Through a series of focus group discussions conducted in northern and central Vietnam, this study gives voice to the lived economic experience of families with disabilities and how they manage the economic challenges associated with disability. The dynamic of low and unstable income combined with on-going health care and other disability-related costs gives rise to a range of coping mechanisms  that helps to maintain living standards in the short-run yet threatens the longer-term welfare of both the individual with disability and their household. Current social protection programs were reported as not accessible to all and while addressing some immediate economic costs of disability, do not successfully meet current needs nor accommodate wider barriers to availing benefits. The conceptual pathways between disability and poverty are often noted. Poverty may increase the risk of disability through malnutrition, lack of access to safe drinking water, unsafe living and working conditions, or limited access to essential health services such as maternal health care or immunization . In the This study was undertaken in Vietnam, a country with a large disabled population. According to census data, 7.8% of the Vietnamese population or 6.7 million people were living with a disability in 2009 –13.Vietnamese people with disabilities experience higher rates of poverty relative to the wider Vietnamese population when accounting for the additional costs of disability , 14. To The following section, Section 2, provides a background on disability costs and their estimation. Section 3 describes the methodology and study design; Section 4 presents focus group interview results; Section 5 discusses the results; Section 6 addresses study limitations; and Section 7 concludes the paper with considerations for policy makers.The economic costs associated with disability can be divided into indirect and direct costs . The dirResearchers have developed several different methodologies to estimate direct and indirect costs. We briefly summarize the key methodologies currently in use with a focus on direct cost estimation which forms the bulk of the literature. One approach is to directly measure consumption patterns in health and non-health expenditures between persons with and without disabilities whilst controlling for other sources of variation , 19, 20.A recent and growing body of studies has adopted an indirect method to estimate disability costs known as the Standard of Living (SOL) approach , 21–24. The above methods do not account for opportunity costs with respect to the loss of income due to disability and care-giving within the household–the ‘earning handicap’ as Sen puts it . One strIn spite of the challenges in estimating the indirect costs among households with disabled members, the rate of income poverty is invariably increased when the direct costs of disability are taken into account , 23, 24.Prevailing quantitative methodologies fail to provide a full picture of disability costs, the inter-connecting relationships of costs and their effect on the individual and household. The purchase of a wheelchair, for example, may reduce indirect costs on the household by leading to improved scores in independence  and levels of employment and income . How indFor the above reasons, we undertook a qualitative study of disability costs in Vietnam. Using a series of focus groups, we give voice to the lived economic experience of families with disabilities and how they balance competing demands on household incomes. In light of the recent efforts on the part of the Vietnamese government to protect and promote the rights of persons with disabilities, we further asked study participants whether and how current social protection schemes contribute to improving the economic status of the household. Our approach suffers from the same limitations as other subjective approaches that rely upon expert panels, or disabled persons themselves, to assess disability costs . ReporteEthical approval for the study was obtained from the University College of London (No.:1967/005). Because of low literacy levels in the population under study, informed verbal rather than written consent was anticipated and applied for as part of our ethical approval process. Verbal consent was approved by the UCL Institutional Review Board and obtained from all study participants in accordance with verbal consent procedures and capacity to consent as determined by legally authorized disabled people’s organizations. Parental or next of kin consent was obtained for persons under age 18 and all consent was documented on record.A pilot focus group discussion (5 participants) was conducted in Da Nang city in November 2012 by two of the authors of this paper  at the central region office of Vietnam Association for the Handicapped (VNAH). Building on this, in September 2013, a series of six focus groups (72 participants) were organized in and around Hanoi in collaboration with research partners Inclusive Development Action (IDEA), a disabled people’s association, and the University of Labour and Social Affairs (ULSA), the university arm of the Ministry of Labour, Invalids and Social Affairs which is responsible for the implementation of the national disability law. The six focus groups in the northern location were evenly divided into an urban ward in Hanoi (Đống Đa) and a semi-urban district outside of Hanoi (Thanh Trì) because we believed that economic costs and concerns might vary in these different localities e.g. labour markets and services  are more limited in semi-urban and rural areas, for example.All participants of the study were identified through local disabled people’s associations since we wanted selection to be based upon people’s own understanding of disability in their lived environment rather than legal or survey definitions so as to provide a nuanced understanding of how the heterogeneous nature of disability impacts the economic lives of families. Among the 77 participants recruited, the vast majority (68) were persons living with a disability of working age (range 17–65 years) as we wanted to better understand the economic priorities and concerns of disabled adults from their own perspective. The other nine participants were the parental guardians of persons with disabilities, including mothers or grandmothers of four children with disabilities (aged 5–7 years) who spoke specifically to the costs associated with raising a child with a disability.Where possible, participants were selected evenly on the basis of disability type and gender. Thirty-nine of the 77 participants were female (51%). A breakdown of the participants by disability type and location is provided in Where possible, focus groups were organized to elicit information from participants within the same disability type so as to make participants feel more at ease and foster a rich discussion. This included a deaf group (with sign interpreter) in Đống Đa, a group of individuals who were blind or vision impaired in Thanh Trì, and a group with physical disabilities in each of the three locations. Two groups contained a mix of people with different disabilities in the northern locations.Questions for the focus groups were developed from reviews of the literature and institutional knowledge of the policy context in Vietnam as well as previous in-country fieldwork on disability by two of the co-authors . To ensure clarity and cultural appropriateness, the questions were reviewed by research partners. Focus groups were conducted by a research team member from IDEA and ULSA, with one additional team member observing and taking notes. The discussions were digitally recorded, transcribed and thematic content analysis was performed. The key themes and quotes that emerged were then summarized and translated into English. Four key themes and linked sub-themes were identified from the discussions and are presented in the following section.The vast majority (88%) of disabled working-aged participants in our study were working. Due to the existence of multiple barriers in entering the formal labor market, persons reported that they often had to create their own jobs in the informal sector. Jobs were typically low-skilled such as small shop vendor, tailor, laborer, agricultural worker, handicraft worker or masseuse. The income derived from these jobs was low and unstable and often insufficient to meet expenditure needs:There are some jobs that I can do but the income is so low that it does not meet my economic needs.Sometimes I have work, sometimes I don’t. We are a family of four with two children going to school. Because of unstable income and school fees are very high, economic challenges are always greatest for