1145 D. Y., A new micro-neutralization test for antibody
(1966). determination and typing of parainfluenza and influ-
82. STARK, J. D., HEATH, R. B., AND CURWEN, M. P., enza viruses, Proc. Soc. Exp. BioI. Med. 125:1045-1049
Infection with influenza and parainfluenza viruses in (1967).
chronic bronchitis, Thorax 20:124 (1965). 96. ZINSERLING, A., Peculiarities of lesion in viral and
83. SULLIVAN, R. J., DOWDLE, W. R., MARINE, W. M., AND mycoplasma infections of the respiratory tract, Vir-
HIERHOLZER, J. c., Adult pneumonia in a general chows Arch. Abt. A Pathol. Anat. 356:259-273 (1972).
hospital, Arch. Intern. Med. 129:935 (1972). 97. ZOLLAR, 1. M., KRAUSE, H. E., AND MUFSON, M. A.,
84. TAl, F.-H., AND CHING, C.-M., Antibody patterns of Microbiologic studies on young infants with lower
parainfluenza viruses in human populations on Tai- respiratory tract disease, Am. J. Dis. Child. 126:56
wan, Am. Rev. Resp. Dis. 97:941 (1968). (1973).
85. TAYLOR-RoBINSON, D., AND BYNOE, M. 1., Parainflu-
enza 2 virus infections in adult volunteers, f. Hyg.
61:407 (1963).
86. TREMONT I, 1. P., LIN, J. S. 1., AND JACKSON, G. G.,
Neutralizing activity in nasal secretions and serum
in resistance of volunteers to parainfluenza virus 12. Suggested Reading
type 2, f. Immunol. 101:572 (1968).
87. TYRRELL, D. A. J., AND BYNOE, M. 1., Studies on CHANOCK, R. M., AND PARROTT, R. H., Acute respiratory
parainfluenza type 2 and 4 viruses obtained from disease in infancy and childhood: Present understand-
patients with common colds, Br. Med. f. 1:471 (1969). ing and prospects for prevention, Pediatrics 36:21-39
88. TYRRELL, D. A. J., BYNOE, M. 1., BIRKUM, K., PETER- (1965).
SEN, S., AND PEREIRA, M. S., Inoculation of human CLARKE, S. K. R., Parainfluenza virus infections, Post-
volunteers with parainfluenza viruses 1 and 3 (Hi\" grad. Med. f. 49:792-797 (1973).
and HA,), Br. Med. f. 2:909 (1959). GLEZEN, W. P., AND DENNY, F. W., Epidemiology of acute
89. VARGOSKO, A. J., CHANOCK, R. M., HUEBNER, R. J., lower respiratory disease in children, N. Engl. J. Med.
LUCKEY, A. H., KIM, H. W., CUMMINGS, c., AND 288:498-505 (1973).
PARROTT, R. A., Association of type 2 hemadsorption JACKSON, G., AND MULDOON, R., Viruses causing com-
(parainfluenza 1) virus and Asian influenza A virus mon respiratory infections in man. II. Enteroviruses
with infectious croup, N. Engl. J. Med. 261:731 (1959). and paramyxoviruses, f. Infect. Dis. 128:387-469 (1973).
90. VELLA, P. P., WEIBEL, R. E., WOODHOUR, A. F., MONTO, A., The Tecumseh study of respiratory illness.
MASCOLI, C. c., LEAGUS, M. B., ITTENSOHN, O. 1., V. Patterns of infection with the parainfluenza viruses,
STOKES, J., JR., AND HILLEMAN, M. R., Respiratory Am. J. Epidemiol. 97:338-348 (1973).
CHAPTER 16
Rabies
Robert E. Shope
1. Introduction 2. Historical Background

The pre-Mosaic Eshnunna Code from the third
Rabies is an acute central nervous system disease
millennium B.C. refers to death in man following
of m~ a~d domestic and wild animals usually
dog bite.(6!) Democritus in 500 B.C. and Aristotle
resultmg m death. The disease follows infection
in 322 B.C. recognized rabies in dogs and other
with a virus which is bullet-shaped, has an enve-
domestic animals. Thus it can be assumed that the
lope, and contains single-stranded RNA. In the
disease existed in Asia, Europe, and perhaps M-
classical pathogenesis, the virus gains entry by the
rica for centuries in a stable form. Periodic epi-
bite of a rabid animal, usually a dog or cat but also
zootics occurred in wild vertebrates; Johnson(28)
wild animals such as bats, wolves, foxes, skunks,
cites wolf rabies in Western Europe in 1271 and in
raccoons, meercats, and coyotes. During an incu-
the same region seven major epizootics in foxes
bation period of from days to several months, the
virus is believed to multiply in the muscle(44l at from 1803 to 1925. After World War II, another
epizootic in foxes swept through Europe from east
the site of entry and then to travel centripetally via
to west at about a rate of 30 km each year and the
nerves to the ganglia and to the CNS. Once the
we~tward movement still continues. Domestic dog
CNS is infected, overt disease appears in the form
of fever, acute excitation, convulsions, excess lacri- rabIes probably stemmed from infection in wild
vertebrates. The first recorded sizable dog rabies
mation and salivation, insomnia, anxiety, diffi-
outbreak was in Italy in 1708, and England had
culty in swallowing, and sometimes maniacal be-
epizootic rabies in 1734.
havior. A form of the disease called "dumb rabies"
Rabies virus probably evolved in the Old World,
is characterized by progressive lassitude, coma,
perhaps Africa or Asia. Rabies was unknown in
and death. There is no cure for rabies, but pre-
the New World until 1753, when dogs in the
vention by cleansing of the wound, vaccination,
colony of Virginia were infected, and in South
and immune serum therapy is effective in many
America until 1803, when it occurred in dogs in
cases.
Peru. Thus probably the virus was imported into
Laboratory animals may survive overt dis-
the New World in the eighteenth century. The
ease, (6) and there has now been a reported
survival in man.(24) There is thus reason for opti- existence in Africa of at least five viruses serologi-
cally related to rabies(42,53l supports the hypothe-
mism that something can be done about rabies in
sis of its Mrican origin with the parallel evolution
man.
of several related viruses. Rabies virus has now
become widely established in wildlife in the
Rob~rt E. Shope . Department of Epidemiology and Americas including vampire bats in South and
Public Health, Yale School of Medicine, New Haven, Central America(25l and insectivorous bats in
Connecticut North America.om
351
352 Chapter 16 • Rabies
The history of rabies has been documented by a quired in other countries. U.S. statistics for man
long series of observations relating to prevention, and animals are compiled from state health depart-
treatment, and laboratory diagnosis. Celsius in A.D. ments by the National Rabies Surveillance Pro-
100 treated rabies by cautery, and Galen in A.D. gram of the Center for Disease Control and are
200 by amputation. Zuike in 1804 first transmitted published in the Morbidity and Mortality Weekly
rabies to a normal dog by inoculation of infected Report. The World Health Organization through
saliva. This observation led to institution of dog the Veterinary Public Health Section collects data
control and muzzle laws. which resulted in elimi- from national governments on deaths in man,
nation of rabies from Denmark, Norway, and numbers of persons exposed, and numbers of
Sweden by 1826. In 1879 Galtier(22) first used the doses of rabies vaccine administered. These data
domestic rabbit as a laboratory host, enabling the are distributed annually to national governments.
classical experiments in which Pasteur developed Death rates, where rabies is looked for, accu-
virus attenuated for the dog(47) but having a rately represent incidence rates of infection in
uniform (fixed) incubation period in the rabbit. man and probably in animals because the disease
He subsequently used this virus, grown in rabbit can be regarded as 100% fatal. Animals which
spinal cords and dried for varying periods, to give develop disease usually die, but it is not clearly
virus doses graded from noninfectious to fully established whether or not naturally infected ani-
infectious for immunization of dogs and man. (46) mals can develop antibodies and recover from or
The first vaccine in man was given in 1885 to a 12- escape disease. Mortality data can be reliable,
yr-old boy, and, because of early success, no provided the diagnOSis is made accurately. Un-
controlled clinical trial of vaccine effectiveness has derreporting is common in some parts of the
ever been carried out. world. For instance, there were estimated to be
Negri(45) in 1903 described intracytoplasmic in- 400-500 human deaths from rabies in Thailand in
clusion bodies in neurons of man and other verte- 1966, more than 10 times the officially reported
brate animals, facilitating the early diagnosis of number.(32)
rabies. In 1908 Fermi developed the first chemi-
cally treated vaccine, and in 1919 Semple showed
that phenol could inactivate rabies virus without 3.2. Sources of Morbidity Data
destroying antigenicity. The Semple vaccine has There is only one well-documented case in man
been used in man extensively for 50 yr. In 1935 of recovery from rabies. (24) Exposures and poten-
rabies immune serum was shown to be effective tial exposures to bites of rabid animals, however,
post exposure in preventing disease, (55) and in are documented indirectly in some countries by
1949 a live virus vaccine using the Flury strain of recording of the number of vaccine doses sold or
egg-adapted virus was developed for use in used. These estimates are crude but are useful to
dogs.(37) Both killed and live virus vaccines are show trends.
effective in preventing rabies in domestic animals.
Their widespread use in the United States, and the
introduction of the Habel test for vaccine stand- 3.3. Serological Surveys
ardization, has resulted since 1960 in excellent
control of rabies in dogs and consequently a Serological surveys in man(50) and domestic(])
marked decrease in numbers of cases in man. and wild animals have been done by the neutrali-
zation test in mice,<29) by the indirect FA test, (39)
and by the Ouchterlony agar gel precipitin testY)
3. Methodology Involved in Epidemiological Serological surveys are infrequently used in the
Analysis study of rabies epidemiology; those surveys re-
ported in the literature should be interpreted with
caution. Naturally occurring substances in sera
3.1. Sources of Mortality Data neutralize or react with rabies virus, and these
Rabies in man is a specified notifiable disease in cannot a priori be considered to be antibody unless
the United States, and reporting is generally re- the substances are also shown to be localized in
Chapter 16 • Rabies 353
the Ig fractions of serum. Rabies often has a long antibody for detection of rabies virus infection,
incubation period during which humoral antibody and specific virus identification by fluorescent
may appear in an animal that is later destined to antibody and neutralization tests. For regulations
become rabid. (S) The presence of antibody in governing shipment of potentially infectious spec-
animal sera does not necessarily mean therefore imens, the local public health laboratory should be
that inapparent rabies infection has occurred, as consulted.
claimed by some.(110 On the other hand, Bell has Negri bodies are cytoplasmic inclusions seen
reported abortive rabies in laboratory experiments under the light microscope. They contain rabies
with mice(7) and has reviewed the evidence for ribonucleoprotein, which accumulates in quan-
inapparent infection and antibody formation in tities large enough to stain by the Sellers, Giemsa,
animals. (6) or Mann methods and be visualized. The Am-
The interpretation of survey results in Mrica mon's hom is the portion of brain usually exam-
may also be complicated by the potential existence ined by smear. Artifacts and inclusions produced
of cross-reacting heterologous antibody to rabies- by other viruses can be differentiated only after
related viruses, (53) although such antibody has considerable experience. Nevertheless, histopath-
not yet been found in nature. ological examination offers a diagnosis as quickly
Detection of antibody responses to vaccination as 30 min after the laboratory receives a specimen.
may be important in evaluating vaccines and in For epidemiological studies, confirmation of Negri
assessing risk in high-exposure popUlations. The bodies by fluorescent antibody or by animal inoc-
rabies fluorescent focus inhibition test(33.39) gives ulation and serological identification should be
a rapid, reliable determination. Rabies antibody attempted since in some laboratories histopathol-
prevents the formation in tissue culture of foci of ogical diagnosis misses 15--20% of rabies infec-
infected cells as visualized under the fluorescence tions.(33)
microscope. This technique is not yet in general The weanling mouse is highly susceptible to
use for serological surveys but should be equally rabies infection by intracerebral inoculation. The
as useful as the mouse neutralization test and time from inoculation to illness varies from 4 days
quicker and less expensive. At present, there is no to 3 wk, but the presence of rabies antigen in
simple, specific, and inexpensive antibody test in mouse brain may sometimes be confirmed much
use for rabies serological surveys of large popula- earlier by fluorescent antibody or complement fix-
tions. ation tests. The identity of the suspected rabies
isolate should always be determined serologically
because animals may die of intercurrent infection
3.4. Laboratory Methods or as a result of infection by other viruses in the
original specimen. In Africa the identity of the
Since other forms of encephalitis may be con- suspected rabies isolate should be confirmed by
fused with rabies, it is essential that epidemiologi- neutralization test rather than by the fluorescent
cal studies be based on carefully documented labo- antibody technique since African viruses related to
ratory confirmation of disease or death from rabies rabies cross-react significantly in the fluorescent
virus infection. Laboratory techniques have antibody test. (53l
evolved for more than 100 yr, and, while success- The direct fluorescent antibody test uses a fluo-
ful variations are in use in many laboratories, the rescein dye conjugated to rabies immune globulin,
standard techniques approved by the World which in tum is reacted with a smear from the
Health Organization's Expert Committee on Ra- brain of the presumed rabid animal or person. The
bies(33) are recommended and widely used. In- antigen/antibody reaction is detected by observing
cluded are methods for collection, preparation, fluorescence under light of the appropriate wave-
and shipping rabies specimens; this WHO source length. The test is rapid and as reliable as animal
and a review by H. N. Johnson(ZS) have been used inoculation when used by an experienced worker.
freely in the following description. Methods in- It should not supplant animal inoculation unless
clude examination of brains for Negri bodies, the operator is skilled and maintains adequate
laboratory animal inoculation, use of fluorescent controls.
4. Biological Characteristics of Virus populations. Superficially there appears to be a

Affecting the Epidemiological Pattern predilection of the virus of a given geographic area
to one species of animal. Sikes (56 ) has given a
The biological characteristics of rabies virus plausible explanation. A strain of virus from a fox
have a very definite although incompletely under- has biological properties such that (1) it requires
stood effect on the epidemiological pattern, espe- 100 times less virus to infect a fox than a skunk,
cially in wildlife. and (2) if a fox is infected with a large dose the fox
Rabies in man is a dead-end disease; man does develops a rapidly progressive disease and dies
not usually transmit or maintain the infection before the salivary glands have time to become
cycle. Biological properties of the virus affecting infected. Thus most of the foxes which transmit
the epidemiology must therefore be properties rabies have relatively low virus titers in the sa-
referable to the domestic animal or wildlife cycle. liva-titers high enough to infect other foxes but
The incubation period is long-Debbie(l5) cites not skunks.
ranges in animals from 10 to 209 days of the The epidemiology of rabies in bat caves may
natural infection, and in man exceptionally as long also be influenced by a little-understood biological
as 3 yr, with 4-10% 6 months or longer. The long property of rabies virus strains of bats-a predilec-
incubation period in dogs is responsible for the tion for nasal mucosa.(J2) The spread of these
ease of introduction of rabies into rabies-free strains by the airborne route in bat caves may
areas. Because of the long incubation period in explain transmission of rabies virus to persons
wildlife, smoldering epizootics allow time for new who entered Frio Cave, Texas, where the air was
susceptible offspring to enter a population so that subsequently shown to contain rabies virus. (lin
the virus continually has fertile ground for mainte- Recently, a bat isolate has been shown to spread
nance of the cycle. In Europe the spread of fox among foxes in an airborne epizootic in a labora-
rabies from west to east is gradual (30 km/yr), and tory building. (69)
this can be related to the approximate distance that
young infected animals range during the long
incubation period.
Two other biological properties-neurotropism
and shedding from exocrine glands in dogs, cats,
5.1. Incidence
and wildlife-account for the unique mode of
transmission via saliva following bites. As R. T. The number of human rabies cases in most areas
Johnson has written, "No other virus is so diaboli- is directly related to the prevalence of rabid dogs.
cally adapted to selective neuronal populations In the United States, where dog rabies was con-
that it can drive the host in a fury to transmit the trolled by a highly effective vaccination program
virus to another host animal.,,(31) Here he refers to and by leash laws, human rabies dropped from 33
the selective relative localization of lesions to the cases reported in 1946 to three or fewer cases per
limbic system and the transmission through bite year since 1962.(26) This striking decrease in hu-
via infected saliva. man rabies is shown in Fig. 1. In otherl'arts of the
Biological properties of the virus also undoubt- world where dog rabies is still prevalent such as
edly account for some of the unexplained apparent parts of South America, Africa, and Asia, human
contradictions in the epidemiology of rabies. For rabies still constitutes a major public health prob-
instance, data collected by the u.s. Public Health lem.
Service indicate that there is relative geographic In some parts of Africa, because of an unusual
compartmentalization of rabies to a single animal virus biotype which produces paralytic or dumb
species.(26) Where rabies occurs in skunks (Cali- rabies in dogs rather than the furious type, the
fornia, midwestern United States), there is little or dogs do not transmit frequently to man. This type
no fox rabies; where rabies occurs in foxes (south- of rabies is referred to as Oulou Fato.
eastern United States), there is a scarcity of skunk Where dog rabies is controlled, the incidence in
rabies; where raccoons are infected (Florida and man relates almost entirely to exposure to wildlife.
Georgia), there is little infection in other wildlife In the United States between 1946 and 1950, nearly
30' The first type of epidemic is well illustrated by

(I)
w the now famous episode in 1954 in which a rabid
«
(I)
1I/h. ACQUIRED OUTSIDE OF
() WI//, UNITED STATES wolf in Iran attacked 29 persons, inflicting severe
II. head wounds.(5) This afforded the first opportu-
0
a: nity to test the efficacy of rabies immune serum as
w
10 an adjunct to vaccine postexposure treatment.
:E The dynamics of the second type of epidemic are
::J
Z poorly understood. Epizootics in wild animals
1950 '52 '54 '56 '58 '60 '62 '64 '66 '68 '70 '72 have historically swept over large areas/ 2Sl infect-
ing people where contact with wild animals oc-
Fig. 1. Reported cases of rabies in humans by year,
United States, 1950-1973. curred. The distribution of the epizootics did not
necessarily conform to that of susceptible animal
populations, and their cessation was not related to
all of the 94 human rabies cases were traced to
public health control measures as far as is known.
rabid dogs and cats. Between 1951 and 1970, dog-
The behavioral and mobility patterns of the animal
and cat-transmitted rabies virtually disappeared;
species, its eating and biting habits, the availabil-
skunks were responsible for ten rabies deaths in
ity of vegetation and meat sources, and the stress
man between 1951 and 1970, foxes six, and bats
of inclement weather on extending foraging prac-
seven. WSl Skunks commonly live near man and
tices undoubtedly affect the incidence and spread
have been sold as household pets. One study of 69
of rabies in nature, but the interplay and separate
skunks sold as pets showed that 80 of 366 persons
importance of these factors have not been carefully
in contact with the pet skunks were bitten, and 15
evaluated.
of these people received postexposure rabies pro-
phylaxisyal
A minority of persons bitten by a rabid animal 5.3. Geographic Distribution
become infected, and it is also possible that one
can be infected without developing disease. Fac- The distribution of rabies in man is directly
tors which influence the initiation of infection and related to its distribution in wild and domestic
the incubation period are those which influence animals. In the United States, rabies occurs in bats
the dose of virus transmitted, such as the titer of in all contiguous states. Skunks, foxes, raccoons,
virus in saliva and whether the bite was through and several less frequently infected animals serve
clothing. In addition, the threshold of infection as reservoirs of infection in different parts of the
(the titer needed to initiate infection) varies with country. In Alaska, the arctic fox is the reservoir,
the host species and with the individual strain of transmitting to sled dogs, wolves, and coyotes.
virus. (5(H If the skin is broken at the time of In South and Central America, dog and cattle
exposure, infection is much more likely to occur. rabies is widespread. Vampire bats are an impor-
Detection of serological positive reactions in tant reservoir; it is likely that nearly a million
apparently normal animals and persons(l.S.5(1l has cattle die each year of vampire bat transmitted
been reported on rare occasions, but the reactive rabies in Latin America and losses are estimated at
substances have not usually been shown to be in $250,000,000 annually.(H()) The mongoose is also a
the Ig fraction of sera and thus the validity of these reservoir of rabies in Puerto Rico and Grenada,
results is in doubt. although not a reservoir in Trinid·ad.
In Southeast Asia, dog rabies is highly enzootic
except in Japan, Taiwan, and Okinawa, where
rabies does not occur. Wild animals in some parts
Rabies epidemics are of two types: cases result- of Southeast Asia such as the Philippine Islands
ing from a single rabid animal biting several are apparently not infected with rabies virus de-
people in series, and cases resulting from a geo- spite high infection rates in domestic dogs.
graphically localized increase of rabies in a domes- Eastern and central Europe are currently in-
tic or wild animal population, the infection spill- volved in a major outbreak of fox rabies which has
ing over into the human population. now spread into Switzerland and France. North
Africa has enzootic dog rabies, and in sub-Saharan

Africa the jackal, the yellow mongoose, the cape
polecat, the weasel, and the civet cat, in addition III
:c [d MALE
to the dog, are known to be rabid. (28) D
~
w
FEMALE
There are five viruses serologically related to
Cl
rabies which can be distinguished in the labora-
tory. These viruses occur in sub-Saharan Africa.
They include Lagos bat, Mokola, and kotonkan
viruses in Nigeria; Obodhiang virus in Sudan;
and Duvenhage virus in South Africa. Kemp et
al. (35) have postulated that antibody to a rabies-
related virus in the cattle population of West
Africa could account for the rarity of observed AGE
rabies in cattle in that region.(35)
Fig. 2. Reported cases of rabies in humans by age and
Several areas are free of rabies either because of sex, United States, 1950-1973.
their island status or because of strict quarantine
and dog control. These include Australia, New
Zealand, Japan, Hawaii, the British Isles, and 6. Mechanisms and Routes of Transmission
much of Scandinavia.
Rabies is transmitted by the bite of r"bid ani-
mals. Intact skin protects against virus entry/28)
5.4. Temporal Distribution although infection may occur through small cuts
and scratches or by way of mucous membranes.
The chances of infection are believed to be less if
Rabies occurs throughout the year. However,
the bite occurs through clothing. Virus appears in
peak numbers of rabid animals in the United
the saliva of dogs and other animals in most cases
States are found in the spring and early summer.
only shortly before disease is evident and not
This seasonality coincides wit;\ the breeding sea-
son.(8) Human exposures are common in the sum- before infection of the brain. Fekadu/ 20l however,
has reported what must be a rare exception in
mer, and this may relate to the period in which
dogs, five animals which survived from 9 to 39
people enjoy peak outdoor activity.
months after first isolation of rabies virus from
their saliva. While one dog died of rabies and
another of pneumonia, three were still alive and
5.5. Age, Sex, Race, Occupation, Socioeconomic, apparently well for at least 2 yr. Rabies virus was
Nutritional, and Genetic Factors isolated repeatedly from these animals. BellO;) has
suggested that some rabies strains in Africa are
Children are much more likely to develop rabies attenuated with "accommodation between host
than adults (Fig. 2). This is partly a result of and virus."
increased susceptibility in the young but is more The offspring of one of these dogs developed
fully explained by the greater contact of children rabies, and the possibility of transplacental or
with dogs and wildlife, the uninhibited curiosity milk-borne infection must be entertained. Trans-
of children, and their inability to evade a rabid placental transmission in a naturally infected cow
animal. By the same token, male children are more has been reported. (41)
likely to be exposed than female children. There Oral transmission through ingestion of rabies-
do not appear to be racial, genetic, nutritional, or contaminated meat has been amply demonstrated
socioeconomic differences in susceptibility to rain experimental animals/ 2 1,58) and Charles Darwin
bies virus. Members of certain occupations such as in The Voyage of the Beagle described possible
veterinarians, laboratory workers, and persons liv- cases of rabies in men in Peru after they consumed
ing in developing tropical areas are at higher risk the meat of a rabid bullock.(la) The oral route of
of rabies exposure. infection might explain natural transmission to
carnivores which frequently eat sick or dead rabid Until recently it was believed that the virus
animals. failed to multiply at the site of introduction. There
Airborne transmission of rabies has been shown was no rise in virus titer demonstrable in muscle
experimentally in the laboratory,((l7) and by an tissue and antigen could not be visualized at the
elegant experiment by Constantine/") who inoculation site.(30l However, Murphy et al. (44)
showed infection of foxes and coyotes to occur have now shown by the fluorescent antibody tech-
when they were placed in a tightly meshed wire nique that antigen is present in muscle cells of
cage in bat-occupied Frio Cave, near Uvalde, hamsters at 36 h post inoculation. This is before
Texas. This seems to explain how rabies occurred antigen is demonstrable by fluorescence methods
in two men who entered Frio Cave in 1956 and in other parts of the body, including the CNS.
1958.(27) Rabies virus spreads via the axoplasm centripe-
Transmission by apparently healthy animal car- tally along peripheral nerves to ganglia. Experi-
riers or by the oral, milk-borne, and airborne ments in mice show that amputation of the inocu-
routes must be considered unusual and relatively lated limb prevents spread of infection and saves
unimportant fro'm the point of view of human the animal. In mice infected with street virus,
infection or the transmission of rabies by dogs and amputation done as long as 18 days after inocula-
cats. Strong evidence indicating that dog and cat tion still permits animal survival. (4) Virus multi-
bites are the important route in human rabies is plication occurs next in the ganglia serving the
the near elimination of human rabies in the nerves from the inoculation site.
United States by effective vaccination of pets and The CNS is invaded, and rapid spread occurs
by leash laws. either by nerve pathways, cerebrospinal fluid, or
Cattle rabies in Latin America remains the major both. Within hours the virus becomes detectable
economic rabies problem in the New World. This throughout the CNS and later in virtually all or-
disease is transmitted primarily by vampire bats, gans of the body. Viremia at this stage has been
which maintain the infection in the bat population detected but is a rare event and is of too Iowa titer
as a closed cycle with approximately 1% of nor- to have epidemiological significance.
mal-appearing vampire bats infected at any The salivary glands of most rabid animals be-
time.(lO) The bats probably maintain the cycle by come infected during the period before onset of
biting each other; the transmission of bat rabies to signs. Dogs, cats, and skunks shed virus in saliva
cattle and occasionally to man occurs secondary to 1-3 days before disease appears, and in some
natural feeding and does not necessitate their animals the titer of virus in salivary glands consid-
being furious or sick. Bats reportedly(48) have erably exceeds that in brain.(;2) Virus is also
virus in their saliva for more than 3 months after found in the respiratory tract, the kidneys, and the
infection, but the mechanism by which the bat milk of infected animals, but these sites are not
remains infected and without disease, while other usually implicated in the spread of rabies to man.
animals regularly become sick following infection, The widespread distribution of rabies antigen in
is not well understood. man just prior to the onset of disease has been the
basis of tests for early diagnosis. For example,
fluorescent antibody methods to detect antigen in
skin biopsies, buccal mucosa, and corneal tissue
7. Pathogenesis and Immunity may sometimes yield a positive diagnosis before
clinical disease develops. However, a negative test
Naturally occurring (street) rabies virus buds does not rule out rabies infection.
from the endothelial reticulum in the cytoplasm of Antibody may be found in serum at the onset of
the neuron and not, as in some other viral infec- illness. Neutralizing antibody appears in high titer
tions of the central nervous system, from the in the brain and CSF of infected individuals(7)
plasma membrane.(43) Cell structure remains in- and is considered a reliable indication of a CNS
tact, and in 14.6% of the brains examined in one infection. There is no doubt that humoral antibody
study of human cases inflammation was ab- prolongs the incubation period of rabies infection,
sent.(17) as demonstrated by passive immunization in ex-
perimental animals. (4) The question has been delayed immunological response exists there could
asked, however, whether the immune reaction be many unrecognized infections of this type,
may in some instances be detrimental and actually especially among the many people who, although
contribute to the pathogenesis of clinical dis- bitten by proved rabid animals, never become ill.
easeY8) Monkeys which were inoculated with The regular employment of rabies vaccine in man
relatively poor antibody-inducing vaccines follow- following exposure does not permit differentiation
ing exposure to rabies virus died earlier than of humoral antibody to vaccine from humoral
rabies-infected animals not given vaccine.(57) Tig- antibody to natural infection. Thus inapparent
nor et al. (62) have demonstrated in mice that infections could go undetected.
immunosuppression induced by drugs and by Rabies is a neurotropic illness, and the signs
thymectomy and irradiation can prolong the incu- relate to neurological functions. A prodromal stage
bation period in experimentally infected animals lasting 2-4 days includes moderate fever, malaise,
and that administration of antibody can induce an loss of appetite, headache, and nausea. There may
early death associated with inflammatory lesions be pain or other abnormal sensation at the site of
of the neurons in rabies-infected animals. This the original wound; unusual sensitivity to light,
suggests that clinical rabies may involve an immu- noise, or sensory stimulation may follow; and
nopathological mechanism of disease. increased muscle tension and tics are common.
The sympathetic nervous system is often involved
in the form of increased sweating, salivation, or
8. Patterns of Host Response lacrimation. Excitement manifested both by man-
iacal behavior, anxiety, and painful muscle con-
tractions in spasms (often precipitated by swal-
lowing and called "hydrophobia") and by
Rabies is often cited in epidemiological teaching paralytic signs may be seen during different stages
as the classic example of an infection that is of the disease. Ascending paralysis, especially in
universally fatal and in which no inapparent to bat-transmitted rabies, has been described. Death
apparent ratio exists. There are, however, many after 2-6 days may be secondary to respiratory or
anecdotal reports and some clear evidence disput- cardiac failure and often is signaled by a convul-
ing this, as reviewed by Bell.Ui) Bats have been sion. The patient is usually alert throughout the
reported to have long-term inapparent infection illness.
accompanied by viral shedding(48); foxes may
survive experimental infection and develop rabies
8.2. Diagnosis
antibody and resistance to challenge(5Hl; and nor-
mal-appearing dogs have been reported to shed The differential diagnosis includes poliomyeli-
virus in saliva for as long as 2 yr. (2.20.H3) In tis, tetanus, herpes encephalitis, arboviral enceph-
addition to inapparent infections, abortive infec- alitis, tularemia, and (in Africa) the rabies-related
tions also occur; one well-established case in man viruses Mokola and Duvenhage, which cause CNS
of survival with recovery has been reported.(24) disease in man. The diagnosis during life may be
It is not known where or in what form the virus established by fluorescent antibody staining of
resides during at least part of the incubation corneal impressions, mucosal scrapings, skin bi-
period. If the clinical disease, rabies, has an im- opsy, or brain biopsy. After death the demonstra-
munological basis (i.e., antigen/antibody reaction), tion of Negri bodies, isolation of virus in mice, or
instead of being the consequence of a direct lytic the finding of specific antigen in brain or other
effect of the virus, then the long period between tissues by the fluorescent antibody technique reli-
exposure and disease in dogs, man, and other ably makes the diagnosis. In animals the use of
animals might represent an inapparent infection fluorescent antibody examination of the brain has
with a delayed immunological response rather permitted early diagnosis; suckling mice are also
than a long incubation period in the traditionaJ highly susceptible to infection but may take up to
sense. Admittedly, there are other rational expla- 3 wk to develop disease, thus delaying diagnosis.
nations for the long incubation period, (4) but if The nearest public health laboratory should be
consulted about the collection and shipment of tion are at high risk. These include veterinarians,
specimens as well as the management of the ex- hunters, campers, laboratory workers, and persons
posed individual. (especially children) living in areas of the world
where dog and cat rabies is not controlled. In the
United States, duck embryo vaccine is given as
9. Control and Prevention two injections at a month's interval followed by a
third dose after 6 months. The vaccine is a fixed
9.1. Epidemiological Methods rabies virus passed in duck eggs and inactivated
with ,B-propiolactone. Ten to twenty percent of
Effective control of human rabies in the United vaccinees do not develop neutralizing antibody, so
States and much of Europe was achieved by dog that serological follow-up is necessary. Those not
and cat measures which included leash laws, li- developing antibody are advised to be revaccin-
censing of dogs, and administration of killed or ated. Should an exposure occur, the vaccinee
live attenuated vaccines. should have a booster inoculation.
The spread of rabies into susceptible areas such The management of susceptible persons follow-
as Great Britain, Scandinavia, Australia, New Zea- ing exposure is outlined in Table 1 according to
land, Hawaii, and Taiwan is prevented by vacci- WHO recommendations.(H4) Effective prevention
nation and strict quarantine of imported animals of infection is achieved by thorough cleansing of
prior to or on entry into the country. Since the the wound immediately after the bite. Soap and
incubation period of rabies may be 6 months or water is an excellent preventative in experimental
even longer, animals must have continued surveil- rabies exposures.(14) Quaternary ammonium com-
lance even after the quarantine, and care must be pounds and rabies immune serum are equally as
taken that exposure to a rabid animal does not effective. Saline, however, is not recommended;
occur in the quarantine facility. substances which actually bind or neutralize the
It is not possible to eradicate rabies in the New virus or physically destroy receptor sites appear to
World, Africa, or much of Asia and Europe where be required for preventing infection.
wildlife reservoirs occur. Depopulation of infected Human immune globulin is now commercially
wildlife populations serves to control rabies tem- available in the United States and should be ad-
porarily and is justified where potentially rabid ministered intramuscularly in a dose of 20 IU/kg,
animals are frequently in contact with people, i.e., with one-half of the dose being infiltrated around
around camp sites and garbage dumps. However, the wound. Alternatively, where horse serum is
depopulation by vacating of previously occupied substituted for human globulin it should be given
territory also allows more of the young, vigorous at 40 IU/kg. Appropriate tests for sensitivity to
animals to grow up and thrive. These same young horse serum should be carried out before adminis-
animals are highly susceptible, and, unless the tration.
control measures are enforced to the point of Inactivated vaccines are administered after
marked population reduction, depopulation is not serum therapy. Nervous tissue vaccines are used
successful. successfully in much of the world; in the United
An alternative suggestion which has been suc- States, duck embryo vaccine is used almost exclu-
cessful experimentally is vaccination of wildlife sively because of the lower rate of neurological
using oral vaccines contained in animal bait.(o) complications following its use. The usual regimen
This appears to be a feasible procedure, but the is 21 daily doses initially, followed by reinforcing
safety to nontarget animals of infected bait distrib- inoculations on days 10,20, and 90 after the initial
uted in the environment has not yet been estab- series.
lished. There are risks involved in the use of both
vaccine and immune horse serum. Actual trans-
mission of rabies virus through an inadvertent
9.2. Immunization Concepts and Practice
failure to inactivate the vaccine properly has oc-
Preexposure vaccination is recommended for curred,(o(;) and demyelinating disease and both
people who because of their profession or avoca- local and generalized allergic reactions following
Table 1. WHO Guide for Postexposure Treatment
A. Local treatment of wounds involving possible exposure to rabies

1. Recommended in all exposures
a. First-aid treatment: Since elimination of rabies virus at the site of infection by chemical or physical means
(see Section 9.2) is the most effective mechanism of protection, immediate washing and flushing with soap
and water, detergent, or water alone are imperative (recommended procedure in all bite wounds including
those unrelated to possible exposure to rabies). Then apply either 40-70% alcohol, tincture or aqueous
solutions of iodine, or 0.1% quaternary ammonium compounds."
b. Treatment by or under direction of a physician:
(1) Treat as above (a) and then
(2) Apply antirabies serum by careful instillation in the depth of the wound and by infiltration around the
wound.
(3) Postpone suturing of wound; if suturing is necessary, use antiserum locally as stated above.
(4) Where indicated, institute antitetanus procedures and administer antibiotics and drugs to control
infections other than rabies.
B. Specific systemic treatment

Status of biting animal irrespective of previous
vaccination
During Recommended
Nature of exposure At time of exposure 10 days' treatment
1. Contact, but no lesions; Rabid None

indirect contact; no contact
2. Licks of the skin; scratches a. Suspected as rabide Healthy Start vaccine. Stop treatment if
or abrasions; minor bites animal remains healthy for 5
(covered areas of arms, days."d
trunk, and legs) Rabid Start vaccine; administer serum
upon positive diagnosis and
complete the course of vaccine
b. Rabid; wild animal/ or Serum + vaccine
animal unavailable for
observation
3. Licks of mucosa; major Suspect' or rabid domestic or Serum + vaccine. Stop treatment if
bites (multiple or on face, wilde animal, or animal animal remains healthy for 5
head, finger, or neck) unavailable for observation days.b.d
" Where soap has been used to clean wounds, all traces of it should be removed before the application of quaternary ammonium
compounds because soap neutralizes the activity of such compounds.
, Observation period in this chart applies only to dogs and cats.
, All unprovoked bites in endemic areas should be considered suspect unless proved negative by laboratory examination (brain FA).
d Or if its brain is found negative by FA examination.
e In general, exposure to rodents and rabbits seldom, if ever, requires specific antirabies treatment.
duck embryo and nervous tissue vaccines are re- diploid cell vaccine which is still in the experi-
ported. (49) With nervous tissue vaccines, it is mental stage.((;(;) Serum sickness and severe skin
estimated that from 1:600 to 1:8000 persons de- reactions (avoidable by using human rabies im-
velop neurological complications and 1:35,000 die. mune globulin) have been recorded in 16.3% of
With duck embryo vaccine, 1:25,000 are reported persons given antiserum prepared in horses. Be-
to have neurological complications and 1:225,000 cause of these risks and the expense of postexpo-
die.(491 The duck embryo vaccine, while safer, sure treatment, it is important to establish that the
does not induce neutralizing antibody as well as biting animal was or was not rabid. If laboratory
nervous tissue vaccines or as well as a new human tests are negative, or if the biting animal is of a
species that can reasonably be judged not to carry or insects. Duvenhage infects man in South Africa,
rabies, or if rabies is known to be absent from that and alert physicians in Nigeria have diagnosed
community or country, then treatment should not two cases of Mokola virus infection in children-
be given. While immune serum in conjunction one a fatal poliomyelitis-like illness(19) and the
with vaccination is believed to be highly effective other a nonfatal one with febrile convulsions. (18)
in prevention following exposure, the risk of horse Important questions remain to be answered. Are
serum must be carefully weighed against the risk rabies-related viruses limited to Africa? How often
of developing rabies. is man infected? How are these viruses transmit-
ted in nature and how are they transmitted to
man? What is the role of arthropods in their
10. Unresolved Problems natural cycles? Will rabies vaccines prevent Du-
venhage and Mokola virus infections in man?
10.1. Epizootiology of Wildlife Rabies
Wildlife rabies constitutes the major reservoir 10.3. Vaccines
and the source of most exposures of man in the The further development of inexpensive, safe,
United States and much of Europe today. Popula- potent vaccines which could be given in a shorter
tions of foxes, skunks, raccoons, coyotes, and bats regimen is needed throughout the world. The
are infected, often in apparently compartmental- observation that effective vaccines also induce in-
ized epizootics, i.e., without very much transmis- terferon(4.(;5) has suggested that interferon might
sion between different populations. Studies of the be effective in conjunction with postexposure ad-
incidence of rabies in these populations, the ministration of commercial vaccines. Both exogen-
means by which the virus is transmitted among ous and endogenous interferon techniques should
animals, the incubation periods and the preval- be tried. Many developing countries where rabies
ence of transplacental infection, the occurrence of exists also lack adequate diagnostic facilities, vac-
abortive infection and of carrier states, and the cine programs for domestic animals, effective sur-
frequency and duration of shedding of virus in the veillance, and the means of producing their own
saliva are all needed. A special situation may exist vaccine and sera. Standardization of potency and
in Czechoslovakia and other parts of Europe, safety of these materials on an international basis
where rabies in rodents has been reported in a is required.
cycle separate from that in foxes.(59) More infor-
mation is needed to understand this cycle and its
possible implications as a permanent reservoir
should rabies in foxes be controlled eventually in
11. References
neighboring regions.
1. AFSHAR, A., AND BAHMANYAR, M., A contribution to
10.2. Rabies-Related Viruses the detection of inapparent rabies in stray dogs, Vet.
Rec. 91:562-565 (1972).
There are five viruses serologically related to 2. ANDRAL, 1., AND SERlE, c., Etudes experimentales
rabies but easily distinguished by their antigenic sur la rage in Ethiopie, Ann. Insf. Pasteur 93:475-488
properties. These are (1) Lagos bat, isolated from (1957).
Eidolon helvum in Lagos, Nigeria(9); (2) Mokola, 3. BAER, G. M., ABELSETH, M. K., AND DEBBIE, J. G.,
from Crocidura spp. shrews in Ibadan, Nigeria(54); Oral vaccination of foxes against rabies, Am. J. Epide-
miol. 93:487-490 (1971).
(3) Duvenhage, from brain of a man bitten on the
4. BAER, G. M., AND CLEARY, W. F., A model in mice
lip by a bat, in South Africa(42); (4) kotonkan,
for the pathogenesis and treatment of rabies, J.
from Culicoides midges in Ibadan, Nigeria(:J5); and Infect. Dis. 125:520-527 (1972).
(5) Obodhiang, from Mansonia uniformis mosquitos 5. BALTAZARD, M., AND BAHMANYAR, M., Essai pratique
in Sudan.(51) These viruses appear to be limited in du serum antirabique chez les mordus par loups
their geographic distribution to regions of Africa, enrages, Bull. WHO 13:747-772 (1955).
and limited in their host range to specific animals 6. BELL, J. F., Latency and abortive rabies, in: The
Natural History of Rabies, Vol. 1 (G. M. BAER, ed.), BAER, G. M., AND GREGG, M. B., Recovery from
pp. 331-354, Academic Press, New York, 1975. rabies: A case report, Ann. Intern. Med. 76:931-942
7. BELL, J. F., LODMELL, D. L., MOORE, G. J., AND (1972).
RAYMOND, G. H., Brain neutralization in rabies virus 25. HAUPT, H., AND REHAAG, H., Durch Fledermiiuse
to distinguish recovered animals from previously verbreitete seuchenhafte Tollwut unter Vieh-
vaccinated animals, J. Immunol. 97:747-753 (1966). bestiinden in Santa Catharina (Sud-Brasilien), Z.
8. BIGLER, W. J., McLEAN, R. G., AND TREVINO, H. A., Infectionskr. Haustiers 22:76-88, 104-127 (1921).
Epizootiologic aspects of raccoon rabies in Florida, 26. HELD, J. R., TIERKEL, E. S., AND STEELE, J. H., Rabies
Am. J. Epidemiol. 93:326-335 (1973). in man and animals in the United States, 1946-65,
9. BOULGER, L. R., AND PORTERFIELD, J. S., Isolation of a Public Health Rep. 82:1009-1018 (1967).
virus from Nigerian fruit bats, Trans. R. Soc. Trop. 27. HUMPHREY, G. L., KEMP, G. E., AND WOOD, E. G., A
Med. Hyg. 52:421-424 (1958). fatal case of rabies in a woman bitten by an insecti-
10. CONSTANTINE, D. G., Bat rabies: Current knowledge vorous bat, Public Health Rep. 75:317-325 (1960).
and future research, in: Rabies (Y. NAGANO AND F. 28. JOHNSON, H. N., Rabies, in: Viral and Rickettsial
M. DAVENPORT, eds.), pp. 253-262, University of Infections of Man (T. M. RIVERS, ed.), pp. 267-299,
Tokyo Press, Tokyo, 1971. Lippincott, Philadelphia, 1952.
11. CONSTANTINE, D. G., Rabies transmission by non- 29. JOHNSON, H. N., The serum-virus neutralization test,
bite route, Public Health Rep. 77:287-289 (1962). in: Laboratory Techniques in Rabies, 2nd ed., Vol. 23,
12. CONSTANTINE, D. G., EMMONS, R. W., AND WOODIE, pp. 81-84, WHO Monograph Series, 1966.
J. D., Rabies virus in nasal mucosa of naturally 30. JOHNSON, R. T., Experimental rabies: Studies of cel-
infected bats, Science 175:1255-1256 (1972). lular vulnerability and pathogenesis using fluores-
13. DARWIN, c., cited in BELL, J. F., AND MOORE, G. J., cent antibody staining, J. Neuropathol. Exp. Neurol.
Susceptibility of Carnivora to rabies virus adminis- 24:662-674 (1965).
tered orally, Am. J. Epidemiol. 93:176-182 (1971). 31. JOHNSON, R. T., The pathogenesis of experimental
14. DEAN, D. J., BAER, G. M., AND THOMPSON, W. R., rabies, in: Rabies (Y. NAGANO AND F. M. DAVENPORT,
Studies on the local treatment of rabies-infected eds.), pp. 59-75, University of Tokyo Press, Tokyo,
wounds, Bull. WHO 28:277-486 (1963). 1970.
15. DEBBIE, J. G., Rabies, Prog. Med. Viral. 18:241-256 32. KAPLAN, M. M., Epidemiology of rabies, Nature
(1974). 221:421-425 (1969).
16. DOEGE, T. c., AND NORTHROP, R. L., Evidence for 33. KAPLAN, M., AND KOPROWSKI, H., eds., Laboratory
inapparent rabies infection, Lancet ii:826-829 (1974). Techniques in Rabies, 367 pp., World Health Organi-
17. DUPONT, J. R., AND EARLE, K. M., Human rabies zation, Geneva, 1973.
encephalitis: A study of forty-nine fatal cases with a 34. KARLINER, J. S., AND BELAVAL, G. S., Incidence of
review of the literature, Neurology 15:1024-1034 reactions following administration of anti rabies
(1965). serum, J. Am. Med. Assoc. 193:359-362 (1965).
18. FAMILUSI, J. B., AND MOORE, D. L., Isolation of 35. KEMP, G. E., LEE, V. H., MOORE, D. L., SHOPE, R. E.,
rabies-related virus from the cerebrospinal fluid of a CAUSEY, o. R., AND MURPHY, F. A., Kotonkan, a new
child with aseptic meningitis, Afr. J. Med. Sci. 3:93- rhabdovirus related to Mokola of the rabies sero-
96 (1972). group, Am. J. Epidemiol. 98:43-49 (1973).
19. FAMILUSI, J. B., OSUNKOYA, B. 0., MOORE, D. L., 36. KOPROWSKI, H., in: First International Conference on
KEMP, G. E., AND FABIYI, A., A fatal human infection Vaccines Against Viral and Rickettsial Diseases of Man,
with Mokola virus, Am. J. Trop. Med. Hyg. 21:959- p. 488, Scientific Publication No. 147, Pan American
963 (1972). Health Organization, Washington, D.C., 1967.
20. FEKADU, M., Atypical rabies in dogs in Ethiopia, Ethi- 37. KOPROWSKI, H., AND BLACK, J., Studies on chick
opian Med. J. 10:79-86 (1972). embryo adapted rabies virus. III. Duration of im-
21. FISCHMAN, H. R., AND WARD, F. E., III, Oral trans- munity in vaccinated dogs, Proc. Soc. Exp. BioI. Med.
mission of rabies virus in experimental animals, Am. 80:410-415 (1952).
J. Epidemiol. 88:132-138 (1968). 38. KOPROWSKI, H., AND Cox, H. R., Studies on chick
22. GALTIER, V., Etudes sur la rage, C. R. Acad. Sci. embryo adapted rabies virus. I. Culture characteris-
89:444-446 (1879). tics and pathogenicity, J. Immunol. 60:533-554 (1948).
23. HATTWICK, M. A. W., MARCUSE, E. K., BRITT, M. R., 39. LENNETTE, E. H., AND EMMONS, R. W., The labora-
ZEHMER, R. B., CURRIER, R. W., II, AND ELLEDGE, W. tory diagnosis of rabies: Review and perspective, in:
N., Skunk rabies: The risk to man-or never trust a Rabies (Y. NAGANO AND F. M. DAVENPORT, eds.), pp.
skunk, Am. J. Public Health 63:1080-1084 (1973). 77-90, University of Tokyo Press, Tokyo, 1970.
24. HATTWICK, M. A. W., WEIS, T. T., STECHSCHULTE, J., 40. MACRAE, A. D., Rabies, Br. Med. J. 1:604-606 (1973).
41. MARTELL, D., M. A., MONTES, F. c., AND ALCOCER, inoculated into foxes and skunks, Am. J. Vet. Res.
B., R., Transplacental transmission of bovine rabies 23:1041-1047 (1962).
after natural infection, J. Infect. Dis. 127:291-293 57. SIKES, R. K., CLEARY, W. F., KOPROWSKI, H., WIK-
(1973). TOR, T. J., AND KAPLAN, M. M., Effective protection
42. MEREDITH, C. D., An unusual case of human rabies of monkeys against death from street virus by post-
thought to be of chiropteran origin, South Afr. Med. exposure administration of tissue-culture rabies vac-
J. 45:767-769 (1971). cine, Bull. WHO 45:1-11 (1971).
43. MIYAMOTO, K., AND MATSUMOTO, S., Comparative 58. SOAVE, O. A., Transmission of rabies to mice by
studies between pathogenesis of street and fixed ingestion of infected tissue, Am. J. Vet. Res. 27:44-46
rabies infection, J. Exp. Med. 125:447-456 (1967). (1966).
44. MURPHY, F. M., BAUER, S. P., HARRISON, A. K., AND 59. SODJA, I., LIM, D., AND MATOUCH, 0., Isolation of
WINN, W. c., JR., Comparative pathogenesis of ra- rabies-like virus from murine rodents, J. Hyg. Epide-
bies and rabies-like viruses, Lab. Invest. 28:361-376 miol. Microbiol. Immunol. 15:229-230 (1971).
(1973). 60. STEELE, J. H., International aspects of veterinary
45. NEGRI, A., Beitrag zum Stadium der Aetiologie der medicine and its relation to health, nutrition and
Tollwuth, Z. Hyg. Infektionskr. 43:507-528 (1903). human welfare, Mil. Med. 131:765-778 (1966).
46. PASTEUR, 1., Methode pour prevenir la rage apres 61. TIERKEL, E. S., Historical review of rabies in Asia, in:
morsure, C. R. Acad. Sci. 101:765--772 (1885). Rabies (Y. NAGANO AND F. M. DAVENPORT, eds.), pp.
47. PASTEUR, 1., CHAMBERLAND, c., AND Roux, E., Nou- - 3-9, University of Tokyo Press, Tokyo, 1971.
velle communication sur la rage, C. R. Acad. Sci. 62. TIGNOR, G. H., SHOPE, R. E., GERSHON, R. K., AND
98:457-463 (1884). WAKSMAN, B. H., Immunopathologic aspects of in-
48. PAWAN. J. 1., Rabies in the vampire bat of Trinidad, fection with Lagos bat virus of the rabies serogroup,
with special reference to the clinical course and the J. Immunol. 112:260-265 (1974).
latency of infection, Ann. Trop. Med. Parasitol. 63. VEERARAGHAVAN, N., GAJANANA, A., RANGSAMI, R.,
30:401-422 (1936). OONNUNNI, P. T., SARASWATHI, K. c., DEVARAJ, R.,
49. RUBIN, R. H., GREGG, M. B., AND SIKES, R. K., Rabies AND HALLAN, K. M., in: Coonoor Scientific Report, p.
in citizens of the United States, 1963-1968: Epide- 66, Pasteur Institute of Southern India, Coonoor,
miology, treatment, and complications of treatment, Tamilnadu, India, 1969.
J. Infect. Dis. 120:26S-273 (1969). 64. WHO Technical Report Series, No. 523, WHO Expert
50. RUEGSEGGER, J. M., BLACK, J., AND SHARPLESS, G. R., Committee on Rabies, Sixth Report, Geneva, 1973.
Primary antirabies immunization in man with HEP 65. WIKTOR, T. J., POSTlC, B., Ho, M., AND KOPROWSKI,
virus vaccine, Am. J. Public Health 51:706--714 (1961). H., Role of interferon induction in the protective
51. SCHMIDT, J. R., WILLIAMS, M. c., LULE, M., MIVULE, activity of rabies vaccine, J. Infect. Dis. 126:408-418
A., AND MUJOMBA, E., Viruses isolated from mosqui- (1972).
toes collected in the southern Sudan and western 66. WIKTOR, T. J., SOKOL, F., KUWERT, E., AND Ko-
Ethiopia, East Afr. Virus Res. Inst. Rep. 15:24--25 PROWSKI, H., Immunogenicity of concentrated and
(1965). purified rabies vaccine of tissue culture origin, Proc.
52. SCHNEIDER, 1., Spread of virus from the central Soc. Exp. BioI. Med. 131:799-805 (1969).
nervous system, in: The Natural History of Rabies, 67. WINKLER, W. G., Airborne rabies virus isolation,
Vol. 1 (G. M. BAER, ed.), pp. 273-301, Academic Bull. Wild/. Dis. Assoc. 4:37-40 (1968).
Press, New York, 1975. 68. WINKLER, W. G., Rabies in the United States, 1951-
53. SHOPE, R. E., Rabies virus antigenic relationships, 1970, J. Infect. Dis. 125:674--675 (1972).
in: The Natural History of Rabies, Vol. 1 (G. M. BAER, 69. WINKLER, W. G., BAKER, E. F., AND HOPKINS, C. c.,
ed.), pp. 141-152, Academic Press, New York, 1975. An outbreak of non-bite transmitted rabies in a
54. SHOPE, R. E., MURPHY, F. A., HARRISON, A. K., laboratory animal colony, Am. J. Epidemiol. 95:267-
CAUSEY, O. R., KEMP, G. E., SIMPSON, D. I. H., AND 277 (1972).
MOORE, D. 1., Two African viruses serologically and
morphologically related to rabies virus, J. Viral.
6:690-692 (1970).
55. SHORTT, H. E., MCGUIRE, J. P., BROOKS, A. G., AND 12. Suggested Reading
STEPHENS, E. D., Antirabies immunization: Probable
lines of progress in improvement of methods, Indian BAER, G. M., ed., The Natural History of Rabies, Vol. 1,
J. Med. Res. 22:537 (1935). 454 pp.; and Vol. 2, 408 pp., Academic Press, New
56. SIKES, E. K., Pathogenesis of rabies in wildlife. I. York,1975.
Comparative effect of varying doses of rabies virus DEBBIE, J. G., Rabies, Prog. Med. Viral. 18:241-256 (1974).
JOHNSON, H. N., Rabies virus, in: Viral and Rickettsial niques in Rabies, 367 pp., World Health Organization,
Infections of Man (F. L. HORSFALL, JR., AND I. TAMM, Geneva, 1973.
eds.), pp. 814-840, Lippincott, Philadelphia, 1%5. NAGANO, Y., AND DAVENPORT, F. M., eds., Rabies, 406
KAPLAN, M., AND KOPROWSKI, H., eds., Laboratory Tech- pp., University of Tokyo Press, Tokyo, 1971.
CHAPTER 17
Respiratory
Syncytial Virus
Robert M. Chanock, Hyun Wha Kim, Carl Brandt,
and Robert H. Parrott
1. Introduction and Historical Background lower respiratory tract produced by this virus
during early infancy. A safe, effective vaccine for
Respiratory syncytial virus (RSV) was first isolated prevention of serious, pediatric RSV illness is not
from a chimpanzee with common-cold-like ill- available at this time. However, studies now in
ness.(5:1a} Shortly thereafter, the virus was re- progress offer some hope that ultimately it should
covered from young children with severe lower be possible to develop effective immunoprophy-
respiratory tract disease in Baltimore.(Il.tH} Since laxis for RSV bronchiolitis and pneumonia.
its initial isolation from infants with respiratory RSV is a medium-sized (120-200 nm) enveloped
virus which contains lipid and RNA and which
disease almost 20 yr ago, RSV has emerged as
the major lower respiratory tract pathogen of in- matures at the limiting membrane of the infected
cell. (5,:18,5.5> Its internal component consists of ri-
fancy and early childhood throughout the
world.(;l.15.lo.(;9} In all geographic areas it is now bonucleoprotein (RNP) which exhibits helical
clear that RSV is the major cause of bronchiolitis symmetry, while its outer envelope is studded
and pneumonia in infants and young children. with glycoprotein, spikelike projections.f:l7·74) Al-
RSV presents a special challenge to the epidemiol- though there is some controversy concerning the
ogist since this virus exhibits a pattern of infection dimensions of the inner RNP helix, it appears to
and disease unlike that of any of the other known have a diameter of 13 nm.(5,37,74l It is thus inter-
respiratory tract viral pathogens. Unanswered are mediate in size between the helix of the influenza
many pressing questions concerning the patho- viruses (9nm) and that of the paramyxoviruses
genesis of serious life-threatening disease of the (18nm).(711 For this reason it has been suggested
that RSV and the pneumonia virus of mice, which
also has a 13-nm inner helix, may comprise a
Robert M. Chanock, Hyun Wha Kim, Carl Brandt, and group of enveloped RNA viruses distinct from the
Robert H. Parrott . Laboratory of Infectious Diseases, orthomyxoviruses (the influenza viruses) and the
National Institute of Allergy and Infectious Diseases, paramyxoviruses (parainfluenza viruses, mumps
National Institutes of Health, Bethesda, Maryland, and virus, Newcastle disease virus, and measles, rin-
Children's Hospital of D.C., Washington, D.C. derpest, and distemper viruses).(5,71l
365
366 Chapter 17 • Respiratory Syncytial Virus
2. Methodology Involved in Epidemiological RSV. «i8) Another factor which should be consid-
Analysis ered in assessing the impact of RSV in pediatric
respiratory disease is the inefficiency of the com-
2.1. Sources of Mortality Data plement fixation and neutralization techniques for
the detection of serological evidence of infection in
Limited information is available concerning the young infants.(I3.57.(;l.li2) This poses a special diffi-
importance of RSV in fatal respiratory disease; culty since the young infant is the individual at
however, from the serious nature of RSV bron- greatest risk of developing RSV disease serious
chiolitis and pneumonia of infancy there is reason enough to require admission to the hospital.
to suspect that the virus is a major cause of fatal The behavior of RSV in pediatric populations
respiratory tract disease during the first year of throughout the world has been discerned primar-
life. This view is supported by a report from ily from the pattern of serious respiratory disease
Britain concerning 22 children with respiratory produced by this virus. Although surveillance of
tract infections who died during a 27-month pe- seriously ill infants and children can serve as a
riod; 19 of the patients were less than 1 yr of age. barometer of the virus in the community, this type
RSV was isolated from eight of the patients post- of study cannot, in itself, yield an estimate of the
mortem.(24) In this study other viruses were not incidence of infection or risk of serious illness
incriminated in the remaining cases of fatal respi- during infection.
ratory tract disease. In another study in Great Another source of morbidity data is the study
Britain, RSV was recovered from three of 12 in- of outbreaks of RSV infection in closed popula-
fants who died with lower respiratory tract dis- tions. Serial studies of such populations have
ease.(;J41 One of these infants had bilateral hydro- yielded data on infection rates, the percentage
nephrosis and the other Down's syndrome, and expressed as illness, and the type and severity of
these conditions were thought to contribute to the the clinical syndrome produced.
fatal outcome of their disease. Other than one
isolated report from Great Britain, there is no
evidence that RSV plays a major role in the syn- 2.3. Serological Surveys
drome of sudden unexpected death in infancy Serological surveys have been performed using
(crib death).(8) the complement fixation and neutralization tech-
niques. The former method is relatively less sensi-
tive than the latter, especially if the plaque reduc-
tion technique is used to measure neutralizing
Although the importance of RSV in fatal respira- antibody. In most studies, neutralizing antibody
tory tract disease in early life, or in any age group has been assayed by the roller tabe culture neu-
for that matter, has not been defined clearly, there tralization technique, which is less sensitive than
is abundant evidence available which suggests the plaque reduction technique.(IS) Nonetheless,
that this virus is a major cause of serious life- in the first seroepidemiological survey performed
threatening disease of the lower respiratory tract the former technique was sufficiently sensitive to
during early life. The data which link RSV to show that the presence of neutralizing antibody
serious lower respiratory tract disease in early life to RSV in serum increased rapidly with age and
come from cross-sectional studies of pediatric pa- reached a frequency of 80% by 4 yr of age in the
tients admitted to the hospital with a diagnosis of Baltimore areaYll In later studies using this tech-
bronchiolitis, pneumonia, bronchitis, or croup. nique, it was found that all adults tested possessed
Estimates of the contribution of RSV to pediatric serum neutralizing antibody and the level of anti-
respiratory disease generally represent an under- body was significantly higher than that detected in
evaluation of the role of this agent. For example, the serum of seropositive children.(3(;) Finally,
human heteroploid cell cultures commonly used newborn infants were shown to possess the same
for the recovery of RSV frequently exhibit marked level of serum neutralizing antibody as their
variation of sensitivity to the agent; at times such mothers. (2)
cell cultures may be completely resistant to In later studies, the plaque reduction technique
Chapter 17 • Respiratory Syncytial Virus 367
was employed for seroepidemiological purposes infection as well as capacity to detect small
since it was shown to be approximately 10 times quantities of virus.
more sensitive for measurement of antibody than
the roller tube culture neutralization method. In a
recent study, each of a group of infants 1-5 months 3. Biological Characteristics of Virus
of age was found to possess serum neutralizing
Affecting the Epidemiological Pattern
antibody when measured by the plaque reduction
technique; in addition, the majority of infants who
There is no information which would link var-
were 6-7 months of age also possessed such neu-
ious biological properties of RSV with its unusual
tralizing activity in their serum.(5S) These infants
epidemiological behavior. Its lability does not
were born after the last epidemic of RSV and
seem to limit its spread in a susceptible popula-
presumably had not been infected with the virus.
tion.
The mean titer of antibody decreased with age,
Antigenic variation among RSV viruses has
dropping approximately twofold per month. This
been recognized in tests with convalescent sera
suggested that the antibody measured by this obtained from RSV-infected ferretsYS) However,
method was passively acquired from the mother.
these differences were not evident when tests were
In summary, serological surveys using tech-
performed with convalescent sera from young in-
niques of varying sensitivity have shown that all
fants with RSV bronchiolitis. Thus the major epi-
adults possess serum neutralizing antibody, as do
demiological patterns of RSV and the occurrence of
infants at the time of birth. Antibody found in the
reinfection are not dependent on antigenic varia-
serum of newborn infants represents passively
tion as with the influenza A viruses. The occurr-
acquired antibody; this antibody has a half-life of
ence of a chronic carrier state has not been demon-
approximately 1 month and cannot be detected
strated in man. The capacity of the virus to reinfect
after 6-7 months of age unless the infant has been
and reinstitute pharyngeal carriage is probably a
infected with RSV.
major mechanism of survival and spread. How-
ever, the relative importance of primary infection
and reinfection as a source of virus in the commu-
2.4. Laboratory Methods nity has not been defined.
RSV is very labile, and for this reason reliance
on virus isolation data often results in an underes-
timate of the importance of the agent in the
population under study. For optimum results, se-
cretions from the respiratory tract should be inoc-
4.1. Incidence and Prevalence Data
ulated directly at the bedside into roller tube cell
cultures of known sensitivity to RSV. Freezing and 4.1.1. Risk of Infection and Reinfection. Based
thawing of respiratory tract secretions or naso- on serological surveys, infection with RSV appears
pharyngeal washings often result in a significant to be a common occurrence during the first few
decrease in titer of virus as well as failure to years of life. In a study performed in Baltimore
recover virus from such specimens.(3) Most inves- shortly after isolation of the first human strains of
tigators have used one of a series of heteroploid RSV, it was found that 48% of children possessed
human cell lines for recovery of RSV, and it would serum neutralizing antibody for the virus by 2 yr
appear that there are a number of such cell lines of age and 77% by 3 yr of ageyll Other studies
which are reasonably effective for this purpose. performed using the roller tube tissue culture
Among those used most extensively are the HEP-2 neutralization technique in Great Britain indicated
and Bristol HeLa cells. It cannot be overemphas- that 45% of children possessed neutralizing anti-
ized that cell cultures used for the recovery of RSV body in their serum by their second birthday.(30l
must be constantly monitored and tested for their A similar serological survey performed in Chicago
sensitivity to RSV, in terms of both development indicated that 25% of infants 1 yr of age had serum
of characteristic syncytial cytopathic effects during neutralizing antibody for RSV and that 80% of
children 4 yr of age possessed such antibody.(2) children. In contrast, only 3-5% of adults in the
Comparable observations have been made in Ja- families under surveillance developed a serological
pan.(67) The results of the Chicago serological response. Since reinfection in older children and
survey can also be interpreted to indicate that 25% adults generally does not evoke a strong serological
of infants who had lived through one period of response, it is likely that reinfection occurred more
RSV prevalence had been infected, while after two frequently than indicated by the data from this
periods of RSV prevalence approximately 50% had study.
been infected. The findings from these serological In summary, it appears that most individuals
surveys most likely underestimate the true inci- become infected with RSV early in life and few
dence of infection during the first few years of life escape attack by this virus during infancy or early
since the most sensitive method was not used for childhood. Further, reinfection occurs with appre-
detection of antibody and the level of antibody in ciable frequency in older children and young
infants and young children is significantly lower adults and probably plays a major role in the
than that found in the serum of adults. As men- spread of virus to the young infant, who is the
tioned previously, in a recent study employing the target host for serious disease. It is highly unlikely
more sensitive plaque reduction method, it was that infants with serious RSV disease are the usual
found that approximately one-half of the infants source of infection for other young infants.
who lived through one RSV epidemic in the Wash- In surveys of serum from adults, it was shown
ington, D.C., area were infected during this pe- that 33-93% of individuals possessed complement-
riod.(43) Futhermore, almost all children who had fixing antibody for RSV.o9,30,35) The presence of
lived through two successive RSV epidemics were such antibody in serum is most likely a reflection
infected, as indicated by the presence of neutraliz- of the frequent occurrence of reinfection rather
ing antibody in their serum. Thus it appeared that than long-term persistence of antibody following a
the risk of infection for previously un infected limited, superficial infection of the respiratory
infants and young children was extremely high in tract,
the limited number of urban populations studied. 4.1.2. Risk of Bronchiolitis. In unpublished ser-
When one considers the overall impact of RSV in oepidemiological studies at the Children's Hospi-
pediatric respiratory disease throughout the tal of D.C. it was found that approximately one-
world, it is likely that the situation described half of the infants tested were infected during their
above for Washington, D.C., Chicago, Japan, and first RSV epidemic and almost all children were
Britain is representative of most geographic areas. infected after living through two RSV epidem-
Reinfection appears to be a relatively frequent ics.(43) These observations suggest that the virus
event and was documented in a longitudinal sur- becomes widely disseminated during each yearly
veillance of 50-70 young children who were stud- epidemic and the risk of infection for previously
ied over a period of 6 yr, an interval spanning six uninfected infants and young children is extremely
successive yearly epidemics of RSV infection in high. If one couples this information with the
the Washington, D.C., area.(43) Of these children, estimated size of the pediatric population which is
8-41 % became reinfected during each of the suc- served by the Children's Hospital of D.C. and the
cessive epidemics. The frequency of reinfection number of hospitalized patients who have RSV
was probably greater than these estimates, since disease, it is possible to derive a very crude
virus recovery and serological response were used estimate of the risk during primary infection of
for detection of reinfection and these are known to severe RSV bronchiolitis, Le., illness serious
be relatively insensitive indicators of this type of enough to require admission of the patient to the
infection.(36) In a serological surveillance of fami- hospital.(43) The crude estimate for the incidence
lies in Tecumsech, Michigan, it was found that of bronchiolitis requiring admission to the hospi-
approximately 20% of children 5-9 yr of age devel- tal per 1000 infants 0-12 months of age is 10, and
oped a serological response to RSV during each of for RSV bronchiolitis the estimate is 4. These
the study years. (53) The estimate for infection estimates lead to a further estimate of one hospital
among adolescents was 17%. Thus reinfection ap- admission for RSV bronchiolitis per 100 primary
peared to be a frequent event among school age RSV infections during infancy. Of course, the toll
of RSV in infancy is considerably higher, sihce for pletely susceptible to both infection and disease,
every hospital admission for RSV bronchiolitis or while others had experienced several RSV infec-
pneumonia there are many infants who develop tions previously and undoubtedly had developed
respiratory disease which is almost as serious as some resistance to this virus.
that seen in the individuals admitted to the hospi- An outbreak of RSV which occurred in a nursery
tal. At the other end of the spectrum is upper in Taiwan also provided significant information
respiratory illness which may not be severe about the pathogenic potential of RSV.(48) The
enough for the mother to bring her infant or outbreak involved 15 normal infants ranging be-
young child to the outpatient clinic of the hospital tween 7~ and 12 months of age. The clinical attack
or to a physician's office. rate was 100%; each of the infants developed
4.1.3. Risk of Pneumonia and Severe Febrile symptoms of respiratory disease, and 13 of the 15
Disease. Forty percent of 90 institutionalized in- developed a febrile response which exceeded 38°C.
fants and young children developed pneumonia A similar experience was recorded during an out-
over a 4-wk period during an outbreak of RSV break of RSV infection in a home for infants in
infection which occurred in a welfare nursery in Stockholm. wfi ) Thus it appears that infection with
Washington, D.C.,o9) An additional 53% of the RSV has a high degree of clinical penetrance and
nursery residents developed a febrile illness. The that most infections which occur in infancy and
relationship of the virus to illness was determined early childhood lead to the development of signs
by cross-sectional analysis in which the illness and symptoms of respiratory tract disease and in
attack rate during a 5-day period bracketing initial most instances an associated febrile response
virus isolation (test period) among infants and occurs.
children who were RSV positive was compared 4.1.4. Role of RSV in Different Clinical Syn-
with the attack rate during the same 5-day period dromes. In a 13-yr surveillance of infants and
among children who were RSV negative. This type young children admitted to the Children's Hospi-
of analysis indicated a significant association of tal of D.C. with lower respiratory tract disease,
virus with febrile illness and with pneumonia. The RSV infection was detected in 43% admitted with
cross-sectional analysis, however, did not adjust the diagnosis of bronchiolitis and in 25% of pa-
for attributes such as age, sex, race, and duration of tients with pneumonia.'4;J) RSV infection was de-
residence in the nursery, some of which might tected less often in the syndromes of bronchitis
influence the occurrence of illness. Therefore, a (10.6%) and croup (9.8%). In contrast, RSV infec-
horizontal analysis was made comparing the febrile tion was detected in only 5.4% of infants and
illness experiences of those children from whom children seen in the clinic or admitted to the
RSV was isolated with the febrile experiences of the hospital for nonrespiratory illness during this in-
same children 2 wk before and 2 wk after as-day terval. The findings which emerged from this
period (test period) bracketing initial virus isola- study of approximately 5000 infants and children
tion. This type of horizontal analysis indicated that with lower respiratory tract disease are representa-
the children who were RSV positive experienced an tive of observations made by others during the
onset of febrile respiratory disease 3 times more past 18 years. Thus it is clear that RSV is the major
often than the expected number of febrile episodes cause of bronchiolitis of early infancy. In addition,
(p = 0.001). This finding indicated a striking asso- the virus is a major cause of pneumonia during the
ciation between the recovery of RSV and the onset first few years of life.
of a febrile illness in the children involved in the
nursery outbreak. In a second outbreak of RSV 4.2. Epidemic Behavior
infection which occurred in the same nursery 6 yr
later, only 10% of infants and young children de- One of the most remarkable features of the
veloped pneumonia.(4()) The reason (or reasons) for epidemiology of RSV is the consistent pattern of
this difference in response is not obvious at this infection and disease. Other respiratory viruses
time. It should be emphasized that in both of the cause epidemics at irregular intervals or exhibit a
outbreaks the population consisted of a mixture of mixed endemic-epidemic pattern, but RSV is the
individuals, some of whom were probably com- only respiratory viral pathogen which produces a
sizable epidemic every year in large urban cen- complement-fixing antibody, 70% of bronchiolitis
ters.(14·5S) This pattern has been observed wher- patients and 56% of all respiratory disease inpa-
ever RSV has been studied. In the temperate areas tients exhibited evidence of RSV infection during
of the world, RSV epidemics have occurred pri- the peak epidemic month. A similar epidemic
marily in the late fall, winter, or spring but never wave was seen in males compared to females and
during the summer. In Washington, D.C., over an in black compared to nonblack children.
interval of 13 yr RSV was most active during the
period from January to April and virtually absent
from the community during August and Septem- 4.3. Geographic Distribution
ber. (43) Large annual variations in the impact of
RSV on the pediatric population of the Washing-
RSV has emerged as the major pediatric respira-
ton, D.C., area were not observed over a 13-yr
tory tract pathogen wherever appropriate studies
period. During 11 consecutive epidemics studied
have been performed to detect infection. Further-
intensively, the number and proportion of infants
more, the epidemic pattern of disease just de-
and children admitted to the Children's Hospital
scribed for the Washington, D.C., area appears to
of D.C. for RSV lqwer respiratory tract disease did
be characteristic of the behavior of this virus in
not vary more than 2.7-fold.(43) Also remarkable
large urban centers throughout the world. Serolog-
was the consistency with which RSV produced the
ical surveys of individuals from remote isolated
same clinical pattern of respiratory tract disease,
populations have in each instance revealed evi-
especially bronchiolitis and pneumonia, year after
dence of RSV infection by the presence of neutral-
year. These illnesses were barometers of RSV in-
izing or complement-fixing antibody in serum (R.
fection in the community; when the virus was at
M. Chanock, unpublished studies).
its epidemic peak, hospitalization for bronchiolitis
and pneumonia in infants and young children
soared. (43) A similar temporal association of RSV
infection and serious lower respiratory illness in 4.4. Temporal Distribution
infants was documented also in Scotland.(29)
More than 15,000 infants and young children In the United States and other temperate areas,
were studied for RSV infection during 11 consecu- RSV epidemics occur in the late fall, winter, or
tive outbreaks in the Washington, D.C., area. Data spring but not during the summer. (43.54) The virus
obtained at monthly intervals during the out- is rarely isolated during August or September. In
breaks were combined to plot a composite epi- Washington, D.C., outbreak peaks were observed
demic curve, which showed a normal distribu- to occur in six different calendar months over a
tion. (7) Of more than 1000 respiratory disease period'of 13 yr.(7,43) The outbreak peak occurred as
patients who yielded an RSV isolate during the late as June and as early as December. Each RSV
composite outbreak, 40% shed virus during the epidemic lasted approximately 5 months.(43) In
peak epidemic month and 82% shed virus during Chicago, the peaks of three successive outbreaks
the period encompassing the peak month and the were separated by an interval of 55-58 wk. (054) A
month preceding and following it; this indicated fourth outbreak occurred after a shorter interval of
the sharpness of the yearly epidemics of the virus 39 wk, and this was followed by a fifth outbreak in
in the Washington, D.C., area. During the peak which the interval between peaks was prolonged
month of the composite epidemic, RSV was re- to 62 wk. Analysis of 13 successive outbreaks
covered from 46% of all inpatients hospitalized which occurred in Washington, D.C., suggested
with bronchiolitis, from 34% of all patients hospi- that the interval between successive peaks was
talized with any type of respiratory disease, and alternately long (13-16 months) and then short (7-
from 32% of patients with respiratory disease who 12 months), resulting in an outbreak early in the
were seen as outpatients in the hospital. Control respiratory season followed by an outbreak later in
subjects who were free of respiratory disease the respiratory season the next year. (54)
rarely yielded RSV (less than 1%). As indicated by In one semitropical area (Trinidad), RSV was
virus recovery and/or the development of serum found to exhibit a temporal pattern different from
that characteristic of temperate regions. Over a 3- 4.6. Sex

yr period of surveillance, RSV epidemics occurred
in Trinidad during the rainy season which ex- Severe RSV disease which requires hospitaliza-
tended from June through December.(Ho) The tion occurs approximately 30% more often among
Trinidad epidemics started in June 1964, Septem- male infants than among female infants.(58)
ber 1965, and August 1966.
4.7. Race
4.5. Age In a study of 13 consecutive epidemics in the

Washington, D.C., area, the proportion of non-
In the largest cross-sectional study of RSV infec- black patients with various forms of lower respira-
tion in pediatric patients admitted to the hospital, tory disease associated with RSV infection was
the peak incidence of RSV bronchiolitis and pneu- somewhat higher than that of black patients.(58) A
monia was observed at 2 months of age.(58) There- plot of all hospitalized respiratory disease patients
after, the incidence of these diseases decreased indicated that in every age category black patients
with increasing age, more rapidly for bronchiolitis yielded RSV slightly less often than nonblack pa-
than for pneumonia. Except for the first month of tients; however, the age pattern of RSV bronchioli-
life, the incidence curve of RSV bronchiolitis ex- tis was the same for both groups of patients. The
hibited a marked downward slope so that by 10-12 non black patients were in most instances from the
months of age few infants were admitted to the suburbs of the Washington, D.C., area, whereas
hospital with this diagnosis. During the first the black patients tended to come from the poorer
month, the incidence of RSV bronchiolitis was areas of the District of Columbia immediately sur-
approximately one-third that observed during the rounding the Children's Hospital.
second month, the period of peak occurrence of
the disease. Although RSV pneumonia occurred 4.8. Occupation
most often at 2 months of age, the incidence of this
disease decreased rather slowly with increasing We have no information about any relationship
age. It was not unusual for the virus to cause of RSV infection to occupation.
pneumonia in older children. It should be empha-
sized that the age distribution of the most serious
RSV disease, i.e., bronchiolitis, is unique among
viral infections of man. RSV is the only virus Differences in the spread of RSV within differ-
which preferentially produces severe disease and ent families were noted in a seroepidemiological
has its maximum impact during the first few study performed in Tecumseh, Michigan.U;;Jl As
months of life. (]2.58) the number of members in the family increased
In the various age groups investigated in the from three to six persons, there was an increase in
Tecumseh seroepidemiological study, a serological the proportion of families in which one or more
response to RSV occurred most frequently in individuals were infected with RSV. This appar-
school-age children 5-9 yr old. (53) The rate of ently was a reflection of the additional opportunity
infection (which presumably was reinfection) fell for introduction of infection into a larger family.
rapidly with increasing age during childhood and The increased number of persons at risk in larger
then more slowly among adults. In children 5-9 yr families also resulted in more multiple infections
of age, approximately 20% underwent infection within the family once the virus was introduced.
during yearly epidemics of RSV in the community. In the Tecumseh study, only 5.5% of persons in
Seventeen percent of children 10-14 yr of age families with three members were infected with
appeared to have been infected, whereas the esti- RSV, whereas the proportion increased to 16.3%
mate for individuals 15-19 yr of age was 10%. In in families which had six members. Data from this
the adult age group, 3-5% developed serological study suggested that the virus was introduced
evidence of infection during the period of RSV most often into the family unit by a school-age
prevalence. child.
4.10. Socioeconomic 6. Pathogenesis and Immunity
The racial pattern of RSV disease was studied in From information obtained during outbreaks in
the Washington, D.C., area as described closed populations, it was estimated that the incu-
above.(5B) Although the findings did not allow bation period from exposure to development of
one to estimate reliably the incidence of RSV fever and signs of RSV lower respiratory disease
bronchiolitis among blacks and nonblacks, it was was approximately 4-5 days.(39.(i(;) When adults
clear that the age pattern of the disease was the were experimentally infected with RSV, the incu-
same in both groupS.(5B) Since there tended to be bation period averaged 5 days and illness lasted an
a significant socioeconomic difference between average of 5! days. (36.46)
blacks and nonblacks in the Washington, D.C., The behavior of RSV in young infants provides a
study population, it appeared that the conse- unique opportunity to assess the protective effect
quences of RSV infection in early infancy were not of serum antibody for this agent in the absence of
strongly influenced by socioeconomic status or any potential effect of local respiratory tract im-
race. Once RSV infection occurred during infancy, munity. During the first 6 months of life, the
the clinical expression of infection appeared to be young infant possesses maternally derived serum
the same in both groups. Data from a study in antibody, whereas local antibody, which is not
North Carolina suggested that serious RSV disease transferred passively from the mother, is presum-
occurred more frequently in infants of low socioec- ably not present. The observation that serious RSV
onomic status from a rural area than in infants of disease occurs most often during this period when
higher socioeconomic status living in an urban infants possess passively transferred serum anti-
center. m .50 ) In this situation, socioeconomic fac- body clearly indicates that such neutralizing anti-
tors probably influenced the risk of infection dur- body (presumable IgG) does not provide effective
ing early infancy and this in tum influenced the protection against the most serious effects of the
pattern of disease. It is likely that delay of primary virus. The high frequency with which RSV infec-
infection past the age of vulnerability (Le., the tion occurs in young infants also indicates that
first 6 months of life) increases the probability that serum antibody does not provide effective resist-
disease will be mild rather than severe. ance to infection. Infants who develop RSV disease
do not differ from their non-ill cohorts with re-
spect to serum neutralizing antibody. (5B) Thus
4.11. Other Factors, Nutrition, Genetics, etc. acute-phase sera of young infants admitted to the
hospital with RSV bronchiolitis or pneumonia
We have no information concerning other fac- contain moderate to high levels of neutralizing an-
tors. tibody as measured by the plaque reduction tech-
nique.<sB) The age pattern of antibody in the acute-
phase sera of patients with RSV bronchiolitis or
pneumonia is similar to that of normal infants and
5. Mechanisms and Routes of Transmission the level of antibody is inversely related to age,
suggesting that this antibody is derived passively
RSV infection- appears to be transmitted from from the mother.
person to person through respiratory secretions. Additional evidence that serum neutralizing an-
The importance of large and small particle aerosols tibody does not provide effective protection was
has not been studied for this virus. obtained during the study of an RSV outbreak
A virus, similar antigenically and biologically to which occurred in a semiclosed nursery whose
RSV, has been recovered from cattle with respira- residents ranged in age from 6 to 65 months.(40)
tory disease in Europe and Asia.(32.:I3.5(l) The bov- Preoutbreak serum specimens were available from
ine strains appear to be related antigenically to the 85 of the nursery residents, and these specimens
human strains, but the ability of bovine strains to were assayed for neutralizing antibody by the
infect man and of human strains to infect cows has plaque reduction technique. The occurrence of
not been ascertained as yet. pneumonia was not related to the level of preexist-
ing serum neutralizing antibody in this popula- from the high antibody group contained very little
tion. It should be emphasized, however, that in virus. This difference was related to nasal anti-
most instances the pneumonia illnesses which body and not serum antibody, since the two
occurred in these older infants and young children groups differed primarily in their level of prechal-
were not severe. lenge nasal antibody. Following infection, none of
Older children and adults develop less serious the high nasal antibody men developed a serum
illness during reinfection with RSV than do young neutralizing, serum complement-fixing, or nasal
infants undergoing primary infection. Since serum secretion neutralizing antibody response. In con-
neutralizing antibody does not appear to be pro- trast, six of the eight low nasal antibody group
tective, other mechanisms of resistance must be developed a rise in one or more of these antibod-
involved. Systemic cell-mediated immunity does ies. The findings from this study indicated that
not appear to playa significant role in resistance, local antibody did not influence susceptibility to
since an inactivated RSV vaccine which stimulated infection; however, the level of local antibody had
cell-mediated immunity did not provide resistance a marked effect on the level of virus replication
to either RSV infection or the development of and secondarily on the immune response to infec-
disease. (45) These considerations led to an exami- tion. This interpretation supports the thesis that
nation of local respiratory tract immune mecha- resistance to RSV disease is a function of the local
nisms in an attempt to explain resistance to RSV. respiratory tract secretory antibody system.
A series of studies were performed in adult volun- One can only speculate about the capacity of
teers to evaluate the properties and effects of local RSV to evade the host's defense mechanisms and
respiratory tract antibody to RSV. Initially, anti- to reinfect with relatively high frequency. RSV
body in nasal secretions was characterized and characteristically induces syncytium formation in
shown to predominantly of the 11 S, IgA vari- tissue culture. This type of viruslhost-cell interac-
ety. (51.52) Each of 104 adults tested possessed such tion may lessen the protective role of local immune
RSV-specific, secretory antibody and levels varied defenses since syncytium formation permits re-
over a wide range. In addition, experimentally cruitment of uninfected cells into the disease pro-
infected adults and naturally infected infants and cess under conditions which minimize the effec-
children were shown to develop neutralizing ac- tiveness of antibody in halting extension of
tivity in their nasal secretions during convales- infection and tissue damage.
cence.<44a,51,52,63) The latter findings indicated that Although the pathogenesis of RSV disease in
the respiratory tract secretory antibody system early infancy is not understood, there are several
operates early in life. observations which suggest that immunological
The significance of local antibody was investi- factors playa role. The level of serum neutralizing
gated in a volunteer study, in which individuals antibody by age during infancy resembles the age
were challenged intranasally with 500 plaque distribution of RSV bronchiolitis except during the
forming units (pfu) of RSV. (52) Eight men had a first month. This similarity has prompted the
low level of prechallenge nasal secretion neutraliz- suggestion that serum antibody might participate
ing activity, while the other eight individuals had in an immunopathological reaction with RSV anti-
a high level, and there was no overlap in level of gens in the lungs and that this reaction might
antibody between the two groups. Each of the contribute to the development and severity of
volunteers possessed a moderately high level of bronchiolitis.(12) Any hypothesis which attempts
serum neutralizing antibody. Following challenge, to explain the pathogenesis of serious RSV disease
each of the men in the two groups shed virus and in early life, however, must take into account the
the temporal pattern of virus shedding was the intrinsic pathogenic potential of the virus itself.
same for men in either group. However, when the For example, in several well-studied nursery out-
virus content of the nasopharyngeal washings was breaks, RSV was found to cause pneumonia in
estimated by the plaque technique it was found children who lacked detectable serum neutralizing
that men in the low nasal antibody group shed antibody. If immunological factors are important
large quantities of virus (up to 105 pfu/ml of in lower respiratory tract disease, they must act to
nasopharyngeal washing), whereas the washings enhance the basic pathogenic effects of the virus.
The level of neutralizing antibody by age in the rarely occurs.<17,21,40,44) It is possible, or course,
sera of normal infants and in the acute-phase sera that the pathogenesis of infantile bronchiolitis is
of infants with RSV bronchiolitis and pneumonia different from that of the vaccine-associated bron-
was reexamined recently using the plaque reduc- chiolitis. But this seems unlikely in view of the
tion neutralization technique.(58) Each of the con- marked similarity of clinical course and progres-
trol infants 1-5 months of age possessed serum sion of these conditions.
neutralizing antibody, as did the majority of con- Possibly an age-related nonimmunologically de-
trol infants 6-7 months. of age. These infants were termined factor could be responsible for the unu-
born after the last epidemic of RSV and presum- sual pattern of RSV illness in early infancy. This
ably had not been infected with the virus. In would mean that the age/disease/antibody rela-
addition, the mean titer of antibody decreased tionships which exist are merely fortuitous. The
with age, suggesting that the antibody measured simplest nonimmunological explanation for the
was passively acquired from the mother. The anti- unusual predilection for RSV disease in early in-
body pattern of infants with RSV bronchiolitis or fancy is that the air pathways at this time are
pneumonia resembled that of the control group; smaller and more easily obstructed than later in
however, a larger proportion of the respiratory life. This anatomical factor may make a contribu-
disease patients lacked detectable serum antibody tion to the occurrence of RSV disease in the first
at 5-7 months of age. Failure to detect acute-phase months of life. But it should be emphasized that
serum antibody in some patients with RSV bron- the majority of RSV vaccinees who developed
chiolitis at 5-7 months of age casts some doubt on severe obstructive pulmonary disease were older
the essential role of serum antibody in the patho- than the usual unvaccinated infant with bronchiol-
genesis of RSV bronchiolitis. On the other hand, itis. More than two-thirds of non-vaccine-associ-
the 5- to 7-month-old patients who appeared to be ated RSV disease in the community occurred in
seronegative may have possessed low levels of infants in the first half year of life, whereas in one
antibody which could not be detected by the assay study 63% of the vaccinees who exhibited altered
system used. This is very likely the case and may reactivity to RSV developed obstructive disease
explain the significantly lower incidence of RSV (bronchiolitis) after 6 months of age.(12,44) The
bronchiolitis at 5-7 months of age compared to development of severe, typical, obstructive RSV
that observed at 2-3 months of age. Although the bronchioli tic disease by the older vaccinees makes
significance of serum antibody in the pathogenesis it unlikely that the size of the air pathways is a
of disease may not be clear at this time, it is major determinant in RSV illness.
evident, nonetheless, that high levels of this type In the early studies of RSV infection in young
of antibody during the first 3--4 months of life do infants, as well as in more recent studies, it was
not protect the young infant from bronchiolitis or observed that the serum antibody response of
pneumonia caused by RSV. young infants to this virus was impaired. «l.1~,57,(i2)
Other findings make it difficult to dismiss com- A delayed and/or decreased immunological re-
pletely the possibility that immunopathological sponse to infection could contribute to the in-
factors play an important role in RSV bronchiolitis. creased severity of RSV disease during infancy.
There was a strong suggestion that an inactivated Recent studies of parainfluenza 1 virus and vesicu-
RSV vaccine, prepared in monkey kidney tissue lar stomatitis virus in mice have shown the occurr-
culture, potentiated the response of vaccinees to ence of an early immunological response in the
RSV infection through an immunological mecha- lungs which developed several days before anti-
nism.(J7,21.4(),44) This vaccine was found to be body was detected in serum. «;,70) If this type of
highly antigenic, stimulating high levels of serum early pulmonary immunological response plays a
plaque reduction antibody in young infants. In role in the resolution of infection, which is likely,
several field trials, a significant proportion of a delay and/or decrease in the response could lead
young children who received the inactivated RSV to a more serious type of disease. One factor
vaccine during infancy developed severe bron- which might contribute to such an impaired re-
chiolitis when they subsequently underwent natu- sponse is immunological suppression produced by
ral RSV infection at an age when RSV bronchiolitis maternally derived serum antibody. This type of
immunological suppression is known to affect the the first exposure to RSV during infancy results in
development of serum antibody, but it is not a silent, but sensitizing infection. Subsequently,
known whether local respiratory tract secretory disease occurs during a second infection when the
antibody can be suppressed in a similar manner. virus induces an allergic, IgE-mediated reaction in
Analysis of the titer of acute-phase serum neutral- the sensitized host. In contrast, RSV pneumonia is
izing antibody and of the convalescent-phase postulated not to require a prior sensitizing RSV
serum CF antibody response during RSV bron- infection. The question of one vs. two infections
chiolitis indicated that the two were inversely in RSV bronchiolitis is not merely of academic
related, and this relationship did not appear to be interest, since efforts to immunize infants with
an effect of age.(5B) Although this inverse relation- live attenuated virus have begun and are being
ship appeared to be significant, the exceptions to continued with the expectation that protection
the rule were sufficiently numerous to suggest that rather than sensitization will result. (41.42) The evi-
immunosuppression may not be invariably in- dence that the sensitization hypothesis is correct is
volved in RSV bronchiolitis. In any case, the based on the study of autopsy material from in-
possible role of impaired immunological response fants with bronchiolitis or pneumonia. The lungs
due to immunological immaturity and/or immuno- of the infants with bronchiolitis contained small
suppression should be kept in mind and evaluated quantities of virus and RSV immunofluorescent
in future studies of RSV disease of infancy. antigen, whereas the lungs of young infants who
There is one observation which is difficult to died of pneumonia contained large amounts of
explain on the basis of serum antibody induced virus and immunofluorescent antigen.(23)
immunopathology or an impaired immunological The sensitization hypothesis was recently evalu-
response mechanism. This concerns the relative ated by analyzing a composite RSV outbreak con-
sparing of I-month-old infants from RSV bron- structed from data obtained during 11 consecutive
chiolitis. RSV bronchiolitis was observed to occur outbreaks in the Washington, D.C., area.(7) If the
approximately one-third as often among infants 1 sensitization hypothesis were correct, one would
month of age as during the time of peak occurr- expect that during an RSV epidemic the incidence
ence at 2 months of age.(aB) If either or both of the of RSV bronchiolitis would increase more slowly
two immunological mechanisms are important in and peak later than other respiratory disease syn-
the pathogenesis of RSV disease, one would antic- dromes caused by the virus, such as pneumonia.
ipate a very high (or the highest) incidence of In other words, a period of time would be re-
disease during the first month of life, and this was quired for young infants born after the last yearly
not seen. However, the relative infrequencY of RSV epidemic to undergo their first RSV infection
RSV bronchiolitis in the first month of age may and this should produce a shift in the time frame of
result from the fact that the infant is isolated in RSV bronchiolitis. In addition, early in a RSV epi-
the hospital for the first few days of life and that demic bronchiolitis patients would be especially
the incubation interval between exposure and de- likely to be 6 months of age or older, because young
velopment of disease is approximately 5 days. infants would not have been born in time to experi-
Thus approximately one-third of the infant's first ence a previous infection. At the epidemic peak,
month may elapse before RSV disease can occur RSV bronchiolitis patients should be younger than
under ordinary circumstancel It is also possible such patients seen prior to the epidemic peak. Fi-
that the relative isolation of infants in the first nally, with increasing age relatively more infants
month of life may contribute to a decreased risk of and young children should be hospitalized with
infection during this period and hence a decreased RSV bronchiolitis than with RSV pneumonia. None
incidence of RSV bronchiolitis. Thus the relative of the expectations was confirmed by analysis of
sparing of infants during the first month of life the composite RSV epidemic; the age pattern of
may be more apparent than real. RSV bronchiolitis remained the same throughout
Another hypothesis which has been offered to the epidemic. (7) Furthermore, the majority of
explain the pathogenesis of RSV bronchiolitis en- young infants with bronchiolitis who are less than
visions the essential process in this disease as an 6 months of age exhibit a slow antibody response or
allergic reaction.(23) According to this hypothesis, a very poor antibody response which is more char-
acteristic of a primary than a secondary immunol- infancy and early childhood there are involvement
ogical reactionY3.57.61.62) Thus there was no sup- and inflammation of the mucous membranes of
port for the sensitization hypothesis from the the nose and throat. Paranasal and eustachian tube
analysis of RSV epidemics or from a study of the obstruction may also occur. In a significant pro-
immunological response of young infants to this portion of infections in early infancy, and in a
virus. minority of instances in later life, there is an
In addition, Polmar et al. (59) and Senterfit and extension of the inflammatory process into the
Kim (unpublished observations, 1974) found nor- trachea, bronchioles, and the parenchyma of the
mal levels of serum IgE in infants during the acute lung. In young infants, there is a tendency for
stage of RSV bronchiolitis. If an allergic reaction necrotizing bronchiolitis and pneumonia to occur.
were involved in pathogenesis of RSV bronchioli- Bronchiolar obstruction results in focal areas of
tis, one would expect a proportion of infants with atelectasis or emphysema. The clinical picture may
the disease to have an elevated level of serum IgE. be dominated by obstructive bronchiolitis or
This expectation is based on the observation that pneumonitis or· a combination of the two patterns.
many patients with extrinsic (allergic) asthma have Inflammation and edema of the larynx may occur,
an elevated level of serum IgE. 14 .2B .47) Finally, but this condition is less frequently observed than
cortisone, which is highly effective in allergic bronchiolitis or pneumonia. Older children or
asthma, does not appear to affect the course of adults who undergo reinfection with RSV often
infantile bronchioli tis. (49) develop mild upper respiratory tract illness indis-
Although the findings just described do not tinguishable from that produced by the multitude
support an allergic pathogenesis of RSV bronchiol- of other viruses which cause the common cold.
itis, there is one set of observations which sug- It has been suggested that exacerbation of
gests that allergy may be related in some manner chronic bronchiolitis and emphysema in adults is
to this disease. Children who had RSV bronchioli- frequently associated with reinfection with
tis during infancy were found to wheeze fre- RSV.19.64l Recent studies have failed to yield evi-
quently when they were 2-7 yr of age. WO ) In an dence which would support this view.
Australian study, 56% of children with a history of In fatal illnesses in young infants caused by
prior infantile RSV bronchiolitis wheezed on one RSV, the most prominent change is necrotizing or
or more occasions, while 43% wheezed on more interstitial pneumonitis, peribronchiolar lympho-
than five occasions. In addition, those children cytic infiltration, necrosis of tracheobronchiolar
who wheezed had a high frequency of allergic epithelium, atelectasis, and emphysema. I 1.24.:!4)
manifestations such as hay fever and eczema. Cytoplasmic inclusions may be present in infected
Finally, children who wheezed had a family his- areas of the lungs.
tory of asthma significantly more often than chil-
dren who did not wheeze. The nature of the
7.2. Diagnosis
relationship between an allergic diathesis and RSV
bronchiolitis remains to be elucidated. Diagnosis of RSV infection can be made by virus
isolation andJor demonstration of a rise in serum
antibody during convalescence. Examination of
exfoliated cells from the respiratory tract by immu-
nofluorescence also provides a highly efficient
method for the diagnosis of RSV infection.122.28)
7.1. Symptoms
Virus is present in the nasal and pharyngeal secre-
The effect of RSV on the host ranges from tions of infected individuals and can be isolated
inapparent infection to severe respiratory tract with greatest efficiency when specimens are inoc-
disease such as bronchiolitis or pneumonia. 'Re- ulated directly into cell culture without prior freez-
sponse to infection is influenced by age and im- ing. It is possible, however, to isolate a large
munological status. Bronchiolitis and pneumonia proportion of strains from frozen specimens when
caused by RSV occur in most instances during the veal infusion broth with 0.5% bovine albumin is
first year of life. Initially in an RSV infection in used as the collecting medium. Human hetero-
ploid cell cultures (HeLa, HEP-2, etc.) represent sequent infection caused by RSV. Thus, when RSV
the most sensitive host system for recovery of was prevalent in the community following the
naturally occurring virus. Characteristic syncytial period of immunization, the frequency of infection
cytopathic changes usually develop 3-10 days after among RSV vaccinees was not remarkably different
inoculation of clinical specimens containing RSV. from that of age-matched subjects who received a
Since sublines of HeLa and HEP-2 cells differ tissue culture-grown type 1 parainfluenza vaccine
considerably in sensitivity to RSV, it is essential or an egg-grown trivalent parainfluenza virus vac-
that cultures of a sensitive cell line be used in cine.(44) More striking than the failure of the
virus isolation attempts.(f;8) Human embryonic vaccine to protect against the virus was the unex-
kidney and human diploid fibroblast cultures can pected response to infection exhibited by the vac-
also be used for virus isolation, but these are cinees. In one vaccine trial, nine of 15 (60%)
generally less sensitive than the heteroploid cell vaccinees, 6-23 months of age, developed pneu-
cultures described above. Except in early infancy, monia or bronchiolitis or both; in five instances,
the complement fixation and tissue culture neu- disease was severe enough to require hospitaliza-
tralization techniques are relatively efficient serol- tion.(40) In contrast, only four of 47 (8%) unvac-
ogical procedures for diagnosis of RSV infection. cinated controls developed pneumonia and none
Infants less than 7 months of age develop neutral- of these children required admission to the hospi-
izing and complement-fixing antibodies less often tal. This difference in response indicated that the
following RSV infection than do older individu- vaccine had induced an altered, exaggerated reac-
als.(I"·57.61.62) In addition, a greater concentration tivity to infection. Definite evidence of such an
of antigen is required for detection of comple- altered response to infection was not seen among
ment-fixing antibody during early life.(J:j) In older vaccinees, who were 24-65 months of age. In
young infants, infection is most accurately deter- another study, 78% of RSV vaccinees required
mined by virus isolation. hospitalization when infected subsequently with
the virus under natural conditions; hospitalization
was necessary because of serious obstructive lower
8. Control and Prevention respiratory tract disease.(44) In contrast, only 5%
of parainfluenza vaccinees who became infected
It is unlikely that an effective, inactivated RSV with RSV developed illness of similar severity. In
vaccine can be developed for prevention of serious fact, the illness experienced by the RSV vaccinees
disease in early life. First, the unusual age distri- was more severe than that seen in younger, unvac-
bution of RSV bronchiolitis and pneumonia makes cinated hospitalized patients from the community.
it difficult to consider the use of an inactivated The parainfluenza type 1 vaccine used in the
vaccine. If a vaccine is to have a major impact on comparison group was prepared in African green
RSV bronchiolitis and pneumonia, it must be monkey kidney tissue cultures in a manner identi-
capable of stimulating effective host resistance in cal to that of the RSV vaccine; in fact, the two
the first month of life, since the peak incidence of vaccines were prepared by the same pharmaceut-
disease occurs during the second month of life. ical manufacturer. Since the parainfluenza vacci-
Second, a highly antigenic, inactivated vaccine nees did not exhibit an exaggerated response to
was tested in older infants and was found to be RSV infection, it was unlikely that a monkey
ineffective in terms of preventing both infection kidney antigen was responsible for the altered
and disease. <t7.21.4().44) reactivity associated with the RSV vaccine. In-
The inactivated vaccine was prepared in African stead, it appeared that a component of the RSV
green monkey kidney tissue culture, and virus was itself was responsible for the potentiation of dis-
concentrated by centrifugation and by adsorption ease by the vaccine.
to alum. This vaccine stimulated high levels of Naturally acquired RSV infection appears to
serum neutralizing antibody in seronegative in- confer a definite degree of protection against ill-
fants.(4()) In addition, the vaccine induced sys- ness caused by the virus. This observation coupled
temic cell-mediated immunity.(45) Unfortunately, with the ineffectiveness of serum antibody sug-
the vaccine did not confer protection against sub- gests that local defense mechanisms in the respira-
tory tract playa major role in resistance to illness rhinitis in infants who had no prior experience
caused by RSV. For this reason, an attentuated with RSV, but this was considered to be an accept-
strain of RSV which could infect the respiratory able price to pay for protection against serious
tract and induce resistance without producing sig- RSV disease of the lower respiratory tract. How-
nificant illness has been sought.(1O) In the initial ever, several of the young infants developed a
attempts to develop an attenuated vaccine, a low- mild otitis media following rhinitis and this was
temperature-adapted strain of RSV was produced thought to be an unacceptable property of the ts-1
in the laboratory and this strain was found to strain. In addition, a proportion of infants and
produce a silent infection in infants and young young children experimentally infected with the
children who had been infected with RSV previ- ts-1 mutant shed virus which appeared to be al-
ouslyY°.4UHowever, mild lower respiratory tract tered genetically in that it was able to produce
disease developed when the potential vaccine plaques at 37', 38", or 3erC, temperatures which
strain was given to young infants who lacked prior were restrictive for the ts mutant. (~1.42) The emerg-
experience with RSV. These findings indicated ence of genetically altered virus with wild-type
that a measurable degree of attenuation had been temperature sensitivity was not associated with
achieved by low-temperature adaptation, but the any signs or symptoms of respiratory tract dis-
residual virulence of the low-temperature-adapted ease.(421 Nonetheless, this pattern of genetic alter-
strain made it unacceptable for use in young ation offered some cause for concern. Although
infants, the group for whom an RSV vaccine is the ts-1 mutant may not be the definitive RSV
most urgently needed. vaccine strain, the initial studies were helpful in
Encouraged by partial success with the low- providing a frame of reference for evaluation of
temperature RSV strain, other candidate vaccine other mutants of this virus. In these studies, a
strains were developed which might offer the sharper definition of the properties required for an
possibility of greater attenuation. The most prom- acceptable vaccine strain was developed, and it
ising of the candidate strains was the temperature- was shown that an attenuated strain can infect and
sensitive (ts) mutant designated ts-1, which was induce an antibody response in young infants
induced by the chemical mutagen 5-fluorouri- without attendant lower respiratory tract disease.
dine,(25) This strain was chosen for clinical trial on Infants who were experimentally infected with the
the basis of its behavior in vitro in tissue culture ts-1 mutant did not exhibit an altered, exaggerated
and in vivo in the hamster. m.m This mutant did response to infection when they were subse-
not produce plaques, i.e., did not initiate foci of quently reinfected with naturally occurring virus
infection in tissue culture, at or above 37'C, unlike 1-2 yr later (Kim, unpublished findings, 1976).
wild-type virus, which produced plaques without Current efforts are directed at the production of
restriction at 3ere. (25) In the hamster, infection temperature-sensitive mutants of RSV which ex-
with the mutant was limited to the cooler upper hibit greater genetic stability than ts-1. It is hoped
respiratory tract, where the temperature was 32- that the introduction of additional genetic lesions
34°C, and virus was not found in the lungs, where into the ts-1 mutant or the production of other
the temperature was 37'e. (73) The temperature- mutants which possess multiple genetic lesions
sensitive characteristics of this mutant were stable will ensure genetic stability during growth in
following growth in cell culture and in hamsters; man. Possibly the introduction of additional ge-
i.e., there was no evidence of reversion to the wild netic lesions into the ts-1 mutant or the develop-
phenotype.(73) The mutant infected adult volun- ment of more defective, multilesion ts mutants will
teers when administered into the nasopharynx, remove the small amount of residual virulence
did not produce disease, and induced resistance which was detected in the ts-1 mutant when it
to subsequent challenge with virulent wild-type induced mild otitis media in young infants.
virus.(72) Finally, the mutant appeared to be ge-
netically stable in adults in that isolates obtained 9. Unsolved Problems
from the volunteers retained their ts property.
When tested in young children, the ts mutant was The major unsolved problem in our understand-
acceptably attenuated. The mutant induced mild ing of RSV concerns the mechanism whereby the
virus produces its most frequent and most severe 8. BRANDT, C. D., PARROTT, R. H., PATRICK, J. K, KIM,
disease manifestations during the first few months H. W., ARROBIO, J. 0., CHANDRA, R., JEFFRIES, B. c.,
of life. The role and relative importance of age, AND CHANOCK, R. M., Epidemiology-Sids and viral
respiratory disease in metropolitan Washington,
immunological immaturity, immunosuppression,
D.C., in: S.I.D.S. Proceedings of the Francis E. Camps
and immunopathology in serious RSV lower respi-
International Symposium on Sudden and Unexpected
ratory disease of early infancy must be assessed in Death in Infancy, (R. R. ROBINSON, ed.), pp. 117-129,
a more definitive manner than in past studies. Canadian Foundation for the Study of Infant Death,
Greater insight in these areas is required before 1974.
the final strategy for prevention or therapy of RSV 9. CARILLI, A. D., COHD, R. S., AND CORDON, W., A
disease can be planned. virologic study of chronic bronchitis, N. Eng/. J. Med.
In addition, we need a more complete under- 270:123--127 (1964).
standing of the manner in which RSV evades the 10. CHANOCK, R. M., Prospects for control of acute viral
host's defense mechanisms and reinfects the same and mycoplasmal respiratory tract disease by vacci-
individual with appreciable frequency over a pe- nation, Science 169:248-256 (1970).
11. CHANOCK, R. M., AND FINBERG, L., Recovery from
riod of years. Greater comprehension in this area
infants with respiratory illness of a virus related to
may allow us to manipulate the host's defenses so
chimpanzee coryza agent (CCA). II. Epidemiological
that the reinfection can be diminished and the aspects of infection in infants and young children,
quantity of virus available for infection of suscep- Am. J. Hyg. 66:291-300 (1957).
tible infants can be decreased significantly. 12. CHANOCK, R. M., KAPIKIAN, A. Z., MILLS, J., KIM, H.
W., AND PARROTT, R. H., Influence of immunological
factors in respiratory syncytial virus disease, Arch.
Environ. Health 21:347-356 (1970).
10. References
13. CHANOCK, R. M., KIM, H. W., VARGOSKO, A. J.,
DELEVA, A., JOHNSON, K. M., CUMMING, c., AND
1. ADAMS, J. M., IMAGAWA, D. T., AND ZIKE, K., Rela- PARROTT, R. H., Respiratory syncytial virus. I. Virus
tionship of pneumonitis in infants to respiratory recovery and other observations during 1960 out-
syncytial virus, J. Lancet 81:502-506 (1961). break of bronchiolitis, pneumonia, and minor respi-
2. BEEM, M., EGERER, R., AND ANDERSON, J., Respira- ratory diseases in children, J. Am. Med. Assoc.
tory syncytial virus neutralizing antibodies in per- 176:647-653 (1961).
sons residing in Chicago, Illinois, Pediatrics 34:761- 14. CHANOCK, R. M., PARROTT, R. H., JOHNSON, K. M.,
770 (1964). MUFSON, M. A., AND KNIGHT, V., Biology and ecol-
3. BEEM, M., WRIGHT, F. H., HAMRE, D., EGERER, R., ogy of two major lower respiratory tract pathogen&-
AND OEHME, M., Association of the chimpanzee RS virus and eaton PPLO, in: Perspectives in Virology
coryza agent with acute respiratory disease in chil- (M. POLLARD, ed.), pp. 257-281, Burgess, Minneapo-
dren, N. Eng/. J. Med. 263:523--530 (1960). lis, 1963.
4. BERG, T., AND JOHANSSON, S. C. 0., IgE concentra- 15. CHANOCK, R. M., AND PARROTT, R. H., Acute respira-
tions in children with atopic diseases, Ann. Arch. tory disease in infancy and childhood: Present under-
Allergy 36:219-232 (1969). standing and prospects for prevention, Pediatrics
5. BERTHIAUME, L., JONCAS, J., AND PAVILANIS, V., 36:21-39 (1965).
Comparative structure, morphogenesis and biologi- 16. CHANOCK, K M., ROIZMAN, B., AND MYERS, R., Re-
cal characteristics of tIle respiratory syncytial (RS) covery from infants with respiratory illness of a virus
virus and the pneumonia virus of mice, Arch. Ges- related to chimpanzee coryza agent. I. Isolation, prop-
amte Virusforsch. 45:39-51 (1974). erties and characterization, Am. J. Hyg. 66:281-290
6. BLANDFORD, c., AND HEATH, R. B., Studies on the (1957).
immune response and pathogenesis of Sendai virus 17. CHIN, J., MAGOFFIN, R. L., SHEARER, L. A., SCHIEBLE,
infection of mice. I. The fate of viral antigens, J. H., AND LENNETTE, E. H., Field evaluation of a
Immunology 22(4):637-650 (1972). respiratory syncytial virus vaccine and a trivalent
7. BRANDT, C. D., KIM, H. W., ARROBIO, J. 0., JEFFRIES, parainfluenza virus vaccine in a pediatric popula-
B. c., WOOD, S. c., CHANOCK, R. M., AND PARROTT, tion, Am. J. Epidemiol. 89:449-463 (1969).
R. H., Epidemiology of respiratory syncytial virus 18. COATES, H. V., ALLING, D. W., AND CHANOCK, R.
infection in Washington, D.C. III. Composite analy- M., An antigenic analysis of respiratory syncytial
sis of eleven consecutive yearly epidemics, Am. J. virus isolates by a plaque reduction neutralization
Epidemiol. 98:355-364 (1973). test, Am. J. Epidemiol. 89:299-313 (1966).
19. DOGGETT, J. E., Antibodies to respiratory syncytial Studies on an outbreak in Japan, 1968-1969, Jpn. J.
virus in human sera from different regions of the Microbial. 16:373-383 (1972).
world, Bull. WHO 32:849-853 (1965). 33. JACOBS, J. W., AND EDGINGTON, N., Isolation of
20. FRIEDEWALD, W. T., FORSYTH, B. R., SMITIi, C. B., respiratory syncytial virus from cattle in Britain, Vet.
GHARPURE, M. A., AND CHANOCK R. M., Low-tem- Rec. 87:694 (1971).
perature-grown RS virus in adult volunteers, J. Am. 34. JACOBS, J. W., PEACOCK, D. B., CORNER, B. D., CAUL,
Med. Assoc. 204:69~694 (1968). E. 0., AND CLARKE, S. K. R, Respiratory syncytial
21. FULGINITI, V. A., ELLER, J. J., SIEBER, O. F., JOYNER, and other viruses associated with respiratory disease
J. W., MINAMITANI, M., AND MEIKLEJOHN, G., Respi- in infants, Lancet 1:871-876 (1971).
ratory virus immunization. I. A field trial of two 35. JENNINGS, R, Adenovirus, parainfluenza virus and
inactivated respiratory virus vaccines: an aqueous respiratory syncytial virus antibodies in the sera of
trivalent parainfluenza virus vaccine and an alum- Jamaicans, J. Hyg. 70:523-529 (1972).
precipitated respiratory syncytial virus vaccine, Am. 36. JOHNSON, K. M., CHANOCK, R. M., RIFKIND, D.,
J. Epidemiol. 89:435-448 (1969). KRAVETZ, H. M., AND KNIGHT, V., Respiratory syncy-
22. GARDNER, P. S., AND McQUILLIN, J., Application of tial virus. IV. COITelation on virus shedding, serol-
immunofluorescent antibody technique in rapid di- ogic response, and illness in adult volunteers, J. Am.
agnosis of respiratory syncytial virus infection, Br. Med. Assoc. 176:663-667 (1961).
Med. J. 3:34~343 (1968). 37. JONCAS, J., BERTHIAUME, 1., AND PAVILANIS, V., The
23. GARDNER, P. S., MCQUILLIN, J., AND COURT, S. D. M., structure of the respiratory syncytial virus, Virology
Speculation on pathogenesis in death from respira- 38:493-496 (1969).
tory syncytial virus infection, Br. Med. J. 1:327-330 38. KALICA, A. R., WRIGHT, P. F., HETRICK, F. M., AND
(1970). CHANOCK, R M., Electron microscopic studies of
24. GARDNER, P. S., TURK, D. c., AHERNE, W. A., BIRD, respiratory syncytial temperature-sensitive mutants,
T., HOLDAWAY, M. D., AND COURT, S. D. M., Deaths Arch. Gesamte Virusforsch. 41:248-258 (1973).
associated with respiratory tract infection in child- 39. KAPIKIAN, A. Z., BELL, J. A., MASTROTA, F. M.,
hood, Br. Med. J. 4:316-320 (1967). JOHNSON, K. M., HUEBNER, R. J., AND CHANOCK, R.
25. GHARPURE, M. A., WRIGHT, P. F., AND CHANOCK, R. M., An outbreak of febrile illness and pneumonia
M., Temperature-sensitive mutant of respiratory associated with respiratory syncytial virus infection.
syncytial virus, J. Viro!. 3:414-421 (1%9). Am. J. HYf{. 74:234-248 (1%1).
26. GLEICR, G. J., AVERBECK, A. K., AND SWEDLUNG, H. 40. KAPIKIAN, A. Z., MITCHELL, R H., CHANOCK, R M.,
A., Measurement of IgE in normal and allergic serum SHVEDOFF, R A., AND STEWART, C. E., An epidemio-
by radioimmunoassay, J. Lab. Clin. Med. 77:69~98 logic study of altered clinical reactivity to respiratory
(1971). syncytial (RS) virus infection in children previously
27. GLEZEN, W. P., AND DENNY, F. W., Epidemiology of vaccinated with an inactivated RS virus vaccine, Am.
acute lower respiratory disease in children, N. Engl. J. Epidemiol. 89:405-421 (1969).
J. Med. 288:498-505 (1973). 41. KIM, H. W., ARROBIO, J. 0., PYLES, G., BRANDT, C.
28. GRAY, K. G., MACFARLANE, D. E., AND SOMERVILLE, D., CAMARGO, E., CHANOCK, R. M., AND PARROTT, R.
R G., Direct immunofluorescent identification of H., Clinical and immunological response of infants
respiratory syncytial virus in throat swabs from chil- and children to administration of low temperature
dren with respiratory illness, Lancet 1:446-448 (1968). adapted respiratory syncytial virus, Pediatrics 48:745-
29. GRIST, N. R, Ross, C. A. c., AND STOTT, E. J., 755 (1971).
Influenza, respiratory syncytial virus, and pneu- 42. KIM, H. W., ARROBIO, J. 0., BRANDT, C. D., WRIGHT,
monia in Glasgow 1962-1965, Br. Med. J. 1:456-457 P., HODES, D., CHANOCK, R. M., AND PARROTT, R.
(1%7). H., Safety and antigenicity of temperature sensitive
30. HAMBLING, M. H., A survey of antibodies to respira- (ts) mutant respiratory syncytial (RS) virus in infants
tory syncytial virus in the population, Br. Med. J. and children, Pediatrics 52:56-63 (1973).
1:1223-1225 (1964). 43. KIM, H. W., ARROBIO, J. 0., BRANDT, C. D., JEFFRIES,
31. HODES, D. S., KIM, H. W., PARROTT, R H., CA- B. c., PYLES, G., REID, J. 1., CHANOCK, R. M., AND
MARGO, E., AND CHANOCK, R M., Genetic alteration PARROTT, R. H., Epidemiology of respiratory syncy-
in a temperature-sensitive mutant of respiratory syn- tial virus infection in Washington, D.C. I. Impor-
cytial virus after replication in vivo, Proc. Soc. Exp. tance of the virus in different respiratory tract dis-
Bioi. Med. 145:1158-1164 (1974). ease syndromes and temporal distribution of
32. INABA, Y., TANAKA, Y., SATO, K., OMORI, T., AND infection, Am. J. Epidemiol. 98:216-225 (1973).
MATUMOTO, M., Bovine respiratory syncytial virus: 44. KIM, H. W., CANCHOLA, J. G., BRANDT, C. D., PYLES,
G., CHANOCK, R. M., JENSEN, K., AND PARROlT, R 54. MUFSON, M. A., LEVINE, H. D., WASIL, R. E., Mo-
H., Respiratory syncytial virus disease in infants CEGA-GONZALEZ, H. E., AND KRAUSE, H. E., Epide-
despite prior administration of antigenic inactivated miology of respiratory syncytial virus infection
vaccine, Am. J. Epidemiol. 89:422-434 (1969). among infants and children in Chicago, Am. J. Epide-
44a. KIM, H. W., BELLANTI, J. A., ARROBIO, J. 0., MILLS, miol. 98:88-95 (1973).
J., BRANDT, C. D., CHANOCK, R. M., AND PARROlT, 55. NORRBY, E., MARUSYK, H., AND ORVELL, c., Ultra-
R. H., Respiratory syncytial virus neutralizing ac- structural studies of the multiplication of RS (respira-
tivity in nasal secretions following natural infection, tory syncytial) virus, Acta Pathol. Microbial. Scand.
Proc. Soc. Exp. Bioi. Med. 131:658--661 (1969). Sect. B. 78:268 (1970).
45. KIM, H. W., LEIKIN, S. L., ARROBIO, J. 0., BRANDT, 56. PACCAUD, M. R., AND JACQUIER, c., A respiratory
C. D., CHANOCK, R M., AND PARROlT, R H., Cell- syncytial virus of bovine origin, Arch. Gesamte Virus-
mediated immunity to respiratory syncytial virus forsch. 30:327-342 (1970).
induced by inactivated vaccine or by infection, Pe- 57. PARROlT, R. H., VARGO SKO , A. J., KIM, H. W.,
diat. Res. 10:75-78 (1976). CUMMING, c., TURNER, H., HUEBNER, R. J., AND
46. KRAVETZ, H. M., KNIGHT, V., CHANOCK, R. M., CHANOCK, R. M., Respiratory syncytial virus. II.
MORRIS, A. J., JOHNSON, K. M., RIFKIND, D., AND Serologic studies over a 34-month period of children
UTZ, J. P., Respiratory syncytial virus. III. Production with bronchiolitis, pneumonia, and minor respira-
of illness and clinical observations in adult volun- tory disease, J. Am. Med. Assoc. 176:653-657 (1961).
teers. J. Am. Med. Assoc. 176:657-663 (1961). 58. PARROTT, R. H., KIM, H. W., ARROBIO, J. 0., HODES,
47. KUMAR, L., NEWCOMB, R. W., ISHIZAKA, K., MIDDLE- D. 5., MURPHY, B. R, BRANDT, C. D., CAMARGO, E.,
TON, E., AND HORNBROOK, M. M., IgE levels in sera of AND CHANOCK, R. M., Epidemiology of respiratory
children with asthma, Pediatrics 47:848-856 (1971). syncytial virus infection in Washington, D.C. II. In-
48. LEE, c., FUNK, G. A., CHEN, S., AND HUANG, T., An fection and disease with respect to age, immunologic
outbreak of respiratory syncytial virus infection in an status, race and sex, Am. J. Epidemiol. 98:289-300
infant nursery, J. Formosan Med. Assoc. 72:39-46 (1973).
(1973). 59. POLMAR, S. H., ROBINSON, S. D., AND MINNEFOR, A.
49. LEER, H. W., BLOOMFIELD, N. J., GREEN, J. L., HEIM- B., Immunoglobulin E in bronchiolitis, Pediatrics
LICH, E. M., HYDE, J. S., MOFFET, H. L., YOUNG, G. 50:279-284 (1972).
A., AND BARRON, B. A., Corticosteroid treatment in 60. ROONEY, J. c., AND WILLIAMS, H. E., The relation-
bronchiolitis, Am. J. Dis. Child. 117:495-503 (1969). ship between proved viral bronchiolitis and subse-
50. LODA, F. A., CLYDE, W. A., GLEZEN, W. P., SENIOR, quent wheezing, J. Pedial. 79:744-747 (1971).
R J., SHEAFFER, C. I., AND DENNY, F. W., Studies on 61. Ross, C. A. c., PINKERTON, I. W., AND ASSAAD, F.
the role of viruses, bacteria and M. pneumoniae as A., Pathogenesis of respiratory syncytial virus di-
causes of lower respiratory tract infections in chil- seases in infancy, Arch. Dis. Child. 46:702-704 (1971).
dren, J. Pedial. 72:161-176 (1968). 62. Ross, C. A. c., STOlT, E. J., McMICHAEL, S., AND
51. MILLS, J., KNOPF, H. L. S., VANKIRR, J., AND CHAN- CROWTHER, I. A., Problems of laboratory diagnosis
OCK, R M., Significance of local respiratory tract anti- or respiratory syncytial virus infection in childhood,
body to respiratory syncytial virus, in: The Secretory Arch. Gesamte Virusforsch. 14:553--562 (1964).
Immunological System (D. H. DAYTON, JR., P. A. 63. SCOlT, R, AND GARDNER, P. 5., Respiratory syncytial
SMALL, JR., R M., CHANOCK, H. E. KAUFMAN, AND T. virus neutralizing activity in nasopharyngeal secre-
B. TOMASI, eds.), pp. 149-165, Government Printing tions, J. Hyg. 68:581-588 (1970).
Office, Washington, D.C., 1971. 64. SOMMERVILLE, R. G., Respiratory syncytial virus in
52. MILLS, J., VANKIRK, J. E., WRIGHT, P. F., AND acute exacerbations of chronic bronchitis, Lancet
CHANOCK, R. M., Experimental respiratory syncytial 2:1246--1248 (1963).
virus infection of adults, J. Immunol. 107:123--130 65. SPENCE, L., AND BARRAlT, N., Respiratory syncytial
(1971). virus associated with acute respiratory infections in
53. MONTO, A. S., AND LIM, S. K., The Tecumseh study Trinidadian patients, Am. J. Epidemiol. 88:257-266
of respiratory illness. III. Incidence and periodicity of (1968).
respiratory syncytial virus and mycoplasma pneu- 66. STERNER, G., WOLONTIS, 5., BLOTH, B., AND DEHEV-
monia infections, Am. J. Epidemiol. 94:290-301 (1971). ESY, G., Respiratory syncytial virus: An outbreak of
53a. MORRIS, J. A., BLOUNT, R. E., JR., AND SAVAGE, R acute respiratory illnesses in a home for infants, Acta
E., Recovery of cytopathogenic agent from chim- Paediat. Scand. 55:273--279 (1966).
panzees with coryza, Proc. Soc. Exp. Bioi. Med. 67. SUTO, T., YANO, N., IKEDA, M., MIYAMOTO, M.,
92:544 (1956). TAKAI, 5., SHIGETA, S., HINUMA, Y., AND ISHIDA, N.,
Respiratory syncytial virus infection and its serologic 11. Suggested Reading
epidemiology, Am. J. Epidemiol. 82:211-224 (1965).
68. TYRRELL, D. A J., Discovering and defining the
etiology of acute respiratory disease, Am. Rev. Resp. GLEZEN, W. P., AND DENNY, F. W., Epidemiology of
Dis. 88:77-84 (1963). acute lower respiratory disease in children, N. Engl. J.
69. TYRRELL, D. A J., A collaborative study of the Med. 288:498--505 (1973).
aetiology of acute respiratory infections in Britain KIM, H. W., ARROBIO, J. 0., BRANDT, C. D., JEFFRIES, B.
1961-1964, Br. Med. J. 2:319-326 (1965). c., PYLES, G., REID, J. 1., CHANOO:, R. M., AND
70. WAGNER, R. R., Pathogenicity and immunogenicity PARROTT, R. H., Epidemiology of respiratory syncytial
for mice of temperature sensitive mutants of vesicu- virus infection in Washington, D.C. I. Importance of
lar stomatitis virus, Infect. Immun. 10:309-315 (1974). the virus in different respiratory tract disease syn-
71. WATERSON, A P., AND HOBSON, D., Relationship dromes and temporal distribution of infection, Am. J.
between respiratory syncytial virus and Newcastle Epidemiol. 98:216-225 (1973).
disease-Parainfluenza group, Br. Med. J. 2:1166- MONTO, A. 5., AND LIM, S. K., The Tecumseh study of
1167 (1962). respiratory illness. III. Incidence and periodicity of
72. WRIGHT, P. F., MILLS, J., AND CHANOO:, R. M., respiratory syncytial virus and mycoplasma pneu-
Evaluation of a temperature sensitive mutant of monia infections, Am. J. Epidemiol. 94:290-301 (1971).
respiratory syncytial virus in adults, J. Infect. Dis. MUFSON, M. A, LEVINE, H. D., WASIL, R. E., MOCEGA-
124:505--511 (1971). GONZALEZ, H. E., AND KRAUSE, H. E., Epidemiology of
73. WRIGHT, P. F., WOODEND, W. G., AND CHANOCK, R. respiratory syncytial virus among infants and children
M., Temperature sensitive mutants of respiratory in Chicago, Am. J. Epidemiol. 98:88--95 (1973).
syncytial virus: In vivo studies in hamsters, J. Infect. PARROTT, R. H., KIM, H. W., ARROBlO, J. 0., HODES, D.
Dis. 122:501-512 (1970). 5., MURPHY, B. R., BRANDT, C. D., CAMARGO, E., AND
74. ZAKSTELSKAYA, 1. Y., AND SHENDERVOCH, S. F., On CHANOCK, R. M., Epidemiology of respiratory syncy-
mechanisms of interference of respiratory syncytial tial virus infection in Washington, D.C. II. Infection
virus by influenza A2 virus, Vopr. Virusol. 15:552-555 and disease with respect to age, immunologic status,
(1970). race and sex, Am. J. Epidemiol. 98:289-300 (1973).
CHAPTER 18
Rhinoviruses
Jack Merrit Gwaltney, Jr.
1. Introduction 2. Historical Background
Rhinoviruses are the most important common cold Another member of the picornavirus family,
viruses to be discovered. The name rhinovirus poliovirus, is known to have caused disease in
reflects the prominent nasal involvement seen in ancient times, so it is probable that rhinoviruses
infections with these viruses. The large rhinovirus were in existence then also. Colds were a nuisance
genus, which is a member of the picornavirus in early civilization; then, as now, many useless
family, contains over 100 different antigenic types. remedies were proposed for their treatment. In 400
The discovery of the rhinoviruses led to the reali- B.C., Hippocrates noted that bleeding was a fre-
zation that the common cold is an enormously quently used, although worthless, treatment for
complex syndrome. The number of antigenic ally colds. In the first century, Pliny the Younger
distinct rhinoviruses is so large that man can be prescribed "kissing the hairy muzzle of a mouse"
infected with a different rhinovirus each year and for colds. The first sound epidemiological knowl-
still not experience all of the known types in a edge about acute respiratory disease came with the
lifetime. Awareness of the complexity of the rhi- observations that sea voyagers and the inhabitants
novirus problem has discouraged work on the of isolated communities were free of colds while
development of common cold vaccines and stimu- not in contact with the outside world but devel-
lated interest in alternative approaches to control, oped colds when such contact was reestablished.
such as chemoprophylaxis and environmental This led to the important conclusion that colds are
measures. Although rhinoviruses are the best contagious.
studied of the common cold viruses, major gaps Direct evidence of the infectious nature of colds
still remain in knowledge of their epidemiological came in 1914 from the volunteer studies of
behavior. The fundamental question of the num- Kruse, (97) who produced experimental colds in
ber of antigenic types in existence is unanswered, volunteers by intranasal inoculation of cell-free
as is the related question of the possible occur- filtrates of nasal secretions from persons with
rence of antigenic drift of serotypes. colds. Similar experiments by Dochez et al. (38) in
1930 confirmed that colds could be transmitted by
Jack Merrit Gwaltney, Jr. . Department of Internal bacteria-free filtrates, suggesting that the respon-
Medicine, University of Virginia School of Medicine, sible agents might be viruses. At the same time,
Charlottesville, Virginia epidemiological studies of acu te respiratory dis-
383
384 Chapter 18 • Rhinoviruses
ease in populations had been started. Van tive program directed by Kapikian et al. (89) as-
Loghem (68 ) measured the incidence of colds and signed numbers lA-55 to the rhinovirus types
observed their relationship to the seasons. Frost then known. In 1971, a second phase of this
and Govet 57 ) made the perceptive observation program added types 56-89.(90) Results of a third
that common respiratory disease appearing during phase of the numbering program currently in
the months of high prevalence, September to progress indicate that approximately 20 more rhi-
March, was composed of a series of short epidem- novirus types will be added to the genus. (71l
ics of irregular sequences and magnitude. This
suggested that colds were caused by a variety of
different agents occurring in succession. In the 3. Methodology Involved in Epidemiological
1940s and 1950s, long-term studies of colds in the Analysis
home by Dingle et al. (36) yielded precise informa-
tion on attack rates by age and the importance of
3.1. Surveillance and Sampling
the home as a site for transmission of respiratory
infections. During the same period, a group at the Three longitudinal studies of rhinovirus epide-
Common Cold Research Unit at Salisbury, Eng- miology have provided data on rhinovirus attack
land, headed by Andrewes and later Tyrrell, was rates. Surveillance of a popUlation of young adults
vigorously pursuing questions related to the etiol- at an insurance company in Charlottesville, Vir-
ogy and epidemiology of colds. (1) Colds were ginia, was conducted by collecting illness data on
successfully transmitted in volunteers using nasal symptom record cards in conjunction with weekly
secretions which were later shown to contain rhi- personal contact by a nurse-epidemiologist. (62)
noviruses. Attempts at the time to establish This nurse also collected samples at the time of
growth of the virus in artificial culture were un- illness. In addition, samples were obtained weekly
successful. from asymptomatic persons in a randomly selected
Specific work on rhinoviruses began in 1956 sample of the study popUlation. In another study,
when Pelon et al. (26 ) and Price,(35) working families from representative segments of the pop-
separately, reported the isolation of a new virus ulation in Tecumseh, Michigan, were surveyed by
which subsequently was given the designation weekly telephone contact with a single household
rhinovirus lA. Within a few years Ketler et al., (93) respondent who provided illness information for
using the highly sensitive human embryonic lung the family.o19) In the third investigation, mothers
cells developed by Hayflick and Moorhead, (74) of families with newborn infants in a group health
isolated a number of different serological types, cooperative in Seattle, Washington, recorded ill-
indicating that the rhinovirus group would not be ness information on their families and were vis-
small. Epidemiological studies conducted by ited biweekly for routine sampling.(SS) In the
Hamre et al. (70) during the same period estab- latter two studies, specimens were collected dur-
lished that rhinoviruses were responsible for a ing home visits by a nurse-epidemiologist when
significant amount of acute respiratory disease. illness was reported to the study team by tele-
Specific rhinovirus infection rates and the finding phone.
of recurrent fall peaks of rhinovirus colds were
reported from a longitudinal study by Gwaltney et
3.2. Methods of Virus Isolation and Propagation
al. (62) In further studies of rhinovirus epidemiol-
ogy by Monto,(1l3) Dick et al.,I35) and Hendley et Cell culture is the standard method for rhinovi-
al., (77l the importance of the family setting and of rus isolation and propagation. Rhinoviruses grow
schoolchildren in particular in favoring rhinovirus best at temperatures of 33-34°C under conditions
transmission was demonstrated. Couch et al. (28) of motion(871 and will not grow in embryonated
noted the surprisingly small amount of virus nec- eggs or suckling mice. Most epidemiological stud-
essary to initiate experimental infections in volun- ies have employed human embryonic lung cells,
teers. This group also provided important infor- strains WI26 and WI38, or strains of human em-
mation on the pathogenesis(42) and immunology bryonic lung cells originated by the laboratory
of rhinovirus infections.o 43 ) In 1967, a collabora- conducting the study. Rhinovirus cytopathic effect
Chapter 18 • Rhinoviruses 385
in WI38 cell culture is readily discernible, making monkey kidney cells, suggesting that the Hand M
this an easy system with which to work. The strain division is not based on major differences in
sensitivity of WI38 cells to rhinoviruses appears to the biological properties of rhinoviruses.(41l
be similar to that of the nasal mucosa of volun- Organ cultures of fetal human trachea and other
teers. Volunteer challenge experiments comparing ciliated epithelium have been used to isolate rhi-
rhinovirus human and tissue culture infectious noviruses which did not grow initially in cell
doseso have shown one human infectious doseso culture.(S2.166) Comparison of the sensitivity for
to be equivalent to 0.03-0.75 tissue culture infec- rhinovirus isolation of standard cell culture and of
tious doseso. (39) organ culture has failed to show clear superiority
There are problems, however, with the use of of the organ culture system(79); both systems are
human embryonic lung cell cultures. The sensitiv- necessary for optimal recovery of these viruses.
ity to rhinovirus of strains of different origin may Once isolated in organ culture, rhinoviruses can
vary a hundredfold or more, for poorly understood be readily adapted to cell culture. The organ cul-
reasons.(S) Also, different lots of the same strain, ture strains have been found to be types which
such as WI38, may have unpredictable variations have also been recovered in cell culture. Because of
in rhinovirus sensitivity which are unex- the limited supply of fetal material, it has not been
plained. (61l Interpretations of rhinovirus morbid- possible to use organ culture systems in large
ity data must take these variations into account epidemiological studies.
since rates of rhinovirus-associated illness are di- Experimental infections with human rhinovi-
rectly related to the sensitivity of the cell cultures ruses have been produced in chimpanzees(34) and
used. gibbons,(133) but attempts to infect small labora-
Rhinoviruses will grow in other cell lines and tory animals have not been successful. Rhinovi-
strains derived from human and primate tissues, ruses have been isolated from cattle,(Jm and res-
including rhesus monkey kidney, human embry- piratory viruses with similar characteristics to
onic kidney, and KB. The sensitivity of these cells human rhinoviruses have been recovered from
for rhinoviruses tends to be less consistent than cats(30l and horses. (37)
that of WI38 cells. A strain of HeLa cells with
enhanced sensitivity to rhinoviruses has been de-
3.3. Methods Used for Serological Surveys and
veloped and proven useful for propagation of
Antibody Measurements
antigen and for serological procedures. (23) These
M-HeLa cells have been used to grow rhinovirus The multiplicity of rhinovirus types and their
harvests with exceptionally high titers (10 9 pful relative immunological specificity have prevented
mlY25) and to prepare large quantities of antigen the general use of serological techniques for meas-
in suspension cultures. (162) All of the first 55 uring infection rates. Serological study of infection
numbered rhinovirus types have been plaqued rates is possible, however, when the types of
using a method which employs HeLa cells and an rhinovirus circulating in small populations, such
agarose overlay containing medium with added as families, are known from viral cultures. Testing
magnesium and DEAE-dextran.(51l for the presence of rhinovirus antibody has been
The earlier division of rhinoviruses into Hand done with the neutralization test, since this
M strains on the basis of growth in cells of human method was the only one available until recently.
or monkey origin has been of limited epidemiol- The neutralization test has also been used to
ogical importance. M strains tend to grow better in identify specific antigenic types of virus and to
cell culture, and thus were more easily recovered measure antibody in human serum and nasal se-
with the less sensitive systems used in earlier cretions.
studies. (65) Consideration should be given to the In experimental rhinovirus infection, viral shed-
greater ease of recovery of M strains when epide- ding was found to be more sensitive than anti-
miological data are being evaluated, since this body response as a means of detecting infec-
variable could result in overestimation of the im- tion,t75) while in studies of natural infections
portance of M rhinoviruses. Recent work has either procedure alone identified only about two-
shown that H strains can be adapted to grow in thirds of the diagnosed infections. (4) In family
studies, 20-40% of total infections were detected Complement fixation tests with rhinoviruses
only by serology in persons who had both tests have been reported(2o.33) but have not been useful
performed. (35.77) as a method of collecting morbidity data. Recently,
For typing rhinoviruses, hyperimmune rhinovi- rhinoviruses have been found to agglutinate sheep
rus. antisera have been produced in a number of erythrocytes.()55) The test holds promise as an-
animal species, including rabbits, guinea pigs, other method of collecting epidemiological data,
calves, goats, and baboons. Some goat and calf although not all serological types show hemagglu-
antisera have contained cytotoxic substances tination under the conditions of pH and tempera-
which have caused difficulties in the interpreta- ture which were studied.
tion of neutralization test results.(23) The large
number of rhinovirus serotypes has led to the use
of antisera pools for serotype identification. An
efficient method of antisera pooling is the combi-
4. Characteristics of Virus Affecting the
natorial method. (92) Serological identifications of Epidemiological Pattern,
rhinoviruses in large epidemiological studies can
be done with pooled antisera used in microneu- 4.1. Physical and Biochemical Characteristics
tralization systems. (59.96) Rhinoviruses have physical and biochemical
The accepted standard for serological identity of properties which put them in the picornavirus
an unknown rhinovirus is neu tralization of virus family (Table 1). ()S6.17m This family also includes
concentrations ranging from 10 to 300 TCIDso by 20 enterovirus and calicivirus. While sharing basic
units of antibody.(87) For measuring neutralizing properties with enteroviruses, such as size, shape,
antibody in human serum and nasal washings, it nucleic acid composition, and ether resistance,
is necessary to use small doses of virus (3-30 rhinoviruses differ in having a greater buoyant
TCID5o ) for the test to have satisfactory sensitiv- density and a susceptibility to inactivation by
ity.(45) Somewhat more sensitive plaque reduction exposure to an acid environment.o 441 The basis
methods of antibody measurement have been de- for acid lability remains unclear, although treat-
veloped(161) but have not been used extensively as ment with acid results in the loss from the virion
an epidemiological tool. of the smallest of the four size classes of rhinovirus
Table 1. Characteristics of Rhinovirus
Physical and biochemical