our family.Limited education and lack of professional training certificates were repeatedly cited as barriers to entering the work force. As one young man with a hearing impairment said: “Most of us have not finished secondary school… in today’s competitive labour market this is very difficult.” Due to a lack of sign-interpreter supports in the classroom, and accessibility to hearing aids, it was difficult for deaf people to progress beyond primary school.But even when people with disabilities had achieved higher qualifications, discrimination by employers was perceived as the greatest barrier to securing paid employment.When arriving at an interview, I was told that they had found someone already. They said this maybe because they saw me as having difficulties in speaking and in weak health.I studied pharmacy but I cannot find work as a pharmacy assistant. Nobody will employ me. I want to open my own small pharmacy shop but I do not have the capital.I tried to create conditions for him (son) to continue studying at technical college in IT and he graduated with average marks. But when he applies for jobs, employers only encourage him, they never accept him.Another barrier identified was that persons with disabilities repeatedly reported that they were anxious to work, but family members often did not believe in the self-reliance and work capability of members with disabilities, reflecting broader restrictive societal views on what persons with disabilities can do.Teaching him how to take care of himself and how to maintain personal hygiene are already high hopes…I don’t dare hope that he is capable of working.People look down on us. When people see me, they ask me whether I could do anything and I tell them that I can do whatever you can do. You do it your way and I do it my way.Hearing and speaking people always think our (sign) language is a joke, a humorous thing to make people laugh. But I don’t think so. I think that is wrong.The majority of study participants did not have high carer support needs but often required transport or had to be accompanied by a family member when out and about in the community. The need for such support was an ongoing drain on carers’ time and infringes upon their work schedules. For these study participants, care-giving duties were incorporated into the daily domestic duties of other family members.It is very difficult to get permission to be late 2 hours for work to take my child to acupuncture. I must work over lunch and stay back late. I don’t dare ask often because I am afraid that I will lose my job.I am retired but I cannot do relief teaching and my monthly pension is low, 3 million (dong) per month, because I have to spend all of my time taking care of my son, taking him to school and to the hospital for check-ups.In some cases the indirect opportunity costs of care-giving responsibilities were substantial, resulting in the partial or complete loss of income.When I found out that my child had autism from the age of three, I quit my job to take care of him carefully.I retired early to take care of my 30 year old son who has cerebral palsy and my grand child who has autism and hyper activism.Respondents reported a series of disability-related expenses clustered around several key topics that consistently proved a drain on household budgets. Hospitalization, school fees, and purchase of an assistive device or adaptation of a vehicle were large periodic expenses for some participants. More commonly, it was the relatively smaller on-going expenses associated with disability including medication, rehabilitation, travel, and private tuition that accumulated over time and proved to be costly for families.Health care and related costs were consistently identified as the most burdensome. Episodic costs associated with hospital visits were compounded by costs associated with the hiring of a private taxi or specialized vehicle, as well as accommodation costs for accompanying family members to take care of the person with disability whilst in hospital which is common due to limited nursing staff. Medication and rehabilitation were considerable on-going expense for many families, with several families reporting monthly medication expenses in excess of 1 million dong or over one-third of the minimum wage  model is being developed across the country but is currently on a small scale. The primary rehabilitation services accessed by participants in our study were acupuncture and acupressure services, available in traditional medicine departments of district level hospitals and private outpatient clinics.The most common assistive devices identified by participants were basic and included walking sticks, crutches and spectacles. There is a large unmet need for assistive devices, particularly prostheses, wheelchairs and hearing devices. Such ‘modern’assistive devices are not easily accessed and are prohibitively expensive:It’s very difficult for me to pay for general medical expenses and I am incapable of buying modern hearing aid devices.Mobile phones have to be designed specifically for us, not every blind person can find or afford them.Assistive devices also entailed periodic costs for repair and replacement. One participant from Da Nang reported prostheses purchases totaling over 6 million dong or 2.5 months equivalent minimum income every three years :I have to buy a walking stick to support me. It costs around 120,000 dong or 150,000 dong and it needs to be replaced every six months.Every three years I must replace the prosthetic pieces at a cost of 2.1 million dong for the groin piece and 4 million for the knee piece. In addition, I must spend approximately 800,000 dong per year on bandages and shoes for my disability. I have a health insurance card but I must pay everything myself.Outside of health-related expenses, transportation costs for taxis or motorcycle taxis were an on-going concern for many participants, over half of whom had mobility disabilities. Costs are attributable, to some extent, to difficulties in accessing public buses, lack of assistive device technology and motorized tricycles that would increase ability to travel within and beyond their communities. As a consequence, the ability to travel to work, to do errands or to seek medical care was limited by affordability of transportation. Family members were often relied on for transport, which carries a further and often forgotten cost for the household.I had an accident recently. It affected my legs so I have to use a motorbike taxi to get around. However, it’s quite expensive. It costs about 10,000 dong per kilometer.I would like to buy a three wheel motorbike but they are very expensive, it costs an additional 4–5 million dong to adapt a two wheel motorbike. Instead, I must rely on my brother to transport me around on his motorbike but I feel like a burden to him.Focus group participants routinely reported economic limitations based on lack of education and vocational training earlier in life. The small group of mothers and grandmothers of disabled children who participated in focus groups shed additional light on this, reporting barriers to entry into public schools for children with disabilities. Because many disabled persons continue to be denied access to public schools many families are forced to seek alternative education for their disabled child through special schools or private home tutors. These are associated with significantly higher fees that are not affordable by all households, and represent a significant drain on household resources over a period of years.I was faced with lots of difficulties when trying to enrol my child into a public school. Private schools or special schools have high fees, not all households can afford to go to such schools.My child has autism and cannot join public schools with normal fees. She has to go to special schools or have a private home tutor which is much more expensive. It costs about 4–5 million (dong) per month.I must hire a private tutor for my child which costs 200,000 dong per hour. Every month, I must pay about 3 million dong for my daughter’s medicine, reflexology and her school fees.The topic of vocational education/training was a greater concern in the focus groups due to the working age of most participants. Here again, few people had benefited from public vocational training programs. Instead they had to seek private vocational training (where available) which were reported as limited in scope and in some cases, prohibitively expensive. One focus group participant gave as an example:There are not many (training) choices for us, even to complete the massage certificate costs 3 million dong which is not affordable to everyone.Borrowing was a primary mechanism through which families coped with the major costs associated with disability. The majority of participants were able to access finance from state subsidized money lenders or the local disabled people’s organization at a low rate of interest to start a business to generate more permanent income. Interest-free loans were secured from relatives and friends to pay for periodic medical or school fees. Difficulties in securing credit from formal money lenders was also mentioned:If a person with a disability is not affiliated with an association (disabled person’s association), nobody dares to lend him money, even as little as 1 million dong.Other coping mechanisms reported were drawing upon private savings and substituting labour within the household, but these were less common. Households commonly had few savings to withdraw (“How could I possibly have savings?”). Labour substitution within the household related mainly to off-farm seasonal work in low-skilled manual jobs which were characterized by low and irregular income therefore supplemented household income only marginally.I cannot do any work, I have a big family with three children going to school. My wife struggles alone to raise the family. Our main income is from agriculture. Between crops, my wife has to find other manual jobs to earn more income. However, income from these sources is low and unstable.Individuals and families routinely reported cutting-back on, or foregoing, disability-related expenditures.The fees for every time I have an operation are very expensive and I must pay everything. I have had four operations already and for two years I have not been to see a doctor after the last operation because I am afraid that I will have to have another operation and I do not yet have the money.…the medicine for his brain is 2 million (dong) for one time so I only buy it occasionally.I must pay 4 million dong per month for my child’s school fees…after one year I had ran out of money so I sent him/her to back to the farm.I would like to buy an electric bicycle so as to commute more conveniently and make me less tired but these days I just use my old bicycle.With the passing of the national disability law in 2010, Vietnam consolidated a range of social protection supports for persons with disabilities across the country , 36. PerDetermination of who is eligible for social protection supports is made by commune committees comprising a president, local Government and union representatives using a disability assessment tool . Over haSocial protection supports, in general, were gladly received but were not consistent with reported needs. The most successful program, as judged by respondents, was the social credit program where applicants could apply for a low-interest loan for business development and job creation activities. Bus fare waivers and education assistance were viewed as the least successful programs due to problems in accessing public buses and schools. Specific comments on each program included:According to our informants, the amount of money currently available through monthly payments did not make a major difference in the expenses of recipient households. Amounts varied from a minimum of 360,000 dong for a single person payment to a maximum of 720,000 dong for a household with an additional carer allowance. These sums constituted between 13–26% of the monthly minimum wage in the areas under study. As one recipient put it, “the amount is not even enough to buy rice (for the family).”Other concerns raised were with complex application procedures and the fact that not all persons with disabilities were eligible for monthly support, including children.I am currently preparing my application file, but the paperwork and administration is excessive/complicated so I am having difficulties. I don’t know when I will receive the money.The wish of every person with a disability is to receive the income support to ease some of their economic difficulties but in reality this is not the case.The majority of recipients found the non-contributory health insurance programme and the health insurance card useful whereas others reported it was “virtually unused” due to out-of-pocket payments, perfunctory examinations, long waiting times and administrative procedures. A repeated concern was that insurance did not cover all of the costs of required services, equipment and medication with some respondents paying a significant proportion of the total health care costs out-of-pocket.I have sleep apnea and it is not included in the list of exempted conditions hence I must buy all the necessary equipment.My child needs acupressure treatment. It costs about 10 million (per year) however insurance only covers 30%, the remaining 70% is a lot for us to cover.My eyes often get sore and need medication. Health insurance covers a part but many types of medication are not included on the list of exempted or discounted medications.Costs associated with assistive devices or travel to health facilities were not covered under insurance, and focus group members reported that often local doctors did not give the referrals needed for rehabilitation services available at provincial hospitals, which imposed higher costs on the families pursuing treatment. As was true of the Monthly Income Support programme, a widely voiced concern was that not all persons with disabilities were able to receive non-contributory health insurance.Currently, only persons that are identified as social beneficiaries and eligible for the monthly income support can receive the free health insurance card. I do not think that this is fair as all people with disabilities have health care needs.Few persons with disabilities reported being able to take advantage of the public bus fare waiver. Part of this was due to difficulties in getting on and off buses without assistance, particularly for people with mobility impairments. As one person stated: “catching a bus on my own is nearly impossible for me.” Many bus drivers and members of the public had little or no awareness of how to assist people with disabilities in getting on or off the bus. The result was, as another physically disabled person stated, “when catching a bus, I am often left behind. There are times I could not get on a bus even after two or three hours waiting.”Loans sourced from the State Social Bank for business development or job creation activities were adjudged as suitably flexible to the needs of persons with disabilities. The loan conditions included a maximum amount of 20 million dong for a term of two years at a monthly rate of interest of 3.6% paid in monthly or tri-monthly instalments.I think it  is good. The interest rate is low and you do not need collateral, which suits us as most of us are poor. The application procedures are simple, not much paperwork. And you have options when you can pay back, this also suits us because sometimes we have money (to pay the loan), sometimes we don’t.It is noted, however, that some respondents reported using the loan for other than its intended purpose, instead being used to meet pressing medical expenses or to purchase an assistive device.Because members of our focus groups were adults, few study participants had benefited from the 2010 Government decree on public school fee exemptions for poor children with disabilities, . One issOverall, the evidence from quantitative studies thus far points toward individuals with disability having sizable extra costs. These include both costs associated with opportunities foregone and those directly associated with disability. Quantitative methods tell us little explicitly about how costs interact and how individuals and families attempt to balance or manage these extra costs and what the longer-term impact on their welfare is. The qualitative approach adopted in this paper offers further insight into these issues in the context of Vietnam, a low-middle income country with a relatively advanced legal and institutional framework for the provision of social protection support for persons with disabilities. We explore the economic costs of disability and how current state supports reflect and address the expressed economic needs of households.With respect to the costs of disability, our study results points to a dynamic of low and unstable income combined with the extra direct costs of disability as the cause of economic difficulty for individuals and families. The majority of our disabled participants were working yet due to multiple barriers in entering the formal labour market, had to create their own employment in the informal labour market. The level of income generated through these informal jobs was not sufficient or stable enough to meet the costs associated with