Size: 8.4 x 10" daltons (20-40 nm)
Shape: capsid with cubic symmetry with proposed structure of 60 identical four-chain subunits.
Nucleic acid: single-stranded RNA of 2.6 ± O.l·x 10· daltons
Ether: resistant
Acid: labile (pH 3-5)
Virus synthesis and maturation in cytoplasm
Biological
Optimal temperature of growth 33-35"C and restriction of growth at 37"C
Inability to survive and replicate in the intestinal tract
Survival on skin and environmental surfaces
Two or more receptor families for host cells
Antigenic
Native antigenicity: type specific (0 antigenicity)
One-hundred or more numbered native antigenic types
Direct and indirect antigenic relationships between some native antigenic types demonstrable with hyperimmune
sera
Altered antigenicity (by heat or urea): cross-reactive between types (C antigenicity)
polypeptides. (95) Recent evidence suggests that 4.3. Antigenic Characteristics

rhinoviruses are structurally similar to· enterovi-
ruses (105 ) and that the greater buoyant density of Rhinoviruses in their native state contain type-
rhinoviruses on a cesium chloride gradient relates specific surface antigens (Table 1). On the basis of
to efficiency of binding of cesium ions and not to a a collaborative program, they have been classified
basic difference from enterovirusesY°6) Rhinovi- as serotypes 1-89 and subtype 1A.188-90) Further
rus gene and cleavage patterns have been found work on rhinovirus numbering is nearing comple-
similar to those of poliovirus. (103 ) Thus the sum of tion, and approximately 20 more types will be
evidence on the physical and biochemical nature added to the classification. l 7l) There are a large
of rhinoviruses suggests that they and enterovi- number of rhinovirus strains that have been re-
ruses are descended from a common ancestor. covered in recent epidemiological studies which
Similarity in physical nature of the two groups are not neutralized by antisera to the numbered
may help explain similarities in epidemiological types.
behavior, i.e., increased prevalence in late sum- The criterion for the selection of numbered pro-
mer and fall and possible spread by direct contact totype viruses was the absence of cross-neutraliza-
with infectious secretions. tion with other prototype candidates using animal
hyperimmune antiserum at dilutions of 1:2 to 1:20
in a standard neutralization test. There was a
4.2. Biological Characteristics virtual absence of cross-reactions with the antisera
which were used in the numbering program. Re-
The biochemical basis for the optimal tempera- cent work with high-titered hyperimmune antis-
ture range for rhinovirus growth is unknown, but era, discussed below, has disclosed antigenic rela-
this property may be of major epidemiological tionships among some of the numbered types
importance (Table 1). The temperature of nasal which were not discovered in the collaborative
mucosa, 33-35°C, corresponds to the optimal tem- program. In spite of these findings, discussed in
perature for rhinovirus replication. At 37"C, virus the next paragraph, the large number of antigeni-
yields fall to 10-50% of optimum.(J51i,W7) In natural cally different types of rhinovirus is undoubtedly
infection in man, rhinovirus concentrations are an important characteristic of the group, influenc-
higher in nasal secretions than in pharyngeal se- ing epidemiological behavior and accounting for
cretions, saliva, or secretions obtained by simu- the frequency of rhinovirus colds.
lated coughs and sneezes. (78) Attempts to isolate In an early study, antigenic relationships among
rhinovirus from blood have not been success- different rhinovirus types were reported, using
ful,142.47) nor does rhinovirus survive and replicate hyperimmune bovine antisera in neutralization
in the intestinal tract. Studies of rhinovirus sur- tests. 150l The bovine antisera were later recog-
vival in the gut suggest that the temperature of nized to contain anticellular antibody. When this
37"C may be a decisive factor in inhibiting growth, antibody was removed, the antigenic cross-reac-
although gastrointestinal secretions and transit tions largely disappeared. (22) More recently, po-
time may also have adverse effect on virus sur- tent monotypic rabbit antisera were used to dem-
vival. (17) On the basis of these observations, it is onstrate four reciprocal and five one-way cross-
tempting to speculate that one reason for the reactions among 37 rhinovirus types studied. 1210
different pathogenic and epidemiological behavior The cross-reactions were usually minor. A number
of enteroviruses and rhinoviruses is the difference of these relationships were indirect and were de-
in the optimal temperature for growth of the two monstrable only by primary immunization with
groups of viruses. one rhinovirus type followed by immunization
Rhinovirus receptors are insensitive to neura- with a different but related type.
minidase but are sensitive to proteolytic enzymes. The importance of cross-reactions in immunity
Studies using HeLa cell cultures have shown that in man is currently unknown, and the results of
rhinoviruses can be separated into at least two work in this area are contradictory. Neutralization
different groups on the basis of attachment at tests carried out with paired sera from patients
receptor sites on the cell surface.(99) have usually not shown significant cross-reactions
following natural rhinovirus infections. (73) On the (Table 2A). Rates in this population ranged from
other hand, in a study of experimental infections 1.21 in the 0-1 yr age group to 0.20 in mothers;
in volunteers, heterotypic antibody responses values were intermediate in children 2-9 yr of age.
were relatively common after infection with some Similar data collected from medical students in
types.(53) Chicago(69) and insurance company employees in
The native antigenicity of rhinoviruses can be Charlottesville(62,65) gave rhinovirus infection
altered by experimental means. Treatment at pH 5 rates of 0.74 and 0.77 per person-yr, respectively,
at 56°C or in 2 M urea produces virus particles True rhinovirus infection rates are probably
which react in immunodiffusion and complement higher than reported, since currently available
fixation tests with heterologous types.(101) When rhinovirus culture methods lack optimal sensitiv-
the virus is in this C-antigenic state, which appar- ity (see Section 3). The overall rhinovirus infection
ently results from a configurational change that rates of 0.74 and 0.77 per person-yr in Chicago and
exposes normally hidden determinants, it is una- Charlottesville, respectively, are probably mini-
ble to attach to cell receptors. This alteration in mum values for the true incidence of rhinovirus
antigenicity, which also occurs after virus attach- infections in young adults. Adjustment of the rates
ment to host cells, may be an important step in the for young adults in Chicago and Charlottesville to
initiation of infection<toO) but probably plays no the consistent trend toward higher rates seen in
role in immunity to infection. children gives projected rhinovirus infection rates
in young children of up to 1.5 per person-yr. Of
particular interest was the slight increase in inci-
5. Descriptive Epidemiology dence of rhinovirus infections in young adults, 20-
29 yr, in the Michigan population and the in-
5.1. Incidence and Prevalence of Infection creased incidence in females in the 16-24 age
group in the Charlottesville population. These
5.1.1. Age- and Sex-Specific Attack Rates. Rhi- findings may relate to the importance of young
novirus infections are the most common of the children in disseminating rhinovirus in the home,
acute respiratory infections(24.65) and probably the particularly to mothers. This is discussed below in
most common of all acute infection~ of man. Infec- relation to rhinovirus infection in the family.
tion rates based on virus isolations from routine Rhinovirus illness rates have been measured in
specimens from family members in Seattle with long-term studies of families and insurance com-
and without symptoms were 0.59 per person-yr pany workers. In Tecumseh, the rhinovirus illness
Table 2A. Rhinovirus Infection Rates: Calculated from

Surveillance and Sampling of All Persons-Well and III
Age Person-yr of Infections per

Location (yr) observation person-yr
Seattle, Wash."') 0-1 144 1.21

2-5 135 0.54
6-9 22 0.55
Mothers 208 0.20
All ages 510 0.59

Chicago, Ill.(69) 19-32 466 0.74"
Charlottesville, Va.'62) 16-45 500 0.77"
a Rhinovirus isolation percentages for well and ill persons 1.5% and 25.4%, respec-
tively; sampling interval of well persons 6 wk; data collected over four periods of 9
months and adjusted to annual rates.
b Rhinovirus isolation percentages for well and ill persons 2.1% and 23.3%, respec-
tively; sampling interval of well persons arbiirarily adjusted to 6 wk; data collected
over 1 yr.
Table 2B. Rhinovirus Infection Rates: Calculated from Surveillance and Sampling of
Persons with Colds
Number of
respiratory
Age Person-yr of illnesses per Number rhinovirus
Location (yr) observation person-yr RIs per person-yr
Tecumseh, Mich.02Ol <1 726 6.1 0.58"

1-4 3,516 5.2 0.50
5-9 5,064 3.5 0.33
10-19 6,228 2.5 0.24
20-29 3,786 2.75 0.26
30-49 8,394 2.0 0.19
50+ 1,716 1.45 0.14
All ages 29,430 3.0 0.29

Males:
Charlottesville, Va. (62.65) 16-24 240 2.2 0.51"
25-34 204 2.1 0.50
35-44 111 2.3 0.54
45+ 24 2.2 0.51
All males 579 2.2 0.51

Females:
16-24 477 2.6 0.60
25-34 237 2.1 0.49
34-44 84 2.1 0.49
45+ 24 1.3 0.31
All females 822 2.4 0.55

All persons 1,401 2.3 0.53
a All rates calculated using rhinovirus isolation percentage of 9.6%.

b All rates calculated using rhinovirus isolation percentage of 23.3% (observed: 22.9% in males, 23.6% in females).
rate for all ages was 0.29 per person-yr.(J2()) Rates used in counting colds, and varying sensitivities
ranged from 0.58 for infants less than 1 yr old to of the cell cultures used for virus recovery.
0.14 adults over the age of 50 (Table 2B). Rates 5.1.2. Prevalence of Antibody and Geographic
declined proportionately with increasing age. Data Distribution. Studies of the prevalence of rhinovi-
collected from the insurance company population rus antibody support the conclusion that rhinovi-
of young adults yielded a rhinovirus illness rate of rus infections begin in early childhood and con-
0.53.((;2) Rates for males and females derived from tinue into adult life (Fig. 1). Antibody to the
this study were 0.51 and 0.55, respectively. The various rhinovirus types begins to appear at an
higher rate in females reflected a greater incidence early age and increases in prevalence throughout
of total colds in females and not an increased childhood and adolescence.(!17.159.lHo l The preval-
incidence of rhinovirus recovery from females, ence of antibody reaches a peak in young adults
since the rhinovirus isolation percentages from (mean percent positive, 50%), probably reflecting
males and females were not different. The reason the effect of exposure to young children in the
for the differences in rhinovirus illness rates in home.(72) Antibody prevalence then declines
these studies is not clear but may relate to varia- slightly to a level (mean percent positive, 4~50%)
bles such as the methods of surveillance, criteria which persists throughout adulthood. Studies of
390 Chapterl8 • Rhinoviruses
~60
N
...I
«
~50
:::l
w
Z
(I) 40
w
(I)
:::l Fig. 1. Distribution of neutral-
a:: izing antibody in human sera ac-
- 30
6
z
cording to age. 184 sera were
tested at 1:4 dilution vs. RV types
lA-55. The vertical bars repre-
~20
sent the standard error of the
:g mean, With permission of Ham-
LI-
010 parian,('1.21
~
z
«
~ 0 ()'0.25 0.3-1 1-4 5-10 11-20 21-30 31-40 41-50 '51-60 >60
(N=12) (N=12) (N=12) (N=12)~N=22) (N=20) (N=27) (N=26) (N=23) (N=18)
AGE GROUP IN YEARS
antibody in sera collected serially from the same differences in prevalence of antibody between
individual show persistence of antibody at rela- countries for any particular virus tested. Rhinovi-
tively stable levels for years. (159) The mechanisms rus antibody prevalence in tropical areas is equal
by which rhinovirus serum antibody levels persist to or greater than that in the temperate zone.
are unknown and could include inherent stability 5.1.3. Seasonal Distribution of Infections. In an
of antibody formed initially and/or recurrent anti- early epidemiological study of acute respiratory
genic stimulation from the same or related types. disease in which virological methods were not
The slight decrease in prevalence of antibody after available, Frost and COVer 57) noted that "during
the early adult peak (Fig. 1) suggests that a decline the season of high prevalence, from September to
in antibody occurs when viral exposure is less- March, inclusive, the incidence curve (for colds) in
ened. Limited work has also shown that artificially each locality exhibited a series of oscillations,
induced neutralizing antibody in nasal secretions constituting a succession of epidemics, each of
may persist for at least 330 days following intra- several weeks' duration, rather irregular in se-
nasal vaccination. (11) quence and magnitude, but clearly not attributable
Information is also available on the prevalence to mere chance fluctation." The data from this
of serum neutralizing antibody in adults to each of study showed that one of the recurrent epidemic
the different serotypes, lA-55. In the groups stud- peaks of colds occurred in the early fall, usually in
ied, antibody was present in all of the types tested September. Later in the Cleveland family study of
(Fig. 2).(72) The prevalence of antibody ranged minor illness, a September peak of colds was a
from a low of 11 % to a high of 94%, and there was prominent feature of the seasonal pattem of ill-
no sharp dividing point between types associated ness, although no respiratory viruses could be
with high and low antibody prevalence. It is of associated with this period. (36) Newer studies
interest that types with high antibody prevalence using virus cultures have now shown that rhinovi-
tended to be M strains and types with low anti- ruses account for a major part of this early fall
body prevalence were H strains. outbreak of colds which annually initiates the
Studies of rhinovirus antibody prevalence in respiratory disease season (Fig. 3).(62.114) In a
specimens from many different parts of the world study of adults with colds in the eastem United
have shown that rhinoviruses have a worldwide States, rhinovirus infection rates reached their
distribution.o 60 ) Broadly speaking, there were highest annual point (3.5 illnesses/lOOO/day, 1.28
80 ALL AGES 49
148 SERA
Fig. 2. Percent of human sera

with neutralizing antibody to
rhinovirus types lA-55. 148 sera
were tested at a 1:4 dilution.
With permission of Hampar-
ian.(12)
per person-yr) in September. At this time, rhino- the rainy season/ 1m but more precise monitoring
viruses accounted for approximately 40% of all of the seasonal prevalence of rhinovirus colds has
colds and greater than 90% of diagnosed colds. not been done. In arctic locations, where the
Rhinovirus infection rates fell and remained low respiratory disease season coincides with cold
(1-l.S/1000/day) 'in the winter and early spring. A weather as in temperate climates, rhinovirus out-
second peak of rhinovirus illness occurred in April breaks have been observed but precise patterns
and May. Although total respiratory rates were have not been studied. (J7J)
falling in the spring, rhinoviruses were associated Although there is a well-established correlation
with a substantial fraction of all colds. Throughout between the lowered temperatures during the fall,
the summer, rhinovirus colds continued to account winter, and spring months and the increased oc-
for an important part of total acute respiratory currence of acute respiratory disease during that
disease, although respiratory illness rates reach period/so) there is no evidence to support a direct
their lowest point at this time. causal relationship between thermal cold and in-
In the tropics, the respiratory disease season creased rates of infection. As to meterological
coincides with the rainy season, beginning in May effects specifically on rhinovirus infections, a thor-
and June and ending in November and Decem- ough study of weather and colds showed that none
ber. (118) Most rhinovirus infections occur during of nine weather variables including temperature
_ TOTAL RESPIRATORY ILLNESS

16 HHHH MEAN ± 1.7 S.D.
14 RHINOVIRUS RESPIRATORY ILLNESS

MEAN ± 1.7 S.D.
~ 12
§ 10
Cl
Fig. 3. Total and rhinovirus respiratory ill-
ness rates (±1.7 SO) in young adults. Data
5i8l1f1~
collected over a 6-yr period (1963-1969).
Adapted from Gwaltney et al. (62) ~
z..J
6
..J 4
o
Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun
had a distribution remotely resembling the au- while others appeared only once or twice, It has
tumn (presumed rhinovirus) peak of colds.(98) been proposed, however, that certain rhinovirus
This is in keeping with the observations from two types might possess a higher degree of infectivity
long-term studies of rhinovirus infections in than others, increasing their importance as a cause
which prominent September peaks of rhinovirus of colds and making them prime candidates for
colds were associated with mild seasonal fall inclusion in vaccines,(115) Analysis of the fre-
weather and not with the more severe cold of quency of isolation of the various rhinovirus
winter which requires heating of homes and alter- types, however, does not show a sharp division
ations in living patterns. (76,116) More direct evi- between "common" and "uncommon" types,
dence on this question comes from a volunteer Also, types most commonly encountered in one
study with rhinovirus type 15 in which exposure study have not necessarily been the same as those
to thermal cold showed no adverse effect on sus- in other studies, From the analysis of combined
ceptibility to experimental infection or severity of data from several studies, it was not possible to
illness. (46) designate a particular year as a nationwide epi-
The reason for seasonal variation in the inci- demic year for a particular type, nor was it possi-
dence of colds remains a mystery, Speculations ble to detect pathways of rhinovirus transmission
include the idea that cold weather, like rain in the by type across the country,(68)
tropics, leads to crowding indoors, thus providing One general pattern of serotype distribution has
better conditions for virus spread. (84) Also, school emerged which raises a basic question about the
openings in the fall bring together into large antigenic nature of rhinoviruses. Long-term stud-
groups a segment of the population highly suscep- ies have shown a gradual change with time in the
tible to rhinoviruses and other respiratory viruses, overall distribution of serotypes in a given geo-
There has also been speculation on the effect of graphic location.(141 Serotypes with lower num-
weather changes on virus infectivity and host bers, which in general were discovered earlier,
resistance, Changes in humidity have been shown have been replaced by higher-numbered, "newer"
to influence the survival of respiratory viruses,(9) types and strains which are untypable with avail-
and seasonal changes may affect hormonal func- able antisera. The reason for the shift in types is
tions in man that influence susceptibility to infec- unknown; one possibility is that all of a very large
tion.(J(;4) In this regard, female volunteers were number of stable antigenic types have not cycled
found to be more susceptible to experimental colds through the locations where rhinovirus surveil-
in the middle third than during other times in the lance is in progress and so have not been discov-
menstrual cycle,<48) possibly because of hormonal ered. Another possibility is that rhinoviruses are
effects on nasal mucosa, undergoing antigenic drift. If this is occurring
5.1.4. Distribution of Serotypes. Tabulation of with sufficient speed to result in marked changes
the isolation of rhinovirus serotypes in the United in the already numbered viruses, they could be
States based on published studies revealed wide mistaken for "new" types. Bearing on the second
dispersal of most types throughout the coun- possibility are two studies showing antigenic dif-
try. (68) Of the first 55 numbered types, only type ferences between strains of the same types isolated
5, an English strain, had not been recovered in the several years apart.<I4(;,157) In one i~stance, the
United States. The serological survey cited ear- newer strain had broader antigenicity than the
lier(72) showed antibody to type 5 virus in sera prototype.
from U.s. populations. Thus the conclusion that
rhinovirus types are widely distributed through-
out the United States and the world is supported
by both virus isolation and serologic data. 5.2.1. Family. One of the major sites of rhinovi-
The current impression, based on longitudinal rus spread in civilian populations is the
studies, is that multiple types circulate in a geo- homeY5,77.113) The characteristic epidemiological
graphic area at any given time with no discernible pattern in this setting is for a schoolchild to
pattern to their appearance or reappearance,(64,68) introduce virus into the home, after which trans-
Over several years, some types were endemic mission occurs to other members of the family
ANTIBODY TO
-
RV 40
ACUTE/CONV
WORKING RV 40
ADULT (Father) <2-8
Fig. 4. A family outbreak of colds due to
-
WORKING
rhinovirus type 40. Black bars represent pe- ADULT (Mother) 8-8
riods of symptomatic illness. RV 40 repre-
HIGH SCHOOL RV 40
sents positive virus culture. The diagnosis of 2-<2
-
CHILD
rhinovirus infection in the index case (gram-
mar school child) was made by serology. JUNIOR RV 40
Adapted from Hendley et aI. (75) HIGH SCHOOL <2-32
-
CHILD
GRAMMAR
SCHOOL <4-16
CHILD
I I I I
8/28 9/4 9/11 9/18 9/25
(Fig. 4). Secondary infections are most common in 50%, and 21 % of persons with titers of :52, 4, and
young children and mothers, but all members of 8-32, respectively, were infected. m .m Based on
the household including fathers, other adults the results of a study of colds in the tropics/I];)
working outside the home, and adolescents are the secondary attack rate with type 39 was calcu-
affected. Two- to five-day intervals are commonly lated to be 56% in antibody-free persons.(7f;)
seen between onsets of cases. 5.2.2. Schools. A key study has shown that
In one study, total respiratory illness rates were rhinoviruses spread efficiently among children in
highest in preschool children.(77) Rates in house- nursery school/ 41 thus establishing transmission
wives were similar to those in schoolchildren and in school as an important step in rhinovirus dis-
were consistently higher than in adults working semination in civilian populations. Spread of some
outside the home. During the height of the epi- types in the schoolroom was extensive, involving
demic, the frequency of rhinovirus infection as up to 77% of children. However, half of the
determined by culture and serology was similar in serotypes introduced into the groups showed no
all age groups. Later, in October, total illness rates evidence of spread. The reason for the lack of
were seen to decline in adults and older children spread of some types is unknown, but the authors
while young children continued to have frequent concluded that it was not due to characteristics of
colds for which no etiology could be established. the associated illness, patterns of viral shedding,
The presence of children in the home was associ- or levels of immunity. Spread was most pronoun-
ated with total respiratory illness infection rates ced during March and April, a recognized time of
for adults which were higher than for adults who increased prevalence of rhinovirus colds. The
did not have this exposure. At the height of a study unfortunately did not extend through the
September peak of illness, rhinovirus respiratory September peak of rhinovirus infections.
illness rates for all family members, adults and Rhinovirus activity has been observed in day
children, were approximately 8/1000/day (2.92 per school groups at various grade levels"m and in
person-yr), calculated on the basis of rhinovirus boarding school, university, and medical school
causing 40% of fall colds. populations. «";'«9.91.111.I:l~) Rhinoviruses are a
In one family study, the rhinovirus attack rate for prominent cause of morbidity in these groups,
two epidemic types was 25% and 50%,to°) while although information on their specific epidemiol-
the attack rate for type 16 in an outbreak in ogical behavior is not available. Presumably,
families in a small Alaskan community was nearly spread in older children, adolescents, and young
70%.mll In another study, the secondary attack adults who are part of closed populations such as
rates for members of families into which a rhino- boarding schools occurs between roommates,
virus had been introduced were inversely propor- friends, members of athletic teams, etc.
tional to preexposure serum antibody levels; 71%, 5.2.3. Military. Rhinoviruses account for a large
amount of the morbidity associated with upper piratory secretions from individuals with natural
respiratory tract infections in military popula- colds have shown that the quantity of virus in
tions.154.80,111) In a prospective study of navy and nasal mucus tends to be ten- to a hundredfold
marine recruits, 90% of the men developed rhino- greater than in pharyngeal secretions. (78) Also,
virus infection during a 28-day period in basic virus was present only 50% of the time in saliva,
training, giving an attack rate for this period of where it was found in low concentrations. In
11.7 per person-yr!(141) Seventy-five percent of the keeping with the relative scarcity of rhinovirus in
infections occurred within the first 2 wk of train- saliva was the finding that virus was infrequently
ing, and simultaneous or closely spaced infections recovered from simulated coughs and sneezes.
with two different serotypes in the same man were The relatively poor yield of virus in saliva can be
common. Although a prominence of some M sero- interpreted as evidence against spread through the
types has been noted in military populations, the air, since aerosols produced by coughing and
epidemiological behavior of the numbered rhino- sneezing are mainly of oral origin, coming primar-
viruses is generally similar to that in civilians, ily from the pool of saliva in the anterior part of
showing a constantly changing mosiac of prevalent the mouth. 17 .85 ) On the other hand, the idea of
types. (12 1) nasal mucus as a direct source of transmissible
virus is appealing because of the relatively high
titers of virus in mucus and the great potential for
6. Mechanisms and Routes of Transmission people with colds to contaminate the environment,
including fingers, with this substance. Rhinovirus
The exact mechanism by which rhinoviruses are has been recovered from the hands of approxi-
passed from person to person is unknown. In mately 50% of adults with natural(78 ) and experi-
civilian populations, as discussed above, school- mentall131l colds. Information obtained on the
children are a very important reservoir of the second step in transmission, virus survival in the
virus; home and school are the places where environment, indicates that rhinovirus in concen-
spread most often occurs. These facts alone, which trations found in nasal mucus survives regularly
indicate that conditions of personal contact are for up to 3 h on skin and a variety of surfaces such
necessary for efficient rhinovirus transmission, as wood, plastic, steel, Formica, and hard fab-
suggest that spread is most often by some type of rics. (78)
short-range exposure to infectious secretions. The Some evidence in favor of spread through the air
possibility of true airborne transmission of rhino- comes from experiments in which biological
virus in droplet nuclei formed from respiratory tracers, the spores of Bacillus mycoides, were placed
secretions is not excluded by these findings, how- in the nose. These experiments showed that blow-
ever. Information on the various steps in the ing the nose and especially sneezing could pro-
sequence of transmission is best evaluated in rela- duce droplets containing the tracer which were
tion to the question of spread by direct manual small enough to remain airborne and yet in the
contact with infectious secretions vs. spread by size range (3-16 JLm) that is likely to be trapped in
contact with virus in contaminated aerosols of the nose yO) Experimental evidence on the dura-
various particle sizes. tion of survival of rhinovirus in particles sus-
Viral shedding, the first step in the sequence, pended in air is not available.
occurs primarily from the nose. Under experimen- To complete the sequence of events leading to
tal conditions, the amount of rhinovirus in the successful spread, virus must reach an appropriate
nasopharyngeal washes of volunteers peaked (832 portal of entry. Under experimental conditions,
TCID50/ml) on the third day after inoculation and small quantities of rhinovirus (the human infec-
then fell to low levels which persisted for up to 2 tious dose5o = 0.032-0.75 tissue culture infectious
wk.(42) Some volunteers showed a different pat- doseso) placed in the nose in coarse drops will
tern of nasal shedding characterized by delayed efficiently initiate infection. (39) There is indirect
onset and slow buildup over 7 days to relatively evidence that similar small amounts of virus may
low maximum virus concentrations (41 TCID50/ml). initiate infection under natural conditions. (75 ) Ex-
Comparisons of rhinovirus concentrations in res- perimental infections have been produced by the
inhalation of rhinovirus aerosols with particle studies of experimental infections. In one volun-
sizes in the true droplet nuclei range (0.3-2.5 JLm) teer experiment in closed barracks, airborne trans-
but require approximately twentyfold greater con- mission of rhinovirus did not occur across a wire
centrations of virus than intranasal challenge. mesh barrier from infected to susceptible volun-
Thus it appears that the nasal mucosa is more teers.(39) In another study, infected volunteers
susceptible to rhinovirus than is the lower respira- failed to spread rhinovirus to susceptible subjects
tory tract.(28) In this experiment, it was not possi- confined in the same closed room by singing and
ble to exclude the possibility that infection re- other activities designed to create infectious aero-
sulted from that fraction of the viral aerosol which sols.(32) On the other hand, self-inoculation of the
was deposited in the nose rather than that reach- nose and eye with virus transmitted on the finger
ing the lower respiratory tract. Experimental rhi- from a previously contaminated site has been
novirus colds have also been produced by drop- successful in initiating experimental infection. (78)
ping small amounts of virus on the con- The sum of evidence, particularly the frequent
junctiva,03,78) indicating that the eye is another finding of rhinovirus on the hands and its relative
portal of entry for rhinovirus. In contrast, rhinovi- scarcity in secretions from simulated coughs and
rus placed in the mouth does not readily initiate sneezes, suggests that manual contact with nasal
infection.(78) In related experiments in which in- mucus may be the more important mode of
fected and susceptible volunteers kissed under spread. It is possible, however, that more than one
controlled conditions, oral contact was an ineffi- method contributes to rhinovirus dispersal under
cient method of causing spread. (!3J) natural conditions. To find a more definite answer
From the results of the above work, it appears to this question, it will be necessary to satisfy
that rhinovirus must reach the nasal or perhaps several postulates, which include a requirement
the conjunctival mucosa for efficient initiation of for proof that interruption of spread by the hy-
infection.' Observations have been carried out on pothesized route results in a reduction in natural
adults at medical conferences and in Sunday infections (Table 3).
school which show that normal behavior includes
placing fingers into the nose or onto the conjunc-
tiva with regularity.(781 Episodes in which finger 7. Pathogenesis
contact with nasal and conjunctival mucosa oc-
curred were measured on the average of 2 per 3 The acute stage of viral rhinitis is characterized
person-h of observation. This type of behavior by hyperemia and edema of the mucous mem-
provides sufficient opportunity for accidental self- brane with exudation of serous and mucinous
inoculation if the fingers are contaminated, with fluid. (140) The nasal cavities are narrowed by
virus. The alternative method of spread, transmis- thickening of the membrane and engorgement of
sion via airborne particles with deposition in the the turbinates. Histologically, there is marked
respiratory tract, is also feasible. The average adult edema of subepithelial connective tissue with
is effectively exposed by inhalation to large sparse infiltration of neutrophils, lymphocytes,
amounts (approximately 10 liters/min) of air; thus plasma cells, and eosinophils. The secretory activ-
small concentrations of virus in the air may be ity of the mucus-secreting submucosal glands is
sufficient to transmit infection. increased.
Direct evidence on the relative importance of Specific work on the gross and histological find-
these different methods of spread is limited to ings in acute rhinovirus infections is limited. In
Table 3. Postulates to Test a Hypothesis of Microbial Transmission
1. Infectious microorganism must be produced in infected host at proposed anatomical source

2. It must be present in secretions or tissues which are shed from host by proposed route
3. It must be present and survive in or on the appropriate environmental substance or object
4. The contaminated environmental substance or object must reach the proposed portal of entry
5, Interruption of transmission by the hypothesized route must prevent spread of infection
one study, nasal biopsies were obtained by curet- possibility cannot be excluded that concurrent in-
tage from volunteers with experimental rhinovirus fection with other viral or bacterial pathogens may
infection.(4()) Fixed smears stained by the Papani- have been present and caused the illness seen. The
colaou technique showed no consistent changes opinion of several workers in the field is that
associated with either infection or illness. In an- rhinoviruses are not an important cause of serious
other investigation, scanning electron microscopy acute lower respiratory tract disease in chil-
was used to examine bovine tracheal organ cul- dren. (6.67.122,134,1711
tures infected with a bovine rhinovirus (Fig. As will be discussed below, there is mounting
5). (137) Characteristic changes were seen in in- evidence that rhinovirus infections are associated
fected cultures which consisted of extrusion of with periods of acute exacerbation in patients with
degenerating ciliated and nonciliated cells and chronic bronchitis. Also, recent work has associ-
relatively smooth areas of denuded epithelium. If ated rhinovirus infections with pulmonary func-
similar anatomical abnormalities occur in human tion abnormalities in patients with chronic bron-
rhinovirus infections, they could explain the chitis, (152) in cigarette smokers/ 56 ) and in healthy
depressions in nasal mucociliary flow rates which adults. (5,IS) The mechanism by which rhinovirus
have been observed in volunteers with experimen- infection might alter pulmonary function is un-
tal infection .0 45 ) known. Direct invasion of the lower respiratory
The mechanism by which rhinovirus produces tract by the virus is a possibility, but reflex mecha-
disease is unknown, but information on the corre- nisms or secondary bacterial infection might also
lation of peak virus titers and illness onsets sug- playa role. Indirect evidence against viral invasion
gests that an important mechanism may be direct of the lower respiratory tract includes the finding
cell injury secondary to the cycle of virus replica- that experimental rhinovirus infection produced
tion.(39.421 In experimental rhinovirus infection, by inhalation of small particle aerosol characterist-
virus may be recovered from nasopharyngeal wash ically produced the clinical picture of an upper
in small amounts by 24 h after inoculation. Virus respiratory tract illness.(2S) Also, the fact that
concentrations then rise rapidly to peak values on rhinovirus grows relatively poorly at the core body
days 2 and 3. Maximal virus shedding is followed temperature of 37'C is against the possibility that
within 24 h by the release of large quantities of rhinovirus frequently invades the lower respira-
protein from the mucous membrane. The incuba- tory tract.
tion period is usually 2-4 days, and the onset of
illness is very closely related to the time of peak
virus shedding. At this time, nasal epithelial cell 8. Immunity
biopsies are uniformly positive for virus; later,
when lesser amounts of virus are shed, they are Work on the immunology of rhinovirus infec-
only occasionally positive. (;WAf)) tions has focused on humoral immunity, particu-
The anatomical limits of rhinovirus infection larly the role of antibody in respiratory secretions.
have not been determined. Comparisons of virus No information is available on the role, if any, of
concentrations recovered from the nose, throat, cellular immunity in resistance to rhinovirus infec-
saliva, coughs, and sneezes, discussed above, sug- tion.
gest that the major site of infection is the nose. It Serum neutralizing antibody titers rise in up to
is currently unknown whether virus recovered 75-80% of persons with natural or experimental
from the pharynx and saliva is produced in these rhinovirus colds. (15,63.65.771 The level of serum neu-
sites or merely represents contamination with na- tralizing antibody prior to natural or experimental
sal secretions. There is also no direct evidence, challenge is inversely proportional to the subse-
such as might be obtained with transtracheal aspi- quent infection rate. Under conditions of exposure
ration or lung puncture, on whether rhinovirus to rhinovirus in the home, naturally acquired
invades the lower respiratory tract. There have serum antibody at a level of 8 was associated with
been multiple reports of rhinovirus infection in a sharp reduction in the infection rate, and serum
patients, especially children, with disease of the antibody levels of 216 were associated with solid
lower respiratory tract/ 21 .31.5S.130) although the immunity.(77) With artificial challenge it is possi-
Fig. 5. Organ cultures of bovine tracheal epithelium. A: Uninfected control culture. Field width
100 /Lm. B: Culture infected with bovine rhinovirus, fixed 6 days after inoculation. E, Extruding
ciliated cells; G, extruding goblet cells. Field width 180 /Lm. Reprinted by permission of the
authors and the Editor of the American Society for Microbiology from Reed and Boyde.{I371
ble to infect volunteers, although at a reduced rate, shedding. This conclusion is in conflict with that
who have higher titers of naturally acquired serum of the investigation cited above(19) and of other
antibody. In one study using relatively small chal- reports which have found that the major effect of
lenge doses of virus (0.05-50 TCID5o ), no infections humoral (serum) immunity was prevention of in-
occurred in volunteers with prechallenge titers of fection and not modification of illness. (42,75,77,123)
:=::64.(75) In other studies in which the infecting Other studies have reported on finding an associa-
inocula contained more virus (17-10,000 TCID5o ), tion between naturally acquired«;a) and vaccine-
infections were observed in volunteers with pre- induced(44) serum antibody and reduction of ill-
challenge titers of up to 512, presumably as a result ness and, in the latter study, diminished virus
of the overwhelming of normal immunity by an shedding. Thus currently available data on the
artificially large virus challenge.<'9.123) mechanism of action of the nasal and serum com-
The above findings do not necessarily indicate ponents of humoral immunity to rhinovirus infec-
that serum neutralizing antibody is the primary tion are not in complete agreement; further work
immune mechanism responsible for resistance to is necessary to provide a clear understanding of
rhinovirus, since naturally acquired serum anti- this area.
body is found in close association with antibody Naturally acquired neutralizing activity against
in nasal secretions. (123.1291 The ratio of nasal secre- rhinovirus in serum has been found to sediment
tion to serum neutralizing antibody appears to be primarily in the 5 S to 7 S region and to be
higher (approximately 1:2) after recent than after associated with fractions containing IgA and
remote (approximately 1:16) infection, suggesting IgG .<'9,142) After recent experimentally induced
a decline in nasal secretion antibody with rhinovirus infection or intranasal vaccination with
time.<' 9) inactivated rhinovirus vaccine, neutralizing activ-
Several attempts have been made to determine ity has also been associated with 19 S IgM.(19.94.142)
the relative importance and specific roles of serum Under normal conditions, nasal secretions con-
and nasal secretion antibody in protection against tain 12 different identifiable proteins found in
rhinovirus infection. Naturally acquired antibody serum as well as six antigenic components not
in nasal wash specimens and serum was associ- present in serum.(143) Secretory IgA, the most
ated with resistance to "infection" if present in abundant protein in nasal secretions, is synthe-
sufficient titer before artificial challenge, but it did sized locally at sites adjacent to the mucosa and
not appear to modify "illness" or virus shed- accounts for 30% or more of total protein in nasal
ding.(19) Because of the close association of natu- secretions. Rhinovirus neutralizing activity in na-
rally acquired antibody in serum and nasal secre- sal secretions is associated primarily with IgA in 9
tions, the findings of this study did not answer the S to 11 S fractions, although secretory IgA is not
questions posed. Another approach to the problem entirely homogeneous in its sedimentation charac-
was to administer inactivated rhinovirus vaccine teristics, being found also in 7 Sand 19 S re-
by either the parenteral or the intranasal route to gions. (94) The symptomatic period of rhinovirus
selectively elicit nasal secretion and/or serum anti- illness is associated with considerable transuda-
body. Vaccine given intranasally in large amounts tion of serum proteins, including IgG, into nasal
led to the production of antibody in both serum secretions. (12.14:J) After cessation of illness, the
and nasal secretions, while parenteral vaccination concentration of serum proteins in nasal secretions
resulted primarily in serum antibody produc- falls rapidly; at this time, the IgA concentration
tion.<'Z8.129) Intranasal challenge with rhinovirus at begins a progressive sustained increase. The IgA
a later date resulted in the reduction of illness which appears during this period is not associated
and virus shedding only in volunteers who re- with an increase in specific neutralizing activity
ceived the intranasal vaccine.(11.128,129) In these for the infecting virus. Specific neutralizing anti-
studies, intranasal vaccination was not associated body first appears in nasal secretions and serum at
with a clear-cut reduction in infection rate de- approximately 2 wk in volunteers lacking detecta-
termined by antibody response. Therefore, this ble antibody. Antibody concentrations increase
work suggested that the primary effect of nasal most rapidly between the third and fourth weeks,
antibody was to modify illness and reduce viral by which time viral shedding is completed. Vol-
unteers with preexisting serum antibody may rhinovirus colds from those caused by other com-
show rises in nasal antibody titers by as early as mon respiratory viruses.
day 7. Neutralizing antibody to rhinovirus has In children, rhinoviruses also produce the com-
also been found in tears and parotid saliva, where mon cold syndrome.(6.la9) Whether rhinoviruses
it is associated with the IgA fraction.(47) cause more serious disease in children, such as
Because of the sequence of events described viral pneumonia, croup, and bronchiolitis, is still
above, it is felt that recovery from rhinovirus not clear. As discussed in Section 7, the prevailing
infection and illness is not dependent on humoral opinion is that rhinoviruses, unlike parainfluenza
immunity.(19) It has been shown that interferon is viruses and respiratory syncytial virus, do not
released into respiratory secretions during the commonly cause serious disease of the lower res-
course of experimental rhinovirus infection. This piratory tract and do not produce more severe
led to the suggestion that in rhinovirus colds, as in illness in children than in adults.
other viral infections, interferon may have an Cough is a prominent feature of rhinovirus colds
important role in recovery.o6) Also, resistance to in patients of all ages, indicating that involvement
experimental rhinovirus infection has been shown of the lower respiratory tract of some type does
to be associated with a nonspecific mechanism of occur. The frequency and duration of cough are
unknown nature which occurs as a result of recent markedly increased in cigarette smokers, particu-
infection with a heterologous rhinovirus type. (52) larly females, with rhinovirus colds.«;:J) Also, it
However, in epidemiological studies of nursery has been reported that up to 40% of exacerbations
school children(4) and military recruits(]411 many in patients with chronic bronchitis may be associ-
instances of closely spaced rhinovirus infections ated with rhinovirus infections.(49.lo4.15a) In pa-
have been seen, raising the question of how im- tients with chronic bronchitis, worsening of forced
portant this nonspecific resistance is in natural expiratory vital capacity has persisted for up to 6
infection. months following rhinovirus infection. (152)
It has also been suggested that rhinovirus infec-
tions may precipitate asthmatic attacks in chil-
dren.(~I.I09) Asthmatic children have been found
9. Patterns of Host Response to experience a significantly greater number of
viral respiratory infections, primarily due to rhi-
noviruses, than do nonasthmatic controls.(I(IS)
These recent findings are of interest in view of an
Rhinoviruses produce a typical common cold earlier report that volunteers with a history of
characterized by rhinorrhea, nasal obstruction, allergy have enhanced susceptibility to experimen-
sneezing, pharyngeal discomfort, and cough. The tal colds. (S4)
median length of natural illness in young adults is During acute rhinovirus illness in volunteers,
7 days, with peak symptomatology occurring on there is a modest increase in total blood leukocyte
the second and third days of illness. (6a) Symptoms counts due to an increase in circulating neutro-
last up to 2 wk in one-fourth of cases and may be phils. (15) Later in the infection, moderate eleva-
prolonged to 1 month, although secondary bacte- tions in the erythrocyte sedimentation rate may
rial infection may play a role when this occurs. occur. The diagnosis of rhinovirus infection is best
The profile of rhinovirus illness can be distin- accomplished by isolation of the virus from nose
guished from that of influenza by the relative and throat swab or nasal wash specimens. There is
severity of systemic complaints and cough with currently very limited availability of facilities for
influenza (Fig. 6). Rhinovirus colds differ from the laboratory diagnOSis of rhinovirus infections in
group A J3-hemolytic streptococcal pharyngitis in routine medical practice.(I:JOl
having more nasal involvement and cough and
less severe and prolonged pharyngeal discomfort.
9.2. Apparent/Inapparent Infection Ratio
This information unfortunately is of limited value
to the clinician. In the individual patient it is Data based on virus isolations are available from
impossible to distinguish, on clinical grounds, several studies for calculating apparent/inapparent
Per Cent
MALAISE FEVERISHNESS CHILLINESS HEADACHE
70 - . . . . . . INFLUENZA
60 ..."'........"'.. /3 STREPTOCOCCUS
RHINOVIRUS
,.....,
50
,, \ ,
"..
f \
~... ' ,
~
, iii i r I
MYALGIA SNEEZING NASAL NASAL

DISCHARGE OBSTRUCTION
70
60
Fig. 6. Comparison of symptom profiles of rhi-
50
novirus colds (139 cases), type A2 influenza (33
40 cases), and group A ,a-hemolytic streptococcal
.,l-·....,,
30 pharyngitis (17 cases). Adapted from Gwaltney
20 et al. (63)
10 .~
..,,, ....
I I I >ti"""T1 j I I i I I i
SORE THROAT SCRATCHY HOARSENESS COUGH

,~-'\
,I
/\
70 THROAT
'., ,
,:
60
'
f::\ r
50
, I
40 ,\
'i.
30 t.,.~
,
20 ............. ;.:.~,i"""""_"""""".""",,
10 :-l' "'""""',
I I I I I I I I I i I I I I I I I I j Iii i I I
1234567 1234567 1234567 1234567
DA Y OF ILLNESS
infection rates for rhinoviruses. The results, which perimental monovalent rhinovirus vaccines given
are in good agreement, indicate that the majority parenterally have met with only partial success.
of rhinovirus infections are associated with symp- Rhinovirus antigens are inferior to poliovirus anti-
tomatic respiratory illness. The percentages of rhi- gens for vaccine production. In volunteers, paren-
novirus infections associated with illness were teral vaccination has been followed by reduction
78% in families/ 55l 88% in medical students, (fm) in illness and virus shedding but not infec-
69% in insurance company employees,({m and 70- tion. (2,44,123) It is difficult to evaluate studies of
74% in military trainees. (SI;.t21l Thus the ratio of parenteral vaccine efficacy under natural condi-
apparent to inapparent infections is approximately tions because of the multiplicity of sero-
3:1. types. lllO ,136l
The discovery of ever-increasing numbers of
10. Control and Prevention apparently highly specific antigenic types has led
to pessimism over the prospects of developing
Methods are not available for controlling or vaccines with practical value."54) One piece of
preventing rhinovirus infections. Studies with ex- information which indicates that there is still some
hope for the eventual development of rhinovirus magnitude of this effect does not seem sufficient at
vaccines of practical value is the recent discovery present to justify a recommendation for the gen-
of antigenic relationships among some of the eral prophylactic use. of large doses of the com-
numbered rhinoviruses.(27) In this work, done in pound. There is no proof of the specific effective-
rabbits, potent monovalent rhinovirus antigens ness of vitamin C against rhinovirus infections.
were successfully used to stimulate heterotypic Rhinovirus colds might also be controlled if
antibody responses to one or more different types. ways are discovered to interrupt their spread from
The problem of vaccine development is further person to person. The development of environ-
complicated by the findings discussed in Section 8 mental control measures is largely dependent on
which indicate an important role for secretory precise knowledge of the mechanism of rhinovirus
antibody in resistance to rhinovirus infection. Par- spread. If accidental self-inoculation of the nose or
enteral vaccination does not appear to be an effi- eye with virus contaminating the fingers is of
cient means of stimulating rhinovirus neutralizing importance, then the simple expedients of avoid-
antibody in nasal secretions, suggesting that im- ing finger contact with the nose and eyes and of
munization via the respiratory tract may be neces- handwashing, particularly when a household
sary for optimum protection. This has led to inter- member develops a cold, may be beneficial in
est in the development of vaccines prepared with reducing the risk of infection.
live attenuated strains of rhinovirus.(43)
Control of rhinovirus infection by chemopro-
phylaxis has also been under investigation. In 11. Unresolved Problems
early work, rhinoviruses were found to be suscep-
tible to 2-(a-hydroxybenzyl)benzimidazole and re- A number of important questions concerning
lated compounds which have specific actions on rhinoviruses remain unanswered. These include
virus replicationY47.15B) Since then a number of the number of virus serotypes and their antigenic
other compounds with activity against rhinovi- stability, the extent of antigenic relatedness, the
ruses in vitro have been discoveredYiO.10Z.138.149.151)
mechanisms by which rhinoviruses produce dis-
Compounds with antirhinovirus activity which ease and stimulate host immunity, their mode of
have been tested in vivo have not been effective, transmission, and finally the biochemical nature of
however.(J38.150.1({31 Interferon and interferon-in-
the virus, particularly as it relates to the action of
ducing agents have also received clinical trials antivirals with potential clinical usefulness. The
with experimental rhinovirus infection.(8o.!07.1241
answers to these questions may have a direct effect
The ultimate value of this approach is still uncer- on the success of solving the overriding practical
tain, but one of the studies yielded encouraging problem, which is the development of methods for
results. (124)
rhinovirus control. The increasing awareness of
In recent years, a controversy has arisen over the the importance of rhinoviruses, not only as a
proposal that large doses of vitamin C be used for major cause of the morbidity of common colds and
the prophylaxis and treatment of common their complications, but also as precipitants of
colds. (125) Controlled trials of the efficacy of 1 and more serious illness such as chronic bronchitis and
2 g per day of vitamin C in the prevention of asthma should stimulate increasing effort to un-
natural colds of undetermined etiology showed an derstand rhinovirus behavior.
approximately 30% reduction of days of disability
or morbidity among volunteers taking this com-
pound. (3.29) On the other hand, 3 g per day of
12. References
vitamin C did not prevent experimental rhinovirus
infections in volunteers and had at most an unim-
1. AN DREWES, c., in: The Common Cold, Norton, New
pressive reduction in the illness scores of prophy-
York,1965.
laxed subjects over those of controls.(148.1({91 Thus,
2. ANDREWES, c., TYRRELL, D. A. J., STONES, P. B.,
while vitamin C taken prophylactically may have BEALE, A. J., ANDREWS, R. D., EDWARD, D. G.,
some beneficial effect on the frequency and/or GaFFE, A. P., DOGGETT, J.
E., HOMER, R. F., CRESPI,
severity of the symptoms of natural colds, the R. S., AND CLEMENTS, E. M. B., Prevention of colds
by vaccination against a rhinovirus: A report by the demonstration of a protective effect not associated
scientific committee on common cold vaccines, Br. with serum antibody, /. CZin. Invest. 43:56 (1964).
Med. /. 1:1344 (1965). 16. CATE, T. R., DOUGLAS, R. G., JR., AND COUCH, R. B.,
3. ANDERSON, T. W., REID, D. B. W., AND BEATON, G. Interferon and resistance to upper respiratory virus
H., Vitamin C and the common cold: A double- illness, Proc. Soc. Exp. BioI. Med. 131:631 (1969).
blind trial, Can. Med. Assoc. /. 107:503 (1972). 17. CATE, T. R., DOUGLAS, R. G., JR., JOHNSON, K. M.,
4. BEEM, M. 0., Acute respiratory illness in nursery COUCH, R. B., AND KNIGHT, V., Studies on the
school children: A longitudinal study of the occurr- inability of rhinovirus to survive and replicate in
ence of illness and respiratory viruses, Am. J. Epide- the intestinal tract of volunteers, Proc. Soc. Exp.
miol. 90:30 (1969). BioI. Med. 124:1290 (1967).
5. BLAIR, H. T., BILUNOS, P. A., STEVENS, P. M., 18. CATE, T. R., ROBERTS, J. S., Russ, M. A., AND
GREENBERG, S. B., AND COUCH, R. B., The effect of PIERCE, J. A., Effects of common colds on pulmo-
viral and mycoplasma respiratory tract infections on nary function, Am. Rev. Resp. Dis. 108:858 (1973).
small airways, CZin. Res. 22:45A, abst. (January 19. CATE, T. R., ROSSEN, R. D., DOUGLAS, R. G., JR.,
1974). BUTLER, W. T., AND COUCH, R. B., The role of nasal
6. BLOOM, H. H., FORSYTH, B. R., JOHNSON, K. M., secretion and serum antibody in the rhinovirus
AND CHANOCK, R. M., Relationship of rhinovirus common cold, Am. /. Epidemiol. 84:352 (1966).
infection to mild upper respiratory disease. 1. Re- 20. CHAPPLE, P. J., HEAD, B., AND TYRRELL, D. A. L A
sults of a survey in young adults and children, J. complement fixing antigen from an M rhinovirus,
Am. Med. Assoc. 186:38 (1963). Arch. Gesamte Virusforsch. 21:123 (1967).
7. BOURDILLON, R. B., AND LIDWELL, O. M., Sneezing 21. CHERRY, J. D., DIDDAMS, J. A., AND DICK, E. c.,
and the spread of infection, Lancet 2:365 (1941). Rhinovirus infections in hospitalized children: Pro-
8. BROWN, P. K., AND TYRRELL, D. A. J., Experiments vocative bacterial interrelationships, Arch. Environ.
on the sensitivity of strains of human fibroblasts to Health 14:390 (1967).
infection with rhinovirus, Br. /. Exp. Pathol. 45:571 22. CONANT, R. M., AND HAMPARIAN, V. V., Rhinovi-
(1964). ruses: Basis for a numbering system. II. Serologic
9. BUCKLAND, F. E., AND TYRRELL, D. A. J., Loss of characterization of prototype strains, J. Immunol.
infectivity on drying various viruses, Nature (Lon- 100:114 (1968).
don) 195:1063 (1962). 23. CONANT, R. M., SOMERSON, N. L., AND HAMPARIAN,
10. BUCKLAND, F. E., AND TYRRELL, D. A. J., Experi- V. V., Rhinovirus: Basis for a numbering system. 1.
ments on the spread of colds. 1. Laboratory studies HeLa cell for propagation and serologic procedures,
on the dispersal of nasal secretion, /. Hyg. 62:365 /. Immunol. 100:107 (1968).
(1964). 24. COONEY, M. K., HALL, C. E., AND Fox, J. P., The
11. BUSCHO, R. F., PERKINS, J. c., KNOPF, H. L. S., Seattle virus watch. III. Evaluation of isolation
KAPIKIAN, A. Z., AND CHANOCK, R. M., Further methods and summary of infections detected by
characterization of the local respiratory tract anti- virus isolations, Am. J. Epidemiol. 96:286 (1972).
body response induced by intranasal instillation of 25. COONEY, M. K., AND KENNY, G. E., Immunogenicity
inactivated rhinovirus 13 vaccine, J. Immunol. of rhinoviruses, Proc. Soc. Exp. BioI. Med. 133:645
108:169 (1972). (1969).
12. BUTLER, W. T., WALDMANN, T. A., ROSSEN, R. D., 26. COONEY, M. K., KENNY, G. E., TAM, R., AND Fox, J.
DOUGLAS, R. G., JR., AND COUCH, R. B., Changes in P., Cross relationships among 37 rhinoviruses dem-
IgA and IgG concentrations in nasal secretions prior onstrated by virus neutralization with potent mono-
to the appearance of antibody during viral respira- typic rabbit antisera, Infect. Immun. 7:335 (1973).
tory infection in man, /. Immunol. 105:584 (1970). 27. COONEY, M. K., AND WISE, J. A., Heterotypic stimu-
13. BYNOE, M. L., HOBSON, D., HORNER, J., KIPPS, A., lation of rhinovirus antibodies in rabbits, in: Ab-
SCHILD, G. c., AND TYRRELL, D. A. J., Inoculation of stracts of the Annual Meeting of the American Society
human volunteers with a strain of virus from a for Microbiology, p. 114, May 6-11, 1973.
common cold, Lancet 1:1194 (1961). 28. COUCH, R. B., CATE, T. R., DOUGLAS, R. G., JR.,
14. CALHOUN, A. M., JORDAN, W. S., JR., AND GWALT- GERONE, P. L AND KNIGHT, V., Effect of route of
NEY, J. M., JR., Rhinovirus infections in an industrial inocula tion on experimental respiratory viral dis-
population. V. Change in distribution of serotypes, ease in volunteers and evidence for airborne trans-
Am. /. Epidemiol. 99:58 (1974). mission, Bacteriol. Rev. 30:517 (1966).
15. CATE, T. R., COUCH, R. B., AND JOHNSON, K. M., 29. COULEHAN, J. L., REISINGER, K. S., ROGERS, K. D.,
Studies with rhinoviruses in volunteers: Production AND BRADLEY, D. W., Vitamin C prophylaxis in a
of illness, effect of naturally acquired antibody, and boarding school, N. Engl. /. Med. 290:6 (1974).
30. CRANDELL, R. A., A description of eight feline sera. I. Standardization of a neutralization test, Proc.
picornaviruses and an attempt to classify them, Soc. Exp. BioI. Med. 127:497 (1968).
Proc. Soc. Exp. BioI. Med. 126:240 (1967). 46. DOUGLAS, R. G., JR., LINDGREN, K. M., AND COUCH,
31. CRAIGHEAD, J. E., MEIER, M., AND COOLEY, M. H., R. B., Exposure to cold environment and rhinovirus
Pulmonary infection due to rhinovirus type 13, N. common cold: Failure to demonstrate effect, N.
Engl. J. Med. 281:1403 (1969). Engl. J. Med. 279:743 (1968).
32. D'ALESSIO, D., DICK, C. R., AND DICK, E. c., 47. DOUGLAS, R. G., JR., ROSSEN, R D., BUTLER, W. T.,
Transmission of rhinovirus type 55 in human vol- AND COUCH, R. B., Rhinovirus neutralizing anti-
unteers, in: International Virology 2 (J. 1. MELNICK, body in tears, parotid saliva, nasal secretions and
ed.), p. 115, Karger, Basel, 1972. serum, J. Immunol. 99:297 (1967).
33. DANS, P. E., FORSYTH, B. R., AND CHANOCK, R. M., 48. DOWLING, H. F., JACKSON, G. G., AND INOUYE, T.,
Density of infectious virus and complement-fixing Transmission of the experimental common cold in
antigens of two rhinovirus strains, J. Bacterial. volunteers. II. The effect of certain host factors upon
91:1605 (1966). susceptibility,]. Lab. Clin. Med. 50:516 (1957).
34. DICK, E. c., Experimental infection of chimpanzees 49. EADIE, M. B., STOTT, E. J., AND GRIST, N. R,
with human rhinovirus type 14 and 43, Proc. Soc. Virological studies in chronic bronchitis, Br. Med. ].
Exp. BioI. Med. 127:1079 (1968). 2:671 (1966).
35. DICK, E. c., BLUMER, C. R., AND EVANS, A. S., 50. FENTERS, J. D., GILLUM, S. S., HOLPER, J. c., AND
Epidemiology of infections with rhinovirus types 43 MARQUIS, G. S., Serotypic relationships among rhi-
and 55 in a group of University of Wisconsin noviruses, Am. J. Epidemiol. 84:10 (1966).
student families, Am. J. Epidemiol. 86:386 (1967). 51. FIALA, M., Plaque formation by 55 rhinovirus sero-
36. DINGLE, J. H., BADGER, G. F., AND JORDAN, W. S., types, Appl. Microbial. 16:1445 (1968).
JR., Patterns of illness, in: Illness in the Home, p. 19, 52. FLEET, W. F., COUCH, R. B., CATE, T. R, AND
Western Reserve University, Cleveland, 1964. KNIGHT, V., Homologous and heterologous resist-
37. DrrCHFIELD, W. J. B., Rhinoviruses and parainflu- ance to rhinovirus common cold, Am. ]. Epidemiol.
enza viruses of horses, J. Am. Vet. Med. Assoc. 82:185 (1965).
155:384 (1969). 53. FLEET, W. F., DOUGLAS, R G., JR., CATE, T. R., AND
38. DOCHEZ, A. R., SHIBLEY, G. S., AND MILLS, K. c., COUCH, R B., Antibody to rhinovirus in human
Studies in the common cold. N. Experimental sera. II. Heterotypic responses, Proc. Soc. Exp. BioI.
transmission of the common cold to anthropoid Med. 127:503 (1968).
apes and human beings by means of a filtrable 54. FORSYTH, B. R., BLOOM, H. H., JOHNSON, K. M.,
agent,]. Exp. Med. 52:701 (1930). AND CHANOCK, R. M., Patterns of illness in rhinovi-
39. DOUGLAS, R. G., JR., Pathogenesis of rhinovirus rus infections of military personnel, N. Engl. ]. Med.
common colds in human volunteers, Ann. Otol. 269:602 (1963).
Rhinal. Laryngol. 79:563 (1970). 55. Fox, J. P., HALL, C. E., COONEY, M. K., LUCE, R E.,
40. DOUGLAS, R G., JR., ALFORD, B. R, AND COUCH, R. AND KRONMAL, R. A., The Seattle vinis watch. II.
B., Atraumatic nasal biopsy for studies of respira- Objectives, study population and its observation,
tory virus infection in volunteers, Antimicrob. data processing and summary of illnesses, Am. ].
Agents Chemother. 8:340-343 (1968). Epidemiol. 96:270 (1972).
41. DOUGLAS, R G., JR., CATE, T. R., AND COUCH, R B., 56. FRIDY, W. W., INGRAM, R H., HIERHOLZER, J. c.,
Growth and cytopathic effect of H type rhinoviruses AND COLEMAN, M. T., Airways function during
in monkey kidney tissue culture, Proc. Soc. Exp. BioI. mild viral respiratory illnesses: The effect of rhino-
Med. 123:238 (1966). virus infection in cigarette smokers, Ann. Intern.
42. DOUGLAS, R. G., JR., CATE, T. R., GERONE, P. J., Med. 80:150 (1974).
AND COUCH, R. B., Quantitative rhinovirus shed- 57. FROST, W. H., AND GOVER, M., The incidence and
ding patterns in volunteers, Am. Rev. Resp. Dis. time distribution of common colds in several
94:159 (1966). groups kept under continuous observation, in: Pa-
43. DOUGLAS, R G., JR., AND COUCH, R. B., Attenuation pers of Wade Hampton Frost, M.D. (K. F. MAXCY,
of rhinovirus type 15 for humans, Nature (London) ed.), p. 359, Commonwealth Fund, New York, 1941.
223:213 (1969). 58. GEORGE, R. B., AND MOGABGAB, W. J., Atypical
44. DOUGLAS, R G., JR., AND COUCH, R B., Parenteral pneumonia in young men with rhinovirus infec-
inactivated rhinovirus vaccine: Minimal protective tions, Ann. Intern. Med. 71:1073 (1969).
effect, Proc. Soc. Exp. BioI. Med. 139:899 (1972). 59. GWALTNEY, J. M., JR., Micro-neutralization test for
45. DOUGLAS, R G., JR., FLEET, W. F., CATE, T. R., AND identification of rhinovirus serotypes, Proc. Soc.
COUCH, R. B., Antibody to rhinovirus in human Exp. BioI. Med. 122:1137 (1966).
60. GWALTNEY, J. M., JR., Rhinovirus inhibition by 3- vation of human diploid cell strains, Exp. Cell Res.
substituted triazinoindoles, Proc. Soc. Exp. Bioi. 25:585 (1961).
Med. 133:1148 (1970). 75. HENDLEY, J. 0., EDMONDSON, W. P., JR., AND
61. GWALTNEY, J. M., JR., AND EDMONDSON, W. P., JR., GWALTNEY, J. M., JR., Relation between naturally
Etiology and Epidemiology of Acute Respiratory acquired immunity and infectivity of two rhinovi-
Disease, Annual Progress Report to the Commission ruses in volunteers, J. Infect. Dis. 125:243 (1972).
on Acute Respiratory Disease of the Armed Forces 76. HENDLEY, J. 0., AND GWALTNEY, J. M., JR., Relation
Epidemiological Board, Contract No. DADA-49-007- of the weather and respiratory illness: Resume of
MD-lOOO, September 15, 1968. analysis to date, conclusions and prospects, unpub-
62. GWALTNEY, J. M., JR., HENDLEY, J. 0., SIMON, G., lished data.
AND JORDAN, W. S., JR., Rhinovirus infections in an 77. HENDLEY, J. 0., GWALTNEY, J. M., JR., AND JORDAN,
industrial population. I. The occurrence of illness, W. S., JR., Rhinovirus infections in an industrial
.N. Engl. J. Med. 275:1261 (1966). population. IV. Infections within families of em-
63. GWALTNEY, J. M., JR., HENDLEY, J. 0., SIMON, G., ployees during two fall peaks of respiratory illness,
AND JORDAN, W. S., JR., Rhinovirus infections in an Am. J. Epidemiol. 89:184 (1969).
industrial population. II. Characteristics of illness 78. HENDLEY, J. 0., WENZEL, R. P., AND GWALTNEY, J.
and antibody response, J. Am. Med. Assoc. 202:494 M., JR., Transmission of rhinovirus colds by self-
(1967). inoculation, N. Engl. J. Med. 288:1361 (1973).
64. GWALTNEY, J. M., JR., HENDLEY, J. 0., SIMON, G., 79. HIGGINS, P. G., ELLIS, E. M., AND WOOLLEY, D. A.,
AND JORDAN, W. S., JR., Rhinovirus infections in an A comparative study of standard methods and or-
industrial population. III. Number and prevalence gan culture for the isolation of respiratory viruses, J.
of serotypes, Am. J. Epidemiol. 87:158 (1968). Med. Microsc. 2:109 (1969).
65. GWALTNEY, J. M., JR., AND JORDAN, W. S., JR., 80. HILL, D. A., BARON, S., PERKINS, J. c., WORTHING-
Rhinoviruses and respiratory disease, Bacteriol. TON, M., VAN KIRK, J. E., MILLS, J., KAPIKIAN, A.
Rev. 28:409 (1964). Z., AND CHANOCK, R. M., Evaluation of an inter-
66. GWALTNEY, J. M., JR., AND JORDAN, W. S., JR., feron inducer in viral respiratory disease, J. Am.
Rhinoviruses and respiratory illness in university Med. Assoc. 219:1179 (1972).
students, Am. Rev. Resp. Dis. 93:362 (1966). 81. HILLEMAN, M. R., REILLY, C. M., STOKES, J., JR.,
AND HAMPARIAN, V. V., Clinical epidemiologic
67. GLEZEN, W. P., LODA, ,F. A., CLYDE, W. A., SENIOR,
findings in coryzavirus infections, Am. Rev. Resp.
R. J., SHEAFFER, C. I., CONLEY, W. G., AND DENNY,
Dis. Suppl. 88:274 (1963).
F. W., Epidemilologic patterns of acute lower respi-
82. HOORN, B., AND TYRRELL, D. A. J., On the growth of
ratory disease of children in a pediatric group
certain "newer" respiratory viruses in organ cul-
practice, J. Pediat. 78:397 (1971).
tures, Br. J. Exp. Pathol. 46:109 (1965).
68. HAMRE, D., Rhinoviruses, in: Monographs in Virol- 83. IpSEN, J., Relationships of Acute Respiratory Dis-
ogy 1 0. 1. MELNICK, ed.), Karger, Basel, 1968. ease to Measurements of Atmospheric Pollution and
69. HAMRE, D., CONNELLY, A. P., JR., AND PROCKNOW, J. Local Meteorological Conditions, Final Report to the
J., Virologic studies of acute respiratory disease in Department of' Health, Education, and Welfare,
young adults. IV. Virus isolations during four years Public Health Service, Bureau of State Services
of surveillance, Am. J. Epidemiol. 83:238 (1966). (October 5, 1960-March 30, 1964), Henry Phipps
70. HAMRE, D., AND PROCKNOW, J. J., Viruses isolated Institute, University of Pennsylvania, Contract No.
from natural common colds among young adult PH 86-63-25, March 1965.
medical students, Am. Rev. Resp. Dis. 88:277 (1963). 84. JACKSON, G. G., DOWLING, H. F., AND MULDOON, R.
71. HAMPARIAN, V. V., Personal communication. 1., Acute respiratory diseases of viral etiology. VII.
72. HAMPARIAN, V. V., CONANT, R. M., AND THOMAS, D. Present concepts of the common cold, Am. J. Public
c., Rhinovirus Reference Laboratory, Annual Con- Health 52:940 (1962).
tract Progress Report to the National Institute of 85. JENNISON, M. W., Atomisation of mouth and nose
Allergy and Infectious Diseases, National Institutes secretions into the air as revealed by high speed
of Health, Bethesda, Md., Contract No. 69-2062, De- photography, Summ. Proc. Am. Assoc. Adv. Sci.
cember 1, 1969-November 30,1970. 17:106 (1942).
73. HAMPARIAN, V. V., LEAGUS, M. B., HILLEMAN, M. 86. JOHNSON, K. M., BLOOM, H. H., FORSYTH, B. R.,
R., AND STOKES, J., JR., Epidemiologic investiga- AND CHANOCK, R. M., Relationship of rhinovirus
tions of rhinovirus infections, Proc. Soc. Exp. Bioi. infection to mild upper respiratory disease. II. Epi-
Med. 117:469 (1964). demiologic observations in male military trainees,
74. HAYFLICK, 1., AND MOORHEAD, P. S., The serial culti- Am. J. Epidemiol. 81:131 (1965).
87. KAPIKIAN, A. Z., Rhinoviruses, in: Diagnostic Proce- teraction of rhinoviruses with host cells, J. Virol.
dures for Viral and Rickettsial Infections, 4th ed. (E. 9:29 (1972).
H. LENNETTE AND N. J. SCHMIDT, eds.), pp. 603-640, 100. LONBERG-HoLM, K., AND NOBLE-HARVEY, J., Com-
American Public Health Association, New York, parison of in vitro and cell-mediated alteration of a
1969. human rhinovirus and its inhibition by sodium
88. KAPIKIAN, A. Z., Rhinoviruses, in: Strains of Human dodecyl sulfate, J. Virol. 12:819 (1973).
Viruses (M. MAJER AND S. A. PLOTKIN, eds.), Karger, 101. LONBERG-HoLM, K., AND YIN, F. H., Antigenic
Basel, 1972. determinants of infective and inactivated human
89. KAPfKIAN, A. Z., CONANT, R. M., HAMPARIAN, V. rhinoviruses type 2, J. Virol. 12:114 (1973).
V., CHANOCK, R. M., CHAPPLE, P. J., DICK, E. c., 102. McDOUGALL, J. K., Antiviral action of gliotoxin,
FENTERS, J. D., GWALTNEY, J. M., JR., HAMRE, D., Arch. Gesamte Virusforsch. 27:255 (1969).
HOPLER, J. c., JORDAN, W. S., JR., LENNETTE, E. H., 103. McLEAN, c., AND RUECKERT, R. R., Picornaviral
MELNICK, J. L., MOGABGAB,W. J., MUFSON, M. A., gene order: Comparison of a rhinovirus with a
PHILLIPS, C. A., SCHIEBLE, J. H., AND TYRRELL, D. cardiovirus, J. Viral. 11:341 (1973).
A. J.; Rhinoviruses: A numbering system, Nature 104. McNAMARA, M. J., PHILLIPS, I. A., AND WILLIAMS,
(London) 213:761 (1967). O. B., Viral and Mycoplasma pneumoniae infections
90. KAPfKIAN, A. Z., CONANT, R. M., HAMPARIAN, V. in exacerbations of chronic lung disease, Am. Rev.
V., CHANOCK, R. M., DICK, E. c., GWALTNEY, J. M., Resp. Dis. 100:19 (1969).
JR., HAMRE, D., JORDAN, W. S., JR., KENNY, G. E., 105. MEDAPPA, K. c., McLEAN, c., AND RUECKERT, R. R.,
LENNETTE, E. H., MELNICK, J. L., MOGABGAB, W. J., On the structure of rhinovirus lA, Virology 44:259
PHILLIPS, C. A. SCHIEBLE, J. H., STOTT, E. J., AND (1971).
TYRRELL, D. A. J., A collaborative report: Rhinovi- 106. MEDAPPA, K. c., AND RUECKERT, R. R., Binding of
ruses-extension of the numbering system, Virology cesium ions to human rhinovirus-14 (R-14), in:
43:524 (1971). Abstracts of the Annual Meeting of the American
91. KENDALL, E. J. c., BYNOE, M. L., AND TYRRELL, D. Society for Microbiology, p. 207, May 12-17,1974.
A. J., Virus isolations from common colds occurring 107. MERIGAN, T. C.,HALL, T. S., REED, S. E., AND TYR-
in a residential school, Br. Med. J. 2:82 (1962). RELL, D. A. J., Inhibition of respiratory virus infec-
92. KENNY, G. E., COONEY, M. K., AND THOMPSON, D. tion by locally applied interferon, Lancet 1:563
J., Analysis of serum pooling schemes for identifi- (1973).
cation of large numbers of viruses, Am. J. Epidemiol. 108. MINOR, T. E., BAKER, J. W., DICK, E. c., DEMEO, A.
91:439 (1970). N., OUELLETTE, J. J., COHEN, M., AND REED, C. E.,
93. KETLER, A., HAMPARIAN, V. V., AND HILLEMAN, M. Greater frequency of viral respiratory infections in
R., Characterization and classification of ECHO 28- asthmatic children as compared with their nonasth-
rhinovirus-coryzavirus agents, Proc. Soc. Exp. BioI. matic siblings, J. Pedial. 85:472 (1974).
Med. 110:821 (1962). 109. MINOR, T. E., DICK, E. c., DEMEO, A. N., OUEL-
94. KNOPF, H. L. S., PERKINS, J. c., BERTRAN, D. M., LETTE, J. J., COHEN, M., AND REED, C. E., Viruses as
KAPIKIAN, A. Z., AND CHANOCK, R. M., Analysis of precipitants of asthmatic attacks in children, J. Am.
the neutralizing activity in nasal wash and serum Med. Assoc. 227:292 (1974).
following intranasal vaccination with inactivated 110. MOGABGAB, W. J., Upper respiratory illness vac-
type 13 rhinovirus, J. Immunol. 104:566 (1970). cines-Perspectives and trials, Ann. Intern. Med.
95. KORANT, B. D., LONBERG-HoLM, K., NOBLE, J., AND 57:526 (1962).
STASNY, J. T., Naturally occurring and artificially 111. MOGABGAB, W. J., Acute respiratory illnesses in uni-
produced components of three rhinoviruses, Virol- versity (1962-1966), military and industrial (1962-
ogy 48:71 (1972). 1963) populations, Am. Rev. Resp. Dis. 98:359 (1968).
96. KRIEL, R. L., WULFF, H., AND CHIN, T. D. Y., Micro- 112. MOHANTY, S. B., LILLIE, M. G., AND ALBERT, T. F.,
neutralization test for determination of rhinovirus Experimental exposure of calves to a bovine rhinovi-
and coxsackievirus A antibody in human diploid rus, Am. J. Vet. Res. 30:1105 (1969).
cells, Appl. Micrbiol. 17:611 (1969). 113. MONTO, A. S., A community study of respiratory
97. KRUSE, W., 'Die Erregen von Husten und Schnupfen infections in the tropics. III. Introduction and trans-
(The etiology of cough and nasal catarrh)" Munch. mission of infections within families, Am. J. Epide-
Med. Wochenschr. 61:1574 (1914). I miol. 88:69 (1968).
98. LIDWELL, O. M., MORGAN, R. W., AND WILLIAMS, R. 114. MONTO, A. S., AND CAVALLARO, J. ]., The Tecumseh
E. 0., The epidemiology of the common cold. IV. study of respiratory illness. II. Patterns of occurr-
The effect of weather, J. Hyg. (Camb.) 63:427 (1965). ence of infection with respiratory illness. II. Pat-
99. LONBERG-HoLM, K., AND KORANT, B. D., Early in- terns of occurrence of infection with respiratory
pathogens, 1965--1969, Am. J. Epidemiol. 94:280 of an inactivated rhinovirus vaccine administered

(1971). by the nasal route, Am. J. Epidemiol. 90:319 (1%9).
115. MONTO, A S., AND CAVALLARO, J. J., Th,e Tecumseh 129. PERKINS, J. C., TUCKER, D. N., KNOPF, H. 1. S.,
study of respiratory illness. N. Prevalence of rhino- WENZEL, R. P., KAPIKIAN, A Z., AND CHANOCK, R.
virus serotypes, 1966-1969, Am. J. Epidemiol. 96:352 M., Comparison of protective effect of neutralizing
(1972). antibody in serum and nasal secretions in experi-
116. MaNTO, A S., AND CAVALLARO, J. J., AND KELLER, J. mental rhinovirus type 13 illness, Am. J. Epidemiol.
B., Seasonal patterns of acute infection in Tecum- 90:519 (1969).
seh, Mich,., Arch. Environ. Health 21:408 (1970). 130. PERSON, D. A., AND HERRMANN, E. c., JR., Experi-
117. MaNTO, A S., AND JOHNSON, K. M., A community ences in laboratory diagnosis of rhinovirus infec-
study of respiratory infections in the tropics. II. The tions in routine medical practice, Mayo Clin. Proc.
spread of six rhinovirus isolates within the commu- 45:517 (1970).
nity, Am. J. Epidemiol. 88:55 (1968). 131. PETERSON, J. A., D'ALESSIO, D. J., AND DICK, E. c.,
118. MaNTO, A. S., AND JOHNSON, K. M., Respiratory Studies on the failure of direct oral contact' to
infections in the American tropics, Am. J. Trop. Med. transmit rhinovirus infection between human vol-
Hyg. 17:867 (1968). unteers, in: Abstracts of the Annual Meeting of the
119. MaNTO, A S., NAPIER, J. A., AND ME1ZNER, H. 1., American Society for Microbiology, p. 214, May 6-11,
The Tecumseh study of respiratory illness. I. Plan of 1973.
study and observations on syndromes of acute res- 132. PHILLIPS, C. A, MELNICK, J. 1., AND GRIM, C. A,
piratory disease, Am. J. Epidemiol. 94:269 (1971). Rhinovirus infections in a student population: Iso-
120. MONTO, A S., AND ULLMAN, B. M., Acute respira- lation of five new serotypes, Am. J. Epidemiol.
tory illness in an American community: The Tecum- 87:447 (1968).
seh study, J. Am. Med. Assoc. 227:164 (1974). 133. PINTO, C. A., AND HAFF, R. F., Experimental infec-
121. MUFSON, M. A, BLOOM, H. H., FORSYTII, B. R., AND tion of gibbons with rhinovirus, Nature (London)
CHANOCK, R. M., Relationship of rhinovirus to mild 224:1310 (1969).
upper respiratory disease. III. Further epidemio- 134. PORTNOY, B.., ECKERT, H. 1., AND SALVATORE, M. A,
logic observations in military personnel, Am. J. Rhinovirus infection in children with acute lower
Epidemiol. 83:379 (1966). respiratory disease: Evidence against etiological im-
122; MUFSON, M. A, KRAUSE, H. E., MOCEGA, H. E., portance, Pediatrics 35:899 (1965).
AND DAWSON, F. W., Viruses, Mycoplasma pneumon- 135. PRICE, W. H., The isolation of a new virus associ-
iae and bacteria associated with lower respiratory ated with respiratory clinical disease in humans,
tract disease among infants, Am. J. Epidemiol. 91:192 Proc. Natl. Acad. Sci. USA 42:892 (1956).
(1970). 136. PRICE, W. H., Vaccine for the prevention in humans
123. MUFSON, M. A., LUDWIG, W. M., JAMES, H. D., JR., of cold-like symptoms associated with the JH virus,
GAULD, 1. W., ROURKE, J. A., HOLPER, J. c., AND Proc. Natl. Acad. Sci. USA 43:790 (1957).
CHANOCK, R. M., Effect of neutralizing antibody on 137. REED, S. E., AND BOYDE, A., Organ cultures of
experimental rhinovirus infection, J. Am. Med. As- respiratory epithelium infected with rhinovirus or
soc. 186:578 (1963). parainfluenza virus studies in a scanning electron
124. PANUSARN, c., STANLEY, E. D., DIRDA, V., RUBENIS, microscope, Infect. Immun. 6:68 (1972).
M., AND JACKSON, G. G., The prevention of illness 138. REED, S. E., AND BYNOE, M. 1., The antiviral activity
from rhinovirus infection by a topical interferon of isoquinoline drugs for rhinoviruses in vitro and
inducer, N. Engl. J. Med. 291:57 (1974). in vivo, J. Med.Microbiol. 3:346 (1970).
125. PAULING, 1. c., Vitamin C and the Common Cold, 139. REILLY, C. M., HOCH, S.M., STOKES, J., MCCLEL-
Freeman, San Francisco, 1970. LAND, 1., HAMPARIAN, V. V., KETLER, A., AND
126. PELON, W., MOGABGAB, W. J., PHILLIPS, I. A, AND HILLEMAN, M. R., Clinical and laboratory findings
PIERCE, W. E., A cytopathogenic agent isolated from in cases of respiratory illness caused by coryzavi-
naval recruits with mild respiratory illness, Proc. ruses, Ann. Intern. Med. 57:515 (1962).
Soc. Exp. BioI. Med. 94:262 (1957). 140. ROBBINS, S. 1., in: Pathologic Basis of Disease, p. 846,
127. PEREIRA, M. A., ANDREWS, B. E., AND GARDNER, S. Saunders, Philadelphia, 1974.
D., A study on the virus aetiology of mild respiratory 141. ROSENBAUM, M. J., DE BERRY, P., SULLIVAN, E. J.,
infections in the primary school child, J. Hyg. PIERCE, W. E., MUELLER, R. E., AND PECKINPAUGH,
(Camb.) 65:475 (1967). R. 0., Epidemiology of the common cold in military
128. PERKINS, J. c., TUCKER, D. N., KNOPF, H. 1. S., recruits with emphasis on infections by rhinovirus
WENZEL, R. P., HOIDJICK, R. B., KAPIKIAN, A Z., types lA, 2, and two unclassified rhinoviruses, Am.
AND CHANOCK, R. M., Evidence for protective effect J. Epidemiol. 93:183 (1971).
142. ROSSEN, R. D., DOUGLAs, R. G., JR., CATE, T. R., responses in human volunteers after rhinovirus
COUCH, R. B., AND BUTLER, W. T., The sedimenta- vaccination, Arch. Gesamte Virusforsch. 28:89 (1%9).
tion behavior of rhinovirus neutralizing activity in 155. STOTT, E. J., AND KILLINGTON, R. A., Haemagglutin-
nasal secretion and serum following the rhinovirus ation by rhinoviruses, Lancet 1:1369 (1972).
common cold, J. Immunol. 97:532 (1966). 156. STOTT, E. J., AND KILLINGTON, R. A., Rhinoviruses,
143. ROSSEN, R. D., KASEL, J. A., AND COUCH, R. B., The Annu. Rev. Microbiol. 26:503 (1972).
secretory immune system: Its relation to respiratory 157. STOTT, E. J., AND WALKER, M., Antigenic variation
viral infection, in: Progress in Medical Virology 0. 1. among strains of rhinovirus type 51, Nature (Lon-
MELNICK, ed.), pp. 194-238, Karger, Basel, 1971. don) 224:1311 (1969).
144. RUECKERT, R. R., Picomaviral architecture, in: Com- 158. TAMM, I., AND CALIGUIRI, 1. A., 2-(a-Hydroxyben-
parative Virology, pp. 225--306, Academic Press, zyl)-benzimidazole and related compounds, in: The
New York, 1971. International Encyclopedia of Pharmacology and Ther-
145. SASAKI, Y., TOGO, Y., WAGNER, H. N., JR., HOR- apeutics, Section 61 (D. J. BAUER, ed.), Pergamon
NICK, R. B., SCHWARTZ, A. R., AND PROCTOR, D. F., Press, New York, 1972.
Mucociliary function during experimentally in- 159. TAYLOR-ROBINSON, D., Studies on some viruses
duced rhinovirus infection in man, Ann. Otol. (rhinoviruses) isolated from common colds, Arch.
82:203 (1973). Gesamte Virusforsch. 13:281 (1963).
146. SCHIEBLE, J. H., LENNETI'E, E. H., AND Fox, V. 1., 160. TAYLOR-ROBINSON, D., Respiratory virus antibodies
Antigenic variation of rhinovirus type 22, Proc. Soc. in human sera from different regions of the world,
Exp. BioI. Med. 133:329 (1970). Bull. WHO 32:833 (1965).
147. SCHLEICHER, J. B., AQUINO, F., RUETER, A., RODER- 161. TAYLOR-ROBINSON, D., JOHNSON, K. M., BLOOM, H.
ICK, W. R., AND ApPELL, R. N., Antiviral activity in H., PARROTT, R. H., MUFSON, M. A., AND CHANOCK,
tissue culture systems of bis-benzimidazoles, po- R. M., Rhinovirus neutralizing antibody responses
tent inhibitors of rhinoviruses, App. Microbiol. and their measurement, Am. J. Hyg. 78:285 (1963).
23:113 (1972). 162. THOMAS, D. c., CONANT, R. M., AND HAMPARIAN,
148. SCHWARTZ, A. R., TOGO, Y., HORNICK, R. B., TOMIN- V. V., Rhinovirus replication in suspension cultures
AGA, S., AND GLECKMAN, R. A., Evaluation of the of HeLa cells, Proc. Soc. Exp. BioI. Med. 133:62
efficacy of ascorbic acid in prophylaxis of induced (1970).
rhinovirus 44 infection in man, J. Infect. Dis. 163. TOGO, Y., SCHWARTZ, A. R., AND HORNICK, R. B.,
128:500 (1973). Failure of a 3-substituted triazinoindole in the pre-
149. SHANNON, W. M., ARNETT, G., AND SCHABEL, F. M., vention of experimental human rhinovirus infec-
JR., 3-Deazauridine: Inhibition of ribonucleic acid tion, Chemotherapy 18:17 (1973).
virus-induced cytopathogenic effect in vitro, Antimi- 164. TROMP, S. W., Biometeorological effect on healthy
crob. Agents Chemother. 2:159 (1972). man (physiological biometeorology), in: Medical
150. SHlPOWITZ, N. E., BOWER, R. R., SCHLEICHER, J. B., Biometeorology, Part IV, pp. 279-280, Elsevier, New
AQUINO, F., ApPELL, R. N., AND RODERICK, W. R., York,1963.
Antiviral activity of a bis-benzimidazole against 165. TYRRELL, D. A. J., Rhinoviruses, in: Virology Mono-
experimental rhinovirus infection in chimpanzees, graphs 2 (VON HERAUSGEGEBEN, S. GARD, C. HAL-
Appl. Microbiol. 23:117 (1972). LAUER, K. F. MYER, eds.), Springer, New York, 1968.
151. SIDWELL, R. W., HUFFMAN, J. H., KHARE, G. P., 166. TYRRELL, D. A. J., BYNOE, M. 1., AND HOORN, B.,
ALLEN, 1. B., WITKOWSKI, J. T., AND ROBINS, R. K., Cultivation of "difficult" viruses from patients with
Broad-spectrum antiviral activity of virazole:1-J3-D- colds, Br. Med. J. 1:606 (1968).
riboftiranosyl-1,2,4-triazole-3-carboxamide, Science 167. TYRRELL, D. A. J., SHEFF, M. D., AND PARSONS, R.,
177:705 (1972). Some virus isolations from common colds. III. Cyto-
152. SMITH, C. B., AND RENZETTI, A., Effect of respiratory pathic effects in tissue cultures, Lancet 1:239 (1%0).
viral infection on pulmonary function in patients 168. VAN LOGHEM, J. J., Epidemiologische bijdrage tot de
with chronic bronchitis, Presented at the Twelfth kennis van de ziekten der ademhalingsorganen,
Interscience Conference on Antimicrobial Agents Ned. Tijdschr. Geneeskd. 72:666 (1928).
and Chemotherapy, Atlantic City, N.J., 1972. 169. WALKER, G. H., BYNOE, M. 1., AND TYRRELL, D. A.
153. STENHOUSE, A. c., Rhinovirus infection in acute J., Trial of ascorbic acid in prevention of colds, Br.
exacerbations of chronic bronchitis: A controlled Med. J. 1:603 (1967).
prospective study, Br. Med. J. 3:461 (1967). 170. WILDY, P., Classification and nomenclature of vi-
154. STOTT, E. J., DRAPER, c., STONES, P. B., AND TYR- ruses, in: Monographs in Virology 0. 1. MELNICK,
RELL, D. A. J., Absence of heterologous antibody ed.), Karger, Basel, 1971.
171. WULFF, H., NOBLE, G. R, MAYNARD, J. E., FELTZ, E. GWALTNEY, J. M., JR., AND JORDAN, W. S., JR., Rhinovi-
T., POLAND, J. D., AND CHIN, T. D. Y., An outbreak rus and respiratory disease, Bacterial. Rev. 28:409
of respiratory infection in children associated with (1964).
rhinovirus types 16 and 29, Am. J. Epidemiol. 90:304 HAMRE, D., Rhinoviruses, in: Monographs in Virology 1
(1969). 0. 1. MELNICK, ed.), Karger, New York, 1968.
JACKSON, G. G., AND MULDOON, R. 1., Viruses causing
common respiratory infections in man, J. Infect. Dis.
127:328 (1973).
13. Suggested Reading STOTI, E. J., AND KILLINGTON, R. A., Rhinoviruses,
Annu. Rev. Microbial. 26:503 (1972).
ANDREWES, c., in: The Common Cold, Norton, New York, TYRRELL, D. A. J., AND CHANOCK, R. M., Rhinoviruses: A
1965. description, Science 141:152 (1963).
CHAPTER 19
Rubella
Dorothy M. Horstmann
1. Introduction Gregg, an Australian ophthalmologist, reported

that an unusual number of newborns with con-
Rubella (German measles) is a common contagious genital cataracts had suddenly appeared in Sydney
disease with mild constitutional symptoms and a and elsewhere in Australia, and that in almost all
generalized rash. In childhood it is an inconse- cases the mothers of the infants had experienced
quential illness, but when it occurs during preg- rubella in the first trimester of pregnancy.caa)
nancy there is a significant risk of severe damage to Gregg also noted the presence of other ocular
the fetus. abnormalities in the affected infants as well as a
high incidence of cardiac lesions. The medical
community was slow to accept his findings and an
2. Historical Background editorial published in The Lancet in 1944 ques-
tioned their validity.c20) But once the way had
Despite its recognition as a clinical entity by been pointed out, confirmatory reports of Gregg's
German authors in the eighteenth century, rubella remarkable discovery began to come in from var-
continued to be regarded by most physicians as a ious parts of the world during the next decade.
mild form of measles or a combination of measles At first, it was difficult to quantitate the poten-
and scarlet fever until the late nineteenth cen- tial risk of fetal damage associated with maternal
tury.(26) Finally in 1881 the International Congress rubella because most of the data came from retros-
of Medicine in London gave official approval to its pective analyses of cases in which the patients had
independent status. That it is not generally called been hospitalized. Estimates ranged as high as a
by its German name, Rotheln, is due to the persua- 90% rate of stillbirths or congenital anomalies
sive Dr. Veale, who in 1866 published a paper in when the disease occurred in the first 12 wk of
the Edinburgh Medical Journal recommending a pregnancy. In the 1950s, prospective studies in
short and euphonius name that could be easily England, (77) the United States/lOa) and Swe-
pronounced, namely, rubella. (113) den(76) permitted a more accurate calculation of
The discovery that changed the concept of ru- the risk of fetal damage. This was found to be of
bella from an inconsequential disease of childhood the order of 15-20% when rubella occurred during
to one of great concern to the medical profession the first trimester of pregnancy.
did not come until 1941. In that year, Sir Norman The viral nature of the infection had been postu-
lated as early as 1914 by Hess on the basis of
Dorothy M. Horsbnann . Department of Epidemiol- trijIlsmission studies in rhesus monkeys. (441 This
ogy and Public Health and Department of Pediatrics, Yale was confirmed in 1938 by Hiro and Tasaka/ 45 )
University School of Medicine, New Haven, Connecticut who produced rubella in children by inoculation
409
410 Chapter 19 • Rubella
of nasal washings, and in 1942 by Habel/ 34 ) who tory for many years. Official statistics tell far less
also succeeded in infecting monkeys using nasal than half the story, however. The reasons for this
washings and blood. In volunteer studies in the are several: (1) the disease is usually so mild that
early 1950s, Krugman and Ward showed that vire- medical care may not be sought; (2) the clinical
mia occurs in the preeruptive stage and proved syndrome is not highly specific and sporadic cases
that the infection can occur without rash. (64.6,) therefore frequently go unrecognized and undi-
With the new prominence of rubella, increased agnosed; and (3) the reporting of even diagnosed
efforts were made in many laboratories to isolate cases by physicians is poor, as is true for other
the etiological agent, but none met with success. notifiable conditions, particularly mild diseases
Following the introduction of practical tissue cul- like rubella that do not seem to have great public
ture methods in the late 1940s, renewed attempts health importance. These factors result in the re-
were made to cultivate rubella virus in vitro. Fi- porting of only about one in five or one in ten
nally, in 1962 this was accomplished. In that year clinical cases. In addition-and most significant-
two groups of investigators, Weller and Neva(!!6) for every frank case there are one or more com-
at the Harvard School of Public Health and Park- pletely inapparent infections, which in epidemiol-
man, Buescher, and Artenstein(S6) at the Walter ogical terms are as important as the clinically mani-
Reed Army Institute of Research, simultaneously fest ones.
reported the growth of rubella virus in cultured
cells. This breakthrough was landmark:. it made 3.3. Serological Surveys
possible an accurate delineation of the clinical
epidemiology of the disease, made available tools Surveys of healthy population groups, primarily
to determine the behavior of the virus in popula- using the hemagglutination inhibition (HI) test,
tion groups, and, most significantly, provided the have been of major importance in mapping the
basis for the development of vaccines for the epidemiology of rubella and documenting differ-
control of congenital rubella. In the United States, ences in its behavior in various parts of the world
the HPV77 strain of live attenuated rubella virus and under various circumstances. The HI test is
vaccine developed by Meyer, Parkman, and specific, is simple, and can be adapted to microti-
Panos(SO) was licensed in 1969, and the Cendehill ter testing of large numbers of sera; since it meas-
strain<9Ol shortly thereafter. The RA 27/3 strain of ures an antibody that is long-lasting, it is highly
Plotkin(S9) was adopted for use in several Euro- suitable for survey purposes.
pean countries at about the same time. These
vaccines have been widely used during the past 7
yr; their impact on the rubella problem is currently
being assessed. 3.4.1. Virus Isolation. Unadapted rubella virus
does not produce significant cytopathic effect
(CPE) in cells in tissue culture. Because of this, the
3. Methodology most commonly employed technique for isolation
of the agent makes use of viral interference as an
3.1. Mortality Data indicator<s7): blood or throat swabs (or other mate-
rials to be tested) are inoculated onto monolayer
Since death from rubella is such a rare event, primary green monkey kidney (GMK) tissue cul-
mortality data are not of significance in under- tures and after 9-12 days the cultures are challenged
standing the epidemiology of the disease. with a virus which normally induces cytopathic
changes and destroys the cell sheet. If rubella virus
is present, it interferes with the challenge virus and
3.2. Morbidity Data
no CPE develops. A second passage is often re-
Rubella did not become a nationally reportable quired before the interference effect can be de-
disease in the United States until 1966. Informa- tected. The first passage may be performed in some
tion on the incidence before that time came from other sensitive cell system such as Vero, a GMK
the 27 states in which reporting has been manda- continuous line, but passage into primary GMK
Chapter 19 • Rubella 411
cultures is necessary for demonstration of interfer- tion tests, the former has become the standard one
ence. in most diagnostic laboratories. Another test that
Growth of rubella virus in tissue culture can also measures antibodies that parallel HI antibodies is
be detected by measuring the production of hem- immunodiffusion for detection of anti-8 re-
agglutinin(73,95) or of CF antigens(95) and by im- sponses.(67) This procedure has advantages simi-
munofluorescence techniques. (119) lar to those of the HI test, but has as yet been little
3.4.2. Serological Tests. There are a number of exploited.
serological methods available for the measurement Among other serological methods available, the
of antibodies to rubella virus. The most widely CF test is useful in establishing the current nature
used is hemagglutination inhibition (HI), (107) and of an infection, for CF antibodies appear later than
less frequently complement fixation (CF)(JOll; oth- HI or neutralizing antibodies; thus significant
ers include neutralization/ 87l immunodiffu- rises in titer between paired sera can be demon-
sion/ 96 .67l indirect fluorescence (FA) /8) platelet strated by CF when the first specimen has been
aggregation (P A), (J 12) and hemadsorption inhibi- collected too late in the course to show a signifi-
tion (HAdI)f88) tests. All are highly specific. The cant increase in titer by HI test. Since CF antibody
one selected depends in large measure on the tends to disappear in many individuals over a
nature of the clinical situation and the purpose for period of years, it is not suitable for use in
which testing is being done. For both diagnosis serological surveys.
and survey work, the HI test is the most suitable. Detection of rubella-specific IgM antibody pres-
Its usefulness was hampered at first because of ent transiently following primary infection is also
nonreproducibility associated with incomplete re- a means of detecting recent or current experience
moval of nonspecific inhibitors which are present with the virus. (2a,35) The test is useful in determin-
in all human sera. Once the variables affecting the ing whether rubella antibody present in a newborn
HI test were defined(7;J) and the procedures for infant is of maternal origin or represents a response
removal of non-specific inhibitors standard- to endogenous infection, since IgM molecules (un-
ized/ 74 ) the test proved to be highly reproducible. like IgG) are not transferred across the placenta.
Absence of antibody as measured by an HI titer of
less than 1:8 correlates well with susceptibility to
infection. The titers of more than 90% of antibody- 4. Biological Characteristics of the Virus
positive sera fall between 1:16 and 1:256. Levels of
1:1024 or higher suggest incomplete removal of Rubella is an ether-sensitive RNA virus, readily
inhibitors; in such instances, the test should be inactivated by a variety of chemical agents, by a
repeated after careful retreatment of the original pH below 6.8 or above 8.1, and by ultraviolet
serum to remove inhibitors. A very low titer-i.e., irradiation. It is unstable at room temperature, at
1:S--probably indicates an antibody-positive 37'C and 56°C, and is best preserved at - 6(J'C or
serum if the result is reproducible. However, since below. In thin sections of infected tissue culture
it is not certain how protective such a low level is, cells examined in the electron microscope, the
it is preferable to consider a titer of 1:8 as indicat- virus appears as spherical particles measuring 50-
ing lack of significant immunity. 70 nm in diameter with 30-nm electron-dense
As in viral infections generally, neutralizing cores; the virions can be seen budding into intra-
antibodies to rubella virus are considered to be cellular vesicles or directly from the marginal
most closely correlated with immunity. Two basic membrane.(821 Released virus is covered with pro-
tissue culture methods for their detection are jections 5-6 nm in length(4fll which cause the
available, the indirect interference test(87l and a particles to hemagglutinate certain fowl red blood
direct test employing virus adapted to a cell line cellsYH.1(7)
such as SIRC 691 in which the end point is read by Not only is the morphological picture of rubella
neutralization of cytopathic effect. Both tests are similar to that of alphaviruses (group A arbovi-
slower, more expensive, and more cumbersome ruses), but there are other similarities as well. The
than the HI test. Because there is a close parallel rubella nucleocapsid core sediments at 150 Sand
between the results of rubella HI and neutraliza- contains a single strand of infectious RNA which
sediments at about 40 5.(55.98) Instability of the tions,t52.70) where close contact also results in a
core has thwarted definitive studies of its struc- similar high degree of communicability. Among
ture. The rubella virion has been reported to susceptible college students, a somewhat lower
contain from three to eight structural proteins, the infection rate (64%) has been recorded.(24)
three major ones being two glycoproteins and a Data on the incidence of reported rubella cases
nonglycosylated core protein.(55.75.1I0) in ten selected areas of the United States are
The taxonomic position of rubella virus is with shown in Fig. 1. The peak years of 1935, 1943, and
the togaviruses, because it is an RNA virus with 1964 are evident. In the period since 1960, the peak
an envelope (toga). There appears to be only one number of cases occurred in 1964, with 488,796
antigenic type, and no cross-reactions with al- reported; this dropped to 100,842 cases the follow-
phaviruses or other members of the togarvirus ing year. Since that time, about 50,000 cases were
group have been found. (79) Differences in the reported annually until 1972, when the number
biological behavior of different strains have been was 25,507; in 1973, 27,804 cases were reported.
demonstrated, however; these include capacity to Congenital rubella became reportable in the
induce interferon in vitro(4) and transmissibility to United States in 1966, when nationwide rubella
rabbit fetuses.(62) reporting was instituted. To encourage better noti-
fication of congenital cases, a National Registry for
the Congenital Rubella Syndrome was established
5. Descriptive Epidemiology by the Center for Disease Control (CDC) in 1969.
The results of retrospective and ongoing surveil-
5.1. Incidence and Prevalence lance are depicted in Fig. 2. By retrospective sur-
vey some 132-203 congenital cases have been
The incidence of rubella infection depends on identified in children born from 1966-1969.(11l In
the periodicity of the epidemic cycle, the degree of order to increase the accuracy of reporting, the
exposure within a group or community, and the CDC is attempting to involve national agencies
number of susceptible persons at risk-Le., lack- which deal with handicapped children.
ing antibody. The risk of an infant acquiring congenital ru-
Prospective serological studies of children in bella depends primarily on the month of preg-
institutions have shown that virtually 100% of nancy in which infection is acquired. Overall,
susceptibles living in cottages in which rubella approximately 16% of infants have major defects at
occurs become infected as secondary and tertiary birth following maternal rubella in the first 3
waves occur. (54) The situation is analogous to months of pregnancy.(76.n.lOO.103) If children are
spread in families(29) and in military installa- followed through childhood for the late appear-
700
§
0 600
0
500
0:
ILl 400
Q.
I/) 300
ILl
I/)
cI:
200
(.)
100
28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72
YEAR
Fig. 1. Incidence of rubella in ten representative United States communities, 1928-1973. From CDC
Rubella Surveillance Report, January 1972-July 1973, issued November, 1973.
15,000
RUBELLA
15
CONGENITAL RUBELLA SYNDROME
10
JFMAMJJASO N DJFMAMJJASO N DJFMAMJJASO N DJFMAMJJASO N DJFMAMJJASOND

•
1968 I 1969 I 1970 I 1971 I 1972 I
Fig. 2. Cases of rubella by period of onset, and of congenital rubella syndrome by period of birth, United States, 1968-
1972. From CDC Rubella Surveillance Report, January 1972-July 1973, issued November 1973.
ance of abnormalities, this rises to approximately ones at intervals up to 30 yr (Fig. 1). Like the
30-35%.(57) On the basis of review of 15 prospec- United States, European countries and Australia
tive studies, Lundstrom(76) in 1962 estimated the have endemic rubella, with the regular occurrence
risk of fetal damage to be 33% when maternal of cases each year and periodic epidemics. This
infection occurs in the first month of pregnancy, pattern correlates well with the approximately 85%
25% if in the second month, 9% in the third immunity level as determined by serological sur-
month and 4% in the fourth month. veys. (21,71.102,108)
Prevalence studies of rubella antibody in healthy A puzzling epidemiological feature is the sud-
populations have been carried out in many coun- den eruption of extensive outbreaks after long
tries of the world. In an extensive collaborative intervals of time in countries such as the United
survey in 1967 sponsored by the World Health States. In the intervening periods, the disease runs
Organization/ 9a ) some 80-87% of women 17-22 yr its usual epidemic cycle of 6-9 yr. This pattern
old in the mainland areas of Europe, Britain, succeeds in immunizing approximately 85% of the
Japan, and Australia were found to possess anti- popUlation by 15 yr of age. Why, then, does a
bodies against rubella. A second collaborative particular epidemic suddenly gather force and re-
study in 1968 of Caribbean and Middle and South sult in such an extraordinary onslaught as charac-
American populations(l7) again revealed an 80% terized the one in 1964? No significant antigenic
antibody prevalence in women of childbearing differences between strains have been docu-
age. A much lower rate was encountered in certain mented, yet conceivably viruses with altered bio-
island groups in these and other surveys, and this logical characteristics and an enhanced capacity to
will be discussed in more detail below. spread may account for such behavior. Host fac-
tors may also be involved: there is evidence that
infected individuals differ in their capacity to
5.2 Epidemic Behavior transmit rubella, and "spreaders" and "non-
In the United States, sizable epidemics have spreaders" have been identified in an epidemiol-
occurred approximately every 6-9 yr, with major ogical study of an outbreak of the disease in
Hawaii.(41a) It seems that there must be some- different from its behavior on the mainland, but
thing-an x factor that we don't know about- no common pattern seems to emerge. Thus Ice-
affecting the dissemination of rubella virus. land, a small island which is sparsely populated,
has had endemic rubella for many years, and the
disease has been reportable since 1888.(]04) The
5.3 Geographic Distribution
conditions for establishing endemicity would
Although serological surveys have documented seem to be far less suitable than on Taiwan or
the worldwide distribution of rubella infection, Barbados, yet rubella long ago gained a foothold in
there are a number of puzzling features that char- Iceland and has maintained it ever since.
acterize the behavior of the disease in certain
island popUlations. Some of these are illustrated
by the history of the· disease on Taiwan. (30.a]) 5.4. Temporal Distribution
Taiwan is a semitropical island with a dense
Epidemics of rubella occur in the continental
population and extensive communication with the
United States about every 6-9 yr (Fig. 1). The
rest of the world. Large epidemics of rubella have
largest number of cases regularly appear in the
occurred there in 1944, 1957-1958, and 1968-1969.
months of March, April, and May, whether the
In both the 1957-1958 and 1968-1969 outbreaks,
year is one of low, moderate, or high incidence.
the disease began in the north, where attack rates
The reason for this consistent seasonal pattern is
were highest, and moved toward the south, where
unknown.
the rates were considerably lower and the occurr-
ence of cases ceased although significant numbers
of susceptibles remained. A serological survey
5.5. Age and Sex
conducted before the 1968-1969 outbreak began
indicated that none of the children born in the 10 In the United States, rubella has been primarily
yr since the previous epidemic had acquired anti- a disease of school~aged children, with a peak
bodies-evidence that the virus had not been incidence in the 5-9 yr age group; the disease is
circulating since that time. Similarly, serological uncommon in preschool children, but many cases
tests in 1971 showed no change in antibody pat- occur iIi. adolescents and young adults.(]lS) The
terns of schoolchildren since the 1968-1969 epi- age distribution is wider than in measles, which
demic, confirming the results of disease surveil- peaks somewhat earlier and then drops off rapidly.
lance which documented absence of cases since In other countries, marked differences in the age at
the outbreak. Thus for unexplained reasons rubella which rubella infection occurs have been revealed
has not succeeded in becoming endemic on the in seroepidemlological surveys. Fig. 3 compares
island of Taiwan. The situation is not unique, for five countries with the United States. In three
similar results were found in 1972 in Barbados, South American countries where the incidence of
where no one born there during the previous 10 yr the disease is unknown (since it is not reported)
had rubella antibodies despite the likelihood of and where congenital rubella does not seem to
introduction of the agent associated with a tourist occur, infection is acquired at an early age; by 5-9
influx of some 250,000 persons yearly.(2a) Factors yr as high as 90% may be immune, as in Chile
such as population size and denSity and climate do (Fig. 3). (]7) In contrast, among island populations
not seem to provide the answers to this puzzling such as those of Hawaii(3S) and Trinidad and
behavior, for on the much smaller and more iso- Jamaica/J7) slow acquisition of antibodies has
lated island of Quemoy near Taiwan a survey been documented, only 30-40% being immune in
indicated that rubella was endemic there, since the age groups over 20 yr. No appreciable differ-
97% of individuals aged 6-50 yr possessed rubella ences are apparent in age-specific attack rates by
antibody.(a]) No information was available about sex in children, but more cases are reported in
previous epidemics on Quemoy, but at the time of women than in men.
the survey no cases were seen and none had been The significant proportion of adults who remain
known to occur in recent months. susceptible reflects the lower communicability of
The epidemiology of rubella on islands is clearly rubella as compared to measles.
100 /A..... ..,L:-._.-.t:, Chile

/' ...... 'i:r- . - '
if U.S. (Florida)
w
90
, ,,
,~ ......
- --0-- -
_---.0 Brazil
Argentino
.' •.• 0
> 80
I-
..p .•,,d···· ... ···0······
.. ' .If
en
.,':. ...
0
Q..
70 cr:"
D"
>-
0
Fig. 3. Age-specific rubella hemag- 0 60
CD
glutination inhibition antibody pat- I-
terns in different population groups. Z
<t 50
Reprinted from Serological Epidemiol-
ogy, ed. by J. R. Paul and C. White, <t
J: 40 Trinidad
Academic Press, New York, 1973.
I- Jamaica
Z
w (rural)
u 30
a::
w
Q..
20
10
~ 4 5-9 10-14 15-19 20-24 25-34

AGE (years)
5.6. Other Factors clinical signs, but is greatest just before and on the
day of onset. Infants with the congenital infection
No ethnic differences in incidence have been
shed relatively large amounts of virus from the
clearly shown, although the characteristic rash is
throat and are effective sources of contagion for
more difficult to diagnose in persons with dark susceptible contacts. (14.48) Persistence of virus in
skin. A lower incidence of congenital rubella was the throat may continue for many months in these
found in outbreaks in Japan/6n but it seems more
infants. (14.9]) In women, the agent can be re-
likely that this was due to the relative avirulence of
covered from the genital trad 99 ); the significance
the strain rather than to ethnic differences.(S) There
of the presence of virus in this site in terms of
is a trend toward higher rates in lower than in
transmission is unknown.
upper socioeconomic groups; this may be due to
increased exposure in crowded homes.
6. Mechanisms and Routes of Transmission Following implantation of the virus on the mu-
cosa of the upper respiratory tract, primary multi-
As with many infections, the exact mode of plication is thought to occur in the respiratory
transmission is not clear, but close person-to- epithelium and/or local lymph nodes. This is fol-
person contact seems to be necessary. The virus is lowed by viremia and virus shedding from the
present in the oropharyngeal secretions and throat. Rubella virus has been detected in pharyn-
spread probably is via the respiratory route. The geal secretions and in the blood as long as a week
period of communicability IS estimated to be from before the appearance of rash.(~2) During the few
5-7 days before to 3-5 days after the appearance of days before onset, the agent has also been re-
covered from leukocytes, conjunctival swabs, and correlation between antibody levels and resist-
synovial fluid. (4;]) ance: reinfection occurs primarily in those with HI
Viremia apparently results in wide distribution titers less than 1:64. In addition, there appear to be
of the virus, including dissemination in the respi- qualitative as well as quantitative differences be-
ratory tract, as suggested by the coryza, cough, tween the resistance acquired through experience
and conjunctivitis that sometimes occur. The virus with wild virus and that acquired by vaccination
has been recovered from skin lesions within 24 h with some attenuated vaccine strains, since 10
of appearance of rash(42); despite this, the rash is times higher reinfection rates have been observed
probably a manifestation of an antigen/antibody in vaccinees compared to natural immunes with
reaction rather than a result of direct viral damage. comparably low HI titers.(m
In the fetal infection, transmission is by hema- A high level of antibody prevalence, and result-
togenous spread during maternal viremia; the re- ant herd immunity, was originally thought to deter
cent demonstration of the presence of the agent in the occurrence of epidemic rubella. This has not
the female genital tract raises the possibility of proved necessarily to be the case. In prospective
involvement by the ascending route, also. During studies, prior antibody prevalence rates of 75% in
the course of maternal viremia, the placenta is college students(24) and the 85-95% or higher in
seeded with virus, followed by development of military recruits(fi2.70) have not prevented the oc-
inflammatory foci in the chorionic villi, granu- currence of rubella outbreaks in which 64-100% of
lomatous changes, and necrosis.(48) Infected cho- the remaining susceptibles are infected.
rionic cells may break off and act as emboli to Immunity following congenital rubella is differ-
target organs. (J(19) ent from that induced by postnatal infection.(106)
The mechanisms by which rubella virus induces Thus some affected infants fail to develop typical
pathological changes in fetal organs and tissues are antibody responses/ 41l while among others who
not clearly understood. Small size is a striking maintain HI antibody until 2 yr of age, approxi-
feature of infants infected in utero; this has been mately 20% may lose detectable HI levels by the
shown by Naeye and Bland 8;]) to be due to an time they are 5 yr old. (1:l.41l Hardyl:J9) has re-
actual diminution in the total number of cells. One ported that a seronegative child with congenital
hypothesis is that the reduction in size of infants rubella developed the clinical disease on exposure
with the congenital disease results from the drop- at school when aged 5 yr. Similarly, apparent(J(\)
ping out of infected clones of cells, whiC;h are and inapparent reinfections('S) in adults who
known to have a shortened life spanYo;) were diagnosed as having congenital rubella in
There is a high mortality in congenital rubella, infancy have also been noted, and Menser(78) has
especially in the first few months of life.(14.48) At described a woman with the syndrome who was
autopsy, lesions have been demonstrated at one apparently reinfected during her own pregnancy
time or another in virtually every organ and tis- and gave birth to an infant with congenital ru-
sue.(22.109) Inflammatory infiltrates occur in the bella. The reasons for the more rapid decline in
heart, lung, middle ear, and choroid plexus. Other antibody levels and the loss of immunity in per-
lesions include giant cell hepatitis, nephritis, vas- sons with congenital rubella are not understood.
culitis with intimal proliferation and epithelial In addition to unusual humoral antibody patterns,
necrosis, iridocyclitis, and meningitis. there is evidence that cellular immunity is im-
Immunity following natural infection is in gen- paired in congenital rubella(28); this defect may
erallong-lasting. However, inapparent reinfection explain the long persistence of virus excretion in
has been shown to occur in approximately 4% of infected infants.
individuals with naturally acquired immunity who
are exposed during epidemics/ 24 .,Z) and frank
clinical rubella has been documented in individu-
als with natural as well as vaccine-induced im- 8. Patterns of Host Response
munity~27,33,117) Inapparent reinfection occurs far
more commonly in vaccinees, with rates as high as In postnatally acquired rubella, the ratio of inap-
50-80% having been reported. (12.,2) There is close parent to apparent infections has been estimated
to be from 1:1 to as high as 6:1.(7·10.29.541 Age ence a prodrome lasting several days, with ma-
probably plays some role in conditioning the clini- laise, low-grade fever, and tender, swollen post-
cal expression of infection, although the relation- auricular and posterior cervical lymph nodes.
ship is not as clear as in diseases such as poliom- Mild sore throat, coryza, cough, and conjunctivitis
yelitis and hepatitis. Brody's'91 observations may be present in the more severe cases. The rash
during an epidemic on the Pribiloff Islands led begins on the face and spreads rapidly to the chest
him to conclude that there were two groups of and abdomen, and within a day or two extends to
adults involved in the outbreak, one whose mem- the extremities; it is pink, maCUlopapular, and not
bers had lost detectable antibody and experienced distinctive in appearance. The lesions are at first
reinfection, largely inapparent, and another group discrete, but later tend to coalesce, particularly on
who had their first experiences with the virus and the face. A helpful diagnostic point is that the rash
exhibited a high clinical attack rate. In two pro- is always present on the face.
spective studies of young adult Hawaiian military The most characteristic clinical feature of rubella
recruits at Fort Ord, California, there was a 1.9:1 is the involvement of specific lymph nodes, i.e.,
ratio of inapparent infections to apparent cases in postauricular, suboccipital, and posterior cervical,
one epidemic in which the men were screened which are often enlarged and tender, sometimes as
intensely for clinical signs(521 and a 3.7:1 ratio in a long as a week before onset. Arthralgia and arthri-
subsequent outbreak during which clinical sur- tis are common complications in young adults,
veillance was less assiduous.(50! The spectrum of particularly women, their frequency increasing
the host response is shown in Table 1. with age. The disease is usually a mild one lasting
no more than a few days, but in rare instances
complications such as encephalitis, thrombocyto-
8.1. Clinical Manifestations
penic purpura, and neuritis may occur.
8.1.1. Acquired Infection. In the postnatally ac- 8.1.2. Congenital Infection. Like postnatally ac-
quired infection, rash is the most prominent clini- quired rubella, the congenital infection may be
cal feature and the first evidence of the disease in inapparent, but much more commonly one or
95% of affected children. Adults frequently experi- more of the characteristic features are present. The
Table 1. Patterns of Host Response to Rubella
I. Acquired rubella
A. Inapparent infection
B. Rubella without rash
C. Rubella with rash
D. Complications
1. Joint involvement (arthralgia, arthritis)
2. Encephalitis
3. Thrombocytopenic purpura
II. Congenital rubella
A. Inapparent infection
B. Congenital rubella syndrome with single or multiple organ involvement
1. Cardiac lesions (patent ductus arteriosus, ventricular septal defect, pulmonary stenosis)
2. Eye defects (cataracts, retinopathy, microphthalmia, glaucoma)
3. Deafness
4. Growth retardation
5. Thrombocytopenic purpura
6. Hepatosplenomegaly
7. Hepatitis
8. Central nervous system defects (psychomotor retardation, microcephaly, encephalitis, aseptic
meningitis)
9. Bone lesions (long bones)
risk to the fetus is greatest early in pregnancy, of fetal life, when organs are developing. The prog-
particularly in the first month, and in the second nosis in severely involved infants is poor, the mor-
month, which is the period of organogenesis, but tality being particularly high in the first year of
fetal involvement can also occur in the second lifeY4,48)
trimester. (40) Maternal rubella in the first trimester
is associated with congenital anomalies recogniz- 8.2. Serological Responses
able at birth in approximately 15-20% of infants.
Late manifestations, particularly deafness, raise The time course of appearance of antibodies is
the proportion of those affected to 30-35%.1,7) The shown in Fig. 4. In addition to HI, CF, neutraliz-
rate of virus isolation from placenta and/or fetus ing, and other antibodies, local secretory IgA anti-
obtained at abortion is considerably higher than body has been demonstrated in the nasopharyn-
this, supporting the probability that inapparent geal secretions. IS:;) Platelet aggregation antibodies
infection in utero is more common than previously are strikingly high in patients with postrubella
suspected. 12 ,48,91,92) thrombocytopenia. (112) HI antibodies are usually
In affected infants, the chief abnormalities are present on the day of onset and rise rapidly; it
heart lesions (most frequently patent ductus arter- may therefore not be possible to show a significant
iosus), cataracts or other ocular lesions (retinopa- increase in titer unless the first serum specimen is
thy, microphthalmia, glaucoma), purpuric and obtained early. CF antibodies appear considerably
petechial skin lesions associatefl with thrombo- later-often not until a week or more after onset,
cytopenia, hepatosplenomegaly, meningoen- so that fourfold or greater rises in titer between
cephalitis, and lesions of the long bones. Hearing paired specimens can be detected when the first
loss and psychomotor retardation become apparent specimen has been collected too late in the course
later. Multiple system involvement is frequent, es- to do so by HI test.
pecially when infection occurs in the second month The immune response to intrauterine rubella
512 RASH
256
128
64
1 -- ---
HAI
__ - Neut.
FA
ANTIBODY
TITERS 32
16
/ ;'
--- - ..... CF
/
/
8
,. /
<8
-7 0 7 14 21 28
VIRUS PRESENT: DAYS
BLOOD //1
THROAT /111111 I 1/ I I I I ,
Fig. 4. Antibody responses to primary infection with rubella virus. HAl, Hemagglutina-
tion inhibition; Neut., neutralizing; FA, fluorescence; and CF, complement-fixing anti-
bodies. Reprinted from Serological Epidemiology, ed. by J. R. Paul and C. White, Academic
Press, New York, 1973.
infection differs from that of the postnatal infec- and passaged 25 times in human diploid Wl38
tion.C2.S.19.106) It is evident that the fetus can make cells, is licensed in England, France, and other
specific IgM after the sixteenth week.(2) At birth, European countries. The'three vaccines are similar
IgM is present and continues to rise in titer for in immunogenic capacity and lack of spread to
approximately 6 months; it commonly persists susceptible contacts, but RA 27/3 differs in that it
through the first year of life. Maternal IgG, detect- has retained the ability to infect by a natural route,
able at 12-16 wk of fetal life, declines over the first viz., intranasally. It also induces a broader range of
few months after birth as the infant's own rubella antibody responses than does either HPV77 or
IgG rises. Cendehill, including the regular appearance of
precipitating antibodies/ 68 ) and local secretory
IgA in the oropharynx. (85) Preliminary evidence
9. Control indicates that a new Japanese vaccine, TO-336, is
also highly immunogenic and has biological char-
9.1. Vaccine Development acteristics that might make it less readily transmis-
sible to the fetus than is the case with other
As soon as the virus was isolated in tissue vaccine strains. (6 )
culture in 1962, efforts to develop a vaccine were
under way. Af first, a killed virus vaccine was
9.2. Responses to Rubella Vaccines
considered to be the only safe approach, but it
soon became apparent that inactivation of the 9.2.1. Clinical Reactions. Some reaction occurs
agent by various means inevitably led to loss of in approximately 10-15% of vaccinees, depending
antigenicity. Attention was therefore turned to on age and sex. By and large, the symptoms and
attenuation of the virus by serial passage in tissue signs are those of mild rubella: low-grade fever,
culture, and by 1966 Meyer, Parkman, and lymphadenopathy, and occasionally rash appear-
Panos CSOl had successfully developed an experi- ing after 10-20 days. As in the natural disease,
mental live virus vaccine. The attenuated strain transient arthritis and arthralgia lasting up to a
which they used, "High Passage ViruSr7" or week may occur, particularly in women over 20 yr.
HPV77 , represented the seventy-seventh passage of Joint involvement is uncommon in children, its
the agent in primary green monkey kidney (GMK) frequency and severity increasing with increasing
cells. A further five passages in duck embryo (DE) age; in women in the 26-41 yr age group, it may
tissue culture resulted in the HPV77DEs vaccine; an reach close to 60%. Cl15) FiI1.gers, wrists, and knees
alternative preparation, HPV77 DK12 , was obtained are most commonly involved; joint effusions may
by 12 passages in dog kidney cell cultures. Admin- develop, as in infection with wild virus. Recurrent
istration of the HPV77 vaccines to humans resulted pain and swelling of the joints over a period of
in the appearance of neutralizing and HI antibod- months have been reported, and in at least three
ies but was not associated with detectable viremia cases the virus has been recovered from knee joint
in recipients or infection in susceptible contacts fluid 4-5 months after vaccination. Cll.S4)
despite the fact that the vaccinees shed virus from HPV77 DK12 vaccine, which was responsible for
the throat for several days. Subsequently, both most of the cases of recurrent arthritis as well as
small and large field trials extended these observa- the late neuropathies involving wrists and hands
tions and attested to the safety and immunogenic- or legs ("catcher's croUch"),cS9) was withdrawn
ity of the HPV77 strain; it was licensed in the from distribution in March 1973. The HPV77 DEs,
United States in 1969. Shortly afterward, another Cendehill, and RA 27/3 vaccines do not appear to
vaccine strain, Cendehill, developed by Huygelen differ significantly in terms of clinical reactions,
et al.,<S6) was licensed. This strain was isolated in although there have been few large-scale compara-
GMK and passaged 51 times in primary rabbit tive studies.
kidney cells. Both HPV77 DEs and Cendehill vac- 9.2.2. Shedding of Virus. Virus excretion from
cines have been widely used in the United States the throat occurs briefly and in relatively small
and have been given to millions of children. A amounts in most vaccinees.(15) Nevertheless, con-
third vaccine, the RA 27/3 of Plotkin (89 ) isolated tact spread is so rare as to be a negligible haz-
ard(37) even for susceptible pregnant women ex- first to determine by serological test if the individ-
posed to their vaccinated children.(97) Viremia has ual lacks antibody and is therefore susceptible.
rarely been documented in vaccinees, but that it Before giving the vaccine, the presence of preg-
does occur is. substantiated by transmission of nancy should be excluded and the necessity for
infection to the fetus in susceptible pregnant suitable birth control measures for at least the next
women who have inadvertently been given rubella two months should be emphasized. Extension of
vaccine. (72) Another site from which vaccine virus the time to 3 months may be advisable in view of
can be recovered transiently is the genital tract in the recent report of infection of the fetus when the
females. (I I J) mother was given vaccine 7 wk before concep-
9.2.3. Serological Responses. Following vaccine tion. (120)
administration, antibody develops in approxi- Despite all warnings, inadvertent vaccination in
mately 95% of susceptibles. The responses are pregnancy has occurred with some frequency. In a
similar to those which follow natural infection, but recent review, Levine et al. (72) noted that among
HI and neutralizing antibody titers are consider- the reported instances the immune status of most
ably 10wer(sJ) and CF antibodies appear only in of the 471 women given rubella vaccine within 90
those who have brisk HI responses. Local IgA and days of conception was unknown and only 81
precipitating antibodies (anti-9, anti-t) comparable (17%) had been shown to lack rubella antibodies.
to those that result from wild virus infection occur Of the 33 known susceptible women given HPV77
only with the RA 27/3 vaccine. (47.6S.S5) vaccine strains, the placenta or decidua obtained
at abortion yielded virus in eight cases, and in one
case the fetus was virus positive. There is less
9.3. Vaccination of Children information concerning the effects of the Cendehill
strain, but virus has been recovered from fetal
In the United States, the decision was made to
tissues in one of 12 abortuses from susceptible
focus on prepubertal children as the main target vaccinees. (I J)
for vaccination. This approach as set forth by the
Like wild virus, the HPV77 attenuated strain can
U.S. Public Health Service Advisory Committee on
induce chronic infection and has been recovered
Immunization Practices was based on the concept
from decidua as long as 20 wk after vaccine ad-
that congenital rubella could be prevented indi- ministration.(6S) The teratogenic potential of the
rectly by inducing a high degree of herd immun-
attenuated strains is unknown, but histological
ity, thus blocking the circulation of virus in the changes typical of rubella have been demonstrated
segment of the population in which most infec- in infected fetal eyes and in other tissues. (25,120)
tions occur, Le., young children who may also act
The number of infants born to mothers known to
as sources of infection for their mothers. The
have been susceptible when vaccinated is small:
vaccine is available for use alone or combined with Wyll and Herrmann(120) reported on 11 babies, all
measles and mumps virus vaccines. The recom-
of whom appeared normal at birth. Long-term
mendation of the Academy of Pediatrics Commit-
observation will be necessary in order to estimate
tee on Infections is that rubella vaccine be given to
the possible impact of the infection on these in-
children between the age of 1 yr and puberty.
fants,
While vaccination is strongly contraindicated
during pregnancy, the screening of women for
9.4. Vaccination of Women of Childbearing Age
antibodies to rubella should be a routine part of
Women of childbearing age are the most impor- prenatal care. An optimum time to immunize the
tant group to protect against rubella; however, susceptibles identified by this means is during the
since the vaccine contains live virus which is first few days postpartum, before they leave the
capable of infecting the placenta and the fetus, hospital. (51) This takes advantage of the very low
great caution is necessary in giving it to postpub- risk of pregnancy in the ensuing weeks; neverthe-
ertal females because of the possibility that they less, depending on the patient, some contraceptive
may be pregnant. The recommended procedure is measure may be desirable.(3)
9.5. Management of the Rubella Problem in to show a rise in CF titer when the serum has been
Pregnancy obtained too late in the course to detect a signifi-
cant increase in HI levels (Fig. 4).
The situation which arises most frequently in-
volves a woman in early pregnancy who has been
exposed to rubella. Under these circumstances, a 9.6. Use of y-Globulin
serum sample should be obtained as soon as In the case of the pregnant woman who has
possible to determine serologically whether or not been exposed to rubella, y-globulin has frequently
she is susceptible. A past history of the disease is been given in the hope of preventing infection
unreliable because a number of other viruses in- should the patient be susceptible. The results have
duce "rubelliform" rashes. If an HI test reveals the been disappointing. That y-globulin, given in ad-
presence of antibody and the blood sample was equate dosage immediately after exposure, has a
collected within a few days of exposure, the indi- modifying effect has been shown by Green et
vidual can be reassured that she is immune and aI., (32) who demonstrated in volunteers that under
therefore not at risk. It a titer of less than 1: 8 is these circumstances it may prevent the disease but
obtained, the patient is susceptible and should be not the infection. There was some suggestion in the
followed to determine whether or not she has been data and in those of others(J6) that the duration of
infected. A second blood specimen should be viremia was shortened, but the numbers were
obtained approximately 3 wk after exposure and small and no firm conclusions could be drawn. In
retested along with the first specimen. If infection any event, there are well-documented examples of
has occurred, antibodies will be detected in the both rubella with rash and of inapparent infection
second serum and appropriate action can then be in women given y-globulin in optimum dose soon
discussed with the patient. after exposure. The effectiveness of this form of
Difficulty in interpreting HI results may be en- prophylaxis is thus unreliable and unpredictable.
countered when there has been a delay of several The only circumstance in which its use might be
weeks in obtaining the first postexposure serum considered is in the case of a woman who, because
sample. If HI antibodies are present, the question of religious or other reasons, would not consent to
arises of whether they represent a recent or current termination of the pregnancy should infection-
infection or one that was experienced years before. clinical or inapparent-occur in the first trimester
This can often be answered by determining the of pregnancy.
immunoglobulin class to which the antibodies
belong. As in other viral infections, the first re-
sponse in a primary infection is IgM, which per-
sists for several weeks or more, along with a rising 10. Unresolved Problems
level of IgG, which eventually represents virtually
all of the detectable antibody. A satisfactory flu- The unpredictable behavior of rubella and the
orescent antibody test has been described for de- peculiarities of the virus lend a note of caution
tection of rubella-specific IgM/35) but a simpler test to any forecast of the impact of vaccination on the
that has proved reliable in identifying primary in- epidemiological behavior of the disease. It is little
fections has recently been introducted by Ankerst more than 7 yr since the vaccine was licensed in
et al. (2a) It involves measurement of rubella-spe- the United States and therefore too soon to assess
cific IgM HI antibody after removal of IgG by ab- its long-range effects. Nevertheless, certain trends
sorption of serum with Staphylococcus aureus pro- are becoming apparent. There has been a decrease
tein A. in the number of cases reported, the incidence
Another serological method that may be used to remaining consistently low since 1969 without the
establish the current nature of the infection is the usual epidemic peak (Figs. 1 and 2). This has been
complement fixation (CF) test. Because CF anti- reflected in a low incidence of reported cases of
bodies appear later in the course of the infection congenital rubella.(63) While part of these results
(7-10 days after onset of rash), it is often possible can be attributed to the natural and unpredictable
behavior of the virus, the pattern shown in Figs. 1 types is more restricted. Reinfection is more com-
and 2 suggests that immunization of children aged mon in those with low antibody titers (less than
1-12 yr has played a role in the decline of the 1:64) and thus occurs far more readily in vaccinees
disease, Nevertheless, fluctuation in the number than in individuals with natural immunity. f12,52)
of cases continues, as in 1973 when the national The interplay of various factors-including the
incidence between February and May was 30% relative immunogenicity of the several vaccines
higher than in 1972.(1]) currently available-is clearly important in assess-
Reduction in the number of cases implies reducing the ultimate quality and effectiveness of the
tion in the dissemination of rubella virus. The resistance induced by vaccination as compared to
extent to which this has occurred is unknown. The naturally acquired resistance.
concept that a relatively high herd immunity rate Several investigators have reported that vaccine-
in prepubertal children will necessarily form an induced antibodies have persisted without signifi-
effective barrier to circulation of the virus has not cant change for periods of from 3~ to 7 yr,W:l.114)
been borne out by the experience of several com- although Davis et al. (15) found some loss of detect-
munities, including the town of Casper, Wyo- able levels after 1-3 yr. In serological surveillance
ming.((W) In 1971, an epidemic occurred there 9 studies of several hundred children 3 and 5 yr after
months after 83% of the elementary school chil- vaccination, a close correlation between the origi-
dren had been vaccinated. That this was insuffi- nal response to vaccine and subsequent mainte-
cient to prevent an outbreak emphasizes the ex- nance of antibody levels has been found. (49) Satis-
traordinarily high herd immunity rate necessary to factory persistence of HI antibodies for 5 yr was
block the spread of rubella virus. The implication apparent in those who had brisk original re-
for the control of the disease is that vaccination sponses. In contrast, those with low HI titers after
alone is not apt to reach a sufficiently high propor- vaccination (1:8-1:16) failed to develop CF or pre-
tion of the population to form an adequate barrier cipitating antibodies, and 5 yr later approximately
to circulation of the virus. Dependence on the 25% had lost detectable HI levels. The crucial
continuing occurrence of natural infection to rein- question is how such individuals might respond
force the immunity of vaccinees and to provide to reinfection with wild virus, and, if this should
infection and resistance for those who have not occur during pregnancy, whether the fetus would
been vaccinated unfortunately carries the hazard be at risk. There is evidence that the presence of
of exposure of susceptible pregnant women to any detectable level of antibody is protective
infection with wild rubella virus. Whether or not against viremia, (l5) but the situation might be
this is a serious problem may be answered in the very different in the individual who has lost all
future by comparing the results of the rubella serological evidence of immunity.
control program in the United States with the find- Long-term clinical and serological surveillance of
ings in England, where vaccination is given just vaccinated populations is necessary in order to
before puberty. The British approach, besides al- monitor immunity levels and to assess the contin-
lowing for acquisition of natural infection and uing effects of current immunization practices.
immunity by preschool and school children, also Should marked reduction in the circulation of
takes into account the likelihood that higher levels rubella virus in the United States occur as a result
of antibody and greater resistance will be main- of current immunization practices, a possible un-
tained over the childbearing years when vaccine is desirable effect may follow-an increase in the
given at 12-13 yr rather than in the first few years number of susceptible women in the childbearing
of life. age group. These women would include those who
The problems of limited persistence of vaccine- were not vaccinated and were prevented from
induced immunity and the greater susceptibility to acquiring infection as a result of decreased dis-
reinfection of vaccinees as compared with natu- semination of wild virus. That such a shift has not
rally immune persons are closely linked. Antibody yet occurred is suggested by combined results of
titers resulting from vaccination are lower than some 52,000 HI screening tests performed between
those acquired through natural infection, and (ex- 1971 and 1973 on sera from women in eight widely
cept with RA 27/3 vaccine) the range of antibody separated areas in the United States: no departure
from the immunity patterns recorded for the same serum: Detection by the indirect fluorescent-anti-
areas before the introduction of vaccine was ob- body technic, Science 145:943-945 (1964).
served. (11) Because of the influence of age, socio- 9. BRODY, J. A., The infectiQusness of rubella and the
economic status, and the previous incidence of possibility of reinfection, Am. ]. Public Health
rubella in any given area, local surveillance of the 56:1082-1087 (1966).
10. BUESCHER, E. 1., Behavior of rubella virus in adult
population of women at risk nevertheless deserves
populations, Arch. Gesamte Virusforsch. 16:470-476
consideration. As an example, in a serological (1965).
survey of postpartum women in New Haven, 11. Center for Disease Control Rubella Surveillance,
Connecticut, in 1969, we fouI1d a 13.9% suscepti- January 1972-July 1973, issued November 1973.
bility rate in the age group 15-45 yr. Results of a 12. CHANG, T.-W., DEsRosmRS, S., AND WEINSTEIN, 1.,
similar survey of New Haven women in this age Clinical and serologic studies of an outbreak of
group in 1973 revealed that 23% lacked HI anti- rubella in a vaccinated population, N. Engl. ]. Med.
body to rubella. This may be a transient trend, but 283:246-248 (1970).
if it continues a dangerous buildup of susceptibles 13. COOPER, 1. Z., FLORMAN, A. 1., ZIRING, P. R., AND
KRUGMAN, S., Loss of rubella hemagglutination in-
among young women in the childbearing age
hibition antibody in congenital rubella, Am. ]. Dis.
group might ensue.
Chi/d. 122:397-403 (1971).
14. COOPER, 1. Z., ZIRING, P. R., OCKERSE, A. B.,
FEDUN, B. A., KmLY, B., AND KRUGMAN, S., Rubella:
Clinical manifestations and management, Am. ].
11. References Dis. Child. 118:1S-29 (1969).
15. DAVIS, W. J., LARSON, H. E., SIMSARIAN, J. P.,
1. ALFORD, C. A., Studies on antibody in congenital PARKMAN, P. D., AND MEYER, H. M., JR., A study of
rubella infections, Am. ]. Dis. Chi/d. 110:455-463 rubella immunity and resistance to infection,]. Am.
(1965). Med. Assoc. 215:600-608 (1971).
2. ALFORD, C. A., NEVA, F. A., AND WELLER, T. H., 16. DOEGE, T. c., AND ~IM, K. S. W., Studies of rubella
Virologic and serologic studies on human products and its prevention with immune globulin, ]. Am.
of conception after maternal rubella, N. Engl. ]. Med. Assoc. 200:584--590 (1967).
Med. 271:1275-1281 (1964). 17. DOWDLE, W. R., FERREIRA, W., DE SALLES GOMES,
2a. ANKERST, J., CHRISTENSEN, P., KJELLEN, 1., AND 1. F., KING, D., KOURANY, M., MADALENGOITIA, J.,
KRONVALL, G., A routine diagnostic test for IgA PEARSON, E., SWANSTON, W. H., TOSI, H. c., AND
and IgM antibodies to rubella virus: Absorption of VILCHES, A. M., WHO collaborative study on the
IgG with Staphylococcus aureus, ]. Inf. Dis. 130:26S- sero-epidemiology of rubella in Caribbean and
273 (1974). Middle and South American populations in 1968,
3. BALDWIN, J. A., AND FREESTONE, D. S., Risk of early Bull. WHO 42:419-422 (1970).
post-partum pregnancy in context of post-partum 18. DRISCOLL, S. G., Histopathology of gestational ru-
vaccination against rubella, Lancet 2:366-367 (1971). bella, Am. J. Dis. Child. 118:49-53 (1969).
4. BANATVALA, J. E., POTTER, J. E., AND BEST, J. M., 19. DUDGEON, J. A., Congenital rubella: Pathogenesis
Interferon response to Sendai and rubella viruses in and immunology, Am. ]. Dis. Child. 118:35-44
human foetal cultures, leukocytes and placental cul- (1%9).
tures,]. Gen. Virol. 13:193-201 (1971). 20. Editorial, Rubella and congenital malformations,
5. BELLANTI, J. A., ARTENSTEIN, M. S., OLSON, 1. C., Lancet 1:316 (1944).
BUESCHER, E. 1., LUHRS, C. E., AND MILSTEAD, K. 21. ENDERS-RUCKLE, G., Seroepidemiology of rubella
1., Congenital rubella, Am. ]. Dis. Chi/d. 110:464-- and reinfection, Am. ]. Dis. Chi/d. 118:139-142
472 (1965). (1969).
6. BEST, J. M., BANATVALA, J. E., AND BOWEN, J. M., 22. ESTERLY, J. R., AND OPPENHEIMER, E. H., Pathologi-
New Japanese rubella vaccine: Comparative trials, cal lesions due to congenital rubella, Arch. Pathol.
Br. Med. ]. 3:221-224 (1974). 87:380-388 (1969).
7. BISNO, A. 1., SPENCE, 1. P., STEWART, J. A., ANI> 23. EVANS, A. S., Cox, F., NANKERVIS, G., OPTON, E.
CASEY, H. 1., Rubella in Trinidad, sero-epidemio- M., SHOPE, R. E., WELLS, A. V., AND WEST,B., A
logic studies of an institutional outbreak, Am. ]. health and seroepidemiological survey of a commu-
Epidemiol. 89:74--81 (1969). nity in Barbados, Int. ]. Epidemiol. 3:167-175 (1974).
8. BROWN, G. C., MAASSAB, H. F., VERONELLI, J. A., 24. EVANS, A. S., NmDERMAN, J. c., AND SAWYER, R.
AND FRANCIS, T., JR., Rubella antibodies in human N., Prospective studies of a group of Yale Univer-
sity freshmen. II. Occurrence of acute respiratory COOPER, 1. Z., ZIRING, P. R., et al., Response to
infections and rubella, J. Infect. Dis. 123:271-278 rubella vaccination among seronegative children
(1971). with congenital rubella, Pediat. Res. 4:513-514
25. FLEET, W. J., JR., BENZ, E. W., JR., KARZON, D. T., (1970).
LEFKowrrz, 1. B., AND HERRMANN, K. 1., Fetal 40. HARDY, J. B., MCCRACKEN, G. H., GILKESON, M. R.,
consequences of maternal rubella immunization, I. AND SEVER, J. 1., Adverse fetal outcome following
Am. Med. Assoc. 227:621-627 (1974). maternal rubella after the first trimester of preg-
26. FORBES, J. A., Rubella, historical aspects, Am. I. Dis. nancy, I. Am. Med. Assoc. 207:2414-2420 (1969).
Child. 118:5--11 (1969). 41. HARDY, J. B., SEVER, J. 1., AND GILKESON, M. R.,
27. FORREST, J. M., MENSER, M. A., AND HONEYMAN, M. Declining antibody titers in children with congeni-
c., Clinical rubella eleven months after vaccination, tal rubella, J. Pediat. 75:213-220 (1969).
Lancet 2:399-400 (1972). 41a. HATTIS, R. P., HALSTEAD, S. B., HERRMANN, K. 1.,
28. FUCCILLO, D. A., STEELE, R. W., HENSEN, S. A., AND WITTE, J. J., Rubella in an immunized island
VINCENT, M. M., HARDY, J. B., AND BELLANTI, J. A., population, I. Am. Med. Assoc. 223:1019-1021 (1973).
Impaired cellular immunity to rubella virus in con- 42. HEGGIE, A. D., Pathogenesis of the rubella exan-
genital rubella, Infect. Immun. 9:81-84 (1974). them: Isolation of rubella virus from the skin, N.
29. GALE, J. 1., DETELS, R., KIM, K. S. W., BEASLEY, R. Engl. J. Med. 285:664-666 (1971).
P., CHEN, K. P., AND GRAYSTON, J. T., The epide- 43. HEGGIE, A. D., AND ROBBINS, F. c., Natural rubella
miology of rubella on Taiwan. III. Family studies in acquired after birth, clinical features and complica-
cities of high and low attack rates, Int. I. Epidemiol. tions, Am. I. Dis. Child. 118:12-17 (1969).
1:261-265 (1972). 44. HESS, A. F., German measles (rubella): An experi-
30. GALE, J. 1., GRAYSTON, J. T., BEASLEY, R. P., DE- mental study, Arch. Intern. Med. 13:913-916 (1914).
TELS, R., AND KIM, K. S. W., The epidemiology of 45. HIRO, Y., AND TASAKA, S., Die Roteln sind eine
rubella on Taiwan. II. 1968-1969 epidemic, Int. I. Viruskrankheit, Monatsschr. Kinderheilkd. 76:328-
Epidemiol. 1:253-260 (1972). 332 (1938).
31. GRAYSTON, J. T., GALE, J. 1., AND WATTEN, R. H., 46. HOLMES, I. H., WARK, M. c., AND WARBURTON, M.
The epidemiology of rubella on Taiwan. I. Introduc- F., Is rubella an arbovirus? II. Ultrastructural mor-
tion and description of the 1957-1958 epidemic, Int. phology and development, Virology 37:15--25 (1969).
I. Epidemiol. 1:245--252 (1972). 47. HORSTMANN, D. M., Rubella: The challenge of its
32. GREEN, R. H., BALSAMO, M. R., GILES, J. P., KRUG- control, I. Infect. Dis. 123:640-654 (1971).
MAN,S., AND MIRICK, G; 5., Studies on the natural 48. HORSTMANN, D. M., BANATVALA, J. E., RIORDAN, J.
history and prevention of rubella, Am. I. Dis. Child. T., PAYNE, M. c., WHITTEMORE, R., OPTON, E. M.,
110:348-365 (1965). AND FLOREY, C. DUVE, Maternal rubella and the
33. GREGG, N. M., Congenital cataract following Ger- rubella syndrome in infants, Am. I. Dis. Child.
man measles in the mother, Trans. Opthalmol. Soc. 110:408-415 (1965).
Aust. 3:35--46 (1941). 49. HORSTMANN, D. M., Controlling rubella: Problems
34. HABEL, K., Transmission of rubella to Macacus mu- and perspectives, Ann. Int. Med. 83:412-417 (1975).
latta monkeys, Public Health Rep. 57:1126-1139 50. HORSTMANN, D. M., LEIGHTON, H. A., AND EM-
(1942). MONS, J., unpublished observations.
35. HAIRE, M., AND HADDEN, D. S. M., Immunoglobu- 51. HORSTMANN, D. M., LIEBHABER, H., AND KOHORN,
lin responses in rubella and its complications, Br. E. I., Post-partum vaccination of rubella-susceptible
Med. I. 3:130-132 (1970). women, Lancet 2:1003-1006 (1970).
36. HALONEN, P. E., RYAN, J. M., AND STEWART, J. A., 52. HORSTMANN, D. M., LIEBHABER, H., LEBouvIER, G.
Rubella hemagglutinin prepared with alkaline ex- 1., ROSENBERG, D. A., AND HALSTEAD, S. B., Ru-
traction of virus grown in suspension culture of bella: Reinfection of vaccinated and naturally im-
BHK-21 cells, Proc. Soc. Exp. BioI. Med. 125:162-167 mune persons exposed in an epidemic, N. Engl. J.
(1967). Med. 283:771-778 (1970).
37. HALSTEAD, S. B., AND DIWAN, A. R., Failure to 53. HORSTMANN, D. M., PA]OT, T., AND LIEBHABER, H.,
transmit rubella virus vaccine: A close-contact study Epidemiology of rubella: Subclinical infection and
in adults, J. Am. Med. Assoc. 215:634-636 (1971). occurrence of reinfection, Am. J. Dis. Child. 118:133-
38. HALSTEAD, S. B., DIWAN, A. R., AND ODA, A. I., 136 (1969).
Susceptibility to rubella among adolescents and 54. HORSTMANN, D. M., RIORDAN, J. T., OHTAWARA,
adults in Hawaii, J. Am. Med. Assoc. 210:1881-1883 M., AND NIEDERMAN, J. c., A natural epidemic of
(1969). rubella in a closed population, Arch. Gesamte Virus-
39. HARDY, J. B., In discussion of FLORMAN, A. 1., forsch. 16:483-487 (1965).
55. HOVI, T., AND VAHERI, A., Infectivity and some JR., Evaluation of rubella herd immunity during an
physicochemical characteristics of rubella virus ri- epidemic, J. Am. Med. Assoc. 213:2236-2239 (1970).
bonucleic acid, Virology 42:1-8 (1970). 71. LEHMANN, N. I., FERRIS, A. A., BENNETT, N. M.,
56. HUVGELEN, c., PEETERMANS, J., AND PRINZIE, A., An AND NEWMAN, J. W., Rubella: Results of serological
attenuated rubella virus vaccine (Cendehill 51 survey of pregnant patients in Melbourne during
strain) grown in primary rabbit kidney cells, Prog. 1968, Med. J. Aust. 1:1282-1283 (1969).
Med. Virol. 11:107-125 (1969). 72. LEVINE, M. M., EDSALL, G., AND BRUCE-CHWATT, L.
57. JACKSON, A. D. M., Deafness following maternal J., Live-virus vaccines in pregnancy risks and rec-
rubella: Results of a prospective investigation, Lan- ommendations, Lancet 2:34-38 (1974).
cet 2:1241-1244 (1958). 73. LIEBHABER, H., Measurement of rubella antibody by
58. KENRICK, K. G., SLlNN, R. F., DORMANN, D. c., AND hemagglutination inhibition. I. Variables affecting
MENSER, M. A., Immunoglobulins and rubella-virus rubella hemagglutination, f. Immunol. 104:818-825
antibodies in adults with congenital rubella, Lancet (1970).
1:548-551 (1968). 74. LIEBHABER, H., Measurement of rubella antibody by
59. KILROY, A. W., SCHAFFNER, W., FLEET, W. F., JR., hemagglutination inhibition. II. Characteristics of
LEFKOWITZ, L. B., JR., KARZON, D. T., AND FENI- an improved HAl test employing a new method for
CHEL, G. M., Two syndromes following rubella the removal of non-immunoglobulin HA inhibitors
immunization. Clinical observations and epide- from serum, J. Immunol. 104:826-834 (1970).
miological studies, J. Am. Med.Assoc. 214:2287-2292 75. LIEBHABER, H., AND GROSS, P. A., The structural
(1970). proteins of rubella virus, Virology 47:684-693 (1972).
60. KLOCK, L. E., AND RACHELEFSKY, G. S., Failure of 76. LUNDSTROM, R., Rubella during pregnancy: A fol-
rubella herd immunity during an epidemic, N. low-up study of children born after an epidemic of
Engl. J. Med. 288:69-72 (1973). rubella in Sweden, 1951, with additional investiga-
61. KONO, R., Rubella epidemiology in Japan, in: Inter- tions on prophylaxis and treatment of maternal ru-
national Symposium on Rubella Vaccines, pp. 37-42, bella, Acta. Paediat. Scand. 51:1-88, Suppl. 133
Karger, Basel, 1969. (1962).
62. KONO, R., HIBI, M., HAYAKAWA, Y., AND ISHII, K., 77. MANSON, M. M., LOGAN, P. D., AND Loy, R. M.,
Experimental vertical transmission of rubella virus
Rubella and other virus infections during preg-
in rabbits, Lancet 1:343-347 (1969).
nancy, in: Report on Public Health and Medical Sub-
63. KRUGMAN, S., AND KATZ, S. L., Rubella immuniza-
jects, No. 101, Her Majesty's Stationery Office, Lon-
tion: A five-year progress report, N. Engl. J. Med. don, 1960.
290:1375-1376 (1974).
78. MENSER, M. A., SLlNN, R. F., DODS, L., HERTZBERG,
64. KRUGMAN, S., AND WARD, R., Rubella: Demonstra-
R., AND HARLEY, J. D., Congenital rubella in a
tion of neutralizing antibody in gamma globulin
mother and son, Aust. Paediat. J. 4:200-202 (1968).
and re-evaluation of the rubella problem, N. Engl. f.
Med. 259:16-19 (1958). 79. METILER, N. E., PETRELLI, R. I., AND CASALS, J.,
65. KRUGMAN, S., WARD, R, JACOBS, K. G., AND LAZAR, Absence of cross-reactions between rubella virus
M., Studies on rubella immunization. I. Demonstra- and arbovirus, Virology 36:503-504 (1968).
tion of rubella without rash, J. Am. Med. Assoc. 80. MEYER, H. M., PARKMAN, P. D., AND PANOS, T. c.,
151:285-288 (1953). Attenuated rubella virus: Production of an experi-
66. LARSON, H. E., PARKMAN, P. D., DAVIS, W., J., mental live virus vaccine and clinical trial, N. Engl.
Hopps, H. E., AND MEYER, H. M., JR., Inadvertent J. Med. 275:575-580 (1966).
rubella virus vaccination during pregnancy, N. 81. MEYER, H. M., PARKMAN, P. D., HOBBINS, T. E.,
Engl. J. Med. 284:870-873 (1971). LARSON, H. E., DAVIS, W. J., SIMSARIAN, J. P., AND
67. LE BOUVIER, G. L., Rubella precipitins, in: Interna- Hopps, H. E., Attenuated rubella viruses: Labora-
tional Symposium on Rubella Vaccines, London, 1968: tory and clinical characteristics, Am. J. Dis. Child.
Symposium Series Immunobiological Standardization, 118:155-165 (1969).
Vol. 11, pp. 133-138, Karger, Basel, 1969. 82. MURPHY, F. A., HALONEN, P. A., AND HARRISON, A.
68. LE BOUVIER, G. L., AND PLOTKIN, S., Precipitin K., Electron microscopy of the development of ru-
responses to rubella vaccine RA 27/3, J. Infect. Dis. bella virus in BHK-21 cells, J. Virol. 2:1223-1227
123:220-223 (1971). (1968).
69. LEERH0Y, J., Neutralization of rubella virus in a rab- 83. NAEYE, R. L., AND BLANC, W., Pathogenesis of
bit cornea cell line (SIRC), Acta Pathol. Microbiol. congenital rubella, f. Am. Med. Assoc. 194:1277-1283
Scand. 67:158-159 (1966). (1965). •
70. LEHANE, D. E., NEWBERG, N. R., AND BEAM, W. E., 84. OGRA, P. L., AND HERD, J. K., Arthritis associated
with induced rubella infection, J. Immuno/. 107:810- 99. SEPPALA, M., AND VAHERI, A., Natural rubella infec-
813 (1971). tion of the female genital tract, Lancet 1:46-47 (1974).
85. OGRA, P. 1., KERR-GRANT, D., UMANA, G., 100. SEVER, J. L., HARDY, J. B., NELSON, K. B., AND
DZIERBA, J., AND WEINTRAUB, D., Antibody re- GILKESON, M. R., Rubella in the collaborative peri-
sponse in serum and nasopharynx after infections natal research study. II. Clinical and laboratory
with rubella virus, N. Eng/. J. Med. 285:1333-1339 findings in children through 3 years of age, Am. J.
(1971). Dis. Child. 118:123-132 (1969).
86. PARKMAN, P. D., BUESCHER, E. 1., AND ARTENSTEIN, 101. SEVER, J. 1., HUEBNER, R. J., CASTELLANO, G. A.,
M. S., Recovery of rubella virus from army recruits, SARMA, P. S., FABIYI, A., SCHIFF, G. M., AND
Pmc. Soc. Exp. BioI. Med. 111:225--230 (1962). CUSUMANO, C. 1., Rubella complement fixation test,
87. PARKMAN, P. D., MUNDON, F. K., MCCOWN, J. M., Science 148:385--387 (1965).
AND BUESCHER, E. 1., Studies of rubella. II. Neutral- 102. SEVER, J. 1., SCHIFF, G. M., BELL, J. A., KAPIKIAN,
ization of the virus, J. Immunol. 93:60~17 (1964). A. Z., HUEBNER, R. J., AND TRAUB, R. G., Rubella:
88. PERLINO, C. A., AND ISACSON, P., Direct hemad- Frequency of antibody among children and adults,
sorption by cell cultures infected with rubella virus, Pediatrics 35:996-998 (1965).
Am. ]. Dis. Child. 118:83-88 (1969). 103. SIEGEL, M., AND GREENBERG, M., Fetal death, mal-
89. PLOTKIN, S. A., Attenuation of RA 27/3 rubella virus formation and prematurity after maternal rubella:
in WI-38 human diploid cells, Am. ]. Dis. Child. Results of prospective study, 1949-1958, N. Eng!. J.
118:178-185 (1969). Med. 262:389-393 (1960).
90. PRINZIE, A., HUYGELEN, c., GOLD, J., FARQUHAR, J., 104. SIGURJONSSON, J., Rubella and congenital deafness,
AND McKEE, J., Experimental live attenuated rubella Am. J. Med. Sci. 240:712-720 (1961).
virus vaccine: Clinical evaluation of Cendehill 105. SIMONS, M. J., Congenital rubella: An immunologi-
strain, Am. J. Dis. Child. 118:172-177 (1969). cal paradox? Lancet 2:1275--1278 (1968).
91. RAWLS, W. E., Congenital rubella: The significance 106. SOOTHILL, J. F., HAYES, K., AND DUDGEON, J. D.,
of virus persistence, Prog. Med. Virol. 10:238-285 The immunoglobulins in congenital rubella, Lancet
(1968). 1:1385--1388 (1966).
92. RAWLS, W. E., DESMYTER, J., AND MELNICK, J. 1., 107. STEWART, G. 1., PARKMAN, P. D., Hopps, H. E.,
Serologic diagnosis and fetal involvement in mater- DOUGLAS, R. D., HAMILTON, J. P., AND MEYER, H.
nal rubella, criteria for abortion, J. Am. Med. Assoc. M., Rubella virus hemagglutination-inhibition test,
203:627-631 (1968). N. Engl. ]. Med. 276:554--557 (1967).
93. RAWLS, W. E., MELNICK, J. 1., BRADSTREET, C. M. P., 108. SVEDMYR, A., LUNDSTROM, R., THOREN, c., Rubella
BAILEY, M., FERRIS, A. A., TIEHMANN, N., NAGLER, immunity as correlated to age and history of overt
F. P., FURESZ, J. KONO, R., OHTAWARA, M., HALO- disease, Arch. Gestamte Virusforsch. 22:48-54 (1967).
NEN, P., STEWART, J., RYAN, J. M., STRAUSS, J., ZDRA- 109. TONDURY, G., AND SMrrH, D. W., Fetal rubella pa-
ZILEK, J., LEERH0Y, J., VON MAGNUS, H., SOHIER,R., thology,]. Pediat. 68:867-879 (1966).
AND FERREIRA, W., WHO Collaborative study on the 110. V AHERI, A., AND HOVI, T., Structural proteins and
sero-epidemiology of rubella, Bull. WHO 37:79-88 subunits of rubella virus, J. Virol. 9:10-16 (1972).
(1967). 111. VAHERI, A., VESIKARI, T., OKER-BLOM, N., SEPPALA,
94. SCHMIDT, N. J., AND LENNETTE, E. H., Rubella M., PARKMAN, P. D., VERONELLI, J., AND ROBBINS, F.
complement-fixing antigens derived from the fluid c., Isolation of attenuated rubella-vaccine virus from
and cellular phases of infected BHK-21 cells: Extrac- human products of conception and uterine cervix, N.
tion of cell-associated antigen with alkaline buffers, Engl. ]. Med. 286:1071:-1074 (1972).
J. Immuno!. 94:815--821 (1966). 112. VAHERI, A., VESIKARI, T., PENTTINEN, K., AND MYL-
95. SCHMIDT, N. J., AND LENNETTE, E. H., Antigens of LYLA, G., Soluble rubella antigens, platelet aggrega-
rubella virus, Am. J. Dis. Child. 118:89-93 (1969). tion and postrubella thrombocytopenia, International
96. SCHMIDT, N. J., AND STYK, B., Immunodiffusion Symposium on Rubella Vaccines, London, 1968: Sym-
reactions with rubella antigens, J. Immuno!. 101:210- posium Series Immunobiological Standardization, Vol.
216 (1968). 11, pp. 107-108, Karger, Basel and New York, 1969.
97. SCOTT, H. D., AND BYRNE, E. B., A serologic study 113. VEALE, H., History of an epidemic of Rotheln, with
of susceptible pregnant women exposed to a state- observations on its pathology, Edinburgh Med. ].
wide rubella (HPV-77 DES) immunization cam- 12:404-414 (1866).
paign,]. Am. Med. Assoc. 215:609-612 (1971). 114. WEIBEL, R. E., BUYNAK, E. B., STOKES, J., JR., AND
98. SEDWICK, W. D., AND SOKOL, F., Nucleic acid of HILLEMAN, M. R., Persistence of immunity after
rubella virus and its replication in hamster kidney measles, mumps, rubella vaccines, Pediatrics 51:467-
cells, J. Virol. 5:478-489 (1970). • 475 (1973).
115. WEIBEL, R. E., STOKES, J., JR., BUYNAK, E. B., AND rubella vaccination of pregnant women: Fetal risk in
HILLEMAN, M. R., Influence of age on clinical re- 215 cases, f. Am. Med. Assoc. 225:1472-1476 (1973).
sponses to HPV77 duck rubella vaccine, f. Am. Med.
Assoc. 222:805--807 (1972).
116. WELLER, T. H., AND NEVA, F. A., Propagation in 12. Suggested Reading
tissue culture of cytopathic agents from patients
with rubella-like illness, Proc. Soc. Exp. BioI. Med. BRODY, J. A., SEVER, J. L., McALISTER, R., SCHIFF, G. M.,
111:215-225 (1962). AND CUTTING, R., Rubella epidemic on St. Paul Island
117. WILKINS, J., LEEDOM, J. M., SALVATORE, M. A., AND in the Pribilofs, 1963. 1. Epidemiologic, clinical, and
PORTNOY, B., Clinical rubella with arthritis resulting serologic findings, f. Am. Med. Assoc. 191:8J-87 (1965).
from reinfection, Ann. Intern. Med. 77:930-932 GREGG, N. M., Congenital cataract following German
(1972). measles in the mother, Trans. Ophthalmol. Soc. Aust.
118. WITTE, J. J., KARCHMER, A. W., CASE, G., HERR- 3:35--46 (1941).
MAN, K. L., KASSANOFF, 1., AND NEILL, J. S., Epide- HORSTMANN, D. M., Rubella: The challenge of its control,
miology of rubella, Am. f. Dis. Child. 118:107-111 j. Infect. Dis. 123:640-654 (1971).
(1969). International Conference on Rubella, Proceedings, Am. f.
119. WOODS, W. A., JOHNSON, R., HOSTETLER, D. D., Dis. Child. 118:1-410 (1969).
LEPOW, M., AND ROBBINS, F., Immunofluorescent MODLIN, J. F., BRANDLING-BENNET, A. D., WITTE, J. J.,
studies on rubella infected tissue cultures and hu- CAMPBELL, C. c., AND MEYERS, J. D., A review of five
man tissues, f. Immunol. 96:25J-260 (1966). years' experience with rubella vaccine in the United
120. WYLL, S. A., AND HERRMANN, K. L., Inadvertent States, Pediatrics 55:20-29 (1975).
CHAPTER 20
Smallpox
Abram S. Benenson
1. Introduction sions on the mummified face of Rameses V, dated

1160 Be., suggest that he died of smallpox. 1]4)
Smallpox is a serious systemic disease which may While smallpox has apparently existed in China
kill 40--50% of the unprotected individuals it af- and India for thousands of years, the disease is not
flicts. The disease has a characteristic exanthem mentioned by the early Greek writers. A Syrian
and disfigures and sometimes blinds most of the epidemic was described in A.D. 302, and during
survivors. A closely related poxvirus, that of var- the next several hundred years reports became
iola minor (or alastrim), causes a similar exanthem more frequent of epidemics which could have
but less severe illness and the case fatality rate is been smallpox. The term variola was used by
2% or less. Bishop Marius of Avenches in 570 to describe an
The story of smallpox is a dramatic tale of a epidemic in Italy and France, but the disease was
disease with such potential epidemic violence that not clearly described until about A.D. 900 by the
it has shaped the history of the past, certainly of Persian physician Rhazes. (42 ) Smallpox was
the New World, and is now at the brink of global spread through Europe by the invasion of the
eradication. Formerly a merciless devastator of continent by the Saracens and then by returning
whole populations, now the very rare complica- crusaders."6) The Spaniards brought smallpox
tions of its preventive measure have assumed an with them to the West Indies in 1507 and to
importance much greater than that of the disease Mexico in 1520, resulting in devastating epidemics
itself. Its decline has not been that of von Economo which decimated the Indians. The phenomenal
encephalitis, which appeared widely over one success of a few conquistadores in subjugating the
short interval and with 110 known cause and was Aztec and Inca kingdoms may well have been
gone for no known reason; the disappearance of abetted by an advancing pandemic of smallpox
smallpox is the result of man's persistent and which is estimated to have caused the death of 3!
organized effort. million people within a few years. (85) While on
the whole this occurred naturally, in certain in-
stances there is documentation that hostile Indians
were deliberately exposed to smallpox with the
There are reasons to believe that smallpox has intent of generating an epidemic. (86)
existed since earliest times; for example, the le- In the seventeenth and eighteenth centuries,
smallpox was the most devastating disease in the
Abram S. Benenson . Department of Community Western world. (52) Queen Mary died of the dis-
Medicine, University of Kentucky College of Medicine, ease in 1694; the Duke of Gloucester, son of Anne,
Lexington, Kentucky died in 1700. In 1711, Emperor Joseph also suc-
429
430 Chapter 20 • Smallpox
cumbed to smallpox. In 1707, 18,000 of the popula- when smallpox hit Boston in 1792, 97% of the
tion of 50,000 in Iceland, or 36% of the total population had been inoculated!(W)
population, died from smallpox in a single year. In The truly great advance in the smallpox story
the New World, Boston experienced eight epidem- was the experiment carried out by Edward Jenner
ics during the eighteenth century with attack rates in testing the old wives' tale that those who had
as high as 52% of the population.(J(D had cowpox were not susceptible to smallpox.
Inoculation of smallpox has been practiced as a After confirming that those who had a history of
protective measure in Asia and apparently in Af- cowpox were insusceptible to variolation, on May
rica for some time. Reverend Cotton Mather in 14, 1796 he vaccinated James Phipps with material
Boston learned of the practice from his slave, (90) obtained from a pustule on the hand of a milk-
and when the Philosophical Transactions of the maid; 6 wk later he challenged Phipps with pus
Royal Society in London published in 1714 the from a patient having smallpox, with no take.
letter by Timoni in which were described inocula- After 12 or more successful other vaccinations, his
tions against smallpox in Turkey, Mather resolved submitted report was rejected and he had to pub-
to introduce the practice should smallpox "again lish his work privately. (4J)
enter into or City."(49) When a major epidemic As with variolation, the Atlantic Ocean posed
occurred in 1721, which ultimately afflicted half no barrier to the news of vaccination(s,(;O); by
the population of Boston, with a fatality rate of 1799, vaccine had been received and vaccinations
approximately 15%, Cotton Mather induced Dr. carried out in the New World. However, Dr.
Zabdiel Boylston to try the technique. On June 26, Benjamin Waterhouse of Boston is acknowledged
1721, Boylston inoculated his 6-yr-old son and two to be the Jenner of America. He received vaccine
slaves without mishap, and not long afterward a and in 1800 vaccinated four of his children, a 12-
13-yr-old son and seven other persons. Despite yr-old servant boy, and two adults. To assure
professional, clinical, and public opposition, protection against smallpox, they were admitted to
Boylston persisted and vaccinated at least 247 the smallpox hospital and variolated; this resulted
individuals, with a fatality rate of 2% in compari- in a lesion which was gone after 2 days and
son to the 15% fatality among those who acquired smallpox was not acquired from exposure to the
smallpox naturally. Despite the continued opposi- highly contaminated environment. (92) Demand for
tion of Boylston's medical colleagues, the public vaccination was immediate, but unfortunately
began to recognize and seek the beneficial effects many vaccinations were performed with material
of variolation. Concurrently, Lady Mary Wortley obtained from pyogenic reactions, so that the next
Montagu, who had lived in Turkey as the wife of exposure to smallpox resulted in disease, or the
the British ambassador and had had her son inoc- "vaccines" were contaminated with smallpox vi-
ulated in 1717, introduced the practice to the rus, resulting in outbreaks of this disease. The
British Court. problem of spurious vaccine was complicated by a
The acceptance of variolation as a protective proliferation of spurious vaccinators, "such as
measure was marred by the fact that, although stage-drivers, peddlers, and in one instance the
fatalities among the inoculated were realtively few, sexton of a church."(fill Strong opposition to vac-
the virus in use was fully pathogenic and could and cination and questions of its effectiveness devel-
did initiate epidemics of typical and fatal disease oped. Waterhouse organized a conclusive public
among uninoculated contacts. Self-styled, un- test of the efficacy of vaccination/ 92 •9;n and in-
trained inoculators went into business and their volved Jefferson in spreading vaccine and vaccine
activities resulted in not only epidemics but also use through much of the country.(oB.fill To avoid
sepsis. As a consequence, many communities out- the mischance of contaminated or spurious vac-
lawed variolation.(7) cine, central sources were established such as the
Smallpox exerted so strong an influence on oper- Vaccine Institute set up in Baltimore in 1802 by
ations during the American Revolution(Bo) that il1 James Smith yO)
1777 Washington ordered the inoculation of all Despite the availability of vaccine, smallpox
Continental troops who had not had the discontinued to be endemic within the United States
ease. (25) The practice became so well accepted that into the 1940s, its incidence varying with the level
Chapter 20 • Smallpox 431
of vaccination. The decline of smallpox has been be so small that routine childhood smallpox vacci-
correlated by Leake(4S) with improved vaccine nation was no longer indicated. It recommended
potency as electric refrigeration came into use. that efforts be devoted to ensure immunization
Military personnel returning from the Far East in only of all personnel involved in health services and
1946 produced outbreaks in Seattle and in San all travelers to and from continents where smallpox
FranciscoYOl In 1947, a traveler from Mexico cre- was not eradicated;OO) in January, 1976, vaccina-
ated a small outbreak in New York City, with 12 tion became required only for travelers who had
cases and two deaths.(91l In 1949, eight cases been in Ethiopia in the 2 wk before returning to the
occurred in the lower Rio Grande Valley in U.S. and for personnel of laboratories working with
Texas(39); since that time, no smallpox has oc- variola virusyoa)
curred within the United States. Smallpox vaccina-
tion programs which reached all segments of the
population removed smallpox from country after 3. Methodology Involved in Epidemiological
country. The world situation in 1950 is presented in Analysis
Fig. 1.
In 1966, the World Health Organization em-
barked on a program of eradication. This had pro-
gressed sufficiently well so that in September 1971 Smallpox is one of the internationally quarantin-
the U.S. Public Health Service considered the risk able diseases, so that the occurrence of any cases
in the United States of infection with the disease to of or deaths from smallpox is to be reported by any
SMALLPOX INCIDENCE IN ENDEMIC COUNTRIES· CASES PER 100000 POPULATION

1950
• > 5.0 cases per 100000 populotion • 0.5·5.0 cases per 100000 population E2l < 0.5 cases per 100000 population
No reports received from China {mainland}, Kuwoit, Liberia, Morocco, Muscat & Oman, Nepal, Panama, Quator, South·West Africa, Trudal Oman and Yemen
Fig.!. Smallpox incidence in endemic countries, 1950. From WHO Chronicle 22:134-146 (1968).
member nation to the World Health Organization. 3.3. Surveys

Since approximately 90% of smallpox patients
have skin lesions characteristic of the disease and 3.3.1. Serological Surveys. Serological surveys
recognized as such by the general public, with a to assess the immunity of a community against
good disease reporting system mortality data on smallpox are relatively unsatisfactory. While the
smallpox can be more accurate than that for any neutralizing antibody level correlates best with
other disease. Howe~er, in many parts of the immunity of the individual and thus the popula-
world, cases are hidden by families to avoid the tion, its performance is cumbersome, so that large
removal of their relatives to truly deplorable isola- numbers of tests can be carried out only with diffi-
tion hospitals, and on occasion communities or culty. Hemagglutination-inhibiting antibodies are
countries have deliberately concealed the presence more easily measured in large numbers, but the
of disease for political-economic reasons. Deaths correlation with immunity is poor. Complement
are generally more accurately reported than the fixation and precipitating antibodies persist only
number of cases. for relatively short intef\lals. Their presence is in-
dicative of recent infection with either variola or
vaccinia virus; history of vaccination is essential for
analysis. Variola usually evokes a much higher an-
3.2. Sources of Morbidity Data tibody level than uncomplicated vaccinia.
3.3.2. Scar Surveys. A unique feature of small-
As noted above, as a quarantinable disease pox is that both the disease and its preventive
smallpox must be reported to WHO from all mem- measure, Jennerian vaccination, leave a dermal
ber nations. While the barriers to reporting of record of their occurrence. This makes it possible
deaths are even more applicable to the reporting of to survey a population for its past experience with
cases, among vaccinated individuals there can be the disease or with its preventive measure by
cases whose differentiation from chickenpox, if the doing a scar survey. By cluster sampling tech-
two diseases are occurring simultaneously, can be niques, activity of the disease and of the vaccina-
established with certainty only by laboratory stud- tors is detailed by recording the ages of those with
ies. or without scars. The survey may be carried out on
The reliability of reporting can be deduced from the whole population or on a segment such as the
the reported death/case ratios; a case fatality rate D-4 or 0-14 yr age group.(35)
over 15-20% is indicative of underreporting. a. Vaccination Scar Survey. The vacination scar
Where a poor reporting system exists, gross un- prOVides an immediate indication of those on
derreporting is to be expected. Thomas et al. (87) whom this preventive procedure was carried out;
established by inquiry in July 1967 that 119 cases those without vaccination or smallpox scars consti-
of smallpox with 29 deaths had occurred within a tute the susceptible popUlation. Unfortunately, the
circumscribed population in East Pakistan (Bang- presence of the scar at the site used for vaccination
ladesh) during the preceding year; only 13 cases of does not necessarily indicate that the individual is
smallpox had been reported to the government presently immune to smallpox. The immunity
from only five of the 23 affected villages. In these might have been present but have waned if many
five villages there was in fact a total of 54 cases. In years have passed since the last vaccination, or the
West Pakistan during a period when 129 outbreaks scar may be the consequence of a pyogenic infec-
occurred with a total of 1040 smallpox cases, only tion which was induced rather than the desired
23 (19%) of these outbreaks and 14% of the cases vaccinial infection. The typical vaccinial scar is
had been officially reported. (88) It is evident that foveated, i.e., pitted and depressed.
routine reporting methods often must be supple- b. Smallpox Scar Survey. The smallpox scar sur-
mented by more aggressive epidemiological explo- vey is facilitated by the centrifugal distribution of
rations if accurate data are required, even with a the pocks, so that residual scars are present on the
disease whose diagnosis is evident in the vast face. An individual is considered positive if at
majority of cases. least five characteristic round, depressed facial
scars, 1 mm or more in diameter, are present. The Visualization of the characteristic brick-shaped vi-
oldest cohort of children with un scarred faces rus particles identifies the lesion as due to a
indicates the period since smallpox was last pres- member of the variola-vaccinia group; the pres-
ent in this population group. ence of the smaller and spherical herpes-type ele-
It is more difficult to estimate what the inci- mentary body is consistent with chickenpox or
dence of smallpox has been from a scar survey. An herpes disease. (51) Thin smears may be examined
approximation, at best, is possible if one corrects under the light microscope for the presence of the
for those who did not survive the disease, and for elementary bodies that have been stained by ap-
those who survived disease and were spared pock propriate methods; this cannot be done with ma-
marks. (55) Rao(74) reported that 30% of smallpox terial from the pustular stage. (17)
survivors in Madras lost their scars within 5 yr; Fluorescent antibody techniques may also give a
Foster obtained a comparable figure in Nigeria. rapid answer, but false positive results may oc-
The outcome was age related: of those in the 0-4 yr cur.(65) Agar gel diffusion of vesicle or pustular
age group, only 30% retained scars; in the 5-9 yr fluid or of a crust extract against a specific anti-
age group, 43% were scarred; of those age 10 yr serum and with a positive control may show a line
and over, 89% retained scars.(lOl) In Pakistan, of precipitation within 2 h, fusing with the lines
Mack et al. (55) found pock marks on 65.9% of from the positive control to indicate antigenic
smallpox survivors examined after 1 yr; only 46% identity with the known vaccinal antigen within
of the 63 survivors under 5 yr old were scarred as 6--8 h.(65.97) The complement fixation procedure
against 76.5% among the 119 who were 5 yr old or may also be used to detect the presence of antigen
older. in the lesion, but this requires 18-24 h before the
test can be read. (65)
In all cases virus should be isolated, preferably
3.4. Laboratory Methods on the chorioallantoic membranes of embryonated
hen's eggs or on appropriate tissue culture. In 2 or
3.4.1. Virus or Antigen Identification. Virus or 3 days, CAM lesions distinguish between variola
antigen identification may be accomplished from and vaccinia virus or the differentiation is made
the skin lesions at any stage and from the blood by subculturing at 35.25"C, 38.25°C, and 39-400C.
usually during the prodromal state; when viremia The virus of variola minor or alastrim will grow
persists, the prognosis is very poor. (18) Blood is only at the lowest temperature; only vaccinia virus
collected with sterile anticoagulant. From the skin will grow at a temperature of 39°C or above.(2.67l
lesions in the maculopapular stage, five or six Varicella virus will not grow on the CAM.
lesions should be scraped with a scalpel or a In support of the WHO eradication program,
Hagedorn needle to obtain blood-free serous and Nakano and Bingham(65) report that at the Center
cellular material from the lower epithelial layers of for Disease Control, Atlanta, Georgia, electron
the skin. This is spread thinly on several clean microscopy, CAM culturing, and agar gel precipi-
glass slides, and the slides are dried in the air tation detected 95.6%,89.1%, and 78.8%, respec-
without heat or preservative. Vesicular or pustular tively, of the 367 positive specimens. Nakano'64l
fluid from several lesions is aspirated into capillary would add tissue culture to these three tests to
glass tubes or a tuberculin syringe; the floor of assure complete confidence in a negative report.
these lesions is scraped gently to obtain cellular Of course, the validity of any laboratory testing
(but not bloody) material which is spread on depends on the quality of the material submitted
slides. If the disease is at the scabbing stage, at to the laboratory.
least six scabs are collected in a screwcapped 3.4.2. Serological Tests. No serological test now
bottle. The virus is stable and can be shipped available can differentiate the antivariola from an-
(with due regard for postal regulations) without tivaccinal antibodies so that recent vaccination
refrigeration. <17.97) must be considered when a titer rise is observed.
If available, the most rapid answer comes from In general, titers following variola are much higher
electron microscopic examination of the smears. than those seen after vaccination. Serological tests
have their greatest value for detecting subclinical variola viruses produce disease in man and mon-
infections or variola sine eruption. keys; they multiply but do not produce disease in
The agar gel precipitation (or immunodiffusion) suckling mice. Cowpox and vaccinia viruses on
test is positive after the eighth day of illness from the other hand have a wide host range. The
smallpox and not infrequently after recent vaccina- purported derivation of present vaccine strains
tion; within several months, this antibody is no from virus taken from smallpox patients and mod-
longer detectable. In the complement fixation test, ified by passage through rabbits and calves was
a titer as high as 1:320 appears by the tenth to the tested by Herrlich et ai. (a6) Despite as many as 100
twelfth day; after vaccination or revaccination, passages, it was impossible to change the host
antibodies appear at a much lower titer. Comple- range of either variola or alastrim strains. They
ment-fixing antibodies are rarely detectable 12 conclude that "modification" was due to the pres-
months after infection. Hemagglutination-inhibit- ence in the original material of vaccinia virus,
ing antibody titers are much higher in the conva- which has the broadest host spectrum. Gispen and
lescent smallpox patient than those seen after vac- Brand-Saathof27l have shown by agar gel precipi-
cination; they tend to drop or disappear after a tation the presence of specific antigens by which
year or more. (19.62) one could differentiate the variola and monkeypox
Virus neutralization tests can be carried out viruses from each other and from the other mem-
either on the chorioallantoic membrane of em- bers of the group; vaccinia, rabbitpox, buffalopox,
bryonated eggs or in tissue cultures. Very much and camelpox could not be differentiated from
higher titers are seen in smallpox convalescent sera each other by this technique.
than after vaccination; neutralizing titers persist The smallpox virus is stable in the dried condi-
for long periods.(19.62) tion. It has survived at room temperatures in
A fourfold rise in any of these titers during the crusts for over a year and for nearly 3 months in
course of the illness indicates infection with a the dark and for over a month in the light when
vaccinia-variola virus; the interpretation of the dried on slides.(15) Viability is greater at lower
high-titered single serum is equivocal. levels of relative humidity. When moist, the virus
is killed by heating at 60"C for 10 min; when dry,
it may withstand 100"C for 5-10 min. It is sensitive
to ultraviolet light (sunlight); vaccinia virus (used
4. Biological Characteristics of the Virus as the laboratory model) is inactivated at pH 3
within an hour. It is inactivated by oxidizing
Smallpox is caused by a member of the group I disinfectants such as hypochlorites or potassium
of poxviruses, which also includes the viruses of permanganate; formaldehyde at a concentration of
cowpox, monkeypox, rabbitpox, and ectromelia, 0.2% destroys infectivity in 24 h at room tempera-
as well as variola and vaccinia viruses. All of these ture. The virus is resistant to 1 % phenol for weeks
viruses are morphologically indistinguishable; at 4°C but is inactivated within 24 h when the
they are large double-stranded deoxyribonucleic temperature is raised to 37"C; it is resistant to
acid viruses, brick-shaped and ranging in size 1:10,000 brilliant green.(IS)
from 250 to 300 nm by 200 to 250 nm wide; this The range of severity of illness and varying case
places them just within the visibility of the light fatality rates observed in different outbreaks raise
microscope. Electron microscopy reveals the pres- the question of the relative virulence of different
ence of a central denser area with certaiil charac- strains. In outbreaks due to variola minor virus,
teristics of a nucleus. While the elementary bodies mild cases predominate but hemorrhagic cases
(Paschen bodies) are indistinguishable and share occur and the fatality rate is approximately 1%;
common antigens and cross-immunity, the mem- deaths are more frequent in outbreaks due to the
bers of the group do vary in' their biological intermediate strains. But even in outbreaks caused
attributes; for example, the variola viruses can be by variola major virus there are variations in the
differentiated into variola major, variola minor, severity of disease among the unvaccinated from
and an intermediate type based on differential place to place and year to year. Sarkar and Mi-
growth temperatures and chick lethality. (2) The tra,!S]) using lethality for chick embryos and for
mice, histological changes produced on the cho- pia; that in Asia in 1973 occurred in Bangladesh
rioallantoic membrane, and the viral count in the and India following the social and natural catastro-
liver of the chick embryos, tested 25 strains iso- phes of war and flood. Of greater import than the
lated from discrete rash cases. All four tests were number of reported cases is the reduction in the
positive with 48% of the strains from hemorrhagic number of countries reporting cases, and espe-
cases and 9% and 0% of strains from confluent cially of those in which smallpox is still endemic.
and discrete cases, respectively. While this indi- Where intensive studies were carried out in re-
cates a relation between severity and strain charac- stricted areas, higher rates were found; in their
teristics, it must be noted that eight (32%) of the Bangladesh study area in 1966-1967, Thomas et al.
strains isolated from hemorrhagic cases were neg- found an incidence of 106 per 100,000(87); in West
ative in all four tests. Pakistan during 1967-1968, Mack et al. found 100
per 100,000 in their study area.(5Hl Based on scar
surveys, only 19% and 12% of the study popula-
5. Descriptive Epidemiology tions, respectively, had not previously been vacci-
nated or had smallpox. (87)
The study carried out in West Africa after indig-
5.1. Incidence and Prevalence Data
enous smallpox had been eradicated from the area
From a disease once so prevalent that recovery found that there still was 17.6% of the population
from smallpox was considered essential for sur- susceptible to smallpox. Smallpox scars were pres-
vival in large areas of the earth, only a few pockets ent in 12.8% and vaccination scars in 82.4%.(;W
of infectivity persist. The incidence in various While the overall susceptibility based on scars was
countries has varied markedly from year to year comparable to that found in Bengal and Punjab,
depending on the intensity and conscientiousness where disease was still endemic, the West African
with which vaccination programs were carried out vaccination scars resulted from the recent WHO
and with which cases were sought out and revaccination program and were associated with a
ported. In 1962, 14 African countries reported to high level of immunity.
the World Health Organization smallpox incidence
rates over 10 per 100,000 population, ranging from
10 to 144; the rate in Brazil was 4; in Asia, three
countries-India, Indonesia, and Pakistan-re- By reputation, smallpox has been considered the
ported rates of 10, 1, and 4 per 100,000 population, most highly contagious of infectious diseases, so
respectively. (94) By 1971, only two countries, that when it appeared in a community an explo-
Ethiopia and Sudan, had rates over 5 per 100,000, sive outbreak was expected among all susceptibles
i.e., 10.1 and 6.9, respectively.(98) In 1974, disease even remotely exposed to the case. In the big cities
was endemic in only four countries: Ethiopia in of Europe during the seventeenth and eighteenth
Africa, with a rate of 16 per 100,000, Pakistan, centuries, disease was constantly present, with
Bangladesh, and India in Asia, with rates of 12, 20, epidemics occurring periodically in rural areas. In
and 32 per 100,000 population, respectively. Dur- less densely populated America, severe epidemics
ing 1974, five countries reported cases introduced followed the arrival of infected ships; then the
from these endemic countries. (](14) By July 1975, disease would disappear until reintroduced.
smallpox transmission persisted in only two coun- Careful epidemiological studies carried out dur-
tries on the globe-Ethiopia in Africa and Bangla- ing the smallpox eradication program in West
desh in Asia; by January 1976, it persisted only in Africa changed this picture of high infectivity to
Ethiopia. Global eradication has come within one of a slowly moving disease with as many as 80
sight. (l05) days elapsing between the onset of symptoms in
The total number of reported cases and conti- the first and last cases among 15 susceptible per-
nents from which these cases were reported are sons living within a single compound and a sec-
shown in Table 1 derived from World Health ondary attack rate of 26-44% in three different ar-
Organization reports. The increase in Africa in eas.(24) In Madras, only 36.9% of unvaccinated
1971 was accounted for by the epidemic in Ethio- family contacts developed smallpox.!7r» In East
Table 1. World Incidence of Smallpox, 1959-1974
Number of
countries
Year Africa Americas Asia Europe Oceania Total reporting
1959 16,307 5,488 71,309 15 93,119 53

1960 16,823 8,021 39,843 47 1 64,735 59
1961 26,060 9,065 53,958 24 89,107 61
1962 24,329 9,828 63,570 136 97,863 55
1963 16,863 7,202 98,784 129 122,978 46
1964 12,506 3,621 43,537 59,664 44
1965 16,952 3,632 91,558 1 112,143 43
1966 14,381 3,665 74,284 72 92,402 43
1967 15,529 4,544 111,340 5 131,418 42
1968 11,068 4,375 64,764 2 80,209 31
1969 3,605 7,410 43,208 54,223 27
1970 3,177 1,795 28,669 22 33,663 23
1971 27,667 19 25,102 52,788 16
1972 19,000 45,977 176 65,153 19 (W
1973 5,462 130,386 135,848 11 (4)
1974 4,450 213,914 218,364 9 (3)
1975 3,894 15,329 19,223 5 (1)
a Number of countries with endemic disease at the end of the year.
Pakistan (Bangladesh), 42.9% of unvaccinated returned to their homes, usually when they be-
family contacts developed disease; the risk of in- came ill. The risk of introductions into a village
fection among susceptibles varied with the charac- did not relate to accessibility or any other factor
teristics of the source of infection. When the in- except increased risk with larger village popula-
troducer had no scar of prior vaccination or had tions.
died from the disease (presumptive evidence of no The situation with regard to transmission dif-
prior vaccination), 50% of susceptible family fered in the Punjab area of West Pakistan. In 1967-
members were infected, but only 8.3% were in- 1968, Mack et al. (56) found a 96% attack rate
fected when the introducer had previously been among unvaccinated compound (household) con-
vaccinated. (87) Rao et al. (75) found that 66% of tacts; virtually all secondary compound cases oc-
unvaccinated family contacts developed smallpox curred within one generation of the index case.
when the member with the primary case died, in Greater spread occurred within the village to other
contrast to 32% when he survived. compounds when the index case was one of severe
The pattern of the disease between July 1, 1966, smallpox. Like the situation in Bangladesh, iqtro-
and June 30, 1967, was studied in a rural area of ductions were principally from large population
East Pakistan. (89) While there were 132 villages in centers outside the study area and the unimmun-
the study area, 30 outbreaks of smallpox occurred ized were much more likely to become introdu-
in only 27 villages. The origin of 22 outbreaks was cers. At no time in this period of relatively high
established; 21 of these were introduced from smallpox incidence (100 per 100,000 in this area)
outside the area and only once did smallpox did the disease occur simultaneously in more than
spread from one village to another within the area. about 50 of the 1717 communities in the study
Over two-thirds of the outbreaks were brought area; during the study period, disease occurred in
from large cities, the introducers being adult males only 99 different communities. In the same area, in
from landless families of the villages who had studies carried out over the next 2 yr, Heiner et ai.
gone to the big city seeking employment and found an incidence of 76.8% among unvaccinated
contacts, again a much higher rate than had been The extent and character of the lesions, partly de-
reported in other endemic areas. (~J) pendent on virus strain, determine the amount of
The effect of vaccination on epidemic behavior virus shedding.
was clearly brought out in Mack's study in West
Pakistan.(.;!O In sharp contrast to a 96% attack rate
in the unvaccinated, smallpox occurred in only 4% 5.3. Geographic Distribution
of those who had been vaccinated within 10 yr and The geographic distribution of smallpox 100 yrs
12% of those vaccinated over 10 yr before. In ago was the distribution of man; today it is "a
Bangladesh, 15% of cases occurred among vacci- reflection of the organized activities directed to-
nated individuals; 8.4% of cases were among ward its eradication. While 25 yr ago the disease
those vaccinated 20 yr or more previously. (89) existed on every continent (Fig. 1), national control
In western Europe, the epidemic behavior var- programs constricted this appreciably. (96) When
ies with the time of the year, with very little the WHO Global Eradication Program was initi-
transmission after introductions during the warm ated in 1967, South America, Africa, and Asia
months of the year (three subsequent cases after were important foci; today endemic disease per-
eight introductions) but a significant number of sists only in Ethiopia (Fig. 2). Eradication has been
secondary cases during the dry seasons. (90) More confirmed (i.e., no cases have occurred in over 2 yr)
intimate contact would seem to be essential in in Brazil and in Indonesia, and the bulk of Africa
West Africa and India for infection to occur. Under has been freed of endemic disease.
certain circumstances, minimal contacts can lead to
major outbreaks. In the Seattle outbreak in 1946,(7(1)
51 cases and 16 deaths came from the illness of a .
woman convalescent from diphtheria who was No characteristic periodicity has been described
housed diagonally across the hall from a smallpox for smallpox; outbreaks have followed viral intro-
patient; she had never been in his room but had duction into susceptible groups. It is a seasonal
wandered up and down the hall. An orderly who disease,(J;l·74.841 but no direct correlation with any
attended the smallpox patient had contact with specific meteorological condition has been de-
this patient but purportedly carried out usual fined. In Bangladesh the seasonality is so marked
isolation techniques. Three generations of disease that the Bengali word for the spring of the year,
occurred in the community after the epidemic was bashunto, is the word for smallpox. While the virus
recognized. In the 1972 experience in Yugoslavia, is more stable under lower humidities and lower
173 cases followed the arrival of a pilgrim from temperature, the spring of the year (late dry sea-
Mecca who had a mild or subclinical illness. His son) in East Bengal is both hot and humid.
contact with several individuals was minimal; one In the Punjab, there is a distinct winter peak
of greatest importance was a man who developed a (November-February), with very few cases be-
fever for which he was given penicillin. A rash tween June and September. Mack et al. <;7) found
appeared which was interpreted to be allergic, and that the high (96%) infection rate within the com-
he was hospitalized and transferred to Belgrade pound of the index cases remained high through-
where he died of a hemorrhagic diathesis; he was out the year; there were differences in the attack
the 'source of infection for 37 secondary cases and rates in other compounds. During the periods of
eight tertiary casesYOO) In both outbreaks, the increasing incidence, the mean intergeneration in-
hospital environment was involved; this will be terval from index case to first-generation cases
considered further in Section 5.9. appearing in different compounds was lengthened
The reported risk of acquiring infection varies in (17.6 vs. 20.6 days), but not within the same
different studies. These differences are best inter- compound (13.6 vs. 13.9 days). This was taken to
preted as the varying likelihood of appropriate indicate longer viral survival under conditions of
contact between the index case and the susceptible lower relative humidity, consistent with the hy-
individuals; incidence is obviously greatly influ- pothesis that infection may be occurring within
enced by the vaccination history of the people, by the compound of the source case--in essence, a
their social habits, and by environmental factors. model of "hospital" spread.
SMALLPOX ENDEMIC COUNTRIES. 1967 AND 1975
• 1975 (Dec.) .1967

...
.. . Eradication confinned by special
international commission
Fig. 2. Smallpox endemic countries, 1967 and 1975. From WHO Weekly Epidemiol. Rec. 51:9 (1976).
Data covering the 27 introductions of smallpox 14 yr age group, a period of greatest mobility, and
into Europe between 1961 and 19731J2 ) are rele- the incidence is lowest in those under a year of age,
vant: 20 in the period from December to May were thanks to passive maternal immunity. Age also af-
followed by 483 subsequent cases, for an average fects the case fatality rate: among the unvaccinated,
of 24.2 and a median of 4.5 subsequent cases per the highest case fatality rates are found in those in
introduction; seven introductions 'during the June- the youngest age group and again in the oldest;
November period produced 11 subsequent cases, those in the ~14 yr group less frequently develop
for an average of 1.6 and a median of one case per the highly fatal forms of disease (Table 2), and
importation. Sarkar et al. (83) found a greater frequency of inap-
parent infections in this age group.
5.5. Age
5.6. Sex
The age distribution of smallpox is related to the
immune status and to the relative mobility at Differences in sex incidence relate to cultural
different ages. In most endemic areas, the overall patterns which may influence the likelihood of
incidence is highest among the age group 0-4 yr exposure to an infectious case. In Bangladesh in
simply because this is the group most likely to be 1966-1967, the incidence rate per 100,000 for males
unvaccinated. However, when age-specific rates was 122, for females 89. The excess is probably
among the unvaccinated are considered, disease related to the fact that the disease was introduced
often occurs most frequently among males in the ~ into the communities by males who had gone to
the cities to work. (89) In the Punjab, attack rates of 5.8. Occupation
village-acquired disease in 1967-1968 among the As was noted above, in Bangladesh the disease
unvaccinated were comparable for boys and girls predominated among the unskilled and semi-
until puberty; then the incidence for boys residing skilled who had gone afield to find employ-
in infected villages reached a peak of approxi- ment(89); in Punjab, the incidence was highest
mately 20%, while that for the girls flattened at among the unskilled and lowest among landown-
approximately 10%; after age 20-30 yr, there was ers,(5m
no difference. (5~) This difference is attributable to
the restrictions placed on young Moslem women.
Pregnancy has an adverse effect on the out- 5.9. Occurrence in Different Settings
come(7~); this will be discussed later. In Europe, the hospital has been a major focus
for infection; those at greatest risk are those who
are in contact with a patient on the ward and those
5.7. Race who handle the laundry. In the 1970 outbreak in
There is no known racial resistance or suscepti- Meschede, Germany, 13 of the 17 secondary cases
bility. Such reports have ignored socioeconomic occurred among patients, three among nurses, and
factors, especially the vaccination status of various one in a hospital visitor. mo) In the 1972 outbreak
population groups. However, Dixon(l4) suggests in Yugoslavia, 48% of the 173 cases were acquired
that the mortality is lower in populations among in hospitals, and 42 of the 48 cases which occurred
whom the disease has been endemic for three or in Belgrade involved hospital transmission. (1()())
four generations, since those who are gerietically The two fatal cases in England in 1973 occurred in
most susceptible will have been removed. visitors to a patient hospitalized for arthritis. (28)
Table 2. Frequency and Case Fatality Rates of Clinical Types of Smallpox by Age and Vaccination
Status, Madras, 1961-1972"
Incidence of clinical types (%)