their disability. Findings are reflected in national living standards data where among persons with disabilities that were working (44%), the overwhelming majority were working the informal sector either as farmers or self-employees (87%)  and high disability threshold as defined in ).Health care and related-costs were particularly burdensome for individuals and families. A major concern reported by our study participants were medication and travel costs associated with health facility visits. Once again, findings are consistent with national living standards data where these two cost items comprise 64% and 75% of total inpatient- and outpatient-related costs, respectively, for persons with disabilities . Aside fWe found significant indirect costs for many households associated with caregiving, which included time spent transporting the family member with disabilities, and in accompanying them on health facility visits. Costs associated with care-giving were greatest for persons with disabilities that were not working, which further compounded income deprivation for these families. This was not the case for the majority of our study participants whose care-giving was incorporated into the daily domestic duties of other household members. People with high care needs were presumably less able to attend our focus groups. Another issue is that the majority of people in the focus groups were disabled adults and thus may be unaware of choices made by carers at some earlier point in their lives where opportunities or options for other types of work were forgone.The costs associated with disability invoked a range of coping mechanisms among households. Borrowing was a primary mechanism through which families coped, consistent with quantitative findings on health and disability shocks from Vietnam , 32. TheQuantitative findings indicate that such coping mechanisms help Vietnamese households to maintain consumption in the short to medium term . HoweverMeeting school fees of children on a single income when one parent was not working due to disability was identified as a particular challenge in these focus groups, comparable with findings from India . FurtherWhilst the proportion of participants in this study receiving Government supports was higher than the national average, likely due to the political connectedness of the group, many households did not receive any social assistance supports. In 2006, about one-third and one-half of Vietnamese persons with a high disability threshold received monthly income support and health insurance, respectively . One concern consistently raised by focus group members was that not all persons with disabilities were eligible for social protection supports. Currently, under the national disability law only persons classified as having severe or profound disabilities—persons with disabilities who are unable to perform some or any basic activities of daily living such as walking, dressing, and personal hygiene—are entitled to social protection supports . This liAnother predominant theme among focus group members was the lack of the current social assistance programmes to provide adequate funding for persons with disabilities to meet their economic needs. Cash transfer amounts were low by income replacement standards, and health insurance did not offer financial protection against all of the costs of care consistent with quantitative findings from Vietnam , 40. AssIt is important therefore not only that benefits are commensurate with needs but sufficient accommodations are made so that persons can avail themselves of benefits. The latter point is supported by quantitative evidence of improved district level health services, roads, and other indicators of good infrastructure lessening the link between disability and poverty in Vietnam . A positWe acknowledge an inherent bias in the recruitment of our sample in that not all persons and families with disabilities in Vietnam are associated with disabled people’s organizations from which participants were recruited. We did not find any significant disparities in the lived economic experience of persons, and their families, by focus group location (semi-urban vs. urban), which may reflect the fact that the semi-urban district was a part of greater Hanoi or that participants in the urban ward were not able to take advantage of increased formal employment opportunities. It is noted, however, that many of the costs and barriers reported in this study are similar to those found among youth ethnic minority people with disabilities, and their families, in a remote area of central Vietnam . FinallyThe economic lives of persons with disabilities and their families are distinct to other population groups with respect to the long-term intra-family effects. However, comparably little is understood on the economics of the population with disabilities. The majority of our study participants were working yet subject to economic hardship through the combination of low and unstable income with the additional burden of the extra costs of disability. The coping mechanisms commonly adopted by families to deal with these costs including borrowing and reducing and foregoing certain expenditures impeded their ability to invest in key expenditures for the individual with disabilities and other household members, threatening their economic welfare over the longer term. These findings show that there is a big gap between the goods and services used and those required thus drawing attention to the limitation of prevailing quantitative methods in the estimation of disability costs focused on the goods and services used.Relative to other countries of equal or even greater level of development, Vietnam offers a strong suite of social protection supports for persons with disabilities. However, large challenges remain in extending supports to all those in need and in providing benefits commensurate with needs while providing sufficient accommodations in the environment so that persons can fully avail themselves of these benefits. One novel finding from this research is that low-interest loans may provide an important short-term safety net for persons with disabilities, and their families in Vietnam and perhaps more generally in countries where, social protection systems are in their infancy.A conclusion based on these focus groups is that co-ordination across government is required to build a strong and integrated system to support the economic integration of persons with disabilities, which remains a considerable challenge for Vietnam and for LMICs in general. In addition, as in many countries, broader attitudinal barriers within the family and the wider community are significant barriers to improving the economic standing of persons with disabilities in Vietnam. Improving attitudes around the capabilities of persons with disabilities within the community may significantly reduce several of the costs associated with disability for the individual and the household.S1 Data(DOC)Click here for additional data file.


To assess the impact of human bocavirus (HBoV) virus load on epidemiologic and clinical characteristics in children with lower respiratory tract infection (LRTI). Clinical records of a total of 654 patients with HBoV infection during January 2013 and December 2014 were retrospectively reviewed. Patients with high HBoV virus load infection had a similar age distribution with the total HBoV infection, which had a peak age group of 6–24 months. Patients with high virus load are significantly younger (P < 0.01) than those with low load. The patients who had wheeze and tachypnea/dyspnea at presentation were more strongly affiliated with the patients with high virus load (both P < 0.01). Co-infection was found significantly more frequently among patients with low virus load than those with high virus load . High virus load was a significant predictor of severe LRTI (P < 0.05). HBoV infections are found in an important proportion of the hospitalized children with respiratory illnesses (8.85% in our series). A high HBoV virus load could be an etiologic agent for LRTI, which may lead to more severe lower respiratory tract symptom and severe disease. The discovery of human bocavirus (HBoV) was the result of a viral study of respiratory secretions from Swedish children with symptoms of acute respiratory infection (ARI) reported in 200523456In this study we aimed to assess the relationship between the HBoV virus load in respiratory tract and clinical characteristics. Samples were referred from January 2013 and December 2014, in Suzhou, China.3 to 3.97 × 109 copies/ml with a median of 1.2 × 103copies/ml. According to the distribution of genomal virus load (4 copies/ml) group (n = 