Vaccination Distribution Case fa tali ty
status Age Number of cases by age (%) Hemorrhagic Flat Ordinary Modified rates (%)
0--4 9 2.6 1.1 3.3 57.8 37.8 15.6

5-14 390 11.5 1.8 0.5 57.7 37.4 3.3
15-24 1159 34.1 2.7 0.6 68.3 28.4 4.1
Vaccinated 25-34 1192 35.1 4.4 1.5 72.5 21.6 7.0
35-44 356 10.5 4.8 2.8 74.7 17.7 9.3
451- 211 6.2 3.3 2.4 79.6 14.7 10.4
Total 3398 100 3.4 1.3 70.0 25.3

Case fatality rates 93.9 66.7 3.2 0.0 6.3
0--4 2091 59.0 1.1 8.1 87.9 2.9 41.2

5-14 862 24.3 1.0 4.2 94.0 0.8 20.3
15-24 304 8.6 8.2 3.9 86.2 1.6 31.6
Unvaccinated 25-34 157 4.4 8.3 6.4 84.7 0.6 36.9
35-44 65 1.8 4.6 1.5 92.3 1.5 43.1
451- 65 1.8 16.9 12.3 69.2 1.5 63.1
Total 3544 100 2.4 6.7 88.8 2.1
Case fatality rates 98.8 94.1 30.3 0.0 35.8
a From Tables 17.1 and 17.2 in Rao' 74l

About one-half of the indigenous cases occur- remained highly infectious until death.(18) From
ring in Europe between 1950 and 1973 were hospi- throat swabs, Sarker et al. (82) recovered 105 pock-
tal acquired(32,54): about 20% among hospital staff forming units of virus per milliliter of swab-
and 30% among patients and visitors.(54) washed fluid from hemorrhagic and severely ill
nonhemorrhagic patients between the second and
the fifth day of illness; throat swab fluids from
5.10. Socioeconomic Distribution
patients with a discrete rash had a maximal virus
Disease has been most common among the titer of 103 pfu. Urine and conjunctival swabs from
lower socioeconomic classes, particularly in the these patients had comparable virus titers. Virus
floating population, which has been most difficult was recovered from patients with fatal, severe non-
to vaccinate. With overcrowding, transmission is hemorrhagic cases as late as the fourteenth day and
more likely. from no survivors after the thirteenth day. The
authors note that the hemorrhagic patients are in-
deed highly infectious, but since they die early (all
5.11. Other Factors in this series by the seventh day) they have less
Important factors in the epidemiology of small- opportunity to spread infection. On an epidemiol-
pox lie in the cultural patterns of the population. ogical basis, Rao et al. (75) concluded that transmis-
Those population segments or religious groups sion occurred predominantly during the first 7 days
who refuse or resist vaccination are at greatest risk of illness, especially between the fourth and the
of acquiring and harboring smallpox. Social seventh day, and no contact became infected after
groups among whom illness in a family member is the thirteenth day of disease in the primary case.
a signal for all family members to gather at the Virus remains viable in crusts for a prolonged pe-
bedside experience increased transmission. The riod of time, but there is no evidence that scabs are
persistence of smallpox for 175 yr after vaccination involved in the'transmission of the disease.
was introduced is evidence of continued resistance
and refusal to accept vaccination; active and effec-
tive antivaccination movements have existed from 6.2. Contact Spread
the days of Jenner and Waterhouse.
In some areas, transmission occurs principally
by direct person-to-person contact through droplet
spread of the saliva and respiratory secretions. The
6. Mechanisms and Routes of Transmission
secondary infection rates on the order of 30%
reported from West Africa, India, and Bangladesh
6.1. Period of Communicability
are consistent with direct contact or droplet
When the exanthem appears, virus is present in spread, as are the observed intervals of up to 80
high concentration in the deeper layers of the skin days for disease to be transmitted within a family
but does not penetrate through the epithelium. group, representing four or five generations of
Concurrent with the exanthem, there is an enan- disease. (24)
them in the mouth and throat from which virus
has ready access to the saliva, which then becomes
6.3. Airborne Spread
the medium for disseminating the infection.
Downie et al. (20) recovered virus most frequently Traditionally smallpox has been assumed to be a
from the mouth washings of smallpox patients highly infectious disease, consistent with airborne
from the sixth to the ninth day of disease, with the spread. Many reports, usually anecdotal, indicate
last positive isolation on the fourteenth day; virus transmission at distances or with very minimal
was not isolated during the first 2 days of the contact, such as the episode when an individual
febrile illness. The appearance of the rash, usually with smallpox walked into a barber shop: two
on the third or fourth day after the fever, thus customers fled and both came down with the
coincides with the period of greatest infectivity. disease; the barber, whose flight took him to the
The blood of patients with hemorrhagic smallpox doctor's office for vaccination, remained well. (37)
The episode in the hospital in Meschede, Ger- months after the study was begun, Thus smallpox
many, in 1970 was more carefully documented, virus could be moved internationally by inanimate
and direct face-to-face or personal contact with the objects. While methods for processing raw cotton
subsequent patients was clearly excluded. By use could break up crusts and could effectively dis-
of a smoke generator a few months later under perse the contained virus into an aerosol, it is not
similar meteorological conditions, it was observed proven that this has occurred. (14)
that the central stairwell served as a chimney, and
that smoke flowed out of the window of the
patient's room and entered rooms at the higher 6.5. Vectors
floors where secondary infection had been ac-
quired. The authors refer to an outbreak in 1961 in The density of houseflies hovering about small-
Monshau in which one 9-yr-old girl infected ten pox patients and on their lesions is often indeed
persons with whom face-to-face contact was ex- remarkable, creating a potential for mechanical
cluded. Both she and the Meschede patient had transmission; however, flies have not been une-
clinical illnesses associated with a considerable quivocally implicated in any outbreaks. Even
amount of coughing which could effectively aero- though Sarkar et al. (SOl found that Culex pipiens
solize the pathogen. mOl and Aedes aegypti retained viable smallpox virus
Heiner et al.,'all studying family contacts of for up to 4 days after feeding on viremic suckling
smallpox cases in West Pakistan during the period mice and that indeed the virus could be recovered
1968-1970, found a secondary attack rate of 76.8% from the proboscides, they felt that, while possi-
among unvaccinated individuals; De Quadros et ble, mosquito transmission "is much less likely
al. (12) reported a secondary attack rate of 69.1% than transmission by direct contact with the pa-
among previously unvaccinated individuals in tients."
their analysis of 27 rural outbreaks of variola
minor in Brazil. These rates are generally compara- 6.6. Animal Reservoirs
ble to the secondary attack rate of about 80% for
measles, which is accepted to be airborne. After the control of smallpox in West Africa had
been achieved, cases of pox disease appeared in
man in 1970 in the absence of any known smallpox
6.4. Spread by Fomites
disease. From these, the isolated virus was identi-
The smallpox patient generously saturates his fied as monkeypox virus.(5Sl To January 1976, 21
pillowcase and bedding with mouth secretions cases of human monkeypox had been recognized,
and sometimes abraded vesicle fluid, both heavily and four patients (19%) had diedY061 Secondary
laden with virus. As a consequence, laundry infections occurred in two of 29 susceptible house-
workers and hotel chambermaids have experi- hold contacts, a transmission rate of 7% compared
enced disproportionately high incidences of small- to the 35-40% rate which had applied for smallpox
pox. Rao(74) could isolate variola virus as long as in this geographic areaY02l Thirteen of these cases
66 days from clothing that had been placed in a occurred in Zaire, four in Liberia, two in Nigeria,
wooden box; when clothing was spread out on a and one each in Sierra Leone and the Ivory Coast;
bed and exposed to indirect light, virus was not 13 of the 21 known monkeypox cases had occurred
recovered' after 7 days. MacCallum and Mc- among children 5 yr of age or younger.o°61
Donald(5;Jl wrapped crusts and material from Of greater concern, however, is the recovery of
smallpox patients in raw cotton and held these at virus strains indistinguishable from variola virus
30"C under various humidities; they were unable from two "normal" monkey kidney cultures from
to recover infectivity from pus or vesicle fluid 3 cynomolgus monkeys imported to Holland from
months later; however, virus survived in the Malaysia(26l and the recovery of a single strain
crusts for over 6 months at a relative humidity of from the kidney cells of a chimpanzee caught in
58%. In the room temperature (20-24°C) controls Zaire in the unsuccessful search for the natural
in which crusts were held in screwcapped bottles reservoir of monkeypox virus.(59l The infectivity
in diffuse light, virus was still recoverable 18 of variola virus for monkeys has been
shown, (29,68) and, while it has been suggested, no endothelial cells, and a perivascular mononuclear
human variola case could be traced to monkey cell accumulation. Virus spreading to the overlying
disease,()) These recent isolates, obtained in the epithelium produces the initial rash. Macules and
absence of known human smallpox disease, indi- papules appear after virus has proliferated in the
cate that there is need for careful study of primate cytoplasm of the epithelial cells of the Malpighian
and other mammalian populations before declar- layer with the formation of acidophilic inclusions
ing that global eradication of smallpox has been (Guarnieri bodies). The cells undergo ballooning
accomplished. (34) degeneration, fluid accumulates and vesicles are
formed which have a roof of keratinized cells and a
floor either of degenerating epithelial cells or of
the dermis; remaining strands of cell walls give the
7. Pathogenesis and Immunity vesicle an umbilicated appearance and a loculated
structure. Polymorphonuclear cells accumulate in
response to the epithelial cell necrosis, converting
7.1. Pathogenesis
the lesion into a pustule, and then the contents
The classical studies by Fenner on mouse pox dry, producing the thick crust under which reepi-
(infectious ectromelia) has provided the clearest thelization occurs. The same initial events occur
concept of the pathogenesis of smallpox. Nor- in the lesions in the mouth and pharnyx, but since
mally, as outlined by Downie/ 16) the virus of there is no keratinize9 layer these rapidly become
variola enters the body through the respiratory shallow ulcers from which virus is discharged, so
tract and, while some multiplication in mucosal that the patient is now highly infectious. Lesions
cells of the lower respiratory tract cannot be ex- are relatively sparse in the internal organs, a
cluded, the virus probably passes through the finding which may be related to the fact that
mucosa without producing lesions and is taken up variola virus does not produce lesions on chorioal-
by phagocytes and carried to neighboring lymph lantoic membranes at a temperature over 3S.soC;
nodes. Here the virus multiplies; an early nonde- in the febrile smallpox patient, only the skin
tectable viremia probably occurs, with virus enter- surfaces, and particularly the exposed skin sur-
ing reticuloendothelial cells in the liver, lymph faces, are under this temperature.
nodes, spleen, bone marrow, and probably lungs In hemorrhagic smallpox, the viremia at the
and multiplying during the incubation period of onset of clinical disease is much more intense and
approximately 12 days during which the individ- presumably reflects a great multiplication of virus
ual is noninfectious. Roberts/ 78 ) working with in the internal organs during the incubation pe-
ectromelia, and Hahon and Wilson/ 29l working riod. Enormous amounts of virus are present in
with monkey variola, showed that considerable the skin even in the absence of microscopically
local multiplication of virus took place in the lungs visible lesions; the basic pathological changes are
after aerosol exposure. similar, with the added hemorrhagic factor. Death,
At the end of the incubation period, the virus which has been attributed to a shock syndrome
spills out of these reticuloendothelial cells to create induced by toxic damage to the vascular endothe-
a viremia which is of short duration in mild cases, lium, terminates further development of the le-
usually persisting no more than 2 days. A high sions. At autopsy, the same hemorrhagic phenom-
viral titer or a viremia persisting after the first 2 ena present in the skin may be found in all the
days of fever indicates a poor prognos~s. The fever viscera.
of 39.5-40.soC appears at the time of this massive Scarring is caused by destruction of sebaceous
viral release, and is probably due to pyrogens glands, and since these are more numerous on the
released from the damaged cells in which vIrus face this is the site of most marked scarring.
had been multiplying. Should secondary bacterial infection supervene,
The circulating virus localizes mainly in the skin there. is involvement into deeper levels of the
and mucous membranes of the mouth and upp'er dermis with resultant permanent scarring. Con-
respiratory tract, resulting in dilatation of the junctival disease with no sequelae is not uncom-
capillaries in the dermal papillae, swelling of the mon; keratitis with residual corneal opacities and
iritis and panophthalmitis with blinding can oc- the firsl 4 or 5 yrs, diminishing thereafter. Against
cur. variola minor, Dixon(14) expects complete protec-
tion for 5 yrs, and almost complete for 10 yrs.
7.2. Immunity Revaccination results in an earlier recall of anti-
bodies, and attainment of higher levels, which
Susceptibility to smallpox is considered to be implies a longer duration of protection. ((;2.(;9) Hei-
universal, but in each outbreak there is a spectrum ner et al. (:Ill found secondary attack rates of 78.5%
of severity with some very mild cases while others among unvaccinated contacts, 8.1% among those
have a fatal fulminating course. Recovery requires who had only primary vaccination, and 3.1 %
the development of specific immunity. While the among those who had also been revaccinated.
individual skin lesion may be limited in its local Smallpox in a vaccinated individual is usually
extension by the production of interferon, recov- milder than that among the unvaccinated, al-
ery from the disease is related to development of though deaths do occur (Table 2), especially
circulating antibody, presumably the neutralizing among pregnant women.(I;!) Vaccination normally
antibody produced by B lymphocytes, and of cell- will protect against death from smallpox for at least
mediated immunity dependent on T lymphocytes. 20 yr. Of the cases acquired in Europe between
Virus neutralizing antibodies appear at about the 1950 and 1971, the case fatality rate among the 149
time vesiculation occurs, about the fourth or fifth unvaccinated patients was 40%, compared to 9%
day; their appearance is usually associated with among the 412 previously vaccinated; the case
clinical improvement but the lesions continue fatality rate was only 11.1 % among the 297 pa-
through their course. In fatal hemorrhagic cases, tients whose last vaccination had been over 20 yr
the antibodies appear later and at a lower level before. (54)
than in the nonhemorrhagic cases. (79) Immunity develops by about the eighth day
Rao(74) reports that second attacks of smallpox after primary vaccination, so that vaccination
may occur in one in 1000 cases after recovery from within the first 24-48 h after contact with a small-
clinical smallpox. They were more frequent among pox case will usually prevent an attack; successful
women and the average interval between the two revaccination as late as 7 days after exposure may
attacks was 15-20 yr; a major reaction to smallpox afford complete protection. (;!:ll
vaccination can be obtained within 1-2 yr after
clinical smallpox, indicating that resistance to var-
iola is greater than that to percutaneously inocu-
lated vaccinia. In his experience, second attacks 8. Patterns of Host Response
were never fatal.
Passive immunity, induced by the injection of
VaCCInia-ImmUne y-globulin, was shown by The clinical picture of smallpox is superbly de-
Kempe et al. (4;!) to produce a 70% reduction in the scribed by Christie. (9) Various classifications of
incidence of smallpox among contacts. Given in variations in this picture have been used.
the incubation period, its effect on circulating Dixon(14) describes nine types; others(55.871 use
virus is to prevent or modify the disease; it is lesion density; the classification of Rao,<14) which
ineffective against intracellular virus. is essentially that of Christie,<9l is used here.
Jennerian vaccination has provided the tool for In the typical case of smallpox, the incubation
smallpox eradication; vaccinia, an immunologi- period (usually of 12 or 13 days but ranging from 8
cally related virus, multiplies at the site of inocula- to 17 days) is followed by an acute preeruptive
tion without disseminating, and evokes immunity illness lasting 2-4 days, with fever, headache, back
which is even more effective against variola than pain, and prostration. This is easily confused with
against itself. The duration of this protection is influenza, meningitis, pneumonia; patients have
difficult to establish because there is always uncer- been admitted to hospitals with a diagnosis of
tainty whether the last vaccination did in fact elicit acute surgical abdomen, lumbosacral strain, etc.
an immunizing vaccinial infection. In general, a The initial rash appears as maculopapules, first on
high level of immunity against smallpox exists for the face or hands and forearms, then on trunk and
lower limbs. The distribution is centrifugal, with Madras in 1.3% and 6.7% of vaccinated and un-
lesions maximal in the distal areas, including vaccinated cases with fatality rates of 66.7% and
palms and the soles. In each region of the body, 94.1 %, respectively (Table 2).(74)
the lesions are in a similar stage. When the rash Most serious is the hemorrhagic type, which,
appears, the temperature falls and toxemia lessens, during the preeruptive illness, may involve a
so that about the second or third day of the rash dusky flush of the skin, hemorrhagic manifesta-
the fever may be gone. The maculopapular lesions tions (petechial or more of a purpura) with sub-
become vesicular within 24-48 h. These may be conjunctival bleeding, bleeding from mouth and
umbilicated, and become turbid and pustular gums, epistaxis, hematuria, and vaginal bleeding;
within a day or so more. The number of lesions death sometimes occurs before a diagnostic focal
can vary markedly and there is a relation between rash appears. In late hemorrhagic disease, death
prognosis and the density of lesions. (56) The pus- occurs on the eighth to tenth day after hemor-
tules dry and scabbing begins from the eighth to rhages have appeared in and between the focal
the tenth day of the eruption and some crusts lesions, which are of the flat type. The disease
begin to separate about the twelfth or thirteenth occurred in Madras in 3.4% and 2.4% of the
day. A secondary fever may recur during the vaccinated and unvaccinated, with fatality rates of
pustular stage; this is not the consequence of 93.9% and 98.8%, respectively (Table 2).(74)
secondary pyogenic infection but part of the dis- The modified type of smallpox occurs principally
ease itself. There is marked facial edema, particu- in vaccinated individuals. While the preeruptive
larly when the lesions are confluent. The concur- illness may be severe, few lesions develop and
rent lesions on the mucous membrane of the these are completely crusted within 10 days. The
mouth and throat can produce marked discomfort lesions are superficial and evolve quickly. All
and inability to swallow. This form, the ordinary patients survive. This type occurred in 25.3% of
type, constitutes the vast majority of cases and had the vaccinated and 2.1 % of those who denied
a case fatality rate in Madras between 1961 and vaccination or prior smallpox (Table 2). Variola sine
1972 of 3.2% among the vaccinated and 30.3% eruptione is a febrile illness with constitutional
among the unvaccinated (Table 2).(74) symptoms not followed by a rash, which represents
More serious cases are those characterized as the the clinical manifestations seen in well-vaccinated
flat type. The focal lesions project little, if any, individuals, usually recognized only in doctors and
above the surrounding skin and are soft and nurses.
velvety to the touch rather than hard and pearly. The distribution of clinical types and case fatal-
This type is relatively rare, having occurred in ity rates seen in Madras over the period 1961-1972,
Table 3. Distribution of Clinical Varieties and

1961-
Unvaccinated and unsuccessfully vaccinated Primary vaccination only after exposure

Clinical type
Number Frequency (%) CFRb (%) Number Frequency (%) CFR (%)
Hemorrhagic 81 2.7 97.5 4 0.8 100

Flat 208 6.8 98.1 28 5.6 96.4
Ordinary 2721 89.5 31.8 426 84.8 20.6
Modified 31 1.0 0.0 44 8.8 0.0
Total 3041 100 37.8 502 100 23.6
a From Tables 5.1 and 17.3 in Rao.(74J

• Case fatality rate.
as influenced by vaccination status, is presented in recovered from 6.7% of the 269 vaccinated contacts
Table 3. vs. 27.1% (16) of the 59 unvaccinated contacts
Subclinical infections had been considered to be suggests that at least some of these represented
rare, but Heiner et al. (;10) in West Pakistan re- inapparent infections rather than mechanical car-
ported that 54.5% of 143 previously vaccinated riage.
household contacts of smallpox patients developed Inapparent infections then must not be consid-
complement-fixing titers equal to or over 1:40 with ered unusual. They may have been important in
no reported illnesses, compared to 6.5% among maintaining immunity where the incidence of
village controls with no household contact. Based smallpox was high. With the present very low
on positive agar gel precipitation tests with variola incidence of disease, they seem to have no epide-
antigen, Rao(74) in Madras reported 34 cases of miological importance, especially since there has
subclinical infection among 109 family contacts, been no suggestion that these cases may be in-
five of whom were unvaccinated. Throat washings volved in disease transmission. However, Sarkar
were obtained from 37 of these contacts and virus et al. suggest that these cases may explain appar-
was isolated from five of these; all five also had ent discrepancies from the usually accepted incu-
serological positivity. Dekking et al. (1ll noted con- bation period.
junctivitis in smallpox patients during the clinical Rao<73·761 has brought attention to the frequency
disease and isolated virus from the conjunctivae of with which the pregnant woman develops hemor-
three of four patients. They "were struck by the rhagic smallpox. He noted that 50% of hemor-
fact that several mothers whose children died of rhagic smallpox cases in his hospital had occurred
smallpox had red eyes for many more days than among pregnant women, and that prior vaccina-
could be explained by their grief alone"; therefore, tion afforded poor protection against this severe
they prepared cultures from the eyes of seven form should a pregnant woman develop smallpox.
individuals and recovered virus from all. Six had Rao et al. (77) have duplicated the phenomenon in
no other symptoms; one did have 1 day of fever. monkeys. Normal animals showed little more than
Five of the seven had not previously been vacci- a mild rash and a slight fever appearing the fifth
nated. day; however, when a pregnant monkey was in-
Sarkar et al. (83) recovered virus at a titer of 10 2 to fected, she died in 12 days with hemorrhagic
10 . 95 from the throats of 34 contacts of smallpox
3 disease. Eleven of 14 nonpregnant monkeys given
patients after 4-8 days of contact; only four devel- cortisone before and after intradermal infection
oped clinical smallpox 5-6 days later. No serologi- with variola died; all 14 non-cortisone-treated con-
cal studies were done; the fact that virus was trols survived. Viremia was detected in two of ten
Case Fatality Rates of Smallpox Patients, Madras,

1972"
Primary vaccination and revaccination

Primary vaccination scar only scars Total
Number Frequency (%) CFR (%) Number Frequency (%) CFR (%) Number CFR (%)
111 3.4 94.0 4 3.0 100 200 95.7

45 1.4 66.7 8 281 92.9
2302 70.5 3.3 75 56.8 0.0 5524 18.6
808 24.7 0.0 53 40.2 0.0 936 0.0
3266 100 6.5 132 100 3.0 6941 21.3

controls tested before the onset of symptoms; after personnel to be recruited and trained, supplies and
the fever had appeared, only one blood culture was transport arranged, and the population educated
positive of the 16 tested from control monkeys, for cooperation, including not only health educa-
while 11 of the 26 blood cultures from the steroid- tion of the public to assure acceptance of vaccina-
treated animals were positive. tion but also recruitment of agencies, voluntary or
Variola minor (alastrim) and intermediate governmental, which could be suborned into be-
strains produce the same clinical types of small- coming active participants in the control program.
pox, but the spectrum is heavily shifted toward 9.1.2. Attack Phase. The active program has
the "modified" type, with discrete lesions and been divided into three phases.(95) During the at-
rapid recovery. Variola minor (alastrim) does have tack phase (while the incidence of smallpox was five
a case fatality rate of 1-1.5%. The intermediate or more cases per 100,000 population per year, and
type of virus was isolated from patients in Tan- less than 80% of the population had vaccination
ganyika, where the case fatality rates varied from scars), a systematic mass vaccination campaign was
2.8 to 10.9%, averaging 5.6% over the period initiated, supported by a concurrent but separate
1954-1963. (2) The case fatality rate in Ethiopia in assessment program to assure adequate and effec-
1971 was 2.1 %; if all deaths occurred only among tive vaccination coverage. The ultimate success of
the unvaccinated, the rate would be 2.3%, with a the program depended heavily on surveillance, i.e.,
maximal age-specific rate of 12.5% in those under locating and following up all cases of possible
1 yr of age. (99) smallpox, with localized intensive vaccination in
the communities where the cases occurred. As·the
program proceeded, an active surveillance network
9. Control and Prevention Based on was established, enlisting the cooperation of the
Epidemiological Data existing health facilities and all other sources for
rapid reporting of possible cases.
Foege et al. (23) found that at the beginning of the
9.1. Control Programs
program in West and central Africa, 95% of small-
Control of smallpox is based on vaccination pox cases coming to attention between January and
breaking the chain of transmission by eliminating July 1968 did so through the official health report-
susceptible hosts. The WHO Smallpox Eradication ing system. However, 58% of the cases were dis-
Program, which was set into motion in 1967, was covered through the nonofficial reporting system
based on the facts that smallpox is transmitted by January 1969. When emphasis was placed on
from man to man, that infection is manifest and immediate and effective response to each of these
carriers do not exist, and that the incubation reported cases, a very sharp drop took place in the
period is almost 2 wk long, allowing time for number of cases, and smallpox was eradicated at
appropriate intervention. Happily it was found least a year earlier than had been expected.
that the disease spread relatively slowly through 9.1.3. Consolidation Phase. The consolidation
the population in the endemic areas, with several phase was reached when the incidence was below
generations of disease within a single family. five cases per 100,000 and over 80% of all segments
The obvious first approach in an area with very of the population showed scars of primary vaccina-
high endemicity is to start an effective mass vacci- tion. A "maintenance vaccination program" pro-
nation program. However, the progress of the vided primary vaccination to immigrants, new-
global eradication program has shown the- great borns, and those who had been missed initially.
value of instituting as early as possible "selective Revaccination is performed on a 3-5 yr cycle. The
epidemiological control," in which vaccination is surveillance network becomes of greater impor-
concentrated on case contacts and places where tance, and now each report of possible smallpox
cases are occurring. (23) must result in an epidemiological investigation,
9.1.1. Preparatory Phase. Before an active eradi- laboratory study, vaccination and observation of
cation operation was initiated, time was allowed ca.se contacts, and containment of infection by iso-
for an appropriate epidemiological assessment of lation of cases and appropriate disinfection.
the distribution of smallpox and of immunity, for 9.1.4. Maintenance Phase. The maintenance
phase exists when there has been no endemic small- often associated with a more intense, systemic
pox for more than 2 yr and the disease persists on illness after primary vaccination. (72)
the continent, at present only Africa. Maintenance 9.2.2. Vaccination Reactions. a. Primary Vac-
vaccination is continued, particularly of the new cination. A papule appears at the vaccination site
members of the population, and intense surveil- about 3 days after vaccination; within 2-3 more
lance is maintained. Each report of a suspected case days, this vesiculates to constitute the umbilicated
is treated as an emergency. From each case or out- and multilocular "Jennerian vesicle." The contents
break, specimens are submitted for laboratory con- become turbid, and erythema and induration sur-
firmation. round this central lesion. The area of erythema
The WHO program of surveillance and case de- reaches its maximal diameter between the eighth
tection, vaccination and' observation of case con- and the twelfth day, most usually on the ninth or
tacts, isolation and appropriate disinfection of pa- tenth day. At this time, axillary lymph nodes are
tients, and localized intensive vaccination in the enlarged and tender and about 50% of patients
community has resulted in the constriction of have a fever over 37.8°C. The pustule dries from
smallpox to only one country, Ethiopia, in which the center out, becoming the dry brown or black
the disease remained endemic in early 1976. scab which falls off in about 3 wk, leaving the
typical foveated pock mark.
b. Revaccination. Successful primary vaccination
9.2. Immunization Concepts and Practice creates not only humoral immunity but also a
longer lasting cell-mediated immunity.Cj.tH) Hu-
9.2.1. Vaccination Problems. The long interval moral immunity can wane, but the persisting
between the introduction of smallpox vaccination dermal hypersensitivity to vaccinial protein will
and promise of giobal eradication can be explained result in a reaction maximal in 24--48 h after
by the complexities involved in the simple proce- revaccination, which is elicited equally well by
dure of infecting a susceptible individual with noninfectious vaccine. It confers no immunity bllt
vaccinia virus by introducing viable elementary is associated with increased resistance to vaccina-
bodies into the stratum germinativum and the tion, even in susceptible individuals. (21) It is the
upper layers of dermis. These complexities war- reaction given by the fully immune individual to
rant consideration. potent vaccine properly applied; this was recog-
Early in the history of vaccination, contaminated nized and described by Jenner. (41) With impotent
vaccines resulted in "spurious takes" with dermal vaccine or poor technique, infection fails and im-
reactions and scars of pyogenic infections, which munity is incorrectly assumed. Cjl
conferred no immunity to smallpox. The usual In those who have lost some immunity, a suc-
vaccines were of low potency to begin with and cessful revaccination produces the "allergic" reac-
rapidly lost potency during storage unless kept at tion which is followed by an enlarging area of skin
below-freezing temperatures. To compensate for erythema which becomes maximal earlier than a
the low concentration of vaccinial virus, various primary take. The area of erythema surrounding
instruments and techniques were developed the central lesion becomes maximal later in time as
which introduced vaccine into such a large area of immunity decreases until it occurs 8-10 days after
skin surface that many takes, when the vaccine revaccination, the same time course as that of pri-
was still relatively potent, resulted in a morbidity mary vaccination. An allergic reaction can be asso-
so severe that the populace fled from the vaccina- ciated with an increase in circulating antibodies in
tor. Less traumatic techniques-such as the multi- those nearly fully immune, but the reaction is in-
ple pressure and scratch methods-involved indi- distinguishable from the nonprotective reaction
vidual skill, with considerable variation in take elicited by noninfectious vaccine; therefore, this
rates in the hands of different vaccinators.") Fur- has been termed an equivocal reaction. In contrast,
thermore, in order to assure that the vaccination when there is still evidence after 1 wk of an active
did result in a good vaccinial infection, strains inflammatory reaction, in contrast to a simple scab
were selected which were most "potent." These which often follows an equivocal reaction, an im-
were selected by their greater take rate and were munizing major reaction is evidenced. (94)
9.2.3. Complications of Smallpox Vaccination. occurred in an unknown number of unvaccinated

a. Progressive Vaccinia. Infection by a live virus, contacts. (46)
even an attenuated one, involves multiplication of d. Other Reactions. In addition to these poten-
the organism within the host's body until immune tially serious complications to smallpox vaccina-
processes terminate the infection. When vaccine is tion, a large number of reactions occur which have
applied to an individual with impaired cell-me- no adverse prognostic significance. These include
diated immunity because of thymic dysplasia or generalized vaccinia, frequent exanthematous reac-
leukemia or similar malignant disease, or because tions, and accidental infections in which virus is
of immunosuppression (chemical or by irradia- transferred to other places. These conditions are
tion), the virus continues to multiply and spreads rarely of consequence, and while they are often of
cell to cell to constitute progressive vaccinia (vacci- great concern to physicians and parents they have
nia necrosum). While this occurs in the United little adverse effect on the prognosis or well-being
States in one or fewer per million vaccinations,<46) of the vaccinee. About 20 cases of congenital vacci-
when it does occur it is a dramatic event. Treat- nia of the fetus have been reported since 1932;
ment with methisazone as a direct antiviral agent, however, a comparative study disclosed no evi-
coupled with vaccinia immune globulin, resulted dence of an increased frequency of congenital
in the survival in 1968 of seven of 11 patients whose malformations among approximately 8000 infants
overall survival prognosis was grave, even without whose mothers were vaccinated during pregnancy
this vaccination complication. when compared to a similar number whose moth-
b. Postvaccinial Encephalitis. Postvaccinial en- ers were not vaccinated.(44)
cephalitis, a puzzling complication, consists of e. Importance of Vaccination Complications.
"postvaccinial central nervous system involve- These complications assume real importance
ment, including separately or in combination the where smallpox does not exist, so that it can truly
following symptoms: meningeal signs, ataxia, be said that the preventive measure is costing
muscular weakness, paralysis, lethargy, coma or more lives than the disease itself. Unfortunately,
convulsions."(4S) It has been reported to occur as emphasis in the Western world on these complica-
frequently as one in every 4000 primary vaccinations results in fear of vaccination and overres-
tions in Holland, (71) and yet in the United States ponse when the unimportant reactions are seen.
it occurs in 2.9 per million primary vaccina- 9.2.4. Resolution of Some Vaccination Prob-
tions,<46) a rate similar to the background rate of lems. Success of the eradication program de-
"nonspecific" encephalitis in the United States. (4) pended on solution of many of these problems.(SI
In Austria(6) and in Holland,<7ll the incidence fell Inadequate potency or excessive bacterial contami-
dramatically with change from the Bern and Co- nation of the vaccines was resolved by the use of a
penhagen vaccinal strains respectively, to the stable freeze-dried vaccine and establishment of
Lister strain. This can be a very serious complica- WHO International Reference Centers for Smallpox
tion, with reported case fatality rates ranging from Vaccine to assure that high-quality vaccines would
50+ % in Holland(7J) to 3-17% in Sweden(22); in be used for the eradication program. Need for
the 1968 U.S. survey, 25% died.(46) Severe perma- skilled individual vaccinators was avoided by the
nent neurological deficiencies remain in some who development of the mechanical jet injector, which
survive. introduces approximately 0.1 ml intradermally of a
c. Eczema Vaccinatum. Eczema vaccinatum con- potent vaccine containing 106.5 pfu/ml and free of
stitutes more of a threat to eczematous contacts detectable bacteria. This was the method of vacci-
than to the vaccinated person, since vaccination is nation used in the West and Central African and
usually deferred when active weeping lesions are in the Brazilian compaigns.
present. When a large area of raw skin surface is The bifurcated needle made available a much
exposed to and infected with vaccinia, the patho- cheaper instrument, also very conserving of vac-
logical event is not too different from that of cine. When it is used in the multiple puncture
smallpox. This was reported to occur in the United methodClOIi with vaccine meeting WHO standards
States 38 times per million primary vaccinations in (a virus titer of 108 pfu/ml after incubation at 37"C
1968; an equal number of cases with one death for 4 wk), infection is reliably produced in suscep-
tibles and is the method used in Asia and Ethio- the first case, notification, and response might be
pia. The vaccines to be used were restricted to the delayed, reliance must be based on maintaining an
Lister or Elstree strain, the EM-63 strain prepar~d immune population by vaccinating as early as
in Moscow, and the New York Board of Health possible in childhood and revaccinating at least at
strains used in the United States(10ll; in compara- school entry until eradication of smallpox has been
tive studies, these had been shown to be the certified.
preferable strains because they caused fewer sys- (2) With Reliable Surveillance. Where there is a
temic symptoms. more developed health care system, decision may
9.2.5. Success of the Program. The success of be based on an analysis of the risk of complica-
these steps carried out in an international coopera- tions of smallpox vaccination against the probabil-
tive effort is well demonstrated graphically by Fig. ity of smallpox importation and the anticipated
2, which shows the status worldwide when the extent of smallpox spread after importation. The
WHO eradication program was initiated, and the U.S. Public Health Service carried out such an
situation which pertained at the end of 1975. analysis in 1971, and estimated that it would
Presently smallpox is constricted to relatively small require 15 importations per year to produce the
regions in rural areas of Ethiopia, where Opera- same mortality which was associated with small-
tion Crocodile, conducted with helicopter trans- pox vaccination in the United States, but there had
portation, is hoped to be in the final phase of been no importations since 1949. On this basis, on
eradication. September 25, 1971, the U.S. Public Health Service
9.2.6. Plans for the Immediate Future. a. En- recommended(lO) discontinuance of routine small-
demic Areas. This success raises the question pox vaccination but continued immunization of all
of the appropriate smallpox control activities of personnel involved in health services and all trav-
today and tomorrow. The eradication strategy(95) elers to and from continents where smallpox has
calls for continued maintenance vaccination for a not been eradicated. In January 1976, this was
2-yr period after the last case of smallpox. In the changed to require vaccinations only for travelers
western hemisphere, the last case was detected in who have been in Ethiopia in the 2 wk before
suburban Rio de Janiero in Brazil in April 1971; returning to the U.S., and for personnel in labora-
the last known case in West Africa occurred in tories working with variola virus. Within 20 yr,
May 1970; the last case in South Africa was noted essentially the total population will be susceptible
in January 1971; and the last case in Indonesia was to smallpox.
noted in January 1972. The last case in Pakistan had Opinions are divided on whether this course
its onset on October 12, 1974, in Nepal on April 6, was indeed wise. (4.47) Action based on the recog-
1975, in India on May 24, 1975, and in Bangladesh nition of the first case places dependence on the
on October 16,1975. It is hoped that the last cases in individual practitioner. The clinical diagnosis of
Africa will occur in 1976 and that in 2 yr eradication smallpox is no longer taught in our medical
will have been officially achieved. schools; it is not a problem of current medical
However, concerned that unrecognized endemic practice. Will the first case be recognized? After
foci might still exist, the World Health Organiza- the global eradication program succeeds in Ethio-
tion Expert Committee in 1972(101) recommended pia, and there is no recurrence of disease within the
that vaccination be continued in endemic regions next 2 yr, can one assume that the specter of small-
and their neighboring countries, with revaccination pox will then be gone? The recovery of a variola-
at 5-10 yr intervals and maintenance of an active like virus from a chimpanzee in a smallpox-free
surveillance system. area puts one on the alert that smallpox may some
b. Nonendemic Areas. (1) With Unreliable Sur- day again emerge and, until we tum our swords
veillance. Experience in the United Kingdom has into plowshares and empty our deepfreezes of pox-
shown that early detection of a smallpox case and viruses, vengeful man may retain one viral agent
immediate mobilization of a program for vaccinat- capable of wreaking havoc in an unvaccinated pop-
ing direct contacts can successfully control an out- ulation.
break. In those countries where the health services c. Essentials after Routine Vaccination Has Been
are not so highly developed, so that recognition of Discontinued. A country which stops routine vac-
cination must have a reserve supply of ready-for- wide spread among an unvaccinated population
use vaccine dispersed in various geographic areas; before the infection is recognized.
those who provide health care must be willing to d. Reliability of the System. The smallpox epi-
suspect smallpox when it appears. There must be a sode which occurred in London in March 1973
detailed plan of action with which all health offi- raises concern over the reliability of the system.
cers are intimately familiar and prepared to imple- The United Kingdom is a country with a superbly
ment on short notice. Basically, recognition of a organized health service, a country which has had
case would initiate an emergency procedure to a relatively large number of smallpox importations
isolate the patient and to locate all direct contacts and experience in handling them. Three cases of
for immediate vaccination with multiple insertions smallpox occurred. The first case occurred in a
("ring vaccination") and appropriate surveil- medical laboratory technician, who was treated for
lanceY4) "glandular fever" on a open hospital ward for 7
This will involve primary vaccination of adults. days before the diagnosis was made by her col-
It is argued by some(13) that childhood vaccina- leagues on vesicle fluid taken without the knowl-
tion affords no protection against complications of edge of her physician. The other two patients, a
revaccination in later life and therefore it is more married couple, both of whom died, were hospital-
logical to withhold primary vaccination until re- ized in another part of London for "virus infection
quired; others argue that early vaccination is asso- causing gastroenteritis," fortunately in an infec-
ciated with fewer complications and protects tious disease hospital. After 2 days of hospitaliza-
against complications after revaccination. The ex- tion, it was learned that 13 days before onset they
perience in Holland reported by Polak,(7]) sum- had visited the patient, hospitalized for arthritis, in
marized in Table 4, indicates that despite a signifi- the bed next to the first smallpox victim.
cant reduction in incidence related to the change Thus three patients with smallpox were hospi-
to the Elstree strain, the risk of postvaccinial talized, but the diagnosis of smallpox was not
encephalitis remains significantly higher among entertained in the first case by the clinician and
adults; the single adult case in the later time only made by accident; the other two patients
period occurred in an individual who had received were under medical care for 4 days (2 in the
vaccinia-immune globulin at the time of vaccina- hospital) without smallpox being suspected. Con-
tion, the usual Dutch prophylaxis against CNS tact tracing failed to take account of the fact that
complications. Thus, if we are to cope with intro- visitors to other patients on a hospital ward could
duction of smallpox into a nonimmune population be contacts; the occupant of the next bed (who had
with present immunization practices, we must been visited by the patients who died) was not
anticipate an increase in the frequency of adverse located until 5 days after the smallpox plan had
reactions as well as the probability of relatively been put in operation and was vaccinated on the
Table 4. Central Nervous System Complications Following Primary

Vaccination of Infants and Adults with Different Strains of Vaccinia Virus in
Different Time Periods, Netherlands a
Vaccinial strain Copenhagen Vaccinial strain Elstree
Infants Adults Infants Adults

1959-1962 1959-1963 1963-1970 1964-1970
Vaccinations 821,000 15,000 1,708,000 21,000

CNS disease (deaths) 31 (16) 4 (1) 19 (11) 1
Rate/million 38 267 11 48
a From Polak et al. (72).

sixth day. This was 13 days after the contact, the How will we maintain an alertness among the
length of the incubation period. medical profession so that smallpox, if it should
appear, is recognized before it has spread into the
second and third generations of cases? How can
10. Unresolved Problems we improve our diagnostic methods and labora-
tory expertise so that rapid differentiation can be
The progress of the global eradication program made among smallpox, monkeypox, and vaccinia
raises high hopes that the endemic areas can be or other pox viruses?
constricted further and further until smallpox will Is this report, as is hoped, a purely historical
be eradicated. Will the unsettled civil conditions document of a former disease of man, to be stud-
which pertain in Ethiopia disrupt the populations ied for guidance in controlling and eradicating
so that eradication programs are interfered with other diseases? Or will it have direct value because
and major epidemics of smallpox emerge? It is in the euphoria of apparent success the support for
hoped that these problems will be surmounted. In continued effort, without which the fire of epi-
that case smallpox will then be the first disease that demic smallpox will be rekindled, is withdrawn
man has deliberately eradicated. This end is being before the last spark has been extinguished?
achieved by developing a high level of immunity Mankind is within reach of an exciting event:
by vaccination of the endemic populations, espe- the planned elimination of a terrible disease. On
cially of their high-risk segments, and maintenance May 14, 1806, Thomas Jefferson, the President of
vaccination where disease no longer occurs. How- the United States, wrote Edward Jenner commend-
ever, with discontinuation of vaccination, the im- ing him for "extirpating" smallpox. '401 Now after
munity of these populations will drop progres- 170 yr, we are achieving what had then seemed
sively as newborns enter the population and imminent. When we do succeed, we will not be
immunity of those now vaccinated falls, so that able to simply forget this disease. We must estab-
within 20 yr the population will again be suscepti- lish an alert and responsive smallpox control sys-
ble to infection should disease recur from some tem and continue it with unremitting diligence
natural or deliberate introduction. throughout future ages.
Can there be some hidden focus of persisting
viable virus? Is there a threat to a smallpox-free
mankind from the poxviruses of animals? Contin-
ued monitoring of animal populations will be
essential. Emergence of monkeypox as a disease 11. References
of humans, transmissible from man to man, raises
1. ARITA, 1., AND HENDERSON, D. A., Smallpox and
concern that, if not variola itself, a related poxvirus
monkeypox in non-human primates, Bull. WHO
can become adapted to an unprotected human 39:277-283 (1968).
population in the years to come. 2. BEDSON, H. 5., DUMBELL, K. R., AND THOMAS, W. R.
At present, WHO is moving to assure that variola G., Variola. in Tanganyika, Lancet 2:1085-1088
virus is retained only in a few laboratories whose (1963).
safety standards and precautions provide assurance 3. BENENSON, A. 5., Immediate (so-called "immune")
that the virus will not inadvertently escape and to reaction to smallpox vaccination, J. Am. Med. Assoc.
establish an international registry of laboratories 143:1238-1240 (1950).
with stocks of virus yo,;) Can we depend that the 4. BENENSON, A. 5., Routine vaccination for all is still
variola viruses sequestered in deepfreezes in many indicated, in: Controversy in Internal Medicine II (F.
laboratories scattered through the world will be J. INGELFINGER, R. V. EBERT, M. FINLAND, AND A. J.
RELMAN, eds.), pp. 371-381, Saunders, Philadel-
reported? Can we trust our fellow man to adhere to
phia, 1974.
the international conventions which outlaw biolog- 5. BENENSON, A. 5., Vaccination factors critical for
ical warfare, for which variola virus is so uniquely eradication of smallpox, in: International Symposium
qualified? Can we be sure that political fanatics will on Smallpox Vaccine (R. REGAMEY AND H. COHEN,
have no access to legitimate or illegitimate stores of eds.), pp. 17-22, Karger, Basel, 1973.
variola virus? 6. BERGER, K., AND HEINRICH, W., Decrease of post-
vaccinal deaths in Austria after introducing a less RATNAKANNAN, N. R., RAO, A. R., KRISHNAN, G. N.
pathogenic virus strain, in: International Symposium V., AND KEMPE, C. H., Studies on the virus content
on Smallpox Vaccine (R. REGAMEY AND H. COHEN, of mouth washings in the acute phase of smallpox,
eds.), pp. 199-203, Karger, Basel, 1973. Bull. WHO 25:49-53 (1961).
7. BERNSTEIN, S. S., Smallpox and variolation: Their 21. ESPMARK, J. A., Smallpox vaccination studies with
historical significance in the American colonies, J. serial dilutions vaccine. 1. Primary vaccination and
Mt. Sinai Hosp. 18:229-244 (1951). revaccination in human adults, Acta Pathol. Micro-
8. BLAKE, J. B., Benjamin Waterhouse and the Introduc- bioI. Scand. 63:97-115 (1965).
tion of Vaccination, p. 61, University of Pennsylva- 22. ESPMARK, J. A., RABO, E., AND HELLER, L., Smallpox
nia Press, Philac\elphia, 1957. vaccination before the age of three months: Evalua-
9. CHRISTIE, A. B., Infectious Diseases: Epidemiology and tion of safety, in: International Symposium on Small-
Clinical Practice, pp. 185-237, E. and S. Livingstone, pox Vaccine (R. H. REGAMEY AND H. COHEN, eds.),
Edinburgh, 1969. pp. 24~248, Karger, Basel, 1973.
10. Center for Disease Control, Public Health Service 23. FOEGE, W. H., MILLAR, J. D., AND LANE, J. M.,
recommendation on smallpox vaccination, Morbidity Selective epidemiologic control in smallpox eradica-
Mortality Weekly Rep. 20:339 (1971). tion, Am. J. Epidemiol. 94:311-315 (1971).
lOa. Center for Disease Control, Smallpox vaccinating 24. FOEGE, W. H., MILLAR, J. D., AND HENDERSON, D.
hospital and health personnel, Morbidity and Mortal- A, Smallpox eradication in West and Central Africa,
ity Weekly Rep. 25:9 (1976). Bull. WHO 52:209-222 (1975).
11. DEKKING, F., RAO, A. R., ST. VINCENT, 1., AND 25. GIBSON, J. E., Dr. Bodo Otto and the Medical Back-
KEMPE, C. H., The weeping mother, an unusual ground of the American Revolution, pp. 88-103, 131-
source of variola virus, Arch. Gesamte Virusforsch. 135, Thomas, Baltimore, 1937.
22:215-218 (1967). 26.GISPEN, R., AND BRAND-SAATHOF, B., White poxvirus
12. DE QUADROS, C. C. A., MORRIS, 1., DA COSTA, E. strains from monkeys, Bull. WHO 46:585-592 (1972).
A., ARNT, N., AND TIGRE, C. H., Epidemiology of 27. GISPEN, R., AND BRAND-SAATHOF, B., Three specific
variola minor in Brazil based on a study of 33 antigens produced in vaccinia, variola, and mon-
outbreaks, Bull. WHO 46:165-171 (1972). keypox infections, J. Infect. Dis. 129:289-295 (1974).
13. DICK, G., Smallpox: A reconsideration of public 28. Great Britain Report of the Committee of Inquiry
health policies, Prog. Med. Virol. 8:1-29 (1966). into the Smallpox Outbreak in London in March
14. DIXON, C. W., Smallpox, J. and A. Churchill, Lon- and April, 1973, Report, Her Majesty's Printing
don, 1962. Office, London, 1974.
15. DOWNIE, A W., Smallpox (variola major and variola 29. HAHON, N., AND WILSON, B. J., Pathogenesis of
minor), in: Virus and Rickettsial Diseases of Man, 4th variola in Macaca irus monkeys, Am. J. Hyg. 71:69-
ed. (S. BEDSON, A. W. DOWNIE, F. O. MACCALLUM, 80 (1959).
AND C. H. STUART-HARRIS), pp. 84-111, Edward 30. HEINER, G. G., FATIMA, N., DANIEL, R. W., COLE, J.
Arnold Ltd., London, 1967. 1., ANTHONY, R. 1., AND MCCRUMB, F. R., JR., A
16. DOWNIE, A. W., Smallpox, in: Infectious Agents and study of inapparent infection in smallpox, Am. J.
Host Reactions (S. MUDD, ed.), pp. 487-518, Saun- Epidemiol. 94:252 (1971),
ders, Philadelphia, 1970. 31. HEINER, G. G., FATIMA, N., AND McCRUMB, F. R.,
17. DOWNIE, A. W., AND KEMPE, C. H., Variola and JR., A study of intrafamilial transmission of small-
other pox virus infections, in: Diagnostic Procedures pox, Am. ]. Epidemiol. 94:316-326 (1971).
for Viral and Rickettsial Disease, 4th ed. (E. H. 32. HENDERSON, D. A., Importations of smallpox into
LENNETTE AND N. J. SCHMIDT, eds.), pp. 281-320, Europe, WHO Chron. 28:428-430 (1974).
American Public Health Association, New York, 33. HENDERSON, D. A., Smallpox, in: Preventive Medi-
1969. cine and Public Health by Maxcy-Rosenau, 10th ed.
18. DOWNIE, A. W., MCCARTHY, K., MACDONALD, A., (P. E. SARTWELL, ed.), pp. 104-116, Appleton-Cen-
MAcCALLUM, F. 0., AND MACRAE, A. D., Virus and tury-Crofts, New York, 1973.
virus antigen in the blood of smallpox patients: 34. HENDERSON, D. A., AND ARITA, I., Monkeypox and
Their significance in early diagnosis and prognosis, its relevance to smallpox eradication, WHO Chron.
Lancet 2:164-166 (1953). 27:145-148 (1973).
19. DOWNIE, A. W., AND MCCARTHY, K., The antibody 35. HENDERSON, R. H., DAVIS, H., EDDINS, D. L., AND
response in man following infection with viruses of FOEGE, W. H., Assessment of vaccination coverage,
the pox group. III. Antibody response in smallpox, vaccination scar rates, and smallpox scarring in five
J. Hyg. 56:479-487 (1958). areas of West Africa, Bull. WHO 48:18~194 (1973).
20. DOWNIE, A. W., ST. VINCENT, 1., MEIKLEJOHN, G., 36. HERRLICH, A., MAYR, A., MAHNEL, H., AND MUNz,
E., Experimental studies on transformation of the 53. MACCALLUM, F. 0., AND McDoNALD,I. R, Survival
variola virus into the vaccinia virus, Arch. Gesamte of variola virus in raw cotton, Bull. WHO 16:247-254
Virusforsch. 12:479-599 (1963). (1957).
37. HULL, E., Smallpox contagiousness, J. Am. Med. 54. MACK, T. M., Smallpox in Europe, 1950--1971, J.
Assoc. 219:750, 755 (1972). Infect. Dis. 125:161-169 (1972).
38. HUNT, J. H., Dr. Benjamin Waterhouse and the 55. MACK, T. M., THOMAS, D. B., AND KHAN, M. M.,
introduction of vaccination into the United States, Variola major in West Pakistan, J. Infect. Dis.
Brooklyn Med. J. 10:391-395 (1896). 122:479-488 (1970).
39. IRONS, J. V., SULLIVAN, T. D., COOK, E. B. M., Cox, 56. MACK, T. M., THOMAS, D. B., ALI, A., AND KHAN,
G. W., AND HALE, R. A., Outbreak of smallpox in M. M., Epidemiology of smallpox in West Pakistan.
the lower Rio Grande Valley of Texas in 1949, Am. J. I. Acquired immunity and the distribution of dis-
Public Health 43:25-29 (1953). ease, Am. J. Epidemiol. 95:157-168 (1972).
40. JEFFERSON, T., Letter from Thomas Jefferson to Dr. 57. MACK, T. M., THOMAS, D. B., AND KHAN, M. M.,
Jenner (quoted by J. H. Hunt), Brooklyn Med. J. Epidemiology of smallpox in West Pakistan. II.
10:395 (1896). Determinants of intravillage spread other than ac-
41. JENNER, E., An Inquiry into the Causes and Effects of quired immunity, Am. J. Epidemiol. 95:169-177
the Variolae Vacciniae, a Disease Discovered in Some (1972).
of the Western Counties of England, Particularly Glou- 58. MARENNlKOVA, S. S., SELUHINA, E. M., MAL'CEVA,
cestershire, and Known by the Name of Cowpox, N. N., CIMISKJAN, K. 1., AND MACEVIC, G. R.,
Sampson Low, London, 1798. Isolation and prroperties of the causal agent of a
42. KAHN, c., History of smallpox and its prevention, new variola-like disease (monkeypox) in man, Bull.
Am. J. Dis. Child. 106:597-609 (1963). WHO 46:599-611 (1972).
43. KEMPE, C. H., BERGE, T. 0., AND ENGLAND, B., 59. MARENNIKOVA, S. S., SELUHINA, E. M., MAL'CEVA,
Hyperimmune vaccinal gamma globulin: Source, N. N., AND LADNYJ, I. D., Poxviruses isolated from
evaluation and use in prophylaxis and therapy, clinically ill and asymptomatic ally infected monkeys
Pediatrics 18:177-188 (1956). and a chimpanzee, Bull. WHO 46:613-620 (1972).
44. KOPLAN, J. P., GOLDSTEIN, J., AND FOSTER, S. 0., 60. MARSHALL, M. S., The first smallpox vaccine in the
Congenital vaccinia: Some doubts, Pediatrics Americas, Am. Soc. Microbiol. News 40:443-445
50:971-972 (1972). (1974).
45. LANE, J. M., Complications following smallpox vac- 61. MARTIN, H. A., Jefferson as a vaccinator, N.C. Med.
cination, in: International Symposium on Smallpox J. 7:1-35 (1881).
Vaccine (R. H. REGAMEY AND H. COHEN, eds.), pp. 62. MCCARTHY, K., AND DOWNIE, A. W., The antibody
217-226, Karger, Basel, 1973. response in man following infection with viruses of
46. LANE, J. M., RUBEN, F. 1., NEFF, J. M., AND MILLAR, the pox group. II. Antibody response following
J. D., Complications of smallpox vaccination, 1968, vaccination, J. Hyg. 56:466-478 (1958).
N. Engl. J. Med. 281:1201-1208 (1969). 63. MILLAR, J. D., ROBERTO, R R., WULFF, H., WENNER,
47. LANGMUIR, A. D., Vaccination should be abolished H. A., AND HENDERSON, D. A., Smallpox vaccina-
in the United States except for selected populations, tion by intradermal jet injection. I. Introduction,
in: Controversy in Internal Medicine II (F. J. INGELFIN- background and results of pilot studies, Bull. WHO
GER,'R V. EBERT, M. FINLAND, AND A. J. RELMAN, 41:749-760 (1969).
eds.), pp. 363-370, Saunders, Philadelphia, 1974. 64. NAKANO, J. H., Evaluation of virological laboratory
48. LEAKE, J. P., Smallpox or variola, Med. Clin. North methods for smallpox diagnosis, Bull. WHO 48:529-
Am. 27:603-616 (1943). 534 (1973).
49. LEIKIND, M. c., Variolation in Europe and America, 65. NAKANO, J. H., AND BINGHAM, P. G., Smallpox,
Ciba Symp. 3:1090--1101 (1942). vaccinia, and human infections with monkeypox
50. LEIKIND, M. c., The introduction of vaccination viruses, in: Manual of Clinical Microbiology, 2nd ed.
into the United States, Ciba Symp. 3:1114-1124 (E. H. LENNETTE, E. H. SPAULDING, AND J. P.
(1942). TRUANT, eds.), pp. 782-794, American Society for
51. LONG, G. W., NOBLE, J., MURPHY, F. A., HERRM- Microbiology, Washington, D.C., 1974.
ANN, K. 1., AND LOURIE, B., Experience with elec- 66. NANNING, W., Prophylactic effect of antivaccinia
tron microscopy in the differential diagnosis of gamma-globulin against post-vaccinal encephalitis,
smallpox, Appl. Microbiol. 20:497-504 (1970). Bull. WHO 27:317-324 (1962).
52. MACAULAY, T. B., The History of England from the 67. NIZAMUDDIN, M. D., AND DUMBELL, K. R., A simple
Accession of James the Second, Vol. 4, p. 369, E. H. laboratory test to distinguish the virus of smallpox
Butler and Co., Philadelphia, 1856. from that of alastrim, Lancet 1:68-69 (1961).
68. NOBLE, J., JR., AND RICH, J. A., Transmission of AND DE, S. K., Virus excretion in smallpox. 2.
smallpox by contact and by aerosol routes in Macaca Excretion in the throats of household contacts, Bull.
irus, Bull. WHO 40:279-286 (1969). WHO 48:523--527 (1973).
69. NYERGES, G., ERDOS, 1., AND MELLY, E., Smallpox 84. SARKAR, J. K., RAY, S., AND MANJI, P., Epidemiol-
vaccination immunity in relation to number of ogical and virological studies on the off-season
insertions, Bull. WHO 48:397-400 (1973). smallpox cases in Calcutta, Indian J. Med. Res.
70. PALMQUIST, E. E., The 1946 smallpox experience in 58:829--839 (1970).
Seattle, Can. J. Public Health 38:213--218 (1947). 85. SIMPSON, H. N., The impact of disease on American
71. POLAK, M. F., Complications of smallpox vaccina- history, N. Engl. ,. Med. 250:679-682 (1954).
tion in the Netherlands, 1959-1970, in: International 86. STEARN, E. W., AND STEARN, A. E., The Effect of
Symposium on Smallpox Vaccine (R. H. REGAMEY AND Smallpox on the Destiny of the Amerindian, pp. 44-45,
H. COHEN, eds.), pp. 235-242, Karger, Basel, 1973. Bruce Humphries, Inc., Boston, 1945.
72. POLAK, M. F., BEUNDERS, J. J. W., VAN DER WERFF, 87. THOMAS, D. B., ARITA, I., MCCORMACK, W. M.,
A. R., SANDERS, E. W., VAN KLAVEREN, J. N., AND KHAN, M. M., ISLAM, S., AND MACK, T. M., En-
BRANS, 1. M., A comparative study of clinical reac- demic smallpox in rural Pakistan. II. Intravillage
tion observed after application of several smallpox transmission and infectiousness, Am. J. Epidemiol.
vaccines in primary vaccination of young adults, 93:373--383 (1971).
Bull. WHO 29:311-322 (1963). 88. THOMAS, D. B., MACK, T. M., Au, A., AND KHAN,
73. RAo, A. R., Haemorrhagic smallpox, a study of 240 M. M., Epidemiology of smallpox in West Pakistan.
cases, J. Indian Med. Assoc. 43:224-229 (1964). III. Outbreak detection and interlocality transmis-
74. RAo, A. R., Smallpox, The Kothari Book Depot, sion, Am. J. Epidemivl. 95:178-189 (1972).
Bombay 12, 1972. 89. THOMAS, D. B., MCCORMACK, W. M., ARITA, I.,
75. RAo, A. R., JACOB, E. S., KAMALAKSHI, S., ApPAS- KHAN, M. M., ISLAM, M. S., AND MACK, T. M.,
WAMY, S., AND BRADBURY, Epidemiological studies Endemic smallpox in rural East Pakistan. II. Meth-
in smallpox: A study of intrafamilial transmission odology, clinical and epidemiological characteristics
in a series of 254 infected families, Indian J. Med. of cases, and intervillage transmission, Am. ,. Epide-
Res. 56:1826-1854 (1968). miol. 93:361-372 (1971).
76. RAo, A. R., PRAHLAD, I., SWAMINATHAN, M., AND 90. WEHRLE, P. F., POSCH, J., RICHTER, K. H., AND
LAKSHMI, A., Pregnancy and smallpox, J. Indian HENDERSON, D. A., An airborne outbreak of small-
Med. Assoc. 40:353--363 (1963). pox in a German hospital and its significance with
77. RAo, A. R., SUKUMAR, M.S., KAMALAKSHI, 5., respect to other recent outbreaks in Europe, Bull.
PARAMASIVAM, T. V., PARASURAMAN, T. A. R., AND WHO 43.:669-679 (1970).
SHANTHA, M., Experimental variola in monkeys. 91. WEINSTEIN, I., An outbreak of smallpox in New
Part 1. Studies on disease enhancing property of York City, Am. J. Public Health 37:1376-1384 (1947).
cortisone in smallpox: a preliminary report, Indian J. 92. WINSLOW, O. E., A Destroying Angel: The Conquest
Med. Res. 56:1855-1865 (1968). of smallpox in Colonial Boston, Houghton Mifflin,
78. ROBERTS, J. A., Histopathogenesis of mousepox. I. Boston, 1974.
Respiratory infection, Br. ,. Exp. Pathol. 43:451-461
93. WOODWARD, S. B., The story of smallpox in Massa-
(1962).
chusetts, N. Engl. J. Med. 206:1182-1191 (1932).
79. SARKAR, J. K., CHATTERJEE, S. N., MITRA, A. c.,
94. World Health Organization, WHO Expert Commit-
AND MONDAL, A., Antibody response in haemor-
tee on Smallpox, First Report, World Health Organi-
rhagic smallpox, Indian J. Med. Res. 55:1143--1149
zation Technical Report Series No. 283 (1964).
(1967).
95. World Health Organization, WHO Scientific Group,
80. SARKAR, J. K., HAT!, A. K., AND MITRA, A. c., Role
of mosquitoes in the spread of smallpox, ]. Infect. Smallpox Eradication, World Health Organization
Dis. 128:781-783 (1973). Technical Report Series No. 393 (1968).
81. SARKAR, J. K., AND MITRA, A. c., Virulence of 96. World Health Organization, A decade of smallpox,
variola virus isolated from smallpox cases of varying WHO Chron. 22:134-141 (1968).
severity, Indian J. Med. Res. 55:13--20 (1967). 97. World Health Organization, Guide to the Laboratory
82. SARKAR, J. K., MITRA, A. c., MUKHERJEE, M. K., DE, Diagnosis of Smallpox for Smallpox Eradication Pro-
S. K., AND MAZUMDAR, D. G., Virus excretion in grammes, WHO, Geneva, 1969.
smallpox. 1. Excretion in the throat, urine, and 98. World Health Organization, Smallpox surveillance,
conjunctiva of patients, Bull. WHO 38:517-522 Weekly Epidemiol. Rec. 47:18 (1972).
(1973). 99. World Health Organization, Smallpox surveillance,
83. SARKAR, J. K., MITRA, A. c., MUKHERJEE, M. K., Weekly Epidemiol. Rec. 47:144 (1972).
100. World Health Organization, Smallpox, Weekly Epi- 12. Suggested Reading
demiol. Rec. 47:161-162 (1972).
BENENSON, A. S., Routine vaccination for all is still
101. World Health Organization, WHO Expert Commit-
indicated, in: Controversy in Internal Medicine II (F. J.
tee on Smallpox Eradication, Second Report, World
INGELFINGER, R. V. EilERT, M. FINLAND, AND A. J.
Health Organization Technical Report Series No.
RELMAN, eds.), pp. 371-381, Saunders, Philadelphia,
493 (1972).
1974.
102. World Health Organization, Smallpox surveillance,
CHRISTIE, A. B., Infectious Diseases: Epidemiology and
Weekly Epidemiol. Rec. 49:9-17 (1974). Clinical Practice, pp. 185-237, E. and S. Livingston,
103.· World Health Organization, Progress in smallpox Edinburgh, 1969.
eradication, WHO Chron. 28:361 (1974). DICK, G., Smallpox: A reconsideration of public health
104. World Health Organization, Smallpox surveillance, policies, Prog. Med. Virol. 8:1-29 (1966).
Weekly Epidemiol. Rec. 50:13-28 (1975). DIXON, C. W., Smallpox, J. and A. Churchill, London,
105. World Health Organization, Smallpox surveillance, 1962.
Weekly Epidemiol. Rec. 50:254-256 (1975). DOWNIE, A. W., Smallpox, in: Infectious Agents and Host
106. World Health Organization, Smallpox surveillance, Reactions (S. MUDD, ed.), pp. 487-518, Saunders, Phila-
Weekly Epidemiol. Rec.51:9-18 (1976). delphia, 1970.
CHAPTER 21
Varicella-Herpes
Zoster Virus
Thomas H. Weller
1. Introduction liform eruption; rarely the individual with vari-

cella may exhibit a zosteriform concentration of
1.1. Definition lesions.
Varicella-zoster virus (Herpesvirus varicella e), com-
monly abbreviated to "V-Z virus," is the etiologi- 1.2. Social Significance
cal agent of two diseases of man, varicella and
Varicella remains on the ever smaller list of
herpes zoster. Varicella (chickenpox) is a ubiqui-
tous, contagious, generalized exanthematous dis- ubiquitous infectious diseases of childhood for
ease of seasonally epidemic propensities that fol- which no vaccine is available. The prevalence of
lows primary exposure of a susceptible individual, its delayed manifestation, herpes zoster, now is
most often a child. Herpes zoster (shingles) is an increasing in the developed world in proportion to
endemic sporadic disease, most frequent in elderly the relative number of older people in the popula-
people, characterized by the appearance of a uni- tion. Additionally, iatrogenic herpes zoster is
lateral, painful, vesicular eruption localized to the more common with the widespread usage of im-
dermatome innervated by a specific dorsal root or munosuppressive and cytotoxic drugs that ad-
extramedullary cranial ganglion. In contrast to var- versely influence host defense mechanisms.
icella, which follows primary exogenous contact
with the causative virus, zoster reflects endogen-
ous activation of a V-Z viral infection that has 2. Historical Background
survived in latent form following an attack of
varicella. The two clinical entities are not as dis- 2.1. Clinical Recognition
tinct as is customarily assumed. The patient with
zoster frequently develops a disseminated varicel- Herpes zoster was described in premedieval
times. Varicella, however, was not differentiated
Thomas H. Weller . Richard Pearson Strong Professor from smallpox (variola) until the end of the nine-
of Tropical Public Health and Head, Department of teenth century. It is of interest that Osler in
Tropical Public Health, Director, Center for Prevention of 1892«;0) deemed it necessary to emphasize that
Infectious Diseases, Harvard School of Public Health, "there can be no question that varicella is an
Boston, Massachusetts affection quite distinct from variola and without at
457
458 Chapter 21 • Varicella-Herpes Zoster Virus
present any relation whatever to it." However, to the isolation and propagation in vitro by us of the
this day, the mild or atypical case of smallpox may etiological virus.188.92) By 1958(91.93,94) we had
pose a problem in differential diagnosis vis a vis completed various investigations on agents re-
varicella, resolvable only with the aid of virological covered from patients with varicella and with
investigations. herpes zoster. These studies revealed no differ-
The infectious nature of varicella was demon- ences in the biological or immunological attributes
strated in 1875 by Steiner/ 77l who induced the of viruses isolated from patients with the two
disease in volunteers by inoculating with vesicle clinical entities. We therefore referred to the agent
fluid from patients with chickenpox. Herpes zoster as varicella-zoster (V-Z) virus and concluded that
was similarly experimentally transmitted by Kun- "the accumulation of epidemiologic and laboratory
dratitz(43) in 1925, with the production of varicel- evidence in support of the hypothesis that a single
liform cutaneous lesions. etiologic agent is responsible for varicella and
herpes zoster appears so impressive that the bur-
2.2. Association of Varicella with Herpes Zoster den of proof must now logically shift to those who
desire to refute the monistic concept."19;])
Interest in the relationship between varicella
and herpes zoster dates from the clinical observa- Since the isolation of V-Z virus, the concept that
tions of von Bokay(;) in 1888 that susceptible cases of herpes zoster reflect activation of a preex-
isting latent V-Z virus has been generally ac-
children acquired varicella after contact with indi-
cepted. Interest has shifted from the hypothesis
viduals with herpes zoster. (Subsequently, this
association was repeatedly observed; the report of that dermatropic and neurotropic strains of V-Z
virus exist to the study of the as yet ill-defined
the School Epidemics Committee of Great Britain
mechanisms of host resistance that, when de-
in 1938/ 74 ) for example, linked 18 outbreaks of
varicella to an exposure to zoster.) Additional pressed, permit activation of a previously latent V-
Z virus. Parenthetically, confusion with herpes
evidence in support of the monistic etiological
concept of the two clinical entities slowly accrued. simplex virus (HSV) is to be avoided; while V-Z
Tyzzer in 1906(85) described superbly the histo- and HSV are both members of the herpes group of
viruses, the relationship is distant and the agents
pathology of the cutaneous lesion in varicella, with
its characteristic intranuclear inclusion-contain- are dis tinct.
ing multinucleate giant cells. An identical histo-
pathological picture for the skin lesion of zoster
was recorded by Lipschutz in 1921.'47) Technically
difficult studies in the 1930s by several workers 3. Methodology Involved in Epidemiological
who employed vesicle fluid material as antigen Analysis
suggested an immunological relationship. In the
early 1940s, Zinsser(10() and Sabin (9 ) alluded to
the probable close relationship of the two etiologi- 3.1. Sources of Mortality Data
cal agents; emphasis at that period focused on the
theoretical existence of strains of virus that pos- In the United States, deaths attributable to
sessed differing dermatropic or neurotropic affini- chickenpox and to herpes zoster are coded sepa-
ties. Garland in 1943(22) suggested that zoster rately and are recprded annually in Vital Statistics
reflected activation of a latent varicella virus, a of the United States, National Center for Health
mechanism similar to that obtaining with the virus Statistics. The fact that for some years reported
of herpes simplex, and he should be credited with deaths(1;]) from herpes zoster (averaging 73 from
first expressing this now generally accepted thesis. 1966 to 1970), unusual as a primary cause of
mortality, approach in number those ascribed to
varicella (averaging 106 per year from 1966 to 1970)
2.3. Isolation and Propagation of the Etiological
Agent of Varicella-Zoster in the United States suggests a degree of error in
attributing death to herpes zoster rather than to an
Substantiation of the view that varicella and inciting disease process. Deaths from varicella,
herpes zoster have a common etiology followed most often due to a specific pneumonia or a
Chapter 21 • Varicella-Herpes Zoster Virus 459
diffuse hemorrhagic process, have a high proba- to the ninth day of illness. In four groups, mean
bility of accurate attribution; however, those re- counts of pocks per child varied from 207 to 510,
sulting from a postinfectious varicella encephalitis with a range of 10-1968. Herpes zoster also may
are subject to errors of diagnosis. exhibit minimal cutaneous lesions. Cases have
been described of zosterlike pain in the absence of
an overt segmental eruption, and in one instance
a concurrent rise in specific antibody was ob-
3.2. Sources of Morbidity Data served. (39)
3.2.2. Clinical Observation and Retrospective
3.2.1. Reporting of Cases. a. Requirement for Histories. Data on the communicability of varicella
Notification in the United States. Varicella, prior to derive primarily from the careful study of exposed
1972, was not reportable nationally in the United susceptible children in households, in schools, or
States. While in certain states chickenpox has been on hospital wards. The accuracy of a negative
notifiable for many years-for example, since 1910 history of varicella depends on the informant and
in Massachusetts-in four states the disease re- on the time span since the period of maximum
mained unnotifiable as of 1976. Herpes zoster is risk. The parent of the young child is a better
generally not reportable. informant than is the subject at an older age.
b. Inadequacies of Notification. Only a fraction of However, in a large-scale retrospective study on
the cases of varicella occurring in the United States the occurrence of chickenpox in the United
are reported. In 1936, 200,000 families in 28 cities States,Cl6) it was concluded that the "forgetting
in the United States were surveyed to establish the factor" became important for subjects as young as
occurrence of communicable diseases; the notifica- 9 yr of age, a period when the parent would be the
tion rate of chickenpox cases was estimated to be major informant. Inability to remember past
20-40% of the actual number.(16) In 1947, Feems- events certainly accounts for the low exposure
ter, as cited by Gordon/ 30l concluded that only attack rate of 12% observed by Hope-Simpson(33)
25% of the cases in Massachusetts were reported. in intimately exposed "susceptibles" aged 15 yr or
This comparatively high rate probably has not more. ROSS(65) reported an attack rate of 5% in
been maintained as interest in infectious diseases "susceptible" parents in contrast to a rate of 87%
has waned. It is currently estimated that the level in "susceptible" children. Conversely, the attack
of reporting in New York City is of the order of 8- rate in children with "positive" histories was 7%.
10%.(48) A report from the National Center for In a recent serological investigation of children
Disease Control(37) suggests an average figure of with "negative" histories, one-third of those
10% for the country. That the level of reporting is tested were reactive with a V-Z antigen. (24)
totally inadequate and extremely variable from The defective memory of the older person with
state to state is shown by the fact that four states herpes zoster, when questioned regarding the pre-
where the disease is notifiable reported fewer than vious occurrence of varicella, has led to confusion.
50 cases of varicella in 1973.(13) Indeed, the "forgetting factor" played a significant
c. Occurrence of Inapparent Infections. In con- role in the slow acceptance of the monistic view of
trast to an infection such as mumps, most cases of the etiology of V-Z. Contrast, for example, the
varicella are clinically apparent. However, in a study in Great Britain of herpes zoster in school-
fraction of infected individuals, probably less than children, (74) wherein a history of varicella could
5%, the exanthem is so sparse and transient that be obtained for 71 % of 66 boys with the disease,
its occurrence; especially in the dark-skinned pa- with the observations of the astute country practi-
tient, may be missed by the qualified observer. tioner of epidemiology, W. N. Pickles/ 62 ) who
From an analysis of secondary and tertiary attack observed 56 cases of herpes zoster in older people.
rates after home exposure, ROSS(65) concluded that Pickles specifically queried all of his patients with
no more than 4% of cases are unrecognized. The shingles regarding prior chickenpox; only one
visibility of the disease is indicated by the study gave a positive response, leading to the erroneous
by Ross of the number of pocks per child as conclusion that "in view of the suffering caused by
established by a single home visit on the sixth day herpes zoster in adults it would seem a great
misfortune not to acquire chickenpox in early 3.4. Laboratory Methods

life."
3.4.1. Isolation of Virus. The definitive diagno-
sis of varicella or herpes zoster is based on the
isolation of the etiological agent.19Ol Since no
3.3.1. Methodology. Several approaches to the common laboratory animals are susceptible, cul-
detection of V-Z antibody are available, including tures of susceptible cells must be used. While V-Z
complement fixation (CF),190.93) neutralization virus exhibits a lesser degree of host specificity in
(N),t12) indirect fluorescent antibody (FAI),t73) vitro than in vivo, cultures of human cells are the
indirect hemagglutination (HAI),t21l and platelet most sensitive indicators of V-Z virus; a further
aggregation (P AY61) procedures. A recently devel- consideration is that confluent, transparent, well-
oped fluorescent technique for the detection of organized sheets of growing cells provide optimal
antibody reactive with membrane antigen of V-Z conditions for detection microscopically of the fo-
infected cells may be useful in assessing suscepti- cal lesions induced by V-Z virus. These criteria are
bility.(24) The complement fixation reaction was satisfied by actively growing cultures of fibro-
developed first and has been most used; therefore, blasts, kidney cells, or amnion cells, all of human
its limitations are most clearly defined. The new origin. Oile or more of these culture systems are
procedures have yet to be used in seroepidemiol- usually employed for the isolation of V-Z virus.
ogical investigations. Because of difficulties inher- V-Z virus can be recbvered with ease by inocu-
ent in obtaining cell-free infectious V-Z virus, lation of appropriate cultures of human cells with
tests for neutralizing antibody remain, for practical the aspirated contents of vesicular lesions. Selec-
purposes, the province of the research tion of the young "dewdrop" lesion containing
investigator. clear fluid is important. Chances of recovery of
3.3.2. Limitations of the Seroepidemiological virus decrease as the lesion becomes pustular, and
Approach. There are problems of sensitivity and of V-Z virus, in contrast to variola virus, cannot be
specificity in use of the CF reaction in surveys isolated from crusts or scabs. V-Z virus can be
designed to detect prevalence of infection with V- readily isolated during the first 3 days of the
Z virus. Within months after a primary attack of exanthem in varicella; isolation of virus thereafter
V-Z, titers of antibody detectable by CF begin to is rare unless the disease is atypical as in the
fall and may reach sub detectable levels. Both in immunologically compromised host. (27.B3.94) Virus
the United States(96) and in England,tB4) a peak can be recovered from the cutaneous lesions of
reactivity of around 70% was demonstrable in the patients with zoster for a longer period of time,
10-20 yr age group; in the Seattle study, the rate i.e., at times to the seventh day or later after the
had fallen to 35% by age 45--49. appearance of the segmental vesiculopustular
With respect to specificity, reports(40.B2) that CF process.
antibodies for V-Z may rise in patients infected The focal cytopathic process produced by V-Z
with herpes simplex virus (HSV) have been amply virus in cultures of susceptible cells has to be
confirmed; conversely, the patient with V-Z may differentiated from the transiently focal lesions of
develop a rise in CF titers of antibody for HSV. (07) the virus of herpes simplex (HSV) or the more
However, it is probable that most heterologous persistent focal lesions induced by the human cyto-
responses, as for example a rise in V-Z titer in a megaloviruses (CMV). The V-Z focal lesion in a
patient infected with HSV, indicate that the re- sheet of susceptible cells may be apparent as early
spective patients have previously experienced an as 2 days after inoculation-or as late as 3-4 wk.
infection with the heterologous agent. (71.72) Thus, Microplaques develop, observable under 100x
in contrast to diagnostic applications, the impor- magnification as consisting of a few small, refractile
tant limitation of the CF reaction in seroepide- cells. Each microplaque slowly enlarges by involve-
miological studies on varicella is not the nonspe- ment of contiguous cells, with progressive degen-
cific rise in titer but rather the significant eration of the older central portion. Very little infec-
percentage of false negatives obtained in older tious virus is released from the infected cells and
individuals who have had an infection in the past. the number of foci increases slowly. However, pe-
ripheral extension of the process continues, with 4. Biological Characteristics of V -Z Virus

eventual involvement of most of the cell sheet. Affecting the Epidemiological Pattern
Stained preparations reveal intranuclear inclusions
in involved cells, particularly at the marginal pla- 4.1. Latency in the Human Host: Primary
que interface. Confirmation of identity of the iso- Infection, Latency, and Reactivation
late, and in particular differentiation from CMV,
can be accomplished immunologically by use of V-Z virus shares with other herpesviruses the
specific V-Z antisera in direct fluorescent antibody capacity to persist in the body after the primary
tests or by performance of CF or other serological infection. Decades later, the virus may again be-
tests in which the antigen derives from the infected come manifest with renewed replication and the
culture. For technical details, the reader is referred production of the clinical syndrome of herpes
to a standard reference on diagnostic proce- zoster. Immunologically inexperienced individuals
dures.(90) in intimate contact with the patient with herpes
3.4.2. Application of Agar Gel Diffusion Tech- zoster can contact varicella. Thus V-Z virus is
niques to Specific Diagnosis of V -Z. Recently a epidemiologically unique in that it can persist for
microgel precipitin diagnostic technique has been years in a mobile human incubator, roam globally,
described. (9.86) Advantages include rapidity of and when host defense mechanisms decay again
performance, i.e., 12-24 h, and the.fact that anti- replicate and initiate an outbreak of the primary
genically reactive material (in contrast to infectious disease.
virus) can be demonstrated in extracts of crusts
from involuting lesions; positive tests were ob- 4.2. Failure of V -Z Virus to Persist in Scabs or
tained from materials collected as late as 14 days Fomites: Limited Period of Communicability
after the onset of. varicella and 23 days after the
onset of herpes zoster. An independent evaluation In contrast to the variola-vaccinia viruses, which
of this promising approach has not yet appeared. survive for long periods in scabs, V-Z virus cannot
3.4.3. Differentiation of Varicella from Variola. be recovered from crusts or from the involuting
The epidemiologist often is in a critical position lesions. The period of communicability is there-
when a community is confronted by a patient in fore discrete and coincident with the duration of
whom the differential diagnosis between varicella vesicular lesions. Room dust is not infectious and
and variola cannot be made with certainty. While terminal disinfection is not indicated.
standard procedures should be followed,"8.901 two
points deserve emphasis. First, specimens col-
lected from an individual with a vesiculopustular 5. Descriptive Epidemiology
exanthem should be handled as if from a case of
smallpox until proved otherwise, i.e., as highly
5.1. Data on Incidence and Prevalence
infectious and dangerous material. Second, in the
desire to obtain confirmation of the diagnosis from 5.1.1. General Comments on Varicella. In mod-
a competent-and often distant-laboratory, one em industrialized societies in the temperate areas
simple test that is immediately applicable is often of the world almost all individuals contract vari-
overlooked. If the patient is infected with V-Z or cella, usually during childhood. Reported annual
HSV, examination of stained smears of scrapings incidence rates of 87.3 and 97.7 per 100,000 popu-
from the base of a fresh lesion should reveal lation in the United States for the years 1972 and
multinucleate giant cells and other cells with in- 1973 do not reflect reality":!); application of a
tranuclear inclusions as originally described by corrective factor of ten- to twentyfold probably
Tyzzer(85); if the lesion is due to variola-vaccinia would yield data closer to the actual situation.
virus, neither giant cells nor intranuclear inclu- Figure 1 summarizes the reported cases of chick-
sions will be present. If additional confirmatory enpox per 100,000 population per year in Massa-
evidence is needed, a lesion may be biopsied and chusetts from 1910 through 1973; these data reflect
the specimen fixed and rapidly processed for his- an unknown degree of underreporting.
topathological examination. Varicella is a benign disease in the immunologi-
600~--------------------------~
summarizes mortality data for Massachusetts by
decade, can be expected to reverse. The benign
0500
o nature of varicella in England has been empha-
o sized(44); in a population of approximately 1 mil-
cS 400 lion, only 12 cases that required hospitalization
Q
occurred in 10 yr. In 1965, about 20 deaths a year
~ 300 were reported from England and Wales. In Aus-
tralia, there were only nine deaths among 1612
a::~ 200
patients with varicella admitted to one hospital
between 1943 and 1959.(6)
.&~
In tropical and the less developed regions of the
100 world, the situation with respect to varicella is less
clear. Morbidity and mortality statistics are essen-
O'-----._--._----.-_---.-_--.-_~--I
tially nonexistent. However, as noted below, frag-
1910 1920 1930 1940 1950 1960 1970 mentary evidence suggests that climatic factors
Year and the relatively rural, isolated distribution of
indigenous peoples combine to inhibit transmis-
Fig. 1. Reported cases of chickenpox per 100,000 popula- sion and to extend susceptibility into the older age
tion per year in Massachusetts from 1910 through 1973.
groups as compared with industrialized societies.
Source: Massachusetts Department of Public Health, Divi-
sion of Communicable Diseases, Dr. Nicholas]. Fiumara,
5.1.2. General Comments on Herpes Zoster.
Director. Herpes zoster is a sporadic endemic disease re-
flecting reactivation of a latent host-contained in-
fection with V-Z virus, with incidence determined
cally uncompromised child in the United States; by factors influencing the host/parasite relation-
the few deaths that do occur usually reflect illness ship. The primary determinant of prevalence is the
in the infant or the adult. However, as physicians age composition of the popUlation, with particular
increasingly employ immunosuppressant agents in reference to time elapsed since acquisition of the
the therapy of conditions such as nephrosis in primary V-Z infection. In a panel practice of some
children, and as the mean life expectancy of chil- 3500 persons in England observed over a period of
dren with malignancies, especially leukemia, is 16 yr by Hope-Simpson, (~4) herpes zoster oc-
prolonged by medical means, fatalities due to a curred at an annual rate of 3.4 per 1000 persons.
complicating varicella infection can be expected to Under similar circumstances in a panel practice in
increase. Thus the downtrend in mortality associ- Scotland, McGregor(54) recorded an annual rate of
ated with varicella as reflected in Table 1, which 4.8 per 1000.
Table 1. Deaths from Chickenoox and Mean Annual Death

Rate per 100,000 Population, by Decades, Massachusetts,
1910-1969a
Mid-decade Mean annual death

Years population Deaths rate
191(}"1919 3,701,000 48 0.13

192(}"1929 4,158,000 83 0.20
193(}"1939 4,361,000 69 0.'16
194(}"1949 4,511,000 39 0.08
19S(}..1959 4,853,000 30 0.06
196(}..1969 5,343,255 22 0.04
a Source: Massachusetts Department of Public Health, Division of Communicable

Diseases, Dr. Nicholas J. Fiumara, Director.
5.1.3. Risk of Infection in Susceptible Individ- The patient with herpes zoster also is infectious.
uals. Although varicella has a justifiable reputa- Anecdotal evidence suggests that the patient with
tion as a highly contagious disease, intimate rather zoster poses less of a risk than does the patient
than casual contact is required for a high transmis- with varicella. Apparently no controlled study has
sion rate. In a recent analysis, based on reported been carried out. It has been postulated that the
cases of varicella in New York City, the infectivity zoster patient is less infectious because the lesions
of chickenpox in households and in society as are circumscribed and often covered with clothing.
expressed as annual exposures divided by average The validity of this thesis is mitigated by the fact
number of susceptibles was 0.61 and 0.12, respec- that approximately one-third of patients with zos-
tively. (99) In comparison with measles (rubeola), ter exhibit disseminated cutaneous lesions, indi-
which was arbitrarily assigned an infectivity po- cating the occurrence of a viremia. (59) Perhaps of
tential of 100%, chickenpox was 80% as infectious more import is the fact that patients with zoster
in households and 46% as infectious in society. often possess significant titers of specific antibody
The most accurate data on the infectivity of at the time the exanthem is fully developed(93);
varicella derive from experimental studies on at- therefore, partial neutralization of free infectious
tempts to modify varicella in which carefully ob- virus in the evolving lesion may occur in vivo
served control populations of susceptible children before it is released into the environment.
were at risk. In such a study, ROSS(65) observed a
secondary attack rate of 87% in susceptible sib-
lings in households following the introduction of
the primary case of varicella; a tertiary attack rate 5.2.1. Varicella. In industrialized societies in
of 71% was observed among those siblings (Le., temperate regions, varicella is endemic in the total
13% of the original group) who had escaped infec- population but epidemic in susceptible clustered
tion on exposure to the primary household con- subgroups and exhibits a characteristic seasonal
tact. fluctuation in incidence. Data from Massachusetts
Hope-Simpson(33) summarized data on the in- reveal a pattern of low levels of endemicity at the
fectiousness of varicella in a semirural area in beginning of the 60-yr period that started in 1910
Gloucestershire, England; the exposure attack rate (Fig. 1 and Table 2). Gordon,<3m who examined
among susceptibles, aged 0-15 yr, in homes was the data from Massachusetts in 1962, concluded
61%. In a hospital environment, Gordon(30J cites that the pattern to that time was one of mildly
an experience with a dozen outbreaks of varicella fluctuating increasing endemicity, with superim-
on the wards in which the attack rate among 81 posed recurring epidemics about equally divided
susceptibles was 68%. between outbreaks at intervals of 2 yr and 3 yr;
Table 2. Reported Cases of Chickenpox and Mean

Annual Case Rate per 100,000, by Decades,
Massachusetts, 1910-1969u
Mean annual rate per

100,000 (based on mid-
Decade Cases per decade decade population)
1910-1919 45,689 123.4

1920-1929 79,765 191.8
1930-1939 106,979 245.3
1940-1949 151,163 335.1
1950-1959 158,084 311.5
1960-1969 125,598 235.1
a Source: Massachusetts Department of Public Health, Division of Com-

municable Disease, Dr. Nicholas J. Fiumara, Director.
two had an interval of 4 yr. The increase in annual term cyclic fluctuations in the prevalence of vari-
rates from 1910 to the 1940s was attributed by cella heretofore unrecognized.
Gordon to a gradual improvement in reporting. In contrast to the endemic nature of varicella in
Now with data since 1962 available, in retro- the popUlation at large, epidemics follow introduc-
spect it would appear that the peak rates of over tion of varicella into intimately associated
4001100,000 in 1944, 1947, 1949, and 1953 in Massa- subgroups or clusters of susceptibles. Typical is
chusetts, with intervening extreme fluctuations, the school situation described by Wells and
reflect the dislocations of the population in the war Holla (5 ); of 67 susceptible children in grades 0-4,
years, followed by postwar spurts in the birth rate. 61 contracted the disease in an explosive outbreak.
A similar but less marked period of fluctuation in Within elements of larger popUlation groups, as in
annual incidence is reflected by the data for the different boroughs in New York City, levels of
period of World War I and immediately thereafter. endemicity vary annually, reflecting the varying
Thus, except for the war periods, reported rates summation of epidemic outbreaks in clusters of
reflect a relatively smooth increase in annual inci- susceptibles(99) within each borough.
dence between .1910 and 1940, little influenced by 5.2.2. Herpes Zoster. Herpes zoster is an en-
epidemics, with a tendency to plateau at a level of demic disease that shows no seasonal pattern and
3001100,000 between 1940 and 1964. Between 1964 appears in "epidemic proportions" only when
and 1966, rates in Massachusetts fell abruptly to induced iatrogenically in specialized groups of
the current level of under 2001100,000 per year. patients such as those under chemotherapy be-
Thus varicella in Massachusetts is at its lowest ebb cause of malignancy. In this instance, the situation
in half a century, a phenomenon not unique to reflects chance concurrent reactivation of a latent
this state, for data from New York City reveal a agent in each patient and not person-to-person
parallel decrease in annual incidence. (99) transmission.
The apparent 50-yr rise and fall in the level of
endemicity of varicella in Massachusetts and in
New York is of interest. Much of the decline in
prevalence observed during the past decade prob- 5.3.1. Varicella. Varicella and herpes zoster oc-
ably is artifactual due to deterioration of the recur throughout the world. There is evidence that
porting process. This explanation is supported by in tropical regions, as contrasted to temperate
authorities in New York City.(52) However, as regions, varicella is seen more often in adults.
noted below, current low levels of prevalence are Annual rates for varicella in the U.S. Army in
paralleled by an altered pattern of seasonal inci- World War II in the Latin American area, where a
dence and to a lesser extent of age-specific attack large number of soldiers from Puerto Rico were
rates; therefore, the cyclical phenomenon is not stationed, were 1.41 and 2.27 per 1000, respec-
solely an artifact of reporting. It is likely that the tively, in 1944 and 1945; the comparable figures for
recent decrease in prevalence also reflects a declin- the continental United States were 0.71 and 0.61
ing birth rate, and a decrease in the relative for the same years. (SOl Brunell'S) notes that a
number of susceptible children. Other hypotheses majority of pregnant women with varicella ob-
deserve examination. Has, for example, some sub- served in New York are of Caribbean origin; of a
tle shift in the host/parasite relationship occurred? group studied by Siegel,(75) 52% were Puerto
Is the disease now associated with fewer pocks Ricans. In Ceylon, varicella was observed to be at
and thus more often overlooked, perhaps because least as common in adults as in children.(o» The
the average child is better nourished' or is less author has also been impressed with the common
likely to experience another concurrent infectious occurrence of varicella in adults in the tropics.
process? Has the virus become attenuated in na- The prevalence of varicella in adults in the
ture? These questions are unanswerable. Time will tropics has been attributed to the rural, discontig-
reveal whether current low levels of prevalence uous distribution of indigenous populations, and
will persist or whether rates will again gradually to an increased emphasis on detection of suspect
rise and then fall, indicating the existence of long- cases of smallpox. Probably of equal or greater
import is a decreased transmission potential due

to ambient temperatures that enhance the rela- 1250 ~
r--
tively labile nature of V-Z virus outside of the If)
Q)
~
human host. If) 1000

As emphasized by Black et al.,"ll V-Z virus can 8 ~
-
persist because of its latent capacity (i.e., zoster) ~
Q) 750
+-
on introduction into a geographically isolated, ~ ;-
small human population; a single isolated Indian a.
a:: 500
Q)
tribe in the Amazon, when surveyed serologically,
was found to have levels of reactivity comparable c ~
c ~
to those in the United States. 250

~
5.3.2. Herpes Zoster. Available data do not sug-
gest geographic differences in the distribution of 0 rf
SONDJFMAMJJA
n
herpes zoster. If, however, varicella is acquired at
a mean older age in tropical areas, herpes zoster Month
should also occur at a relatively older age. Fig. 2. Reported cases of chickenpox, mean numbers by
month, state of Massachusetts, for the 5-yr period Sep-
5.4. Temporal Distribution tember 1968 through August 1973. Source: Massachusetts
Department of Public Health, Division of Communicable
5.4.1. Varicella. In the United States, varicella Diseases, Dr. Nicholas J. Fiumara, Director.
regularly shows a striking seasonal distribution.
At the national level for the years 1972 and 1973, greater percentage of the pool of susceptibles is
annual lows occurred in September (about 2000 infected earlier in the transmission season. During
cases), rose to peaks of 26,000 and of 34,000 cases, periods of low prevalence, there is a temporal lag
respectively, in March, remained relatively high in progression of varicella through a community
through May, and then abruptly fell to typical with extension of the seasonal epidemic into the
summertime lows.'u, [In evaluating data on tem- late spring. A similar conclusion was reached by
poral distribution in terms of date of transmission, Yorke and London,'99l who calculated that in New
corrective factors for the duration of the incubation York City the mean monthly contact rates for 14 yr
period (10-21 days) and for the lag in reporting of high prevalence are about 5% higher in Sep-
must be considered.] tember and October (p <0.01) and about 4% lower
A somewhat similar seasonal distribution of in May and June (p <0.05) than the mean monthly
cases reported in Massachusetts for the 5-yr period contact rates for 16 yr of low prevalence. Using the
ending in 1973 is depicted in Fig. 2. The peak seasonal data on varicella in New York City, we
incidence, however, is in May, as contrasted to the have summarized the mean monthly cases re-
peak in March at the national level. Gordon';)O) ported for two 5-yr periods, one of high and one of
analyzed data for the 5 yr between September 1956 low prevalence (see Fig. 3). For the current period.
and August 1961 (a period of relatively high prev- of low prevalence in New York City, the seasonal
alence, when 78,000 cases of varicella were re- pattern of gradually increasing rates that peak in
ported, as contrasted to the 1968-1973 period, the late spring is even more striking than in
when 42,000 cases were reported); a bell-shaped Massach usetts.
monthly distribution was obtained with peak Varicella in the United States is primarily a
mean numbers of cases in March and with slowly disease of winter and spring. The customary ex-
decreasing numbers through April, May, and planation of the seasonal pattern relates to aggre-
June. Comparison of the data for the 1956-1961 gation of susceptible children in schools in the fall,
period with those for 1968-1973 (presented in Fig. the introduction of the agent, and its subsequent
2) suggests that transmission differs seasonally in dissemination to contacts in the classroom and to
years of high prevalence as contrasted to periods susceptible siblings in the home. This epidemiol-
of low prevalence. In years of high prevalence, a ogical pattern is dominant in the United States. It
1750 , . . - - - - - - - - - - - - ,
at a younger age during periods of high prevalence
than during periods of low prevalence. This trend,
1500 while not pronounced, is also apparent on exami-
nation of age-specific attack rates for 2 yr of high
(I)
CD
(I) 1250 and 2 yr of low prevalence (Table 3) .
8 Varicella may occur in the neonatal period as a
consequence of infection acquired either in utero
"C 1000
...
~
0
or at birth if the mother is in the acute phase of the
disease shortly prior to or during labor.(56.63)
Q.
CD 750 P'_o-~
a:: I '
Some observers have an impression, unsupported
c I ' by epidemiological data, that infants during the
tJ '
500
~ first 6 months of life acquire varicella more fre-
II ',
Sf';! quently than they contract other viral infections

250 I
I such as measles. Brunell,(7) however, has demon-
_.11 strated that V-Z antibody (CF) crosses the placen-
A'P
0 tal barrier. Passive protection of the newborn of a
SONDJ FMAMJJI A varicella-immune mother via placental transfer of
maternal antibody probably occurs as in other
Month viral diseases, but at a lower level of effectiveness.
Fig. 3. Reported cases of chickenpox, mean numbers The author has observed intimately exposed in-
by month, New York City, for two 5-yr periods, one of fants who have appeared to escape infection, and
high prevalence, i.e., September, 1937 to August 1942 others in whom the illness, reflected by develop-
(e-e), and one of low prevalence, i.e., September
ment of only a few pocks, strongly suggested
1966 to August 1971 (0---0). Prepared from tabular data
appended by Yorke and London.(OO) modification by preexistent maternal antibody.
-
is questionable whether physical clustering of sus-
ceptibles should be considered the sole factor "C
CD 70 D High Prevalence
influencing transmission. Do similar patterns ob- ~
0 • LQw Prevalence
tain when exposed susceptibles cluster under cli- Q. 60
matic conditions that are less favorable to the ~
survival of V-Z virus in the environment, as for
III
CD
50
example in summer schools and camps? jg
u 40
5.4.2. Herpes Zoster. Herpes zoster has no tem-
poral proclivities, appearing sporadically through-
out the year and independently of the prevalence
of varicella . (34)
--
"6
{l
c
30
20
CD
~ 10
5.5. Age
5.5.1. Varicella. Varicella, in industrialized so- 0-4yrs
cieties in temperate climates, is primarily a disease Age
of childhood. In Massachusetts, 60-65% of re- .
Fig. 4. Distribution of reported cases of chickenpox by
ported cases are in the 5-9 yr age group and 20-
age in Massachusetts during a 4-yr period of relatively
25% of cases occur in children under 5 yr of age
high prevalence (1962-1965; mean annual rate 281.9/100,-
(see Fig. 4). In the United States, varicella can be 000; total cases 59,652) and during a 4-yr period of rela-
considered as an occupational hazard of nursery tively low prevalence (1969-1972; mean annual rate 138.91
and primary school attendance that few children 100,000; total cases 31,164). Source: Massachusetts Depart-
escape. Figure 4 summarizes data for Massachu- ment of Public Health, Division of Communicable Di-
setts indicating that varicella tends to be acquired seases, Dr. Nicholas J. Fiumara, Director.
Table 3. Age-Specific Rates per 1000 for Reported Cases of Chickenpox in Massachusetts during
2 Recent yr of High Prevalence and for 2 yr of Minimal Prevalencea
Rate by age group Total
Year <5yr 5-9 yr 10-14 yr 15-19 yr >20 yr Cases Rate
High prevalence
1960 7.8 20.9 2.8 0.5 0.1 16,352 3.2
1962 8.0 20.4 2.6 0.4 0.1 16,359 3.1
Low prevalence
1970 2.5 9.2 1.6 0.2 0.03 7115 1.3
1971 3.0 8.2 1.5 0.2 0.1 6996 1.2
a Source: Massachusetts Department of Public Health, Division of Communicable Diseases, Dr. Nicholas J. Fiumara, Director.
The observed failure of varicella to spread in a at any age in the subject who has had a prior
newborn nursery following introduction of a case attack of varicella but is age related, with risk
has been attributed to thf' passively protected state increasing sharply in the later decades of life.
of susceptible contacts.(53l McGregor(54l and Hope-Simpson(34l reviewed
The age distribution of varicella in rural, under- data on age distribution based on observations in
developed, upland, populated areas may differ their panel practices in Scotland and in England.
from that in industrialized countries and from that McGregor recorded 81 cases of zoster over a 7-yr
in the lowland tropics. In the course of an epi- period in a practice of 2400 patients; 61 (75%) of
demic in a rural mountain village in Guatemala, these were in individuals over 45 yr of age. Hope-
85% of cases were in children under 6 yr of age, Simpson tabulated data on 192 cases observed over
and varicella was common in children under 2 yr a 16-yr period in a population of 3534 individuals
of ageYOl Mention has previously been made of (Table 4). Incidence rose gradually to age 29, tended
the frequency of varicella in adults in the lowland to plateau through the ages of 30-49, and thereafter
tropics. again increased.
5.5.2. Herpes Zoster. Herpes zoster may occur The amply documented occurrence of cases of
Table 4. Distribution by Age of 192 Cases of Herpes Zoster Observed over a 16-yr
Period in a Population of 3534 People in England a
Annual incidence
Age (yr) Population Number of cases Rate per 1000 per 1000
0-9 510 6 11.8 0.74

10-19 455 10 22.0 1.38
20-29 412 17 41.3 2.58
30-39 491 18 36.6 2.29
40-49 492 23 46.7 2.92
50-59 454 37 81.5 5.09
60-69 350 38 108.6 6.79
70-79 263 27 102.7 6.42
80-89 99 16 161.6 10.10
90-99 8 0
Total or mean 3534 192 54.3 3.39
a After Hope-Simpson(34). By personal communication, Hope-Simpson states that the population in each age
group represents the mean obtained from 6 of the annual censuses taken during the 16-year period.
herpes zoster in young children with a past history contact. Introduction of V-Z virus into the home or
of varicella continues to be the subject of case into a primary school with a large percentage of
reports in the literature. With the application of susceptible children characteristically results in an
specific virological and serological techniques, un- epidemic, usually with exhaustion of the suscepti-
usual cases of zoster are now being recognized in ble population by the second or third cycle of
children in whom the possibility of prior unde- transmission.
tected intrauterine infection with V-Z virus or an 5.9.2. In the Military. In contrast to the situa-
inapparent postnatal infection must be consid- tion in primary school populations, varicella is of
ered. (42.46) little consequence in the military of the United
States with its predominantly immune population.
5.6. Sex In World War I, there were only 1757 hospital
admissions with varicella for the total U.S.
No convincing data suggesting differences in Army. (SO) In terms of man-days lost from duty,
susceptibility by sex have been recorded for either 31,534 in all, varicella was a relatively insignificant
varicella or herpes zoster. The prevalence of zoster cause; the noneffective rate for measles was 62
in women over 70 yr of age as observed in a times higher and for mumps 129 times higher than
clinical setting is a reflection of the longer life that recorded for chickenpox. Similarly, in World
expectancy of the female. War II varicella posed no problem(29J; between
1942 and 1945, 10,664 cases were reported in the
U.S. Army, an annual incidence rate per 1000
5.7. Race
average strength of 0.42. No deaths from varicella
There is no indication of differing racial suscep- occurred in the army during the same period.
tibilities to V-Z virus. The previously noted oc-
currence of varicella pneumonia in adult black or
Puerto Rican immigrants to the continental United 5.10. Socioeconomic Factors
States is explainable on the basis of diminished Little information has been published on the
opportunities for infection during childhood in epidemiological role of socioeconomic factors.
their countries of origin. Strom(SlJ carried out a retrospective analysis in
Sweden of 2000 children born in 1939 and of 2000
born in 1949 in which the children were divided
5.8. Occupation
into three social classes. In contrast to pertussis,
As varicella is predominantly a disease of child- scarlet fever, and measles, which were less fre-
hood in this country, no specific occupational quent in the 1949 group, varicella had occurred in
associations have been described. For the suscep- the 1939 and 1949 groups with equal frequency
tible adult in the United States, in decreasing (67% and 69% by history) by age 12, peaking at 5-
order parenthood, primary school teaching, and 6 yr of age. No differences in attack rates were
patient-associated medical professions could be noted in the three social classes.
considered as occupations of high risk. In Ceylon, However, on a priori grounds the risk of acquisi-
where varicella. in adults is common, many cases tion of varicella early in childhood would appear
occur in hospital personnel. (5]) Trauma has re- directly related to family size and to density of
peatedly been described as a precipitating factor in housing and of classroom popUlations.
herpes zoster. If trauma does play a causal role,
then physically hazardous occupations may in-
volve an increased risk of precipitating this dis- 5.11. Other Factors
ease.
5.11.1. Nutrition. While there is no evidence
that malnutrition influences susceptibility to vari-
5.9. Occurrence of Varicella in Different Settings
£ella, concurrence enhances the severity of both
5.9.1. Home and Schools. As previously em- pathological conditions. In studies on six children
phasized, varicella is highly infectious on intimate in the recovery phase of kwashiorkor, the onset of
varicella reduced intake of food and diminished after renal transplantation; of these, six (8%) aged
nitrogen retention. (98) In a rural Guatemalan vil- 12-40 yr developed herpes zoster. In a recently
lage, varicella was commonly accompanied by reported study of 200 consecutive renal transplant
diarrhea. In children with varicella under 5 yr of recipients treated with immunosuppressive
age, diarrhea was observed 3 times more fre- agents, zoster occurred in 13%.(41)
quently than in an un infected control group. no) Certain types of malignancy, especially Hodg-
While only 12.5% of well-nourished children with kin's disease and lymphatic leukemia, are recog-
varicella developed diarrhea, this symptom devel- nized as inducers of attacks of herpes zoster, a
oped in 75% of those who were moderately mal- relationship potentiated by concurrent measures
nourished. Five of 50 children with varicella-asso- prolonging life expectancy. Analysis of a group of
ciated diarrhea developed kwashiorkor; one 1132 children with cancer, hospitalized during the
subsequently died. 10-yr period ending in 1972, revealed that 9%
5.11.2. Genetic Factors. Hook et al. (32) de- developed herpes zoster; the attack rate was high-
scribed an unusual situation wherein five children est in Hodgkin's disease, occurring in 22% of 97
in a family contracted severe varicella within a 2- cases.(20)
wk interval; three developed pneumonia and two
died. No predisposing genetic factor could be
identified. McKusick/ oO ) referring to this episode, .
called attention to his observation that varicella 6. Mechanisms and Routes of Transmission
may be severe and even fatal in persons with
cartilage/hair hypoplasia (CHH), a recessively in-
6.1. Varicella
herited skeletal dysplasia. Lux et al. (49) studied
two patients with CHH, both of whom had unu- 6.1.1. Congenital Infections. The pregnant
sually persistent and severe varicella; one had woman acquiring varicella near term rarely may
successive crops of vesicles over a 9-day period, transmit the infection to the fetus; onset of disease
and the other for 14 days. Immunological studies in the infant within 10 days of birth is arbitrarily
revealed normal humoral immune responses. A considered as indicating congenital transmission.
distinct cellular immune defect residing in the Meyers(06) has recently summarized data on 43
small lymphocytes was reflected by chronic neu- cases of congenital varicella collected from the
tropenia, lymphopenia, diminished delayed skin literature since 1878; the case fatality rate was
hypersensitivity, diminished responsiveness of 10%. However, the attack rate is lower than would
lymphocytes in vitro to phytohemagglutinin and to be expected. Reports were available on 46 women
allogeneic cells, and delayed rejection of a skin with varicella in the last 17 days of pregnancy who
allograft. were delivered of live infants at term; only 11
As cited by Lux et al.,<49) varicella is also severe (24%) infants had overt varicella.
in patients with another hereditary immunological Although sporadic observations continue to be
disease, Nezelof's syndrome, in which there is an published that suggest an association between
autosomal recessive lymphopenia. varicella in the pregnant woman and congenital
5.11.3. Iatrogenic Factors. a. Varicella. Varicella malformations, large-scale retrospective and pro-
may be life threatening in children with leukemia spective studies have not confirmed this thesis. A
and other malignant diseases(14); with advances prospective study on a national scale in the United
in therapy now prolonging the life of the leukemic Kingdom found 298 pregnancies complicated by
child, severe infections are a relatively common varicella; the outcome did not differ from that in
complication. Corticosteroid, (14.23) immunosup- pregnancies in the control group. (00) Similarly, a
pressive, and antimetabolic therapy may convert a prospective study in New York of 135 pregnant
benign illness into a fulminating disease. women with varicella revealed no difference be-
b. Herpes Zoster. Immunosuppressive or anti- tween the mean birth weight of babies in the
metabolite therapy may disturb the delicate bal- study group and that of matched controls.n(l) A
ance that maintains V-Z virus in a latent state. subsequent cohort study in New York City, in-
Rifkind(64) studied 73 patients for 21-37 months volving a 5-yr follow-up of children born after
maternal varicella, revealed no associated malfor- ble. Old World monkeys do not develop general-
mations. (75) ized disease on inoculation with V-Z virus, al-
6.1.2. Postnatal Transmission. The typical case though a varicellalike disease, produced by a virus
of varicella is probably infectious for 1-2 days closely related to but distinct from V-Z virus, has
prior to the appearance of the generalized eruption been described in macaques.(4) While monkeys
and for 4-5 days thereafter, i.e., until the last crop have not been shown to be susceptible, anthro-
of vesicles has evolved to the purulent and crusted poid apes apparently can contract varicella if in
state. The period of infectibility is prolonged in contact with a human case. (97) Thus, theoretically,
the immunoincompetent host who exhibits suc- the higher apes could maintain V-Z virus in na-
cessive crops of cutaneous lesions over a period of ture.
1 wk or more. Airborne droplet infection has been
emphasized in the past as an important mode of
transmission. Evidence on the role of intimate 6.2. Herpes Zoster
association suggests that infections are also spread The individual with herpes zoster is infectious
by direct contact, and less frequently by indirect and can initiate an outbreak of varicella in suscep-
contact. The duration of infectivity of droplets tibles. The mechanism of transmission is even less
containing labile virus must be relatively limited. well defined than in varicella, although probably it
The mechanism whereby virus is shed is ill is basically similar. Not sufficiently appreciated is
defined. A viremia occurs in the prodromal stage the fact that in herpes zoster a chickenpoxlike
as indicated by disseminated cutaneous lesions dissemination of cutaneous lesions, apparently re-
and by Tyzzer's observation(S5) that specific histo- flecting a transient viremia, is a common occur-
logical changes in the evolving cutaneous lesion rence. In a prospective study in Sweden of 100
first appear in the capillary endothelium. Lesions consecutive hospitalized patients with herpes zos-
are not confined to the skin, but also occur in the ter, Oberg and Svedmyr(59) observed the appear-
respiratory, urinary, and gastrointestinal tracts; ance of disseminated cutaneous lesions--usually
thus, theoretically, various routes exist for dissem- several days after development of the segmental
ination of virus. However, virus has been re- process--in 33% of their patients. Similarly, 15
covered with regularity only from the cutaneous (16%) of 91 patients in England developed widely
lesions. Gold(27) could not recover virus from distributed lesions. (39)
respiratory tract secretions that were obtained
daily from three children, beginning in the latter
part of the incubation period and continuing to 7. Pathogenesis and Immunity
after appearance of the rash. From an additional
case, a single isolate was made from pharyngeal
7.1. Varicella
secretions collected 1 day after the exanthem de-
veloped. In another study(58) of 29 children, V-Z 7.1.1. Pathogenesis. Circumstantial rather than
virus could not be isolated from oropharyngeal factual evidence and analogies to experimental
swabbings collected before or after appearance of models of other virus/host interactions provide the
the rash; most of the specimens, however, were basis for hypotheses bearing on the sequence of
frozen before examination. Interpretation of the events following infection of the human host.
significance of failures to isolate V-Z virus in vitro Entry of the virus is probably via the mucosa of
is an uncertain endeavor. There is no reason to the oropharynx, the upper respiratory tract, the
assume that as an indicator of V-Z virus the conjunctiva, or, less likely, the skin. Viral replica-
sensitivity of a culture of human cells equals that tion occurs intracellularly at the site of lodgement,
of the susceptible human host. with subsequent cycles of replication involving
6.1.3. Vectors and Animal Reservoirs. There is contiguous cells and leading to dissemination via
no indication that arthropod vectors play a role in the blood and lymphatics. Data on growth curves
the transmission of V-Z virus. Animal reservoirs of V-Z virus in vitro suggest that multiple cycles of
are unknown and unlikely to exist. V-Z virus is focal replication (perhaps in reticuloendothelial
highly host specific and rodents are not suscepti- cells) occur during the relatively prolonged incu-
bation period. Early in this stage, nonspecific host varicella. The clear-cut evidence, repeatedly re-
immune responses as well as a developing specific corded, that cases occur sporadically with no tem-
immunity partially contain the virus. After 7 days poral or spatial relationship to varicella in epi-
o'r more, these responses are overwhelmed, the demic form documents endogenous reactivation as
viremia increases quantitatively, and prodromal the usual source of virus. Whether herpes zoster
symptoms develop, followed by cutaneous lesions. exceptionally may follow exogenous reinfection of
Successive crops of vesicles probably reflect a the partially immune host is not clear. Most re-
cyclic viremia. In the immunologically competent ports of cases attributed to exogenous infection(2)
subject, specific humoral and cellular immune re- may also be interpreted as reflecting the accidental
sponses thereafter rapidly terminate the viremic concurrence of two relatively common diseases.
phase, although direct cell-to-cell extension with Statistically impressive aggregations of cases of
enlargement of established focal lesions continues herpes zoster-disregarding clusters iatrogenically
briefly. As previously mentioned, the natural his- induced-have not been reported.
tory of varicella is influenced by various host The site wherein V-Z virus perists in the quies-
factors. Additionally, physical factors that injure cent intervening period is not known. Hope-
the skin, including trauma and ultraviolet Simpson(34) theorizes that most sensory ganglia
light,<26) may produce focal concentrations of le- harbor latent V-Z virus following varicella. He
sions. Thus, while the well-cared-for baby shows further suggests that when the defense mecha-
no concentration of lesions in the diaper area, in nisms deteriorate below the threshold of viral
infants with a constantly wet excoriated anogeni- containment V-Z virus replicates selectively in a
tal skin surface as high as 68% of the total body sensory ganglion. Virions are then transported
pocks count may be concentrated in that re- antidromically down the sensory nerve and re-
gion.(65) leased around sensory nerve endings in the skin,
7.1.2. Incubation Period. The average incuba- producing characteristic clusters of zoster vesicles;
tion period of varicella is 14 or 15 days. In the virus thereafter can be shed into the environment.
carefully studied series of ROSS,<65) the range was That this is not the complete picture is apparent
10-23 days, with 99% of cases falling between 11 from the previously cited data on the common
and 20 days. appearance of disseminated cutaneous lesions
7.1.3. Immunity. An attack of varicella confers a within a few days of appearance of the segmental
lasting immunity. While second attacks have been eruption; a viremia must often occur.
reported, these rare sporadic episodes lack virol- While specific pathology in the involved gan-
ogical or serological confirmation. glion has long been recognized, V-Z virus has now
been demonstrated in affected nervous elements
by ultrastructural(19.25) and specific immunoflu-
7.2. Herpes Zoster
orescent<19) procedures. However, unpublished
7.2.1. Pathogenesis. a. General. Knowledge of attempts in our laboratory and by others to recover
the pathogenesis of herpes zoster is incomplete, V-Z virus from dorsal root ganglia obtained ran-
and currently assumption dominates fact. In the domly at autopsy from varicella-immune adults
great majority of cases, if not all, V-Z virus must have been unsuccessful to date; therefore, the the-
be present in the body during the years that ory that the virus persists in that location is still
intervene between the attack of varicella and the unconfirmed.
appearance of herpes zoster. It is not known b. Intrinsic Factors. In the immunoresponsive
whether in the interim the infection is persistent, host, the attack of zoster terminates. when reacti-
i.e., one in which at least a few virions are vated defense mechanisms exceed the hypothetical
constantly being elaborated, or is latent, i.e., one critical threshold level. However, subsequent de-
in which the viral genome persists but without clines below the threshold level may occur as
viral replication. In either case, the onset of herpes second and third attacks of herpes zoster develop.
zoster reflects an episode of renewed replication of The relative roles of humoral and of cellular im-
V-Z virus in a host sensitized and partially immunity have not been defined. As might be ex-
mune as the consequence of a prior attack of pected, specific antibody, as detected by various
procedures, usually develops earlier and rises to herpes zoster, as assessed by transformation on
higher levels in herpes zoster than in varicella; this exposure to V-Z antigens, exhibited an impaired
anamnestic response may pose practical problems response. Therefore, it was postulated that reacti-
in applying serological diagnostic procedures. In- vation of V-Z virus reflects a state of cell-mediated
creases in titer beyond an initial high level mayor immune hyporesponsiveness. However, Jordan
may not be demonstrable on examination of and Merigan(36) observed that lymphocytes col-
paired sera. The humoral response after zoster lected from zoster patients 2-11wk convalescent
poses questions per se. If it is secondary in nature, and from varicella-immune children responded in
significant titers of specific IgM macroglobulin a similar manner on stimulation with V-Z antigen;
would not be anticipated. Ross and McDaid(6(;) thus, if a state of hyporesponsiveness in fact exists
demonstrated IgM V-Z reactive antibody in 20 of at the onset of zoster, the defect is rapidly re-
40 convalescent sera from zoster patients, although paired.
Leonard et al. (45) had earlier been unable to do so. The interferon levels of vesicle fluid in zoster
However, Leonard et al., (45) in investigating the have been examined. Patients who have dissemi-
humoral responses after varicella and zoster, ex- nated lesions, as contrasted to those whose vesi-
amined subclasses of IgG, one of which migrated cles remain segmental, exhibit a delay in inter-
more rapidly than the other; varicella sera lacked feron production. (7D> Recent studies in vitro on the
specific neutralizing activity in the rapidly migrat- elaboration of interferon by lymphocytes from var-
ing fraction, whereas specific activity was demon- icella-immune and nonimmune individuals indi-
strable in both slow and fast IgG subclasses in sera cate an apparent nonspecificity(36) of the reaction.
derived from patients with herpes zoster. It was Whether interferon production per se significantly
therefore postulated that the host response is "in- influences the pathogenesis of herpes zoster re-
complete" after varicella, as compared to zoster, mains problematic.
thus accounting for failure of elimination of the Epidemiological data clearly establish "elapsed
virus. Differences in the nature of the antibody time," i.e., time since the attack of varicella, as an
response after varicella as compared to the re- important determinant in the pathogenesis of zos-
sponse after zoster have also been demonstrated ter. Regardless of extrinsic factors that may im-
by Palosuo(6l> on application of the platelet aggre- pinge, it is the ill-defined gradual decay with
gation (PA) technique; platelet aggregating anti- advancing age of the constraining immune proc-
bodies were demonstrable only in zoster convales- esses that allows reactivation of latent V-Z virus.
cent sera. While quantitative and qualitative Herpes zoster is a benchmark of immunological
differences in the humoral responses following senility.
varicella and zoster are established, their patho- c. Extrinsic Factors. Iatrogenic herpes zoster is
genic significance remains to be defined. In pa- not a new entity. An association with administra-
tients with disseminated lesions, as contrasted to tion of metallic drugs, especially lead and arsenic,
those with the nondisseminated form, the anti- has long been established. Only recently, how-
body response as assessed by CF may be de- ever, has depression of immunological activity
layed. (79) It is premature to assume that this become a desirable therapeutic objective in medi-
association is causally related. cine; whether achieved by physical, biological, or
An impaired cellular immunity probably is an chemotherapeutic means, the resillt entails an en-
important factor in the pathogenesis of herpes hanced risk that zoster will appear if the subject
zoster, as reflected by the association with iatro- has had a prior attack of varicella·.
genic immunosuppression and with malignancies The role of trauma as a precipitant of zoster is
associated with depressed cellular immunity. Gold controversial. Hope-Simpson(34) established an
and Nankervis(28) review~d evidence for an im- association in only two of 192 cases and consid-
paired cellular immunity in Hodgkin's disease, an ered that these episodes might have been coinci-
entity commonly associated with zoster. Experi- dental. In contrast, Juel-Jensen and Mac-
mental data on the role of cellular immunity are Callum/ 3D> on evaluating 100 consecutive cases,
sparse. Russell et al. (68) found that lymphocytes elicited a history of trauma to the involved area in
obtained from patients in the acute phase of 38% of the series.
7.2.2. Incubation Period. There is no informa- are confined to the skin; similar involvement of
tion on the interval between endogenous reactiva- the mucosa of the oropharynx and vagina can be
tion and the appearance of symptoms. Exception- seen and it is probable that lesions comparable to
ally, pain in the dermatome subsequently involved those in the skin develop to a varying degree in
may develop 10-14 days prior to the appearance of each patient in the respiratory and the gastrointes-
the eruption; usually the interval is 2-4 days. (~9) tinal tracts.
7.2.3. Immunity. In contrast to varicella, there c. Course. In the immunocompetent child, the
are numerous reports in the literature of the oc- illness is typically benign, accompanied by mild
currence of second and rarely of third attacks of malaise, and is reflected by pruritus and fever
herpes zoster. Hope-Simpson(~4) summarized (100-102°F) for 2-3 days. In the adult, systemic
data on age incidence and concluded that if a symptoms are more marked, and varicella pneu-
cohort of 1000 people were to live to be 85 yr old monia that may be life threatening is a common
half would have experienced one attack of herpes complication. In one series of 114 consecutive
zoster, ten would have had two attacks, and possi- cases in a military population (average age 25 yr),
bly one would had a third attack. Juel-Jensen and lung involvement was demonstrable roentgeno-
MacCallum(~9) saw second attacks in five of 100 graphically in 16%.(87) Secondary bacterial infec-
patients with zoster; one subject with multiple tion of the cutaneous lesions occurs frequently.
myeloma had four attacks of herpes zoster within a Reference should be made to· a text on infectious
period of 2 yr. diseases for information on rarer complications
such as encephalitis.
In the immunologically compromised subject, all
8. Patterns of Host Response clinicopathological manifestations may be en-
hanced. Focal pocklike lesions may occur through-
out the gastrointestinal and respiratory tracts and
S.l. Clinical Patterns
in the liver and .spleen; there may be widespread
8.1.1. Varicella. a. Prodromal Symptoms. Adults vascular damage with prominent hemorrhagic le-
may have 1 or 2 days of fever and malaise prior to sions.(14)
appearance of the rash. In children, premonitory d. Inapparent Infections. Inapparent infections
symptoms usually are mild, and appearance of the obviously occur, although, as noted earlier, obser-
exanthem often is the first evidence of illness. vational studies suggest a frequency of less than
b. The Exanthem. There are three aspects of the 5% in susceptible children.
vesicular eruption that are of diagnostic signifi- 8.1.2. Herpes Zoster. a. The Exanthem. The
cance: the nature and evolution of individual le- varicelliform eruption in zoster is characteristically
sions, the concurrent presence of lesions at differ- unilateral and initially sharply limited in a band or
ent stages of development, and the distribution of patchlike distribution to the dermatome (or,
the process over the body. Individual lesions de- rarely, associated dermatomes) supplied by a spe-
velop as small, irregular, rose-colored macules in cific dorsal root or extramedullary cranial nerve
the center of which appears a delicate 1-4 mm ganglion. Within the segmental area of localiza-
"dewdroplike" vesicle containing clear fluid. This tion, lesions may be scattered and few or may be
may rupture; if not, within a few hours the conso numerous as to form an almost confluent large
tents become purulent and then dry and crusted. plaque. Hope-Simpson(~4) noted that the derma-
Successive crops of new lesions appear over a tomes most frequently involved in herpes zoster-
period of 2-4 days so that characteristically at the i.e., the region supplied by the fifth cranial nerve,
peak of the illness there are in anyone area and the trunk supplied by ganglia extending from
cutaneous lesions at all stages of evolution and of the third dorsal to the second lumbar segments-
resolution. Lesions appear first on the scalp and are those areas where the lesions of varicella are
then on the trunk. The distribution of the lesions also most prominent. The lesions of zoster rarely
is centripetal. The greatest concentration is on the involve the extremities.
trunk, and the distal extremities are the least b. Course. Prior to the appearance of the erup-
involved. It is misleading to assume that lesions tion there may be pain and extreme paresthesia in
the involved segment. The lesions appear in crops are of overriding importance, the mislabeling of a
and, while often larger in comparison, evolve and case of varicella as one of variola may unnecessar-
resolve as in varicella but at a slower pace so that ily activate programs of vaccination that are not
virus ma}' be recovered from vesicles for as long as completely devoid of risk and are expensive to
a week after appearance of the eruption. Scabs, as execute.
in varicella, are noninfectious but may persist for 2 Infections caused by V-Z virus therefore should
wk or more. A regional lymphadenopathy is a first be distinguished from variola and other pox
characteristic feature if the segmental process is viral infections, such as generalized vaccinia or
extensive. Severe posthetpetic neuralgia that is circumscribed inoculation vaccinia. Infections due
refractory to treatment is a distressing complica- to herpes simplex virus (HSV) that present as a
tion. generalized vesiculopustular eruption (eczema
It is to be noted that evidence of central nervous herpeticum) or as a circumscribed zosterlike proc-
system involvement with a spinal fluid pleocytosis ess are more difficult to differentiate from clini-
is common, that motor involvement with weak- cally similar eruptions produced by V-Z virus.
ness or paralysis may occur, but that a fatal out- Lesions caused by either V-Z or HSV virus will
come attributable to zoster per se is extremely rare. morphologically manifest intranuclear inclusions
Reference should be made elsewhere for a discus- and multinucleate giant cells. Reliance on the
sion of other complications. demonstration of a rise in titer of complement-
c. Inapparent Infections. The term "zoster sine fixing antibody against V-Z virus, contrary to
herpete" has been applied to situations wherein statements in some texts, cannot be considered as
unilateral focal zosterlike premonitory pain is ex- diagnostic unless tests for HSV CF antibodies fail
perienced but vesicles fail subsequently to develop to show a concurrent increase in titer; this is due,
over the involved area. Juel-Jensen personally ex- as earlier noted, to the heterologous anamnestic
perienced such an episode associated with a rise response induced by either agent in immunologi-
in V-Z antibody titer. (39) Such transitory imbal- cally experienced individuals. Other serological
ances in the host/virus relationship would be epi- approaches such as FA or attempts at isolation of
demiologically unimportant unless accompanied by the responsible agent must be undertaken.
patterns of viral dissemination now unrecognized. The eruption of varicella should also be distin-
guished from that of rickettsial pox, of infections
caused by certain coxsackieviruses, of secondary
syphilis in some forms, and from dermatitis her-
8.2. Diagnosis petiformis. The focal process of zoster, most fre-
quently simulated by herpes simplex, may also be
When presented with a patient with a vesiculo- confused with impetigo contagiosa.
pustular rash of unknown etiology, the immediate
priority is to exclude variola. The atypical modi-
fied case of smallpox may closely simulate vari-
cella, and the case of severe hemorrhagic varicella
may resemble variola. Such distinctions cannot be
made clinically with certainty, and the assistance 9.1. General Concepts
of the laboratory (Section 3.4) must be immedi-
ately sought. Typical cases can be differentiated on As herpes zoster is endogenous in origin, pre-
clinical grounds by the experienced observer; the vention theoretically could be achieved either by
criteria are summarized in textbooks on infectious an effective varicella vaccine or by manipulation of
disease, to which reference may be made. How- the host/parasite interaction so as to prevent decay
ever, smallpox has now retreated beyond the expe- of defense mechanisms in the latently infected
rience of most physicians in the Western world; if individual. Neither approach has yet been
the slightest doubt exists, confirmatory evidence achieved. The economics of preparing an adequate
from the laboratory should be obtained. While the antigenic mass of killed V-Z virus makes consider-
consequences of misdiagnosing a case of smallpox ation of a killed V -Z virus vaccine unrealistic at
present. However, the possibility that minute 9.3. Modification or Prevention of Varicella
stimulating doses of killed V-Z virus could boost
deteriorating defenses in the elderly should be 9.3.1. Administration of Specific Antibody.
explored for the prevention of herpes zoster.(89) Ross in 1962(65) demonstrated that administration
The ability of V-Z virus to persist in the body for to susceptible children exposed to varicella of ')1-
decades poses a major impediment to the develop- globulin obtained from adults at large did not
ment of an "attenuated" live V-Z vaccine. While prevent disease but modified the illness as indi-
the protective capacity of such a product could be cated by fewer pocks and a diminished febrile
expeditiously assessed in terms of the prevention response. Since patients with zoster develop high
of varicella in susceptible children, the possibility titers of specific antibody, a logical extension of
that the vaccine virus may persist and induce a this observation was to utilize zoster-immune
particularly virulent form of herpes zoster decades globulin (ZIG) prepared from blood collected from
later presents an apparently insurmountable prob- zoster convalescent patients with high V-Z CF
lem of safety testing. titers()ll; a 2-ml dose given within 3 days of
exposure prevented varicella in exposed suscepti-
ble children. Collaborative studies followed to
9.2. Interruption of Transmission evaluate ZIG as a preventive measure in children
at high risk, specifically those with leukemia or
9.2.1. Isolation and Quarantine in Homes and lymphoma, with immunodeficiency syndromes, or
Schools. Neither isolation nor quarantine is effec- under treatment with immunosuppressive medi-
tive in interrupting the spread of the disease in cations. (10.37) A current report from the Center for
groups of susceptible children; therefore, both Disease Control, Atlanta, summarizes results of
practices generally have been abandoned. Indeed, use of ZIG in 143 high-risk patients over a 2-yr
as practically all individuals will eventually ac- period. (57) Excluding treated children who devel-
quire the disease, there is merit in the acquisition oped varicella within 4 days and one child who
of varicella in childhood, for the illness then will died of underlying illness, an overt attack rate of
be less severe and less socially disruptive than if 11 % was observed. The Brunell groUp/24) using a
experienced in adulthood. For the same reason, new V-Z membrane antigen technique to detect
the movement of adults with herpes zoster is not and exclude patients with prior contact with vari-
~sually constrained. . cella, found·that use of ZIG in 15 exposed suscep-
9.2.2. Protection of Groups at Special Risk. tible immunocompromised children resulted in a
Varicella is a potentially fatal disease in suscepti- subclinical infection in five, attenuated overt dis-
ble children who are undergoing immunosuppres- ease in nine, and severe illness in one. Thus,
sive therapy or who concurrently have malignant while administration of ZIG does not offer solid
diseases such as leukemia or Hodgkin's disease. protection in exposed children at high risk, the
Therefore, efforts should be made to minimize limited evidence suggests that attack rates are
infectious contacts in such high-risk individuals reduced and that the severity of the process is
by protective isolation procedures. Contact with modified.
adults with herpes zoster and with non immune 9.3.2. Use of Interferon. Patients with cancer
children who might be incubating varicella should who develop disseminated herpes zoster have re-
be precluded if possible. However, the appearance duced levels of interferon in vesicle fluid. Further,
of a case among patients on a ward poses prob- cessation of dissemination correlates with appear-
lems, even with the strictest of precautions. Spo- ance of interferon.(1) It is to be noted, however,
radic cases may mysteriously appear for several that appearance of interferon may reflect the influx
generations, reflecting either unrecognized breaks of host cells into the lesion and have no direct
in isolation technique or airborne spread. The relationship to cessation of viral replication. Stud-
customary solution is to remove all known suscep- ies are in progress to evaluate the therapeutic
tibles for a 3-wk period. Children at high risk with usefulness of interferon. As available synthetic
a known exposure should be given zoster-immune inducers of interferon are toxic on systemic ad-
globulin (see below). ministration, the use of human leukocyte inter-
feron is under investigation. Significant levels of 10. Unresolved Problems

circulating interferon can be maintained without
evidence of toxicity and without inhibiting V-Z 10.1. Prevention
antibody responses.(35) Reports of the use of in-
terferon in controlled clinical trials should be Varicella is now second only' to gonorrhea in
forthcoming shortly. incidence among reportable diseases in the United
9.3.3. Antiviral Chemotherapy. Three com- States. Although a relatively benign disease, vari-
pounds that interfere with normal synthesis of cella is a major cause of childhood morbidity and
viral DNA deserve brief comment. Idoxuri- of days lost from school. Therefore, prevention of
dine (IUdR, 5-iodo-2-deoxyuridine) is a synthetic varicella in children is a highly desirable objective.
halogenated analogue of thymidine. Problems of Additionally, recrudescent varicella, i.e., herpes
insolubility and of toxicity on systemic administra- zoster, is a common cause of disability in the aged
tion, plus the availability of more promising com- and of intractable pain in some of those afflicted.
pounds, now limit use of IUdR. In controlled stud- Prevention of the primary attack of varicella
ies summarized by Juel-Jensen and MacCallum/ 39 ) should have priority of attention by the small
topical application of 40% IUdR in dimethylsulfox- cadre of scientists in the United States interested
ide to newly emergent zoster lesions markedly in the prevention of infectious diseases. Unfortu-
shortened the period of pain as well as the time to nately, the body politic in the United States now
complete healing. focuses on support of research on categorical di-
Cytosine arabinoside (ara-C, l-,B-o-arabinofura- seases and there is little appreciation that infec-
nosylcytosine) is a synthetic nucleoside with ara- tious agents, of which herpes zoster is only one
binose as the sugar moiety rather than ribose or example, not only commonly complicate the han-
deoxyribose. It was considered a promising ap- dling of the patient with cancer but also deserve
proach to the systemic treatment of zoster on the priority of attention as common and potentially
basis of case reports, but recent controlled trials preventable impediments to the enjoyment of life
have demonstrated that ara-C actually potentiated in the developing and socially productive years.
viral dissemination by further depressing the de-
fense mechanisms of the host. (J7,78) 10.2. Pathogenesis
Adenine arabinoside (ara-A,9-,B-o-arabinofura- The deficiencies in the host defense mechanism
nosyladenine) exhibits less immunodepressive that permit a latent V-Z infection to become activ'e
and toxic activity than does ara-C. Clinical trials of remain unknown, and the site has not been de-
ara-A for the treatment of infections caused by fined where V-Z virus persists after the primary
herpes-group agents are in progress. In an exten- attack. It is likely that current investigative em-
sive study of human cytomegalovirus (CMV) in- phasis on the role of cellular, as contrasted to
fections, ara-A temporarily suppressed or reduced humoral, immunity in V-Z infections will assist in
CMV viruria in some patients but had little influ- elucidation of these questions.
ence on CMV excretion by immunosuppressed Other problems require resolution. How does V-
renal transplant patients.(]5) Juel-Jensen employed Z virus enter the susceptible host? What are the
ara-A for the containment of herpes zoster in two primary or secondary sites of replication that pre-
patients under treatment for malignancy; he con- cede or intervene in the viremic phase (a hypothe-
sidered the results excellent. (39) sis in itself not adequately documented)? If latent
The past 15 yr have witnessed the development V-Z virus does persist in sensory ganglia, was this
of compounds that inhibit replication of V-Z virus anatomical site infected by centripetal movement
in the human host, and therefore a new approach along nerves or was there selective anatomical
to the interruption of transmission of the agent invasion following a viremic phase?
evolved. The hazards of using compounds that
potentially can alter DNA replication in the host
10.3. Epidemiological Unknowns
cell, as well as in the viral particle, may take
decades of epidemiological observation to eluci- The manner in which V-Z virus is disseminated
date. by the infected host has not been defined. Does
failure to demonstrate virus in oropharyngeal se- EVANS, A. S., WOODALL, J. P., OPTON, E. M.,
cretions indeed indicate that the primary source of EMMONS, J. E., WEST, B. S., EDSALL, G., DOWNS, W.
infectious material is the cutaneous lesion? If so, G., AND WALLACE, G. D., Evidence for persistence
what is the relative infective potential of the indi- of infectious agents in isolated human populations,
vidual with herpes zoster? How do varying envi- Am. J. Epidemiol. 100:230-250 (1974).
4. BLAKELY, G. A., LOURIE, B., MORTON, W. G., Ev-
ronmental conditions, particularly temperature
ANS, H. H., AND KAUFMANN, A. F., A varicella-like
and humidity, influence transmission? What is the disease in macaque monkeys, J. Infect. Dis. 127:617-
relative importance of airborne dissemination of 623 (1973).
V-Z virus as contrasted to direct or indirect con- 5. VON BOKAY, J., Uber den aetiologischen Zusammen-
tact? hang der Varicellen mit gewissen Fallen von Herpes
zoster, Wien. Klin. Wochenschr. 22:1323-1326 (1909).
6. BOUGHTON, C. R., Varicella-zoster in Sydney. I.
10.4. In the Laboratory Varicella and its complications, Med. J. Aust. 2:392-
397 (1966).
10.4.1. Seroepidemiological Surveys. The newer
7. BRUNELL, P. A., Placental transfer of varicella-zoster
procedures for detection of V-Z viral antibody antibody, Pediatrics 38:1034-1038 (1966).
have had limited application in seroepidemiologi- 8. BRUNELL, P. A., Varicella-zoster infections in preg-
cal surveys. Their usefulness needs to be deter- nancy, J. Am. Med. Assoc. 199:315-317 (1967).
mined. 9. BRUNELL, P. A., COHEN, B. H., AND GRANAT, M., A
10.4.2. Application of ZIG to Prevention or gel-precipitin test for the diagnosis of varicella,
Modification of V-Z Infections. Improved meth- Bull. WHO 44:811-814 (1971).
ods for determining the disease-modifying capac- 10. BRUNELL, P. A., GERSHON, A. A., HUGHES, W. T.,
ity of lots of ZIG should be developed. Additional RILEY, H. D., JR., AND SMITH, J., Prevention of
varicella in high risk children; a collaborative study,
information is needed to validate the assumption
Pediatrics 50:718-722 (1972).
that newer techniques, i.e., membrane fluores-
11. BRUNELL, P. A., Ross, A., MILLER, L. H, AND Kuo,
cence, can be used to establish the presence or B., Prevention of varicella by zoster immune globu-
absence of susceptibility ot V-Z virus in the ex- lin, N. Engl. J. Med. 280:1191-1194 (1969).
posed individual. 12. CAUNT, A. E., AND SHAW, D. G., Neutralization
tests with varicella-zoster virus, J. Hyg. 67:343-352
(1969).
13. Center for Disease Control: Reported morbidity and
ACKNOWLEDGMENTS mortality in the United States, 1973, Mobidity Mor-
tality Weekly Rep. 22(53}:1-60 (July 15, 1974).
14. CHEATHAM, W. J., WELLER, T. H., DOLAN, T. F., JR.,
The continuing support of the National Institute
AND DOWER, J. c., Varicella: Report of two fatal
of Allergy and Infectious Diseases of the National
cases with necropsy, virus isolation, and serologic
Institutes of Health (Grant AI-OI023) for studies on studies, Am. J. Pathol. 32:1015-1035 (1956).
varicella-zoster virus is acknowledged. 15. CH'IEN, L. T., CANNON, N. J., WHITLEY, R. J.,
DIETHELM, A. G., DISMUKES, W. E., SCOTT, C. W.,
BUCHANAN, R. A., AND ALFORD, C. A., JR., Effect of
adenine arabinoside on cytomegalovirus infections,
J. Infect. Dis. 130:32-39 (1974).
11. References 16. COLLINS, S. D., WHEELER, R. E., AND SHANNON, R.
D., The Occurrence of Whooping Cough, Chicken-
1. ARMSTRONG, R. W., GURWITH, M. J., WADDELL, D., pox, Mumps, Measles, and German Measles in
AND MERIGAN, T. c., Cutaneous interferon produc- 200,000 Surveyed Families in 28 Large Cities, Spe-
tion in patients with Hodgkin's disease and other cial Study Series, No.1, Division of Public Health
cancers infected with varicella or vaccinia, N. Engl. Methods, NIH, USPHS., Washington, D.C. (1942).
J. Med. 283:1182-1187 (1970). ·17. DAVIS, C. M., VAN DERSARL, J. V., AND COLTMAN,
2. BERLIN, B. S., AND CAMPBELL, T., Hospital acquired C. A., Failure of cytarabine in varicella-zoster infec-
herpes zoster following exposure to chickenpox, J. tions, J. Am. Med. Assoc. 224:122-123 (1973).
Am. Med. Assoc. 211:1831-1833 (1970). 18. DOWNIE, A. W., AND KEMPE, C. H., Poxviruses, in:
3. BLACK, F. L., HIERHOLZER, W. J., PINHEIRO, F. DEP., Diagnostic Procedures for Viral and Rickettsial Infec-
tions (E. H. LENNETTE AND N. J. SCHMIDT, eds.), pp. immunity to varicella-zoster virus: In vitro lympho-
281-320, American Public Health Association, Inc., cyte responses, J. Infect. Dis. 130:495-501 (1974).
New York, 1969. 37. JUDELSOHN, R. G., Prevention and control of vari-
19. ESIRI, M. M., AND TOMLINSON, A. H., Herpes zos- cella-zoster infections, J. Infect. Dis. 125:82-84
ter: Demonstration of virus in trigeminal nerve and (1972).
ganglion by immunofluorescence and electron mi- 38. JUEL-JENSEN, B. E., A new look at infectious di-
croscopy, J. Neurol. Sci. 15:35-48 (1972). seases: Herpes simplex and zoster, Br. Med. J.
20. FELDMAN, S., HUGHES, W. T., AND KIM, H. Y., 1:406-410 (1973).
Herpes zoster in children with cancer, Am. J. Dis. 39. JUEL-JENSEN, B. E., AND MACCALLUM, F. 0., Herpes
Child. 126:178-184 (1973). Simplex, Varicella and Zoster: Clinical Manifestations
21. FURUKAWA, T., AND PLOTKIN, S. A., Indirect hemag- and Treatment, Lippincott, Philadelphia, 1972.
glutination test for varicella-zoster infection, Infect. 40. KAPSENBERG, J. G., Possible antigenic relationships
Immun. 5:835-839 (1972). between varicella/zoster virus and herpes simplex
22. GARLAND, J., Varicella following exposure to herpes virus, Arch. Gesamte Virusforsch. 15(1):67-73 (1964).
zoster, N. Engl. J. Med. 228:336-337 (1943). 41. KORANDA, F. c., DEHMEL, E. M., KAHN, G., AND
23. GERSHON, A. A., BRUNELL, P. A., DOYLE, E. F., AND PENN, I., Cutaneous complications in immunosup-
CLAPS, A. A., Steroid therapy and varicella, J. pressed renal homograft recipients, J. Am. Med.
Pediat. 81:1034 (1972). Assoc. 229:419-424 (1974).
24. GERSHON, A. A., STEINBERG, S., AND BRUNELL, P. 42. KOUVALAINEN, K., SALMI, A., AND SALMI, T. T.,
A., Zoster immune globulin: A further assessment, Infantile herpes zoster, Scand. J. Infect. Dis. 4:91-96
N. Engl. J. Med. 290:243-245 (1974). (1972).
25. GHATAK, N. R., AND ZIMMERMAN, H. M., Spinal 43. KUNDRATITZ, K., Experimentelle Ubertragung von
ganglion in herpes zoster: A light and electron Herpes zoster auf den Menschen und die Beziehun-
microscopic study, Arch. Pathol. 95:411-455 (1973). gen von Herpes zoster zu Varicellen, Monatsschr.
26. GILCHREST, B., AND BADEN, H. P., Photodistribu- Kinderheilkd. 29:516-522 (1925).
tion of viral exanthems, Pediatrics 54:136-138 (1974). 44. Leading Article, Fatal chickenpox, Br. Med. J. 2:954-
27. GOLD, E., Serologic and virus-isolation studies of 955 (1965).
patients with varicella or herpes-zoster infection, N. 45. LEONARD, L. L., SCHMIDT, N. J., AND LENNETTE, E.
Engl. J. Med. 274:181-185 (1966). H., Demonstration of viral antibody activity in two
28. GOLD, E., AND NANKERVIS, G. A., Varicella-zoster immunoglobulin G subclasses in patients with vari-
viruses, in: The Herpesviruses (A. S. KAPLAN, ed.), cella-zoster infection, J. Immunol. 104:23-27 (1970).
pp. 327-351, Academic Press, New York, 1973. 46. LEWKONIA, I. K., AND JACKSON, A. A., Infantile
29. GORDON, J. E., General considerations of modes of herpes zoster after intrauterine exposure to vari-
transmission, in: Preventive Medicine in Worla War cella, Br. Med. J. 3:149 (1973).
II, Vol. IV: Communicable Diseases, p. 27, Depart- 47. LIPSCHUTZ, B., Untersuchungen liber die Atiologie
ment of the Army, Washington, D.C., 1958. der Krankheiten der Herpesgruppe (Herpes zoster,
30. GORDON, J. E., Chickenpox: An epidemiological Herpes genitalis, Herpes febrilis), Arch. Dermatol.
review, Am. J. Med. Sci. 244:362-389 (1962). Syph. Orig. 136:428-482 (1921).
31. HAGGERTY, R. J., AND ELEY, R. c., Varicella and 48. LONDON, W. P., AND YORKE, J. A., RecuITent out-
cortisone, Pediatrics 18:160-162 (1956). breaks of measles, chickenpox, and mumps. I. Sea-
32. HOOK, E. B., ORANDI, M., TEN BENSEL, R. W., sonal variations in contact rates, Am. J. Epidemiol.
SCHAMBER, W. F., AND ST. GEME, J. W., JR., Familial 98:453-468 (1973).
fatal varicella, J. Am. Med. Assoc. 206:305-311 (1968). 49. Lux, S. E., JOHNSTON, R. B., JR., AUGUST, C. S., SAY,
33. HOPE-SIMPSON, R. E., Infectiousness of communica- B., PENCHASZADEH, V. B., ROSEN, F. S., AND McKu-
ble diseases in the household (measles, chickenpox, SICK, V. A., Chronic neutropenia and abnormal cel-
and mumps), Lancet 2:549-554 (September 20,1952). lular immunity in cartilage-hair hypoplasia, N. Engl.
34. HOPE-SIMPSON, R. E., The nature of herpes zoster: J. Med. 282:231-236 (1970).
A long-term study and a new hypothesis, Proc. R. 50. MANSON, M. M., LOGAN, W. P. D., AND LoY, R. M.,
Soc. Med. 58:9-20 (1965). Rubella and Other Virus Infections During Preg-
35. JORDAN, G. W., FRIED, R. P., AND MERIGAN, T. c., nancy, Report Ull, pp. 1-101, Ministry of Health,
Administration of human leukocyte interferon in Her Majesty's Stationery Office, London, 1960.
herpes zoster. I. Safety, circulating antiviral activ- 51. MARETIC, A., AND COORAY, M. P. M., Comparisons
ity, and host responses to infection, J. Infect. Dis. between chickenpox in a tropical and a European
130:56-62 (1974). country, J. Trop. Med. Hyg. 66:311-315 (1963).
36. JORDAN, G. W., AND MERIGAN, T. c., Cell-mediated 52. MARR, J. S., Personal communication, Director, Bu-
reau of Infectious Disease Control, New York City rise in complement fixing antibodies against her-
Department of Health (1974). pesvirus hominis and varicella-zoster virus, Arch.
53. MATSEOANE, S. 1., AND ABLER, c., Occurrence of Gesamte Virusforsch. 17:495-503 (1968).
neonatal varicella in a hospital nursery, Am. J. 72. SCHMIDT, N. J., LENNETTE, E. H., AND MAGOFFIN, R.
Obstet. Gynecol. 92:575-576 (1965). 1., Immunologic relationship between herpes sim-
54. MCGREGOR, R. M., Herpes zoster, chickenpox and plex and varicella-zoster viruses demonstrated by
cancer in general practice, Br. Med. J. 1:84-87 (1957). complement-fixation, neutralization, and fluores-
55. McKuSICK, V. A., Fatal varicella (letter to the edi- cent antibody tests, J. Gen. Virol. 4:321-328 (1969).
tor), ,. Am. Med. Assoc. 207:370 (1969). 73. SCHMIDT, N. J., LENNETTE, E. H., WooDm, J. D.,
56. MEYERS, J. D., Congenital varicella in term infants: AND Ho, H. H., Immunofluorescent staining in the
Risk reconsidered, J. Infect. Dis. 129:215-217 (1974). laboratory diagnosis of varicella-zoster virus infec-
57. MEYERS, J. D., AND WrrTE, J. J., Zoster immune tions, J. Lab. Clin. Med. 66:403-412 (1965).
globulin in high risk children, ,. Infect. Dis. 74. School Epidemics Committee of Great Britain, Epi-
129:61Cr618 (1974). demics in Schools, Medical Research Council, Spe-
58. NELSON, A. N., AND ST. GEME, M. W., JR., On the cial Report Series No. 227, London, His Majesty's
respiratory spread of varicella-zoster virus, Pediat- Stationery Office, 1938.
rics 37:1007-1009 (1%6). 75. SmGEL, M., Congenital malformations following
59. OBERG, G., AND SVEDMYR, A., Varicelliform erup- chickenpox, measles, mumps, and hepatitis: Results
tions in herpes zoster-Some clinical and serologi- of a cohort study, J. Am. Med. Assoc. 226:1521-1524
cal observations, Scand. J. Infect. Dis. 1:47-49 (1969). (1973).
60. OSLER, W., The Principles and Practice of Medicine, p. 76. SmGEL, M., AND FUERST, H. T., Low birth weight
65, D. Appleton and Co., New York, 1892. and maternal virus disease: A prospective study of
61. PALOSUO, T., Varicella and herpes zoster: Differ- rubella, measles, mumps, chickenpox, and hepati-
ences in antibody response revealed by the platelet tis, ,. Am. Med. Assoc. 197:680-684 (1966).
aggregation technique, Scand. J. Infect Dis. 4:83-89 77. STEINER, Zur Inokulation der Varicellen, Wien. Med.
(1972). Wochenschr. 25:306 (1875).
62. PICKLES, W. N., Epidemiology in Country Practice, 78. STEVENS, D. A., JORDAN, G. W., WADDELL, T. F.,
pp. 46-47, Williams and Wilkins, Baltimore, 1939. AND MERIGAN, T. c., Adverse effect of cytOSine
63. RAINE, D. N., Varicella infections contracted in arabinoside on disseminated zoster in a controlled
utero; sex incidence and incubation period, Am. J. trial, N. Engl. J. Med. 289:873-878 (1973).
Obstet. Gynecol. 94:1144-1145 (1966). 79. STEVENS, D. A., AND MERIGAN, T. c., Interferon,
64. RIFKIND, D., The activation of varicella-zoster virus antibody, and other host factors in herpes zoster, J.
infections by immunosuppressive therapy, J. Lab. Clin. Invest. 51:1170-1178 (1972).
Clin. Med. 68:463-474 (1966). 80. STOKES, J., JR., Chickenpox, in: Preventive Medicine
65. Ross, A. H., Modification of chickenpox in family in World War II, Vol. IV: Communicable Diseases,
contacts by administration of gamma globulin, N. Transmitted Chiefly Through Respiratory and Alimen-
Engl. J. Med. 267:369-376 (1962). tary Tracts, pp. 55-56, Department of Army, Wash-
66. Ross, C. A. c., AND McDAID, R., Specific IgM ington, D.C., 1958.
antibody in serum of patients with herpes zoster 81. STROM, J., Social development and declining inci-
infections, Br. Med. J. 4:522-523 (1972). dence of some common epidemic diseases in chil-
67. Ross, C. A. c., SUBAK SHARPE, J. H., AND FERRY, P., dren: A study of the incidence in different age
Antigenic relationship of varicella-zoster and groups in Stockholm, J. Acta Paediat. Scand. 56:159-
herpes simplex, Lancet 2:708-711 (1965). 163 (1967).
68. RUSSELL, A. S., MAINI, R. A., BAILEY, M., AND 82. SVEDMYR, A., Varicella virus in HeLa cells, Arch.
DUMONDE, D. c., Cell mediated immunity to vari- Gesamte Virusforsch. 17:495-503 (1965).
cella-zoster antigen in acute herpes zoster (shin- 83. TAYLOR-RoBINSON, D., Chickenpox and herpes zos-
gles), Clin. Exp. Immunol. 14:181-185 (1973). ter. III. Tissue culture studies, Br. J. Exp. Pathol.
69. SABIN, A. B., Neurotropic virus diseases of man, 40:521-532 (1959).
J. Pediat. 19:445-451 (1941). 84. TOMLINSON, A. H., AND MACCALLUM, F. 0., The
70. SALOMON, J. B., GORDON, J. E., AND SCRIMSHAW, N. incidence of complement-fixing antibody to vari-
S., Studies of diarrheal disease in Central America. cella-zoster virus in hospital patients and blood
X. Associated chickenpox, diarrhea and kwashior- donors, J. Hyg. 68:411-416 (1970).
kor in a highland Guatemalan village, Am. J. Trop. 85. TYZZER, E. E., The histology of the skin lesions in
Med. 15:997-1002 (1966). varicella, Philipp. J. Sci. 1:349-372 (1906).
71. SCHAAP, G. J. P., AND JUISMAN, J., Simultaneous 86. UDUMAN, S. A., GERSHON, A. A., AND BRUNELL, P.
A., Rapid diagnosis of varicella-zoster by agar-gel virus agents, in: Virus and Rickettsial Diseases, p.
diffusion, J. Infect. Dis. 126:193-195 (1972). 106, Harvard University Press, Cambridge, Mass.,
87. WEBER, D. M., AND PELLECCHIA, J. A., Varicella 1940.
pneumonia: Study of prevalence in adult men, J.
Am. Med. Assoc. 192:572-573 (1965).
88. WELLER, T. H., The propagation in vitro of agents 12. Suggested Reading
producing inclusion bodies derived from varicella
and herpes zoster, Proc. Soc. Exp. BioI. Med. 83:340- 12.1. Monograpic Summaries of Information on
346 (1953). Varicella and on Herpes Zoster
89. WELLER, T. H., Prospects for immunization against
varicella and cytomegalovirus infections, in: First JUEL-JENSEN, B. E., AND MACCALLUM, F. 0., Herpes
Intemationl Conference on Vaccines Against Viral and Simplex, Varicella and Zoster, pp. 1-194, Lippincott,
Rickettsial Diseases of Man, pp. 276-282, Scientific Philadelphia, 1972.
Publication 147, Pan American Health Organiza- TAYLOR-RoBINSON, D., AND CAUNT, A. E., Varicella Virus,
tion, Washington, D.C., 1967. Virology Monograph No. 12, pp. 1-88, Springer, New
90. WELLER, T. H., Varicella-zoster virus, in: Diagnostic York,1972.
Procedures for Viral and Rickettsial Infections, 4th ed.
(E. H. LENNETIE AND N. J. SCHMIDT, eds.), pp. 733- 12.2. Comprehensive Review of the Epidemiology
754, American Public Health Association, Inc., New
of Varicella, with 257 References Covering
York,1969.
91. WELLER, T. H., AND COONS, A. H., Fluorescent
the Literature Through 1961
antibody studies with agents of varicella and herpes GORDON, J. E., Chickenpox: An epidemiological review,
zoster propagated in vitro, Proc. Soc. Exp. Bioi. Med. Am. J. Med. Sci. 244:362-389 (1962).
86:789-794 (1954).
92. WELLER, T. H., AND STODDARD, M. B., Intranuclear
inclusion bodies in cultures of human tissue inocu- 12.3. Summary of Procedures for Isolation and
lated with varicella vesicle fluid, J. Immunol. 68:311- Study of Varicella-Zoster Virus in the
319 (1952). Laboratory
93. WELLER, T. H., AND WITTON, H. M., The etiologic
agents of varicella and herpes zoster: Serologic WELLER, T. H., Varicella-zoster virus, in: Diagnostic
studies with the viruses as propagated in vitro, J. Procedures for Viral and Rickettsial Infections, 4th ed.
Exp. Med. 108:869-890 (1958). (E. H. LENNETTE AND N. J. SCHMIDT, eds.), pp. 733-
94. WELLER, T. H., WITTON, H. M., AND BELL, E. J., The 754, American Public Health Association, Inc., New
etiologic agents of varicella and herpes zoster: Isola- York,1969.
tion, propagation, and cultural characteristics in
vitro, ,. Exp. Med. 108:843-868 (1958). 12.4. Clinical Descriptions of Varicella and of
95. WELLS, M. W., AND HOLLA, W. A., Ventilation in
Zoster, Including Complications and
the flow of measles and chickenpox through a
community, J. Am. Med. Assoc. 142:1337-1344
Differential Diagnosis
(1950). BRUNELL, P. A., Chickenpox, in: Communicable and Infec-
96. WENTWORTH, B. B., AND ALEXANDER, E. R, Seroepi- tious Diseases, 7th ed. (F. H. Top, SR., AND P. R
demiology of infections due to members of herpes- WEHRLE, eds.), pp. 132-141, Mosby, St. Louis, 1972.
virus group, Am. J. Epidemiol. 94:496-507 (1971). KRUGMAN, S., AND WARD, R, Varicella and zoster infec-
97. WHITE, R. J.; SIMMONS, 1., AND WILSON, R. B., tions, in: Infectious Diseases of Children and Adults, 5th
Chickenpox in young anthropoid apes: clinical and ed., pp. 406-422, Mosby, St. Louis, 1973.
laboratory findings, J. Am. Vet. Med. Assoc. 161:690- MARCY, S. M., AND KIBRICK, S., Varicella and herpes
692 (1972). zoster, in: Infectious Diseases, 1st ed. (P. D. HOEPRICH,
98. WILSON, D., BRESSANI, R, AND SCRIMSHAW, N. S., ed.), Harper and Row, Hagerstown, Md., 1972.
Infection and nutritional status. I. Effect of chicken-
pox on nitrogen metabolism in children, Am. J.
Clin. Nutr. 9:154-158 (1961). 12.5. An Encyclopedic, Multiauthored Summary
99. YORKE, J. A., AND LONDON, W. P., Recurrent out- of Knowledge of the Herpesviruses of Man
breaks of measles, chickenpox, and mumps. II. and of Animals
Systematic differences in contact rates and stochas-
tic effects, Am. ,. Epidemiol. 98:469-482 (1973). KAPLAN, A. S., ed, with 26 coauthors, The Herpesviruses,
100. ZINSSER, H., Immunology of infections by filterable pp. 1-739, Academic Press, New York, 1973.
CHAPTER 22
Epidemiology of
Burkitt
Lymphoma
George Miller
1. Introduction At this point of time in the state of our knowl-

edge it would seem justified to make an associa-
Burkitt lymphoma is a malignant lymphoma of tion with the Epstein-Barr virus (EBV) part of the
children occurring with highest frequency in cer- definition of the disease as it occurs in the en-
tain parts of Africa and New Guinea where ma- demic areas. The tumor itself contains, in nearly
laria is hyperendemic. It is found in low frequency all instances, the EBV genome(91) and certain EBV
throughout the world and in nonmalarious areas. antigens,'"4) and EBV-producing cell lines can be
The epidemiology of the disease is highly char- derived from the tumors, as initially shown by
acteristic and provoked Burkitt's hypothesis that Epstein et al. '24.20) Patients with Burkitt lym-
the causal agent might be a vectored virus. It is a phoma have elevated antibody titers to EBVCI81
disease of children and is rare before the age of 2 and certain unique EBV-related antibodies.'4))
yr and after the age of 20 yr. The median age of The etiological association of EBV with Burkitt
patients in all areas is approximately 8 yr.'21 lymphoma is strengthened by experimental obser-
Burkitt tumor is the commonest childhood tumor vations that EBV is capable of providing immortal-
in Africa, and its incidence in the two major ity in vitro to normal lymphocytes of humans and
endemic areas, equatorial Africa and Papua New certain primates(;l9.o9.7m and that EBV induces a
Guinea, may reach as high as 101100,000. The lymphoma upon inoculation into certain species of
tumor is found primarily in the hot, wet, lowlands New World nonhuman primatesY"·(;2.80l
of Africa and New Guinea, although sporadic
cases have been described throughout the
world. (1,87) 2. Historical Background
The clinical syndrome described in detail by
George Miller . Department of Pediatrics and Depart- Burkitt in 1958,m during his tour as a surgeon in
ment of Epidemiology and Public Health, Yale Univer- East Africa had been, in retrospect, known to
sity School of Medicine, New Haven, Connecticut clinicians and pathologists since the beginning of
481
482 Chapter 22 • Epidemiology of Burkitt Lymphoma
the twentieth century. (16.19) However, through Medical School in Kampala, Uganda. Finally, the
Burkitt's efforts the disease was unified into a epidemiology of Burkitt lymphoma has been stud-
clearly delineated entity with characteristic clini- ied intensively by close surveillance of limited
cal, pathological, and epidemiological fea- geographic areas where there is a high incidence
tures. (6,7,10,11> of disease. In particular, the West Nile district of
The concept that this lymphoma might be due to Uganda has been intensively studied on a house-
a virus was suggested by Burkitt in 1962,<6a) but to-house basis and is the site of a prospective
the initial search for an agent was unsuccessful. In serological survey in which the protective effects
1964, Epstein and Barr'24) and Pulvertaft(76a) si- of EBY antibodies are being assessed.(47,75)
multaneously reported in the same issue of Lancet
the successful growth of tumor cells from Burkitt
lymphoma tissue in the laboratory; this was rap- 3.2. Serological Surveys
idly followed by the observation of herpeslike Studies for the presence of antibody to EBY have
particles in these cultured cells under the electron been carried out throughout the world using the
microscope. (25a) The agent was found to be dis- indirect immunofluorescent test of the Henles(37)
tinct from other known herpesviruses of man and for antibody to viral capsid antigen as the major
it was designated as Epstein-Barr virus. Attempts epidemiological tool. Occasionally, the comple-
to cultivate EBY in other tissue culture systems ment fixation test, the membrane antigen immu--
were unsuccessful, but the development of an nofluorescent test, and precipitin tests in agar
immunofluorescent test for EBY antibody by the gel(14) have been employed in antibody surveys.
Henles in 1966(37) facilitated epidemiological and Quantitations of antibody levels in different popu-
diagnostic inquiry. The presence of EBY genome lations are in progress as well as efforts to charac-
in lymphoma cells was demonstrated by zur Hau- terize the types of antibody present, particularly
sen et al. in 1970,!91l and the experimental pro- those directed against different components (D
duction of lymphomas with EBY in nonhuman and R) of the early antigen.(41l
primates was reported in 1973 by Shope et al. (80)
and by Epstein et al. (26)
3.3. Laboratory Diagnosis
The pathological criteria of Burkitt lymphoma
3. Methodology have been well established through conferences
under the auspices of the U.S. National Cancer
3.1. Mortality and Morbidity Data Institute, the International Agency for Cancer Re-
search, and the World Health Organization.(4)
The high mortality from Burkitt lymphomas
The virological features of African lymphomas as-
would be expected to reflect the occurrence of the
sociated with EBY are (1) presence of antibody to
tumor. However, since the disease is rare and it
EBY, (2) elevation of yeA antibody titers to
occurs in areas with few laboratory facilities, there
<==1:160, and (3) presence of antibodies to early and
are no comprehensive mortality statistics.
membrane antigens and, if tissue is available,
Three types of case surveillance have been un-
demonstration of the EBY genome by hybridiza-
dertaken. After he observed the disease in tion (92) with EBY nucleic acid and by the EBNA or
Uganda, Burkitt undertook a series of "tumor anticomplement immunofluorescent test. (771
safaris," traveling thousands of miles by jeep
throughout Africa. (7) Similar informal surveys
have been conducted in New Guinea. In areas
where the disease is common, for example, in East 4. Biology of Epstein-Barr Virus
Africa, tumor registries and records of cancer hos-
pitals have served as a source of case finding, 4.1. Structure and Morphology
particularly the Kenyatta National Hospital in Nai- In order to appreciate the nature of the evidence
robi, Kenya, the Mulogo Hospital in Kampala, relating Epstein-Barr virus to Burkitt lymphoma, a
Uganda, and the Makerere University College
Chapter 22 • Epidemiology of Burkitt Lymphoma 483
brief introduction to the biology of this agent is ment with halogenated pyrimidines.(3o.35.36) A nu-
necessary. On the basis of its morphology and the clear antigen (EBNA) is found in all living cells of
size of its nucleic acid, which is double-stranded continuous lymphoblastoid cell lines which con-
DNA, this virus belongs to the herpes group. (79) The tain the EBV genome. (77) It is also found in vivo in
mature virus possesses a lipoprotein envelope and Burkitt lymphoma, in nasopharyngeal carcinoma,
inner capsid structure with regular capsimeres, 162 and in experimental EBV-induced lymphoma of
in number, and a nucleoid which contains the marmosets. (54,,;7.78.88) This important antigen is
nucleic acid. A limited amount of information is present whether or not the cells are producing
available about the structure of the virion since it mature virus. Antigen complexes have also been
has been exceedingly difficult to grow the virus in detected in cell extracts by complement fixation
large quantities. There are at least two strains of and represent at least three distinct compo-
EBV known, one represented by the P3JHR-1 virus nents.(84) Some of the complement-fixing reactiv-
and the other represented by many other exam- ity of cell lines is no doubt due to the EBNA
ples.(43.611 These strains are defined on the basis reactivity. A soluble antigen has been found in
of biological differences, and the structural corre- continuous lymphoblastoid cell lines detectable by
lates for these differences have not yet been made. immunodiffusion. This antigen appears to be
The P3JHR-1 virus causes abortive infection but identical in cell lines of various sources. (72) There
not cell transformation. It is not yet known are as yet no studies which demonstrate differ-
whether different virus strains are associated with ences between the cell-associated antigens found
different diseases. in Burkitt lymphoma cells and comparable antigens
found in cells derived from patients with infec-
4.2. EBV Cell-Associated Antigens tious mononucleosis or nasopharyngeal cancer or
from normal individuals. This, however, may be
The mature EBV has been seen only rarely in the result of inadequate techniques. A summary of
Burkitt lymphoma biopsies. (33) However, if EBV-related antigens found in Burkitt lymphoma
lymphoid tissues from the tumors are cultivated in biopsies and in cell lines derived therefrom is
vitro, continuous lymphoid cell lines are obtained found in Table 1.
in which mature EBV may be found in a small
proportion of the cells. (25.67) Such continuous
4.3. Cell/Virus Relationships
lymphoid cell lines have served to define a num-
ber of cell-associated EBV-related antigens. Such Only a fraction of cells in continuous lympho-
antigens have served as one basis for search for blastoid cell lines from Burkitt lymphoma contain
evidence of the virus in human tumors. A mem- viral particles or the viral capsid antigen; nonethe-
brane antigen (MA) is found on the surface of less, all the cells contain the viral genome. If single
Burkitt lymphoma biopsies as well as on the sur- cells are plated from a line which contains only 1-
face of certain continuous lymphoblastoid cell 5% of cells with virus, all the daughter clones
lines.(48) An intracellular antigen, designated viral contain virus.(64) This finding demonstrates that
capsid antigen (VCA), is found in a small percent- the viral genome is present in cells which are not
age of cells of continuous lymphoblastoid cell lines making virus but its expression is somehow in-
which are productive of virus.(37) This antigen is hibited. Furthermore, continuous cell lines com-
not usually detected in biopsies of Burkitt lym- pletely lacking in signs of mature virus production
phoma and is only present in those cell lines have been derived from Burkitt lymphoma. The
which are also productive of virus. Some continu- prototype of such a cell line is called Raji. (23) Raji
ous cell lines produce MA but not VCA. A third nonetheless contains certain viral antigens, partic-
antigen, called early antigen (EA), appears upon ularly EBNA, and contains the viral genome de-
abortive infection of continuous lymphoblastoid tectable by nucleic acid hybridization. (69,90)
cells by EBV.(411 This antigen is not detected in Considerable effort has gone into defining the
vivo but appears in a subpopulation of cells of state of the viral genome in Raji cells; The genome
productive lymphoblastoid cell lines. EA can also appears to be associated with cellular chromo-
be induced in nonproductive cell lines by treat- somes.(69) The number of copies of EBV genes per
Table 1. A Scheme Illustrating Differences in the Expression of the EBV

Genome in Burkitt Lymphoma Cells
Burkitt lymphoma
Nonproductive cell Productive cell

Viral function detected Biopsies lines lines
Viral DNA + + +
Viral-specific RNA NO + +
CF antigen + + +
Nuclear antigen + + +
Membrane antigen + +
Early antigen Inducible +
Viral capsid antigen +
Nucleocapsids +
Enveloped virus ±
Raji cell is relatively constant between 40 and 60 ture.(09.59.76) This process, sometimes referred to as
per cell as the line is maintained in culture. The immortalization, is not well understood but is
number of EBV genome copies doubles early in clearly due to the effects of the virus. The process
the S (DNA synthesis) phase of the cell mitotic is preceded by stimulation of cellular DNA synthe-
cycle. "l51 According to Nonoyama and his collabo- sis.(aJ) The envelope of the virus appears neces-
rators, the viral genome is not covalently inte- sary for immortalization, since ether- or chloro-
grated into cellular DNA but rather exists in close form-treated virus does not immortalize. EBV also
juxtaposition to cellular DNA. (69) immortalizes lymphocytes from certain species of
Several lines of evidence indicate that the host New World monkeys, including cottontop marmo-
cell modulates the expression of the resident viral sets, squirrel monkeys, cebus monkeys, and owl
genome. For example, when a somatic cell hybrid monkeys, and leukocytes from great apes. (27.60.85)
is produced between a cell line productive of EBV In general, most EBV-converted nonhuman pri-
and an epithelioid cell line, the resulting cell hy- mate cells appear to be more permissive for EBV
brid contains the EBV genome detectable by nu- than comparable human cells.
cleic acid hybridization but no longer produces Recent experiments have demonstrated that EBV
virus particles. (02) Furthermore, there is a marked produces a lymphoma in nonhuman pri-
difference in the expression of the viral genome in mates.(26.55.57.62.80) The experimental disease repro-
cells of different species, all containing the same duces many of the characteristics of the human
strain of EBV. Human cells derived from umbilical infections. There is a spectrum of responses of the
cord lymphocytes are nonproductive and express inoculated marmosets varying from inapparent in-
only EBNA; by contrast, marmoset lymphocytes fection to transient lymphoid hyperplasia to ma-
containing the same strain of virus are fully pro- lignant lymphoma of the reticulum cell type. (62)
ductive and release considerable quantities of ex- Those tumored animals which live for a long time
tracellular virus. (58) develop elevated antibody levels to EBV. The virus
can be recovered from the abdominal lymph nodes
in the form of continuous lymphoblastoid cell lines
4.4. Cell Transformation and Oncogenicity and EBNA appears in imprints made directly from
tumor cells. The EBV genome has been detected in
When EBV is added in vitro to normal human one instance in an experimental tumor.(87a) The
lymphocytes derived from an antibody-negative incidence of tumors in inoculated marmosets is
individual or from umbilical cord blood, the cells increased by treatment with immunosuppressive
acquire the ability to grow continuously in cul- drugs.
4.5. Relationship of EBV to Burkitt Lymphoma tumors of the head and neck, including a reticu-
lum cell sarcoma, a malignant melanoma, a cancer
4.5.1. Demonstration of EBV in the Tumor. of the antrum, and two adenocarcinomas of the
Biopsies of Burkitt lymphoma from the endemic mandible.
area contain the viral genome detectable by nucleic The nucleic acid hybridization studies do not
acid hybridization. <54,68,73,91) Over 90 biopsies define the proportion of cells which contain the
from Uganda and Kenya have been examined by EBV information; however, recently the group
this technique and only two histologically compat- from Stockholm has shown that Burkitt tumor
ible Burkitt lymphomas have failed to demonstrate biopsies contain EBNA in a majority of the
the viral genome. The viral DNA has not been cells.(54)
detected in lymph nodes affected with a variety of Cell lines can be regularly established from
other lymphoproliferative disease, nor has it been Burkitt lymphoma, and thus far all but one contin-
found outside the endemic area. For example, uous cell line from Burkitt lymphoma has con-
Lindahl et al. (54) have studied 21 Swedish patients tained both EBV antigens and the viral genome. In
with Hodgkin's disease, lymphocytic lymphoma, the initial biopsy from which the cell lines are
or chronic leukemia and have failed to detect the derived, there is usually no evidence for mature
EBV genome by hybridization. Pagano et al. (73) virus or viral capsid antigen. However, these ap-
have demonstrated EBV DNA in 22 of 23 African pear within several days after the cells have been
Burkitt lymphomas but have failed to detect com- cultivated in vitro. (67)
plementary sequences in four American Burkitt Continuous lymphoblastoid cell lines which
lymphomas (see Table 2). On the bases of nucleic have been derived from Burkitt lymphoma have
acid hybridization, there are between six and 100 the characteristics of B lymphocytes, namely, im-
copies of the viral genome per cell in the tumors. munoglobulin on their surface. (45) It is notewor-
Of interest, sequences complementary to EBV thy, however, that a B-Iymphocyte cell line has
DNA were also detected in five of 24 other African been obtained from a Burkitt lymphoma biopsy
Table 2. Detection of EBV DNA in Tissues and Cells with Tritiated EBV Complementary RNA (cRNAI
DNA Hybridization)'!
Number of genome. Specimens without

Specimens with EBV equivalents detectable EBV DNA"
DNA (number (number negative/total
Tumor tissue or cell line positive/total number) Range Mean number)
African tumors
Burkitt's lymphomaC 22123 4-113 38 1/23
Nasopharyngeal carcinoma 18/22 5-85 19 4122
Other tumorsC 5/24 6-45 13 19/24
American tumors
Burkitt's lymphoma" 0/4 <2 414
Melanomad 0/3 <2 3/3
Other tumors d 0112 <2 12112
Lymphocytic lines (B-cell origin)e
Containing viral capsid antigen 11111 29-510 104 0111
No viral capsid antigen 6/6 5-100 49 0/6
• From Pagano et al. (73)

• Less than two genome equivalents per cell.
e Data of Nonoyama et al."·)
d Unupublished data.
e Data of Minowada et al. (unpublished), Nonoyama and Pagano,'s.) and Pagano et al.(73)
which contained neither the EBV genome nor approximately the same frequency of antibody to
EBV-related antigens. (49) This cell line is likewise EBV.
devoid of recognizable markers of EBV. Thus the picture that emerged from initial seroe-
4.5.2. Seroepidemiological Relationships. Ser- pidemiological study was that infection with EBV
oepidemiological surveys for antibodies against was ubiquitous. However, marked differences
the viral capsid antigen have demonstrated that were encountered in antibody titers between
EBV is worldwide in its distribution and there is Burkitt lymphoma patients and control popula-
no major difference in the incidence of antibodies tions.(3B) For example, the Henles and their col-
in patients and control groups from the endemic laborators found that of 139 patients with Burkitt
area. (~B.5~) However, the relative rate of acquisi- lymphoma 81.3% had antibodies with titers of
tion of antibodies differs markedly by geographic 1:160 or greater and the geometric mean titer was
locale and socioeconomic class. For example, in 275. By contrast, the geometric mean titer of 489
East Africa nearly 80% of 2-yr-olds have antibod- control patients was 1:37 and only 14% of the
ies to YeA; by contrast, only 40% of sera from 2- positive titers were greater than 1:160. Patients
yr-olds of American lower socioeconomic classes with other cancers, including patients with lym-
are positive for antibodies to the same antigen.(~B) phomas, did not have elevated EBV antibodies as
This result strongly suggests that jn the endemic a rule, although patients with Hodgkin's disease
area infection is acquired at a very early age (see have slightly higher geometric mean titers than
Fig. 1). As part of the prospective study in the normal. (21.51)
West Nile district of Uganda, the rate at which The association of elevated EB viral capsid anti-
susceptibles in East Africa become infected has body titers with Burkitt tumors is most striking in
been investigated: 50% of the susceptibles age 0-5 the endemic area. In contrast, studies reported
yr acquired antibodies in the 18 months between a from two laboratories indicate that between one-
first and a second serum sample. The infection sixth and one-third of American patients with a
was not as readily transmitted in older individu- histological diagnosis of Burkitt lymphoma failed
als, for the rate of seroconversion of susceptibles to demonstrate antibodies to EBV and the levels of
was 37% in the age group 6-10 and nil in the age such antibodies in sera of American Burkitt lym-
group 11_15.(47) There does not seem to be any phoma patients are in the range found in normal
marked difference in incidence of positive anti- persons. (44,52)
body titers in Burkitt lymphoma patients and in a Very few studies have attempted to compare the
wide variety of control groups including individu- height of the titers of antibodies to viruses other
als matched for age, sex, and tribe. Siblings and than EBV, but a recent study has shown that
neighbors, individuals from areas of high Burkitt antibody titers to cytomegalovirus and varicella-
lymphoma incidence, or individuals from areas of zoster virus were approximately fourfold higher in
low Burkitt lymphoma incidence all seem to have Burkitt lymphoma patients than in matched con-
I~~----------------------------I
~~
\&J 80
>
;::
~60 -- u.s. LOW SOCIOECONOMIC
......-.-........
LEVEL
f
('
Fig. 1. Age distribution of antibodies to EBV in East

c[
ct:40 Africa and the United States. From Henle et al. (38)
III
"it
20
o i i i • i I
0-3 4-12 13-24 2-4 5-7 8-10 11-13 14-16 17-
-MONTHS- ··----yEARS
trois. Antibodies to herpes simplex were not sig- incidence have been described for Uganda dis-
nificantly different in Burkitt lymphoma patients tricts (see Fig. 2), with high rates in the northern
and ,control patients.(42) districts and low rates in the southwestern dis-
Elevated antibody titers to EBV have been en- trictsYO)
countered in other diseases such as sarcoi- In certain areas of Uganda, for example, the
dosis. (12) The cause of antibody elevation in pa- Mengo districts in central Uganda, there appears
tients with Burkitt lymphoma remains conjectural. to have been a marked decrease in incidence in
Elevated EBV titers are not a feature of malignancy recent years. In the Mengo districts the rate was
in general. (21) 30/1,000,000 per year early in the 1960s and de-
clined to 911,000,000 per year by the end of the
1960s, at a time when case-finding efforts were
probably increased.(!;") By contrast, in other areas
of Uganda, for example, the northern region, the
incidence remained stable at a rate of 5-101100,000
5.1. Incidence
per year.
In the endemic areas, Burkitt lymphoma is the In many areas of the world, a clinical pathologi-
most common childhood cancer and may reach an cal entity resembling Burkitt lymphoma has been
incidence of as high as 8-10 cases per 100,000 per identified, although in none of these sporadic
year in certain circumscribed geographic locales. cases has a clear-cut association with EBV been
Within Kenya, for example, as illustrated in Table made. In some countries, fur example, Malaysia,
3, the incidence of childhood lymphoma varies Colombia, and Brazil/loB.14) there is an incidence
markedly among tribes in different geographic of Burkitt lymphoma which is intermediate be-
areas. This variation in incidence is not seen in tween that in the endemic areas of Africa and New
adult lymphoma or in squamous cell carcinoma. In Guinea and that in the rest of the world where the
Kenya, the highest incidence occurs in the Bantu disease is only sporadic.
tribes living along the coast, whereas a low inci- Burkitt lymphoma occurs in endemic pattern
dence (approximately one-eighth the incidence only in areas of the world where malaria is "hol-
among the coastal tribes) occurs in tribes living in oendemic." In these areas, malaria infection is
central highlands. This does not seem to be an universal, occurs very early in life, and is trans-
ethnic factor since both the coastal and highland mitted throughout the year.(9,18,4Hl Conversely,
tribes are of Bantu origin. ( 9 ) Similar variations in endemic Burkitt lymphoma has not been encoun-
Table 3. Tribal Distribution of Lymphomas and Epitheliomas in Kenya"
Lymphomas b Squamous cell

cartinomab
Children Adults (adults and
children, per
Ethnic groups Tribes Number Per 100,000 Number Per 100,000 100,000)
Bantu Coastal 31 8.2 11 2.9 8.3

Nilotic Luo 48 6.3 21 2.8 5.7
Bantu Luhya 30 4.5 13 2.0 6.6
Bantu Kisii 9 3.5 9 3.5 9.7
Bantu Kamba 18 3.1 28 4.6 9.2
Bantu Kikuya 31 2.0 53 3.3 9.5
N ilo-Hami tic Kalenjin 5 1.2 9 2.2 8.5
a From Dalldorf et al.<'''

b This is not the annual incidence per 100,000, but the number of tumors identified in the Nairobi Cancer Registry during 1957-1962
inclusive, related to the standardized tribal breakdown of the population in Kenya,
1-3.5
4-5.9
Fig. 2. A: Incidence of Burkitt lymphoma

in Uganda. Cases per 100,000 children
aged 1-15 yrperannum. B: Map of Uganda
showing altitudes above sea level. C: Map
of Uganda showing mean annual mini-
Below 60· F
60-65" F c mum temperature. From Burkitt and
Over ·65· F Wright,(1) p. 200.
tered in nonmalarious areas of the world. Of great endemic areas of Africa is approximately twice
interest is the low incidence of disease in certain that of acute lymphoblastic leukemia in the United
isolated areas, for example, the islands of Zanzibar States, the most common malignant disease of
and Pemba, which are only 20 miles from the coast childhood. In the United States, lymphoma is
of Tanzania where the tumor is endemic. (9) The third as a cause of childhood cancer and is approx-
low tumor incidence can also be correlated with a imately one-eighth as common as leukemia. Thus
very low incidence of malaria resulting from ma- Dalldorf([7) suggested that there appeared to be a
laria eradication campaigns. Furthermore, the de- reciprocal relationship between the incidence of
creasing incidence of disease in Uganda and in leukemia and that of lymphoma. However, the low
Natal, as well as in New Guinea, can be correlated incidence of leukemia in Africa may be related to
with programs of malaria eradication. ease of diagnosis rather than real differences in
The incidence of childhood lymphoma in the incidence. (83)
5.2. Geographic Factors

As a general rule, Burkitt lymphoma occurs in
hot, wet, rural lowlands. Exceptions to these gen-
eralizations have been found/ 5 ) but it appears
that this constellation of geographic attributes is
characteristic for those areas where the disease is
endemic. On the basis of his personal surveys,
Burkitt suggested that endemic areas for the tumor
are lower than 3000 ft above sea level and have an
annual rainfall of more than 40 inches. Figure 3 is
one of the early maps showing the distribution of
the tumor in a belt across central Africa.
Within the endemic areas, there are some in-
stances of microepidemics which result in marked
clustering of cases in space and time. WH •7S ) For
example, Pike et al. (75) noted that in the West Nile
district of Uganda five cases in 2 yr occurred in
one village and that most cases occurred in adja-
cent counties. Morrow et al.(HH) identified seven
cases in 27 months in Bwamba County, Uganda.
In the West Nile district, new cases are diagnosed
twice as often in the second half of the year as in Fig. 3. Known tumor distribution in Africa. From
Burkitt.m
the first, although cases appear during each
month. (8(;)
and New Guinea, the median age ranges from 7.7
yr to 9.2 yr. (2) Burkitt noted that the age of
5.3. Age and Sex
patients with African lymphoma who are immi-
The ages of 661 patients recorded in Uganda by grant to central Uganda is greater than the age of
Burkitt are given in Fig. 4. The median age of lymphoma patients who are born in the endemic
patients is remarkably constant from one area to areas. For example, nearly 50% of patients who are
another. For example, in Uganda, Nigeria, Ghana, immigrant Banyarwanda and Bakiga tribesmen
100
90
-- 70
80
.
c
;; 60
Co.
Fig. 4. Age distribution of 661 pa- ';; 50

tients recorded in Uganda. From Burk- "
itt and Wright/Ill p. 7. •
.<J 40
,E
Z 30
I
20
10
4 6 10 12 14 16 18 20 22 24 26 28 over 30
Age in Years
from Rwanda and Burundi to the southwest distribution of yellow fever in Africa; this
where there is a low incidence of Burkitt lym- prompted the initial suggestion that the disease
phoma, are over 15 yr old and 26% are over 30 yr was transmitted by an arthropod vector. This route
old. Furthermore, within Uganda, the age of pa- of transmission has not been proved. Recently,
tients is greater in low-incidence areas than in the however, EBV has been demonstrated in the oro-
high-incidence areas. pharyngeal secretions of patients with infectious
The overall sex incidence is 2.3 males to 1 mononucleosis, normal individuals, and patients
female. This is apparently a real difference, for sex with diverse disease states, although the exact site
ratio of cases of Wilm's tumor and retinoblastoma of viral replication in the oropharynx has not been
recorded in the Kampala registry is approximately defined. (I5,60) It is attractive to speculate that
1. Burkitt lymphoma begins in the vicinity of the
oropharynx, because this is the first site of viral
5.4. Genetic and Other Host Factors exposure and replication. Dean et al. (20) have
Since Burkitt lymphoma is endemic in both East recently described a form of stomatitis which ap-
Africa and New Guinea, it is unlikely that there is pears to precede or coincide with the onset of
a genetic predisposition limited to a relatively Burkitt lymphoma. The etiology of the stomatitis is
small ethnic or tribal group. However, since the not known, but its existence may also help account
association between malaria and Burkitt lym- for the original site of tumor involvement.
phoma appears so strong, some effort has been
made to determine whether genetic factors which
protect against malaria might influence the epide- 7. Pathogenesis
miology of Burkitt lymphoma. For example, Pike et
al. (74) studied the frequency of the sickle-cell 7.1. Cell Ttansformation
hemoglobin heterozygous trait in patients with Presumably during the course of oropharyngeal
Burkitt tumor as compared with hospitalized and replication of the virus some lymphoid cells in the
normal control individuals. They found AS hemo- vicinity are transformed by the virus; that is, their
globin in approximately 17% of Burkitt tumor growth potential is increased by interaction with
patients compared to 24-29% of controls. Since the the virus. The available results from study of
sickle-cell trait is associated with protection Burkitt lymphoma biopsies suggest that the
against malaria, this observation is compatible lymphoid cells converted by EBV represent a ho-
with the hypothesis that sickle-cell trait may also mogeneous or possibly clonal subpopulation. (29)
be somewhat protective against Burkitt lymphoma Two markers have been examined, surface immu-
(see Table 4). noglobulin and the enzyme glucose 6-phosphate
dehydrogenase (G6PD). Burkitt lymphoma biopsy
6. Mechanism and Route of Transmission specimens examined for the presence of immu-
noglobulin M on their surface fall into two groups:
The geographic and climatic distribution of in approximately 84% of the tumors all of the cells
Burkitt lymphoma was found to correspond to the demonstrate immunoglobulin staining, and in
Table 4. Hemoglobin Genotype in Nigerian Burkitt Tumor Patients and Controls
Hemoglobin Ibadan Hospital Burkitt

genotype tumor patients Ibadan Hospital controls Ilora village controls
AA 78 (78.0%) 225 (68.0%) 142 (70.3%)

AS 17 (17.0%) 95 (28.7%) 49 (24.3%)
SC,SS,CC,AC 5 (5.0%) 11 (3.3%) 11 (5.4%)
Total 100 (100.0%) 331 (100.0%) 202 (100.0%)

about 16% of the tumors there is no immunoglob- ious immune mechanisms and new antigens
ulin staining. A proportion of female Burkitt lym- which appear on the surface of the transformed
'Phoma patients are heterozygous for the G6PD cells. The exact nature of the new antigens which
enzyme, which is associated with the X chromo- call forth the immune response is not known.
some. In females, one or the other of .the X These antigens may include viral-specified altera-
chromosomes is inactivated in each cell. Conse- tions in the cell membrane, which are known to
quently, if the Burkitt tumor had a multicellular occur with the herpesvirus group, and they also
origin, then one might anticipate that Burkitt tu- may include cell determinants which are un-
mors from heterozygous patients would demon- masked or rearranged following virus transforma-
strate both the A and B subtypes of G6PD. How- tion. The only well-studied external antigen in-
ever, 33 of 34 individual Burkitt tumors from 19 duced by the virus is the membrane antigen. The
patients had single-enzyme phenotypes. Tumors exact nature of the immune response which elim-
from different sites in the same patient had the inates the transformed cells in the normal individ-
same single-enzyme phenotype. These findings ual and fails to eliminate these cells in the tumored
suggest that the disease has a clonal origin; that is, individual is also not understood. Cytotoxic anti-
it emerges from one cell and then spreads to the bodies may, with the collaboration of complement,
other part of the body. result in lysis of virus-transformed cells. Cell-
The mode of spread of the transformed cells has mediated lymphocyte reactions may also result in
not been defined for Burkitt tumor patients, and destruction of transformed cells. Patients with
there are no published studies about the circula- Burkitt lymphoma exhibit some form of cell-me-
tion of transformed cells in the peripheral blood. diated sensitivity to their own tumors, for they
However, in the experimental infection of marmo- develop delayed-type skin reactions when inocu-
sets, EBV-converted cells can be detected in the lated with extracts of autologous tumor cells.(2S)
peripheral blood from the second to the fourth In general, untreated Burkitt lymphoma patients
week after inoculation of the virus. (56) appear to be somewhat hyporeactive in their ca-
pacity to mount delayed hypersensitivity reactions
(see Table 5). For example, only two of ten un-
treated Burkitt tumor patients could be sensitized
7.2. Immunological Surveillance
to respond to a chemical hapten DNCB by compar-
It is assumed but not demonstrated that cell ison to 11 of 15 controls of the same age.(SJ) With
transformation occurs regularly as part of the ini- chemotherapy or in remission, the ability to re-
tial EBV infection in all individuals. Presumably in spond to DNCB rose to 13 out of 32 or five out of
the majority of individuals transformed cells are seven, respectively. Similarly, the response of un-
eliminated rapidly through an interaction of var- treated Burkitt lymphoma tumor patients' lympho-
Table 5. Delayed Hypersensitivity Reaction against DNCB and PHA Response of Lymphocytes of
Burkitt Lymphoma Patients in Relation to the Tumor Burden of the Patients a
Reactivity of patients' lymphocytes toward PHA
Number of DNCB-positive patients Percentage of Number of

Tumor burden over number tested CMP/10· cells age controls patients tested
Untreated with tumor 2/10 (20%) 4500 58 25

Under chemotherapy 13/32 (40%) 7400 96 24
Without tumor 5/7 (71%) 9700 126 11
Controls
5-12 yr old 11/15 (73%) 7700 100 34
20-50 yr old 29/31 (97%) 8600 100 30
a From Burkitt and Wright,'lll p. 165.

cytes to phytohemagglutinin was approximately 8. Patterns of Host Response

60% that of the control group; Burkitt lymphoma
patients under chemotherapy or in remission
S.l. Clinical and Pathological Features
showed normal responses to PHA.
An important problem to solve is the relation- The disease presents in more than half the chil-
ship between malaria and successful immunosur- dren as a unilateral swelling of the jaw. Jaw
veillance against EBV-transformed cells. There are tumors are characteristically found as the present-
two theories about the way in which malaria ing sign in younger children and abdominal mas-
might act as a promoter in Burkitt lymphoma. ses in older children. However, even in young
Malaria induces a state of reticuloendothelial hy- children the disease is multifocal at the time of
perplasia secondary to reactions involved in dis- diagnosis and there are usually additional sites of
posal of the malaria parasites and of the products tumor involvement in abdominal viscera, kidney,
of hemolysis. The frequency of transformation by liver, and lymphatic tissue of the gastrointestinal
an exogenous virus such as EBV may be markedly tract. (1]) Other favored sites for occurrence of the
greater in the already stimulated reticuloendothe- tumor are the endocrine and exocrine glands,
lial system of the young child with malaria. (71) particularly thyroid, ovary, and salivary glands.
Alternatively, malaria may produce a degree of The anatomical distribution of the disease is char-
immunological paralysis and allow a small number acteristic not only for the organs involved but also
of virus-transformed cells to multiply beyond the for the organs and sites spared. Characteristically
point where they can be eliminated by immune the lymphoma less frequently involves peripheral
mechanisms. The total dose of tumor cells is a lymph nodes, lung, and the lymphatic tissue of
well-known determinant of experimental tumori- Waldeyer's ring in the nasopharynx; it has never
genesis by virally transformed cells and may be been found in the thymus. A summary of anatom-
crucial in determining the outcome of viral trans- ical involvement from an autopsy series is shown
formation in vivo. Finally, the environmental cir- in Table 6.
cumstances associated with malaria and EBV in- In addition to anatomical location of the tumors,
fection at .an early age may permit the operation of a clinical characteristic of the disease is its favorable
still unidentified cocarcinogens to function to response to cytoxic chemotherapy. In earlier series,
bring about a cellular mutation which increases long survival was not usual: approximately 20% of
the oncogenicity of EBV. the patients survived more than 2 yr.(ll) With im-
Several observations support the general hy- provements in chemotherapy, the 2-yr survival rate
pothesis that EBV-induced lymphomas are highly for Burkitt lymphoma approaches 80% and is mark-
antigenic and that failure of immune recognition is edly better than the survival rate for lymphoblastic
responsible for their tumorigenicity. The histolog- or histiocytic lymphomasya.a9) It is characteristic
ical appearance of the tumors with extensive his- of the survival curves that additional deaths are rare
tiocytic infiltration suggests a process of cell killing after the second year (see Figs. 5 and 6).
and elimination. The relatively high frequency of Although the histopathological definition of the
long-term remissions following chemotherapy disease was initially somewhat confused, O'Conor
suggests that natural immune mechanisms can et al.(70) classified the tumor as a poorly differen-
eliminate the remainder of the tumor cells once the tiated, diffuse lymphoma. A group of experts in
tumor mass is reduced to a low level. Finally, the the pathology of the lymphoreticular system de-
fall of membrane-reactive antibodies prior to tu- fined the entity as an undiffereri.tiated malignant
mor relapse suggests that these antibodies may be lymphoma in which the predominant cell type is
important in maintaining tumor regression. The usually a primitive stem cell and much less fre-
experimental model provides support for this con- quently either a lymphoblast or a reticulum cell.(4)
cept of pathogenesis since marmosets treated with Interspersed among the tumor are histiocytes or
immunosuppressive drugs develop malignant macrophages giving the tumor a starry-sky ap-
lymphoma at a higher rate than non treated ani- pearance; this appearance is not seen only in
mals. Burkitt lymphoma. The tumors show large areas of
Table 6. Organ Involvement in Burkitt Lymphoma: Postmortem Series 1953-1967 Inclusive"
Children (65) Adults (23) Total (88)
Number Percent Number Percent Number Percent
Skeleton
Jaw 37 57 7 30 42 48
Skull vault 6 9 6 26 12 14
Other bones 8 12 7 30 15 17
Central nervous system
Brain 12 18 3 13 15 17
Spinal cord (paraplegia) 6 9 4 17 10 11
Thoracic cavity
Pericardium 3 5 1 4 4 5
Heart 21 32 5 22 26 30
Pleura 6 9 3 13 9 10
Lung 11 17 2 9 13 15
Digestive system
Salivary glands 6 9 3 13 9 10
Peritoneum 8 12 2 9 10 11
Stomach 17 26 3 13 20 23
Small intestine 18 28 6 26 24 27
Large intestine 9 14 3 13 12 14
Liver 24 37 10 43 34 39
Gallbladder 3 5 2 9 5 6
Pancreas 28 43 9 39 37 42
Lymphoreticular system
Lymph nodes 45 69 16 70 60 68
Spleen 20 31 8 35 28 32
Genitourinary system
Kidney 50 77 16 70 64 73
Bladder 2 3 2 9 4 5
Prostateb 1 2 1 1
Testes b 6 12 1 5 7 10
Ovaries' 14 82 3 75 17 81
Breast 1 2 3 13 3 3
Endocrine system
Pituitary 8 12 3 13 11 12
Thyroid 24 37 8 35 30 34
Adrenals 38 58 11 48 49 56
a From Burkitt and Wright,'") p. 65.

b Percentages based on the number of males in the series.
, Percentages based on the number of females in the series.
necrosis, presumably because of rapid growth, 8.2. Serological Features

and cell death is thought to account for the histio-
cytic infiltration. The tumor is generally thought to The sera of nearly 100% of African patients with
arise in the trabecular marrow of the mandible, Burkitt lymphoma contain antibody against the
but this point is not definitely established. Usually viral capsid antigen and approximately 70% anti-
the tumor does not involve the distal bone marrow body directed against the EBV early antigen. Anti-
and leukemia is not a feature of the disease. bodies to EA are not usually found in the sera of
en
'~~
II:
0
>
> Fig. 5. Survival of patients with childhood malig-
II:
:::l
nant lymphoma in Uganda. From Burkitt and
(/)
2~ : Wright,Ol) p. 48.
'* 0 500 1000
DAYS AFTER ADMISSION
1500 2000
normal individuals and, if present, are of low titer. other approach to this question would be to study
The presence of high-titered antibody to EA corre- whether Burkitt lymphoma patients at the time of
lates with a poor prognosis: it is found in 100% of diagnosis have IgM anti-EBV antibodies in their
Burkitt lymphoma patients with a short course sera. In a small number of Burkitt lymphoma
between diagnosis and death but in only 43% of patients studied thus far, EBV IgM antibodies
patients surviving more than 2 yr. (401 have not been detected. (al
Following therapy with local radiation to the
Burkitt tumor, there is a small increase (one two-
fold serum dilution or less) to the EA and VCA. 9. Therapy and Control
This result might be anticipated if local therapy
allowed release of antigen into the circulation. (22) 9.1. Chemotherapy
Gunren et al. (34) found that in three out of four
Burkitt lymphoma patients studied sequentially Chemotherapy, particularly with the alkylating
there is a small decrease in the antibody titer to agent cyclophosmamide (cytoxan), is highly effec-
the membrane antigen which precedes relapse. tive in Burkitt lymphoma. Long-term survivals of 1
The interpretation of this finding is that with yr or more can be obtained in as many as 80% of
progressive increase in tumor mass the circulating patients. The improvements in chemotherapy are
antibodies are removed by MA on the tumor cells. no doubt due to a number of factors, perhaps the
The crucial seroepidemiological study which most important of which is early detection of the
would determine whether the presence of antibod- disease and treatment in early stages. Other factors
ies to EBV is protective against Burkitt lymphoma include recognition and treatment of central nerv-
or is an essential requisite of its occurrence is in ous system involvement with Burkitt tumor. It
progress, but the results have not yet been re- would appear that chemotherapy will provide the
ported. This might demonstrate whether Burkitt mainstay of treatment for the foreseeable future.
lymphoma is a primary infection with EBV. An-
9.2. Malaria Control
The disease rarely occurs in nonmalarious areas
100
O~~ittIS (45)
even in the endemic belt, and whatever the mech-
anisms involved it would seem that control of
(!)
80 \ C-=<XXIICOoco-oo.ooo--<>e>
~ malaria in the form of control of its vectors is
->> 60 \ Lymphoblostic (6) associated with a decreased incidence of Burkitt
0:: X x-x lymphoma. Consequently, the long-range control
~
40
III of Burkitt lymphoma will be closely linked with
Histiocytic (6)
:.!!
0 success in malaria eradication.
20 6
0
25 50 75 100
WEEKS FROM INITIAL TREATMENT
9.3. Vaccines
Fig. 6. Comparison of survival of patients with Burkitt Even though there has been success in the
lymphoma, lymphoblastic lymphoma, and histiocytic application of vaccines in prevention of Marek's
lymphoma. From Ziegler et al. (891 disease, a malignant lymphoma of chickens caused
by a herpesvirus, it seems unlikely that the vac- Part of the problem of the limited geographic
cine approach will be very feasible for Burkitt distribution of the EBV-associated tumors is the
lymphoma. The major problem envisioned is that apparent lack of association of EBV with American
the' herpes group of viruses establish long-term Burkitt lymphoma and certain rare cases of histo-
residence in their host and can be reactivated by a logically consistent Burkitt lymphoma in Africa.
variety of stimuli. This phenomenon appears to be This leads to the inevitable conclusion that multi-
the case for EBV as well, which is apparently ple etiological agents may be associated with the
reactivated under conditions of renal transplanta- same histopathological entity. This, of course, is
tion and immunosuppressive therapy. (82) Conse- not an uncommon finding in the epidemiology of
quently, it would be very difficult to determine the infectious diseases. The alternate explanation is
ultimate safety of a vaccine against EBV if the that EBV is a passenger virus even in the endemic
vaccine virus could be reactivated in future years area and is not etiologically related to the Burkitt
and cause disease. Nonetheless, immunization tumor. This hypothesis now seems very unlikely,
against cell membrane associated EBV-determined for several reasons. First, EBV is now known to
antigens which are important in surveillance of the possess oncogenicity on the basis of animal exper-
transformed cells might ultimately be attempted. iments. Second, one fails to understand why, if
EBV is a passenger virus, it should be present in
every cell of Burkitt tumor in the endemic area and
in nearly every Burkitt tumor. Third, if it is a
10. Unresolved Problems passenger virus why does it specifically select a
particular tumor in a particular geographic locale
The major unresolved problem is the geographic and not appear regularly in other lymphomas?
oncogenesis of a ubiquitous virus. EBV is associ-
ated with inapparent infections, with infectious
mononucleosis, and with two malignant diseases, ACKNOWLEDGMENTS
Burkitt lymphoma and nasopharyngeal carcinoma.
The malignancies occur in sharply circumscribed This work was supported by grants from the
geographic locales, yet the virus is worldwide in American Cancer Society (VC-l07), the U.S. Public
distribution. One possibility to explain this para- Health Service (CA16038, CA12055), and the Da-
dox, which has not yet received sufficient explora- mon Runyon Memorial Fund (DRG1147). The
tion, is that different viral strains or subtypes are author is an Investigator of the Howard Hughes
involved. Although extensive cross-reaction has Medical Institute.
been found in a variety of cell-associated antigens
among various EBV strains, the structural details
of a number of different EBV strains have not 11. References
been analyzed. More sensitive quantitative tech-
niques are needed to detect differences in the 1. Collected reports of cases of Burkitt's lymphoma
constituent polypeptides and nucleic acids of a from countries outside the endemic areas, Int. J.
variety of EBV strains. If host factors are underly- Cancer 2:559-609 (1967).
ing the different responses of different population 2. ARMENIAN, H. K., AND LILLIENFELD, A. M., The
groups to the same virus, one would very much distribution of incubation periods of neoplastic di-
like to know how such host factors operate. One seases, Am. ]. Epidemiol. 99:92-100 (1974).
hypothesis explored in some detail by Kufe et 3. BANATVALA, J. E., BEST, J. M., AND WALLER, D. K.,
Epstein-Barr virus-specific IgM in infectious monon-
al. (50) is that Burkitt lymphoma results from coop-
ucleosis, Burkitt lymphoma, and nasopharyngeal car-
erative infection with EBV and an endogenous cinoma, Lancet 1:1205-1208 (1972).
RNA tumor virus. Although the presence of RNA 4. BEARD, C. W., O'CONOR, G. T., THOMAS, L. B., AND
tumor viruses in Burkitt lymphoma has not yet TORLONI, H., Histopathological definition of Burk-
been confirmed in other laboratories, the mere itt's tumor, Bull. WHO 40:601-607 (1969).
presence of the RNA tumor virus does not indicate 5. BERRY, C. G., Lymphoma syndrome in northern
its causal role. Nigeria, Br. Med. J. 2:668-670 (1964).
6. BURKITT, D. P., A sarcoma involving the jaws in EB-virus associated serology in malignant disease:
African children, Br. I. Surg. 46:218-223 (1958). Antibody levels to viral capsid antigens (VCA) ,
6a. BURKITT,. D. P., A children's cancer dependent on membrane antigens (MA) and early antigens (EA) in
climatic factors, Nature (London) 194:232-234 (1962). patients with various neoplastic conditions, Int. I.
7. BURKITT, D., Determining the climatic limitations of Cancer 9:353-364 (1972).
a children's cancer common in Africa, Br. Med. J. 22. EINHORN, N., HENLE, G., HENLE, W., KLEIN, G., AND
2:1019-1023 (1962). CLIFFORD, P., Effect of local radiotherapy on the
8. BURKITT, D., Burkitt's lymphoma outside the known antibody levels against EBV-induced early and cap-
endemic areas of Africa and New Guinea, Int. I. sid antigens (EA and VCA) in patients with certain
Cancer 2:562-565 (1967). malignant tumours, Int. I. Cancer 9:182 (1972).
9. BURKITT, D., Etiology of Burkitt's lymphoma-An 23. EpSTEIN, M. A., ACHONG, B. G., BARR, Y. M., ZAJAC,
alternative hypothesis to a vectored virus, J. Natl. B., HENLE, G., AND HENLE, W., Morphological and
Cancer Inst. 42:19-28 (1969). virological investigations on cultured Burkitt tumor
10. BURKITT, D., AND WRIGHT, D. H., Geographical and lymphoblasts (strain Raji), J. Natl. Cancer Inst.
tribal distribution of the African lymphoma in 37:547-559 (1966).
Uganda, Br. Med. I. 5487:569-573 (1966). 24. EpSTEIN, M. A., AND BARR, Y. M., Cultivation in vitro
11. BURKITT, D. P., AND WRIGHT, D. H. (eds.), Burkitt's of human lymphoblasts from Burkitt's malignant
Lymphoma, Livingstone, Edinburgh, 1970. lymphoma, Lancet 1:252-253 (1964).
12. BYRNE, E. B., EVANS, A. S., FONTS, D. W., AND 25. EpSTEIN, M. A., HENLE, G., ACHONG, B. G., AND
ISRAEL, H. L., A seroepidemiological study of Ep- BARR, Y. M., Morpholollical and biological studies
stein-Barr virus and other antigens in sarcoidosis, on a virus in cultured lymphoblasts from Burkitt's
Am. I. Epidemiol. 97:355-363 (1973). lymphoma, J. Exp. Med. 121:761-770 (1965).
13. CARBONE, P., BERNARD, C. W., BENNETT, J. M., 25a. EpSTEIN, M. A., ACHONG, B. G., AND BARR, Y. M.,
ZIEGLER, J. L., COHEN, M. H., AND GERBER, P., Virus particles in cultured lymphoblasts from Burk-
National Institutes of Health clinical staff conference: itt's lymphoma, Lancet 1:702-703 (1964).
Burkitt's tumor, Ann. Intern. Med. 70:817-832 (1969). 26. EpSTEIN, M. A., HUNT, R. D., AND RABIN, H., Pilot
14. CARVALHO, R. P. S., EVANS, A. S., FROST, P., DAL- experiments with EB virus in owl monkeys (Aotus
LDORF, G., CAMARGO, M. F., AND JAMRA, M., EBV trivirgatus). I. Reticuloproliferative disease in an in-
infections in Brazil. I. Occurrence in normal persons, oculated animal, Int. I. Cancer 12:309-318 (1973).
in lymphomas and in leukemias, Int. I. Cancer 27. FALK, L., WOLFE, L., DEINHARDT, F., PACIGA, J.,
11:191-201 (1973). DOMBOS, 1., KLEIN, G., HENLE, W., AND HENLE, G.,
15. CHANG, R. S., LEWIS, J. P., AND ABILDGAARD, C. F., Epstein-Barr virus: Transformation of non-human
Prevalence of oropharyngeal excreters of leukocyte- primate lymphocytes in vitro. Int. I. Cancer 13:353-
transforming agents among a human population, N. 376 (1974).
Engl. I. Med. 289:1325-1329 (1973). 28. FASS, L., HERBERMAN, R. B., AND ZIEGLER, J., De-
16. COOK, A. R., Uganda Memories, Uganda Society, layed cutaneous hypersensitivity reactions to autolo-
1945. gous extracts of Burkitt-lymphoma cells, N. Engl. I.
17. DALLDORF, G., Lymphomas of African children, J. Med. 282:776-780 (1970).
Am. Med. Assoc. 181:1026-1028 (1962). 29. FIALKOW, P. J., KLEIN, E., KLEIN, G., CLIFFORD, P.,
18. DALLDORF, G., LINSELL, C. A., BARNHART, F. c., AND AND SINGH, S., Immunoglobulin and glucose-6-phos-
MARTYN, R., An epidemiologic approach to the lym- phate dehydrogenase as markers of cellular origin in
phomas of African children and Burkitt's sarcoma of Burkitt lymphoma, I. Exp. Med. 138:89-101 (1973).
the jaws, Perspect. BioI. Med. 7:435--449 (1964). 30. GERBER, P., Activation of Epstein-Barr virus by 5-
19. DAVIES, J. N. P., ELMES, S., HUTT, M. S. R., MTIMA- bromodeoxyuridine in virus free human cells, Proc.
VALYE, L. A. R., OWOR, R., AND SHAPER, L., Cancer Natl. Acad. Sci. USA 69:83-85 (1972).
in an African community, 1897-1956: An analysis of 31. GERBER, P., AND HOYER, B. H., Induction of cellular
the records of Mengo Hospital, Kampala, Uganda: DNA synthesis in human leucocytes by Epstein-Barr
Part 2, Br. Med. I. 1:336-341 (1964). virus, Nature (London) 231:46-47 (1971).
20. DEAN, A. G., WILLIAMS, E. H., ATTOBUA, G., 32. GLASER, R., AND RAPP, F., Rescue of Epstein-Barr
OMEDA, J., GAOl, A., AMUTI, A., AND ATIMA, S. B., virus from somatic cell hybrids of Burkitt lymphob-
Clinical events suggesting herpes-simplex infection lastoid cells, I. Viral. 10:288-296 (1972).
before onset of Burkitt's lymphoma, Lancet 2:1225- 33. GRIFFIN, E. R., WRIGHT, D. H., BELL, T. M., AND
1228 (1973. Ross, M. G. R., Demonstration of virus particles in
21. DESCHRYVER, A., KLEIN, G., HENLE, G., HENLE, W., biopsy material from cases of Burkitt's tumour, Eur.
CAMERON, H. M., SANTESSON, L., AND CLIFFORD, P., I. Cancer 2:353-358 (1966).
34. GUNREN, P., KLEIN, G., CLIFFORD, P., AND SINGH, S., Barr virus receptors on B lymphocytes, J. Exp. Med.
Epstein-Barr virus-associated membrane-reactive an- 138:1365-1378 (1973).
tibodies during long term survival after Burkitt's 46. KAFUKO, G. W., AND BURKrrT, D. P., 'Burkitt's lym-
lymphoma, Proc. Natl. Acad. Sci. USA 71:1422-1426 phoma and malaria, Int. J. Cancer 6:1-9 (1970).
(1974). 47. KAFUKO, G. W., HENDERSON, B. E., KIRYA, B. G.,
35. HAMPAR, B., DERGE, J. G., MARTOS, L. M., TAGA- MUNUBE, G. M. R., TUKEI, P. M., DAY, N. E., HENLE,
METS, M. A., CHANGE, S. Y., AND CHAKRABARTY, M., G., HENLE, W., MORROW, R H., PIKE, M. c., SMITH,
Identification of a critical period during the S phase P. G., AND WILLIAMS, E. H., Epstein-Barr virus
for activation of the Epstein-Barr virus by 5-iodo- antibody levels in children from the West Nile Dis-
deoxyuridine, Nature (London) New BioI. 244:214-217 trict of Uganda, Lancet 1:706 (1972).
(1973). 48. KLEIN, G., CLIFFORD, P., KLEIN, E., AND STJERNS-
36. HAMPAR, B., DERGE, J. G., MARTOS, L. M., AND WARD, J., Search for tumor specific immune reactions
WALKER, J. L., Synthesis of Epstein-Barr virus after in Burkitt lymphoma patients by the membrane
activation of the viral genome in a virus negative immunofluorescence reaction, Proc. Natl. Acad. Sci.
human lymphoblastoid cell (Raji) made resistant to USA 55:1628-1635 (1966).
five bromodeoxyuridine, Proc. Natl. Acad. Sci. USA 49. KLEIN, G., LINDAHL, T., JONDAL, M., LEIBOLD, W.,
69:78-82 (1972). MENEZES, J., NILSSON, K., AND SUNDSTROM, CH.,
37. HENLE, G., AND HENLE, W., Immunofluorescence in Continuous lymphoid cell lines with B-cell character-
cells derived from Burkitt's lymphoma, J. Bacterial. istics that lack the Epstein-Barr virus genome, derived
91:1248-1256 (1966). from three human lymphomas, Proc. Nat. Acad. Sci.
38. HENLE, G., HENLE, W., CLIFFORD, P., DIEHL, V., 71:3283-3286 (1974).
KAFUKO, G. W., KIRYA, B. G., KLEIN, G., MORROW, 50. KUFE, D., HEHLMANN, R, AND SPIEGELMAN, S., RNA
R H., MUNUBE, G. M., R, PIKE, P., TUKEI, P. M., related to that of a murine leukemia virus in Burkitt's
AND ZIEGLER, J. L., Antibodies to Epstein-Barr virus tumors and nasopharyngeal carcinoma, Proc. Natl.
in Burkitt's lymphoma and control groups, J. Nat/. Acad. Sci. USA 70:5-9 (1973).
Cancer Inst. 43:1147-1157 (1969). 51. LEVINE, P. H., ABLASHI, D. V., AND BERARD, C. W.,
39. HENLE, W., DIEHL, V., KOHN, G., ZUR HAUSEN, H., Elevated antibody titers to Epstein-Barr virus in
AND HENLE, G., Herpes-type virus and chromosome Hodgkin's disease, Cancer 27:416-421 (1971).
marker in normal leukocytes after growth with irra- 52. LEVINE, P. H., O'CONOR, G. T., AND BERARD, C. W.,
diated Burkitt cells, Science 157:1064-1065 (1967). Antibodies to Epstein-Barr virus (EBV) in American
patients with Burkitt's lymphoma, Cancer 30:610-615
40. HENLE, W., HENLE, G., GUNVEN, P., KLEIN, G.,
(1972).
CLIFFORD, P., AND SINGH, S., Patterns of antibodies
53. LEVY, J. A., AND HENLE, G., Indirect immunoflu-
to Epstein-Barr virus-induced early antigens in Burk-
orescence tests with sera from African children and
itt's lymphoma: Comparison of dying patients with
cultured Burkitt lymphoma celis, J. Bacterial. 92:275-
long term survivors, J. Natl. Cancer Inst. 50:1163-1173
276 (1966).
(1973).
54. LINDAHL, T., KLEIN, G., REEDMAN, B. M., JOHANS-
41. HENLE, W., HENLE, G., ZAJAC, B. A., PEARSON, G.,
SON, B., AND SINGH, S., Relationship between Ep-
W AUBKE, R, AND SCRIBA, M., Differential reactivity
stein-Barr virus (EBV) DNA and the EBV-determined
of human serums with early antigens induced by
nuclear antigen (EBNA) in Burkitt lymphoma biop-
Epstein-Barr virus, Science 169:188-190 (1970).
sies and other lymphoproliferative malignancies, Int.
42. HILGERS, F., DEAN, A. G., AND DE-THE, G. B., Ele-
J. Cancer 13:764-772 (1974).
vated immunofluorescence titers to several herpes
55. MILLER, G., Oncogenicity of Epstein-Barr virus, J.
viruses in Burkitt's lymphoma patients: Are high
Infect. Dis. 130:187-205 (1974).
titers unique? (manuscript).
56. MILLER, G., AND COOPE, D., unpublished results.
43. HINUMA, Y., KONN, M., YAMAGUCHI, J., WUDARSKI, 57. MILLER, G., AND COOPE, D., Epstein-Barr viral nu-
D. J., BLAKESLEE, J. R, AND GRACE, J. T., JR., Immu- clear antigen (EBNA) in tumor cell imprints of experi-
nofluorescence and herpes-type virus particles in the mental lymphoma of marmosets, Trans. Assoc. Am.
P3HR-1 Burkitt lymphoma cell line, J. Viral. 1:1045- Physicians 87:205-218 (1974).
1051 (1967). 58. MILLER, G., AND LIPMAN, M., Comparison of the
44. HIRSHAUT, Y., COHEN, M. H., AND STEVENS, D. A., yield of infectious virus from clones of human and
Epstein-Barr virus antibodies in American and Afri- simian lymphoblastoid lines transformed by Epstein-
can Burkitt's lymphoma, Lancet 2:114-116 (1973). Barr virus, J. Exp. Med, 138:1398-1412 (1973).
45. JONDAL, M., AND KLEIN, G., Surface markers on 59. MILLER, G., LIsco, H., KOHN, H.!., AND STITT, D.,
human Band T lymphocytes. II. Presence of Epstein- Establishment of cell lines from normal adult human
blood leukocytes by exposure to Epstein-Barr virus 72. OLD, 1. J., BOYSE, E. A., OETTGEN, H. F., DEHARVEN,
and neutralization by human sera with Epstein-Barr E., GEE RING, G., WILLIAMSON, B., AND CLIFFORD, P.,
virus antibody, ProC. Soc. Exp. BioI. Med. 137:1459- Precipitating antibody in human serum to an antigen
1465 (1971). present in cultured Burkitt's lymphoma cells, Proc.
60. MILLER, G., NIEDERMAN, J. c., AND ANDREWS, 1., Natl. Acad. Sci. USA 56:1699-1704 (1966).
Prolonged oropharyngeal excretion of EB virus fol- 73. PAGANO, J. S., HUANG, C. H., AND LEVINE, P.,
lowing infectious mononucleosis, N. Engl. J. Med. Absence of Epstein-Barr viral DNA in American
288:229-232 (1973). Burkitt's lymphoma, N. Engl. ]. Med. 289:1395-1399
61. MILLER, G., ROBINSON: J., HESTON, 1., AND LIPMAN, (1973).
M., Differences between laboratory strains of Ep- 74. PIKE, M. c., MORROW, R. H., KISUULE, A., AND
stein-Barr virus based on immortalization, abortive MAFIGIRI, J., Burkitt's lymphoma and sickle cell trait,
infection and interference, Proc. Natl. Acad. Sci. USA Br. J. Prevo Soc. Med. 24:39-41 (1970).
71:400&-4010 (1974). 75. PIKE, M. c., WILLIAMS, E. H., AND WRIGHT, B.,
62. MILLER, G., SHOPE, T., AND COOPE, D., Aspects of the Burkitt's tumour in the West Nile District of Uganda
pathogenesis of lymphoma in cotton-top marmosets 1961-5, Br. Med. J. 2:395-399 (1967).
following inoculation of EB virus, in: Mechanisms of 76. POPE, J. H., HORNE, M. K, AND SCOTT, W., Identifi-
Virus Diseases Vol. 1, (W. S. ROBINSON AND F. C. Fox, cation of the filtrable leukocyte-transforming factor
eds.), pp. 429-454, W. A. Benjamin, Inc., Menlo Park, of QIMR-WIL cells as herpes-like virus, Int. J. Cancer
California, 1974. 4:255-260 (1969).
63. MILLER, G., SHOPE, T., LISCO, H., STITT, D., AND 76a. PULVERTAFT, R. J. V., Cytology of Burkitt's tumor
LIPMAN, M., Epstein-Barr virus: Transformation, cy- (African lymphoma), Lancet 1:238--240 (1964).
topathic changes, and viral antigens in squirrel mon- 77. REEDMAN, B. M., AND KLEIN, G., Cellular localization
key and marmoset leukocytes, Proc. Nail. Acad. Sci. of an Epstein-Barr virus (EBV)-associated comple-
USA 69:383-387 (1972). ment -fixing antigen in producer and non-producer
64. MILLER, M. H., STITT, D., AND MILLER, G., Epstein- lymphoblastoid cell lines, Int. ]. Cancer 11:499-520
Barr viral antigen in single cell clones of two human (1973).
leukocytic lines,]. Viral. 6:699-701 (1970). 78. REEDMAN, B. M., KLEIN, G., POPE, J. H., WALTERS,
65. MORROW, R. H., PIKE, M. c., AND SMITH, P. G., M. 1., HILGERS, J., SINGH, S., AND JOHANSSON, B.,
Epidemiology of Burkitt's lymphoma in the Mengo Epstein-Barr virus-associated complement-fixing and
Districts, Uganda, 1957-1968, presented at the an- nuclear antigens in Burkitt lymphoma biopsies, Int.
nual meeting of the American Epidemiological Society, J. Cancer 13:755-763 (1974).
April 5-6, 1974. 79. SCHULTE-HoLTHAUSEN, H., AND ZUR HAUSEN, H.,
66. MORROW, R. H., PIKE, M. c., SMITH, P. G., ZIEGLER, Partial purification of the Epstein-Barr virus and
J. 1., AND KISUULE, A., Burkitt's lymphoma: A time- some properties of its DNA, Virology 40:776--779
space cluster of cases in Bwamba County of Uganda, (1970).
Br. Med. J. 2:491-492 (1971). 80. SHOPE, T., DECHAIRO, D., AND MILLER, G., Malig-
67. NADKARNI, J. S., NADKARNI, J. J., KLEIN, G., HENLE, nant lymphoma in cotton-top marmosets following
W., HENLE, G., AND CLIFFORD, P., EB viral antigens inoculation of Epstein-Barr virus, Proc. Nat!. Acad.
in Burkitt tumor biopsies and early cultures, Int. ]. Sci. USA 70:2487-2491 (1973).
Cancer 6: 10--17 (1970). 81. STJERNSWARD, J., CLIFFORD, P., AND SVEDMYR, E.,
68. NONOYAMA, M., HUANG, C. H., PAGANO, J. S., General and tumor destructive cellular immunologi-
KLEIN, G., AND SINGH, S., DNA of Epstein-Barr virus cal reactivity, in: Burkitt's Lymphoma (D. P. BURKITT
detected in tissue of Burkitt's lymphoma and naso- AND D. H. WRIGHT, eds.), pp. 164-171, Livingstone,
pharyngeal carcinoma, Proc. Nail. Acad. Sci. USA Edinburgh, 1970.
70:3265-3268, (1973). 82. STRAUCH, B., SIEGEL, N., ANDREWS, 1., AND MILLER,
69. NONOYAMA, M., AND PAGANO, J. S., Separation of G., Oropharyngeal excretion of Epstein-Barr virus by
Epstein-Barr virus DNA from large chromosomal renal transplant recipients and other patients treated
DNA in non-virus producing cells, Nature (London) with immunosuppressive drugs, Lancet 1:234-237
New BioI. 238:169 (1972). (1974).
70. O'CONOR, G. T., Malignant lymphoma in African 83. VANIER, T. M., AND PIKE, M. c., Leukemia incidence
children. II. A pathological entity, Cancer 14:270--283 in tropical Africa, Lancet 1:512-513 (1967).
(1961). 84. WALTERS, M. K., AND POPE, J. H., Studies of the EB
71. O'CONOR, G. T., Persistent immunologic stimulation virus-related antigens of human leukocyte cell lines,
as a factor in oncogenesis, with special reference to Int. ]. Cancer 8:32-40 (1971).
Burkitt's tumor. Am. J. Med. 48:279-285 (1970). 85. WERNER, J., HENLE, G., PINTO, C. A., HAFF, R. F.,
AND HENLE, W., Establishment of continuous lym- genomes in epithelial nasopharyngeal carcinoma
phoblast cultures from leukocytes of gibbons (Hylo- cells, Nature (London) New Bio!. 244:245--247 (1973).
bates lar), Int. J. Cancer 10:557-567 (1972). 89. ZIEGLER, J. L., MORROW, R. H., JR., TEMPLETON, A.
86. WILLIAMS, E. H., DAY, N. E., AND GESER, A. G., c., TEMPLETON, c., BLUMING, A. Z., FASS, L., AND
Seasonal variation in onset of Burkitt's lymphoma in KYALWAZI, S. K., Clinical features and treatment of
the West Nile District of Uganda, Lancet 2:19-22 childhood malignant lymphoma in Uganda, Int. J.
(1974). Cancer 5:415-425 (1970).
87. WITKEY, I. 5., Malignant lymphoma in Papua, New 90. ZUR HAUSEN, H., AND SCHULTE-HoLTHAUSEN, H.,
Guinea: Epidemiologic aspects, J. Nat!. Cancer Inst. Presence of EB virus nucleic acid homology in a "vi-
50:1703-1711 (1973). rus-free" line of Burkitt tumor cells, Nature (London)
87a. WOLF, H., WERNER, J., AND ZUR HAUSEN, H., EBV 227:245-248 (1970).
DNA in nonlymphoid cells of nasopharyngeal carci- 91. ZUR HAUSEN, H., SCHULTE-HoLTHAUSEN, H., KLEIN,
nomas and in a malignant lymphoma obtained after G., HENLE, W., HENLE, G., CLIFFORD, P., AND
inoculation of EBV into cottontop marmosets, Cold SANTESSON, L., EB-virus DNA in biopsies of Burkitt
Spring Harbor Symp. Quant. Bio!. 39:791-796 tumors and anaplastic carcinomas of the nasophar-
88. WOLF, H., zURHAUSEN, H., AND BECKER, V., EB viral ynx, Nature (London 228:1056--1057 (1970).
CHAPTER 23
Epidemiology of
Cervical Cancer
Andre J. Nahmias, William E. Josey,
and James M. Oieske
1. Introduction their detection can be accomplished without re-