326) and low virus load (≤104 copies/ml) group (n = 328).Of the 7393 patients with LRTI, HBoV were positive in 654 patients with a positive rate of 8.85%. The virus load ranged from <10rus load , we clasOf the 654 patients with HBoV infection, 431 (65.90%) were males and 223 (34.10%) were females. The male to female ratio was 1.93:1. The median age was 16 months (range from 1 month to 14 years). The age distribution of the patients is shown in There were no significant differences between high and low virus load in different age groups less than 36 months  patients were co-infected with other respiratory pathogens, including 236 (36.1%) patients with Mycoplasma pneumoniae (MP), 46 (7.0%) with respiratory syncytial virus (RSV), 20 (3.1%) with parainfluenza virus (PIV) 1-3, 11 (1.7%) with influenza virus (IV)-A, 8 (1.2%) with adenovirus (ADV). Among the 321 cases, 36 patients were with two other pathogens.Co-infection was found significantly more frequently among patients with low virus load than those with high virus load . Co-infection with RSV was more strongly affiliated with the patients with low virus load . None of the patients transferred to ICU. Requirement for O2 was used to evaluate disease severity. In unadjusted analysis, requirement for O2 was associated with young age, HBoV single infection and high virus load . Other variables  showed no difference.Fifty-one (7.8%) patients received O2 is shown in 2 were age <2 months and high virus load (both P < 0.05).The multivariable logistic regression model for requirement for OAs far as we know, this is by far the largest study focus on the clinical significance of different virus load of HBoV in patients with LRTI. We included a series of patients in the Suzhou region over two consecutive years. Also, this is the first study comprehensively describe the impact of HBoV virus load on epidemiology, clinical features, laboratory values and microbiological evaluation in children with HBoV LRTI.During the last decade since its discovery, HBoV is found to be one of the most common pathogens that leads children to acute respiratory tract infection, especially LRTI4Age profile noted for individuals with HBoV was similar to RSV infections, with infections almost completely confine to infants and young children <24 months). Our study are in line with most of the previous studies14 months.Seasonal peaks of HBoV infection vary among different counties because of climate and geographic factors. Previous studies suggested that HBoV infection had a higher detection rate in winter122In our study, wheezing and tachypnea occurred more frequently in children with high virus load. Actually, wheezing and tachypnea have been recognized as important clinical manifestations in HBoV infection2341415Co-infection was found significantly more frequently among patients with low virus load than those with high virus load , indicating that patients with low HBoV virus load were more likely to be co-infected with other pathogens, which is consistent with the studies of Brieu8Indeed, HBoV has been detected in infants and children with and without respiratory symptoms1920212), while virus co-infection would not increase disease severity. Therefore the more severe lower respiratory tract symptom presented in high HBoV virus load patients may solely depend on HBoV virus load. Different from the previous study, our study use multivariable logistic regression which highlight the role of high virus load in severe LRTI.Previous studies6The present study has potential limitations. First, quantitative PCR combined with serology would give a better idea of whether the viral infection was active or incipientIn conclusion, HBoV infections are found in an important proportion of the hospitalized children with respiratory illnesses (8.85% in our series). A high HBoV virus load could be an etiologic agent for LRTI, which may lead to more severe lower respiratory tract symptom and severe disease.All experiments were performed following the relevant guidelines and regulations of Soochow University. The methods were carried out in accordance with the approved guidelines. The study was approved by the Medical Ethics Committee of Soochow University. The parents of all study participants gave both verbal and written informed consent before study enrollment. A total of 7393 patients with a clinical and radiological diagnosis of LRTI in Children’s Hospital of Soochow University during January 2013 and December 2014 were enrolled in the study.Nasopharyngeal aspirates were obtained from all patients within 24 hours of admission. This involved passing a suction catheter through the nose with the intent of passing it into the lower part of the pharynx. The depth of penetration for the nasopharyngeal aspirate catheter was set at 7–9 cm. A total of 2 ml nasopharyngeal aspirates was obtained and centrifuged at 500 × g for 10 minutes and resuspended in 2 ml saline and divided into 2 aliquots for pathogen detection using direct immunofluorescence assay (DFA) and PCR. One of the equally divided samples of nasopharyngeal aspirate was centrifuged at 12000 × g for 5 minutes, followed by extraction of DNA from a 400-ul KL sample using DNA-EZ Reagents  or TRIzol Reagent  in accordance with the manufacturer’s instructions. A final 200 KL of DNA was eluted and DNA sample was divided into 2 aliquots for HBoV and Mycoplasma pneumoniae (MP) gene amplification via PCR.Direct immunofluorescence assay was done directly on nasal aspirate specimens by use of murine monoclonal antibodies (Chemicon). The specimens were tested for respiratory syncytial virus (RSV), adenovirus (ADV), parainfluenza virus (PIV) types 1–3, and influenza virus (IV) types A and B. All staining procedures were performed according to the manufacturer’s instructions. Immunostained preparations were viewed with a fluorescence microscope . Sputum DNA was extracted as described above, and hBoV-DNA was detected by real-time fluorescent PCR.Specimens were tested for the presence of MP by real-time PCR, acute IgM and IgG serology were also evaluated using enzyme-linked immunosorbent assay (ELISA). MP infection was confirmed if a positive PCR and an elevated IgM at admission or a fourfold increase in IgG at follow-up was detected.Demographic, clinical features and laboratory tests including white blood cells (WBC), neutrophils, platelet, C-reaction protein (CRP) and nasopharyngeal aspirates tests were routinely performed of each patient.t test and non-normally distributed variables were analyzed using Mann-Whitney U test. Categorical data were analyzed using the chi-squared (χ2) test or Fisher’s exact test. P value < 0.05 was considered statistically significant. Multivariable logistic regression analyses were conducted to identify different clinical characteristics associated with different virus load, and to evaluate independent predictors of requirement for O2. Factors were considered for inclusion in the model if they were found to be associated with the outcome in unadjusted analyses (P < 0.20) or were potentially clinically important.Statistical analyses were performed using the Statistical Package for the Social Sciences . Data were expressed as number with percentage, mean and standard deviation (SD) or median as appropriate. Normally distributed continuous variables were compared using the Student How to cite this article: Jiang, W. et al. Clinical significance of different virus load of human bocavirus in patients with lower respiratory tract infection. Sci. Rep.6, 20246; doi: 10.1038/srep20246 (2016).


The complete genome sequence of an isolate of tomato mottle mosaic virus (ToMMV) infecting tomatoes in New York was obtained using small RNA (sRNA) deep sequencing. ToMMV_NY-13 shared 99% sequence identity with isolates from Mexico and Florida. Broader distribution of this emerging virus is a cause for concern to the tomato industry. Tobamovirus in the family Virgaviridae  and tomato mosaic virus (ToMV) have been two of the most common recognizable tobamoviruses infecting tomatoes. These seed-borne and mechanically transmitted viruses are managed through the breeding of tobamovirus-resistant tomato cultivars and in the use of certified, virus-tested seed lots. However, a novel tobamovirus, tomato mottle mosaic virus (ToMMV), was first identified in tomatoes in Mexico in 2013 . Based oaviridae , 6. Totaaviridae  and sequaviridae . A contiKT810183.The complete genome sequence of ToMMV_NY-13 has been deposited in GenBank under the accession number