moval of tissue by cytological examination of ex-
foliated cervical cells and/or by direct magnified
Carcinoma of the uterine cervix is one of the most
observations made with the colposcope. The mor-
common cancers in women in the United States
tality associated with cervical cancer has decreased
and throughout the world. Because of its fre-
significantly in most places where these early
quency and accessibility to methods of early detec-
detection methods are employed.
tion,. cervical cancer is among the most thoroughly
A small percen tage of cervical malignancies are
studIed of all human malignant diseases. Its natural
adenocarcinomas rather than squamous cell (epi-
history has been extensively investigated, and the
dermoid) carcinomas. Such adenocarcinomas may
gradation from intraepithelial neoplastic cervical
also occur in situ. An even smaller number are
changes (dysplasia and carcinoma in situ) to inva-
adenoacanthomas (mixed type), sarcomas, and
sive carcinoma has been well documented. Al-
lymphomas. The discussion herein is concerned
though such progression of the disease does not
primarily with the common squamous cell type.
appear to be an inevitable process, ample evidence
A large number of epidemiological studies have
has accumulated to indicate that when invasive
been conducted in various countries to elucidate
cancer occurs it is practically always preceded by
risk factors associated with cervical cancer. These
a preinvasive phase in its development.
investigations, which have shown greatest con-
T~e intraepithelial and early invasive stages of
sistency for such variables as early onset of coitus
cervIcal cancer are infrequently detected by the
and exposure to multiple sexual consorts, strongly
traditional methods of history taking, speculum
support the concept that one or more sexually
examination, palpation, and probing. However,
transmitted agents are involved in cervical carcin-
ogenesis. Over the past decade, genital herpes
Andre J. Nahmias, William E. Josey, and James M. simplex viruses (HSV) have received increasing
Oleske' Departments of Pediatrics and Gynecology attention as possible etiological agents. Emphasis
and Obstetrics, Emory University School of Medicine, will be given in this chapter to studies relating
Atlanta, Georgia these viruses to cervical cancer.
501
502 Chapter 23 • Epidemiology of Cervical Cancer
2. History tal HSV in cervical carcinogenesis was first sus-

pected from a different line of evidence.
In 1964, studies of an infant with neonatal
In the nineteenth century, clinicopathological herpes simplex virus infection and of his mother's
studies established that squamous carcinoma of cervical HSV infection led to further investigations
the cervix was distinct from cancer of the body of by our group at Emory which provided the first
the uterus. In the late part of that century and in suspicion of an association between genital herpes
the early part of the twentieth century, the micro- and cervical neoplasia.(m We observed that
scopic features of intraepithelial carcinoma were women with cytological findings consistent with
described, but the term carcinoma in situ was not HSV infection in cervicovaginal smears had an
introduced until 1932, by Broders. (HI) In the late increased frequency of cervical precancer and can-
1920s, Schiller introduced the iodine test which cer. During studies to confirm the specificity of the
distinguishes glycogen-containing epithelium cytological changes-first in humans, then in
(positive stain) from one lacking glycogen (no mice-it was noted that mice genitally infected
staining). Although helping to delineate normal with human genital HSV isolates died at a much
from abnormal epithelium, this test did not estab- higher frequency than mice inoculated with non-
lish a diagnosis of the abnormal epithelium. In genital HSV strains. Other biological differences
1925, Hinselmann developed the colposcope to were also found between genital and nongenital
allow direct magnified observation of the cervix. strains.(a7J Serological testing permitted differen-
His discovery that the earliest cancer focus origi- tiation of HSV strains' according to their site of
nated from atypical epithelium rather than from a origin and mode of transmission into two anti-
nodule was an important initial step toward eluci- genic types, HSV-1 and HSV-2, described earlier
dation of the natural history of the disease. Al- by Schneweis and Plummer(53.67) (see Chapter 11).
though exfoliative cytology of the cervix had been These differences between genital and nongenital
described earlier, the systematic 15-yr studies of viruses thus provided another approach to the
Papanicolaou and Traut, published in 1943/ 52 ) study of the genital herpes-cervical cancer associa-
. provided great impetus for the use of that tech- tion, as serological differentiation of antibodies to
nique for the detection of precancer and cancer. In the two types then became possible. These early
addition to facilitating diagnosis, the application seroepidemiological studies demonstrated a higher
of these various methods, including histopathol- frequency of HSV-2 antibodies in women with
ogy, either singly or in combination, contributed cervical cancer as compared to controls. (4.38.58)
significantly to present-day understanding of the Many other types of approaches, from the molecu-
biology of cervical carcinoma. lar to the epidemiological and comparative, have
Significant epidemiological observations related provided further evidence linking genital herpes
to cervical cancer were first reported in 1842 by an to cervical cancer. Results of these studies and the
Italian physician, Rigoni -Stem. (62) This investiga- problems of establishing a causal relationship are
tor was the first to point to the rarity of the cancer discussed in later sections of this chapter.
in nuns and its greater frequency in married than
in unmarried women, observations which took
another century to be confirmed and extended.
The more recent epidemiological studies have led 3. Methodology
to the concept that early sexual intercourse is the
pivotal event in setting up risk, allowing the
3.1. Mortality and Morbidity of Cervical
transmission of some carcinogenic agent from the
Neoplasia
coital male to the female at risk. (4 ) Speculations
on the nature of the putative carcinogen have Several factors have contributed to the problem
included various noninfectious factors such as of defining mortality and morbidity data in var-
smegma and spermatozoa as well as a variety of ious geographic regions. First is the fact that until
infectious agents such as Treponema pallidum and the 1940s cervical cancer and cancer of the corpus
Trichomonas vagina/is. (3) The possible role of geni- uteri were reported together as cancer of the
Chapter 23 • Epidemiology of Cervical Cancer 503
uterus. (28) Another problem is that it is not always all, the technique has an 80-95% reliability in
clear whether the number of new cases per year is detecting cervical cell abnormalities.
comprised of both in situ and invasive cancer or 3.1.2. Colposcopic Methods. The competence of
only the latter. In the United States, for instance, the observer is also important when colposcopic
estimates of new cases of cervical cancer which methods are used. Such techniques are also about
have been obtained from the NCI National Cancer 80-95% reliable in detecting cervical neoplasia. (9)
Survey do not include cases of carcinoma in situ Since some negative results obtained by cytologi-
(CIS). Mortality rates are also available from the cal methods may be positive by colposcopy and
Vital Statistics records of the United States and vice versa, the combined use of the two techniques
other countries. The true rates may be compro- increases the accuracy.
mised by the problem of whether the cancer is 3.1.3. Histological Methods. Since the histo-
listed as the cause of death on the death certifi- pathological diagnOSis is the most usually accepted
cate. C30 ) finite criterion, albeit occasionally yielding false
Another factor which has greatly influenced negative results,<72) differences in interpretation
mortality rates has been the extent to which meth- would make comparison of results obtained in dif-
ods for the detection of cervical cancer in its early ferent areas problematical. Diagnostic variability
stages have been employed in a particular geo- has been repeatedly demonstrated in studies
graphic region. Improved methods of therapy in wherein the same slide sections were submitted to
certain areas would also be exp.ected to influence a number of different pathologists, particularly in
mortality rates. Access to optimum medical care cases of intraepithelial abnormalities.(C;1) It is also
therefore might affect the differences encountered appreciated that diagnostic biopsies may affect the
in age-specific rates, particularly mortality rates, progression of the process by removal of some of
since symptoms are not usually apparent until the the tumor tissue. (60)
disease has progressed to a relatively advanced 3.1.4. Appropriate Controls. In studies attempt-
stage. ing to determine specific risk factors in women
Prevalence rates of dysplasia, CIS, and invasive with cervical neoplasia as compared to those with
cancer have been obtained in several surveys by no evidence of cervical precancer or cancer, the
application of detection methods, chiefly cytologi- problem comes up of the validity of historical
cal techniques, followed by histological confirma- information, e.g., number of sexual partners and
tion. (28) Incidence rates have been determined by contraceptive usage. In reference particularly to
following women over varying periods of years the presence or absence of circumcision in the
who had previously negative cytological findings. male contacts, the adequacy of historical informa-
The incidence rates for women with dysplasia who tion has been challenged repeatedly.(4)
went on to develop CIS or invasive cancer have
also been compared with the rates for those whose
3.2. Studies Relating HSV to Cervical Cancer
initial smears were cytologically negative. Of
course, the duration of follow-up studies in a Several of the methods used for diagnosing
disease with a long latency period affects the HSV-l and/or HSV-2 infections and related prob-
results obtained. lems have been detailed in Chapter 11. The fea-
The rates obtained in the various studies will tures related more specifically to studies attempt-
depend on the adequacy and interpretations of the ing to link HSV to cervical cancer are emphasized
techniques employed. here.
3.1.1. Cytological Methods. The sensitivity of 3.2.1. Epidemiological Studies. a. Prospective
the cytological methods will depend on how the Studies. Women with currently active (primary or
smears were obtained, the adequacy of the speci- recurrent) genital herpetic lesions or with asymp-
men, the number of smears obtained, and the tomatic HSV-2 infections, or those with prior
competence of the observer. C1 •71l Variations in HSV-l and/or HSV-2 infections, can be identified
interpretation are not uncommon. Also, in cases of with the use of clinical, cytological, virological,
advanced invasive disease, concomitant inflamma- and/or serological methods. In view of the large
tion may obscure the cytological diagnosis. Over- number of subclinical genital HSV infections, es-
pecially of the cervix,(27) it is not possible to rule cells and the anticomplement immunofluorescent
out infection at any specific time unless virological test to biopsy specimens. '5.451 Problems with non-
and/or cytological techniques are applied continu- specific positive fluorescence can occur, and here
ously at weekly intervals. Therefore, serological again confirmatory work and characterization of
techniques demonstrating the absence of HSV-2 the antigens would provide greater reliability to
antibodies in sera constitute the only practical way results obtained.
of identifying control groups. It is worth reem- The detection of viral DNA or RNA in cancer
phasizing here that the serological tests are of cells by molecular hybridization techniques is lim-
great variability, and that the ability to detect ited by the sensitivity of these assays. If only a
HSV-2 antibodies in an individual with prior small fraction of the viral genome is present in the
HSV-1 infection using currently available tech- cancer, the assay might not be sensitive enough to
niques is no better than 85%. allow its detection. It is also to be emphasized that
b. Seroepidemiological Studies. Besides the prob- the cancer tissue being tested should be examined
lems noted above, serological studies conducted for the proportion of cancer cells and normal cells
with sera obtained from one geographic area and in the tissue, since it is crucial for the assay that
tested with viruses obtained from another area may cancer cells should comprise the large majority
prejudice the results. This is because of the possi- of cells in the tissues.
bility of antigenic differences among strains ob-
tained from different geographic regions.«lS)
Seroepidemiological studies have also been con-
4. Biology of the Cancer and the Virus
ducted recently with "nonvirion" or "early" anti-
gens of HSV-infected cells.'6.23,65) It must be borne
4.1. Cervical Cancer
in mind that until the results of these various tests
are confirmed in several laboratories, and prefera- Knowledge of the natural history of cervical
bly until the antigens being tested are character- cancer is of particular importance in delineating at
ized, these studies must be interpreted with cau- which phase a potentially oncogenic agent might
tion. act. Despite a large amount of research in this
c. Appropriate Controls. The problem of appro- area, controversial points still exist. For instance, it
priate controls for either seroepidemiological or is still not resolved whether dysplasia begins in a
prospective studies is critical. Because of the pos- single precursor cell or within a larger field of
sibility that genital HSV infection and cervical cells, and whether it spreads by multiplication of
'neoplasia may be coindependent, both tending to the single abnormal cell or by conversion of neigh-
be found in women whose sexual habits or those boring normal epithelium into dysplastic epithe-
of their consorts would enhance the likelihood of lium.(2(l.(;]) The various possibilities of the pro-
occurrence of the two entities, it is particularly gression from normal cells to invasive cancer
important to control for a variety of variables include (1) directly, (2) via dysplasia only, (3) via
related to sexual attributes. carcinoma in situ to invasion, or (4) via dysplasia
3.2.2. Detection of Virus or Virus Markers in to CIS to invasion. The evidence is strongest for
Cancer Cells. The induction of virus replication the fourth alternative, although the other path-
and its isolation in cervical cancer tissues or cells ways cannot be ruled out entirely.(2(H This pro-
in culture constitute the most direct approach. gression is suggested by the peak age distribution
However, such isolation does not necessarily es- of dysplasias, which precedes by several years that
tablish a causal role for HSV. It might also result for CIS, which in tum precedes by several years
from coincidental active HSV infection in a woman that for invasive cancer. Similar progression has
with cervical neoplasia, or from laboratory con- also been observed in mouse models in which
tamination of the cell culture by the virus. chemical carcinogens have been applied to the
Attempts to detect HSV antigens in exfoliated cervix. (121 Of special interest is the finding from
cervical cells or biopsy specimens can be per- these animal studies that the rate of progression
formed by immunofluorescent (IF) techniques. The depends on genetic features of the host and on the
indirect IF method has been applied to exfoliated frequency of application of the carc~nogen. It is
also accepted by most though not all investigators This concept would explain the peculiar suscep-
that dysplasias can regress in varying frequencies, tibility of the cervix to neoplastic transformation if
and that not all cases of carcinoma in situ progress it is assumed that the immature metaplastic epi-
to invasive cancer. (]4.2J.26) thelium is more sensitive to an oncogenic agent
There is now almost general acceptance of the like HSV than mature squamous epithelium. It is
concept that cervical neopl~sia usually begins in also attractive in offering an explanation for the
the region of the squamocolumnar junction, in disparity in frequency of cervical cancer and penile
accordance with findings from the early studies of cancer, despite the approximately equal frequen-
Pund and Auerbach. (55 ) Colposcopic examination cies of penile and cervical herpetic infections.
of the cervix reveals a transformation zone Vulvar carcinoma, although sometimes discovered
wherein the columnar epithelium is often replaced to be associated with cervical carcinoma/ 17l also
by squamous cells (metaplasia). It has not been occurs at a much lower frequency. Squamous me-
established whether the metaplastic cells originate taplasia, of course, does not occur in either penile
from embryonal rests of urogenital sinus epithe- or vulvar epithelium. It is worth noting here that
lium, directly from columnar cells, or from multi- female sexual contacts of males with penile cancer
potential "reserve" cells in the underlying stroma. show a higher frequency of cervical cancer than
The studies of Coppleson and Reid(14 ) indicate control women whose contacts do not have penile
that this normally occurring process of squamous cancer.C31l This suggests that the same oncogenic
metaplasia, which can be noted in varying fre- agents may be involved, even though the inci-
quencies in the cervix of women, occurs with dence of penile cancer is much lower.
highest frequency in association with the first
pregnancy. These authors concluded that dysplasia
and CIS do not originate from native squamous 4.2. Herpes Simplex Viruses
epithelium but rather from metaplastic cells. They
further postulated that transformation of meta- The biological characteristics of herpes simplex
plastic cells to atypical cells is caused by some viruses have already been described in Chapter 11.
oncogenic agent and proposed the scheme out- Of particular relevance to the coherence of a possi-
lined in Fig. 1. According to this concept, the ble role of HSV in cervical carcinogenesis was the
effect of the oncogenic agent, which might be need to establish that the cervix is indeed a com-
HSV, would be that of converting normal squa- mon site of infection by the virus. Several studies
mous metaplasia to atypical metaplasia. have confirmed this point, which was not well
squamou.:f::tt:laSia. ~
. . /
Virus?' ~
PhYSIOlogical MetaplaSia AtypiCal MetaplaSia Atypical Metaplasia
! ! !
Nonnal Squamous Dysplasia:;;,=====~·'Carcinoma in situ
Epithelium !
Invasive Carcinoma
!
Progression to Metastases
Fig. 1. Adaptation of the Coppleson-Reid hypothesis(l4) to the possible role of herpes-
viruses and host immune factors in cervical carcinogenesis. "The virus could act as an
inducer or promoter of cell transfonnation. Immune factors could operate in (1) prevent-
ing the establishment of initial atypical or dysplastic cells, (2) causing the regression of
dysplasia, (3) preventing progression from CIS to invasive cancer, or (4) influencing the
progression of invasive cancer and its metastasis to distant body sites.
appreciated previously, since cervical herpetic in- vivo studies, which of course cannot be used as
fections are most often subclinical and require proof of the oncogenic potential of HSV in hu-
laboratory methods for their detection. (27) Histo- mans, are possible differences in the oncogenic
pathological studies have also revealed that the potential of different strains of HSV and the low
virus commonly infects areas at or near the frequency of transformation obtained. (45.(;8) Tech-
squamocolumnar junction, the site of origin of nical variations may, however, account for these
most cervical neoplastic lesions. (48) results. Of possible relevance to the oncogenicity
The oncogenic potential of herpesviruses in gen- of HSV is the recent in vitro demonstration of
eral, and of HSV in particular, has only recently defective DNA in some of the virus strains.«;3)
been established. Since the 1960s, a large number A large number of seroepidemiological studies
of herpesviruses have been discovered from spe- have been conducted in several geographic areas
cies as widely different as fungi and man, and since the first three investigations were performed
include HSV-2 and the Epstein-Barr virus.(44) Sev- by the Baylor, Emory, and Hopkins groupS.(4.38.58)
eral herpesvirus infections of animals have been The different neutralization assays (kinetic neu-
associated with neoplastic disease.(44.s7) The evi- tralization, microneutralization potency, and mul-
dence for a causal relation of the herpesviruses to tiplicity analysis) and different HSV-1 and HSV-2
neoplasia, whether of lymphohematopoeitic or strains were employed. All three studies indicated
solid organs, varies from weak to strong. The that the frequency of HSV-2 antibodies is higher
point to stress, however, is that because herpesvi- in women with invasive cervical cancer than in
ruses have been definitely linked causally to can- control groups matched for age and socioeconomic
cer in some species all other herpesviruses are status. Variabilities in results were observed,
rendered suspect of the same capability. however. Thus two of the three studies showed a
More specifically in regard to herpes simplex higher frequency of HSV-2 antibodies in women
viruses, it has now been shown that when HSV-1 with intraepithelial neoplasia than that found in
or HSV-2 is inactivated by any of several methods the control group, whereas one did not. Further-
(ultraviolet, with or without antibodies, or photo- more, the percentage of women positive for HSV-2
dynamic inactivation), it can transform hamster antibodies by the use of the multiplicity analysis
embryonic cells in vitro. (29.56) This can also occur test in both the study and control groups was
with temperature-sensitive mutants of HSV-2.(29) higher than that found with the use of the other
The transforming event is apparently infrequent, two serological tests. In a later study, comparing
and some, but not all, of the in vitro transformed the multiplicity analysis tests with the microneu-
cells can cause tumors when inoculated into ham- tralization index (HSV-21HSV-1), the correlation
sters.
(S) Tumor-bearing hamsters have been between the two assays was very poor. (28)
shown to possess HSV antibodies in their serum In a limited number of studies, comparisons in
and HSV antigens can be demonstrated in a vary- titers between cancer and control women have
ing number of the tumor cells.(29,5(;) So far, viral- indicated higher mean titers in the cancer group,
specific RNA, but not DNA, has been detected in Such analyses also suggested that women with
some of the hamster tumors,CI3) In vitro cellular cervical cancer are infected earlier in life than
cytological transformation has also been accom- control women.(1.2) However, the problems asso-
plished with HSV-2 in other mammalian cellsY9) ciated with the serological tests have provided a
Sarcomas have been found at the site of inocula- major difficultly in the interpretation of results
tion of about 1% of newborn hamsters inocqlated obtained in seroepidemiological studies, as re-
directly with several strains of HSV-2.(4OJ Viral viewed elsewhere(2.34.46.s9) and as reported in
antigens have been detected in some of the trans- more recent studies. Cl8.24.28.32.51)
planted or cultured tumors.(45) A few mice geni- Another problem has been noted when women
tally inoculated with HSV-2 have developed cervi- in the control groups were found to have such a
cal neoplasia, although cervical cancers have also high frequency of HSV-2 antibodies that no signif-
been noted in mice treated only with female hor- icant excess could be detected in comparison to the
mones. (3(;.39) cancer cases. To circumvent this difficulty, we
Important points raised by these in vitro and in studied 57 women with CIS who were 21 yr of age
or younger, since the frequency of HSV-2 antibod- have been conducted by several groups. We are
ies in the 87 women in the control group of young currently engaged(43) in a follow-up study of
women was only 15%. The frequency of HSV-2 about 800 women whom we had identified over
antibodies in the CIS group of 65% constitutes a the years as having evidence of genital herpetic or
significant difference.(46) HSV-2 infection and of about the same number of
Even in studies in which the frequency of HSV- women who had no HSV-2 antibodies by our
2 antibodies was significantly higher than in con- assay (80--85% sensitivity and specificity). Both
trols, the percentage of those with antibodies in groups of women had cytologically negative
the cancer cases has been as low as 30-40%. smears for cervical abnormalities on entry into the
Together with negative studies in New Zealand, study. A higher frequency of severe cervical dys-
Israel, Colombia, and Taiwan, these findings pro- plasia and CIS has so far been detected in the
vide important questions to be resolved as regards herpes groups as compared to the control group.
the herpes/cancer association. Several explanations Preliminary evaluations of the two groups for
for these findings could be given and include (1) various epidemiological variables have not re-
the difficulty of detecting HSV-2 antibodies in vealed significant differences between the two
individuals with prior HSV-1 infection, (2) the groups, particularly as regards sexual and parity
possible variability in geographic strains of HSV, variables. Further follow-up and statistical evalua-
and (3) different causes of cervical cancer, of which tions should allow a firmer interpretation of the
HSV may only be one, and in which geographic results obtained in this ongoing study.
variabilities in causation may occur. Another approach has been used by Swedish
Another problem has been the selection of ap- workers who defined a group of women clinically
propriate controls. However, in several studies in diagnosed to have genital herpes between 1948
which the attributes of sexual promiscuity were and 1958 and a group of control women attending
equalized among cases and controls, significant the same clinics over this period in whom this
differences in the frequency of HSV-2 antibodies clinical diagnosis was not made.(2!i) The availabil-
in the two groups were still observed.(J.4.4(;) It can ity of a tumor registry in Sweden permitted these
be concluded that further seroepidemiological investigators to determine the number of women
studies based on case/control comparisons are unin the herpes and control groups who developed
likely to resolve the problem of the association cervical cancer in later years. A significantly
between HSV-2 and cervical cancer. Further serol- higher frequency of cervical cancer was observed
ogical approaches with this method would be in the herpes group, particularly in patients in
more advantageous only with the use of HSV type- whom genital herpes was diagnosed when they
specific antigens, when these become available, ot were 15-19 yr old. Major deficiencies with this
with well-characterized HSV cancer-related anti- approach are the lack of information regarding
gens. The investigation made with the "early" or subclinical genital herpetic infection in either
"nonvirion" antigens noted above would be more group, and the absence of information regarding
significant if these antigens could be better charac- possibly important epidemiological variables in
terized. the two groups.
Prospective studies of the incidence of cervical A third approach is to test sera collected and
cancer in relation to various risk factors could stored for other purposes. For instance, serum of
provide a different approach to this problem. women without evidence of cervical neoplasia had
Since the ideal prospective study, as described in been stored during the NIH Perinatal Viral Disease
detail elsewhere/ 43 ) would require very specific Study in Boston.oJ) Serum was then obtained
serological tests, as well as be extremely expen- around the time some of these same women were
sive, it would appear, at present, that such studies diagnosed as having CIS. Serial samples from
should await better technology. They would be women without cervical cancer were also available
particularly warranted if some method of prevent- for testing. The frequency of serological evidence
ing HSV infection (see Section 9) could be incor- of HSV-2 infection in women developing cancer in
porated in the overall investigation. situ was significantly higher than that noted in
Prospective studies of a less idealized nature control women.
5. Descriptive Epidemiology (prevalence) and those identified later (incidence).

The rates obtained in these surveys are generally
In the following section, the epidemiological 5--25 times higher than those obtained by inci-
patterns of cervical neoplasia are presented and dence statistics from cancer registries or special
compared, wherever possible, with the epidemiol- surveys. The longer the follow-up studies are con-
ogical patterns found with HSV-2 infection. Even ducted during such surveys, the closer the results
though the incidence and mortality rates for cervi- would reflect incidence rates. These cytological
cal neoplasia will be listed according to various studies have demonstrated several points of value:
attributes-geographic, socioeconomic, ethnic ori- (1) with single cervical cytological screening, up to
gin, etc.-the pivotal points will be tied up in the 1 % of women will be found with CIS or invasive
latter part of the discussion. cancer; (2) fewer invasive cancers are usually de-
tected on later screenings of the same women; (3)
women found to have cervical dysplasia in their
5.1. Incidence and Mortality Data
initial smears will have a higher likelihood of
The incidence of cervical cancer has been ascer- developing CIS or invasive cancer on later screen-
tained from time trends in mortality and by inci- ing than women with initially negative smears.
dence data obtained from national cancer surveys,
as well as from a number of cancer registries and
special studies performed in various areas. Most 5.2. Lifetime Risk
striking are differences in mortality and incidence It has been estimated from New York State
rates between the U.S. white and nonwhite popu- figures that the likelihood, from birth onward, of a
lation, the rates in nonwhite females being over woman developing cervical cancer is around
twice as high as those in white females. (3OJ A 2 %. (21) On the basis of various serological studies
reduction in the mortality rates for cervical cancer done in the United States, the probability of a
has been noted over recent years. Thus the rates woman developing HSV-2 infection in her lifetime
for 1950-1955 of 9.6 per 100,000 women for whites is 10-50%. As will be indicated later, both of these
and 22.6 per 100,000 for nonwhites declined to 5.8 probabilities depend on certain attributes of the
and 15.8, respectively, by 1967-1968.(28) woman. Nevertheless, these estimates suggest that
In 1961, cancer of the cervix represented almost if HSV-2 is indeed causally related to cervical
15% of the age-adjusted rate for total cancer deaths cancer, the case/cancer rate would be around 1:5 to
in nonwhite women, and less than 7% of cancer 1:25. This is of a much higher order, for instance,
deaths in white women. (21l Because of the de- than that postulated for the Epstein-Barr virus-
crease in mortality rate from cancer of the cervix in Burkitt lymphoma association in that the risk of
recent years and the increase in mortality rates of EBV infection is almost 100% while the risk of
other cancers in women, the proportion of deaths developing the tumor is approximately one in
attributed to cervical cancer is probably less than 10,000 in endemic areas.
half that in 1961. Thus, based on the NCI National
Cancer Survey, 7800 women are estimated to have
5.3. Age
died of cervical cancer in the United States in 1975.
The estimated number of new cases of invasive The incidence rate for CIS is highest in the 30-39
cancer is 19,000 for 1975. Since two or three cases yr age group and that for invasive cancer is high-
of carcinoma in situ have been found in recent est after the age of 40 yr. The age-adjusted inci-
years for every case of invasive cancer, the total dence of cervical cancer has almost doubled in the
number of new cases of cervical cancer in the United States since 1950 and is primarily due to in
United States can be estimated to have been situ cancer.(3OJ This may reflect the increased use
around 50,000 for 1975. of cytological screening. It could also be that,
Kesslet 28 ) has reviewed a number of commu- concomitant with the overall increase of gonorrhea
nity-based cytological surveys for cervical neopla- during this period, other venereally transmitted
sia during the past two decades. These surveys agents, such as HSV, may have been on the rise.
incorporate cases detected at the start of the survey Information of the incidence of both cervical can-
cer and HSV-2 in a country such as China, where 5.6. Ethnic or Religious Origin
venereal diseases are alleged to be on the decline,
would be of particular interest.
The lowest frequency of cervical cancer has been
noted in Jewish women and in Amish women in
5.4. Geographic Distribution the United States, and the highest frequency in
There are significant variations in the mortality black and Puerto Rican women.(3m American In-
and age-specific rates for cervical cancer in differ- dians also have a higher rate of cervical cancer
ent countries. Munoz(3fi) has separated countries than whites. In general, migrant women to the
into those of high risk, intermediate risk, and low United States have a lower mortality from cancer
risk. Among the high-risk countries are Colombia, of the cervix compared to U.S. native whites.
Chile, and Poland; in the intermediate-risk group However, excess mortality has been recorded in
are the Scandinavian countries and the United Mexican, Canadian, and Yugoslavian migrants to
States; in the low-risk group are Israel and New the United States.
Zealand. These differences may be due to a large
number of factors, including the extent of applica-
tion of early detection methods, sexual practices in
5.7. Other Variables
various socioeconomic levels, and other national
and cultural variables to be discussed below.
Within the United States, a higher mortality rate It was recognized over a century ago that celi-
for cervical cancer has been recorded generally in bate women, such as nuns, are very unlikely to
southern cities as compared to northern cities, the develop cervical cancer. (62) This point has been
lowest rate being found in the Northeast. Women confirmed in several recent studies. ((;4) We have
from urban counties have higher mortality rates found only one out of 34 nuns to have HSV-2
than those from suburban counties; women from antibodies; higher rates were found in all other
rural areas have higher rates than either urban or populations studied. Increased rates of cervical
suburban women. These differences may reflect cancer have been found in women with syphilis,
the availability of diagnostic and therapeutic facil- in prisoners, and prostitutes.( 4) The rate of HSV-
ities in different settings. 2 antibodies in prostitutes is very high, approach-
The frequency of HSV-2 antibodies has been ing 70%."(;)
determined in a relatively small number of adult Rotkin(64) has recently reviewed studies which
women between the ages of 30 and 50 yr in assayed the following variables: early marriage,
various countries. It was found to be 9-67% in the multiple marriages, broken marriage, early coi-
United States, 35% in Colombia, 50% in Taiwan, tus, multiple sexual consorts, coital frequency,
70% in Uganda, 13%-50% in Israel, 47% in Den- unstable sexual relationship, parity, gravidity and
mark, and 32% in Belgium. It should be reem- abortions, contraception, and circumcision. This
phasized that the methods used in the serological worker portrayed the relative strength, consist-
surveys differed greatly and that the composition ency, and inconsistency of accumulated trends for
of the populations serologically tested varied specific variables in a simplified table. A remarka-
widely. ble consistency was found for variables associated
with early onset of coitus, including early mar-
riage. Variables related to multiple sex partners
5.5. Socioeconomic Status
were also observed to be significantly increased in
Studies in the United States and abroad have women with cervical cancer as compared to con-
indicated that the highest incidence of cervical trols. Obstructive methods of contraception, in-
cancer is in women of the lowest economic cluding condoms and diaphragms, were more
groups. (7(;) A decreasing cancer incidence was widely used in controls than in cancer cases. The
noted with improved socioeconomic status. A hypothesis that noncircumcision of sexual consorts
similar relationship exists for HSV-2 infec- increases the risk of cervical cancer has not been
tions. (33) corroborated in the majority of recent studies.
6. Mechanisms and Routes of Transmission exception of cytomegaloviruses (CMV). Ultravi-

olet-inactivated CMV has been found to transform
hamster cells in vitro. (5ll One of three serological
One conclusion to be drawn from all of the studies(2o.fl9.74l noted a higher frequency of CMV
above studies is that the most important determi- antibodies in women with cervical cancer as com-
nant for cervical carcinogenesis is sexual inter- pared to controls, although the difference was less
course. These epidemiological findings strongly than that observed for HSV-2 antibodies.
support the concept that the oncogenic agent is Current knowledge on the epidemiology of gen-
acquired sexually, often during the period of ado- ital HSV infection (Chapter 11) fits well the epide-
lescence. Exposure to many males would increase miological pattern of the suspect factor. The virus
the likelihood of acquisition of oncogenic agents, has been demonstrated to be sexually transmitted.
although sexual contact with only one partner who The infection is particularly common in adoles-
had acquired the agent from other sources must cents and young adults, with a peak age of around
also be considered. It is unfortunate, incidentally, 19--20 yr. From a temporal viewpoint, this peak
that studies have infrequently been performed of age is several years earlier than that for cervical
the husbands or most usual male sexual contacts of dysplasia and cancer. The similarities in the epi-
women with either cervical cancer or genital HSV demiological patterns for genital HSV infection
and appropriate controls. and cervical cancer, however, provide one of the
The data noted earlier regarding geographic most difficult problems in establishing causality,
area, socioeconomic status, and ethnic origin are since it is well appreciated that an individual who
most likely related to the more critical factors acquires one venereally transmitted agent is likely
associated with sexual variables. Although the to be exposed to other agents, either concurrently
numbers of pregnancies and deliveries do not or at another time.
appear to contribute to an increased risk, little
attention has been paid to the age at first preg-
nancy. This is a more objective criterion than age
at first coitus. In addition, it may have significant 7. Pathogenesis and Immunity
bearing regarding the possible role of metaplasia
in cervical carcinogenesis because metaplasia oc- 7.1. Pathogenesis
curs with higher frequency in the first pregnancy
(see Fig. 1). The pathogenesis of preinvasive cervical neopla-
The epidemiological aspects of cervical cancer sia has been described in Section 4. Progression of
could thus fit several possible etiological agents, the invasive cancer occurs primarily by involve-
anyone of which could be introduced with sexual ment of contiguous areas and lymphatic channels.
intercourse. Epidemiological observations make it This local extension of the tumor and its conse-
unlikely that sperm would represent the oncogenic quent effects on the ureters, with subsequent
factor, as suggested by Copple son and ReidY4) urinary tract obstruction, infection, and uremia,
Smegma would also be an unlikely candidate in are the principal causes of death in patients with
view of the negative epidemiological data related advanced disease. Death often intervenes before
to circumcision. (fi4l Alexander(3l has recently re- the development of metastases to other organs.
viewed several candidate infectious agents other The pathogenesis of HSV in acute or recurrent
than HSV. These include Trichomonas vaginalis, infections has been discussed in Chapter 11. It is
Treponema pallidum, Neisseria gonorrhoeae, myco- amplified here to develop a possible scheme for
plasmas, chlamydiae, and cytomegaloviruses. The the events leading to cell transformation. Such a
relative frequency of genital infection with all of scheme, presented in Fig. 2, is based on a variety
these agents, except possibly T. pallidum, is higher of in vitro and in vivo animal or human observa-
than that for HSV. However, there is little epide- tions. It should be appreciated that several of these
miological or biological information on the onco- observations, as noted earlier, require confirma-
genic potential of any of these agents with the tion for validation.
/nitial Herpesvirus Infection
Intact Viral Genome Defec~ Viral Genome

~
Productive
1
Latent-----
------- :I
Infection Infection I
(Cells Killed) (Cells Initially I
Not Killed) I
~
Partial Viral
I
Genome in Nucleus
Cells Not Killed,

t
Partial RNf' Transcription
May Be Transformed I
Translatio~ of a Few Virus-Specified Proteins

(ACIF l}ntigens, Nonvirion Antigens ?)
•
Recurrent Stimulation of Antibodies to these
Antigens Resulting in the Detection of These
Antibodies in the Sera of Women with Cervi-
cal Cancer
Fig. 2. A tentative scheme of various herpesvirus/cell interactions.
Three types of cell/virus interactions can be serum antibodies on virus progeny. This scheme
considered: (1) a productive infection, which would also explain why, in some cases, HSV has
causes cell death and results in a subclinical or been isolated around, or after, the time of the
clinically apparent infection; (2) a latent infection, detection of the cervical neoplasia.'48) Another
with later reactivation of a presumably intact virus less likely possibility is that the virus could remain
genome resulting in a productive infection in latent in the cancer cell, as suggested by the still
mucocutaneous or ocular sites; (3) cell transforma- unduplicated recovery of HSV from a culture of
tion, wherein the cell survives and retains the CIS in one instance.'o)
ability to multiply, but may contain an incomplete Molecular hybridization studies in hamster tu-
viral genome having a limited capacity to be mors, produced after in vitro transformation with
expressed. inactivated HSV and in one human cervical cancer
The presence of defective viral DNA in some specimen, suggest the presence of incomplete viral
HSV strains has been demonstrated in vitro.'''") genome. In the hamster tumors, viral DNA has not
Ultraviolet irradiation and photodynamic inactiva- yet been demonstrated with molecular hybridiza-
tion, both of which can cause defects in the viral tion techniques which should be able to detect two
DNA, have been shown to cause the virus to or more viral genomes per cell (for comparison, ten
transform cells.'29.oHl The presence of latent HSV to more than 100 genomes have been detected
in human trigeminal and sacral ganglia has also with such techniques in EBV-transformed cells). A
been demonstrated recently. '7.8) It is possible that small amount of viral RNA has, however, been
a recurrent infection might be as important, if not demonstrated in some of the hamster tumors.'):lI
more important, than the initial infection in trans- In addition, in a still unconfirmed report (77 ) only
forming cells. The transforming event by the re- fractions of the HSV viral genome and viral RNA
current viral infection, or by the initial HSV-2 were detected in a human invasive cervical cancer
infection in an individual with prior HSV -1 infec- in which no infectious virus was demonstra-
tion, might also be enhanced by the effect of ble.''')1
Even if the viral DNA present in the tumor cells has been noted.<'4) Some evidence has also been
were only partially expressed, viral antigens still obtained, using in vitro assays, that lymphocytes
might be detectable in the tumors. Indeed, such or serum (plus complement) from women with
HSV antigens have been found in the in vitro or in cervical cancer can lyse cervical cancer target
vivo transformed hamster cells.(29.45.5(;) Of interest cells.(15.75) These and other assays are currently
is that only a small percentage of the cells demon- being used in several laboratories to study the
strate positive fluorescence by a variety of immu- immunology of cervical cancer and its association
nofluorescent assays, including the anticomple- with HSV.
ment immunofluorescent (ACIF) test. (45) Such a Results of testing for delayed hypersensitivity
test applied to 40 invasive cancer biopsies demon- with a variety of common skin test antigens, such
strated positive fluorescence in 25; the percentage as candida antigens, showed that there was no
of positive cells varied from 5% to 50%. No depression of skin reactivity until the women were
positive tests were obtained in 20 normal cervical in late stages of invasive cancer. (49)
specimens. In an earlier study, using the less
sensitive indirect IF tests, positive results were
obtained with exfoliated cells from women with
cervical neoplasia but not in biopsy specimens.(5)
Common antigens among cervical cancer tissues,
8.1. Clinical and Pathological Features
hamster tumors, and HSV-2 have also been re-
ported by the use of different serological tests/ 22 ) There are no symptoms characteristic of cervical
and "early" antigens have been detected in cervi- cancer. The most significant symptom is bleeding,
cal cancer tissues. (6) which occurs in some cases when the ~ancer
HSV antigens, expressed in tumor cells, might breaks through the protective epithelium. How-
be able to stimulate specific immune responses as ever, there may be extensive spread of the cancer
the transformed cells carrying them multiply. through the pelviS without any bleeding.
These antibodies might be less readily stimulated In case of intraepithelial cervical lesions (dyspla-
by productive infection, even with multiple re- sia or CIS), physical examination is usually nega-
currences. Thus women with cervical cancer might tive. Similarly, many cases of early invasive cancer
then be found to possess antibodies to these are clinically inapparent. Invasive cancer may
antigens in higher frequency than that occurring manifest itself as an erosion, an ulcer, and a mass
in women with primary or recurrent infections. with or without ulceration. The most readily diag-
This would explain the findings of a higher fre- nosed cervical cancer is that associated with an
quency of antibodies to "early" or "nonvirion" exophytic type of growth.
antigens reported by three groups of investiga- Dysplasia is a disturbance in the normal orderly
tors.,"·23.H5) It should be stressed that these results arrangement of cells in the epithelial lining of the
require confirmation, particularly since a member cervix and its glands, and can be further differen-
of one of the three groups reported that he could tiated into mild, moderate, or severe, according to
not reproduce initial positive observations."H" the extent of involvement of the surface epithe-
lium. When cellular alterations are noted through
the full thickness of the cervical epithelium, the
7.2. Immunity
process is classified as carcinoma in situ (intraepi-
As noted earlier, antibodies may playa role in thelial carcinoma, stage 0 carcinoma). The diagno-
increasing the potential of a transforming event. sis of invasive cervical carcinoma is made when
Immune mechanisms may also provide surveil- there is stromal penetration by the abnormal cells.
lance to remove transformed cells before they mul- For clinical, therapeutic, and prognostic purposes,
tiply. They may thus help in causing a regression invasive carcinoma is classified as stage I (con-
of some of the precancerous cervical lesions or in fined to the cervix), stage II (extending beyond the
delaying the progress of the tumor or its metas- cervix, but not to the pelvic wall or lower vagina),
tases (Fig. 1). The presence of mononuclear and stage III (extending to the pelvic wall or lower
plasma cells in precancer and invasive cancer sites third of the vagina), stage IV (with invasion of the
bladder or rectum, or with metastases beyond the creasing complement-dependent HSV antibodies
true pelvis). Subdivisions of stages I and II are also with progression of cervical neoplasia. f7o .7:l)
recognized for further refinement in clinical stag- Attempts have also' been made to determine if
ing of the disease. antibodies to various "nonvirion" or "early" HSV
It has been very difficult to determine the period antigens could be used prognostically. In one
of time required for progression of the cancer from analysis no significant difference was ob-
one stage to another in anyone individual. Lymph served.'2:l) The results of another investigation
node involvement occurs with increasing fre- suggested that antibodies to "nonvirion" antigens,
quency from stage Ion-about 15% in stage I, which were present in the sera of all women with
30% in stage II, and 50% in stage III. The extent of cervical cancer tested, were no longer detectable in
spread of cancer is limited in the majority of cases the sera of another group of women who had been
to involvement of pelvic structures, with perhaps treated.«;5) However, the inability of one of the
5% causing death rapidly by metastases.'21l The workers in the group to reproduce the test casts
low frequency of distant spread may be partially a doubt on this finding.«";) In another report, a
result of death from ureteral obstruction, hemor- small group of women with cervical cancer de-
rhage, infection, or intercurrent disease before tected with antibodies to "early" antigens were
metastastic involvement of vital organs. Immune noted to have lost their positive reactivity after
host factors might also be operative in preventing treatment. «;)
spread to distant body sites. Although metastases
are uncommon, they have been encountered with
increasing frequency in patients previously treated 9. Therapy and Control
for advanced cervical carcinoma. They can occur in
a large number of tissues, although the majority The possible approaches to control of cervical
are found in the lungs and liver."1l Local exten- cancer include (1) eradication of the causal
sion of the tumor is mainly in a lateral direction, agent(s), (2) prevention of transmission of the
rather than vertically. The ureters are most fre- disease, whether the causal agent(s) is known or
quently affected, the bladder is less commonly in- not, and (3) early detection of the disease and
volved, and intrinsic rectal involvement is unu- treatment, preferably in its preinvasive form. Of
sual. these three approaches, the most desirable in the
Squamous cell carcinomas comprise over 90% of long run is the first. As regards the second ap-
cervical cancers; adenocarcinomas and rare tu- proach, on the basis of the epidemiological evi-
mors, such as sarcomas, comprise the remainder. dence it is likely that sexual abstention could
The squamous tumors can be differentiated into prevent cervical cancer, but that approach is not
three histological grades: grade I, keratinizing very acceptable. The use of obstructive forms of
type; grade II, large cell nonkeratinizing; grade III, contraception, such as condoms, does not appear
small cell cancer. W ()) These types differ in their to be very practical or to be based on sufficient
frequency in that grade II is more common than evidence of success at present.
grade I, which in tum is more common than grade The third approach, which is the one currently
III. Their location in the cervix and their prognosis employed, is associated with a great number of
may differ, although data on these points are still problems. First, it requires that all women, from
limited. adolescence on, have repeat cytological screening
at frequent intervals. One of the major problems is
8.2. Serological Features that of obtaining pap smears on those women who
are at highest risk of developing cervical cancer.
One study attempting to relate the frequency of As such women are the least likely to seek preven-
HSV-2 antibodies to the grade of tumor presented tive services, this approach requires a great
limited evidence of a higher frequency of HSV-2 amount of public education and community effort.
antibodies in grade I and II cervical cancers."l3) A second problem is the enormous cost of routine
Some correlation has been found between increas- screening programs, which includes the cost of
ing HSV -2 neutralizing antibody titers and de- educating qualified personnel. This cost, in the
long run, would probably be less than that associ- be used to prevent recurrences, assuming that
ated with the hospitalization and treatment costs exogenous reinfection is an infrequent cause of
for invasive carcinomas and, of course, does not recurrences: (1) preventing the virus genome in its
enter into the discussion of the worth of a human latent site from becoming reactivated and (2) pre-
life. A third problem is that of the need of ade- venting the virus, once reactivated, from propa-
quate follow-up in mobile populations for fear of gating at the mucocutaneous or ocular site. The
progression to more serious forms. In this regard, former approach requires a better understanding
even though cervical conization or possibly of mechanisms of viral reactivation from the sen-
cryotherapy may be sufficient to treat severe dys- sory ganglia, and the latter demands improved
plasia or CIS in most cases, the problems of knowledge of the immunology of HSV infections.
adequate follow-up have forced many physicians Problems related to HSV vaccines which could be
to prefer hysterectomy for these lesions. One sug- used to prevent the initial infection have been
gested scheme for the "detection-follow-up-treat- discussed in Chapter 11. Other methods of control
ment-follow-up" approach has been de- that are of potential use in individual cases, but
scribed. (50) This scheme emphasizes all of the not in large numbers, are noted in that chapter,
problems at the human level, as regards necessary also.
health personnel and patient education, for its
satisfactory accomplishment.
The therapy for invasive cancer is still relatively 10. Unresolved Problems
individualized and consists of various forms of
surgical and radiological treatment. These methods 10.1. Control of Cervical Cancer with Available
can be found in standard textbooks. The value of Knowledge
such treatment is borne out by earlier data which
indicated that the 5-yr survival in untreated cases Control of cervical cancer requires a very large
was 5%, whereas today the overa1l5-yr survival is effort in education of the public and of health
around 40-50%.(21) The survival rates are greatly professionals, as well as a great outlay of support
dependent on the stage of the disease at which the on a continuous rather than spotty basis for rou-
diagnosis is first made. Thus intraepithelial cancer tine cytological screening. Many of these same
is virtually 100% curable and the 5-yr survival of problems would be encountered if an infectious
patients in stage I is around 90%. Survival rates agent, such as HSV, were found to be causally
decrease with eaCh stage, to reach ~10% for stage related.
IV cases. The value of adjunctive chemotherapy
and immunotherapy, under investigation in var-
10.2. Establishing a Causal Role of HSV in Human
ious centers, is still undetermined.
Carcinogenesis
Besides its importance in relation to the overall
concept of the possible viral causation of human Two types of approaches appear necessary to
cancers, the studies on the relation of HSV to establish that HSV plays a causal role in human
cervical cancer have had as their final goal the carcinogenesis. The first, mentioned earlier, is the
possibility that preventing the viral infection could development of methods for preventing HSV in-
prevent the cancer. Indeed, such a demonstration fections. This requires a better basic knowledge of
would provide the best evidence of causality. As viral proteins which are immunogenic, of the
noted in Chapter 11, two strategies can be used to mechanisms of latency, and of the immunology of
approach prevention: (1) preventing the initial HSV and of cervical cancer. The second approach
infection and (2) preventing the herpetic recurr- is a continued effort to employ every discipline,
ence. Accomplishment of the latter should dimin- from the molecular to the epidemiological, to pro-
ish the reservoir of infectious virus which could be vide evidence so overwhelming that a causal rela-
transmitted to other individuals. In addition, re- tion between HSV infection and cervical carci-
currences may actually be as important or more noma becomes as likely as that for cigarette
important in inducing cell transformation, if HSV smoking and lung cancer.(411 Confirmation of
is causally related (see Fig. 2). Two approaches can many of the preliminary findings, as noted in Fig.
2, is badly needed: Le., the presence of viral with cervical atypia and carcinoma in situ, J. Nat!.
genome and viral-specified antigens in the suspect Cancer Inst. 45:455-464 (1970).
human cancers and not in control tissues, and the 5. AURELlAN, 1., Virions and antigens of herpes virus
type 2 in cervical carcinoma, Cancer Res. 33:1539-1547
finding of a high frequency of antibodies to spe-
(1973).
cial well-characterized or type-specific HSV anti- 6. AURELIAN, 1., STRANDBERG, J. D., AND MARCUS, R. 1.,
gens in the sera of women with cervical neoplasia Neutralization, immunofluorescence and comple-
as compared to a well-controlled group of women ment fixation tests in identification of antibody to a
without cancer. In addition, the results of prospec- herpesvirus type 2-induced, tumor-specific antigen
tive studies in humans would provide important in sera from squamous cervical carcinoma: Immunol-
support. The definition of potentially oncogenic ogy of cancer, Prog. Exp. Tumor Res. 19:165-181 (1974).
and nononcogenic variants of HSV and the 7. BARINGER, J. R., AND SWOVELAND, P., Recovery of
delineation of the specific part of the viral genome herpes-simplex virus from human trigeminal gan-
glions, N. Engl. J. Med. 288:648-650 (1973).
related to oncogenicity should provide extremely
8. BARINGER, J. R., Recovery of herpes simplex virus
important information needed to resolve these
from human sacral ganglions, N. Engl. J. Med.
problems. 291:828-830 (1974).
Studies under way in monkeysc42l will provide 9. BOLTEN, K. A., Practical colposcopy in early cervical
very strong evidence of causality if it is found that and vaginal cancer, Clin. Obstet. Gyneco!. 10(4):808-
(1) genital inoculation of HSV-2 but not control 837 (1967).
material induces cervical neoplasia, (2) the cancers 10. BRODERS, A. C, Carcinoma in situ contrasted with
contain similar viral markers as those demon- benign penetrating epithelium, J. Am. Med. Assoc.
strated in in vitro transformed animal or human 99:1670-1674 (1932).
cells, and (3) the sera of tumor-bearing monkeys 11. CATALANO, 1. W.,JR., AND JOHNSON, 1. D.,Herpesvi-
rus antibody and carcinoma in situ of the cervix, J.
react with specific HSV antigens. Finally, it should
Am. Med. Assoc. 217:447-450 (1971).
be emphasized that, even if HSV-2 can be shown 12. CHRISTOPHERSON, W. M., Concepts of genesis and
to induce cervical cancer, the possibility of other development in early cervical neoplasia, Obstet. Gyne-
causes, including other infectious agents, cannot col. Survey 24(2):842-850 (1969).
be eliminated. 13. COLLARD, W., THORNTON, H., AND GREEN, M., Cells
transformed by human herpesvirus type 2 transcribe
virus-specific RNA sequences shared by herpesvirus
types 1 and 2, Nature (London) New Bio!. 243:264-266
ACKNOWLEDGMENTS
(1973).
14. COPPLESON, M., AND REID, B., Preclinical Carcinoma of
This work was supported by grants from the the Cervix Uteri, Permagon Press, Oxford, 1967.
American Cancer Society and the National Cancer 15. DISAIA, P. J., SINKOVICS, J. G., RUTLEDGE, F. N., AND
Institute. SMITH, J. P., Cell-mediated immunity to human ma-
lignant cells, Am. J. Obstet. Gyneco!. 114:979-989
(1972).
16. DUENAS, A., ADAM, E., MELNICK, J. 1., AND RAWLS,
11. References W. E., Herpesvirus type 2 in a prostitute population,
Am. J. Epidemiol. 95:483-489 (1972).
1. ADAM, E., KAUFMAN, R. H., MELNICK, J. 1., LEVY, A 17. FRANKLIN, E. W., III, AND RUTLEDGE, F. D., Epide-
H., AND RAWLS, W. E., Seroepidemiologic studies of miology of epidermoid carcinoma of the vulva, Ob-
herpesvirus type 2 and carcinoma of the cervix. III.- stet. Gynecol. 39:165-172 (1972).
Houston, Texas, Am. J. Epidemiol. 96:427--442 (1972). 18. FREEDMAN, R. S., JOOSTING, ACC, RYAN, J.T., AND
2. ADAM, E., RAWLS, W. E., AND MELNICK, J. 1., The NKONI, S., A study of associated factors, including
association of herpesvirus type 2 infection and cervi- genital herpes, in black women with cervical carci-
cal cancer, Prevo Med. 3:122-141 (1974). noma in Johannesburg, S. Afr. Med. J. 48:1747-1752
3. ALEXANDER, E. R., Possible etiologies of cancer of the (1974).
cervix other than herpesvirus, Cancer Res. 33:1485- 19. FRENKEL, N., ROIZMAN, B., CASSAI, E., AND NAHMIAS,
1496 (1973). A A DNA fragment of herpes simplex 2 and its
4. AURELIAN, 1., ROYSTON, I., AND DAVIS, H. J., Anti- transcription in human cervical cancer tissue, Proc.
body to genital herpes simplex virus: Association Nat!. Acad. Sci. USA 69:3784-3789 (1972).
20. FUCCILLO, D. A, SEVER, J. 1., MODER, F. 1., CHEN, T. 35. MUNOZ, N., Discussion on general aspects of cervical
c., CATALANO, 1. W., AND JOHNSON, 1. D., Cytome- cancer, Cancer Res. 33:1382-1384 (1973).
galovirus antibody in patients with carcinoma of the 36. MUNOZ, N., Effect of herpesvirus type 2 and hormonal
uterine cervix, Obstet. Gynecol. 38:599--601 (1971). imbalance on the uterine cervix of the mouse, Cancer
21. GUSBERG, S. B., AND FRICK, H. c., II, Corscaden's Res. 33:1504-1508 (1973).
Gyneccologic Cancer, 4th ed., Williams and Wilkins, 37. NAHMIAS, A. J., AND DOWDLE, W. R., Antigenic and
Baltimore, 1970. biologic differences in herpesvirus hominis, Prog.
22. HOLLINSHEAD, A. c., AND TARRO, G., Soluble mem- Med. Virol. 10:110-159 (1968).
brane antigens of lip and cervical carcinomas: Reac- 38. NAHMIAS, A J.,JOSEY, W. E., NAIB, Z. M., LUCE, C.F.,
tivity with antibody for herpes-virus nonvirion anti- AND GUEST, B. A., Antibodies to herpesvirus homin-
gens, Science 179:698-700 (1973). iss types 1 and 2 in humans. II. Women with cervical
23. HOLLINSHEAD, A c., LEE, 0., CHRETIEN, P. B., TAR- cancer, Am. J. Epidemiol. 91:547-552 (1970).
PLEY, J. 1., RAWLS, W. E., AND ADAM, E., Antibodies 39. NAHMIAS, A. J., NAIB, Z. M., AND JOSEY, W. E.,
to herpesvirus nonvirion antigens in squamous carci- Herpesvirus hominis type 2 infection-Association
nomas, Science 182:713-715 (1973). with cervical cancer and perinatal disease, Perspect.
24. JANDA, Z., KANDA, J., VONKA, V., AND SVOBODA, B., A Virol. 7:73-89 (1970).
study of herpes simplex type 2 antibody status in 40. NAHMIAS, A. J., NAIB, Z. M., JOSEY, W. E., MURPHY,
groups of patients with cervical neoplasia in Czecho- F. A, AND LUCE, C. F., Sarcomas after inoculation of
slovakia, Int. J. Cancer 12:626-630 (1973). . newborn hamsters with herpesvirus hominis type 2
25. JEANSSON, S., AND MOLIN, 1., Prospective study of strains, Proc. Soc. Exp. Bioi. Med. 134:1065--1069
clinically detected genital herpes in Sweden, pre- (1970).
sented at the International Cancer Congress, Florence, 41. NAHMIAS, A. J., NAIB, Z. M., AND JOSEY, W. E.,
Italy, 1974. Genital herpes and cervical cancer-can a causal rela-
26. JOHNSON, 1. D., The histopathological approach to tion be proven?-A review, in: Oncogenesis and Her-
early cervical neoplasia, Obstet. Gynol. Survey. pesviruses (P. M. BIGGS, G. DE-TaE, AND 1. N. PAYNE,
24(2):735--767 (1969). eds.), International Agency for Research on Cancer,
27. JOSEY, W. E., NAHMIAS, A. J., AND Z. M., Genital Lyon, 1971.
infection with type 2 herpesvirus hominis: Present 42. NAHMIAS, A. J., LONDON, W. T., AND CATALANO, 1.
knowledge and possible relation to cervical cancer, W., FUCCIELO, D.A., AND SEVER, J. 1., Genital herpes-
Am. J. Obstet. Gynecol. 101:711!--729 (1968). virus hominis type 2 infection: An experimental
28. KESSLER, I. I., Perspectives on the epidemiology of model in cebus monkeys, Science 171:297-298 (1971).
cervical cancer with special reference to the herpesvi- 43. NAHMIAS, A. J., NAIB, Z. M., JOSEY, W. E., FRANKLIN,
rus hypothesis, Cancer Res. 34:1091-1110 (1974). E., AND JENKINS, R., Prospective studies of the associ-
29. KIMURA, S., FLANNERY, V. 1., LEVY, B., AND SCHAF- ation of genital herpes simplex infection and cervical
FER, P. A, Oncogenic transformation of primary ham- anaplasia, Cancer Res. 33:1491-1497 (1973).
ster cells by herpes simplex virus type 2 (HSV-2) and 44. NAHMIAS, A. J., The evolution (evovirology) of her-
HSV-2 temperature sensitive mutant, Int. J. Cancer pesviruses, in: Viruses, Evolution and Cancer (E. KUR-
15:786-798 (1975). STAK AND K. MARAMOROSCH, eds.), pp. 605--624, Aca-
30. LILIENFELD, A. M., LEVINE, M. 1., AND KESSLER, I. I., demic Press, New York, 1974.
Cancer in the United States, Harvard University Press, 45. NAHMIAS, A., IBRAHIM, I., AND DELBUONO, I., Anti-
Cambridge, Mass., 1972. genic relation between herpes simplex viruses, hu-
31. MARTINEZ, I., Relationship of squamous cell carci- man cervical cancer and HSV-associated hamster tu-
noma of the cervix uteri to squamous cell carcinoma of mors, in: Herpesviruses and Oncogenesis, Vol. 2, in
the penis, Cancer 24:777-780 (1969). press, 1975.
32. McDONALD, A. D., WILLIAMS, M. c., MANFREDA, J., 46. NAHMIAS, A. J., NAIB, Z. M., AND JOSEY, W. E.,
AND WEST, R., Neutralizing antibodies to herpesvirus Epidemiological studies relating genital herpetic in-
types 1 and 2 in carcinoma of the cervix, carcinoma in fection to cervical carcinoma, Cancer Res. 34:1111-
situ and cervical dysplasia, Am. J. Epidemiol. 100:130- 1117 (1974).
135 (1974). 47. NAIB, Z. M., NAHMIAS, A. J., AND JpSEY, W. E.,
33. MELNICK, J. 1., AND RAWLS, W. E., Herpesvirus type 2 Cytology and histopathology of cervical herpes sim-
and cervical carcinoma, Ann. N.Y. Acad. Sci. 174:993- plex infection, Cancer 19:1026-1031 (1966).
998 (1970). 48. NAIB, Z. M., NAHMIAS, A J., JOSEY, W. E., AND ZAKI,
34. MELNICK, J. 1., ADAM, E., AND RAWLS, W. E., The S. A, Relation of cytohistopathology of genital her-
causative role of herpesvirus type 2 in cervical cancer, pesvirus infection to cervical analplasia, Cancer Res.
Cancer 34:1375--1385 (1974). 33:1452-1463 (1973).
49. NALICK, R. H., DISAIA, P. J., REA, T. H., AND MOR- searches for transmissible agents, Cancer Res.
ROW, M. H., Immunological response in gynecologic 33:1353--1367 (1973).
.malignancy as demonstrated by the delayed hyper- 65. SABIN, A. B., AND TARRO, G., Herpes simplex and
sensitivity reaction: Clinical correlations, Am. J. Ob- herpes genitalis viruses in etiology of some human
stet. Gynecol. 118:393--405 (1974). cancers, Proc. Natl. Acad. Sci. USA 70:3225-3229
50. NELSON, J. H., JR., AND HALL, J. E., Detection, diag- (1973).
nostic evaluation, and treatment of dysplasia and 66. SABIN, A. B., Herpes simplex-genitalis virus non-
early carcinoma of the cervix, Ca.-Cancer ]. Physi- virion antigens and their implication in certain hu-
cians 20:150-163 (1970). man cancers: Unconfirmed, Proc. Nat!. Acad. Sci. USA
51. ORY, H., CONGER, B., RICHART, R., AND BARRON, B., 71:3248--3253 (1974).
Relation of type 2 herpesvirus antibodies to cervical 67. SCHNEWEIS, K. E., Serologische Untersuchungen zur
neoplasia in Barbados, West Indies, 1971, Obstet. Gy- Typendifferenzierung des Herpesvirus hominis, Z.
necol. 43:901-904 (1974). Immunitaetsforsch. 124:24--48 (1962).
52. PAPANICOLAOU, G. N., AND TRAUT, H. F., Diagnosis of 68. SETH, P., RAWLS, W. E., DUFF, R., RAPP, F., ADAM, E.,
Uterine Cancer by the Vaginal Smear, Commonwealth AND MELNICK, J. L., Antigenic differences between
Fund, New York, 1943. isolates of herpesvirus type 2, Intervirology 3:1-14
53. PLUMMER, G., Serological comparison of the herpesvi- (1974).
ruses, Br. ]. Exp. Pathol. 4.5:135-141 (1964). 69. SPRECHER-GOLDBERGER, S., THIRY, L., LEFEBVRE, N.,
54. PLUMMER, G., A review of the identification and titra- DEKEGEL, D., AND DEHALLEUX, F., Complement-fixa-
tion of antibodies to herpes simplex viruses type 1 tion antibodies to adenovirus-associated viruses, ad-
and type 2 in human sera, Cancer Res. 33:1469-1476 enoviruses, cytomegaloviruses and herpes simplex
(1973). viruses in patients with tumors and in control indi-
55. PUND, E. R., AND AUERBACH, S. H., Preinvasive carci- viduals, Am. ]. Epidemiol. 94:351-358 (1971).
noma of the cervix uteri, J. Am. Med. Assoc. 131:960- 70. SPRECHER-GOLDBERGER, S., THIRY, L., GOULD, I., FAS-
963 (1946). SIN, Y., AND GOMPEL, c., Increasing antibody titers to
56. RAPP, F., AND DUFF, R., Transformation of hamster herpes simplex virus type 2 during follow-up of
embryo fibroblasts by herpes simplex viruses type 1 women with cervical dysplasia, Am. ]. Epidemiol.
and type 2, Cancer Res. 33:1527-1534 (1973). 97:103--110 (1973).
57. RAPP, F., Herpesviruses and cancer, Adv. Cancer Res. 71. SPJUT, H. J., AND FECHNER, R. E., Cytologic diagnosis
19:265-302 (1974). of cervical dysplasia and carcinoma in situ, Clin. Ob-
58. RAWLS, W. E., TOMPKINS, W. A. F., AND MELNICK, J. stet. Gynecol. 10(4):785-807 (1967).
L., The association of herpesvirus type 2 and carci- 72. STAFL, A., FRIEDRICH, E. G., AND MATTINGLY, R. F.,
noma of the uterine cervix. Am. ]. Epidemiol. 89:547- Detection of cervical neoplasia: Reducing the risk of
554 (1969). error. Ca.-Cancer J. Physicians 24(1):22-30 (1974).
59. RAWLS, W. E., ADAM, E., AND MELNICK, J. L., An 73. THIRY, L., SPKECHER-GOLDBERGER, 5., FASSIN, Y.,
analysis of seroepidemiological studies of herpesvirus GOULD, I., GOMPEL, c., PESTIAU, J., AND DEHALLEUX,
type 2 and carcinoma of the cervix, Cancer Res. F., Variations of cytotoxic antibodies to cells with
33:1477-1482 (1973). herpes simplex virus antigens in women with pro-
60. REAGAN, J. W., AND WENTZ, W. B., Genesis of carci- gressing or regressing cancerous lesions of the cervix,
noma of the uterine cervix, Clin. Obstet. Gynecol. Am. ]. Epidemiol. 100:251-261 (1974).
10(4):883--921 (1967). 74. VESTERGAARD, B. F., HORNSLETH, A., AND PEDERSEN,
61. RICHART, R. M., Natural history of cervical intraepi- S. N., Occurrence of herpes and adenovirus antibod-
thelial neoplasia, Clin. Obstet. Gynecol. 10(4):748--784 ies in patients with carcinoma of the cervix uteri,
(1967). Cancer 30:68--74 (1972).
62. RIGONI-STERN, D., Fatti statistici relativi aile malattie 75. WEINTRAUB, I., KLISAK, I., LAGASSE, L. D., AND By-
cancrose che servirono di base alle poche cose dette FIELD, J. E., Evidence for specific tumor cytotoxic
dalDott. G. Servire, Prog. Pathol. Terap. Ser. 2:507- antibodies in serum of cervical cancer patients, Am. J.
517 (1842). Obstet. Gynecol. 116:985-992 (1973).
63. ROIZMAN, B., AND FURLONG, D., The replication of 76. WYNDER, E. L., Epidemiology of carcinoma in situ of
herpesviruses in: Comprehensive Virology, Vol. 3 (H. the cervix, Obstet. Gynecol. Survey 24(2):697-711
FRAENKEL-CONRAT AND R. R. WAGNER, eds.), pp. 229- (1969).
403, Plenum, New York, 1974. 77. ZUR HAUSEN, J., SCHULTE-HoLTHAUSEN, H., WOLF,
64. ROTKIN, I. D., A comparison review of key epidemiol- H., DORRIES, K., AND EGGER, H., Attempts to detect
ogical studies in cervical cancer related to current virus-specific DNA in human tumors. II. Nucleic acid
hybridizations with complementary RNA of human COPPLESON, M., AND REID, B., Preclinical Carcinoma of the
herpes group viruses, Int. J. Cancer 13:657-664 (1974). Cervix uteri, Pergamon Press, Oxford, 1967.
Clin. Obstet. Gynecol. 10(4):741-1049 (1967).
LEVINE, P. H., GAYLORD, C. E., AND BURTON, G. J., eds.,
International Symposium on Human Tumors Associ-
12. Suggested Reading ated with Herpesviruses, Cancer Res. 34:1083-1244
(1974).
Conference on Early Cervical Neoplasia, Obstet. Gynecol. Symposium on Herpesvirus and Cervical Cancer, Cancer
Survey 24(2):675--1048 (1969). Res. 33:1345--1563 (1973).
CHAPTER 24
Chronic
Neurological
Diseases:
Subacute Sclerosing Panencephalitis, Progressive
Multifocal Leukoencephalopathy, Kuru,
Creutzfeldt-Jakob Disease
Jacob A. Brody and Clarence Joseph Gibbs, Jr.
1. Introduction might have infection as their etiology was not

recognized until the subacute progressive degen-
Most subacute and chronic progressive degenera- erative heredofamilial disease kuru was transmit-
tive diseases of the central nervous system of man ted to chimpanzees and was subsequently shown
have been classified as disorders of unknown to be serially transmissible in experiment!!l ani-
etiology. Few if any are curable, and, although mals inoculated with bacteria-free filtrates of brain
some are genetically determined, most are spo- tissues from animals dying with the disease. Kuru
radic in occurrence and there appears not to be a thus became the first subacute fatal central nerv-
history of the disease in close relatives. That any ous system disease of man to have a virus-induced
one or more of these chronic idiopathic disorders "slow infection" established as its etiology.
Even though the possibility of a virus etiology
Jacob A. Brody . Senior Research Epidemiologist, Na- for kuru was postulated early in the discovery of
tional Institute of Neurological and Communicative Dis- the disease, the lack of febrile response or acute
orders and Stroke, National Institutes of Health, Be-
inflammatory lesions and the failure to detect
thesda, Maryland Clarence Joseph Gibbs, Jr. .
Laboratory of Central Nervous System Studies, National abnormal clinical, chemical, or hematological val-
Institute of Neurological and Communicative Disorders ues at any stage of the disease in man did not
and Stroke, National Institutes of Health, Bethesda, support this hypothesis. Nevertheless, it was the
Maryland elucidation of the viral etiology of kuru that led to
519
520 Chapter 24 • Chronic Neurological Diseases
Table 1. Slow Infections Caused by tional" viruses, viruses which can be visualized by
Unconventional Viruses electron microscopy, induce specific antigen/anti-
body reactions, and have either an RNA or a DNA
Man type of nucleic acid. In Table 2 are·listed a number
Kuru
of "slow infections" of man which are caused by
Creutzfeldt-Jakob disease
conventional viruses.
Animals
Scrapie That conventional viruses can and do cause
Mink encephalopathy diseases associated with long incubation periods,
chronic diseases, persistent infections, and di-
seases with varied pathological reactions has been
known since the dawn of classical virology. What
the discovery that both the familial and sporadic is new is the establishment of an unconventional-
types of Creutzfeldt-Jakob disease (CJD) were type virus etiology for heredofamilial and presen-
caused by a virus that is transmissible to subhu- ile dementias of man as well as the isolation of
man primates. CJD thus became the first presenile conventional viruses from the brains of patients
dementia of man to have an established viral with chronic neurological disorders months to
etiology. years after initial contact with the invading virus.
The transmissible agents of kuru and Creutz- In this chapter, we present information on two
feldt-Jakob disease share biological, physical, and diseases of the central nervous system caused
chemical properties with those of scrapie and by "conventional viruses," subacute sclerosing
transmissible mink encephalopathy and have been panencephalitis caused by defective measles virus
classified as prototype viruses of the subacute and progressive multi focal leukoencephalopathy
spongiforrn virus encephalopathies (Table 1). Be- caused by papovaviruses, and two diseases of the
cause of their unusual properties, they have been central nervous system of man caused by "uncon-
referred to as "unconventional viruses." They are ventional viruses," kuru and Creutzfeldt-Jakob
unconventional in that they do not induce inflam- disease.
matory lesions, are thermostable, have not yet
been shown to induce an immune response, are
resistant to ultraviolet light, and have not yet been
2. Subacute Sclerosing Panencephalitis
associated with a nucleic acid type.
There are, however, other slow infections of the
2.1. Introduction
human brain which, subsequent to work on kuru
and CJD, have been shown to have a virus etiol- Subacute sclerosing panencephalitis (SSPE) is a
ogy. These are slow infections caused by "conven- progressive, fatal disease of the central nervous
Table 2. Slow Infections Caused by Conventional Viruses
Disease Virus
Subacute sclerosing panencephali tis (SSPE) Measles

Subacute postmeasles leukoencephalopathy Measles
Multiple sclerosis (Measles?)
Progressive multifocalleukoencephalopathy (PML) Papovaviruses (JC and SV40 re-
lated)
Progressive congenital rubella Rubella
Cytomegalovirus brain infection Cytomegalovirus
Subacute encephalitis Herpes simplex Adenovirus
type 32
Homologous serum jaundice Echovirus
Infectious hepatitis Hepatitis B
Hepatitis A
Chapter 24 • Chronic Neurological Diseases 521
system, affecting children and young adults. The way causally involved, and even if there is a
virus is etiologically related to the measles virus or secondary precipitating virus the critical factor
a close variant, and as such is easier to work with involves the host response to natural measles,
using conventional laboratory methods than the which permits the establishment of a chronic in-
other three diseases discussed in this chapter. This fection, rather than the properties of the virus
has resulted in voluminous literature on SSPE, and itself.
in attempting to present the epidemiological pic-
ture the authors were forced to be selective in both
the data presented and the references cited. 2.5. Descriptive Epidemiology
SSPE is a rare disease with fewer than 40 new
patients reported per year in the United States.
2.2. Historical Background Accepting the limitations of diagnosis and report-
ing, the published rates have varied from section
Subacute sclerosing panencephalitis was first
to section and from country to country from 0.12 to
described by Dawson in 1933 and then again by
1.4 per million. (44.57) The disease appears to be
von Bogaert in 1945. In 1965, a pseudomyxovirus
worldwide in distribution. There is a suggestion
was observed in brain tissue of SSPE patients by
in the United States that rates are higher in the
electron microscopy, and in 1967 a very high
Southeast.(44) For the most part, rates are either
measles antibody titer was demonstrated in the
stable over time or declining. Exceptions to this
cerebrospinal fluid (CSF) and in serum. The pub-
have been noted in New Zealand(4) and South
lished proceedings of an international conference
Africa/ 57 ) where a gradual increase over time was
on SSPE reviewed the state of knowledge through
found.
1967.(68) Subsequently, the virus was isolated
Almost all authors have observed a nonurban
from brain tissue by various groups, and numer-
preponderance of cases.(17) While some series
ous surveys and clinical and laboratory studies
have not revealed a striking difference, the obser-
have been conducted.
vation merits increased credence since the diagno-
sis of SSPE is made only in urban centers. In
virtually all series, males have outnumbered fem-
2.3. Methodology ales in a ratio of 3:1, or greater. (44) The mean age
The largest single source of epidemiological data at onset is generally about 7 yr, with a range of 2-
is a registry started by Jabbour et al. in 1969.(44) 21 yr. The great majority of cases occur between
Its chief shortcoming is that it is dependent on ages 4 and 12. Although data on race are not
voluntary submission of data from medical centers definitive, SSPE has been reported in all ethnic
throughout the United States. Various forms of groups studied.
registries have been initiated in other countries. There are several reports that SSPE occurs more
Other sources of data are found in numerous case frequently in families of lower socioeconomic
reports and series from clinical centers since 1933. level, although there are many exceptions to this
One case/control study has been completed with observation. Cases tend to occur in large sibships.
the obvious limitations of numbers of patients and In a study of 43 patients, median birth order was
choice of controls. (m fourth, and for their controls it was third.(m
There are several reports of SSPE developing in
children following exposure to sick animals, pri-
marily dogs and fowl.(12.1;J.17.W) Some credence to
2.4. Biological Characteristics of the Virus
these observations emerged from a case/control
There is still dispute as to whether the SSPE study in which the controls were matched by
virus is classical measles virus or a variant. If it is a having been lifelong friends of the patients. Pa-
variant, this could of course affect the epidemiol- tients had significantly more exposure through
ogical pattern. There are also suggestions that a contact ;yith fowl, primarily chickens, or with
second virus or other triggering events are in- dogs which died of distemper or a distemperlike
volved etiologically. The bulk of the evidence illness.(m These authors also report a cluster of
indicates that the natural measles virus is in some three patients within a ten-block area near St.
Louis in 1968, immediately following a distemper measles virus, and most survived. The challenge
epidemic in the same region. CI7 ) apparently produced a latent infection in the ham-
Multiple cases of SSPE have been reported but sters. After 1 month, the animals were given an
are rare. There is also a report of SSPE occurring in immunosuppressive drug and rapidly developed
only one of a set of identical twins. cS2 ) Measles fatal measles encephalitis. c7!Jl
antibody titers among siblings of patients are
within the normal range. CS .4o ) These observations
argue against genetic factors as playing an impor- 2.7. Patterns of Host Response
tant role.
While laboratory data are considerable, some of
the observations are unconfirmed, and in a sense
2.6. Pathogenesis and Immunity the implications of various reports are contradic-
tory. Epidemiological observations may prove of
Clinically and pathologically, the disease is considerable importance in elucidating the patho-
primarily a sclerosing encephalitis. In some in- genesis of SSPE and possibly in clarifying the
stances, the rapidly progressive phase of the dis- implications of the available laboratory data. We
ease with paralysis myoclonus and dementia is have already alluded to the observation that it is a
preceded by a variable period of unusual behavior disease of childhood with a considerable male
or deterioration of learning ability at school. The excess and for the most part confined to nonmetro-
diagnosis is frequently made clinically, and is politan areas. A key finding was that in a large
readily confirmed by finding very high measles proportion of SSPE patients measles occurred very
antibody titer in the serum and the presence of early in life. (7 ) This finding was subsequently
measles-specific antibody in CSF. The virus can be confirmed by the observation that in the United
seen by electron microscopyWS) and with special States 55% of 198 patients with SSPE had measles
techniques has been isolated from all portions of under age 2 yr. (44 ) In Finland, 12 of 14 patients
the brainc43.(3) and on two occasions early in the had measles between 6 and 24 months of age. C1S )
course of the disease from biopsies of lymph In a case/control study of 42 patients, the mean age
nodes. (42 ) In addition, immune complexes con- at measles infection was 15 months among SSPE
taining measles antigen, complement, and IgG patients and 48 months in controls. cI7 ) In this
have been found in organs throughout the latter series, 11 patients had no history of measles
body. CHi) The virus apparently multiplies in the and 12 had measles under age 1 yr. Those with no
presence of extraordinarily high amounts of mea- history of measles had known household expo-
sles antibody in the CSF and serum. IgM as well as sure, and measles antibody titer was present in the
IgG is present in these fluids. Clo) In addition, same range as in other SSPE patients. Presumably
some authors have found in blood and spinal fluid some of these had measles so early in life that
of patients with SSPE specific blocking factors of there was sufficient passively acquired maternal
celblar immunity to measles. (73 ) antibody to modify the clinical manifestations of
There is an observation by electron microscopy the disease. Thus early onset of measles, perhaps
of a papova-like virus associated with the myxovi- in the presence of maternal antibody, which inter-
rus in the brain of an SSPE patient. Coll SSPE virus, fered with the normal complete host response,
but not measles virus, has produced a subacute may have permitted the measles virus to establish
encephalitis in dogs/ 42 ) calves, and lambs (74 ) in itself as a chronic infection. This led to the specu-
the absence of a detectable serological response. lation that an unusual measles infection in some
There appears to be an encephalitogenic factor for way contributed to the development of SSPE.
ferrets C4!).7l;) and hamsters, and in rats an encepha- Since early age of measles was not observed in
litis was produced by inoculation at a critical about half of the SSPE patients, other factors
age. C11l attendant on the measles infection may exist
Adult female hamsters were immunized with which permit the virus to become established as a
measles virus and subsequently bred. At 48-72 h chronic infection. The only suggestion of such a
after birth, the offspring were challenged with factor thus far has been the observation in one
study that a significant excess of patients had above, it seems unlikely that measles vaccine is
chickenpox (six of 31) immediately prior to the the cause of SSPE, and the likelihood that the asso-
onset of measles."71 ciation that has been noted is coincidental, result-
The observation that an aberrant immunological ing from the fact that the median age at onset of
host response to measles is etiologically involved SSPE is about 7 yr, which coincides with the time
is supported by the finding in one large series that when school vaccination programs are conducted.
the interval between measles and SSPE is nonran- Of potentially greater importance is the role of mea-
dom and fairly close to 6 yrym Laboratory data sles vaccine in preventing unusual cases of natural
suggesting altered globulin fractions, immune measles and actually diminishing the rate of SSPE
globulin complexes, and specific serum and CSF or even eliminating the disease. Some evidence of a
factors which inhibit cellular immunity to measles decline in the number of new cases of SSPE has
virus in SSPE patients also support this concept. been observed in recent years, and while the data
Depressed skin reactivity to test antigens and are far from solid they may indeed reflect the bene-
reduced IgA levels have been reported.(3Jl ficial effects of measles vaccination on SSPE.(44)
The observation that SSPE occurs primarily in
nonurban males m .13 .17 .44) has prompted several
workers to suggest that the unusual measles infec- 2.9. Unresolved Problems
tion is a priming event but a second triggering
event initiates the process of cellular destruction in While far more is known about SSPE than other
the central nervous system. It is probable that slow virus diseases of man, the basic questions of
early onset of measles and events such as chicken- etiology and pathogenesis are not yet solved.
pox preceding measles infection occur more fre- There is no consensus on whether the SSPE virus
quently in urban inner-city populations, which is the measles virus or a central nervous system
seem to be relatively immune to SSPE. It is con- adapted strain or a related virus. If an induced
ceivable that repeated exposure to measles at an aberrant host response occurs, as would appear to
early age, which also occurs more frequently in be the case, it is critical to understand the patho-
urban settings, could convert an incomplete host genesis and to determine whether a secondary
response to a complete one, thus protecting the triggering event is necessary for development of
child from subsequent SSPE. An equally compel- the disease. While SSPE is an extremely rare con-
ling argument is that the group at highest risk, the dition, elucidation of the mechanisms involved
nonurban males, are exposed to higher doses of may provide a model for better understanding of
numerous environmental factors including zoon- such diseases as multiple sclerosis, connective tis-
otic infections. Support for this latter thesis that
(8)
sue disorders, and even cancer.
a triggering event occurs following the unusual
measles infection is (1) more frequent contact with
sick fowl and dogs, (2) the observation of a second
virus in the central nervous system in an SSPE 3. Progressive Multifocal
patient, and (3) the observation that an immuno- Leukoencephalopathy
suppressive drug precipitated a latent measles in-
fection into a fatal measles encephalitis in ham-
3.1. Introduction and Historical Background
sters.
Progressive multifocal leukoencephalopathy
(PML) is a rare and unusual demyelinating disease
first described in 1958. It almost invariably occurs
2.8. Control and Prevention
in patients with other severe diseases, usually
There are reports of SSPE developing shortly those that affect the reticuloendothelial system.
after measles vaccination. Current scientific infor- Thus far, approximately 100-150 cases have been
mation cannot rule out this possibility, and sur- described. Early authors postulated a viral etiol-
veillance programs have been instituted to clarify ogy,";4) and papova-like virions were seen by
it. In view of the data and concepts expressed electron microscopy first in 1964(8:)) and subse-
quently by many other neuropathologists. Isola- occurred or who is at risk. The JC strain has been
tion of papovaviruses from brain material was found capable of inducing brain tumors in ham-
reported in the early 1970s. we .B()) sters. (78)
3.2. Methodology 3.4. Descriptive Epidemiology
The only available sources for morbidity and Limited epidemiological information is available
mortality data are case reports and reviews of the from the 150 or so documented cases. Apparently
literature. The two most recent and complete stud- occasional cases go undiagnosed, but extensive
ies to our knowledge are by ZuRhein(B3) and retrospective reviews of brains of patients who
Brun et al. (IOJ There have been several serological died in large clinical centers of leukemia or lym-
surveys in patients and in the general population phoma detected only a handful of previously undi-
for papovaviruses.(29.fil.H9) The viruses have been agnosed PML cases.(B3) Patients have thus far
recovered from human brain material either by been reported in the United States, Canada, most
inoculating homogenated brain tissue into mono- European countries, Israel, Australia, and Japan.
layers of human fetal brain cells(fie) or by using The disease is very rare under age 30; the earliest
dispersion cultures of brain cells fused to African case was reported by Castaigne et al. (14) in an 18-
green monkey kidney cells.(8m These isolation yr-old male who was diagnosed as having PML
procedures are cumbersome, and rapid identifica- and multiple astrocytic tumor nodules in the white
tion of the virus in brain cells has been achieved matter of the brain. The oldest known patient was
by preparing specific sera to the virus strains and 84. The great majority of cases occur from the fifth
using fluorescent antibody or electron microscopic to the seventh decade of life. There appears to be a
agglutination. (BIl slight excess of cases among males of about 1.5:1.
Occupation was recorded for about 30 patients.
Since this was a highly selected group seen ulti-
mately by a neuropathologist, the information is of
limited value. While most of the patients were
In recent years, viruses have been identified in white-collar workers, some at the executive level,
13 PML patients.(5B) Two have been indistin- farmers and people engaged in outdoor occupa-
tions were represented.(B3)
guishable from SV40, a simian papovavirus, while
the remaining 11 have been the JC virus isolated
from a patient in Wisconsin. wZ ) Another human
papovavirus, the BK virus isolated in England 3.5. Pathogenesis and Immunity
recently(30) from the urine of an immunosup-
pressed renal transplant patient, has not been Papovavirus infections without known illness
encountered in PML. Serological surveys have in- are very common as shown by antibody surveys
dicated that infections with JC and BK viruses are but PML is extremely rare. More than half of the
very common, with the majority of adults having known patients have had malignant lymphoproli-
antibody.(29.(iJ) SV40 virus antibody has been ob- ferative diseases, including lymphosarcoma. Non-
served in a small percentage of humans who lymphoproliferative diseases such as chronic and
received poliomyelitis vaccine contaminated with acute myelogenous leukemia and carcinomatosis
this virus, and also in about 3% of humans who and benign disease of the reticuloendothelial sys-
were not vaccinated against poliomyelitis. om) tem, especially tuberculosis and sarcoidosis, make
PML patients in whom virus has been identified up the bulk of the residual cases. There are reports
do not invariably possess antibody at a detectable of PML developing up to 30 yr after pulmonary
level. (5B) This may be a result of their generally anthracosilicosis, chronic bronchitis and asthma,
depressed immunological status or immune com- idiopathic thrombocytopenic purpura, and lupus
plex formation. Thus it is difficult from serological erythematosus. Recently there have been several
data to determine how and when the infection reports of PML following renal transplants.(52."a,B4 1
There are three cases in which the only prior standing of diseases which develop in hyporeac-
pathology was senility or severe arterioscle- tive immune states.
rosis.(83) There are at least three reports of PML
occurring in the absence of any associated sys-
temic disease. (21. 72)
Because of the background conditions in most 4. Kuru
patients who develop PML, they have received X-
radiation, cytotoxic agents, and steroids, either
alone or in combination, prior to onset of the 4.1. Introduction
central nervous system disease. These immuno- Kuru was the first slow virus disease to be
suppressants may be etiologically related to PML, demonstrated in man. Pertinent information
although there are well-documented instances of through 1964 was presented in a symposium on
patients who never received such therapy.(83) Slow, Latent, and Temperate Virus Infections/ 281
and recently Gajdusek(221 prepared an excellent
summary of the important aspects of the study.
3.6. Patterns of Host Response Because of the properties of the kuru virus and the
neuropathological appearance of the brain, it has
The nature and frequency of the background
been classified as a subacute spongiform virus
diseases strongly suggest that the papovaviruses
encephalopathy along with Creutzfeldt-Jakob dis-
become destructive in the central nervous system
ease of man, scrapie of sheep, and mink encepha-
as a result of a hypo reactive immune system in the lopathy. (32) The disease is a heredofamilial sub-
host. Whether the virus has been latent for a long
acute degeneration of the central nervous system,
period prior to onset of PML or is acquired once
confined essentially to people of the Eastern High-
the host defenses are weakened cannot be deter-
lands region of Papua New Guinea.
mined.
Neurological signs appear insidiously but prog-
ress rapidly, with death occurring in an average of
4.2. Historical Background
4 months. There are occasional patients who have
survived more than a year, and there is one report The great majority of patients belong to the Fore
of a patient who developed PML and had a remis- linguistic group, who until recently lived a stone-
sion and died 5 yr later of an apparently unrelated age existence. Since 1950, there has been increas-
pneumonia. (371 ing Westernization. Known environmental and
cultural changes in the kuru region have been
described by Alpers.'21 It appears that kuru was
3.7. Unresolved Problems not recognized until the first or second decade of
the twentieth century. Rates slowly increased and
PML is an extremely rare disease. It is of great reached "epidemic" proportions during the
interest, however, because it is caused by appar- 1950s.(2)
ently widespread viruses which become patho- Intensive study of kuru began in 1956. Initially,
genic in an apparent hypoactive immune state in while a simple genetic hypothesis was enter-
the host. Conditions which compromise the host tained, extensive attempts using classical tech-
defense mechanisms are common, and a fairly niques were employed to detect infectious agents.
wide range of diseases have been implicated with Subsequently, when no evidence of a sufficient
PML. This suggests that (1) many diseases share a compensatory reproductive advantage with in-
very rare but specific immunosuppressing factor, creased fertility in kuru patients was found that
(2) the host has a very rare immune deficit which would account for the survival of the genes, other
permits these background diseases to precipitate explanations were sought.'22lIn 1959, Hadlow(31ll
PML, or (3) an as yet unknown rare precipitating pointed out the similarity of the neuropathology of
event is involved. Clarification of this problem scrapie and kuru. This led to renewed attempts to
could have far-reaching implications in the under- transmit kuru to laboratory animals including pri-
mates. In 1965, after 20 months of incubation, 4.5. Descriptive Epidemiology

chimpanzees inoculated intracerebrally with sus-
pensions of human brain from kuru patients de- Kuru is confined to a number of adjacent valleys
veloped the disease.(26) in the mountainous interior of the Eastern High-
lands of New Guinea, which include 160 villages
with a total population of 35,000. Approximately
80% of all known cases occur in individuals be-
4.3. Methodology
longing to the Fore linguistic group. There have
Since 1956, census information has been avail- been wide variations in rates in individual villages
able through the Australian administrative offices with considerable change over time.
and patrols in the region, and through the efforts Since 1956, some 2500 cases have been docu-
of the research group under Dr. Gajdusek who mented and critically analyzed by age and sex over
conduct total population surveys at 6-month inter- time.(3.22) In the early years of study, approxi-
vals. It is believed that case finding is com- mately 200 deaths per year occurred from Kuru,
plete. (22) Appropriate serological and pathological which at that time approached 1% per annum of
materials have been collected through the years. the total population. Rates have been declining
With the establishment of the Laboratory of Slow, steadily and now number about 60 per year. Dur-
Latent, and Temperate Viruses at the National ing the years when rates were high, the disease
Institute of Neurological and Communicative Dis- was found to affect all ages beyond infants and
orders and Stroke in 1962, concentrated efforts toddlers. Among preadolescents the sex ratio was
using conventional laboratory techniques, plus a approximately equal, while among adults there
wide program of primate inoculation, have been was a marked female excess, giving an overall rate
utilized in order to transmit, identify, and charac- of almost three females to one male. During the
terize the kuru virus. (32) past decade, the rates among males have been
generally stable, while the female rate has declined
notably. In addition, preadolescent cases are no
longer seen, and no child under 10 yr old has
developed kuru since 1967.(22)
To date, no virus has been visualized by elec- Kuru has been observed among people born in
tron microscopy, and there are no serological tests the endemic area many years after they migrated
which detect antibody or neutralize infectious ma- away. There have been no secondary cases among
terial. For these reasons, plus the stability of the persons in close contact with these migrants. Fur-
infectious particle and several other unusual prop- thermore, there has been considerable immigra-
erties, some investigators have chosen to refer to tion into the endemic area, and in spite of many
the transmitting property of kuru and the other thousands of man-years of close contact with the
subacute virus encephalopathies as an "agent" flora, fauna, food, and people of the region no case
rather than a virus. The present authors favor the of kuru has occurred among these new settlers.
designation "virus." The virus is filtrable through The culture of the kuru region resembles that of
membranes of 220 nm minimum pore diameter, the surrounding kuru-free highland people.
and reaches titers of 10 7 LDso per gram in brain Women and small children share the women's
tissue of primates. It is transmissible by peripheral houses, while adult men, the group least affected
or intracerebral inoculation thus far into chimpan- by kuru, live separately. Diets, however, are simi-
zees and eight species of monkeys in from 10 lar for males and females and not distinguishable
months to over 8 yr on primary inoculation. The from those of neighboring kuru-free groups.(22)
virus is stable for many years at -7U'C or on
lyophilization and is not totally inactivated by
temperature of 85°C for 30 min. There is firm 4.6. Mechanisms and Routes of Transmission
evidence that the virus can be maintained in vitro
in tissue cultures for many months without losing Ritual cannibalism, the practice of consumption
its virulence for the chimpanzee.(22) of dead kinsmen as a rite of mourning, was
apparently introduced into the kuru region about are still occurring in migrants from the kuru area,
1920.(2) There are compelling reasons to believe which means that the incubation period can be at
this practice to have been involved in the trans- least 18 yr and perhaps much longer.
mission of the disease. Women for the most part
conducted the butchery of the dead, which was
carried out bare-handed. Brain tissue was 4.8. Patterns of Host Response
squeezed to a pulp and packed into bamboo cylin-
ders, in which it was steamed. In the mountainous The symptomatology of kuru is remarkably uni-
highland area, water boils at 90-9S"C. It is likely form, leading to total incapacitation and death
that the extremely heat-stable virus which is pres- usually in 3-9 months. The disease is characterized
ent at concentrations as high as 10 7 would not be by a cerebellar ataxia and a shiverlike tremor
completely inactivated under these conditions. (22) which progresses to complete motor incapac-
Adult men rarely participated in this ceremony ity.(41l The word kuru means "shivering" or
and seldom ate the flesh of dead kuru victims. As "trembling" in the Fore language.
mentioned, women lived with small children of
both sexes, but young boys went to live with men
as they approached adolescence. Thus in the early 4.9. Control and Prevention
days the rates of kuru among preadolescents were
Although impossible to prove, it appears that
the same for males and females but the adult rates
the kuru virus was introduced into the Eastern
were higher for females, which coincides with the
Highlands some time after the tum of the century
degree of exposure to kuru brains. Since the virus
from an unidentified source, perhaps a human or
is infectious by the peripheral route, Gajdusek(22)
animal with a spongiform encephalopathy. It was
suggests that the most likely route of infection
allowed to spread because of the ritual of cannibal-
from contaminated brain was precutaneous,
ism and by 1950 had reached astonishing rates in a
through cuts or sores in the hands or other parts of
general familial pattern. Since the disease is disap-
the body or by being rubbed by unwashed hands
pearing with the cessation of cannibalism, it ap-
into the nose or eyes.
pears that prevention is achieved by avoiding
Perhaps the most convincing argument relating
exposure to infectious brain material.
cannibalism with kuru is the steady decline in
rates since the abandonment of the practice of
cannibalism between 1957 and 1962 and the strik-
ing observation that no child under 10 yr old has 4.10. Unresolved Problems
developed kuru since 1967.
Contagion can virtually be ruled out as a means The major unresolved problem is to determine
of transmission. There were no secondary cases the nature of the virus that causes kuru and to
among contacts of kuru victims who had migrated determine the relationship between the virus of
from the kuru regiOn and no cases in immigrants kuru and the other spongiform virus encephalopa-
to the endemic area. thies of man and animals. While the phenomeil.On
in the New Guinea highlands is unique and re-
lated to the disappearing practice of cannibalism,
4.7. Pathogenesis and Immunity humans are exposed to brains from many sources.
It is not inconceivable that these exposures present
There is no detectable immunity to kuru. Ap- a constant hazard to man. To clarify this matter, it
parently, the virus gradually accumulates in the is essential that kuru and related viruses be char-
central nervous system and destroys enough cells acterized. Cheaper, less cumbersome, and less
to produce the clinical picture. The incubation time-consuming laboratory methods would greatly
period is variable. Children as young as 3 yr of age facilitate this. The development of serological
have developed the disease, which would be a tests, if possible, would make the overall under-
minimal estimate of the incubation period. The standing of the spongiform encephalopathies far
study has been in progress since 1956 and cases easier and more complete.
5. Creutzfeldt-Jakob Disease were reviews of published clinical series.(oO.56)

Recently an area-wide survey was conducted in
Israel using all available medical resources for case
5.1. Introduction finding/ 48 ) and a case/control study was con-
ducted in the United States where the source of
Since 1968, convincing evidence has emerged
cases was patients from selected medical centers
that Creutzfeldt-Jakob disease (CJD) is one of four
and patients from whom central nervous system
classical slow virus infections which involve spon-
material was sent to Drs. Gajdusek and Gibbs at
giform degeneration of the central nervous system.
the National Institutes of Health for virus trans-
Others thus far identified are kuru in man, scrapie
mission studies.(5) There is also a report on the
in sheep, and transmissible mink encephalopathy.
characteristics of 12 CJD patients whose brain
material was used in an unsuccessful attempt to
transmit the disease to chimpanzees/ 65 ) as well as
5.2. Historical Background one serological study of 13 such patients and ten
chimpanzees which were inoculated with CJD ma-
CJD, first delineated in early 1920s by Creutz-
terial. (9) By far the largest series of patients pres-
feldt and Jakob, occurs throughout the world. It is
ently available (approximately 150) is represented
uncommon but not rare. The disease has recently
by those from whom materials have been sent to
been the subject of a neurological symposium/ ll a
NIH for transmission studies. (34)
complete survey of the literature/ 56 ) and an exten-
sive monograph. (50) Gibbs et al. (35) provided crit-
ical insight into the nature of this disease in 1968
by successfully transmitting it from human brain 5.4. Biological Characteristics of the Virus
biopsy material to chimpanzees.
Primarily because of the variety of clinical fea- As with the other spongiform encephalopathies,
the disease has been transmitted to a variety of
tures of CJD and the fact that no individual has
animals inoculated intracerebrally or by multiple
seen more than a few patients, there are at least 20
synonyms for it in the literature.(50) While there is peripheral routes, but not by the peroral route.
still not complete agreement, there is increasing The causative agent has not been identified by
electron microscopic study, and no serological
acceptance of the unity of this disease entity as a
tests are yet available. On primary transmission
destructive process of the gray matter of the central
from man, the incubation period in experimentally
nervous system usually presenting as a variable
infected apes has ranged from 10 to 71 months, in
~eriod of vague psychic disturbance progressing
monkeys from 11 to 68 months, and in the domes-
In a few weeks or months to frank dementia
tic cat it has been 30 months. In vitro cultures of
complicated by cerebellar, extrapyramidal, or pyr-
amidal symptoms and finally to mutism, rigidity, human tissues and tissues from animals with nat-
and death. Various subclassifications have been ural and experimentally induced disease remain
attempted. A useful though probably not defini- infectious for subhuman primates for more than a
tive classification of CJD was developed by Bo- year. Tissue culture cells from the brain of one CJD
bowick et al. (5) (Table 3) and by Roos et al. (65) In patient spontaneously transformed, and a virus
particle akin to oncogenic RNA viruses was pres-
this scheme, three major types are recognized and
presented in order of diminishing severity. The ent in the transformed cells but has been shown to
have no relationship to CJD.(4()) Two types of
table includes the clinical characteristics and other
viruslike particles were observed by electron mi-
terms in the literature assigned to these three
croscopy in brain biopsy specimens of two addi-
general types.
tional patients.(28) The significance of these obser-
vations and their etiological relationship to CJD
remain obscure, since preparations of purified
5.3. Methodology
virus do not reveal classical virions or nucleocap-
Mortality and morbidity data for CJD are lim- sids. The virus can be transmitted to subhuman
ited. Until 1965, the only sources of information primates by inoculation of human liver, kidney,
Table 3. Creutzfeldt-Jakob Disease: Classification System with Equivalent Terms from the Literature
and Essential Characteristics
Type I. Names: Subacute spongiform encephalopathy, Heidenhain, amaurotic, spongy, myoclonic, cortical.
Characteristics: Visual disturbances, dementia, aphasia, myoclonus, "burst suppression" EEG, acute
course of 1 to several months.
Type II. Names: Transitional, diffuse cerebral, thalamic, niger, cerebellar, corticostriatal.
Characteristics: Rigidity, dementia, ataxia, tremors, subacute course of less than 9 months.
Type III. Names: Classic, Jakob, spastic pseudosclerosis, amyotrophic, corticostriatospinal, corticospinal.
Characteristics: Parkinsonian features and/or ALS syndrome, all features of types I and II especially
terminally, chronic course of 1-2 yr.
spleen, and lymphoid tissues from patients dying CJD in a husband and wife. Several families with
wi th the disease. (24.25) The consistency with multiple cases are known (see below), and in two
which subhuman primates are affected after inoc- instances brain material from familial cases trans-
ulation with brain and visceral tissues from pa- mitted successfully to chimpanzees. (20.34) In light
tients with CJD, the clinical and neuropathological of the rarity of these combinations, it is probable
similarity between the disease in humans and that that common exposure to an infectious agent, to
in apes and monkeys, the ability to transmit the an extrinsic factor which activated the agent al-
disease with bacteria-free filtrates, and the ability ready latent, or to an unidentified toxin was in-
of the agent to self-replicate in vitro are all strong volved, with a possible genetic component in
evidence that the causative agent is a virus. At some instances.
present, however, with the exception that brain The geographic distribution of cases appears to
and visceral tissues are known to contain the be worldwide. The bulk of reports have come
transmissible agent in at least some cases, virolog- from Europe and North America/ 5) while there
ical studies are not useful in determining the are reports of CJD in South America, Israel, Japan,
epidemiological pattern of CJD. India, Africa, and Australia. (5.47.48.54.55)
There is little information on temporal trends.
Tabulations of May(56) and Kirschbaum(50) of case
reports from the world literature list about 70 cases
5.5. Descriptive Epidemiology for the period 1920-1960, and from 1960-1968 ap-
proximately 150 cases are listed. Following trans-
Incidence data are not available. The only infor- mission experiments and attendant heightened in-
mation on prevalence comes from an Israeli re- terest in CJD, another 150 cases have been
port(48) where a rate of one per million was observed in the past 5 yr.(20) In a review of
encountered. In this study, there was a marked patients from designated neurological centers in
disparity among immigrants from different coun- the United States from 1966 to 1971 no temporal
tries, with a much higher rate (31 per million) trend was observed. (5.65)
encountered among migrants from Libya. Siedler Approximately 90% of cases occur in the 40-69
and Malamud(71) in a series of autopsied patients yr age group. The mean age at death is about age
from California found 15 cases of CJD, which 60 for types 1 and 2 (see Table 4), while for type 3
made it one-fifth as frequent as Alzheimer's dis- disease it is 48 yr. (5.71l The mean survivorship for
ease and one-half as frequent as Pick's disease. type 1 disease is 5 months after onset, with a range
There is no convincing evidence of co~tagion of 2-10 months; for type 2 disease the mean is 8
among humans or animals for CJD. The only months, with a range of 3-15 months; and for type
strongly suggestive evidence so far in regard to 3 disease the mean is 30 months, with a range of
possible contact transmission comes from the re- 10-72 months. In many instances, there is a rapid
port of Jellinger et al. (46) in which they describe progressive evolution over a period of weeks to
Table 4. Comparison of Certain Features
Descriptive epidemiology
M:F Ethnic
Disease Virus Geographic Age ratio group Other
SSPE Defective measles Worldwide 5-7 3:1 All Rural, exposure to fowl
and dogs
PML Papovavirus Many countries 50-70 1.5:1 Hodgkin's disease,

leukemia, etc.
Kuru Subacute spongiform Eastern Highlands of All ages 1:3 Fore Ritualistic cannibalism
encephalopathy Papua New Guinea people resulting in self-
only inocula tion;
heredofamilial
CJD Subacute spongiform Worldwide 40-69 About All Organltissue

encephalopathy equal transplantation; head
trauma; ?neurosurgicalJ
neuropathological
accidents; sporadic,
familial, and conjugal
months, reducing the patient to a vegetative state 3. It is probable that there was an overrepresenta-
for a more prolonged period. tion of type 1 CJD, the most acute form of the
Males and females were equally affected in most disease, since these are the patients who are most
reports, although in two series(5) there was a likely to be referred for diagnostic and virological
slight preponderance of males, primarily of type 2 studies. We did not detect any patterns or prac-
patients, and in the first 12 cases transmitted by tices which distinguished among the three types
Gibbs and Gajdusek the ratio was ten males to two of disease, with the exception mentioned above
females. (71) The Israeli study also has a slight male that type 3 patients die approximately 10 yr earlier
excess.(48) Present information indicates that all than the others. Comparison for the numerous
races are susceptible, although comparative rates parameters referred to above did not yield discern-
are not available. In a case/control study,<5) 38 ible differences among the patients. In all groups a
confirmed patients were compared with their wide range of occupations, residencies both urban
spouse or nearest surviving relative and a desig- and rural, degree of education, history of familial
nated lifelong friend of the same age and sex. illness, and life styles were equally represented.
Broad categories of information were ascertained There was a slight excess among patients for
at interview regarding recent health prior to ill- severe upper respiratory infection during the 6-
ness, immunological history, previous hospitaliza- month interval prior to onset than during the same
tion and illnesses, family history, residential his- time period for controls, particularly for patients
tory and foreign travel, occupational history, with type 2 disease. This observation must be
education, smoking habits, vacations, food habits, viewed with caution because of the obvious differ-
and animal exposure history. In this series, ap- ences in recall among patients with catastrophic
proximately half of the patients were classified as illness. There was also a tendency for more mental
type 1, while 30% were type 2 and 20% were type illness in the families of patients and in the pa-
of Slow Virus Infections of Man
Pathogenesis
High Depressed
Incubation antibody immune Animal
period titer response transmission
6yr ++ + + Dogs, hamsters, calves,

lambs
Unknown ± Usually
?Spontaneous occurrence in
M. rhesus
Years? No antibody demonstrable Unknown + Chimpanzees,

Old World monkeys,
New World monkeys,
mink
4-18 mos. No antibody demonstrable Unknown +Chimpanzees, domestic

cat,
New World monkeys,
Old World monkeys,
guinea pigs
tients themselves than among controls. Antecedent six families with multiple cases have been docu-
mental illness has been commented on by Roos et mented.(2o.24.25) In some of these families (includ-
al. (65) and by Ferber et al. (20) Evidence of prior ing one with successful transmission), cases have
hepatic disease was not encountered, although appeared in multiple generations in an autosomal
Kirschbaum(50l and Roos et al. (65) have noted dominant pattern. This leads to speculation that
abnormal liver function tests and histological some families have a genetic defect determining
changes in the liver in CJD patients. In their series the susceptibility to a latent virus. On the other
of cases, Gajdusek and Gibbs have four patients hand, there might be vertical transmission of the
who had experienced traumatic injuries immedi- agent within some families, with long incubation
ately prior to the onset of CJD. (76) periods.(24) Another interpretation would 'be that
An intriguing observation in the study by Bo- shared environment in the absence of any genetic
bowick et al. (5) was that one-third of patients and determinants caused these familial patterns,
one-third of controls gave a history of eating
animal brains. Of these, ten of 14 patients and
5.6. Mechanisms and Routes of Transmission
three of 12 controls specifically stated a preference
for hog brains. There are no data available on the Little is known concerning the mode of acquisi-
frequency of brain consumption in the general tion of CJD in humans. Human brain material
population or the animal source of the brains from CJD patients has been successfully transmit-
eaten. ted to a wide variety of animals, including the
Interest in genetic factors in CJD has increased chimpanzee, five species of New World monkeys
greatly. (24) In addition to the two familial cases (spider, squirrel, capuchin, woolly, and marmoset),
referred to above from which successful transmis- and six species of Old World monkeys (bushbaby,
sion to chimpanzees was accomplished, another mangabey, African green, rhesus, cynomolgus,
and stumptail), and the domestic cat. Many other has not revealed similar occurrences in hospital
species are still under observation.(25.33) The pos- records of about half of these patients.(3m
sible influence of a genetic factor has already been Creutzfeldt-Jakob disease has been transmitted
mentioned. All known spongiform encephalopa- from human to human via a cornea transplant. (19)
thies can be transmitted by inoculation of infected However, since the donor's eye was enucleated
brain and visceral tissues into susceptible host prior to removal of the cornea, the cornea was
material. Scrapie and mink encephalopathy have almost certainly contaminated with optic nerve. In
been transmitted from animal to animal by contact addition, the neurosurgical cases of Nevin et
and by ingestion of infected tissues. Thus the al. (59) suggest that CJD may be transmissible to
abovementioned observation of a high rate of man by direct inoculation. Recently, inoculation of
consumption of animal brains by CJD patients, brain from a neurosurgeon who died of papulosis
while not different from that of controls except in atrophicans maligna (Kohlmeier-Degos) with asso-
preference for hog brains, provides a possible ciated neuropathological features of CJD has pro-
tenuous clue. The Israeli data, with high rates in duced experimental spongiform encephalopathy in
migrants from Libya, a Moslem country where subhuman primates.(27l It is not known whether
pigs are not eaten, would indicate that consump- this patient developed the disease because of con-
tion of hog brains is not etiologically involved or tact with a CJD brain during his neurosurgical
that other animals whose brains are ingested may practice; however, this must be considered a pos-
be capable of transmitting the virus. Herzberg et sibility. These cases, together with the known
al. (18) have recently suggested that the dietary transmissibility to primates of at least some CJD
habit of eating sheep eyeballs, a gastronomic deli- and the presence of the CJD virus in visceral
cacy among Bedouin and Moroccan Arabs and also tissue, have important practical implications. It is
Libyans, may be associated with the high inci- unwise to transplant tissues, including skin, kid-
dence of CJD in this population since the tissues ney, and cornea, from any patient with presenile
could be infected with scrapie, a subacute spongi- dementia.(76) Further, because of the presumed
form virus encephalopathy of sheep. Although an stability of CJD virus by analogy with scrapie
increasing range of animal hosts susceptible to the virus, tissues from presenile dementia patients
CJD virus is developing, it must be reemphasized may pose a hazard to neurosurgeons, pathologists,
that there are no firm data that ingested animal and others coming in contact with them.
brains are the source of CJD infection in humans. Transmissibility to the domestic cat raises the
possibility of an animal reservoir, although there
has been no report of natural disease in cats
5.7. Pathogenesis and Immunity resembling experimental feline CJD.
Little is known about the pathogenesis of CJD in Immune mechanisms have not been demon-
humans. From animal inoculation data, it may be strated in CJD, and specific antibodies to infected
inferred that a lengthy incubation period precedes brain material or high antibody titers to a large
onset of clinical manifestations. In general, once series of known viruses have not been demon-
symptoms appear the disease is rapidly progres- strated. (9)
sive. There are suggestions in some patients that
mental disturbances many years prior to docu- 5.B. Patterns of Host Response
mented clinical onset may in fact be an early sign
of the disease.(65.7(;1 There is also the observation The range of clinical manifestations is outlined
that in some instances the disease appears during in Table 3. As mentioned above, with the excep-
severe upper respiratory illness, which is compati- tion of earlier onset in type 3 CJD and the ques-
ble with the hypothesis that a debilitating disease tionable data on hepatic involvement or upper
could cause the release of a latent virus infection. respiratory disease prior to onset there are no
In one series quoted above/ 51 the respiratory detectable patterns of prior host response. As a
illness was most frequently encountered in type 2 result, there is little in the way of control and
(ataxic) CJD. Preliminary information from another prevention available through epidemiological data
report of 22 patients with the ataxic form of CJD other than the suggestion that heightened interest
be directed toward the consumption of animal of man in the Eastern Highlands of Papua New
brains as a factor. Guinea, and scrapie, a subacute progressive de-
There have been reports of three CJD patients generative central nervous system disease of sheep
treated with amantadine in whom rapid improve- that has been recognized for more than 200 yr in
ment over varying periods of time was ob- Europe, have largely been responsible for our
served. foo ) In at least one of these, autopsy confir- knowledge that viruses cause chronic, slowly
mation of the diagnosis is available. Along with its evolving, relentlessly progressive, fatal diseases of
many other effects, amantadine is an antiviral the central nervous system. It was the study of
agent. Another independent action is in the dopa- these two diseases which led to the demonstration
minergic pathways of the central nervous system. that Creutzfeldt-Jakob disease, an uncommon but
Whether either of these actions caused the im- not rare presenile dementia of man, is also caused
provement or if other CJD patients will improve by a virus closely related or identical to the viruses
after treatment with amantadine remains to be of kuru and scrapie. Because of their unique phys-
determined. ical, biological, and biochemical properties, they
are classified as the subacute spongiform virus
5.9. Unresolved Problems encephalopathies.
These advances during the past decade led to
It is obvious from the above discussion that CJD
the elucidation of "conventional" virus etiologies
is a fascinating human disease which is transmis-
for other chronic neurological diseases such as
sible to a variety of animal species. Aside from
subacute sclerosing panencephalitis, caused by
this, most aspects of acquisition, prevention, and
defective measles virus, and progressive multifocal
control are still to be resolved. While the disease is
leukoencephalopathy, caused by papovaviruses. It
rare, approximately 150 new patients have been
thus became apparent that a wide diversity of
reported since the successful transmission studies,
clinical courses and pathological lesions could be
a number which exceeds the entire accumulation
produced by viral invasions of the central nervous
of cases previously reported. The full range of
system.
susceptible animals remains to be worked out.
The studies of "slow infections" of the central
Since a dominant feature of the disease is de-
nervous system have necessitated new concepts
mentia, attention has been directed to other hu-
concerning the spectrum of neurological diseases
man dementias with the thought that there may be
that might be related to viruses. A viral etiology
possible overlap with CJD or that perhaps they are
must now be considered in neurological diseases
caused by other slow viruses.(23) Indeed, the
that are manifested by chronic, subacute, progres-
transmission of CJD to subhuman primates has
sive, or relapsing degenerative courses with or
made it possible to define a subgroup of CJD
without associated dementia and in which nonin-
patients whose disease is transmissible and to
flammatory pathological lesions are observed.
determine whether some cases diagnosed as CJD
may represent a distinct nontransmissible neurol-
ogical illness. It has further permitted an inquiry
into the possibility that there are cases of trans- 7. Unresolved Problems
missible virus dementias which are being given
clinical or pathological diagnosis other than CJD.
A major unresolved problem associated with
These diagnoses may include such syndromes as
chronic subacute progressive degenerative di-
Alzheimer's or Pick's disease, parkinsonism with
seases of the central nervous system of viral etiol-
dementia, and "cortical atrophy" or "dementia of
ogy continues to be our lack of knowledge of the
unknown etiology."
definitive nature of the subacute spongiform virus
encephalopathies. In the case where more conven-
6. Summary and Comparison tional viruses produce chronic infections, the
problem is our lack of knowledge of the mecha-
It is a well-established fact that kuru, a rare and nisms of virus/host cell relationships that permit
disappearing transmissible heredofamilial disease these viruses to enter the central nervous system
and establish progressive and ultimately fatal di- AND GIBBS, C. J. JR., Attempt to identify the agent of
seases. New methods will certainly be required to Creutzfeldt-Jakob disease by antibody relationship
determine whether infection is involved in the to known viruses, Nature (London) New Biol. 235:149-
etiology of other chronic neurological diseases 152 (1972).
10. BRUN, A., NORDENFELDT, E., AND KJELLEN, 1., As-
such as multiple sclerosis, amyotrophic lateral
pects on the variability of progressive multifocal
sclerosis, and Parkinson's disease, and perhaps
leukoencephalopathy, Acta Neuropathol. 24:232-243
even diseases which appear to follow a genetic (1973).
pattern. We must concern ourselves with classical 11. BYINGTON, D. P., AND BURNSTEIN, T., Measles en-
virological knowledge of latency, masking, persist- cephalitis produced in suckling rats, Exp. Mol. Pa-
ence, temperateness, existence of proviruses, and thol. 19:36-43 (1973).
defectiveness; we must take into account the prob- 12. CANAL, N., AND TORCK, P., An epidemiological
lems of host range specificity, and the need for study of subacute sclerosing leucoencephalitis in
helper viruses. Finally we must also recognize that Belgium, J. Neurol. Sci. 1:380--389 (1964).
viruses will prove to be responsible for only a 13. CANELAS, H. M., JULIAO, O. F., LEFEVRE, A. B., et al.,
Subacute sclerosing panencephalitis: An epidemiol-
limited number of chronic neurological diseases.
ogical, clinical and biochemical study of 31 cases,
Arch. Neuro-Psychiat. (Sao Paulo) 25:255-268 (1967).
14. CASTAIGNE, P., RONDOT, P., ESCOURELLE, R., RIDA-
DEAU, D., LUMAS, J. 1., CATHALA, F., AND HAUW, J.
8. References J., Leucoencephalopathe multifocale progressive et
"gliomes" multiples, Rev. Neurol. 130:379-392 (1974).
1. ALEMA, G., Transmissible and genetic late dementiae, 15. CONNOLLY, J. H., HAIRE, M., AND HADDEN, D. S. M.,
in: Proceedings of the Tenth International Congress of Measles immunoglobulins in subacute sclerosing
Neurology, (A. SUBIRANA AND J. M. BURROWS, eds.) panencephalitis, Br. Med. J. 1:23-25 (1971).
Barcelona, September 9-14, 1973, International Con- 16. DAYAN, A. D., AND STOKES, M. I., Immune com-
gress Series No. 319, Excerpta Medica, Amsterdam, plexes and visceral deposits of measles antigens in
1973. subacute sclerosing panencephalitis, Br. Med. J.
2. ALPERS, M., Epidemiological changes in kuru, 1957 2:374-376 (1972).
to 1963, in: NINDB Monograph No.2 (D. C. GAJDU- 17. DETELS, R., BRODY, J. A., McNEW, J., AND EDGAR, A.
SEK, C. J. GIBBS, AND M. ALPERS, eds.), pp. 65-82, H., Further epidemiologic studies of subacute scle-
Department of Health, Education, and Welfare, Gov- rosing panencephalitis, Lancet 7819(11):11-14 (1973).
ernment Printing Office, Washington, D.C., 1965. 18. DONNER, M., HALONEN, H., AND HALTIA, M., Subak-
3. ALPERS, M. P., Kuru: Implications ofits transmissibil- uutti sklerosoiva panenkefaliitti, Duodecim85:541-553
ity for the interpretation of its changing epidemio- (1969).
logic pattern, in: The Central Nervous System, Vol. 14, 19. DUFFY, P., WOLF, J., COLLINS, G., DEVOE, A. G.,
pp. 234-251, Williams and Wilkins, Baltimore, 1968. STREETEN, B., AND COWEN, D., Person-to-person
4. BAGULEY, D. M., AND GLASGOW, G. 1., Subacute transmission of Creutzfeldt-Jakob disease, N. Engl. J.
sclerosing panencephalitis and Salk vaccine, Lancet Med. 299:692-693 (1974).
7832(11):763-765 (1973). 20. FERBER, R. A., WmSENFELD, S. 1., Roos, R. P., BOBOW-
5. BOBOWICK, A. R., BRODY, J. A., MAITHEws, M. R., ICK, A. R., GIBBS, C. J., JR., AND GAJDUSEK, D. c.,
Roos, R., AND GAJDUSEK, D. c., Creutzfeldt-Jakob Familial Creutzfeldt-Jakob disease: Transmission of
disease: A case control study, Am. J. Epidemiol. the familial disease to primates, in: Proceedings of the
98(5):381-394 (1973). Tenth International Congress of Neurology (A. SUB-
6. BOLTON, C. F., AND ROZDILSKY, B., Primary progres- RIANA AND J. M. BURROWS, eds.), pp. 358-380, Interna-
sive multifocal leUkoencephalopathy, Neurology tional Congress Series No. 319 (ISBN 9021902273),
21:72-77 (1971). Excerpta Medica, Amsterdam, 1973.
7. BRODY, J. A., AND DETELS, R., Subacute sclerosing 21. FERMAGLICH, J., HARDMAN, J. M., AND EARLE, K. M.,
panencephalitis: A zoonosis following aberrant mea- Spontaneous progressive multifocal leukoencephalo-
sles. Hypothesis, Lancet 11:500--501 (1970). pathy, Neurology 20:479-484 (1970).
8. BRODY, J. A., DETELS, R., AND SEVER, J. 1., Measles- 22. GAJDUSEK, D. c., Kuru in the New Guinea high-
antibody titers in sibships of patients with subacute lands, in: Tropical Neurology, Vol. 290. D. SPILLANE,
sclerosing panencephalitis and controls, Lancet ed.), pp. 376-383, Oxford University Press, London,
7743(1):177-178 (1972). 1973.
9. BROWN, P., HOOKS, J., Roos, R., GAJDUSEK, D. c., 23. GAJDUSEK, D. c., AND GIBBS, C. J., JR., Kuru and the
virus dementi as in: Conference on Biohazards in Can- mates and other laboratory animals, Science 182:67-68
cer Research, Pacific Grove, California, January 22-24, (1973).
1973, Biohazards in Biological Research (A. HELLMEN, 34. GIBBS, C. J., JR., AND GAJDUSEK, D. c., Biology of kuru
M. N. OXMAN, AND R POLLACK, eds.), pp. 288-299, and Creutzfeldt-Jakob disease, in: Slow Virus Diseases,
Cold Spring Harbor Press, Cold Spring Harbor, New (W. ZEMAN AND E. H. LENNETTE, eds.), pp. 39-48,
York, 1973. Williams and Wilkins, Baltimore, 1973.
24. GAJDUSEK, D. c., AND GIBBS, C. J., JR., Subacute and 35. GIBBS, C. J., JR., GAJDUSEK, D. c., ASHER, D. M.,
chronic diseases caused by atypical infections with ALPERS, M. P., BECK, E., DANIEL, P. M., AND MAT-
unconventional viruses in aberrant hosts, in: Persist- THEWS, W. B., Creutzfeldt-Jakob disease (subacute
ent Virus Infections, Perspectives in Virology, Vo!' VIII spongiform encephalopathy): Transmission to the
(M. POLLARD, ed.), pp. 279-311, Academic Press, New chimpanzee, Science 161:388-389 (1968).
York,1973. 36. HADLOW, W. J., Scrapie and kuru, Lancet 1959:289-
25. GAJDUSEK, D. c., AND GIBBS, C. J., JR., Familial and 290.
sporadic chronic neurologic degenerative disorders 37. HEDLEY-WHYTE, E. T., SMrrH, B. P., TYLER, H. R, AND
transmitted from man to primates, in: Advances in PETERSON, W. P., Multifocal leukoencephalopathy
Neurology, Vo!' 10: Primate Models of Neurological Dis- with remission and five year survival, f. Neuropathol.
orders (B. S. MELDRUM AND C. D. MARSDEN, eds.), pp. Exp. Neurol. 25:107-116 (1966).
291-375, Raven Press, New York, 1975. 38. HERZBERG, L., HERZBERG, B. W., GIBBS, C. J., JR.,
26. GAJDUSEK, D. c., GIBBS, C. J., AND ALPERS, M., Exper- SULLIVAN, W., AMYX, H." AND GAJDUSEK, D. c.,
imental transmission of a kuru-like syndrome to Creutzfeldt-Jakob disease: Hypothesis for high inci-
chimpanzees, Nature (London) 209:794-796 (1966). dence in Libyan Jews in Israel, Science 186:848 (1974).
27. GAJDUSEK, D. c., GIBBS, C. J., JR., EARLE, K., DAM- 39. HIRANO, A., personal communication, 1974.
MIN, G. J., SCHOENE, W. c., AND TYLER, H. R., Trans- 40. HOOKS, J. J., GIBBS, C. J., JR., CHOPRA, H., LEWIS, M.,
mission of subacute spongiform encephalopathy to AND GAJDUSEK, D. c., Spontaneous transformation of
the chimpanzee and squirrel monkey from a patient human brain cells grown in vitro and characterization
with papulosis atrophicans maligna of K6hlmeier- of associated virus particles, Science 176:1420-1422
Degos, in: Proceedings of the Tenth International Con- (1972).
gress on Neurology (A. SUBlRANA AND J. BURROWS, 41. HORNABROOK, R W., Kuru-A subacute cerebellar
eds.), International Congress Series No. 319, pp. 390- degeneration. The natural history and clinical fea-
392, Excerpta Medica, Amsterdam, December 1973. tures, Brain 91:53-74 (1968).
28. GAJDUSEK, D. c., GIBBS, C. J., AND ALPERS, M., Slow, 42. HORTA-BARBOSA, L., Subacute sclerosing panenceph-
Latent and Temperate Virus Infections, NINDB Mon- alitis: Isolation of suppressed measles virus from
ograph No.2, National Institutes of Health, PNS Pub- lymph node biopsies, Science 173:840-841 (1971).
lication No. 1378, Department of Health, Education, 43. HORTA-BARBOSA, L., FUCCILLO, D. A., LONDON, W.
and Welfare, Government Printing Office, Washing- T., JABBOUR, J. T., ZEMAN, W., AND SEVER, J. L.,
ton, D.C., 1965. Isolation of measles virus from brain cell cultures of
29. GARDNER, S. D., Prevalence in England of antibody to two patients with subacute sclerosing panencephali-
human polyomavirus (B.K.), Br. Med. f. 1:77-78 tis, Proc. Soc. Exp. Bioi. Med. 132:272-277 (1969).
(1973). 44. JABBOUR, J. T., DUENAS, D. A., SEVER, J. L., KREBS, H.
30. GARDNER, S. D., FIELD, A., COLEMAN, D., AND M., AND HORTA-BARBOSA, L., Epidemiology "Of sub-
HULME, B., New human papovavirus (B.K.) isolated acute sclerosing panencephalitis (SSPE), f. Am. Med.
from urine after renal transplantation, Lancet Assoc. 220:959-962 (1972).
1(7712):1253-1257 (1971). 45. JABBOUR, J. T., AND SEVER, J. L., Serum measles
31. GERSON, K. L., AND HASLAM, R H. A., Subtle immu- antibody titers in patients with subacute sclerosing
nologic abnormalities in SSPE, N. Engl. f. Med. panencephalitis, compared with parents and sib-
285(2):78-82 (1971). lings, f. Pediat. 73:905-907 (1968).
32. GIBBS, C. J., JR., AND GAJDUSEK, D. c., Transmission 46. JELLINGER, V. K., SEITELBERGER, F., HEISS, W. D.,
and characterization of the agents of spongiform virus AND HOLCZABEK, W., Konjugale Form der subakuten
encephalopathies, kuru, Creutzfeldt-Jakob disease, spongiosen Enzephalopathie (Jakob-Creutzfeldt-Er-
scrapie and mink encephalopathy, in: Immunological krankung), Wien. Klin. Wochenschr. 84(15):245-249
Disorders of the Nervous System, Vo!' XLIX (L. P. Row- (1972).
LAND, ed.), Res. Pub!. A.R.N.M.D., pp. 383-410, Wil- 47. JOASOO, A., AND WOLFENDEN, W. H., Subacute spon-
liams and Wilkins, Baltimore, 1971. giform encephalopathy, Med. f. Aust. 1:354-356
33. GIBBS, C. J., JR., AND GAJDUSEK, D. c., Experimental (1968).
subacute spongiform virus encephalopathies in pri- 48. KAHANA, E., ALTER, M., BRAHAM, J., AND SOFER, D.,
Creutzfeldt-Jakob disease: A focus among Libyan 63. PAYNE, F. E., BAUBLIS, J. V., AND ITABASHI, H. H.,
Jews in Israel, Science 183:90--91 (1974). Isolation of measles virus from cell cultures of brain
49. KATZ, M., RORKE, L. B., MASLAND, W. S., BRODANO, from a patient with subacute sclerosing panencepha-
G. B., AND KOPROWSKI, H., Subacute sclerosing pan- litis, N. Engl. J. Med. 281:585--589 (1969).
encephalitis: Isolation of a virus encephalitogenic for 64. RICHARDSON, E. P., Progressive multifocalleukoence-
ferrets, J. Infect. Dis. 121:188--195 (1970). phalopathy, in: The Remote Effects of Cancer of the
50. KIRSCHBAUM, W. R., Jakob-Creutzfeldt Disease, 251 Nervous System (L. BRAIN AND F. H. NORRIS, JR.,
pp., American Elsevier, New York, 1968. eds.), pp. 6-16, Grune and Sratton, New York, 1965.
51. KOPROWSKI, H., Interaction between papova-like vi- 65. Roos, R, GAJDUSEK, D. c., AND GIBBS, C. J., JR., The
rus and paramyxovirus in human brain cells: A clinical characteristics of transmissible Creutzfeldt-
hypothesis, Nature (London) 225:1045--1047 (1970). Jakob disease, Brain 96:1-20 (1973).
52. LEGRAIN, M., et al., Leuco-encepholie multifocal pro- 66. SANDERS, D., AND POSKANZER, D. c., personal com-
gressive apres transplantation renale, J. Neurol. Sci. munication, 1973.
23:49--62 (1974). 67. SEVER, J. L., JABBOUR, J. T., BEADLE, E., AND KREBS,
53. MANZ, H. A., et al., Progressive multifocalleucocytes H., Constant incubation period for subacute scleros-
after renal transplantation, Ann. Intern. Med. 75:77- ing panencephalitis (abst.), Proc. Exp. Med. Bioi.
81 (1971). (April 1974).
54. MATHUR, W. N., AND KARAN I, H. J., Jakob-Creutz- 68. SEVER, J. L., AND ZEMAN, W., eds., Conference on
feldt syndrome, J. Indian Med. Assoc. 49(3):142-143 Measles Virus and Subacute Sclerosing Panencepha-
(1967). litis, Bethesda, Md., September 13, 1967, Neurology
55. MATSUOKA, T., HAMANAKA, T., TAIL, S., TATEBAY- 19(1):30--51, Part 2 (1968).
ASHI, Y., KIJIMA, S., AND NISHIKAWA, T., (Subacute 69. SHAH, K. V., DANIEL, R. W., AND WARSZAWSKI, R
spongiform encephalopathy as a subtype of Creutz- M., High prevalence of antibodies to BK virus, an
feldt-Jakob disease---A report of two cases), Psychiat. SV-40 related papovavirus, in residents of Maryland,
Neurol. Japon. 72(7):669--690 (1970). J. Infect. Dis. 128:784-787 (1973).
56. MAY, W. W., Creutzfeldt-Jakob disease. I. Survey of 70. SHAW, C.-M., BUCHAN, G. c., AND CARLSON, C. B.,
the literature and clinical diagnosis, Acta Neurol. Myxovirus as a possible etiologic agent in subacute
Scand. 44:1-32 (1968). inclusion-body encephalitis, N. Engl. J. Med.
57. McDONALD, R, KIPPS, A., AND LEARY, P. M., Sub- 277:511-515 (1967).
acute sclerosing panencephalitis in the Cape Prov- 71. SIEDLER, H., AND MALAMUD, N., Creutzfeldt-Jakob
ince, S. Afr. Med. J. 48:7-9 (1974). disease: Clinicopathologic report of 15 cases and
58. NARAYAN, 0., PENNEY, J. B., JOHNSON, R T., HERN- review of the literature (with special reference to a
DON, R. M., AND WEINER, L. P., Etiology of progres- related disorder designated as subacute spongiform
sive multifocal leukoencephalopathy: Identification encephalopathy), ]. Neuropathol. Exp. Neurol.
of papovavirus, N. Engl. J. Med. 289(24):1278--1282 22:3:381-402 (1963).
(1973). 72. SILVERMAN, L., AND RUBINSTEIN, L. G., Electron
59. NEVIN, S., McMENEMEY, W. H., BEHRMAN, S., AND microscopic observations on a case of progressive
JONES, D. P., Subacute spongiform encephalopathy- multifocal leukoencephalopathy, Acta Neuropathol.
A subacute form of encephalopathy attributable to 5:215-224 (1965).
vascular dysfunction (spongiform cerebral atrophy), 73. STEELE, R. W., FUCCILLO, D. A., HENSEN, S. A, VIN-
Brain 83:519--564 (1960). CENT, M. M., AND BELLANTI, J. A., Specific inhibitory
60. NOTERMANS, S. L. H., TIJL, W. F. J., WILLENS, F. T. factors of cellular immunity in patients with subacute
c., AND SLOOFF, J. L., Experimentally induced sub- sclerosing panencephalitis, J. Pediatr. 88(1): 52--62,
acute sclerosing panencephalitis in young dogs, Neu- January, 1976.
rology 23:543-553 (1973). 74. THEIN, P., MAYR, A., TER MEULEN, V., KOPROWSKI,
61. PADGETT, B. L., AND WALKER, D. L., Prevalence of H., KACKELL, M. Y., MULLER, D., AND MEYERMANN,
antibodies in human sera against ]C virus, an isolate R, Subacute sclerosing panencephalitis: Transmis-
from a case of progressive multifocal leukoencephal- sion of the virus to calves and lambs, Arch. Neurol.
opathy, J. Infect. Dis. 127:467-470 (1973). 27(6):540--548 (1972).
62. PADGETT, B. L., Zu RHEIN, G. M., WALKER, D. L., 75. THORMAR, H., JERVIS, G. A., KARL, S. c., AND
ECKROADE, R. J., AND DESSEL, B. H., C1;lltivation of BROWN, H. R., Passage in ferrets of encephalitogenic
papova-like virus from human brain w~th progres- cell-associated measles virus isolated from brain of a
sive multifocalleukoencephalopathy, La,/cet 1(7712): patient with subacute sclerosing panencephalitis, J.
1257-1260 (1971). Infect. Dis. 127:678--685 (1973).
76. TRAUB, R. D., GAJDUSEK, D. c., AND GIBBS, C. J., JR., 9. Suggested Reading
Transmissible virus dementia: The relation of trans-
missible spongiform encephalopathy to Creutzfeldt- GAJDUSEK, D. c., Kuru and Creutzfeldt-Jacob disease:
Jakob disease, in: Aging, Dementia and Cerebral Func- Experimental models of non-inflammatory degenera-
tion (M. KINSBOURNE AND L. SMITH, eds.), Spectrum tive slow virus disease of the central nervous system,
Pub!. Co., New York, in press. Ann. Clin. Res. 5:254-261 (1973).
77. VERNON, M. L., HORTA-BARBOSA, L., FUCCILLO, D. GAJDUSEK, D. c., Kuru in the New Guinea highlands, in:
A., SEVER, J. L., BARINGER, J:R., AND BIRNBAUM, G., Tropical Neurology, Vo!' 29 0. D. SPILLANE, ed.), pp.
Virus-like particles and nucleoprotein-type filaments 376-383, Oxford University Press, London, 1973.
in brain tissue from two patients with Creutzfeldt- GAJDUSEK, D. c., AND GIBBS, C. J., JR., Familial and
Jakob disease, Lancet 1(7654):964-967 (1970). sporadic chronic neurological degenerative disorders
78. WALKER, D. L., PADGETT, B. L., Zu RHEIN, G. M., transmitted from man to primates, in: Advances in Neu-
ALBERT, A. E., AND MARSH, R. F., Human papovavi- rology, Vo!' 10: Primate Models of Neurological Disorders
rus OC): Induction of brain tumors in hamsters, (B. S. MELDRUM AND C. D. MARSDEN, eds.), pp. 291-
Science 181(4100):67~76 (1973). 375, Raven Press, New York, 1975.
79. WEAR, D., AND RAPP, F., Latent measles virus infec- GAJDUSEK, C. D., GIBBS, C. J., AND ALPERS, M., Slow,
tion of the hamster central nervous system, J. Immu- Latent and Temperate Virus Infections, NINDB Mono-
nolo 107:1593-1598 (1971). graph No.2, U.5. Department of Health, Education,
80. WEINER, L. P., HERNDON, R M., NARAYAN, 0., JOHN- and Welfare, Government Printing Office, Washing-
SON, R T., SHAH, K., RUBINSTEIN, L. J., PREZIOSI, T J., ton, D.C., 1965.
AND CONLEY, F. K., Isolation of virus related to SV-40 GIBBS, C. J., JR., AND GAJDUSEK, D. c., Transmission and
from patients with progressive multifocalleukoence- characterization of the agents of spongiform virus ence-
phalopathy, N. Engl. J. Med. 286:385-390 (1972). phalopathies, kuru, Creutzfeldt-Jakob disease, scrapie
81. WEINER, L. P., NARAYAN, 0., PENNEY, J. B., JR., and mink encephalopathy, in: Immunological Disorders
HERNDON, R. M., FERINGA, E. R, TOURTELLOTTE, W. of the Nervous System; Vo!' XLIX (L. P. ROWLAND, ed.),
W., AND JOHNSON, R. T., Papovavirus of JC type in Res. Pub!. A.R.N.M.D., pp. 383-410, Williams and
progressive multifocal leukoencephalopathy, Arch. Wilkins, Baltimore, 1971.
Neural. 29(1):1-3 (1973). NARAYAN, 0., PENNY, J. B., JOHNSON, R. T., HERNDON,
82. WHITAKER, J. N., SEVER, J. L., AND ENGEL, W. K., R. M., AND WEINER, L. P., Etiology of progressive
S.ubacute sclerosing panencephalitis in only one of multifocal leucoencephalopathy: Identification of pa-
identical twins, N. Engl. J. Med. 287:864--866 (1972). povavirus, N. Engl. J. Med. 289:127&--1282 (1973).
83. Zu RHEIN, G. M., Association of papova-virions with WEINER, L. P., JOHNSON, R. T., AND HERDON, R. M.,
a human demyelinating disease (progressive multifo- Viral infections and demyelinating diseases, N. Engl. J.
cal leukoencephalopathy), Prog. Med. Viral. 11:185- Med. 288:1103-1110 (1973).
247 (1969). ZURHEIN, G. M., Association of papova-virions with a
84. ZURHEIN, G., AND VARAKIS, J., Progressive multifocal human demyelinating disease (progressive multifocal
leucoencephalopathy in a renal allograft regiment, N. leucoencephalopathy), Prog. Med. Viral. 11:185-247
Engl. J. Med. 291:798 (1974). (1969).
CHAPTER 25
Nasopharyngeal
Carcinoma
G. de-The, J. H. C. Ho, and C. Muir
1. Introduction
lymphoma and carcinoma of the cervix uteri, h~ve
epidemiological characteristics which make the m-
It may appear out of place to have chapters on tervention of a biological factor likely. Burkitt
nasopharyngeal carcinoma (NPC) and Burkitt lym- lymphoma, described in Chapter 22, has unique
phoma (BL) in a volume dedicated to the epide- epidemiological properties, and the recent finding
miology and control of viral infections in man. Yet of seasonal variation of the disease(132) further
their inclusion betrays the role of epidemiology in reinforces the likelihood that an environmental
investigating the relationship between viruses and factor(s) triggers the development of the clinical
human tumors. disease. NPC is quite different epidemiologically
There are two different approaches to the study from BL, affecting different racial and age groups,
of the role of viruses in the development of human but the same serological and virological associa-'
tumors. The first is to follow the trail emerging tion exists between that tumor and the Epstein-
from the study of tumors in experimental and Barr herpesvirus (EBV). As shown below, the
domestic animals, where RNA tumor viruses are epidemiological characteristics of NPC suggest
felt by some to constitute the final common path- that genetic factors have a considerable role in the
way for oncogenesis.(SH) Major efforts, mostly in determination of risk. As genetic factors play a
the United States, have been made to uncover crucial role in controlling susceptibility and resist-
oncogenic RNA viruses (oncornaviruses) in man. ance of mice to microbiological agents, including
There is indirect evidence that such viruses exist, oncogenic viruses/ 80 .81 ) the association between
and search in this area must continue as leukemias, EBV and NPC assumes a new dimension.
sarcomas, and breast carcinomas in humans are The study of NPC is an example of multidisci-
possibly linked with such agents. plinary and international effod 27 ) where clini-
The second approach is to follow an epidemiol- cians, epidemiologists, statisticians, pathologists,
ogicallead. Certain human tumors, such as Burkitt viral oncologists, and immunologists from many
G. de-The and C. Muir . International Agency for countries join forces and complementary technol-
Research on Cancer, Lyon, France J. H. C. Ho . ogy to seek the etiology of a tumor which repre-
Institute of Radiology, Queen Elizabeth Hospital, sents one of the most frequent cancers in South
Kowloon, Hong Kong China and in some parts of Southeast Asia.
539
540 Chapter 25 • Nasopharyngeal Carcinoma
2. Historical Background ica debated the classification and histogenesis of