To extend the platform of clinically utilised chemoembolic agents based on ion-exchange systems to support the delivery of anionic drugs, a series of PVA-based beads was produced with different levels of (3-acrylamidopropyl)trimethylammonium chloride (APTA) in their formulation. The beads were characterised to confirm composition and the effect of formulation variation on physical properties was assessed. Suspension polymerisation was shown to successfully produce uniformly spherical copolymer beads with APTA content up to 60 wt%. Equilibrium water content and resistance to compression both increased with increasing APTA content in the formulation. Confocal laser scanning microscopy was used with model drugs to demonstrate that by increasing APTA content, compounds between the molecular weight range 70–250 kDa could permeate the microsphere structures. Interaction with anionic drugs was modelled using multivalent dyes. Dyes with multi-binding sites had increased interaction with the polymer, slowing the release and also demonstrating a reduced rate of elution from beads with higher charge density. The model drug release studies demonstrate that these systems can be engineered for different potential anionic drugs for local therapeutic delivery in the clinic. Ion-exchange is the interchange of ions in a liquid phase with counter ions of a solid ionic polymer (resin) and is commonly utilised in drug delivery systems as a method of loading and subsequently controlling the release of a charged drug . ExchangWe have previously reported on the development of a commercial drug delivery embolisation system known as DC Bead™ which is a cationic exchange system formed by the copolymerisation of a modified polyvinyl alcohol (PVA) macromer and an acrylamido sulfonate monomer –6. In thThere have previously been a number of studies which have considered the synthesis of cationic polymers for the delivery of anionic drugs using the cationic quaternary monomer (3-acrylamidopropyl)trimethylammonium chloride  and 10 % cellulose acetate butyrate  solution in ethyl acetate. Pyrene sulfonic acid based sodium salts P1, P2, P3 and P4 were supplied by Sigma Aldrich, UK. Water was purified by reverse osmosis using a Millipore (UK) Ltd Elxi 10 water purification system. Sodium chloride was supplied by Fisher Scientific UK. Phosphate buffered serology saline (PBS) was supplied by Inverclyde Biologicals, UK. Solvents were supplied by Romil Ltd. UK and all other materials were supplied by Sigma-Aldrich, UK and were used as received.Polyvinyl alcohol (PVA) partly saponified, 88 % hydrolysed, 12 % acetate content, average molecular weight of 67,000 Da (trade name Mowiol 8-88) was supplied by IMCD UK Ltd, Surrey, UK. (3-acrylamidopropyl)trimethylammonium chloride (APTA) (75 % w/w) was supplied by Sigma-Aldrich, UK. PVA (300 g) was dissolved in 2L of purified water with heating to 95 °C for 2–3 h. NAAADA (4.98 g) was then added to the PVA solution followed by the addition of concentrated hydrochloric acid (238 g), which catalysed the addition of the NAAADA to the PVA backbone through the acetal groups at 40 °C. After 1 h the solution was neutralised by the addition of 2.5 M NaOH solution to achieve pH 7.4. In this acid catalysed reaction, the cyclic acetal of the macromer may be formed through the removal of methanol and reaction with the pendant 1,3-diols of PVA; it is also likely that in the presence of water, the acid will also act to hydrolyse the NAAADA. This leads to the formation of the aldehyde and subsequently its conversion, through the formation of hemiacetal, to the cyclic acetal of the macromer.Organic Phase: 600 g n-butyl acetate and 11.5 g of a 10 % (w/w) CAB in ethyl acetate were added to a glass 1 L jacketed vessel connected to a heater-chiller unit and stirred at approximately 300 rpm at 25 °C and purged with N2 (g). Aqueous phase: A known amount of PVA macromer (21 g non-volatile weight), 1.3 g APS, the appropriate amount of APTA solution and an additional amount of purified water were mixed together and added to the reaction vessel. Water was added so that the total amount of water in the formulation was approximately 130 g. Polymerisation was activated through the addition of 1.6 mL tetramethylethylenediamine (TMEDA). An excess amount of TMEDA to APS was used to ensure complete reaction of APS. The reaction was allowed to continue for 3 h at 55 °C under an inert N2 (g) atmosphere. The beads were then purified by washing in ethyl acetate and acetone to remove residual CAB, before hydration and washing in water. The beads were heat extracted by boiling in 80 mM disodium hydrogen phosphate in 0.29 % (w/w) NaCl solution before rehydration in water, followed by equilibration in saline. Beads were produced in various sizes, typically 100–1500 µm.Insoluble beads were produced by water in oil suspension polymerisation where the macromer was copolymerised with APTA by redox-initiated polymerisation using the following phase systems: 43 denotes 43 wt% APTA: 57 wt% macromer. APTA0 are beads composed of solely the cross-linked PVA macromer; APTA100 was prepared using APTA alone and an additional non-ionic acrylamide monomer  in order to provide cross-linking and prevent dissolution of the beads.Formulation of the aqueous phase was varied to produce beads with different concentrations of APTA. In all formulations the total amount of water, macromer and APS remained the same. Seven batches of beads were produced using different formulations as outlined in Table The beads were characterised using image analysis, compression testing and measurement of equilibrium water content as described previously , 10, 11.The weight percentage of carbon, hydrogen and nitrogen in each formulation was determined by elemental analysis. Samples were prepared by dehydrating the hydrated beads of each formulation in acetone and then drying under vacuum at 120 °C. The beads were ground into a powder using a pestle and mortar before final drying to a constant weight. The samples were sent to Medac Ltd, UK for testing. Elemental analysis was performed by combustion testing in the presence of oxygen.Optical microscopy imaging was performed using an Olympus BX50F4 microscope equipped with phase contrast filters. Images were captured with a ColorView III camera  which is a high resolution digital camera and was attached to the microscope. Bead sizing was performed manually using the sizing tool of AnalySIS software (Soft Imaging System GmbH).2 probe attached to a 50 N load cell with a crosshead speed of 5.0 mm min−1.Beads used in compression testing were collected from the 710 to 850 µm sieved fraction. Compression testing was performed using an Instron 4411 tensile testing system with Series IX software  to generate curves of load versus percentage strain. The Young’s modulus of the beads was then determined from the slope of the curve and is an indication of resistance to compression. After the beads were distributed on the testing surface to form a monolayer, residual water was removed by wicking using tissue paper. The beads were compressed using a 5.0 mmEquilibrium water content (EWC) of the beads hydrated in water was tested gravimetrically. Excess water was removed from the beads in solution to form a slurry. The beads slurries were then dehydrated in an oven at 120 °C under vacuum until a constant weight was reached. EWC is defined as the weight of dehydrated beads as a percentage of the weight of the initial hydrated slurry.−1 FITC-Ds of different molecular weights of between 4 and 250 kDa  using a Leica TCS SP5 confocal, with a Leica DMI6000 B inverted microscope.The molecular weight cut-off was determined as described by Vandenbossche et al. . In summA selection of beads of each formulation were dehydrated and ground to a fine powder using the same method as the samples tested by elemental analysis. The powder was analysed using a diamond crystal on a PerkinElmer Spectrum One FTIR Spectrometer with a Universal Attenuated Total Reflectance (UATR) accessory.The chemical structures of the model dyes used in this study are shown in Fig. The maximum binding capacity of each formulation with each dye was determined by extraction in an ionic solution. The bead slurries were mixed for 72 h with approximately 5 mg of excess dye per mL of beads, based on calculated theoretical capacities. The beads were then repeatedly washed with purified water to remove residual unbound dye. To extract the dyes the loaded beads were eluted in 500 mL of a saturated KCl solution in water, mixed to a 50:50 ratio with ethanol. The solutions were stirred to mix for 7 h before sampling.16, APTA43, and APTA60. A fixed volume of beads  had been previously measured out using a measuring cylinder and loaded with a known amount of dye. The remaining loading solution was removed and the slurry of beads was added to 200 mL of PBS. The experiments were carried out in amber jars. The solutions were rolled to provide continuous mixing for the duration of each experiment. At each time point the eluent was sampled and tested by visible spectroscopy as previously described. The volume of sampled eluent was replaced with fresh PBS to maintain the elution volume.Elution of Dye loaded beads was performed in a fixed volume of PBS and the experiment was performed in triplicate for the formulations APTAThe results of elemental analysis for the beads prepared in this study are summarised in Table 0, APTA16, APTA27, and APTA43, are presented in Fig. 16 is similar to PVA only beads (APTA0) with an additional peak at approximately 1545 cm−1. This corresponds to the amide II band caused by bending of the amide N–H groups. With increasing concentration of APTA in the formulation the relative intensity of the amide I and amide II peaks appear to increase. In the spectral analysis of formulations APTA0, APTA16, APTA27 and APTA43 there is a peak present at approximately 1712 ± 4 cm−1. This peak is characteristic of a carbonyl stretching for a ketone group and is due to residual acetone within the beads which was confirmed by GC analysis. The FTIR studies therefore support the elemental analysis in confirming the presence of the appropriate functional groups according to the target formulations.The ATR-FTIR spectra of APTA0 to APTA60, show that they are spherical and although these beads were not imaged using phase contrast light microscopy, APTA60 beads are visibly more opaque than the other formulations . This technique is useful to predict the loading capability of large macromolecules for the prepared bead formulations, as fluorescence can be observed within the centralised regions of the beads if the FITC-Ds are able to diffuse into the structure. A summary of the molecular weight cut-off range, above which FITC-D were not observed in the centre of beads, are summarised in Table 60 beads have the highest measured loading capacity with all dyes. The maximum binding capacity of the cationic beads decreased when using dyes of increasing charge density and hence multiple binding points, as these species have the ability to occupy more than one cationic site on the polymer per molecule of dye.The theoretical loading capacity for each formulation per volume of beads was calculated by multiplying the theoretical capacity per mg of polymer by the mass of polymer per mL of beads. The maximum binding capacity was measured by complete elution in a saturated ionic solution Table . The theTransmitted light images of the loaded beads in water demonstrate that they all sequester dye from solution and retain it in their matrix. This is suggestive of an ion-exchange process of loading as there appears to be no diffusion of dye into the surrounding solution. The colour of the loaded cationic beads was dependent upon the type of dye and the amount loaded Fig. .Fig. 6TrIn Table 43 beads loaded to maximum capacity with P1, P2, P3 and P4 is presented. There is no significant difference in the resistance to compression of the beads when loaded to maximum capacity using dyes of varying charge density in comparison to the unloaded beads in water . The measured modulus is not greater than 50 kPa, unlike that observed for doxorubicin interaction with AMPS-based beads [In Fig. ed beads  and so m43 beads was assessed and it can be observed that there is a difference in elution rate of the different dyes  were used to confirm the conversion of materials during synthesis and identify the presence of residual materials used in sample preparation. Suspension polymerisation was shown to successfully produce uniformly spherical copolymer beads with APTA content up to 60 wt%. The synthetic process was limited above this concentration and beads prepared using 86 wt% APTA appeared fragmented with an outer skin peeling away. EWC, permeability of large molecular weight compounds and resistance to compression increased with increasing APTA content in the formulation. It was demonstrated that the cationic microspheres could bind and release anionic compounds via an ion-exchange process through interaction with the positively charged quaternary ammonium groups of the copolymer. In elution studies as the charge density of the model drugs increased there was a reduction in the equilibrium concentration achieved and the total amount eluted in a closed release system. It was observed that the monovalent dye had the fastest rate of elution in comparison to the other dyes. Its interaction with the cationic polymer was shown to be relatively weak and when released from microspheres with increased charge density there was no reduction in the rate of elution. However when using a dye with multi-binding sites there was increased interaction with the polymer, slowing the release and also a reduced rate of elution from beads with higher charge density. The drug release studies demonstrate that these systems can be engineered for different potential anionic drugs for local therapeutic delivery in clinical applications.


A recent outbreak of Zika virus has been linked to fetal abnormalities in pregnant women who have been infected. The scientific community is working toward understanding Zika virus pathogenesis to better manage affected women and children. In an interview with Dr. Catherine Spong, we discuss the aims and challenges of a forthcoming longitudinal study of a cohort of pregnant women in areas of current active Zika virus transmission. Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health. In this role, she oversees research on pediatric health and development, maternal and reproductive health, intellectual and developmental disabilities, and rehabilitation medicine, among other areas. Her areas of expertise include maternal and child health, particularly prematurity, fetal complications, and improvement of child health outcomes. Her Institute is currently recruiting for a multicenter, longitudinal cohort study looking at the effects of Zika in infants and pregnancy.Dr. Catherine Spong Fig.  is the AZika virus infection in pregnancy has been linked to adverse complications, including miscarriage, stillbirth, fetal brain anomalies, and eye disorders. Many questions about prenatal Zika virus infection remain unanswered. With the information currently available, we are unable to inform a woman about the risk to her pregnancy if she is infected with the Zika virus. We have little information on how often prenatal Zika infection results in adverse outcomes such as miscarriage or microcephaly. The current literature is populated mostly by studies that followed women who had symptoms of Zika virus infection, such as rash or fever. Given that an estimated 80 % of people with Zika virus infection have no symptoms, we need to conduct studies in this population to understand the risk of asymptomatic Zika virus infection among pregnant women. We know that in other infections in pregnancy, the timing of the infection will help determine the outcome. The first trimester (weeks 0–13) is commonly thought to be the most vulnerable period because that is when most of the organ formation occurs. Some viral infections cause the most damage when the infection occurs during this time period. However, studies of symptomatic pregnant women with Zika virus have found that infection even in the second or third trimesters has resulted in anomalies in the fetal brain and other serious outcomes, including stillbirth, which is very concerning.The National Institutes of Health (NIH) is very interested in studying Zika virus and has published two notices (NOT-AI-16-026 and NOT-HD-16-004) highlighting the critical areas for research. Notably, we have launched a rapid solicitation (PAR-16-106) for R21 applications that allows submissions without preliminary data. The solicitation opened on March 20, 2016, and applications are being accepted on a rolling basis. In my over 20 years of experience at NICHD, this is the first time I have seen the use of the rapid funding opportunity announcement, which is a mechanism that enables continuous receipt and review of applications and then expedited funding. Eight NIH institutes and centers have signed on to this opportunity: NICHD, the National Institute of Allergy and Infectious Diseases, the National Institute of Dental and Craniofacial Research, the National Institute of Neurological Disorders and Stroke, the National Institute of Mental Health, the National Eye Institute, the National Institute of Biomedical Imaging, the National Heart, Lung, and Blood Institute, and the NIH Division of Program Coordination, Planning, and Strategic Initiatives. Other institutes are likely to join given the multifocal nature of this public health emergency.NIH’s interest includes