the neoplasms, notably the so-called lymphoepi-
On the basis of the work of Derry,(]S) Smith and thelioma and transitional cell carcinomas, New
Dawson/ lI7) Krogman/ 76l and Wells/130.13J) Clif- and Kirch, and later others including Digby et
ford has stated that the oldest known pathological al.,<30l concluded that all were variants of squa-
specimens of nasopharyngeal carcinoma were de- mous cell carcinoma-a view since upheld by
rived from inhabitants of northeast Africa and the ultrastructural studies. (39.121)
Middle East from the period 3500--3000 B.C. (16) Before 1962 there was no real attempt to study
Reviewing the evidence, Hd 59 ) concluded that the epidemiology of NPC. The medical profession
only one of the Romano-Egyptian cases described seemed to be quite satisfied with the hypothesis
by Smith and Dawson(117l could have been a advanced by Dobson(3J) that the high frequency
nasopharyngeal cancer. In Europe, Durand-Far- of NPC in Chinese was related to the poorly
del(32) is generally credited as giving the first ventilated houses in which they lived, inhaling the
clinical description of a case of NPC, while Mi- carcinogen-laden domestic smoke. This was later
chaux(86) reported the first histologically proven disputed by Ho(55.59) when he found that the
case. frequency of NPC in Chinese fisherfolk who lived
In China, NPC has been recognized, at least practically all their lives in boats and cooked their
since the early part of this century, as the "Kwan- food in the open was significantly higher than that
tung (Guangdong) tumor," stressing the high fre- in the rest of the Chinese population in Hong
quency of this neoplasm in Kwantung, the south- Kong, the majority of whom lived in congested
ernmost province. Ho/59) in his search for a dwellings on land.
description of the disease in early Chinese medical Credit for initiating multinational epidemiologi-
writings, could only find a fatal disease called shih cal studies of this cancer goes to the International
ying, also known as shih yung, both meaning Union Against Cancer (UICC), which organized
literally "loss of nutrition." The description given the first Symposium on Nasopharyngeal Cancer,
in the Encyclopaedia of Chinese Medical Terms, held in Singapore in 1964. Subsequently, the task
edited by WU/ 137 ) of the clinical picture of shih of promoting multinational collaborative epide-
ying is consistent with that of the "mainly metas- miological and laboratory studies was taken up by
tatic type" of NPC 571 (see Section 8.2.1). How- the International Agency for Research on Cancer
ever, no mention was made in the encyclopedia as (IARC) leading to the association between EBV and
to when the disease was first described. The NPC. (22.23.46.97)
apparent lack of a full description of NPC in early
Chinese medical writings may be because the
disease is largely confined to the south, whereas
practically all the early writings were by physi- 3. Methodology Involved in Epidemiological
cians in northern and central China. (56) and Virological Studies
In parts of Asia it was some time before it was
realized that the malignant deposits in the neck 3.1. Sources of Mortality Data
lymph nodes were secondary to a nasopharyngeal
primary tumor, and Bonne and others continued Mortality data are derived from cause-of-death
to describe such neoplasms as "reticuloendothe- statements on death certificates. The figures avail-
lioma lymphoglandulae colli lateralis." It was able for nasopharyngeal cancer* for a wide variety
probably Digby et al. (301 who first drew attention of countries have been aggregated by the World
to the unusual frequency of NPC among Chinese
• All rates in this chapter are age-adjusted to the world
in Hong Kong and over large parts of China in a population distribution (UICe, 1970)(124) and are ex-
remarkably detailed description of the clinical and pressed per 100,000 per annum. In this chapter, naso-
pathological features in 103 cases in which it was pharyngeal cancer refers not only to the carcinomas
stated categorically that the tumors arose in the (NPC) but also to neoplasms of other cell types, e.g.,
epithelium of the nasopharynx. (79) chordoma, multiple myeloma, and the malignant lym-
While pathologists in Europe and North Amer- phomas.
Chapter 25 • Nasopharyngeal Carcinoma 541
Health Organization(135l and age-specific rates, type is represented by case/control studies aimed
but not age-adjusted rates, provided. In general, at evaluating the humoral immune response of the
the disease is exceedingly rare. Further, national NPC patients compared to that of various con-
mortality data rarely give figures for racial groups trols.!52l The second type is population-based sur-
within a country. Although rates for administra- veys aimed at establishing the epidemiological
tive divisions such as provinces are often available characteristics of the virus in populations at differ-
on request, these are usually based on small num- ent risk for EBV-associated diseases. We have
bers of cases and are subject to considerable statis- been conducting such a study covering Chinese in
tical fluctuation. Hong Kong, Indians, Chinese and Malays in Sin-
gapore, Nilotic tribes in Uganda, and Caucasians
in France.(2Bl
3.2. Sources of Morbidity (Incidence) Data 3.4.1. Selection of Groups. In the first type of
studies, controls were usually selected among pa-
Morbidity data for nasopharyngeal cancer* are tients of the same age group and sex with tumors
obtained from cancer registries, being derived other than NPC. Whenever possible, normal indi-
from reports on newly diagnosed cases of cancer viduals such as volunteer blood donors also served
occurring in a defined population. Regrettably, as controls. In these seroepidemiological studies,
such information is generally lacking for much of the choice of groups to be bled was a matter of
the United States, for most of South America, compromise between representativeness and feasi-
Africa, Asia, and Oceania, and for large parts of bility, and included volunteers in maternity and
Europe and the USSR. Even though there are large child clinics, primary and secondary schools, uni-
gaps in geographic coverage,<91) the morbidity versities, and army and police groups. Soon it was
from cancer is probably better measured than for found that such selected groups were not a good
any other chronic disease and for many infectious representation of the population at large. Successful
and acute processes. Available morbidity data of efforts were then made to obtain representative
good quality are published in the DICC mono- samples of the general population, and randomly
graphs Cancer Incidence in Five Continents!l23.124l selected families were visited and interviewed and
and are presented in Fig. 1. It will be observed the eligible individuals bled.
that for the vast majority of cancer registries not 3.4.2. Serological Tests. Three techniques are
only are the age-adjusted rates below one per mainly utilized in EBV serology: immunofluores-
100,000 per annum* but also many rates are based cence, complement fixation, and immunoprecipi-
on fewer than ten cases. tation.
a. Immunofluorescence Tests. Immunofluoresc-
ence is the main tool of EBV serology as it is used
3.3. Sources of Relative Frequency Data for the detection of four different groups of EBV-
determined antigens: VCA, EA, MA, and EBNA.
Relative frequency data, indicating the propor- (1) The VCA Test: As described by the
tion of nasopharyngeal cancer* observed in a se- Henles/ 45l the VCA test is an indirect immuno-
ries of patients with all types of cancer, are derived fluorescence test, detecting intracellular structural
from the files of pathology and radiotherapy de- antigens (virion capsid antigens) in EBV-produc-
partments. The sources of bias in measuring rela- ing cell lines. In routine testing one detects IgG,
tive frequency as well as in mortality and morbid- and a positive test (i.e., 2:1:10) merely reflects that
ity data have been analyzed.(M.91l the individual concerned has been infected and
has reacted to the infection. The titers of VCA
antibodies obtained in various laboratories on the
3.4. Serological Surveys same sera can vary from one to three dilutions; the
causes of such variations are multiple, the main
Two types of serological surveys have been being the lymphoblastoid cell line and the propor-
carried out to unravel the relationship between the tion of VCA-positive cells at the time of test-
Epstein-Barr herpesvirus (EBV) and NPC. The first ing.(43l All serological tests carried out within the
MALES
==:==--
FEMALES
~~~~~~§§§§~===1=====:- - .
!
• SINGAPORE: CHINESE
• HAWAII: CHINESE HAWAII: CHINESE
HAWAII: HAWAIIAN SINGAPORE: CHINESE
SINGAPORE: MALAYS
• SINGAPORE: NAlAYS • ICELAND
HAWAII: FILIPINO JOHANNESBURG: BANTU
• JAMAICA • JEWS BORN IN AFR./ASIA
Lc.JRENCO MARQUES HAWAII: CAUCASIAN
• JEWS BORN AFR./ASIA HAWAII: HAWAIIAN
• ROMANIA, BANAT JAMAICA
ISRAEL: NON JEWS ISRAEL: NON JEWS
MISKOLC ROMANIA: BANAT
ICELAND * B<»IBAY
HAWAII: CAUCASIAN • ISRAEL: ALL JEWS
• ISRAEL: ALL JEWS IBADAN
JOHANNESBURG: BANTU CAPE PROV. WHITE
HAWAII: JAPANESE • ALBERTA
NEW BRUNSWICK NEW BRUNSWICK
NEWFOUNDlAND NEVADA
• SASKATCHEWAN MISKOLC
• PUERTO RICO MANITOBA
JEWS BORN IN ISRAEL Nl,FOUNDLAND
CAPE PROV. COLOURED JEWS BORN IN ISRAEL
EL PASO: NON LATIN , FINLAND
• BOMBAY • KATOWICE
• JEWS BORN EUR./ AMER. , SWEDEN
• SWEDEN HAWAII: JAPANESE
IBADAN NATAL AFRICAN
• ALBERTA SASKATCHEWAN
• ALAMEDA WHITE PUERTO RICO
• CONNECTICUT ALAMEDA WHITE
NEVADA 'N.Y. STATE
• N.V. STATE NORWAY RURAL
• NORWAV: URBAN WARSAW
• CRACOW , U.K. BIRNINGHAM REG.
• U.K. BIRNINGHAM REG. , U.K. SHEFFIELD REG.
• U.K. LIVERPOOL REG. , U.K. S.W. REGION
• U. K. SCOTLANO , U.K. LIVERPOOL REG.
CAPE PROV. WHITE • SLOVENIA
JAPAN: OKAVAMA CAPE PROV. COLOUREO
• FINLAND CONNECTICUT
• NORWAV JEWS BORN EUR./AMER.
• U.K. OXFORD REG. JAPAN, MIVAGI
• U.K. SHEFFIELD REG. * OOR
• U.K. S.W. REGION SZABOlCS-SZATMAR
SLOVENIA NETHERLANDS
MANITOBA * NORWAY
* oDR NORWAV URBAN
COUNTY VAS POLANO, 4 RURAL AREAS
• NORWAV RURAL U.K. OXFORD REG.
WARSAW • U. K. SCOTLAND REG.
• N. ZEALAND: EUROPEAN N. ZEALAND: EUROPEAN
NETHERLANDS LOURENCO MARQUES
KATOWICE BULAWAYO: AFRICAN
N.ZEALAND: MAORI CAPE PROV. BANTU
SINGAPORE INC.. PAK. NATAL: INDIAN
BULAWAYO: AFRICAN UGANDA: KVADONDO
CHILE CHILE
JAPAN: MHAGI CALI
SZABDlCS-SZATHAR ALAMEDA: NEGRO
CAPE PROV. BANTU EL PASO: LATIN
NATAL AFRICAN EL PASO: NON LATIN
UGANDA: KVADONDO JAPAN: OKAVAMA
CALI COUNTY VAS
ALAMEDA NEGRO CRACOW
EL PASO LATIN N. ZEALAND: MAORI
POLAND, 4 RURAL AREAS HAWAII: FILIPINO
SINGAPORE IND. PAK.
Fig. 1. Age-adjusted morbidity rates for NPC by sex. All rates are standardized to the world population distribution
(UICe, 1970).<124) Data are mainly derived from Cancer Incidence in Five Continents 1966, 1970<123,(24) and Muir.(90)
• Rates based on more than 10 cases.
IARe seroepidemiological survey were done using duced within a few hours after superinfection by
the Jijoye cell line as the source of antigen. Large EBV of non-virus-producing lymphoblastoid lines
antigen batches were prepared to minimize the such as Raji. Early antigen synthesis does not
variation of titers related to the percentage of IF- require DNA replication, and appears to consist of
positive cells. The small variations still observed two different antigens: a diffuse (D) antigen and a
were evaluated and, if necessary, were corrected restricted (R) one.'48) Antibodies against EA re-
during statistical analysis. flect an active infection of the organism concerned.
(2) The EA Test: Also described by Henle et (3) The MA Test: Developed and extensively
al. ,<47.49) the EA test detects "early antigens" pro- used by Klein et al.,";9) the MA test detects EBV-
determined membrane-bound antigens. The test is useful to survey the way of life of groups at high
done on live cells, in contrast to the VCA and EA and low risk for the disease to determine whether
tests where acetone fixation is used. Membrane there are habits or exposures which may be perti-
an.tigens are comprised of at least three different nent to disease development. Such surveys are
antigenic components. ' 7J) Antibodies against MA usually best conducted by anthropologists or soci-
seem to be of clinical and prognostic value in BL ologists. As the sum total of life style embraces so
and NPC patients.<7o) many factors, it is essential to describe the current
(4) The EBNA Test: As described by Reedman etiological hypothesis of carcinogenesis to such
and Klein/ 1(12 ) the EBNA test detects the EBV- investigators so that their studies may have spe-
determined nuclear antigen(s) which appears to be cific areas of focus. The very detailed analysis of
related to the soluble antigen, as detected by the the way of life in the Caspian region of Iran
CF test.(29.74,77a) This nuclear antigen appears a few carried out in connection with esophageal cancer
hours after EBV infection/ 3,l39) and is present in in that area typifies the possible scope of such
EBV-transformed lymphoid cells even when they investigations. (75)
are not virus producers. Because of the long induction time for cancer,
EBNA is also detected in BL'1(13) and NPC 21UH;J the conditions as they obtained 20-30 yr ago
biopsies, as well as in NPC biopsies transplanted should be ascertained rather than those prevailing
into nude mice.'73) at the time of the survey.
b. Complement Fixation Tests. Complement fixa-
tion is used in EBV serology with either particulate
antigen, i.e., semipurified virus,'40l or soluble 3.6. Laboratory Diagnosis
antigen, extracted from non-virus-producing cell
lines.(119.12o) These CF antigens seem to divide 3.6.1. Histopathology. Diagnosis depends on
into three components: one is sedimentable and the demonstration of the neoplasm in a biopsy of
heat resistant, corresponding to a structural anti- the nasopharynx.(lI Biopsies from many areas and
gen, one is heat labile and sedimentable, and one at several times may be needed, as the tumorous
is heat stable and soluble, the last two components process often infiltrates underneath an apparently
being non structural antigens.'129) Antibodies normal mucosa. The microscopic appearances of
against particulate antigen(s) parallel those di- the neoplasms have been authoritatively reviewed
rected against VCA, whereas antibodies directed by Shanmugaratnam and Muir(1OS) and by Yeh.(l40)
against soluble antigen from a non-virus-produc- The vast majority of NPCs arise from the nasophar-
ing line (Raji) appear to parallel those directed yngeal epithelium and should be considered, irres-
against EBNA and seem to reflect a prolonged pective of their appearance on light microscopy, as
infection with this virus. The CF/S antibodies variants of squamous cell carcinomas. This state-
develop only weeks or months after infectious ment is based on electron microscopic studies
mononucleosis. r IIS.12") which have revealed the presence of tonofibrils and
c. Immunoprecipitation 1 est. This test for EBV other epithelial markers in most of the histological
was developed by Old et al. (97) using the Ouchter- variants.<39,l20,l2l) Any of the histological types of
lony immunodiffusion technique. This immuno- NPC may be infiltrated by varying amounts of lym-
precipitation (IP) antigen seems to be closely re- phocytes: this feature is not restricted to the lym-
lated, if not identical, to complement fixation phoepitheliomas and may be pertinent to the asso-
soluble (CF/S) antigen. (ll1ll This test needs large ciation with a lymphotropic virus. For the
amounts of antigen, and is not quantitative. experienced pathologist working in a high-inci-
dence area, diagnosis rarely poses any problems;
however, the Schminke variant composed of single
3.5. Sociological Surveys or small loose aggregations of malignant cells set in
a dense lymphoid stroma and the rarer spindle cell
When no clear lead to the etiology of a neoplasm and clear cell variants may cause difficulties to
or a plausible hypothesis to test exists, it is often those unfamiliar with the region. While the diag-
nosis, particularly of the Regaud variant of the neo- ies are mostly directed against the D or diffuse
plasm, can usually be made with confidence from component of the EA complex, whereas in BL pa-
the biopsied secondary deposits in a neck lymph tients EA antibodies are directed against the R or
node, this practice is to be deprecated as it does not restricted component.(48) The EA reactivity in NPC
indicate unequivocally the site of the primary tu- patients is also stage dependent, and Henle et al. is
mor and nasopharyngeal biopsy is simpler to per- of the opinion that reactivity to D component prob-
form. ably reflects the degree of lymph node involve-
The pathologist working in a low-incidence area ment.(S2)
should ask himself, when confronted by a naso- Antibodies against complement fixation soluble
pharyngeal biopsy or a secondary deposit in an (CF/S) antigen are already very high in Chinese
upper neck lymph node, "Is this a Schminke NPC patients in stage 1'25) (see Table 1), in con-
variant?" and "What about the nasopharynx?" trast to BL patients where CF/S antibodies are low
3.6.2. Serology. There is no serological diagno- at an early stage and increase with clinical deterio-
sis for NPC per se, but there is a characteristic EBV ration. (]]8.119) CF antibodies against soluble anti-
antibody pattern associated with this tumor. NPC gen increase slightly from stage I to stage V of
patients, regardless of their ethnic or geographic NPC and in both diseases appear to have a prog-
origin, have high serological reactivities against nostic value and can be used as a useful clinical
EBV antigens. This regularity in humoral response guide. Antibodies against membrane antigen are
of NPC; patients to EBV, regardless of origin, con- also regularly high in NPC patients.(20)
trasts with the situation of BL patients from Mrica, 3.6.3. Molecular Virology. As is true for serol-
who have high EBV reactivities and high EBV DNA ogical diagnosis, there is no virological test allow-
content, whereas patients from the United States ing the identification of NPC, but there is a
have inconsistently elevated EBV reactivities and characteristic pattern indicating the regular pres-
EBV genome content in tumor cells.(78,98) ence of viral fingerprints in NPC tumor tissue. In
NPC patients are characterized by high serologi- the first place, EBV DNA sequences have been
cal reactivities against every EBV antigen in a found by DNNDNA hybridization, DNNcRNA
manner similar to that of BL patients, as seen in hybridization, and DNNDNA reassociation kinet-
Table 1. High antibody titers against viral capsid ics in whole NPC biopsies.(95.143) Because EBV is a
antigen (VCA) have been found in sera from NPC lymphotropic virus and NPC is an epithelial tumor
patients, with geometric mean titers (GMT) in- (see Section 3.6.1), it was believed that the EBV
creasing with the severity of the disease, from stage DNA detected was localized in lymphoid cells,
I to stage V.(46,29) Antibodies against early antigen which are regularly present in NPC tumors and
(EAy47> are of special interest as they reflect an not in the epithelial tumor cells. However, the
active EBV infection. In NPC patients, as in pa- opposite has now been demonstrated by zur Hau-
tients with infectious mononucleosis, EA antibod- sen's group, who showed that EBV DNA se-
Table 1. Geometric Mean Titers of EBV Reactivities in NPC Chinese Sera at Different Clinical Stages
Type of sera
EBV reactivity NPC stage I NPC stage II NPC stage III NPC stage IV NPC stage V
VCA Jijoye 578.6 764.8 1198.7 1062.1 1205.4

EA Raji 36.2 48.9 140.7 147.0 176.9
EBNA (ACIF) Raji 389.9 450.6 465.8 853.3 1157.2
CFtS Raji 32.0 32.0 50.2 59.5 93.0
Number of sera 17 19 20 19 16
quences were predominantly in epithelial in the nasopharynx are obvious candidates to repli-
cells./ 1a4 ) More recent studies, where EBV DNA cate the virus under normal conditions, but up to
was detected in separated cell populations from now nobody has succeeded in demonstrating such
NPC biopsies (epithelial tumor cells on one hand eventuality. On the other hand, the lymphoid cells
and lymphocytes on the other), confirmed that regularly present in the submucosa of the naso-
viral genomes are predominantly present in epi- pharynx might playa critical role both in the repli-
thelial tumor cells. (21.98a) cation of the virus and in tumor deve,lopment, as
3.6.4 Immunofluorescence on tumor biopsies. the EBV is mainly lymphotropic, and as this tumor
EBV fingerprints can also be detected by the pres- arises only in the area of the lymphoepithelium.
ence of specific nuclear antigens (EBNA) in touch The B or T nature of the lymphocytes present in the
smears of NPC biopsies (see Fig. 2).(26.65) Klein et tumor is a matter of controversy: Yata et al. (139a)
al. (73) successfully grafted NPC tumor biopsies to found that both Band T cells were present in tumor
nude mice and observed that these grafted tumors tissue but that a relative increase of B cells was
contained only epithelial cells and regularly exhib- observed in the lymphoid depleted areas as well as
ited EBV-specific nuclear antigen. These epithelial in direct contact with epithelial cells. In contrast,
characteristics were confirmed by electron micros- Jondal and Klein(66a) found that the lymphocytes
copy.(29a). After treatment with IUdR or BUdR, or present in tumor biopsies were mostly of T type.
after superinfection with HR1-EB virus, epithelial The study of the lymphocytes of the normal naso-
tumor cells can synthetize EN43a), suggesting that pharyngeal mucosa and in NPC is therefore of great
such epithelial cells have surface receptors for EBV importance in understanding the pathogenesis of
and that, under certain circumstances, the viral such tumor.
genome can be derepressed in tumor cells. Latent infection by EBV is present in every
population around the world, but age at primary
infection varies greatly between ethnic groups and
geographic areas. As is true for other herpesvi-
ruses, EBV reinfection might occur, as. well as
4. Biological Characteristics of EBV in Its
reactivation of a latent infection by factors which are
Relationship with NPC unknown at present. One abnormal condition
which "turns on" viral replication is the transfer of
The herpesvirus discovered by Epstein et al. in circulating lymphocytes to in vitro culture, leading
1964/ aa ) in a culture derived from a Burkitt lym- to the establishment of lymphoblastoid lines. This
phoma biopsy is a widespread and silent parasite phenomenon (called "lymphoblastoid transforma-
of human B lymphoid cells. The lack of a permis- tion")<S) is of as great interest to oncovirologists as
sive cell system allowing in vitro virus titration and it is to immunologists. Although poorly understood
virus cloning makes virological studies on the EBV (see review of Klein),(72) there is agreement that
rather difficult. In vivo, the EBV probably infects B such a phenomenon is caused by the presence of
lymphocytes in circulating blood, lymph nodes, EBV-infected lymphocytes. (~~.23.94)
spleen, etc., where the viral infection becomes Does "lymphoblastoid transformation" occur in
latent. vivo and are such transformed cells eliminated by
A number of investigators have searched for a immunosurveillance mechanisms? Expression of
reservoir of EBV in the human organism outside viral-determined antigens occurs in BL tumor cells,
the lymphocytes (which represent a semipermis- where the EBNA (see Section 3.4)«;9.103) and MA
sive system), but with no success to date. Only B can be detected.
lymphocytes appear to be permissive for EBV In vitro (i.e., in lymphoblastoid lines) viral repli-
infection: when Band T lymphoid populations are cation is also controlled by unknown factors and
separated from the blood of EBV seropositive indi- synthesis of VCA, EA, etc., taking place in a chang-
viduals, only B-cell populations eventually give ing proportion of cells. Such variation in "viral
rise to permanent lymphoblastoid cell lines, the expression" is line dependent, and also time de-
best marker for EBV infectionY39) Epithelial cell:; pendent for most lines.<23·41) Early functions in-
clude the nuclear (EBNA), membrane, and early ditions. The lack of similar serological reactivities
antigens, and those appearing later include struc- in patients with other carcinomas localized in
tural viral capsid and probably the immunoprecipi- nearby tissues such as the oro- and hypopharynx
tating (IP) antigens. (Table 2), and even in patients with tumors of the
The mode of transmission of EBV is not fully nasopharynx other than carcinomas,<l9l indicates
established, but saliva appears to play an impor- that a peculiar relationship must exist between
tant role in horizontal transmission, as infectious EBV and NPC.
and transforming EBV has regularly been found in The nature of the association between EBV and
the saliva of 1M patients and of seropositive nor- both BL and NPC is still to be established. Since
mal individuals.(34,42,87,93) Sociocultural customs or EBV is a lymphotropic virus, a logical hypothesis
habits, in which exchange of saliva between adults is that EBV causes BL as it causes 1M. In. this
and young infants takes place, could playa role in regard, a prospective seroepidemiological study on
EBV infection in early infancy. Breast feeding may BL is now being carried out in Uganda by
play a role in EBV transmission, as milk does IARC,<24) where pre-BL sera will be available to
contain EBV-infected cells, as demonstrated by the determine the EBV immune status of BL patients
establishment of lymphoblastoid lines from hu- before the clinical disease develops. Such a pro-
man milk (Feller, personal communication). All spective study is out of the question for NPC. In
data available indicate that EBV infection is not this tumor, however, the regular presence of EBV
vertically transmitted. (35.50.99) genoines in epithelial tumor cells opposes the
The full spectrum of host response to EBV in the passenger hypothesis and favors an etiological role
human organism is still ill defined. This virus for this virus, which can no longer be called
causes Paul-Bunnell positive infectious mononu- strictly lymphotropic.
cleosis (1M) in young adults.(35.5o.511 Most primary
infections, however, are asymptomatic, and this
virus would have been considered as a mild,
inoffensive parasite if it had not been associated
with two malignancies: BL and NPC. We saw in
Section 3.4 that the association between EBV and
NPC is based on serological data and on the
5.1. Incidence, Frequency, and Geographic
evidence for the presence of EBV fingerprints
Distribution
(DNA and EBNA) in tumor cells of both BL and
NPC. For the vast majority of population groups, the
This characteristic pattern is found in NPC pa- incidence rates for nasopharyngeal cancer are be-
tients originating from various parts of the world, low one per 100,000 per annum. In persons of
and such consistency is of particular importance Chinese descent, much higher rates have been
since NPC is a distinctive pathological entity found and morbidity rates have recently become
which cannot be readily confused with other con- available for selected Chinese populations (Fig. 3).
Table 2. Geometric Mean Titers of EBV Reactivities in Different Groups of Chinese Sera
EBV reactivities
Type of sera VCAJijoye EA Raji EBNA (ACIF) Raji CF/S Raji Number of sera
NPC patients 937.3 93.3 605.4 49.9 91

Tumor other than NPC 296.2 3.9 115.2 11.6 37
Normal individuals 128 2.2 92.1 9.0 47
Fig. 2. Touch smear from an NPC biopsy originating from Hong Kong (Reg. No.
74/1173), stained for EBNA by the anticomplement immunofluorescent test (ACIF)
using an NPC serum (Tu 125) having no detectable antinuclear factor. Note the coarse,
granular aspect of the EBNA. The positive cells here are believed to be epithelial.
HONG KONG 'I;':::'::~..~..'.'

..•.•..~..~...1.0..2• • • • • • 24.3
SINGAPORE CANTONESE 'LIII:III

.. l1li
.. l1li
.. l1li
.. 1III .. I I .I I : :I I : : I I : : ~i.10•.S• • • • • • • • 29.4
.. IIII
TEOCHEW ....•....•.::"j151.9-_ _•
•.....111 17.4
Fig. 3. Age-adjusted morbidity for

NPC for selected Chinese popula- ~.::::.:::::1I!:::~4•.•0 • • • 13.7
HOKKIENE£j
E££3
tions, by sex (see text).
12.4
CALIFORNIA 5.4
HAWAII
TAIWAN MAIN I ..............:....... '1 11 .4

LANDERS···························.!·············· 11.7
TAIWANESE r$.
&;;;;.;;;.;J 2.8
5.9
The rates for Singapore and Hong Kong Chinese among the "boat people" was higher (rate of 16.4)
are similar, being almost twice those for Chinese than that among the land dwellers (rate of 10.2).
in Hawaii, California, and Taiwan (the rates for The sex incidence ratio of nasopharyngeal cancer
California and Hawaii are based on small numbers in the boat group was 2.7 males to 1 female, much
of cases). the same as for land dwellers. cc'2.c;aJ The boat
With respect to the principal Chinese language people are so called because they live on boats
groups Hving in Singapore, the rates for both sexes with only occasional visits to land. They speak
in the Cantonese are twice those of the Teochew their own distinctive dialects of Cantonese and
(known as Chiu Chau in Hong Kong) and the have been present in the Hong Kong region since
Hokkien (who come from the province of Fukien, time unknown.
which is to the north of and in continuity with the The rates for Taiwan indicate differences in risk
Chiu Chau district, northeast of Hong Kong). As between those born in China and those born in
the Cantonese have a much lower risk of esopha- Taiwan. Lin et ai. (82) do not give rates by province
geal cancer than the Hokkien and Teochew, it is of birth in China, which is unfortunate as it would
unlikely that these differences could be due to be of great interest to have an estimate of inci-
differential reporting between the various dence for the northern provinces (there are few
groups.Cl12) migrants from north China in Southeast Asia).
In his studies of Hong Kong Chinese, Ho coo.o9) Chinese in Australia appear to have a raised
noted that the lowest incidence rate" was found in risk. C1o «.13«) There are regrettably no incidence
Chinese originating from the central coastal prov- data from China itself. Relative frequency figures
inces (4.0) and that a 3-4 times higher incidence published in 1959CCi4 ) suggest an increase from
was observed in persons originating from Kwan- north to south.
tung (Guangdong) Province. The Chiu Chau area The Malay people of Singapore, who in general
of this province, located to the northeast of Hong use the medical facilities much less than the other
Kong, showed a rate of B.D. On further examina- groups, have comparatively high rates (see Fig. 1).
tion of the Hong Kong population/ o7 ) it was This group tends to live in the rural districts of the
noted that nasopharyngeal cancer incidence" island and has a way of life which varies consider-
ably from that of the Chinese. The incidence rates
.. These rates are not strictly comparable to those in Fig. 1, in the Caucasoid Indian and Pakistani moiety of
being adjusted to the 1961 Hong Kong census popula- the Singapore population are very low (see Fig. 1).
tion. Incidence rates for all ethnic groups living on
Hawaii are raised, but these are based on very related to the entire Tunisian population, the
small numbers (see Fig. 1). In Israel, although the crude minimum rates for males and females are 2.6
cancer is at a much lower incidence level, there are and 0.9 respectively. As the period covered repre-
still interesting differences among Jews coming sents when the Institute was begun, it is likely
from various parts of the world. The highest rates that there was gross underreporting.
are noted in the Jews born in Asia or Africa (M, F: In summary, the disease is very common in
1.8, 1.0) and in non-Jews (M, F: 1.3, 0.6). Both of southern Chinese and is somewhat less so in the
these groups are much less likely to seek medical Chinese-mixed populations of Southeast Asia.
advice than the Jews born in Israel or in Europe Rare in Japan and infrequent in north China, NPC
and America, in whom the rates are much lower is of moderate incidence in the Maghreb (Tunisia,
(M, F: 0.6, 0.1). Many of the Jews from Mrica and possibly Algeria and Morocco), in Sudan/ 1U41
migrated from Morocco, Algeria, and Tunisia, in northern parts of Kenya and Uganda, and in
where there is evidence (see below) that NPC is of Israel in migrants from North Africa. Elsewhere it
raised frequency. is rare.
Most of the other information on the distribu-
tion of NPC comes from relative frequency series
(Table 3). This has been summarized by Muir. !90l 5.2. Epidemic Behavior
NPC is common in many populations of Southeast
Asia such as Malays, Thais, Vietnamese, and Ja- There have not been any reports of clustering in
vanese in which Chinese admixture and racial nasopharyngeal cancer. This does not preclude a
intertningling cannot be excluded, although it is part-viral etiology because, as with a varying and
very rare in Japanese and probably infrequent in lengthy latent period, the cases resulting from an
the populations of Korea/ HO ) Mongolia, and infectious process occurring every few years would
North China. ((;4) be unlikely to appear in cyclical fashion.
Clifford! 15) has claimed that NPC is of high
relative frequency among head and neck malig-
nancies treated in Nairobi. However, Linsell(84 ) 5.3. Sex and Age
noted a more modest relative frequency of 2.3% in
Kenya biopsy material in 1957-1961, this being Most series show a male preponderance of
greatest in the Kalenjin tribe (3.2%) and least in around twofold.
the coastal Bantu (0.2%). Computing crude inci- The curves of age-specific incidence for naEO-
dence rates from Clifford's material, Muir!SOl pharyngeal cancer in Chinese populations in Hong
noted a maximum rate of 1.3 in male Nandi. This Kong and Singapore are very similar in that they
rate is not age adjusted, and it is likely that there show a fairly steep rise from 2(}-24 yr of age to
is considerableunderdiagnosis. Nevertheless, it is about 5(}-54, with a fall thereafter. f591 This could
doubtful that the "true" age-adjusted rate would be interpreted as representing a cessation of expo-
be greater than 5. sure at around 40 yr of age, a cohort effect such as
In Uganda, Schmauz and Templeton(]()5) noted a has been noted for breast cancer 71 or, the exhaus-
higher minimum age-adjusted incidence rate in tion of a pool of susceptibles.
Nilotics and para-Nilotics than in the Bantu-Su- The curve for NPC in Swedes is dissimilar in
danic groups. In general, the north of the country that the rise occurs two decades later and contin-
showed a higher incidence than did the south, ues until age 7(}-74.!591 Bailar 4 ) noted that NPC
despite the better hospital and transport systems tends to appear at an earlier age than most other
in the south. forms of cancer in Caucasian populations. How-
Relative frequency studies from Algeria, Mo- ever, comparison of the age distribution of pa-
rocco, and Tunisia suggest a moderately elevated tients in areas where NPC is common and else-
NPC level. In Tunisia, Zaouche(142) noted that in where is difficult because it is likely that each
23 months 156 nasopharyngeal cancers were diag- series contains some systematic malignant lym-
nosed at the Institut National de Cancerologie phomas which first presented in the nasopharyn-
(Institut Salah Azaiz) in Tunis. If these cases are geal region and such neoplasms are proportion-
Table 3. Rela ti ve Frequency of Nasop haryngeal Cancer in African and Asian Populations"
Relative Rela ti ve
Cases frequency (%) Cases frequency (%)
Population group M F M F Population group M F M F
Malaysia Algeria
Chinese lSO 77 11 .5 6.0 Algerians 364 5.0
Malays 54 20 10.6 ' .2 Europeans 83 35
Indians 7 2 1.3 OA
Tunisia
Singapore Tunisians 125 25 '.3
Chinese 442 202 13.9 8.1 Europeans 1.6
Malays 20 5 11.2 2.8
Indians 2 0 0.5 0 Congo (Brazzaville) 1 0 OA 0
Senegal (Dakar) 1 0 0.1 0

Thaila nd (Bangkok)
Chinese 27 15.9 Ivory Coast (Abidjan) 2 0 0.5 0
ChinesefThai 20 10.3
Thais 29 ' .6 Morocco 95 46 8.5 38
North Thais 34 19 3.7 2.1 Sudan 27 12 5.6 2.1

(Chiang Mai) Zanzibar
Negroes OA
Sabah Arabs 1.3
. Chinese 9 0 8.9 0
Indigenous 11 3 9.2 3. Mozambique
(Louren~o Marques) 3 0 0.7 0
Sarawak
Chinese 6 5 ' .8 3.8 Nigeria (Ibadan) 5 3 0.7 OA
Malays 1 32 '.2
Dayaks 8 • 86 ' .9 South Africa (Cape
Province: Coloureds)
• 0.5 0.1
Java
Chinese 31 3 18.2 1.4
Javanese 108 44 10.3 2.9
Formosa 1260 .46 23.2 5.2

Filipinos (Philippines) 182 2.9
Filipinos (Hawaii) 8 0 25 0
Vietnamese lOS
163 " 3.7
• For reference, ~ Muir.''''
ately much commoner in low-incidence popu- 5.4. Occupation

la lionsYOT.l08. lt(I)
It is of interest to note that in Tunisia and the Analysis of mortality rates in males by occupa-
Sudan the age curve appears to be bimodal, 20% tion in Taiwan'IIa' revealed excess risks in those
of cases in the Sudan appearing before the age of engaged in salt production, national defense, pub-
20 yr.'IJ .'()oI) lie service, and min ing. The h igher risk in salt
workers and miners did not, of course, account for Indians and Pakistanis living in Singapore (see
the overall high rate, and the higher rates in the Fig. 1) would be of the greatest interest.
other two groups could be due to the high propor-
tion of mainlanders engaged in these occupations
(see Fig. 3). The "boat" people of Hong Kong are 5.6. Environmental Factors
largely fishermen, but fishermen elsewhere do not PoluninClO()} reviewed the ways of life of "peoples
have a high risk of NPC. The bizarre finding of with high risk of nasopharyngeal cancer and was
three cases of NPC in Canadian bush pilots could unable to identify any single distinguishing fea-
be due to chance. (2) ture. Indeed, Muir and Oakley(88} commented on
the large differences in life style among Chinese,
5.5. Change of Risk on Migration Malays, and Dayaks living in Sarawak (Borneo)
who had, nevertheless, substantially the same fre-
An environmental theory of causation would be quency of the disease.
much more convincing if it could be shown that While there has been no lack of speculation and
groups not normally at high risk for NPC acquired anecdote since the disease was first characterized,
such a risk after a sojourn in a high-incidence Shanmugaratnam and HigginsonCH}9) were the
area, or if migrants from a high-incidence area first to conduct a retrospective survey on a group
were to lose their risk on moving to a low- of .patients with histologically proven primary
incidence area. This is an oversimplification, as NPC and a group of control patients with a variety
migrants often take much of their environment of diseases (including cancer of other sites). There
with them in the form of diet and culture. were no significant occupational or dietary differ-
Buell/89 ) reviewed California death certificates ences, in particular in the use of spices and
for 1955-1964 and found that five of 273 white Chinese soya sauce. The use of traditional Chinese
male decendents with NPC were born in the medicines did not appear to be related, nor were
Philippines or China, areas where the disease is inhalations or intranasal applications of Chinese
endemic. The expected number, based on death medicinal balms, oils, drops, or powders for ail-
certificates for other cancer deaths, was much less ments of the nose, throat, or mouth. Previously
than 1. Analysis of name and birthplace of parents suggested etiological factors such as smoking, op-
of the decenq,ents showed that all were of Cauca- ium use, and use of incense and mosquito coils
sian stock. did not differ between cases and controls.
Fraumeni and Mason(38} noted that the "mortal- Lin et al./ 83 ) in a case/control study in Taiwan,
i ty from NPC was 26-fold in Chinese males and noted that there was a significant excess of smok-
22-fold in Chinese females when compared to the ers among patients, the relative risk for persons
black and white populations of the United States. smoking more than 20 cigarettes a day compared
During the study period, 1950-1969, there was, with those who had never smoked being greater
however, a diminution in risk. This decline could than twofold. Working under poorly ventilated
be due to changed food habits or other environ- conditions was found to enhance risk, as did the
mental factors, or to an increase in the proportion use of herbal drugs and nasal balms or oils. In this
of low-risk central and northern Chinese in the study, the controls used were chosen not from
United States following 1945. Prior to this period, hospital patients but from neighbors of the naso-
immigration was largely confined to high-risk pharyngeal cancer patients. In Taiwan, the neigh-
southern Chinese. King and Haenszel((l8} exam- borhood is a small administrative unit composed
ined mortality among the foreign and native-born of about 20 households. The use of neighborhood
Chinese in the United States. There was an indica- rather than hospital controls has much to com-
tion of a lower risk for Erdai (the U.S.-born mend it in that the controls are much more likely
Chinese). However, Shanmugaratnam and to be representative of the "normal" population.
Tye(]]O} have suggested that the rate is increased Unfortunately, however, the place of origin and
for Singapore-born Chinese, but this question is the period of stay in the neighborhood of the
being reexamined using the most recent Singapore controls were not matched. Working in a poorly
Cancer Registry data. Any rise in incidence among ventilated atmosphere is unlikely to explain the
high risk found in the Hong Kong "boat people," istic genetic profile.(lU) Red cell blood group
who spend most of their lives on their boats and analyses were unrewarding,'44) but highly signifi-
cook their food in the open air.(H2.Ha) cant differences of HL-A type were found between
Clifford"o) suggested that the smoke and Chinese NPC patients and controls.
benzpyrene-containing soot so prominent in the The HL-A antigen profile associated with a high
huts of Kenyan groups with a raised frequency of risk of NPC consisted of an increase in the fre-
the disease could be a causal factor, but the dis- quency of the first-locus antigen (HL-A2) and a
ease was found to be more common in males, who deficit in the frequency of antigens detected at the
spend much less time in the huts. second locus ("blank").'11a) This pattern showed a
Ho(oS.59.H2.Hal suspects that the disease may be relation to the NPC incidence trend in Chinese.
linked with the consumption of one or more tradi- Stated differently, there is an indication that the
tional food items and considers that attention strength of the HL-A association with NPC may
should be given to the use of Cantonese salted reflect the thirty- to fiftyfold difference in inci-
fish, which has been found to contain traces of dence between highest-risk Cantonese Chinese
dimethylnitrosamine (ni trosodimethylamine). (a7) and lowest-risk Indians.'115) Only a small number
This comestible is a traditional item of food of of non-Chinese NPC patients (such as Malays and
southern, but not northern or central, Chinese and Kadazans) have so far been studied, but there is
is eaten from early childhood on. This hypothesis preliminary evidence of an increased frequency of
may be difficult to test as the reliable quantitation the deficit in the second-sublocus antigens. Tu-
of intake by recall during a case/control interview nisians have an incidence of NPC similar to that of
study is difficult. On the other hand, if a nitrosa- the Malays. Betuel et al. ((;) have obtained evidence
mine is involved, it has been shown in animal suggesting that the second-sublocus deficit is also
experiments that a single dose of N-nitrosodime- seen among Tunisian NPC patients, but to a much
thylamine is capable of inducing tumors in more lesser extent than in Chinese.
than 70% of rats.(122) The most likely explanation of the association
between the disease and a deficit in the second-
sub locus HL-A antigens was that an additional
5.7. Genetic Factors antigen existed which was undetectable with the
Descriptive epidemiology has established that reagents used and that this new antigen was
persons of southern Chinese descent, no matter associated with NPC risk. Alternatively, the deficit
where they live, or Southeast Asian populations in patients with NPC was a disease artifact. A new
who have genetic similarities to southern Chinese, antigen, provisionally designated as Singapore 2,
e.g., the Malays, are at high risk for this cancer. has recently been discovered.'1J;) Singapore 2
The disease is less common in north China and appears to have a frequency four- to ninefold
rare in the Japanese, who are also of north Mon- higher in NPC patients than in controls.
goloid origin. The high-risk HL-A pattern in not present in all
Familial aggregation of NPC cases takes place NPC patients and, conversely, such a pattern is
both in high-risk areas, as repeatedly stressed by present in some individuals with no NPC. The
HO,"5.09.H2.Hal and in low-risk areas.(1aa) most likely interpretation is that the HL-A data
Walshe,'12S) in a review of the physical anthro- reveal the existence of NPC disease susceptibility
pology of races with a high incidence of nasophar- gene(s). A reasonable postulate(So) is that the
yngeal cancer, suggested that in the absence of a putative disease susceptibility genes function as
single physical characteristic common to popula- immune response genes.
tions of those countries with a high incidence of
the disease, and not found in others, the most
5.S. Epidemiological Behavior of EBV
profitable approach to the problem would be to
concentrate on patients and controls. One ap- EBV infection is present in every population
proach was to study blood genetic markers (red around the world, but age at primary infection
cell antigens, red cell enzymes, HL-A, etc.) to seems to vary with socioeconomic level. As for
determine whether NPC patients had a character- poliomyelitis, there seems to exist a gradient of
prevalence of infection in young children from 100 d

......--------------------------------------
cold to tropical countries.'3m Such conclusions are
based on investigations carried out in many differ- i\. _-----~--------
:
)
c
ent laboratories involving relatively small numbers 75
of sera, not representing the population at large.
Furthermore, important variabilities have been
observed in the serological results from different 50
laboratories. '4:))
From data accumulated in experimental viral
oncology, we known that the oncogenicity of a
virus depends on such factors as age at infection,
dose and route of infection, and genetic suscepti-
bility. It is therefore felt essential to have reliable Fig. 4. Age-specific prevalence of antibodies to EBV
data on the epidemiology of EBV in populations at VCA in (a) Singapore Indians, (b) Singapore Chinese, (c)
different risk for EBV-related diseases (IM, BL, Caucasians, and (d) Ugandans. Note the important differ-
NPC). Such data would not only be important for ence between 1 and 5 yr of age in these groups.
proposing testable hypothesis regarding the role of
EBV in human malignancies but would also be geometric mean titers of VCA antibodies in the I-
essential for following possible measures to control S yr age group reached or passed 200 (Fig. 5). After
EBV infection, if found desirable. With the above this initial stress, Ugandan children show a dra-
in mind, IARC implemented an international col- matic fall of detectable EBV antibodies, possibly
laborative seroepidemiological study on EBV due to formation of antigen/antibody complexes or
among Chinese (high risk for NPC, nil for 1M and loss of immunity. This phenomen occurs just be-
BL), Ugandans (high risk for BL, low for NPC, nil fore the peak of BL incidence at 7-9 yr of age. The
for 1M), and Europeans (high risk for 1M, low to deterioration with age of the EBV immune re-
nil for NPC and BL). sponse in Ugandans is such that after 10 yr of age
This study took place in Hong Kong, Singapore, the VCA geometric mean titer of Ugandans is the
Uganda, and France, In a first phase, volunteers lowest of the four groups studied. Indians in
from various sources were accepted: maternity and Singapore, who are at very low risk for NPC, BL,
child clinics, army and police, university students,
etc. As such groups did not cover all age groups
and did not represent the populations at large,
200
randomly selected families were visited, inter-
viewed, and bled. A preliminary report of this
i
!
study has been given elsewhere,(28) but the high-
lights pertinent to NPC and BL are given below. :1\/" . 150
The age at primary infection by EBV varies

markedly among the groups studied. As seen in ,I 100
Fig. 4, in the 2-3 yr age group, 97% of Ugandans
were EBV antibody positive, compared with only
\ J
\t----
¥
20% of Singapore Chinese and 30% of Indians. 50
Such differences tapered off at around 10 yr of age,
when 100% of Ugandans, 75% of Chinese, 85% of
Indians, and 65% of Europeans were found to be 12345 10 15 20 25 30 35 40 45 55 65
EBV antibody positive. An unexpected finding
Fig. 5. Geometric mean antibody titers against EBV
was that Hong Kong Chinese might have earlier VCA in the different age and ethnic groups (as identified
EBV infection than Singapore Chinese (to be rein the caption of Fig. 4). Note that the Ugandans after a
ported). very high peak between 1 and 3 yr of age become the
Ugandan children respond to EBV infection lower responders, whereas the Indians exhibit a relatively
early in life by a strong humoral response. The stable and high humoral response against the virus.
and 1M, have the strongest immune response to cate a mode of intercellular interaction through
EBV VCA. Chinese in Singapore are in between, which EBV might operate.
closer to Ugandans than to Indians (Fig. 4).'281 Clifford"7) and HO'59.(3) have repeatedly sug-
When CF antibodies against soluble antigen gested that chemical factors, such as benzpyrene
were studied in these four groups, it was found in soot or nitrosamines in Cantonese uncleaned
that Ugandans and Chinese had a much higher salted fish, are of etiological importance, but there
proportion of CF/S-positive individuals than Indi- are as yet no firm supporting data. The possibility
ans and Caucasians, in the various age groups. does exist that chemical and viral factors operate
The CF/S reactivity as measured by GMT is also jointly.
higher in Chinese and Ugandans than in the two
other groups in the first two decades of life.
The above differences in the infection rate and 8. Patterns of Host Response
the immune response to EBV among ethnic groups
and geographic areas may reflect cultural differ-
8.1. Clinical Course of NPC
ences, and a correlation of EBV serology and
socioeconomic data is being carried out. They may The clinical course of NPC varies widely in
also reflect a genetically dependent immune re- duration. Without any form of specific therapy or
sponse to EBV antigens. The latter is an attractive with only palliative or inadequate radiation ther-
hypothesis as NPC has a strong genetic compo- apy, the patient may live from a few months to 13
nent (see above), and since genetics plays an yr from the date of diagnosis.'5'"
important role in determining the susceptibility of The presenting symptoms depend on the loca-
animals to oncogenic viruses in genera1'80.811 and tion within the nasopharynx of the primary tumor,
to herpesviruses in particular (Marek's disease). its tendency to invade neighboring structures, the
direction of invasion, and its predilection to me-
tastasize to regional lymph nodes. Thus the signs
and symptoms in order of frequency (see Table 4)
6. Mechanism of Transmission are cervical nodal enlargement, nasal symptoms
(obstruction, postnasal discharge, epistaxis), aural
So far, only B lymphoid cells are known to be symptoms due to eustachian tubal obstruction
permissive for viral infection and semipermissive (impairment of hearing of the conductive type,
for viral multiplication. Although saliva may play with or without tinnitus and serous otitis media),
a crucial role in the epidemiology of EBV as a involvement of cranial nerves (V, especially its
reservoir, it is probable that much is still to be maxillary branch, VI, IX, X, XI, XII, and upper
discovered in this area. The possible role of milk cervical sympathetics), persistent headache, and
has already been noted above.
Table 4. Order of Frequency of Signs and

Symptoms in NPC Patients: All Cases (513)
7. Pathogenesis and Immunity Presenting symptoms Frequency Percent
The evidence available thus far does not permit Nodal enlargement 288 43.31
the conclusion that EBV alone is the cause of NPC. Nasal 132 19.85
While the various forms of serological reactivity to Aural 133 20.00
EBV in NPC patients can be interpreted as either Pain 85 12.78
Cranial nerve impairment 20 3.01
cause or effect, the regular presence of EBV finger-
Miscellaneous
prints in epithelial tumor cells leaves no doubt that
Hawking 4 0.60
there is a strong link between the two. Evidence of Trismus 3 0.45
close contacts and cytoplasmic bridges between
epithelial and lymphoid cells in both normal naso- Total 665 100.00
pharyngeal mucosa and in NpC'39.1271 might indi-
stiffness of the jaw due to lateral spread of the bones, cranial nerves, paranasal sinuses, the orbit,
tumor to the pterygoid muscles. About one-fifth of veins, and venous sinuses at the base of the skull.
cases have more than one presenting symptom: Cervical nodal metastases are either insignificant
their frequency distribution is shown in Table 4. or not detected, even until the death of the patient.
However, in some patients hematogenous metas-
tases occur, usually after intracranial spread has
8.2. Clinical Types of Disease
become evident. Presumably these metastases are
The biological behavior of the tumor determines the result of tumor invasion of the basal venous
the clinical types of the disease, which may be sinuses which communicate with the internal jug-
classified as (1) metastatic, (2) invasive, and (3) ular vein and perivertebral plexus of veins.
combined.(5(l) 8.2.3. The Combined Type. The combined type,
8.2.1. The Metastatic Type. The metastatic type, constituting about 59% of all cases, is character-
constituting about 33% of all cases, is characterized by a combination of direct spread of the
ized by the appearance of metastases, initially in primary tumor and the appearance of cervical
the cervical lymph nodes (with the upper nodes nodal metastases. These may occur at about the
involved before the lower) and later in distant same time or one after the other, with varying
organs, or, much less commonly, the two may intervals in between. What causes the change in
appear about the same time, while the primary behavior in the latter group in not known.
tumor apparently does not extend locally, remain-
ing confined to the nasopharynx throughout. Only
in exceptional cases, probably less than 0.1% of
patients, have distant metastases been observed
after a course of radiation therapy without cervical
nodal metastases being detected before the course In the absence of knowledge of etiology, rational
or afterward. The spread may be confined to the prevention is difficult and efforts have to be con-
cervical nodes for 1-3 yr and in some for as long as centrated on detecting early disease in groups
5 yr or more. known or suspected to have a high risk of NPC.
Survival is longest with this type, and it is also Groups suspected from epidemiological studies
with this variety that occasional patients are en- to be at very high risk of NPC include first-degree
countered in whom the tumor is apparently con- relatives of NPC patients, especially those with
trolled for long periods, following what is nor- more than one member of the family af-
mally considered as inadequate radiation therapy. fected. (62.(;3) Should the work on the HL-A system
The common sites of distant metastases are the described earlier be confirmed, it may be possible
skeleton, especially the spine, the liver, lung, and to define the groups at higher risk and to have
skin. The lymph nodes below the clavicles to as them examined clinically at frequent intervals. For
low as the femoral and inguinal nodes may be such groups, the radiological investigations rec-
involved. Epidural and meningeal metastases oc- ommended by Hd 6O •(1 ) and the anti-EBV capsid
cur, but metastases in the brain have not been and early antigen serology should be included.
encountered, although the brain is susceptible to Education of the public, as well as the medical
direct invasion by the upward spread of the pri- profession, on the early signals of the disease is
mary tumor or by adjacent meningeal metastases. essential in high-risk populations. The lack of
The brain is believed to be devoid of a lymphatic awareness of these signals has been the cause of
system but is nevertheless a common site of me- unnecessary delay in seeking medical advice on
tastases from carcinomas of bronchus and breast. the part of the patient and in early diagnosis by
It is possible that NPC may be peculiar in that the profession. A painless lump high up in the
blood-borne metastases require the presence of neck in an adult southern Chinese should be
lymphatics for their establishment. considered as due to NPC until proved otherwise.
8.2.2. The Invasive Type. The invasive type This is as much an aphorism for NPC as a lump in
occurs only in about 8% of all cases. There is the breast in a female over 40 yr is for breast
evidence of direct spread· to adjacent muscles, carcinoma.
It must be emphasized that the absence of a If EBV is shown to be an etiological factor, the
clinically demonstrable tumor in the nasopharynx preparation of a vaccine would have to be consid-
does not exclude NPC. If inspection of the lateral ered, particularly for use in higher-risk groups.
pharyngeal recesses (fossa of Rosenmiiller) by the Live vaccine, using turkey herpesvirus, has been
use of a Yankauer speculum were routinely em- found very efficient in preventing Marek's dis-
ployed in examination, fewer tumors would be ease.(13) Laufs(77) has demonstrated that a killed
considered occult. In the mainly submucosal pri- vaccine for herpesvirus saimiri (HVS) can be pre-
mary tumors, the earliest detectable sign is a pared which is safe with respect to infectivity and
hemorrhagic finely granular or velvety patch, oncogenicity and that the killed vaccine induces
which can be missed if only the postnasal mirror is high titers of HVS antibodies and delayed malig-
used. Exfoliative cytology, using a saline-soaked nant lymphoma development in cottontop marmo-
swab rubbing against different areas of the mu- sets after challenge with a very large dose of
cosa and dropped into a test tube of saline, which infectious HVS. However, the efficacy of any such
is later passed through a Millipore filter membrane vaccine in humans would require 10--20 yr to
for collection of cells which are then fixed and evaluate-a problem discussed in detail by Hig-
stained in situ, has been found by Ho (unpub- ginson et al. (53)
lished data) to detect "occult" carcinomatous
areas. These were subsequently confirmed by tis-
sue biopsy.
The treatment of NPC is mainly a matter of 10. Unresolved Problems
radiation therapy, both for the primary tumor and
for the cervical lymph nodes. The latter should be
given a course of prophylactic irradiation to full From various points of view, NPC is an unusual
doses, even if no nodes are palpable. Despite tumor: its strong genetic component and its asso-
advances in therapy, the 5-yr survival rate of ciation with a herpesvirus make its study one of
patients with localized disease i.e. stages I and the most challenging and potentially most reward-
H(S6) (Fig. 6) in most well-equipped centers is only ing problems in the etiological research on human
about 70%. Once the immune status (tumor spe- tumors. Three groups of problems can be outlined:
cific and EBV specific) of NPC patients becomes those related to the etiology of NPC, those related
better understood, immunotherapy may be able to to questions which can be answered in short-term
improve the present results when used in conjunc- projects, and those related to long-term goals such
tion with radiation therapy. as early detection and prevention of the disease.
Alive % N.E.D. Stage I

100 II
90 III
IV
80
V
70
Fig. 6. Crude survival and "no evidence of disease"
60
(N.E.D.) rates for Chinese NPC patients from Hong
Kong by stage . according to Ho's classification(56) 50
I
and year after commencement of treatment. ,,' 40
~ I ,
, ,,-
tJfI'.
.' .-
,
,
, 30
-
.. -.. -._- ..
~' 20 ,
" ,, 10
"
••• , •• (///JI
" ""
765432 234567
Years Years
10.1. Etiology of NPC A prospective study of the type presently being

At present, there are two main leads in the carried out by IARC for BU 241 cannot be proposed
understanding of the etiology of NPC. The first is for NPC, except possibly for first-degree relatives
the immunogenetical marker (HL-A pattern) found of NPC patients, as the peak of NPC incidence is
to be associated with NPC risk in Chinese'l14); the too late in life (40--50 yr of age). At the present
second is the virus regularly associated with this time, laboratory and animal experiments appear
tumor. Apart from these well-documented find- more important than further epidemiological stud-
ings, the role of cultural, chemical, and environ- ies.
mental factors peculiar to southern Chinese is One of the objections to a possible causal rela-
currently being investigated. «;3) tionship between EBV and NPC or BL is the
10.1.1. The Immunogenetic Marker (HL-A Pat- difficulty of accepting that a virus as widespread
tern) Associated with NPC Risk in Chinese. That as EBV could be the cause of such rare events as
genetic factors are of considerable relevance for the development of a few tumors in people living
NPC has been shown by Ho from the family history in specific geographic areas or in ethnic groups.
data«;2) and has been demonstrated by Simons et Clinical infectious mononucleosis is largely limited
al. (113) with regard to the HL-A system. to some well-defined middle socioeconomic
The question to be answered next was whether groupS/3S) and is uncommon in populations
such an HL-A pattern represented a marker found where EBV infection is maximal (e.g., Uganda),
only in Chinese or whether it was associated with yet nobody will deny that this ubiquitous EBV is
NPC patients from all ethnic groups. A study of the the cause of Paul-Bunnell positive 1M syn-
HL-A pattern of NPC patients from Tunisia and dromes.""') Similarly, EBV could induce tumors in
Europe showed that the antigen Sin-2 does not some peculiar situations where various synergistic
exist in Tunisia nor in Europe. «(;) The possibility co factors act either simultaneously or in a given
of the existence of a NPC "disease susceptibility" consecutive order. Such cofactors could either alter
gene, situated outside but close to the HL-A loci, the immune surveillance mechanism of the orga-
has recently been stressed. mel nism or reactivate a latent viral infection, or both.
10.1.2. The Virus Associated with NPC. Under- Indeed, like most herpesviruses, EBV is a latent
standing the nature of the association between a virus, probably subject to reactivation by yet un-
"lymphotropic" virus and a carcinoma is in itself a known factors. The reactivating factors for HSV-l
challenge for the virologist, the oncologist, and the vary from person to person (temperature, ultravi-
immunologis t. olet radiation, hormonal changes). There is no
There is still a possible alternative: that EBV is an reason why internal and/or external factors may
occasional parasite of the NPC epithelial tumor not reactivate EBV latent infection and influence
cells, i.e., a "passenger." However, this concept its oncogenic potential. Malaria has repeatedly
does not explain why carcinomas of other sites been stressed as a possible cofactor of BL, impair-
infiltrated by lymphocytes do not present the same ing the immune surveillance mechanism and/or
EBV serological reactivities as in NPC. (Zo) stimulating the reticuloendothelial system. This
Two alternatives can be advanced for an etiologi- would result in the multiplication of target cells for
cal role for EBV in NPC. The first considers the EBV EBV infection as proposed by O'ConorIfH ') and
as a "necessary and sufficient" factor for NPC de- Burki tt.' 1(1)
velopment; the second considers EBV to be a neces- Another possibility is that EBV represents a
sary but insufficient factor with one or more cofac- group of closely related virus strains, some having
tors involved in causation. Support for the first a much greater oncogenic potential than others,
hypothesis may be obtained indirectly through an- infection with a nononcogenic strain resulting in
imal experiments, where Koch's postulates can be "production." Such an alternative could also in-
met, rather than directly in humans. The control of volve differences in tissue specificity among EBV
EBV infection by vaccine or by any other hygienic strains. With the above in mind, a central reposi-
measures, if followed by a decrease in NPC inci- tory of lymphoblastoid cell lines and of EBV iso-
dence, would prove that EBV plays a role, but this lates would be of considerable value.
role could still be that of a cofactor. Apart from the "passenger" and "driver" hy-
potheses discussed above, a third hypothesis im- prognostic value for the patients and which may
plies that the EBV acts as a cofactor, neither neces- also shed some light on etiology.
sary nor sufficient, but acting in synergy with
specific organic chemicals. EBV infection would
alter the target organ and prepare the ground for 10.3. Long-Term Problems
the specific chemical. The two families of chemicals The control of NPC is a major public health
which are considered as being of etiological impor- problem in south China and in some parts of
tance for NPC are polynuclear hydrocarbons(14,1(;) Southeast Asia. In order to achieve meaningful
and nitrosamines.(58,62) Nitrosamines are of special early detection, one must first determine which
interest as they are known to have specific organo- groups are at highest risk for the tumor within the
tropism. populations under study and then devise efficient
early detection tests having a high sensitivity but
with a low proportion of false positive results.
Short-term projects, of the type listed above,
10.2. Problems Which May Be Resolved in Short-
aimed at establishing the immunogenetic, serolog-
Term Projects
ical, and CMI profiles associated with a high risk
of NPC, may help to define high-risk groups
In addition to the immunogenetic aspect dis- within high-risk populations. Once this is
cussed above, immunological studies oriented to- achieved, a prospective study may test the value of
ward the cell-mediated immunological (CMI) sta- a number of factors and could eventually lead to
tus of NPC patients are important and may allow large-scale tumor detection.
immunotherapy in the future. Preliminary results Early diagnosis must be associated with success-
indicate that NPC patients have depressed in vivo ful treatment. One day, immunovirological meas-
cell-mediated responses to the Mantoux tuberculin ures may be combined with radiotherapy,"")) and
test, combined with phytohemagglutinin hypores- preliminary collaborative studies are in progress
ponsiveness of their lymphocytes in vitro. (Ie) using transfer factors obtained from convalescent
Furthermore, when skin testing using mem- 1M patients in Manitoba as an adjuvant in the
brane extracts of lymphoblastoid lines was done in radiation treatment of NPC patients in Hong
NPC patients and controls, a high percentage with Kong.(61l
positive reactions to the NPC-derived HKLY-28, Prevention of a disease does not imply knowl-
but low to other EBV-associated lines, was ob- edge of the cause of the disease, but it does help.
served.(63.78a) This preliminary work raised the fol- At present, nobody knows what preventive meas-
lowing questions: What is the extent of the CMI ures could be proposed to successfully eliminate
impairment in NPC patients? Is this CMI impair- NPC. Trials on an EBV vaccine are still out of sight
ment specifically pronounced for EBV-related anti- for the near future, for technical and epidemiologi-
gens? Is there any relationship between CMI altera- cal reasons.(53) No one has yet succeeded in mak-
tions and HL-A pattern? Can CMI detect specific ing an effective vaccine against any human her-
tumor antigens? Is there any correlation of EBV pesvirus, and the fact that herpesvirus infections
serological data, the HL-A pattern, and CMI dis- can be reactivated, even in the presence of specific
turbance? antibodies, is not encouraging. However, the use
In an attempt to answer these questions, collab- of turkey herpesvirus to vaccinate chickens against
orative projects have been implemented in Hong Marek's disease has proven very effective; a solu-
Kong, Singapore, Tunisia, Perth, and France, tion to the human problem may yet be possible.
aimed at investigating in vivo immune status (by In conclusion, etiological research on NPC, as on
skin testing) and in vitro CMI, in parallel with the any other human cancer, requires a multidiscipli-
HL-A and EBV serological patterns of NPC pa- nary and coordinated approach where epidemiolo-
tients and controls. gists, clinicians, virologists, immunologists, statis-
Longitudinal studies of CMI, and serology of ticians, and others work together to control the
NPC patients before and at various intervals after disease. The challenge is great; so must be our
radiotherapy, may uncover a pattern which has a determination.
ACKNOWLEDGMENT 12. CHAN, S. H., SIMONS, M. J., CHEW, B. K., DE-THE,

G., AND SHANMUGARATNAM, K., Immunological as-
Some of the work presented in this chapter was pects of nasopharyngeal carcinoma (NPC). I. In vitro
lymphocyte hyporesponsiveness to stimulation
supported in part by Contract No. NOl-CP-43296
with phytohaemagglutinin (PHA)., Int. J. Cancer (in
within the Virus Cancer Program, National Cancer press).
Institute, United States. 13. CHURCHILL, A. E., PAYNE, L. N., AND CHUBB, R. C,
Immunization against Marek's disease using a live
attenuated virus, Nature (London) 221:744-747
11. References (1969).
14. CLIFFORD, P., Carcinoma of the nasopharynx in
1. ALI, M. Y., AND SHANMUGARATNAM, K., Cytodi- Kenya, East Afr. Med. J. 42:373-396 (1965).
agnosis of nasopharyngeal carcinoma, Acta Cytol. 15. CLIFFORD, P., Malignant diseases of the nasopharynx
11:51-60 (1967). and paranasal sinuses in Kenya, in: Cancer of the
2. ANDREWS, P. A. I., AND MICHAELS, I., Nasopharyn- Nasopharynx (C S. MUIR AND K. SHANMUGARAT-
geal carcinoma in Canadian bush pilots, and avia- NAM, eds.), pp. 82-94, VICC Monograph Series, Vol.
tor's cancer, Lancet 2:85, 640 (1968). 1, Munksgaard, Copenhagen, 1967.
3. AYA, T., AND OSATO, T., Early events in transforma- 16. CLIFFORD, P., A review on the epidemiology of
tion of human cord leukocytes by Epstein-Barr nasopharyngeal carcinoma, Int. J. Cancer 5:287-309
virus: Induction of DNA synthesis, mitosis and the (1970).
virus associated nuclear antigen synthesis, Int. J. 17. CLIFFORD, P., Carcinogens in the nose and throat:
Cancer 14:341-347 (1974). Nasopharyngeal carcinoma in Kenya, Proc. Roy.
4. BAILAR, J. C, III, Race, environment and family in Soc. Med. 65:682-686 (1972).
the epidemiology of cancer of the nasopharynx, in: 18. DERRY, D. E., Anatomical report (B), in: Archaeolog-
Cancer of the Nasopharynx (C S. MUIR AND K. SHAN- ical Survey of Nubia, Cairo, Egyptian Ministry of
MUGARATNAM, eds.), pp. 101-105, VICC Monograph Finance (Bulletin No.3), pp. 40-42, 1909.
Series Vol. 1, Munksgaard, Copenhagen 1967. 19. DE SCHRYVER, A., FRIBERG, S., JR., KLEIN, G.,
5. BENYESH-MELNICK, M., FERNBARCH, D. J., AND HENLE, W., HENLE, G., DE-THE, G., CLIFFORD, P.,
LEWIS, R. T., Studies on human leukemia. I. Spon- AND Ho, H. C, Epstein-Barr associated antibody
taneous lymphoblastoid transformation of fibro- patterns in carcinoma of the post-nasal space, Clin.
blastic bone marrow cultures derived from leukemic Exp. Immuno/. 5:443-459 (1969).
and non-leukemic children, J. Nat/. Cancer Inst. 20. DE SCHRYVER, A., KLEIN, G., HENLE, G., HENLE, W.,
31:1311-1331 (1963). CAMERON, H., SANTESSON, L., AND CLIFFORD, P.,
6. BETUEL, H., CAMMOUN, M., COLOMBANI, J., DAY, N. Epstein-Barr virus associated serology in malignant
E., ELLOUZ, R., AND DE-THE, G., The relationship disease: Antibody levels to viral capsid antigens
between nasopharyngeal carcinoma and the HL-A (VCA), membrane antigens (MA) and early antigens
system among Tunisians, Int. J. Cancer 16:249-254 (EA) in patients with various neoplastic conditions,
(1975). Int. J. Cancer 9:353-364 (1972).
7. BJARNAsoN, 0., DAY, N., SNAEDAL, G., AND TULI- 21. DESGRANGES, C, WOLF, H., DE-THE, G., SHANMU-
NIUS, H., The effect of year on the breast cancer age GARATNAM, K., ELLOUZ, R., CAMMOUN, N., KLEIN,
incidence curve in Iceland, Int. J. Cancer 13:689-696 G., zURHAUSEN, H., Nasopharyngeal carcinoma X-
(1974). Presence of Epstein-Barr genomes in epithelial cells
8. BUELL, P., Nasopharyngeal cancer in Chinese of of tumours from high and medium risk areas, Int. J.
California, Br. J. Cancer 19:459-470 (1965). Cancer 16:7-15 (1975).
9. BUELL, P., Race and place in the etiology of naso- 22. DE-THE, G., AMBROSIONI, J. C, Ho, H. C, AND
pharyngeal cancer: A study based on California KWAN, H. C, Lymphoblastoid transformation and
death certificates, Int. J. Cancer 11:268-272 (1973). presence of herpes-type viral particles in a Chinese
10. BURKITT, D. P., The trail to a virus, in: Oncogenesis nasopharyngeal tumour cultured in vitro, Nature
and Herpesviruses (P. M. BIGGS, G. DE-THE, AND L. (London) 221:770-771 (1969).
N. PAYNE, eds.), pp. 345-348, IARC Scientific Publi- 23. DE-THE, G., Ho, H. C, KWAN, H. C, DESGRANGES,
cations No.2, Lyon, 1972. C, AND FAVRE, M. C, Nasopharyngeal carcinoma
11. CAMMOUN, M., VOGT-HoERNER, G., AND MOURALI, (NPC). I. Types of cultures derived from tumour
N., Les tumeurs du naso-pharynx en Tunisie: Etude biopsies and non-tumorous tissues of Chinese pa-
anatomo-clinique de 143 observations, Tunis Med. tients with special reference to lymphoblastoid
49(3):131-141 (1971). transformation, Int. J. Cancer 6:189-206 (1970).
24. DE-THE, G., AND GESER, A, A prospective sero- 36. EVANS, A. S., New discoveries in infectious monon-
epidemiological study to investigate the role of EBV ucleosis, Mod. Med. i:18-24 (1974).
in Burkitt's lymphoma, in: Unifying Concepts of 37. FONG, Y. Y., AND CHAN, W. c., Bacterial production
Leukemia (R. M. DUTCHER AND L. CHmco-BIANCHI, of di-methyl nitrosamine in salted fish, Nature (Lon-
eds.), Bibl. Haematol. (Basel) 39:448-456 (1973). don) 243:421--422 (1973).
25. DE-THE, G., SOHmR, R, Ho, J. H. c., AND FREUND, 38. FRAUMENI, J. F., JR., AND MASON, T. J., Cancer
R., Nasopharyngeal carcinoma. IV. Evolution of mortality among Chinese Americans, 1950--69, J.
complement fixing antibodies during the course of Natl. Cancer Inst. 52:659-665 (1974).
the disease, Int. J. Cancer 12:368-377 (1973). 39. GAZZOLO, L., DE-THE, G., AND VUILLAUME, M.,
26. DE-THE, G., ABLASHI, D. V., LIABEUF, A, AND Nasopharyngeal carcinoma. II. Ultrastructure of
MOURALI, N., Nasopharyngeal Carcinoma (NPC). normal mucosa, tumor biopsies and subsequent
VI. Presence of an EBV nuclear antigen in fresh epithelial growth in vitro, J. Natl. Cancer Inst. 48:73-
tumour biopsies: Preliminary results, Biomedicine 86 (1972).
19:349-352 (1973). 40. GERBER, P., AND BIRCH, S., Complement-fixing an-
27. DE-THE, G., AND GESER, A, Nasopharyngeal carci- tibodies in sera of human and non-human primates
nomas: Recent studies and outlook for a viral etiol- to viral antigens derived from Burkitt's lymphoma
ogy, Cancer Res. 34:1196-1206 (1974). cells, Proc. Natl. Acad. Sci. USA 58:478-484 (1967).
28. DE-THE, G., DAY, N. E., GESER, A., Ho, J. H. c., 41. GERBER, P., WHANG-PENG, J., AND MONROE, J.,
LAVOUE, M. F., SIMONS, M. J., SOHmR, R, AND Tu- Transformation and chromosome changes induced
KEI, P., Epidemiology of the Epstein-Barr virus: Pre- by Epstein-Barr virus in normal human leukocyte
liminary analysis of an international study, in: Onco- cultures, Proc. Natl. Acad. Sci. USA 63:740--747
genesis and Herpesviruses II (G. DE-THE, M. A., (1969).
EpSTEIN, AND H. ZUR HAUSEN, eds.), pp. 3-16, IARC 42. GERBER, P., NONOYAMA, M., LUCAS, S., PERLIN, E.,
Scientific Publication No. 11, Vol. 2, IARC, Lyon, AND GOLDSTEIN, L., Oral excretion of EBV by
France, 1975. healthy subjects and patients with infectious mon-
29. DE-THE, G., Ho, J. H. c., ABLASHI, D. V., DAY, N. E., onucleosis, Lancet 2:988-289 (1972).
MACARIO, A. J. L., MARTIN-BERTHELON, M. c., PEAR- 43. GESER, A., DAY, N. E., DE-THE, G., CHEW, T. S.,
SON, G., AND SOHmR, R, Nasopharyngeal carcinoma FREUND, R J., KWAN, H. c., LAVOuE, M. F.,
IX-Antibodies to EBNA and correlation with re- SIMKOVIC, D., AND SOHIER, R., The variability in
sponse to other EBV antigens in Chinese patients, immunofluorescent viral capsid antigen antibody
Int. J. Cancer 16:713-721 (1975). testing in population surveys of Epstein-Barr virus
infection, Bull WHO 50:389--400 (1974).
29a. DE-THE, G., VUILLAUME, M., GIOVANELLA, B. C.,
43a. GLASER, R., DE-THE, G., LENOIR, G., AND Ho, J. H.
AND KLEIN, G., Epithelial characteristics of tumour
cells in nasopharyngeal carcinoma (NPC) passaged
c., Superinfection of nasopharyngeal carcinoma
epithelial tumour cells with Epstein-Barr virus,
in nude mice-an ultrastructural study, J.N.C.I. (in
press).
Proc. Nat. Acad. Sci. USA 73:960--963 (1976).
44. HAWKINS, B. R., SIMONS, M. J., GOH, E. H., CHIA,
30. DIGBY, K. H., THOMAS, G. H., AND HSIU, S. T.,
K. B., AND SHANMUGARATNAM, K., Immunogenetic
Notes on carcinoma of the nasopharynx, Caduceus
aspects of nasopharyngeal carcinoma. II. Analysis of
9:45--64 (1930).
ABO, Rhesus and MNS's red cell systems, Int. J.
31. DOBSON, W. c., Cervical lymphosarcoma (letter to
Cancer 13:116-121 (1974).
the editor), Chin. Med. J. 38:786 (1924).
45. HENLE, G., AND HENLE, W., Immunofluorescence in
32. DURAND-FARDEL, Cancer du pharynx-ossification
cells derived from Burkitt's lymphoma, J. Bacterial.
dans la substance musculaire du coeur, Bull. Soc.
91:1248-1256 (1966).
Anat. (Paris) 12:73--80 (1837). 46. HENLE, W., HENLE, G., BURTIN, P., CACHIN, Y.,
33. EpSTEIN, M. A., ACHONG, B. G., AND BARR, Y. M., CLIFFORD, P., DE SCHRYVER, A., DE-THE, G., DmHL,
Virus particles in cultured lymphoblasts from Burk- V., Ho, H. c., AND KLEIN, G., Antibodies to Ep-
itt's lymphoma, Lancet 1:702-703 (1964). stein-Barr virus in nasopharyngeal carcinoma, other
34. EVANS, A. S., AND NmDERMAN, J. c., Epidemiology head and neck neoplasms and control groups, J.
of infectious mononucleosis, in: Oncogenesis and Natl. Cancer Inst. 44:225--231 (1970).
Herpesviruses (P. M. BIGGS, G. DE-THE, AND L. N. 47. HENLE, W., HENLE, G., ZAJAC, B. A., PEARSON, G.,
PAYNE, eds.), pp. 351-356, IARC Scientific Publica- WAUBKE, R., AND SCRmA, M., Differential reactivity
tions No.2, Lyon, 1972. of human serums with early antigens induced by
35. EVANS, A. S., The history of infectious mononucleo- Epstein-Barr virus, Science 169:188-190 (1970).
sis, Am. J. Med. Sci. 267:189 (1974). 48. HENLE, G., HENLE, W., AND KLEIN, G., Demonstra-
tion of two distinct components in the early antigen 60. Ho, H. c., Radiologic diagnosis of nasopharyngeal
complex of EBV infected cells, Int. J. Cancer 8:272- carcinoma with special reference to its spread
282 (1971). through the base of skull, in: Cancer of the Naso-
49. HENLE, G., Antibodies to EBV-induced early anti- pharynx (c. S. MUIR AND K. SHANMUGARATNAM,
gens in infectious mononucleosis, Burkitt's lym- eds.), pp. 238-246, UICC Monograph Series, Vol. 1,
phoma and nasopharyngeal carcinoma, in: Recent Medical Examination Publishing Co., New York,
Advances in Human Tumor Virology and Immunology 1972.
(W. NAKAHARA, K. NISHIOKA, T. HIRAYAMA, AND T. 61. Ho, H. c., Head and neck-Radiologic diagnosis,].
ITO, eds.), pp. 34~359, University of Tokyo Press, Am. Med. Assoc. 220:396 (1972).
Tokyo, 1971. 62. Ho, H. c., Current knowledge of the epidemiology
50. HENLE, W., AND HENLE, G., Epstein-Barr virus: The of nasopharyngeal carcinoma-A review, in: Onco-
cause of infectious mononucleosis, in: Oncogenesis genesis and Herpesviruses (P. M. BIGGS, G. DE-THE,
and Herpesviruses (P. M. BIGGS, G. DE-THE, AND L. AND L. N. PAYNE, eds), pp. 357-366, IARC Scien-
N. PAYNE, eds.), pp. 358-370, IARC Scientific Publi- tific Publication No.2, Lyon, 1972.
cation No.2, Lyon, 1972. 63. Ho, H. c., Epidemiology of nasopharyngeal carci-
51. HENLE, W., AND HENLE, G., Epstein-Barr virus and noma (NPC), in: Proceedings of the 1st Asian Cancer
infectious mononucleosis, N. Eng/. J. Med. 288:26~ Conference, Shima and Tokyo, September 22-25,
264 (1973). 1973 (in press).
52. HENLE, W., Ho, H. c., AND KWAN, H. c., Antibod- 64. Hu, C. H., AND YANG, Co, A decade of progress in
ies to Epstein -Barr virus related antigens in naso- morphologic pathology, Chin. Med. ]. 79:409-422
pharyJ;l.geal carcinoma: Comparison of active cases (1959).
with long term survivors, J. Natl. Cancer Inst. 65. HUANG, D. P., Ho, J. H. c., HENLE, W., AND
51:361-369 (1973). HENLE, G., Demonstration of Epstein-Barr virus-
53. HIGGINSON, J., DE-THE, G., GESER, A., AND DAY, N. associated nuclear antigen in nasopharyngeal carci-
E., An epidemiological analysis of cancer vaccines, noma cells from fresh biopsies, Int. ]. Cancer 14:580-
Int. J. Cancer 7:565--574 (1971). 588 (1974).
54. HIGGINSON, J., AND MACLENNAN, R., The world 66. HUEBNER, R. J., AND TODARO, G. T., Oncogenesis of
pattern of cancer incidence, in: Modern Trends in RNA tumor viruses as determinants of cancer, Proc.
Oncology-Research Progress (R. W. RAVEN, ed.), Natl. Acad. Sci. USA 64:1087-1-94 (1969).
pp. 9-27, Butterworths, London, 1973. 66a. JONDAL, M., AND KLEIN, G., Classification of lym-
55. Ho, H. c., Nasopharyngeal carcinoma in Hong phocytes in nasopharyngeal carcinoma (NPC)
Kong, in: Cancer of the Nasopharynx (c. S. MUIR biopsies, Biomedicine 23:16~165 (1975).
AND K. SHANMUGARATNAM, eds.), pp. 58-63, UICC 67. JUNG, P. F., AND Yu, c., Nasopharyngeal cancer in
Monograph Series, Vol. 1, Munksgaard, Copen- China, Postgrad. Med. 33:A77-A82 (1963).
hagen, 1967. 68. KING, H., AND HAENSZEL, K., Cancer mortality
56. Ho, J. H. c., The natural history and treatment of among foreign and native-born Chinese in the
nasopharyngeal carcinoma (NPC), in: Oncology, United States, J. Chron. Dis. 26:62~646 (1972).
Vol. 4, (Proceedings of the 10th International Cancer 69. KLEIN, G., CLIFFORD, P., KLEIN, E., AND STJERN-
Congress) (R. LEE-CLARK, R. W. CUMLEY, J. E. SWARD, J., Search for tumor-specific immune reac-
MCCAY, AND M. COPELAND, eds.), pp. 1-14, Year tions in Burkitt lymphoma patients by the mem-
Book Medical Publishers, Chicago, 1970. brane immunofluorescence reaction, Proc. Nat/.
57. Ho, H. c., Incidence of nasopharyngeal cancer in Acad. Sci. USA 55:1628-1635 (1966).
Hong Kong, UICC Bulletin, Cancer 9(2):5 (1971). 70. KLEIN, G., PEARSON, G., HENLE, G., HENLE, W.,
58. Ho, J. H. c., Genetic and environmental factors in DIEHL, V., AND NIEDERMAN, J. c., Relation between
nasopharyngeal carcinoma, in: Recent Advances in Epstein-Barr viral and cell membrane immunoflu-
Human Tumor Virology and Immunology (Proceedings orescence in Burkitt tumour cells. I. Dependence of
of the First International Cancer Symposium of the cell membrane immunofluorescence on presence of
Princess Takamatsu Cancer Research Fund) (W. EB virus, J. Exp. Med. 128:1011-1020 (1968).
NAKAHARA, K. NISHIOKA, T. HIRAYAMA, AND Y. ITO, 71. KLEIN, G., EBV associated membrane antigens, in:
eds.), pp. 275--295, University of Tokyo Press, To- Oncogenesis and Herpesviruses (P. M. BIGGS, G. DE-
kyo, 1971. THE, AND L. N. PAYNE, eds.), pp. 295--301, IARC
59. Ho, J. H. c., Nasopharyngeal carcinoma (NPC), in: Scientific Publication No.2, Lyon, 1972.
Advances in Cancer Research (G. KLEIN, S. WEIN- 72. KLEIN, G., The Epstein-Barr virus, in: The Herpesvi-
HOUSE, AND A. HADDOW, eds.), pp. 57-92, Aca- ruses (A. KAPLAN, ed.), pp. 521-555, Academic
demic Press, New York and London, 1972. Press, New York, 1973.
73. KLEIN, G., GIOVANELLA, B. c., LINDAHL, T., FI- TIMMS, eds.), pp. 7-12, East African Publishing
ALKOW, P. J., SINGH, S., AND STEHLIN, J., Direct House, Nairobi, 1968.
evidence for the presence of Epstein-Barr virus 85. Mc DEVITT, H. 0., AND BODMER, W. J., HL-A,
DNA and nuclear antigen in malignant epithelial immune response genes, and disease: Occasional
cells from patients with anaplastic carcinoma of the survey, Lancet i:1269-1275 (1974).
nasopharynx, Proc. Natl. Acad. Sci. USA 71:4737- 86. MICHAUX, L., Carcinome de base du crane. Cited by
4741 (1974). Godtfredson, E., Ophthalmologic and neurologic
74. KLEIN, G., AND VONKA, V., Relationship between symptoms at malignant nasopharyngeal tumours:
the Epstein-Barr virus (EBV) determined comple- Clinical study comprising 454 cases, with special
ment fixing antigen and the nuclear antigen (EBNA) reference to histo-pathology and possibility of ear-
detected by anti-complement fluorescence, Int. J. lier recognition. Acta Psychiat. Scand. Suppl. 34:1-
Cancer 53:1645-1646 (1974). 323 (1944).
75. KMET, J., AND MAHBOUBI, E., Esophageal cancer in 87. MILLER, G., NIEDERMAN, J. c., AND STILL, D. A.,
the Gaspian littoral of Iran: Initial studies, Science Infectious mononucleosis: Appearance of neutraliz-
175:846-853 (1972). ing antibody to Epstein-Barr virus measured by
76. KROGMAN, W. M., The skeletal and dental pathol- inhibition of formation of lymphoblastoid cell lines,
ogy of an early Iranian site, Bull. Hist. Med. 8:28-48 J. Infect. Dis. 125:403-406 (1972).
(1940). 88. MUIR, C. S., AND OAKLEY, W. F., Nasopharyngeal
77. LAUFS, R., Immunisation of marmoset monkeys carcinoma in Sarawak (Borneo), J. Laryngol. 81:197-
with a killed oncogenic herpesvirus, Nature (Lon- 207 (1967).
don) 249:571-572 (1974). 89. MUIR, C. S., AND SHANMUGARATNAM, K., The inci-
77a. LENOIR, G., MARTIN-BERTHELON, M. c., FAVRE, M. dence of nasopharyngeal cancer in Singapore, in:
c., DE-THE, G., Characterization of EBV antigens Cancer of the Nasopharynx (c. S. MUIR AND K.
I-Biochemical analysis of the complement-fixing SHANMUGARATNAM, eds.), pp. 47-53, VICC Mono-
soluble antigen and relationship with EBNA, J. graph Series No. 1, Munksgaard, Copenhagen,
Virol. 17:672-674 (1976). 1967.
78. LEVINE, P., CHO, B., CONNELLY, R, DE VrrA, c., 90. MUIR, C. S., Nasopharyngeal carcinoma in non-
BERARD, c., O'CONOR, G., AND DORHMAN, R, The Chinese populations, in: Oncogenesis and Herpesvi-
American Burkitt's lymphoma registry: A progress ruses (P. M. BIGGS, G. DE-THE, AND L. N. PAYNE,
report, Ann. Intern. Med. 83:82-83 (1975). eds.), pp. 367-371, IARC Scientific Publication No.
78a. LEVINE, P. H., DE-THE, G., BRUGERE, J., SCHWAAB, 2, Lyon, 1972.
G., MOURALI, N., HEBERMAN, R. B., AMBROSIONI, 91. MUIR, C. S., Geographical differences in cancer pat-
J. c., AND REVOL, P., Immunity to antigens associ- terns, in: Host Environment Interactions in the Etiology
ated with a cell line derived from nasopharyngeal of Cancer in Men (R. DOLL AND 1. VODOPIJA, eds.),
carcionma (NPC) in non-Chinese NPC patients, rARe Scientific Publication No.7, rARC, Lyon, pp.
Int. J. Cancer 17:155-160 (1976). 1-13, 1973.
79. LIANG, P. c., Studies on nasopharyngeal carcinoma 92. NEVO, S., MEYER, W., AND ALTMAN, M., Carcinoma
in the Chinese: Statistical and laboratory investiga- of nasopharynx in twins, Cancer 28:807-809 (1971).
tions, Chin. Med. J. 83:373-390 (1964). 93. NIEDERMAN, J. c., AND EVANS, A. S., Infectious
80. LILLY, F., The inheritance of susceptibility of the mononucleosis, in: Serological Epidemiology, pp.
gross leukemia virus in mice, Genetics 53:529-539 119-132, Academic Press, New York, 1973.
(1966). 94. NILSSON, K., KLEIN, G., HENLE, G., AND HENLE,
81. LILLY, F., Mouse leukemia: A model of a multiple- W., The role of EBV in the establishment of lym-
gene disease, J. Nat!. Cancer Inst. 49:927-934 (1972). phoblastoid cell lines from adult and foetal lymph-
82. LIN, T. M., Hsu, M. M., CHENG, K. P., CHIANG, T. oid tissue, in: Oncogenesis and Herpesviruses (P. M.
c., JUNG, P. F., AND HIRAYAMA, T., Morbidity and BIGGS, G. DE-THE, AND L. N. PAYNE, eds.), pp. 285-
mortality of cancer of the nasopharynx in Taiwan, 290, IARC Scientific Publication No.2, Lyon, 1972.
Gann Monogr. 10:137-144 (1971). 95. NONOYAMA, M., AND PAGANO, J. S., Homology
83. LIN, T. M., CHEN, K. P., LIN, C. c., Hsu, M. M., between Epstein-Barr viruses DNA and viral DNA
Tu, S. M., CHIANG, T. c., JUNG, P. F., AND HIRAY- from Burkitt's lymphoma and nasopharyngeal carci-
AMA, T., Retrospective study on nasopharyngeal noma determined by DNA-DNA reassociation ki-
carcinoma, J. Nat!. Cancer Inst. 51:1403-1408 (1975). netics, Nature (London) 242:44-47 (1973).
84. LINSELL, C. A., Cancer in Kenya, in: Cancer in 96. O'CONOR, G. T., Persistent immunological stimula-
Africa (P. CLIFFORD, C. A. LINSELL, AND G. L. tion as a factor in oncogenesis with special refer-
ence to Burkitt's tumour, Am. J. Med. 48:279-285 107. SHANMUGARATNAM, K., Nasopharyngeal carcinoma
(1970). in Asia, in: Racial and Geographical Factors in Tumour
97. OLD, L. J., BOYSE, E. A., OETTGEN, H. F., DE incidence (A. A. SHIV AS, ed.), pp. 169-188, Pfizer
HARVEN, E., GEERING, G., WILLIAMSON, E., AND Medical Monograph, Vol. 2, Edinburgh University
CLIFFORD, P., Precipitation antibody in human Press, Edinburgh, 1967.
serum to an antigen present in cultured Burkitt's 108. SHANMUGARATNAM, K., AND MUIR, C. S., Naso-
lymphoma cells, Proc. Natl. Acad. Sci. USA 56:1699- pharyngeal carcinoma: Origin and structure, in:
1704 (1966). Cancer of the Nasopharynx (c. S. MUIR AND K.
98. PAGANO, J. S., HUANG, C. H., AND LEVINE, P., SHANMUGARATNAM, eds.), pp. 153-162, UICC Mon-
Absence of Epstein-Barr viral DNA in American ograph Series, Vol. 1, Munksgaard, Copenhagen,
Burkitt's lymphoma, N. Engl. J. Med. 289:1395-1399 1967.
(1973). 109. SHANMUGARATNAM, K., AND HIGGINSON, J., Aetiol-
98a. PAGANO, J. S., HUANG, C. H., KLEIN, G., DE-THE, ogy of nasopharyngeal carcinoma: Report on a re-
G., SHANMUGARATNAM, K., SIMONS, M. J., trospective survey in Singapore, in: Cancer of the
AND YAN, C. S., Homology of Epstein-Barr viral Nasopharynx (c. S. MUIR AND K. SHANMUGARAT-
DNA in nasopharyngeal carcinoma from Kenya, NAM, eds.), pp. 130-137, VICC Monograph Series,
Taiwan, Singapore and Tunis, in: Oncogenesis and Vol. 1, Munksgaard, Copenhagen, 1967.
Herpesviruses II (G. DE-THE, M. A. EpSTEIN, AND H. 110. SHANMUGARATNAM, K., AND TYE, C. Y., A study of
ZURHAUSEN, eds.), pp. 191-193, IARCScientificPub- nasopharyngeal cancer among Singapore Chinese
lication No. 11, Vol. 2, IARC, Lyon, France, 1975. with special reference to migrant status and specific
99. PEREIRA, M. S., FIELD, A. M., BLAKE, J. M., RODG- community (dialect group), J. Chron. Dis. 23:433-441
ERS, F. G., AND BAILEY, L. A., Evidence for oral (1970).
excretion of EB virus in infectious mononucleosis, 111. SHANMUGARATNAM, K., Studies on the etiology of
Lancet i:710-711 (1972). nasopharyngeal carcinoma, Int. Rev. of Exp. Pathol.
100. POLUNIN, I., The ways of life of people with high 10:361-413 (1971).
rates of nasopharyngeal carcinoma, in: Cancer of the 112. SHANMUGARATNAM, K., Cancer in Singapore-Eth-
Nasopharynx (c. S. MUIR AND K. SHANMUGARAT- nic and dialect group variations in cancer incidence,
NAM, eds.), pp. 106-111, IUCC Monograph Series, Singapore Med. ]. 14:68-81 (1973).
Vol. 1, Munksgaard, Copenhagen, 1967. 113. SIMONS, M. J., WEE, G. B., DAY, N. E., DE-THE, G.,
101. REEDMAN, B. M., POPE, J. H., AND Moss, D. J., MORRIS, P. J., AND SHANMUGARATNAM, K., Im-
Identity of tRe soluble EBV associated antigens of muno-genetic aspects of nasopharyngeal carcinoma.
human lymphoid cell lines, Int. ]. Cancer 9:172-181 I. Differences in HL-A antigen profiles between
(1972). patients and comparison groups, Int. J. Cancer
102. REEDMAN, B. M., AND KLEIN, G., Cellular localiza- 13:122-134 (1974).
tion of an Epstein-Barr virus (EBV) associated com- 114. SIMONS, M. J., DAY, N. E., WEE, G. B., SHANMUGAR-
plement-fixing antigen in producer and nonprodu- ATNAM, K., Ho, H. c., WONG, S. H., TI, T. K.,
cer lymphoblastoid cell lines, Int. J. Cancer 11:499- YONG, N. K., DARMALINGAM, S., AND DE-THE, G.,
520 (1973). Nasopharyngeal carcinoma. V. Immunogenetic
103. REEDMAN, B. M., KLEIN, G., POPE, J. H., WALTERS, studies of South East Asian ethnic groups with high
M. K., HILGERS, J., SMITH, S., AND JOHANSSON, B., and low risk for the tumor, Cancer Res. 34:1192-1195
Epstein-Barr virus associated complement fixing (1974).
and nuclear antigens in Burkitt's lymphoma biop- 115. SIMONS, M. J., WEE, G. B., DAY, N. E., CHAN, S. H.,
sies, Int. J. Cancer 13:755-763 (1974). SHANMUGARATNAM, K., AND DE-THE, G., Immuno-
104. SAAD, A., Observations on nasopharyngeal carci- genetic aspects of nasopharyngeal carcinoma (NPC).
noma in the Sudan, in: Cancer in Africa (c. A. IV. Probable identification of an HL-A second anti-
LINSELL AND G. L. LIMMS, eds.), pp. 281-285, East gen associated with a high risk for NPC, Lancet
African Publishing House, Nairobi, 1%8. i:142-143 (1975).
105. SCHMAUZ, R., AND TEMPLETON, A. c., Nasopharyn- 116. SIMONS, M. J., DAY, N. E., WEE, G. B., CHAN, S. H.,
geal cancer in Uganda, Cancer 29:610-621 (1972). SHANMUGARATNAM, K., AND DE-THE, G., Immuno-
106. SCOTT, G. c., AND ATKINSON, L., Demographic fea- genetic aspects of nasopharyngeal carcinoma (NPC).
tures of the Chinese population in Australia and the III. HL-A type as a genetic marker of NPC predispo-
relative prevalence of nasopharyngeal cancer among sition to test the hypothesis that EBV is an aetiologic
Caucasians and Chinese, in: Cancer of the Nasophar- factor in NPC, in: Oncogenesis and Herpesviruses II
ynx (c. S. MUIR AND K. SHANMUGARATNAM, eds.), (G. DE-THE, M. A. EpSTEIN, AND H. ZUR HAUSEN,
pp. 64-72, VICC Monograph Series, Vol. 1, Munks- eds.), pp. 249-258, IARC Scientific Publication No.
gaard, Copenhagen, 1967. 11, Vol. 2, IARC, Lyon, France, 1975.
117. SMITH, G. E., AND DAWSON, W. R., in: Egyptian 130. WELLS, c., Ancient Egyptian pathology, J. Laryngol.
Mummies, pp. 157, Allen and Unwin, London, 1924. 77:261-265 (1963).
118. SOHIER, R., AND DE-THE, G., Fixation du com- 131. WELLS, c., Two mediaeval cases of malignant dis-
plement avec un antigene soluble: Differences ease, Br. Med. J. 1:1611-1612 (1964).
d'activite importantes entre les serums de lym- 132. WILLIAMS, E. H., DAY, N. E., AND GESER, A.,
phoma de Burkitt, de cancer du rhinopharynx et de Seasorial variation in onset of Burkitt's lymphoma
mononucleose infectieuse, C. R. Acad. Sci. 273:121- in the West Nile district of Uganda, Lancet ii:19-22
124 (1971). (1974).
119. SOHIER, R., AND DE-THE, G., Evolution of comple- 133. WILLIAMS, E. H., AND DE-THE, G., Familial aggrega-
ment-fixing antibody titers with the development of tion in nasopharyngeal carcinoma (letter to editor),
Burkitt's lymphoma, Int. J. Cancer 9:524-528 (1972). Lancet ii:295 (1974).
120. SVOBODA, D. J., KIRCHNER, K. R., AND SHANMU- 134. WOLF, H., ZUR HAUSEN, H., AND BECKER, V., EB
GARATNAM, K., Ultrastructure of nasopharyngeal viral genomes in epithelial nasopharyngeal carci-
carcinomas in American and Chinese patients; An noma cells, Nature (London) BioI. 244:245-257 (1973).
application of electron microscopy to geographic 135. World Health Organization, Mortality from Malig-
pathology, Exp. Mol. Pathol. 4:189-204 (1965). nant Neoplasms 1955-1965, Geneva, 1970.
121. SVOBODA, D. J., KIRCHNER, K. R., AND SHANMU- 136. WORTH, R. M., AND VALENTINE, R., Nasopharyn-
GARATNAM, K., The fine structure of nasopharyngeal carcinoma in New South Wales, Australia, in:
geal carcinoma, in: Cancer of the Nasopharynx (c. S. Cancer of the Nasopharynx (c. S. MUIR AND K.
MUIR AND K. SHANMUGARATNAM, eds.), pp. 163- SHANMUGARATNAM, eds.), pp. 73-76, DICC Mono-
171, UICC Monograph Series, Vol. 1, Munksgaard, graph Series, Vol. 1, Munksgaard, Copenhagen,
Copenhagen, 1967. 1967.
122. TERRACINI, B., MAGEE, P. N., AND BARNES, J. M., 137. Wu, C. H., in: The Encylopaedia of Chinese Medical
Hepatic pathology on low dietary levels of dimethyl- Terms, Vol. 1, p. 756, Commercial Press, Shanghai,
nitrosamine, Br. J. Cancer 21:599-565 (1967). 1921 (in Chinese).
138. YATA, J., DESGRANGES, c., DE-THE, G., AND TACHI-
123. Union International Contre Ie Cancer, Cancer Inci-
BANA, T., Lymphocytes in infectious mononucleosis
dence in Five Continents-Technical Report (R. DOLL,
properties of atypical cells and origin of the lym-
P. PAYNE, AND J. WATERHOUSE, eds.), UICC, Ge-
phoblastoid lines, Biomedicine 19:479-483 (1973).
neva, 1966.
139. YATA, J., DESGRANGES, c., NAKAGAWA, T., FAVRE, M.
124. Union International Contre Ie Cancer, Cancer Inci- c., AND DE-THE, G., Lymphoblastoid transformation
dence in Five Continents, Vol. 2 (R. DOLL, C. MUIR, and kinetics in the appearance of Epstein-Barr viral
AND J. WATERHOUSE, eds.), UICC, Geneva, 1970. nuclear antigen (EBNA) in cord blood B cells by
125. VONKA, V., BENYESH-MELNICK, M., LEWIS, R. T., Epstein-Barr virus infection, Int. J. Cancer 15:377-384
AND WIMBERLY, 1., Some properties of the soluble (1975).
(S) antigen of cultured lymphobIastoid cell lines, 139a. YATA, J., DESGRANGES, C., DE-THE, G., AND TACH-
Arch. Gesamte Virusforsch. 31:113-124 (1970). mANA, T., Nasopharyngeal carcinoma VII-Lym-
126. VONKA, V., VLCHOVA, 1., ZAVADOVA, H., KOUBA, K., phocyte subpopulations in the blood and tumour
LAZOVSKA, J., AND DUBEN, J., Antibodies to EB virus tissue, Biomedicine 21:244-250 (1974).
capsid antigen and to soluble antigen of Iymphob- 140. YEH, S., Histology of nasopharyngeal cancer, in:
lastoid cell in infectious mononucleosis patients, Cancer of the Nasopharynx (c. S. MUIR AND K. SHAN-
Int. /. Cancer 9:529-535 (1972). MUGARATNAM, eds.), pp. 147-152, DICC Monograph
127. VUILLAUME, M., AND DE-THE, G., Nasopharyngeal Series, Vol. 1, Munksgaard, Copenhagen, 1967.
carcinoma. III. Ultrastructure of different growths 141. YUN, 1. S., A statistical study of tumours among
leading to lymphoblastoid transformation in vitro, J. Koreans, Cancer Res. 9:370-371 (1949).
Nat!. Cancer Inst. 51:67-80 (1973). 142. ZAOUCHE, A., Les tumeurs malignes de la sphere
128. WALSHE, R. J., The physical anthropology of races ORL en Tunisie: A propos des 644 tumeurs des
with a high incidence of nasopharyngeal cancer, in: voies aero-digestives superieures a l'Institut N a-
Cancer of the Nasopharynx (c. S. MUIR AND K. tional de Carcinologie de Tunis due 1.10.67 au
SHANMUGARATNAM, eds.), pp. 112-118, DICC Mon- 15.8.69, thesis, Paris.
ograph Series, Vol. 1, Munksgaard, Copenhagen, 143. ZUR HAUSEN, H., SCHULTE-HoLTHAUSEN, H., KLEIN,
1967. G., HENLE, W., HENLE, G., CLIFFORD, P., AND
129. WALTERS, M. K., AND POPE, J. H., Studies of the EB SANTESSON, L., EBV DNA in biopsies of Burkitt
virus-related antigens of human leukocyte cell lines, tumours and anaplastic carcinomas of the nasophar-
Int. J. Cancer 8:32-40 (1971). ynx, Nature (London) 228:1056-1058, (1970).
Index
Absenteeism in industry, 38 Adenoviruses (cant.) Adenoviruses (cant.)
in school, 38 history, 53-54 transmission, 57, 62-63
Abu Beer, 297 in Holland, 60 type 2 spread to infants, 58
Acera, Ghana, 179 host response, 63-64 Aedes aegypti, 72, 77, 82-84, 93, 94,
Adenine arabinoside (ara-A), 268 human, groups I, II, lll, 55 110
Adenocarcinoma, 501 hybridization, 56 cell culture, 77
Acute respiratory disease (ARD), 18- immunity,63 A. triseriatus, 84, 90
19, see Respiratory disease, inCidence, 56 Aerosol containing virus particles, 8
acute, and individual infection, latent, 65 African Burkitt lymphoma, see
viruses intussusception, 62 Burkitt's lymphoma
Adenoviruses, 53--69 isolation from adenoid tissue, 53 African swine fever virus, 77
Acute respiratory disease in isolation of, 55 Agents in search of disease, 46-47
military recruits, 58-61 laboratory tests, 55 AHF, see Argentinian hemorrhagic
age, 56 military recruits, acute respiratory fever
antibody, neutralizing disease in, 58-61 Akodon,113
in New Orleans, 57 in the Netherlands, 60 Alastrim, 433, 434, 446
in New York, 57 neutralization antibody test, 55 Al Yehudi, 297
in Seattle, 57 occurrence in different settings, 56 Amantadine, 291, 533
in Stockholm, 57 occupation, 56 Amapari virus, 103, 107
-associated viruses, 56 pathogenesis, 63 Amazon tribes, 305
characteristics of, 55-56 pertussislike syndrome, 62 American Committee on Arthorpod-
childhood infections, 57 pharyngoconjunctival fever, 61 borne Viruses, 71
in orphanages, 58 pH range, 56 Analytical epidemiology, see
complement fixation test, 55 pneumonia, 59, 63 Epidemiology, analytical
control, ~5 in children, 57, 63 Animal
cystitis, acute hemorrhagic, 62 prevalence, 56 models, 3
distribution, geographic, 56 prevention, ~5 reservoir, 37
DNA, double-stranded, 55 problems, unresolved, 65 Antibody
endemic adenovirus infections, 56- setting, occurrence in different, 56 development, 14, 15, 116, 119, 129,
58 sex, 56 138, 145, 214
envelope lacking, 5 Sibling excreting virus, 58 Australian, 47 see Hepatitis
epidemic behavior, 56 size, 55 against enteroviruses, 189
epidemic keratoconjunctivitis, 61- survival outside host, 55 fluorescent, 104, 106, 353
62 syndrome, specific, 56-62 heterophil, 209, 210, 212, 226
epidemiology, descriptive, 56-62 associated with humoral,63
methodology, 54-55 acute hemorrhagic cystitis, 62 patterns, 78
ether-resistant, 56 intussusception, 62 prevalence, 43,
genes, number of, 55 pertussislike syndrome, 6Z rate, 43
geographic distribution, 56 temperature range, 56 survey, 43
heat resistance, 56 temporal distribution, 56 surveys, 37, 41, 43
hemagglutination inhibition in tonsils, surgically removed, 58, "tagged", 73
antibody test, 55 63 tests for enteroviral, 169-171
565
566 Index
Antibody (cant.) Arboviruses (cant.) Arenaviruses (cant.)

tests for enteroviral (cant.) isolation, 76 pathogenesis, 108-109
direct fluorescent, 104, 106,353 in Kenya, 76 problems, unresolved, 119-121
titer, 24 Japanese encephalitis, 94 properties
Antigen laboratory methods, 76 biochemical, 105
Australian, 237, 242, 247 morbidity, 75 biological, 107-108
0,173 mortality, 74-75 physical, 105
drift, influenza, 275 Murray Valley encephalitis, 94 viruses
H,173 O'nyong nyong, 93-94 biochemical and physical
HL-A,49 pathogenesis, 81-85 properties, 105
N,173 pattern of, 76-77 biological properties, 107-108
relationship among arenaviruses, plague of man, modem, 71 morphology, 105-106
106 powassan virus, 91 vaccine, 119-120
soluble, arenavirus, 106 prevalence, 78 Argentinian hemorrhagic fever
shift, influenza, 275 problems, unresolved, 95-97 (AHF), 103, 112-115
Antigenic sin, doctrine of original, prevention, 86-87 clinical features, 113-114
274 as RNA virus, 77 control, 115
Antiserum pool, lyophilized, 168 RNA homology, 96 in com harvesters, 119
equine, 168, 169 sex, 79 diagnosis, 114-115
Antiviral drug, topical, 268 St. Louis encephalitis, 89-90, 92-93 distribution
Apodemus agrarius, 120 survey, serological, 75-76 geographical, 113
A. sylvaticus, 120 survival in nature, 77 seasonal, 113
Arboviruses, 71-101 temporal distribution, 79 epidemiology, descriptive, 113
age, 79 the term, definition of, 71 history, 113
California encephalitis, 90 tick-borne em:ephalitis, 94-95 host response, 113-114
categories, 95-96 transmission, 74, 80-81 mortality, 104
characteristics of virus, 87-95 by ticks, 74 occurrence, 114
chikungunya, 93-94 in the U.s.A., 78, 87-92 prevalence in man, 113
classification, serological, 73 elsewhere, 92-95 prevention, 115
clinical features, 85 western equine encephalitis, 88- reservoir, 113
Congo virus, 95 89,92-93 Akodon, 113
Colorado tick, 90-91 Venezuelan equine encephalitis, Azarae, 113
control, 86-87, 97 91,93 Calomys laucha, 113
Crimean hemorrhagic fever, 95 vesicular stomatitis, 91-92 Calomys musculinus, 113
definition, 80 ARD, see Respiratory disease, acute Mus musculus, 113
dengue and dengue hemorrhagic Arenaviruses, 103-125 as rural disease, 113
fever, 93 antigen relationships among, 106- transmission, 113
diagnosis, 85-86 107 treatment, 115
distribution, geographic, 79 Argentinian hemorrhagic fever, Aristotle, 351
temporal, 79 112-115 Arthritis in adults, 329
epidemic behavior, 78-79 Bolivian hemorrhagic fever, 115- Arthropods, 71, 77
eastern equine encephalitis, 88, 92 117 blackflies, 71
epidemiology, general, 77-80 effect on man, 108 control, 86
descriptive (U.s.A.), selected ether, inactivation by, 105
horseflies, 71
viruses 80-81, 87-92 history, 103
mites, 71
methodology, 74 immunity, 108-109
Lassa fever, 117-119 mosquitoes, 71
factors, 78-79
laboratory diagnosis, 104 sandflies, 71
geographic distribution, 79
groups, 72 lymphocytic cporiomeningitis, specifici ty, 77
history, 71-74 109-112 ticks, 71
host response, 85-86 methodology, 103-104 vectors, 10, 79, 86
immunity, 81-85 morbidity, 104 Aseptic meningitis, see Meningitis,
cell-mediated, 84 morphogenesis, 105-106 aseptic
incidence, 78 morphology, 103, 105-106 Asian influenza surveillance, see
infections of humans, 82-83 mortality, 103-104 Influenza
Index 567
Australia antigen, see Hepatitis Burkitt's lymphoma (cant.) Burkitt's lymphoma (cant.)
Azarae, as vector, 113 chemotherapy, 494 virus, biology of (cant.)
in children, 481 relation to Burkitt lymphoma,
B cell, 16 clinical findings, 492-493 485-486
BK virus, 524 control, 494-495 structure and morphology, 482-
Babesia bigemina, 72 description of tumor (1958), 481 483
Barbados, survey, 43, 149,414 description of virus, 481, see transformation and oncogenicity,
Bartlett's equation, 302 Epstein-Barr virus 484
BHF, see Bolivian hemorrhagic fever distribution of tumor, 489
Birds as reservoir, 80 in Kenya, 489 California encephalitis, 75, 80-81, 84-
Black death in Europe (1348), 33 in Uganda, 486, 488, 489 87,90
Blood-brain barrier, 12 epidemiology, 48 California virus infections
Blood transfusion descriptive, 487-490 evidence from diagnostic serology,
CMV, 154 epidemics, 487 44
EBV, 213 Epstein-Barr virus, 26, 213, 482-487 infection and antibody pattern, 78
Hep B, 243 present in Burkitt tumor, 485-487 Calomys callosus, as vector, 115, 116
Bolivian hemorrhagic fever (BHF), see Epstein-Barr virus C. laucha, as vector, 113
103, 115-117 genetic factors, 490 C. musculinus, 113
control, 117 geographic factors, 489 Canine distemper viruses, 298
diagnosis, 5 hemoglobin genotype, 490 Cannibalism, 526
distribution, geographic, 115 history, 481-482 Capsid, see individual viruses
epidemiology, descriptive, 115 host factors, 490, 492-494 Capsomere, see individual viruses
main foci, 115 humidity,489 Carcinoma
history, 115 incidence, 487-488 cervical, see Cervical Cancer
host response, 116 in Kenya, tribal distribution, 487, in situ, 502
incubation period, 116 489 vulvar, 505
mortality, 104, 116 laboratory diagnosis, 482 see Cancer, Neoplasia, Tumor
prevalence in man, 115 and malaria, 487, 491-492, 494 Cardiovirus, 175
prevention, 117 malaria control, 494 Case
reservoir, 116 methodology, 482 control methods, 3
transmission, 115-116 microepidemics, 489 control studies, 2
to man, 115-116 morbidity,482 prevalence, 43
treatment, 117 mortality,482 Catalogue of Arthropod-borne Viruses
Bornholm disease, 164, 180, 190 oncogenicity,484-487 of the World, 71
Boston exanthem disease, 191 pathogenesis, 490-492 Cataract, 418
Boylston inoculates his son (1721), pathological features, 492-493 Causation, proof of, 24-28
430 postmoretm findings, 493 classical concepts, 24
Br Cr strain, 191 problems, unresolved, 495 Henle's (1840), 24
British Medical Research Councils's seroepidemiology, 486-487 Koch's (1884, 1890), 24,25
Common Cold Research serologic features, 493-494 postulates, 25, 395
Unit, 127 serology, 482, 486, 493, 494 Cell-mediated immunity, see
Bronchiolitis, 337, 344 surveys, 482 Immunity
Burkitt's lymphoma, 481-499 sex, 489 Central nervous system infections,
age distribution, 489-490 structure of virus, 482-483 causes of, 12, 19-20
of antibody, 486-487 surveillance, immunological, 491- Cervical cancer, 26, 501-518
in animals, 484 492 age, 508-509
antigen therapy, 494-495 antigen, herpes, 502
cell-associated, 483 transformation of cell, 484, 490-491 biology of cancer, 506-507
virus-associated, 483 transmission, 490 of the virus, 506-507
among Bantu, 487 tumor safaris (surveillance), 482 bleeding, a major symptom, 512
biology of Epstein-Barr virus, 482- tumor, virus in, 485-486 causation by herpes simplex virus,
487 vaccine, 494-495 514
cell virus, biology of, 482-487 clinical picture, 512
transformation, 484-487, 490 cell-associated antigen and cell- colposcopy, 502, 503
-virus relationship, 483-484 virus relationships, 483-484 control, 503, 504, 513-514
568 Index
Cervical cancer (cant.) Cervical cancer (cant.) Congo virus, 95

cytology, 503 survival rate, 514 Conjunctivitis enteroviral, 164, 187,
dysplasia, 512 susceptibility to, 505 192
epidemiology in syphilis patients, 509 see Keratoconjunctivitis
descriptive, 508-509 therapy, 513--514 Coronaviruses, 127-141
first epidemics reported (1842), transmission, 510 age, 136-137
502 in the U.S.A., 509 biological characteristics of virus,
ethnic origin, 509 virus, biology, 505-507 130--132
first epidemics reported (1842), 502 detection in cancer cells, 504 children, school-aged, 137
first suspicion of genital herpes Chemoprophylaxis, 28 cold-like illness, 138
and cervical neoplasia Chikungunya virus, 82--83, 93--94 complement fixation test, 130
(1964),502 Chlamydia trachomatis, 61 distribution
geographic distribution, 509 Chloroform inactivates arenaviruses, geographic, 135
Chile, 509 105 temporal, 135-136
Colombia, 509 Cholera, 24 epidemiology, 127-141
Poland,509 Chromosome 19 and poliovirus, 174 descriptive, 132-137
herpes simplex virus, 502-514, see Chronic illnesses, epidemics of, 4 methodology, 128-130
Herpes simplex virus Chronic neurological diseases, 499- in Tecumseh, Michigan, 132
histological methods, 503 537 fluorescent antibody test, indirect,
history, 502 Creutzfeldt-Jakob disease, see 130
host response, 512-513 Creutzfeldt-Jakob disease geographic distribution, 135
immunity,512 central nervous system, hemagglutination inhibition test,
incidence, 508 spongiform degeneration of, 130
intraepitheliallesion, 512 525,528 history, 127-128
iodine test, 502 kuru, see Kuru host response, 138-139
in Israel, 509 measles antibodies in, 521 immunity,l38
lesion, intraepithelial; 512 mink encephalopathy, see Mink incidence, 132-135
methodology, 502-504 papovaviruses in, 524 infection, factors of, 136-137
morbidity, 502 scrapie, see Scrapie isolation of virus, 129-130
mortality, 502, 508 slow virus infection, 520 laboratory methods, 129-130
natural history, 504 subacute sc1eropanencephalitis, see methodology, 128-130
neutralization test for antibody, Scleropanencephali tis morbidity, 128-129
506 Clethrionymus glareolus, 120 morphology, 127
in New Zealand, 509 Cleveland family study of respiratory mortality, 128
Papanicolaou-Traut test (1943), 502 illnesses, 220 neutralization test, 130
pathogenesis, 510--512 Climate, role of, 5 pathogenesis, 138
prevalence, Cold, common, 127, 164 prevalence, 132-134
in prisoners, 509 Coli tis, ulcerative, 155 recovery of human strains, 127
problems, unresolved, 514-515 Colorado tick fever, 79--81, 84, 87, 90-- reinfection rate, 138
progression, 504 91 respiratory disease, chronic
in prostitutes, 509 and arthropod-borne encephalitis, obstructive, 137
religion, 509 79 RNA-containing, 127
Irish, 509 Colposcopy, 502, 503 serology, 130--131
Jewish, 509 Commission on Acute Respiratory surveys, 129-133
nuns, 509 Diseases of U.S. Armed tests, 130
risk factors, 507, 508 Forces Epidemiological sex, 136
in Scandinavia, 509 Board, 53, 54
strains
seroepidemiology,504 Common cold, see Cold, common
B814, 128
serological features, 513 Common Cold Research Unit, British
229E, 127, 128, 136, 137, 139
and sexual intercourse, 502, 510 Medical Research Council,
smegma, role of, 510 studies, 133
127,135
socioeconomic status, 509 Communicable Disease Center in swine, 138
sperm, role of, 510 (U.S.A.), 34 temporal distribution, 135-136
squamous cell carcinoma, 502, 513 Complement fixation test, 104, 116, transmission, 137-138
s tart of. 505 130, 144, 277 Coughing and viral particles, 8
Index 569
Coxsackievirus, 163, 164, 178, 180-- Croup epidemics, 337, 344, 345 Cytomegalovirus (cont.)
182, 185, 189-191, 193 in males, 342 incidence (cont.)
A, 163, 193 in winter, 340 in young adults, 148, 149
antigenic characteristics of virus, Culex annulirostris, 82 infection, asymptomatic, 144, 145,
172-173 C. musculinus, 113 152
aseptic meningitis, 190 C. nigripalpus, 84, 89 isolation of virus, 144
B, 192, 193, 328 C. pipiens, 84, 89 laboratory diagnosis, 144-145
characteristics, biological, 171-176 C. quinquefasciatus, 84, 89 methodology, 144-145
epidemic at boys' camp on lake, C. tarsalis, 84, 88, 89, 97 mononucleosis, spontaneous, 149,
187 C. tritaeniorhynchus, 82 151-152, 154
and diabetes, 192 Culicoides, 72, 95 morbidity, 144
Du Toit strain, 172 Culiseta me/anura, 84, 88, 89 mortality, 144
epidemics, 177 Cystitis, acute, 62 neonate, pathogenesis in, 143, 147,
at boys' camp on lake, 187 Cytomegalia, 143 152
among Eskimos, 179 Cytomegalic inc1 usion disease, 144, occupation, 150
Faukner strain, 172 146 oncogenicity, 145
hand, foot and mouth disease, 190 Cytomegalovirus, 143--161, 254 open-heart surgery, 149
herpangina, 189 age, 149-150 organ transplant
host response, 189-197 allograft reception, 155 host response, 155
isolation of, 168-169 antibody, 143, 152 pathogenesis of, 151
in lake water, 187 antigen, 144 posttransfusion, 154-155
meningitis, aseptic, 190 In blood of donor, 155 pathogenesis, 150--152
myocardiopathy, 190--191 and cancer, 155 pregnancy, 147, 149, 156
in nasal secretions, 187 characteristics, biological, of virus, prevalence, 146-147
neonatal disease, 190 145 problems, unresolved, 156
in mice, 173 and colitis, ulcerative, 155 race, 150
paresis, 190 complement fixation test, 144 renal transplant, 155
pleurodynia, 190 distribution, serodiagnosis, 144-145
replication of virus, 174-175 geographic, 149 indirect hemagglutination, 145
respiratory infections, 190 world-wide, 147 serological survey, 144, 146
strains, list of, 193 temporal, 150 serological test, 144-145
summer minor illness, 190 epidemiology, descriptive, 146-150 sex, 149-150
syndromes, clinical, 189-197 methodology, 144-145 socioeconomic setting, 150
Creutzfeldt-Jakob disease, 528-534 geographic distribution, 149 spontaneous mononucleosis, 151-
amantadine helpful, 533 giant form, 145 154
cause unidentified, 529 his tory, 143--144 temporal distribution, 150
classification, 529 host response, 152-156 transformation of hamster cell, 145,
distribution, world-wide, 529 acquired, 153 510
eating human brain, 532 of adult, 153--154 transmission, 150
eating sheep eyeballs, 532 of child, 153--154 from cervix, 150, 153
epidemiology, descriptive, 529-531 congenital, 152-153 ulcerative colitis, 155
first description (1920s), 528 hepatitis, 154 vaccine, 156
history, 528 and malignant disease, 155 Cytopathogenic effect (CPE), 55, 107,
host response, 532-533 posttransfusion, 154 168, 174
immunity, 532 posttransplant, 155
incidence, 529, 530 syndromes, 155-156
methods, 528 immunity,152 Dane particle of hepatitis virus, 237
pathogenesis, 532 immunization, 156 Data networks, 37
and slow virus infections, 530 immunosuppressive therapy, 155 Democritus, 351
transmission, 528, 531-532 incidence, 147-149 Dengue, 93
from human brain to in freshmen college students, 149 Dengue hemorrhagic fever, 73, 82-84,
chimpanzee, 528 in marine recruits, 149 93
virus and, 529, 530 in pregnant women, 147-149 shock syndrome, 84
biological characteristics, 528 in prospective studies, 148 Deoxycholic acid, 77
Crimean hemorrhagic fever, 82, 95 in surgical patients, 148, 149 Dermacentor andersoni (tick), 84, 90
570 Index
Descriptive epidemiology, see Encephalopathy, subacute Enteroviruses (cont.)

Epidemiology, descriptive spongiform, 525 laboratory methods, 168--171
see also individual viruses English boarding school children, 150 meningitis, aseptic, 20
Diabetes with mumps, 328 Enteroviruses, 163--207; see also morbidity, 165-166
Diagnosis, viral, see Viral diagnosis Coxsackieviruses, mortality, 165
Diagnostic serology, see Serology, Echoviruses, and pathogenesis, 187-188
diagnostic Polioviruses poliomyelitis, 183--186
Dimethylbenzanthracene (DMBA), acid sensitivity, 171 portal of entry, 187
435 age, 180-181 prevalence, 176--177
and mammary tumor induction, antibody tests, 169-171, 177 in sewage, 177
435 antigen, 172-173 in stool of healthy humans, 177
Dimethylnitrosamine, 550 antigenic characteristics of viruses, prevention, 195-201
Diplococcus pneumoniae, 19 171-176 problems, unresolved, 201
Disease, aseptic meningitis, 20 reaction to agents, chemical and
chronic, 48 characteristics, biological, 171-176 physical, 171-172
incidence of, 2 climate, 178--180 replication, 174-176
rate of, 2 clinical picture, 189-192 serological surveys, 166--167
serological approach to, 46 in closed ecological unit, 181-183 serological tests, 164, 177
Distemper, 298, 521 conjunctivitis, acute hemorrhagic, sex, 180-181
Dog, distemper virus, 298 187, 192 socioeconomic factors, 183
Druesenfieber (glandular fever), 209 control, 195-201 surface waters, isolation of viruses,
Dunenhage virus, 356 Coxsackievirus infections, 189-191 167
Duovirus,21 cytopathogenic human orphan transmission, 186--187
Dust suppression, 65 (ECHO),164 types, 191-192
cytopathogenicity, 178 vectors, 187
Eastern equine encephalitis, 80--81, diagnoses, 192-194 flies as, 187
84, 87-89, 92 diarrhea, 21 Environmental control, 65
EBV, see Epstein-Barr virus distribution, geographic, 178--180 chlorination of swimming pool, 65
Echoviruses, 163, 164, 180, 182, 185, Echovirus infections, 191-192 dust suppression, 65
191; see Enteroviruses entry, 187 heat sterilization of
clinical syndromes, 191 epidemic-endemic behavior, 177 ophthalmological
diagnoses, 192-194 epidemiology, descriptive, 176--186 instruments, 65
epidemics, 177 distribution, geographic, 178-- Epidemic field investigations, 36
strains, 172, 194 180 epidemics, 3, 5, 58, 61
Ectromelia, infectious, .12, 442 epidemics, 177-178 see individual viruses
Egg, embryonated, 277 incidence, 176--177 Epidemiological
Electron microscopy, 73, 106 serological surveys, 166--167 circumstances, 22
Encephalitis, 75, 86, 297, 310, 327 morbidity, 165-166 probabilities, 18
arthropod-borne, 79, 86-87 mortality, 165 surveillance, 33--40
in California, 192 prevalence, 176--177 Epidemiological Investigation Unit,
causes, 87 methodology, 165-171 36
Colorado tick fever, see Colorado socioeconomic setting, 183, 185 Epidemiology, 77-88
tick fever ether sensitivity, 171 analytical, 2
Connecticut study, 75 in family, 181-183 descriptive, 2
and cytomegalovirus, 155 geographic distribution, 178--180 experimental, 3
and herpesvirus, 266 history, 164-165 marker, 36
in horse, see Western equine host range in vivo and in vitro, 173-- serological, 3, 40-49
encephalitis 174 Epstein-Barr virus (EBV) 26, 48, 209-
due to mumps, 320, 323 host response, 189-192 233,254,482
Japanese, 82-83, 94 of human origin, 163 age, 219
in measles, 310 identification, 168--169 antibody, 212, 215, 219, 225, 226,
postvaccinal, 448, 450 immunity, 188--189 544,546
Venezuelan, 79, 82, 83, 88, 91, 93 incidence, 176--177 to early antigen, 212
and virus, 328 incubation period, 187 heterophile, 212-213, 225-226
Encephalomyocarditis in infants, 165 isolation, 168--169 IgM, 214, 225, 226
Index 571
Epstein-Barr virus (EBV) (cant.) Epstein-Barr virus (EBV) (cant.) Haemaphysalis, 82

antigen, 212, 225 occupation, 220 HB Ag, see Hepatitis B antigen
early, 212 occurrence, 220 HEK, see Kidney, human embryonic,
Burkitt's description of tumor oncogenicity,484 primary,
(1958),481,482 oral transmission, 221 Hemagglutination, 73
in Burkitt's lymphoma, see pathogenesis, 222-224 inhibition, 73, 130, 277
Burkitt's lymphoma in prevalence, 215-217 viral, 287
Africa prevention, 226-227 Hemagglutinin, 173, 278
causation, proof of, 214-215 problems, unresolved, 227-228 Hemorrhagic conjunctivitis, 164
cell-associated antigens, 483 race, 220 by enterovirus, 187
cell-virus relationships, 483 recovery of virus from throat, 221 Hemorrhagic disease
characteristics, biological, 213-215, seroepidemiological relationships, infant mortality, 144
482-487, 545-546 486 HemorrhagiC fever
clinical picture, 224-225 serological surveys, 211-212, 482, distribution in
complement fixation test, 212, 543 544 Argentina, 103, 112-115
control, 226-227 serological tests, 212, 541-543 Bashkirian, 120
diagnosis, 225-226 sex, 219 Bolivian, 115-117
discovery, 46, 215 socioeconomic factors, 221 Dengue, 93
distribution, geographic, 218 structure, 482 Hungary, 120
temporal, 218 temporal distribution, 218.--219 Korea, 120
EBNA test, 212, 543 in throat, 221 Sweden, 120
epidemiological behavior, 551-553 transformation, 212, 213, 484 renal syndrome, 120
epidemiology, descriptive, 215-221 transmission, 215, 221-222, 546 Hemorrhagic nephrosonephritis, 120
methodology, 210-213 in tumor, 385, 481, 485 Henle/Koch postulates, 24
experiments with, 215 Equine antiserum, 168 Hepatitis viruses, 235-252
extracellular, low yield, 213 Eshnunna Code, 351 Hepatitis viruses, 235-252
geographic distribution, 218 Exanthem, 11-12, 20 general
genome, 26, 213, 385, 481-483, 485 Excretion, urinary, of virus, 9 characteristics, biological, of
heterophile antibody, 212-213, Eye as portal of entry of virus, 63, 532 viruses, 239-240
225-226 history, 235-236
history, 46, 209-210, 215 Fecal contamination, 8 epidemiology, descriptive, 242
host response, 224-226 Fecal excretion, 55 laboratory methods, 238-239
hybridization test, 485, 544 Fermon strain, 191 methodology, 236-239
immunity, 222-224 Fibroelastosis, endocardial, 328 morbidity, 236
immunofluorescence method, 212, Field epidemiological team, 74 mortali ty, 236
541-542 Fiji Islands, 187 serological surveys, 237-238
indirect, 212 Finlay, Carlos, 72 unresolved problems, 248-249
incidence, 215-217 Foot and mouth disease virus, 175 hepatitis A (HAV), 9, 10, 173, 235,
incubation period, 222 Fore tribe, 525-526 236, 240, 241, 245, 247
infection, 11, 151, 214, 223, 482 . age, 240-241
isolation of virus, 212, 542 Gamma-globulin, see antigen, 237-238
laboratory methods, 212-213, 541- Immunoglobulin antibody, 238
543 Gastroenteritis, viral, 21 characteristics, 238-239
lymphatopic, 546 Gastrointestinal syndromes, causes in chimpanzees, 239
membrane fluorescence test, 212 of,20-22 complement fixation test, 237
methodology, 210-213 Genetics and N.P.C., 551 control, 247-248
mononucleosis, 26, 151, 211, 215 Genetics and viral disease, 48-49 distribution,
molecular virology, 544-545 Genital tract, 9 geographic, 240
morbidity,211 Glomerulonephritis, 22 temporal, 240
morphology, 482 Gradient, biologicat 16-18 epidemic, 240, 243
mortality, 210 Guarnieri bodies, 442 epidemiology
nasopharyngeal carcinoma, 543- Guillain-Barre syndrome, 328 descriptive, 240-241
553, 556 see Nasopharyngeal methodology, 236-239
carcinoma Habel test, 352 geographic distribution, 240
nucleic acid, 213, 485 Haemagogus, 82, 93 his tory, 235
572 Index
Hepatitis viruses (cont.) Hepatitis viruses (cont.) Herpes viruses (cont.)

hepatitis A (HAV) (cont.) hepatitis B (HBV) (cont.) antibody, 507, 509
host response history, 235-236 antigen, 502, 504, 512
clinical features, 246-247 host response, 246 autoinoculation, 262
laboratory diagnoses, 246 illicit drug use, 241 behavior, epidemic, 259
immunity,245 immunity, 245--246 and cancer, 514
infection, intestinal, 245 cell-mediated, 245 cell-mediated immunity, 257
in marmoset, 238 immunoelectronmicroscopy, 238 cell to cell interaction, 511
methodology, 236-239 immunofluorescence, 238 spread, 15, 265
Milan antigen, 237-238 jaundice, 246 in cervical cancer, 26, 503-507
morbidity,236 in Korea, 248 characteristics, biological, 257-258
mortality,236 laboratory methods, 238-239 clinical entity, 260, 265-267
occupation, 241 in liver inflammation, 235 in newborn, 266-267
in oyster, 243 in lymph, human, glycerinated, picture, 260-261
pathogenesis, 245 243 spectrum, 264
prevention, 247 in marmoset, 239 in college wrestlers, 260
problems, unresolved, 248-249 methodology, 236-239 congenital malformation, 267
race, 242 military significance, 235 control, 267-268
replication, viral, 245 morbidity, 236 cytohistological, 255
in rhesus monkeys, 239 mortality,236 cytology, 256
serological survey, 237 in mosquito, 244 diagnosis, 256-257
sex, 240-241 nomenclature, 237 distribution, geographic, 259
surveillance, 34 occupation, 241, 242 temporal, 259--260
survey, serological, 237 pathogenesis, 245--246 DNA, defective, 511
temporal distribution, 240 perinatal transmission, 244 encephali tis, 267
tissue culture, 239 prevalence, 245--246 epidemiology, 253-271
transmission, 242-243 prevention, 246-248 clinical, of specific syndromes,
virus, biological characteristics, problems, unresolved, 248-249 260-262
239-240, 241 race, 242 descriptive, 258-262
hepatitis B (HBV) radioimmunoassay, 238, 247 general, 258-260
age, 241-242 replication, viral, 245 methodology, 254-257
antibody, 237 reservoir, 244 epidemic behavior, 259
antigen, 26, 46, 237-239, 246 in rhesus monkey, 239 eVQ.1ution, 254
Australia, 237, 242, 247 serological survey, 237 eyes, 266
discovery, 236 serum sickness, transient, 245 in fetus, 266-267
particle, 237 serum transaminase, elevated, 246 in gastrointestinal tract, 265
in blood donor, 247 setting, 242 genital infection, 260-262, 507, 510
characteristics, biological, 239--240, sex, 240, 242 history, 254
241 subtypes, 239-240 host response, 265-267
and chimpanzee, 238 surveillance, 34 identification
committee on, 237 survey, serological, 237 by immunofluorescence, 256
complement fixation test, 238 tatooing, 241 by neutralization, 256
control, 247-248 temporal distribution, 241 incidence, 258-259
counterelectrophoresis, 238 tissue culture, 236 immunity,263-265
Dane particle, 237 transmission, 236, 239, 243-245 cell-mediated,257
distribution, geographic, 240, 241 perinatal, 244 immunization, 267
temporal, 241 sexual,244 active, 267
epidemic, 243 tatooing, 241 passive, 267
epidemiology, 240-242 transfusion of whole blood, 244 immunosuppression, 260
descriptive, 241-242 vector, 244 infection, 258-259
methodology, 236-239 Herd immunity, 4, 416 among children in institutions,
geographic distribution, 241 Herodotus, 254 259
in hemodialysis patient, 242 Herpes gladiatorum, 256, 260 geographic distribution, 259
in hemodialysis staff, 242 Herpes viruses, 48, 253-271, 505 isolation of virus, 256
in hepatitis, acute, 246 age, 260 keratitis, herpatic, 261
Index 573
Herpes viruses (cant.) Heterophil antibody, 209, 210,225- Infection without disease, 1
labial herpes, 261 226 inapparent, 16
laboratory diagnosis, 256--257 beef (ox) cell hemolysin test, 212, Infectious bronchi tis virus (IBV), 128,
latency, 258 226 131
labial herpes, 265-266 commercial kits, 212 antibody, 138
in medical personnel, 260 in diagnosis, 225-226 transmission by aerosol, 138
morbidi ty, 255 discovery, 209 Infectious disease, prognostication,
morphology, 257 enzyme test by Wollner, 212 40
mortality,254-255 horse cell test, 226 Infectious hepatitis, see Hepatitis
mouth,265 Paul-Bunnell test, 212 viruses
mutant, temperature-sensitive, 257 persistence, 226 Infectious mononucleosis, see
neonatal, 262-263, 266--267 sheep cell test, 226 Mononucleosis
nervous system, 266 tests, 212-213 Influenza Commission, 291
neurological, 261 Hippocrates and epidemic jaundice, Influenza viruses, 273-296
newborn, see neonatal above 235 age, 284-286
occupation, 260 Hodgkin's disease, 16, 209 antibody, nasal, 288
occurrence, 260 Hog brain, eating of, 531 secretory, 288
in old people, 262 Hospital and medical care plans, 37 in serum, 288
oral infection, epidemiology of, 261 cooperative group health surveys, 41
oral to genitals, 263 insurance, 37 antigen drift, 273, 291
Papanicolaou-Traut screening of Kaiser-Permanente plan, 37 shift, 273
cervico-vaginal smears, 255- national health insurance plans, 37 behavior, epidemic, 284
256 professional activities service, 37 characteristics, biological, 278
pathogenesis, 263-265 Host response patterns, 6, 16--22 as chronic debilitating disease, 280
in pregnant women, 258 see individual viruses chronological antibody survey, 274
prevention, 267-268 Huebner's concepts of causation, 24- clinical picture, 289
prevalence, 258-259 25 complications, 289
in primary infection, 263 Hyalomma plumbeums, 82 control, 290-291
problems, unresolved, 268 Hypogammaglobulinemics, in polio death from, 35, 278-283
in prostitutes, 258, 260 immunization, 197 excessive in U.S.A. cities (1887-
race, 260 1956),279-280
recurrent infection, 265 Ig, see Immunoglobulin diagnoses, 289-290
respiratory tract infection, 261, 265 Immune complex nephritis, 16 dissemination, 284
serological survey, 255-256 Immune response, 14-16 distribution, geographic, 284
setting of occurrence, 260 Immunity temporal, 284
sex, 260 cell-mediated, 15-16 drift, antigenic, 273, 291
skin infection, 261, 266 delayed hypersensitivity, 15 epidemic, 273
social significance, 253-254 humoral, 14-15, 106 see pandemics
socioeconomic setting, 260 immune response, 14-16 epidemic behavior, 284
in stomatitis, 259 lasting, 59 epidemiology, 273-296
temporal distribution, 259-260 local, 15 descriptive, 278-287
the term, origin of, 254 Immunization, 27-28 methodology, 275-278
transmission, 256, 262-263, 267-268 of host, 28 factors, other epidemiologic, 286
by genital route, 262, 263 program, evaluation of, 45-46 geographic distribution, 284
by kissing, 262 Immunoglobulin classes, 15,47, 138, high-risk categories of people, 280
by oro-genital route, 262 153, 197, 226 h{story, 274-275
Inclusion body disease, 144 host response, 289-290
by saliva, 262
Incubation period, defined, 13 immunity,288-289
by trauma, 266
graphic portrayal in viral diseases, incidence, 278-280
by wrestling, 262 infection, subclinical, 289
14
traumatic infection, 266 Individual case investigation, 36 inhibitors, 288
in tumor cell, 512 alert card, 36 interferon, 288
in urogenital tract, 266 Infant mortality due to hemorrhagic isolation of virus, 277-278
u.v. inactivation, 506 disease, 144 laboratory methods, 277-278
as veneral disease, 253 Infant mouse technique, 73 morbidity, 276--277, 278-280
574 Index
Influenza viruses (cont.) Keratoconjunctivitis, epidemic, 53, Lassa fever virus (cant.)
mortality, 275--276 54,61-62 distribution, geographic (cont.)
nomenclature of subtypes, 273 called "shipyard eye", 61 Central African Republic, 117
nucleocapsid, 278 in Japan, 62 Guinea, 117 .
in older age groups, 280 outbreaks around Jos, 117
pandemics of 1580,1889,1918,274, ophthalmologists, 62 Lassa,117
278, 280 in Taiwan, 62 Liberia, 117
pathogenesis, 287-288 Kidney, primary human embryonic, Nigeria, 117
in pregnant women, 280 169 Onitsha, 117
prevalence, 275, 278-280 Koch's postulates, 24-25 Sierra Leone, 117
problems, unresolved, 291 Koplik spots, 297, 309, 311 epidemiology, descriptive, 117-118
recycling, antigenic, 291 Korean hemorrhagic fever, 120 first described, 117
respiratory disease surveillance Kotonkan virus, 356 in hospital personnel, 119
(U.s.A.),276 Kuru, 14, 525--527 host response, 118-119
and respiratory secretions, 287 cannibalism started (ca. 1920), 527 incubation period, 118
in school-aged children, 285 abandoned (ca. 1960), 527 isolation of virus, 119
serodiagnosis, 278 characteristics, biological, of virus, in Vero cells, 120
serological survey, 277 526 mortality, 104, 117
strain Hong-Kong, 274 control, 527 organ involvement, generalized,
subtype nomenclature, 273 epidemiology, descriptive, 526-527 118
Surgeon General's Advisory first slow virus disease in man, 525 outbreak in hospital, 117, 120
Commission on Influenza Fore linguistic group, 525 patient, how to transport, 120
(U.S.A.), 280, 290 history, 425--426 prevention, 119
surveillance (U .s.A.), 34, 276 host response, 527 /3-propiolactone effect, 105
swine, 274 immunity, 527 reservoir in rodents, 118
temporal distribution, 284 methodology, 526 Mastamys natalensis, 118
transmission, 287 neuropathology, 526 spread,118
by droplet nuclei, 287 pathogenesis, 527 transmission, 118
type B, 275 prevention, 527 transportation of patient, 120
type C, 275 problems, unresolved, 527 treatment, 119
vaccination, 273 and scrapie, 525 types, 117-118
Informed consent, 3 symptomatology, surprisingly Latino virus, 103, 107
Insect cells grown in culture, 77 uniform, 527 Leukocyte, 49
Insect vector,S, 72 transmission, 527 Leukoencephalopathy, progressive,
Interference, 196 to chimpanzee, 526 multifocal (PML), 26, 520,
Interferon, 288, 291, 326, 399, 400, Kyasanur Forest disease virus of 524-525
443,475 India, 82-83, 91, 95 Leukopenia, 22
Interrelationships of disciplines, 48- Liver inflammation, 523, 524
49 Laboratory of Slow, Latent and Lymphocyte, 8, 15, 47, 213
Iododeoxyuridine, 476 Temperate Viruses (NIH), atypical, 151-152
Ixades coakei, 91, 95 526 B-cell, 8, 222-223, 545
I. marxi, 91, 95 Laboratory accidents, Lassa fever, T-cell, 8, 223, 545
I. persulcatus, 91, 94 117 Lymphocytic choriomeningitis virus
I. ricinus, 82, 91, 94 La Crosse virus, 74 (LCM), 109-112
transovarial transmission, 74 age, 110
Lagos bat virus, 356 characteristics, biological, of the
JC virus, 524 Laryngotracheobronchitis, 344 virus, 105--108
Japanese encephalitis, 82-83, 94 Lassa fever virus, 103, 106, 108, 109, clinical aspects, 112
Jaundice, 86 117-119 diagnosis, 112
epidemic, 235 characteristics, biological, of the distribution, geographic, 110
described by Hippocrates, 235 virus, 105-108 in West Germany, 109
Jenner, Edward, 430 death rate, 119 epidemiology, descriptive, 109-110
Jet transport, 86 diagnosis, 119 first isolation, 109
Junin virus, 103, 115 early, 120 in hamster, 110, 111
isolation, 113 distribution, geographic, 117 host response, 112
Index 575
Lymphocytic choriomeningitis virus Measles virus (cant.) Measles virus (cant.)

(LCM) (cant.) distribution (cant.) subacute sclerosing
incidence, 109-:110 geographic (cant.) panencephalitis, 310--311
in man, 108 Iceland, 303 temporal distribution, 304
in military ptrsonnel, 109 New Haven, Connecticut, 303 transmission, 307-308
in mouse, 108, 110, 111 St. Helena, 303 vaccination, 290--291
occupation, 110 U.S.A., 301, 307 vaccine, 301, 305, 311, 313, 330
occurrence, 114 temporal, 304 distribution, 312-313
prevalence, 109-:110 electroencephalogram, abnormal, killed, reactions to, 313
prevention, 112 310 live, attenuated, 311
reservoir, 110--111 encephalitis, 297, 310 in the U.S.S.R., 291
sex, 110 see Encephalitis unusual reactions following
transmission, 110--112 endemic, 306 killed,313
treatment, 112 epidemic behavior, 301-303 Meningitis, aseptic, 20, 112, 164, 180,
Lymphocytosis, 22, 151, 222 epidemics, 298, 301, 306 182,191
Lymphoma, 501 epidemiology acute, benign, 103
Lymphosarcoma, 525 cyclic, 298 causes of, 20
Machupo virus, 103, 116 descriptive, 300--307 due to echovirus, 182, 190
Macrophage, affected by agents, 451- methodology, 298--300 due to mumps virus, 20, 327
452 eruption, 297 on Pacific coast (U.S.A.), 182
Malaria exanthem, macular, 297 Meningoencephalitis, 86, 327, 328
appraisal, 34 excretion, 308 Mesacricetus auratus, 111
and Burkitt's lymphoma, 487, 491- on Faroe Islands, 298 Metaplasia, 505
492,494 first isolation, 298 Micronesians, 305
surveillance, 34 geographic distribution, 303-304 Microtiter
Manson, Patrick (1878), 71 hemagglutination inhibition, 300 procedure, 42
Marek's disease, 553, 555 hemolysis inhibition, 300 test, 42
vaccine, 494 herd immunity, 290, 312 Microtus fortis, 121
Mastitis, 327 history, 297-298 Milan antigen, 237
Mastamys natalensis, 118 host response, 310--311 Mokola virus, 356
Mathematical models, 4 immunity,308--310 Molecular epidemiology, see
for measles, 302-303 incidence, 300--301, 303 Epidemiology, molecular
Mather, Cotton, 430 incubation period, 308 Monkeypox, 451
Measles virus, 48, 64, 297-316, 521 infection, 309 Mononucleosis
aerosol, 308 Koplik's spots, 297, 309, 311 CMV, 151-152, 154
age, 304-305 laboratory methods, 300 and Epstein-Barr virus, 26, 151,
antibody, 299, 300, 309-:311 malnutrition, 307 210, 211, 215
maternal, 304 models, 302 infectious (EBV), 46
behavior, epidemic, 301-303 morbidity, 298--299 age, 219, 220
in body tissue, 308 mortality, 298, 304-306 antibody, heterophile, 225-226
catarrhal symptoms, 311 and multiple sclerosis, 26, 313 in Canadian families, 220
characteristics, biological, 300 neutralization test, 300 causation, proof of, 214-215
clinical features, 308--311 nutrition, 307 clinical picture, 216, 218, 224-225
complement fixation test, 300 occupation, 306 in college populations, 218, 220
control, 311-312 pathogenesis, 308--310 commercial testing kits, 213
diagnosis, 311 prevention, 311-312 delayed hypersensitivity
clinical, 311 problems, unresolved, 312-313 depressed by, 222
laboratory, 311 quarantine, 311 diagnosis, 225-226
distribution distribution, geographic, 216,
race, 305-306
in body, 308 220
rash,311
geographic, 303-304 in Canada, 220
Casablanca, 303 serological survey, 299-:300 in Sweden, 220
Egypt, 303 sex, 305 In the U.s.A., 216, 220
Faroe Islands, 298, 306 social setting, 306--307 in hospital personnel, 220
Greenland, 304 socioeconomic factors, 307 liver function test, abnormal, 224
576 Index
Mononucleosis (cont.) Mumps virus (cont.) Mumps virus (cont.)

infectious (EBV) (cont.) distribution (cont.) sex, 323
in Marine recruits, 220 temporal, 322-323 skin test, 319, 321
in military academy (U.S.A.), encephalitis, 20, 87, 320, 323 sterility, 328
218 endemic in U.S. cities, 322 surveillance program, 318
named,209 epidemics survey data, 321-322
in nurseries, 222 behavior of, 322 temporal distribution, 322-323
socioeconomic setting, 221 Hirsch's collection, 317 transmission, 325
spontaneous (CMV), 149, 151-154 in military personnel, 324 to monkey, 317, 319
surveillance report, 211 in World War 1,324 underreporting, 320
transmission, 221-222 among virgin populations, 322, in urine, 325, 326
by kissing, 210 326,327 vaccine, 318, 329-333, 345
virus, biological characteristics, Eskimos on Bering Sea islands, Murray Valley encephalitis, 82-83, 94
213-214, 482-485 326,327 Mus musculus, 110, 113
Morbidity reporting -on Faroe Islands, 326 Myalgia, epidemic, 190
advantages, 35 epidemiology Myocardiopathy, acute, 191
disadvantages, 35 descriptive, 319 Mycoplasma pneumoniae, 19, 220
information, 42 methodology, 318-319 Myocarditis, 328
rates, 58 in families, 324 Myxovirus, 317
weekly, 74 geographic distribution, 322-323
Morphine heart involvement, 328 Nasopharyngeal cancer, see
effect on antibody-forming cells, hemagglutination, 319 Nasopharyngeal carcinoma
458 inhibition, 319 Nasopharyngeal carcinoma, 26, 49,
Mortali ty registration, 35 history, 317-318 213,539-563
excess in influenza, 275 in hospitals, 324 in Africa, 548, 549
perception of, 276 host response, 326-329 age, 548, 552
weekly reporting, 74 immunity,325-326 behavior, epidemiological, 548,
Mosquitoes, see individual species incidence, 319-322 551-553
Mouse hepatitis virus (MHV), 128, in institutions, 324 causation, 550, 553
131 interferon, 326 see Epstein-Barr virus
Mousepox, 12,442 isolation of the virus, 319 characteristics of Epstein-Barr virus
Multiple sclerosis, 49, 392 laboratory methods, 319 in relation to, 545--546
and measles virus, 26, 313 meningitis, aseptic, 20, 327-328 in Chinese, 227, 549, 556
Mumps virus, 317-336 methodology, 318-319 boat people, 547
age, 323 in military personnel, 324 clinical course, 553-554
agent of, 318 in milk, .human, 325 clinical picture, 553-554
antibody, 321, 326 mortality, 320, 323 clinical types, 554
in serum of WHO collection, 321 a myxovirus, 317 combined types, 554
antigen, 318 neuraminidase, 318 complement fixation test, 543
in army personnel, 317 neutralization test, 319 control, 554-555
aseptic meningitis, 20 notifiable disease, 318, 331 cranial nerve impairment, 553
behavior, epidemic, 322 occupation, 323 dimethylnitrosamine, 550
in blood, 325 occurrence in different settings, distribution, geographic
.characteristics, biological, of the 323 in Africa, 548, 549
virus, 318 orchitis, 328 among Chinese, 227, 549
in chick embryo,318, 319, 345 parotitis, epidemic, 317, 318, 322 boat dwellers, 547
central nervous system pathogenesis, 325--326 land dwellers, 547
involvement, 327-328 pneumonia, 324 in Eastern cultures, 546-547
clinical picture, 326-329 prevalence, 319-322 on Java, 549
complement fixation test, 319, 321 prevention, 329 in Malaysia, 547-549
complications, 329 problems, unresolved, 332 in males, predominantly, 548
contagiousness, 322 race, 323 in Philippines, 549
control, 329-333 rhesus monkey infected, 317, 319 on Sabah, 549
diabetes and, 328 in saliva, 326 on Sarawak, 549
distribution serological survey, 319, 321 in Singapore, 547-549
geographic, 322 in serum, 321 in Thailand, 549
and temperature, 322 setting, occurrence in, 323 in Eastern culture, 546-547
Index 577
Nasopharyngeal carcinoma (cont.) Nasopharyngeal carcinoma (cont.) OC strain of coronavirus (cont.)

environmental factor, 550 tumor (cont.) suckling mouse brain, 129
epidemic behavior, 548 unusual, 555 see Coronavirus
epidemiology, 546-553 virology, molecular, 544 Organ transplant and
behavior of Epstein-Barr virus, virus, associated with, 545--546, cytomegalovirus infection,
551-553 556-557 151
methodology, 540--545 see Epstein-Barr virus
Epstein-Barr virus and, see National Academy of Sciences, 237 Panum on Faroe Islands, 298
Epstein-Barr virus National Disease and Therapeutic Papanicolaou-Traut exfoliative
etiology, 556 Index, 37 cytology of cervix (1943),
exfoliative cytology, 555 National Health Survey, 276 256,502
in families, 551 National Institutes of Health Papovaviruses,48
frequency of occurrence, sources of in Japan, 41 and central nervous system
data, 541 in U.S.A., 128 destruction, 525
genetic factor, 557 National Research Council, 237 infection without illness, 524, 525
genetics in South China, 551 Negri bodies, 352, 353 isolation from brain of PML
geographic distribution, 547-548 Neonatal infection, congenital, 15I, patients, 524
histopathology, 543--544 152 relation to PML (progressive
history, 540 Nephritis, see Glomerulonephritis multifocal
HL-A pattern, 556 Nephrosonephritis, hemorrhagic, 120 leukoencephalopathy), 26,
host response, 553--554 Neural spread of rabies along nerves, 524
immunity,553 12, 357 Parainfluenza viruses, 19,48,337-347
immunofluorescence tests, 541-543 Neuraminidase, viral, 6, 278, 287 age, 341-342
in tumor biopsies, 545 Neurotropic Viral Diseases agent, 339
immunogenetic marker, 556 Surveillance Program bovine, 344, 346
immunoprecipitation, 543 (U.s.A.),196 in calf, see bovine
incidence, 546-548 Neutral red, 268 characteristics, biological, of virus,
sources of data, 541 Neutralization test, 73, 78, 106, 130, 339
invasive type, 554 170, 277 clinical picture, 344--345
laboratory diagnosis, 543--545 see individual viruses in young children, 337
lymph node enlargement, 553 New York City Virus Watch, 38, 181- control, 345--346
methodology, 540 182 diagnosis, 345
metastatic type, 554 Nodamura virus, 187 distribution
migration, risks of, 550 Norwalk agent, 21 geographic, 341
morbidity, 541 Nucleocapsid temporal, 341
molecular virology, 544--545 see individual viruses epidemic behavior, 340--341
mortali ty, 540--541 epidemiology
nerve impairment, cranial, 553 descriptive, 339
occupation, 549--550 Obodhiang virus, 356 methodology, 337-339
pathogenesis, 553 OC, see Organ culture settings, 342
prevention, 554--555 Olfactory pathway, spreading, 12 geographic distribution, 341
primary infection, 552 Oncogenicity, 65 history, 337
problems, unresolved, 555 EBV, 484--485, 545--546 hospital-acquired infection, 342
risk on migration, 550 Onlou Fato virus, 354 host response, 344
seroepidemiology, 552 O'Nyong Nyong, 93--94 immunity,343--344
serological survey, 541-543 Orbivirus, 21 illnesses associated with, 339--340
serological tests, 541-543, 544 Orchi tis, 328 incidence, 339--340
sex, 541, 548 OC strain of coronavirus, 128, 136,137 infection, 339--340
signs, 553 age, 136-137 hospital-acquired, 342
sociological survey, 543 as antigen, 130 infectiousness, 339
symptoms, 553 fluorescent antibody technique, 130 isolation of the virus, 338
transmission, 553 incidence, 134 laboratory methods, 338--339
treatment, 555 prevalence, 134 morbidity data, 337
tumor studies, 133--134 mortality data, 338
epithelial, 556 in Charlottesville, 134 methodology, 337-339
invasive, 554 by State Farm Insurance Co .. 133 occupation, 342
metastatic, 554 in Tecumseh, 134 occurrence, 342
578 Index
Parainfluenza viruses (cont.) Pneumonia (cont.) Poliomyelitis viruses (cont.)

pathogenesis, 343 viral, 19, 59, 288, 337, 344, 369, 376 prevention, 195-200
pneumonia, 337, 344 see Respiratory diseases prototype strains
prevalence, 339-340 Poliomyelitis viruses, 207; see also Brunhilde, 192
prevention, 345-346 Enteroviruses LanSing, 192
problems, unresolved, 346 abortive, 189 Leon, 192
race, 342 affecting chimpanzee only, 173 at receptor site, 174, 175
reinfection, 344 affecting monkey only, 173 replication, 174-175
serological survey, 338, 339 antibody, 166 Research Foundation, 41
serotypes, 337, 345 antigens, 172 serological surveys, 166-167
settings, occurrences in, 342 behavior in developed countries, serotype, 172
sex, 342 183 in sewage, 167
socioeconomic factors, 342 in developing countries, 184 surveillance program, 34, 167
temporal distribution, 341 in postvaccine era, 184 serological, 166-167
in tissue culture temperate zones, 183 transmission to monkey, 164
human embryonic, 339 tropical areas, 184 vaccine, 177, 195-197
monkey kidney, 338 biological characteristics of the current status, 197-198
respiratory, 339 virus, 171 killed, 195
transmission, 343 case fatality rate, 165 live, 184, 195
Paramyxovirus group, 300 and chromosome 19,174 oral, 195-197
Parana virus, 103, 107 climate, 178-180 problems, 196-197
Parotitis, 317 clinical picture, 189 social failures, 198-199
epidemic, 322 . complement fixation test, 172 schedules, 195-196
by myxovirus, 318 control, 195-201 successful, 185
Particle, budding from plasma nonspecific measures, 20~201 trivalent, 195
membrane, 105 diagnosis, 192-193 wild, circulating, 198, 200
Paschen bodies, 434 epidemiology, 183-186 Population
Pathogenesis, 5, 1~13, 343 endemic phase, 183 closed,137
see individual viruses epidemic phase, 183 and environment, 37
Person-to-person contact, 10 postvaccination phase, 183 incidence, rate, 37
Petechiae, 116,224 geographic distribution, 178-180 prevalence rate, 37
Phaenicia sericata, 187 host range, in vivo and in vitro, 173 surveillance, 2
Pharyngitis host response, 189 Posttransfusion infection, 151, 154,
acute, causes of, 18 in Houston, Texas, 199 213, 243
in 1M, 224 immunity,188-189 Postulates of causation, 24-26, 395
Pharyngoconjunctival fever, 53, 54, interference, 196 Powassan virus, 91, 95
59,61 isolation, 168 Pox lesion, 9, see Smallpox
from swimming pool, 59 from feces of healthy children, Pregnancy and virus infection, 7,
Phenotypic mixing, 176 postvaccination, 186 147-149, 156,417-418,445
Phlebotomus from sewage, 167 Prevalence, see individual viruses
fever, 73 in Japan, 185 Proflavine, 268
flies as vector, 72, 77, 92 low income families in Houston, Progressive multifocal
Phormia regina, 187 Texas, 199 leukoencephalopathy (PML),
Pichinde virus, 103, 105, 107 as model, 176 16,524-525
Picornavirus, divisions of, 175 neutralization test, 40, 170 biological characteristics of the
named,163 nonparalytic, 189 virus, 524
Plague, pneumonic, (Black Death) in outbreaks, 184 comparison with other slow
Europe (1348), 33 Central America, 184 viruses, 53~531
Plaque formation, in enteroviruses, Guinea, 184 and BK virus, 524
174 Niger, 184 a demyelinating disease, 524
Pleurodynia, 164 South America, 184 epidemiology, deSCriptive, 524
PML, see Progressive multifocal paralytic, 164, 177, 184, 189,200 first description (1958), 524
leukoencephalopathy as social failure, not as vaccine first virion see, (1964), 524
Pneumonia failure, 200 following renal transplant, 525
bacterial, 19, 288, 289 postvaccine era (after 1955), 184 history, 524
excess deaths due to, 278-284 prevalence, seasonal, in sewage, 167 host response, 525
staphylococcal, 288 general, 176-177 immunity,524-525
Index 579
Progressive multifocal (cont.) Rabies (cont.) Rash, 11-12, 20

]C virus, 16, 524 morbidity data, 352 Receptor-destroying enzyme (ROE),
methodology, 524 mortality data, 352 278
papovavirus isolated from brain of in mouse, 353 Red water fever of cattle, 72
patients, 524 Negri bodies, 358 Reinfection rate, 144
pathogenesis, 524-525 a neurotropic disease, 358 CMV,144
SV40,524 notifiable disease, 352 parainfluenza, 343-344
virus, biological characteristics, nutrition, 356 Reed, Walter, 72
identified, 524 occupation, 356 Renal syndrome, 20-22
Pseudomyxovirus, 521 Oulou Fato type, 354 with hemorrhagic fever, 120
Public Health Laboratory Reports, 37 pathogenesis, 357-358 Reovirus-like agent, 21
in patient (bitten person), 359 Respiratory diseases
Rabies, 28, 351-364 prevention, 359-361 acute, 38, 44, 54, 58-61
age, 356 problems, unresolved, 361 causes, 18-19
airborne transmission, 357 quarantine of imported animal, 359 epidemics, 54
animal bite, 355 race, 356 epithelium, desquamation of, 10
antibody in serum, 357 in racoon, 354, 361 longitudinal study in Tecumseh,
antigen, 357 related viruses in Africa, 356 Michigan, 129, 338
in bat, 351, 354, 356, 357, 358, 361 reported in the U.S.A. (1950-1973), in mili tary recruits, 58-61
in cat, 355 355 pathogenesis, 10-11
in cattle, 357 in saliva, 354, 357 route of infection, 6
in central nervous system, 357 spread by, 356 surveys, 338
characteristics, biological, of the sex, 356 in Chapel Hill, North Carolina,
virus, 354 in skunk, 354, 361 338
clinical picture, 358 serological surveys, 352-353 in Great Britain, 338
control, 359-360 socioeconomic factors, 356 in Seattle, Washington, 338
in coyote, 361 spread in Tecumseh, Michigan, 338
'diagnosis; 358-359 via axoplasm, 357 in Washington, D.C., 338
in dog, 351, 354 via saliva, 356 syndrome, 19
in England, 352 in wildlife populations, 359, 361 transmission, 63
epidemic behavior, 355 surveillance program, 352 viruses, 10, 11, 19
epidemiology, 359 temporal distribution, 356 see also individual viruses
methodology, 352-354 transmission, 356-357 Respiratory syncytial virus, 365-382
first recorded (1708), 351 airborne, 357 age, 371
fluorescent focus inhibition test, in bat cave, 357 antibody, 367, 372
353 animal bite, 355 behavior, epidemic, 369-370
Fleury strain, 352 eating contaminated meat, 356 biological characteristics of the
in fox, 351, 354, 361 oral, 356 virus, 367
genetic factors, 356 treatment, 360 bronchiolitis, 368-369, 374'
geographic distribution, 355-356 in the U.S.A., 355 characteristics, biological, 367
globulin, immune, 359 vaccination, postexposure, clinical picture, 369, 376
in hamster, 357 preexposure, 359 clinical syndrome, role in, 369
his tory, 351 vaccine complement fixation test, 366-367
horse serum, risk of, 361 duck embryo, 359, 360 control, 377-378
host response, 358 Fermi,352 diagnosis, 376-377
immunity,357-358 first used (1885), 352 distribution, geographic, 370
immunization, 359 Pasteur, 352 temporal, 370
concepts, 359 Semple, 352 in Trinidad, 370
practice, 359 virus epidemic behavior, 369-370
as immunopathology, 358 biological characteristics of, 354 epidemiology, 367
inapparent infection, 17, 358 isolation of, 353 descriptive, 367-372
incidence, 344-345 in wild animals, 355 methodology, 366-367
incubation period, 14, 353, 354, 358 WHO recommendations, 359-360 factors, 372
laboratory methods, 353 in wolf, 351 first isolation from children in
in man, a dead-end disease, 354, one infecting 29 persons (1954), Baltimore, 365
355 355 from a chimpanzee, 365
methodology, 359 Ramses V, 429 genetics, 372
580 Index
Respiratory syncytial virus (cant.) Rhinoviruses (cant.) Rubella (cant.)

history, 365-366 characteristics, biological, 386-387 age, 414
host response, 376-377 clinical picture, 399-400 agent, 411-412
immunity, 372-376 control, 400-401 shedding of, 419
immunopathology, 374 distribution antibody, 415, 418
incidence, 367 geographic, 389-390 on Barbados, 43, 414
incubation period, 372 of serotypes, 392 behavior, epidemic, 413
infection, risk of, 367-369 temporal, 390--392 characteristics, biological, 411-412
isolation, 367 epidemiology, descriptive, 388--394 clinical picture, 417-418
laboratory methods, 367 methodology, 384-386 response to vaccines, 419
lower respiratory tract infection, in family, 392 communicability, 415
365 his tory, 383--384 complement fixation test, 411, 421
methodology, 366-367 host response, 399-400 congenital, 417-418
morbidity, 366, 367 immunity,396-399 first trimester, 418
morphology, 365 incidence, 388--389 incidence, 412-413
mortality,366 infection, 388--389 mortality,416
major cause of death'in first year ratio apparent/inapparent, 399- in U.S.A. (1968--1972),413
of life, 366 400 control, 419-421
mutant, temperature-sensitive, 378 interferon, 399-400 cycliC behavior, 413
neutralization test, 366-367 distribution
isolation, 384-386
nutrition, 372 geographic, 414, 415
lung cell cultivation, human WI-38,
occupation, 371 temporal, 414
384
occurrence, 371 endemic, 413
methodology, 384-386 epidemic behavior, 413-414
pathogenesis, 372-376
in military personnel, 393--394 epidemiology, descriptive, 412-415
plaque reduction technique, 366-
367,372 nasal secretion, 387 methodology, 410-411
pneumonia, 369 neutralization test, 385-386 factors, other epidemiological, 415
prevalence, 367 occurrence, 392-394 fetal infection, 416
prevention, 377-378 pathogenesis, 395-396 fluorescent antibody test, 411, 421
problems, unresolved, 378--379 physical and biochemical y-globulin in prevention, 421
race, 371 properties, 386 Gregg associates cataracts in
reinfection, frequent, 367, 368 postulates of transmission, 395 neonates with rubella in
risk of infection and reinfection, propagation, 384-385 mother, 409
367 prevalence, 388--390 on Hawaii, 414, 417
role in clinical syndromes, 369 prevention, 400-401 hearing loss, 418
sensitization hypothesis, 375-376 problems, unresolved, 401 heart lesions, 418
serological survey, 366-367 propagation, 384-385 hemagglutination inhibition test,
settings, occurrence in different, respiratory illness rate (1963--1969), 410, 411, 415
371 391 herd immunity, 422
sex, 371 in schools, 393 history, 409-410
socioeconomic factors, 372 seasonal distribution, 390--393 viral nature (1914), 409
symptoms, 376 serological survey, 385-386 confirmed (1938), 409
transmission, 372 serotypes, 392 host response, 416-419
by secretions, 372 settings, occurrence in, 392-394 on Iceland, 414
on Trinidad, 370 sex, 388 immunity,415-416
vaccine, live, attenuated, 378 surveillance program, 384-386 immunoglobulin
exaggerated response, 377 transmission, 394-395 A (IgA) in nasopharynx, 418
Rhazes, 297, 298,429 microbial, 395 M (IgM) in serum, 411, 419, 421
Rhesus monkey, kidney cell culture, vaccine, 28, 396-399 inapparent infection
173,277 Rinderpest, 298 inapparent/apparent ratio, 17,
Rhinoviruses, 171-175, 383-408 Rivers postulates (1937), 24 416
age, 388 Rockefeller Foundation, 73 in utero, 418
antibody, 385-386, 389, 390, 399 Rodents, 118, 120 incidence, 412-413
antigen, 387-388 see Mouse, Mus incubation period, 14
antigenic characteristics of virus, Rotavirus, 21 infection
387-388 Rubella, 48, 409-427 acquired,417
apparent inapparent ratio, 399 acquired, 417 congenital, 417-418
Index 581
Rubella (cant.) Salivary gland, virus infection of, 144 Smallpox virus (cant.)
infection (COllt.) Salmonella surveillance program, 34 allergy in revaccinated persons, 447
fetal,416 Sarcoma, 501 animal reservoirs, 441-442
inapparent, 418 Sarcophaga, 187 . in Bangladesh, endemic, 432, 435,
in utero, 416, 418 Sclerosing panencephalopathy, see .436, 438, 439, 449
isolation of virus, 410-411 Subacute sclerosing in biological warfare, 451
in Jamaica, 414 panencephalopathy blindness due to, 429
in Japan, 415 Scrapie, 526 and B-lymphocyte, 443
laboratory methods, 410-41] Seattle Virus Wafch, 38 Boston epidemics of 18th century,
methodology, 410 Semple rabies vaccine, 352 430
in military personnel, 417 Sendai virus, 337, 343 major (1721), 430
morbidity,410 Seroconversion, 95, 144 Boylston inoculates his son (1971),
mortality, 410 Seroepidemiology, 3, 40-52, 166 430
congenital,416 advantages, 42 in Brazil, 441
National Registry for Congenital definition, 3, 40 case fatality rate, 439, 444-445
Rubella Syndrome (1969), 412 history, 40-41 characteristics, biological, of virus,
pathogenesis, 415-416 laboratory tests, 42 434-435
pharyngeal excretion, 415 limitations, 42 clinical picture, 443-446
platelet aggregation test, 418 methodology, 41-42 flat lesion type, 444
in pregnancy, 421 survey, 40, 42, 46, 104, 166, 167, hemorrhagic type, 444
use of gamma globulin, 421 352 modified type, 444
prevalence, 412-413 uses variola sine eruption, 444
Pribiloff Islands epidemic, 416 for agents in search of disease, clinical varieties, 444
problems, unresolved, 421-423 46 communicability,440
on Quemoy, 414 to evaluate immunological status complement fixation test, 433
rash, 20, 416 of healthy persons, 47 contact spread, 440
in recruits, military, 417 to evaluate immunization Continental Army inoculated in
reinfection, 416, 422 programs, 45 1777,430
in school-age children, 414 for incidence data, 44 control, 446-451
serological responses, 418-419 for interrelationships between control programs, 446-447
tests, 411 disciplines, 48 cultural factors, 440
surveys, 410-415 for prevalence data, 42 devastating whole populations, 429
after vaccination, 420 in prospective studies, 44 disfiguring, 429
sex, 414 Serological surveillance, 41, 166 ectromelia infection, 442
shedding of virus, 419 Serological tests, 23, 43 eczema vaccinatum, 448
skin lesions, 416 false positive and false negative, 23 encephalitis, postvaccinal, 448, 450
strains, 410 requests for, 23 endemic countries, 435, 449
surveys, serological, 410 in serological surveys, 43 Bangladesh, 432, 435-437, 441,
on Taiwan, 414 see individual viruses 445,449
transmission, 415 Serum hepatitis, see Hepatitis B Ethiopia, 435, 446, 447, 449
on Trinidad, 414 Sewage, sampling of, 167 India, 435, 449
vaccination Shipyard eye, see Pakistan, 432, 435-437, 441, 445,
of children, 420 Keratoconjunctivitis, 449
clinical reactions, 419 epidemic epidemic behavior, 435-437
serological responses, 420 Shock, hemorrhagic epidemics (outbreaks) in
virus shedding, 419-420 in dengue,93 Iceland (1701), 430
of women of childbearing age, in Argentine HF, 114 Indonesia (1972), 449
420 Skin London, England (1973), 450
vaccine development, 419, 430 entry area of viruses, 9 Madras, India (1961-1972), 433,
. virus, 410-412 vesicles, 9 439, 444, 445
biological characteristics, 411-412 Slow viruses, 13; see Kuru and Meschede, Germany (1970), 439,
growth in tissue culture, 410-411 Cruetzfeldt-Jakob disease 441
in genital tract, 415 Smallpox virus, 4, 429-455 Mexico (1520),429
in respiratory tract, 415 agar gel precipitation test, 434 Nepal (1975), 449
isolation, 410 age, 438 New York City (1947), 431
shedding, 419 airborne spread, 440 Punjab, 437, 439
Rubeola, 297 alastrim, 433, 434, 446 Rio Grande Valley (1949), 431
582 Index
Smallpox virus (cont.) Smallpox virus (cont.) Smallpox virus (cont.)

epidemics (outbreaks) in reportable disease, 432 WHO Eradication Program (19661
San Francisco (1946), 431 revaccination, 447 67),431,437,446,449
Seattle (1946), 437 scar survey, 432-433 Smith, Theobald, 72
South Africa (197l), 449 scarring, 442 Sneezing and virus spread, 7, 8
Syria (302), 429 scratch method, 447 Sodium deoxycholate, 105
West Indies (1507), 429 seasonality,437 Squamous cell carcinoma, 502, 513
Yugoslavia (1972), 437, 439 second attack, 443 Squamous metaplasia, 505
epidemiology, descriptive, 435-440 serological survey, 432 St. Louis encephalitis, 75, 80-81, 85,
methodology, 431-434 serological tests, 433-434 87,89-93
eradication, global, 435, 449, 451 settings of occurrence, 439-440 diagnosis, 89
fever before rash, 440 sex, 438-439 outbreaks, 79
fomite, spread by, 441 skin infection, 442 in Tennessee, 89
fluorescent antibody, 433 socioeconomic factors, 440 Sterility of males after mumps, 328
geographic distribution, 437 spread by droplet, 440 Stomatitis, herpetic, 259
global eradication, 435, 449, 451 by saliva, 440 Subacute sclerosing panencephalitis,
Guarnieri bodies, 442 subclinical, infection, 445 520-523
hemagglutination inhibition, 434 surveillance, 449 characteristics, biological, of virus,
hemorrhagic, 442 surveys, 432-433 521
in pregnant women, 445 T-Iymphoblast,443 chickenpox, 523
history, 429-431 temporal distribution, 437-438 control, 523
hospital-acquired, 439 transmission, 440-442 epidemiology, descriptive, 521-522
host response, 443-446 by mosquito, 441 first described, 521
housefly, 441 vaccination, 447 history, 521
immunity, 443 CNS complications after, 450 host response, 522-523
immunization, 447-451 complications, 448 immunity,522
immunodiffusion test, 434 encep halitis after, 448 measles antibody titer, high, 522,
inapparent infection, 445 eczema vaccinatum after, 448 523
incidence, 435 future vaccine plans, 449-451 after measles vaccination, 523
incubation period, 443 Jennerian, 443 methodology, 521
interferon, 443 primary, 447 pathogenesis, 522
isolation in embryonated hen's problems, 447 prevention, 523
egg, 433 resolution of, 448 problems, unresolved, 523
Jenner, Edward, 430 program, 446 sex, 523
laboratory methods, 433-434 reactions, 447 virus, characteristics of, 521
lesion density, 442 resolution of vaccine problems, Summer encephalitis, 90
Mather, Cotton, 430 448-449 Surface waters, isolation of
methodology, 431-434 scar survey, 432 enteroviruses, 167
monkeypox in human, 441, 451 success of, 449 Surveillance, 33-40
Montague, Lady Mary Wortley, 430 terminated in U.S.A. in 1971, 431 absenteeism, 37, 38
morbidity, 432 vaccine animal reservoir distribution
mortality, 431-432 contaminated, 447 study, 37
mousepox, 442 freeze-dried, 448 Asian influenza, 34
neutralization test, 434 low potency, 447 biologics, utilization of, 34
occupation, 439 nervous complication, 450 case investigations, 34
Paschen bodies, 434 reaction, 447, 448 data, 37
pathogenesis, 442-443 strains, 449-450 definition, 33, 34
person-to-person contact, 440 vaccinia necrosum, 448 drug, utilization of, 34
pregnancy, clinical picture in, 445 variola, a major virus, 434 elements, 34--37
prevalence, 435 sine eruptione, 444 epidemic field investigation, 34--37
prevention, 446-451 term introduced in 570, 429 reporting, 34--37
problems, unresolved, 451 variolation outlawed, 430 of hepatitis, 34
vaccine, 447 vectors, 441 history, 33--34
race, 439 virus, characteristics of, 434-435 hospital care statistics, 37
rash,.440 isolation, 433 of influenza, 34
reservoirs, animal, 441-442 Waterhouse, Benjamin, in Boston, knowledge of population and
Rhazes described disease, 429 430 environment, 34--37
Index 583
Surveillance (cant.) Transission routes (cant.) Varicella-herpes zoster virus (cant.)

laboratory investigations, 34-37 fecal, 8 chemotherapy, antiviral (cant.)
medical care statistics, 37 food,10 iododeoxy uridine, 476
methodology, 37-38 gastrointesinal, !>--9 chickenpox, 462, 466, 467
morbidity reporting, 34-37 genital,9 death rate in Massachusetts
mortality reporting, 34-37 genitourinary, 9 (1910--1969), 462
newspaper reporting, 37, 38 mechanical, 71 in Massachusetts (196!>--1973), 465
physicians, panels of, 37 mosquito, 74, 77 clinical picture, 457, 459, 473-476
of poliomyelitis, 34 oral,8 herpes zoster, 473-474
predictive, 39--40 person-to-person contact, 10 varicella, 473
principles of, 34 respiratory, 6-8 communicability, short-lived, 459,
public health reporting, 37 skin, 9 461
requirement for clinical case, 42 transovarial, 74, 95, 96 contagiousness, high, 463
research studies, 3!>--39 vertical, 80, 90 control, 474-476
publications, 39 water, 10 definition, 457
serological, see seroepidemiology see also individual viruses diagnosis, 474
survey distribution, geographic, 464-465
house-to-house, 37, 38 Ulcerative colitis with England, 463
by telephone, 37, 38 cytomegalovirus infection, Puerto Rico, 464
SV 5,343 155 tropics, 464
SV 40, 64, 524 United States of America, 240 distribution, temporal, 465-466
Swab specimen, fecal, 55 immunization survey, 331 differentiation of varicella and
rectal, 55 military academy, 218, 221, 224 varioia, 461
Swimming pool, 65 military populations, 59 epidemiology
Swine national health survey, 38 descriptive, 461-469
infection via, 59 Upper respiratory tract infections, 10 factors, 468
coronavirus, 138 causes of, 18 methodology, 458-461
fever virus, 77 unknown aspects, 476
influenza, 274 Vaccination, see individual viruses exanthem, 473-476
Syrian hamster, see Mesocricetus Vaccination refusal because of extrinsic factors in pathogenesis,
auratus religious beliefs, 198 472
Systemic infections involve viremia, Vaccines, 27, 53, 227 fatal in leukemia in children, 469,
11 live attenuated, 64, 177, 184 475
Systemic lupus erythematosus, 22 in monkey kidney tissue, 64 genetic factors, 469
oral, 64, 195-196 globulin, immune, in high-risk
T cell transformation, 16 social failures of administering, patients, 475
T lymphocyte, 15 198,201 hemorrhagic, 474
in infectious mononucleosis, 223 trivalent, 330 history, 457-458
Tacaribe virus, 103, 105, 107 types of, 65 host response, 473-476
Tamiami virus, 103, 107, 108 viral vaccines, 27 iatrogenic factor, 469
Tanzania, 149 see individual viruses immunity, 470--473
Tecumseh study, 132, 134, 137, 139 Vaccinia necrosum, 448 impaired cellular, 472-473
Theiler's work with yellow fever Varicella-herpes zoster virus, 254, inapparent infection, 472-476
virus, strain 0 17,74 457-480 incidence, 461-464
Tick agar gel diffusion test, 461 incubation period, 471, 473
and encephalitis, 72,82-83,91,94- age, 466--467 interferon, 475-476
95 anamnestic response, 470 interruption of transmission, 475
Toluca Strain, 191 animal reservoir, 470 intrinsic factors in pathogenesis,
Transfer factor, 48 antibody, in prevention, 475 471-472
Transformation and oncogenicity, association of varicella with herpes isolation of virus, 458, 460
484 zoster, 458 laboratory methods, 477
Transfusion, see Blood transfusion behavior, epidemic, 463-464 latency in humans, 461
Transmission routes, 6--10 in Ceylon, 464 methodology, 458-461
arthropod-borne, 10, 77 hospital personnel, 464 military personnel, 468
biological, 71 chemotherapy, antiviral, 476 modification, 475-476 •
cycles of virus, vector and adenine arabinoside, 476 morbidity,459--461
vertebrate, 96--97 cytosine arabinoside, 476 clinical aberrations, 459
584 Index
Varicella-herpes zoster virus (eont.) Vector (coni.) Virus (coni.)

morbidity (coni.) distribution study, 37 organs involved, 22
reporting of cases, 459 see Arthropod, individual viruses outbreak of disease, 4
retrospective histories, 459--460 Viral pathogenesis, 16
mortality, 458-459 diagnosis, 22-24 persistence, 11-13, 48
nutrition, 468-469 collection of specimens, 22 prevention, 28
occupation, 468 false positive and false negative protein, 105
occurrence, 468 tests, 23 shedding, 222
home, 468 interpretation of tests, 24 fecal, 63
school,468 requests for testing, 23 shift, antigenic, 45
pathogenesis, 470-473 see also individual viruses spreading, 5
postnatal transmission, 470 Viremia, 77 respiratory, 10
prevalence, 464 maternal, 151 tests for
prevention, 474-476 primary, 12 false negative, 23
problems, unresolved, 476-477 secondary, 12 false positive, 23
propagation of virus, 458 and systematic infection, 11 in family members, 24
protection, see quarantine Virologist's dilemma, 26 interpretation, 24
quarantine, effective, 475 Virology, molecular, of EBV, 544, 545 vaccine, 97
race, 468 Viruria, 329 vector specificity, 80
reactivation, 461 in ch;Jdren of virus-excreting Virus Subcommittee of the
recrudescence, 476 mothers, 153 International Nomenclature
reportable disease, 476 Virus, see individual viruses Committee, 73
reporting of cases, 459 in aerosol, 8 Virus Watch programs, 38, 48, 165,
reservoir in animals, 470 antibody, 16 166
risk,463 rise in titer, 24 Vital statistics, 34
seroepidemiology, 477 antigenic shift, 45
serological surveys, 460 in blood, 11, 12 Wassermann test, 40
limitations of, 460 in cancer cell, 504 Waterhouse, Benjamin, 430
methods, 460-461 cell-bound, 6 Weekly Epidemiological Record, 74
setting, 468 clinical features, 22 'Weekly Epidemiological Report, 74
sex, 468 collection, specimen, 22-23 Western equine encephalitis, 75, 80,
social significance, 457 control, 28 81, 84-85, 87-89, 92-93
socioeconomic factor, 468 breaking chain of causation, 28 WI-38 cell line, 169-195
transmission, 469--470, 475 diagnosis of disease, 22-24 Women, pregnant, see Pregnancy
congenital, 469--470 defective DNA, 506 World Health Assembly, 21st, 33
postnatal, 470 in effluent, 167 World Health Organization, 165, 166
vector, 470 entry,S collaborative study, 276
vesicle, 470-473 epidemiological aspects, 22 influenza centers, 34
Variola minor, see Alastrim excretion, 9 serum reference banks, 34, 41
Variola sine eruptione, 444 extracellular, 213 Wuchereria banerofli, 72
Venezuelan encephalitis, 79, 82-83, hyperreactivity,48
88,91,93 immune response, 16 Yale poliomyelitis pattern in Alaskan
first outbreak, 91 incomplete, 6 eskimos, 41
Vero cell infection in man, production of,S Yellow fever virus, 72, 73,84
infected with arenavirus, 105 isolation, 22-24, 168 distribution, world-wide, 78
with Lassa fever virus, 120 from surface water, 167 jungle, 82-83
Vertical transmission, see from swimming pool, 61 neutralization test, 78
Transmission in Junior Village, 39 urban, 82--83
Vesicular stomatitis virus, 88 latency, 26 vaccine, 74
Indiana SUbtype, 91-,92 in nephritis, 22 17D strain of Theiler, 74
Vector, 96 neutralization, 188
control of level of, 97 double, 176 Zoonoses, 37, 523

Alfred S. Evans (Auth.), Alfred S. Evans (Eds.) - Viral Infections of Humans - Epidemiology and Control (1976, Springer) (10.1007 - 978-1-4613-3988-5) - Libgen - Li

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Alfred S. Evans (Auth.), Alfred S. Evans (Eds.) - Viral Infections of Humans - Epidemiology and Control (1976, Springer) (10.1007 - 978-1-4613-3988-5) - Libgen - Li

Uploaded by

Copyright:

Available Formats

Viral Infections

PLENUM MEDICAL BOOK COMPANY

First paperback printing 1978

© 1976 Plenum Publishing Corporation

Plenum Medical Book Company is an imprint of

All rights reserved

No part of this book may be reproduced, stored in a retrieval system,

School of Public Health and Community Medicine, University of Wash-

GEORGE A. NANKERVIS, Department of Pediatrics, Case Western Reserve

10. Diagnosis of Viral Diseases 22

Chapter 2 Surveillance and Seroepidemiology

10. Unresolved Problems 65

7.2. Immunity 152

9.3. Current Status of Immunization for Poliomyelitis in the United

Chapter 9 Epstein-Barr Virus

Chapter 10 Viral Hepatitis

Chapter 11 Epidemiology of Herpes Simplex Viruses

5.2. Epidemiological Aspects of Specific Clinical Entities 260

Chapter 12 Influenza Viruses

7.2. Immunity 288

Chapter 15 The Parainfluenza Viruses

3.3. Serological Surveys . 338

5.5. Age, Sex, Race, Occupation, Socioeconomic, Nutritional, and

Chapter 17 Respiratory Syncytial Virus

7. Patterns of Host Response 376

3.2. Morbidity Data . 410

5.5. Age 438

Chapter 21 Varicella-Herpes Zoster Virus

4.1. Latency in the Human Host: Primary Infection, Latency, and

Chapter 22 Epidemiology of Burkitt Lymphoma

3.1. Mortality and Morbidity Data 482

Chapter 23 Epidemiology of Cervical Cancer

5.4. Geographic Distribution . 509

Chapter 24 Chronic Neurological Diseases: Subacute Sclerosing

Chapter 25 Nasopharyngeal Carcinoma

5.4. Occupation 549

1. Introduction nants for many common infections lie within the

Table 1. Transmission of Viral Infections

Route of exit Routes of transmission Examples Factors Routes of entry

Respiratory Bite Rabies Animal Skin

Gastrointestinal tract Stool -> hand Enteroviruses- Poor hygiene Mouth

Skin Air Poxviruses Also via objects Respiratory

Blood Mosquitos Arboviruses Extrinsic I. P. Skin

Urine Rarely transmitted CMV, measles, Unknown Unknown

Genital Cervix Herpes simplex, CMV, ? Venereal Genital

Placental Vertical to embryo CMV, rubella, Congenital Blood

Eye Tonometer Adenovirus Exam for glaucoma Eye

5.6. Personal Contact 6. Pathogenesis

6.2. Gastrointestinal 6.4. The Exanthem

Fig. 1. Incubation periods in viral diseases.

Table 2. Subclinical/Clinical Ratio in Viral Infections (Inapparent/Apparent Ratio)

Age at Estimated subclinical1 Percent of infection

Poliomyelitis Paralysis Child ±1000:1 0.1-1

CELL RESPONSE* HOST RESPONSE

COMMON COLD IN ADULTS ACUTE TONSI LLiTIS/PHARYNGITIS

ACUTE UPPER RESPIRATORY ACUTE LOWER RESPIRATORY

INFANTS AND CHILDREN HOSPITALIZED ADULTS

ENCEPHALITIS ASEPTIC MENINGITIS

Fig. 6. Causes of acute gastroenteritis in 378 UNKNOWN

diagnostic laboratory-usually a governmental collected or in the laboratory where the test is

Table 4. Viral Diagnosis: Some Causes of False-Positive and False-Negative Tests

10.3. Interpretation of Tests 11. Proof of Causation

Table 5. Postulates of Causation