basic research to understand Zika infection pathogenesis and transmission to the fetus, establishment of animal models to help translate laboratory findings into living systems, developing diagnostics and vaccines, and clinical studies. This clinical work includes understanding the role of Zika infection in pregnancy complications, as well as studies of children and non-pregnant adults to evaluate neurologic complications such as Guillain–Barre syndrome. I encourage wide dissemination of this funding opportunity to the scientific community.We plan to study pregnant women in regions where the virus is spreading to discern the risk of adverse outcomes to a woman infected during her pregnancy, whether she is symptomatic or not. We also want to establish the impact that the timing of infection has on pregnancy outcomes and the role, if any, of prior exposures to other pathogens, such as dengue virus, and to environmental factors such as pesticides, larvicides, and insect repellents.Additionally, we want to document the spectrum of neonatal outcomes related to fetal exposure to Zika virus infection. This includes not only microcephaly, which has been reported extensively since the outbreak began, but also other serious brain anomalies, fetal loss/stillbirth, eye abnormalities, and developmental and motor outcomes. It is likely that microcephaly is one of the severe complications and that more subtle anomalies will be identified once systematic studies are performed.We aim to recruit approximately 10,000 pregnant women at up to 15 sites across Latin America and the Caribbean, regions currently experiencing active Zika virus transmission. We anticipate starting recruitment in early summer. The participants will be in their first trimester, and we will follow them to determine timing of exposure to Zika virus and whether the women become symptomatic or not. We will use CDC testing kits to detect Zika infection. However, if new, validated diagnostic tests become available, we will systematically incorporate them into the study.We also want to study the presence of potential confounding factors, such as prior infections, including dengue and cytomegalovirus, and environmental exposures to determine what role they may play in the severity of maternal or infant disease. Our preference is to have patients enroll as early as possible in pregnancy because this will improve our ability to evaluate the impact of the timing of infection on pregnancy outcome.Recruitment will occur through prenatal clinics and other community outreach, depending on the study site, region, and country. We recognize that there are different cultures and methods of providing healthcare globally, and we will work with local groups to determine the optimal method for recruitment.For each site, we will obtain ethics approvals and participant consent in accordance with local practices. To participate in this study, all sites will be using the same methods to gather information and materials, and the data will be sent to a central location for monitoring and analysis.We intend to monitor the women for the duration of their pregnancies and for 6 weeks after they give birth. We will follow the infants for up to 2 years after birth. It will be important for us to follow the children and mothers after delivery to determine the impact of prenatal Zika virus infection and to provide sufficient assessment to document the outcomes. This follow-up will require clinical examinations, eye exams, imaging studies, and the collection and analysis of biospecimens.Clinical research is inherently challenging. For this study, we will be challenged by our ability to diagnose women who are infected with Zika virus – but are asymptomatic – in areas where dengue virus is also endemic. The current diagnostic test for Zika cross-reacts with dengue virus, and therefore diagnosing Zika infection may be complicated. In addition, viremia evaluation, or the presence of virus in the blood, following Zika exposure may vary between asymptomatic and symptomatic women.Some women may not want to participate or will decide to drop out of the study given the concerns and implications of a Zika diagnosis. Although all studies are concerned with loss to follow-up or “drop-out”, in this situation where the visibility is so high and the risks so personal, it is something we need to watch closely. Follow-up may be difficult, especially if children have no signs of abnormalities at birth.For this study, it will be critically important to have follow-up of all the children, and not just those with complications at delivery, to determine the complication rate and to evaluate brain and developmental milestones. The concern with losing study participants is the ensuing difficulty of interpreting the study results.One of the key components of this study is that all participating sites will use the same protocol, so the same information will be collected regardless of site or country. This is essential for us to be able to perform the analyses and to answer the critical questions. We have worked very closely with several other groups interested in studying the impact of Zika virus on pregnancy, and we have shared our protocol so that they too will collect information in the same way, enabling us to possibly collaborate in the future. In addition, we are working in concert with health agencies in affected countries.https://zika.labkey.com/project/OConnor/ZIKV-001/begin.view). This allows the community to learn their findings immediately, provides opportunities for collaboration, and helps others to generate new research ideas.There has been significant outreach by the research community. Some groups are making their data available immediately. One example is the Zika Open Research portal of O’Connor and Osorio , is partnering with NIH on the study by providing scientific expertise and co-funding some of the sites. We encourage other groups interested in launching similar studies to contact us, so we can share information and facilitate potential collaborations.We have been working with other groups on the upcoming cohort study. For example, Fiocruz, a research institution that is part of the Brazilian Ministry of Health , global cerebral hypogyration , and intracranial calcifications , have already been reported in these children, and we need a comprehensive evaluation of these cases. We also need to understand the spectrum of outcomes in asymptomatic women.Further, we need better understanding of Zika virus-related eye and hearing abnormalities, as well as neurobehavioral effects such as altered motor function, stiffness, irritability, and incessant crying. It will be essential to follow the children after birth to evaluate their neurodevelopment and developmental milestones, including children who show no signs of anomalies, to fully characterize the impact of Zika on child health outcomes. Characterizing the full extent of Zika virus impact on fetal development will enable the development of strategies to assess and monitor the growth of children exposed to the virus in the womb and to define and optimize ways to treat and care for these children.See reference list –10.


Various chemotherapy regimens for advanced colorectal cancer have been introduced to clinical practice in Japan over the past decade. The cost profiles of these regimens, however, remain unclear in Japan. To explore the detailed costs of different regimens used to treat advanced colorectal cancer during the entire course of chemotherapy in patients treated in a practical setting, we conducted a so-called “real-world” cost analysis.A detailed cost analysis was performed retrospectively. Patients with advanced colorectal cancer who had received chemotherapy in a practical healthcare setting from July 2004 through October 2010 were extracted from the ordering system database of Showa University Hospital. Direct medical costs of chemotherapy regimens were calculated from the hospital billing data of the patients. The analysis was conducted from a payer’s perspective.A total of 30 patients with advanced colorectal cancer were identified. Twenty patients received up to second-line treatment, and 8 received up to third-line treatment. The regimens identified from among all courses of treatment in all patients were 13 oxaliplatin-based regimens, 31 irinotecan-based regimens, and 11 regimens including molecular targeted agents. The average  monthly cost during the overall period from the beginning of treatment to the end of treatment was 308,363  Japanese yen (JPY). According to the type of regimen, the average monthly cost was 418,463  JPY for oxaliplatin-based regimens, 215,499  JPY for irinotecan-based regimens, and 705,460  JPY for regimens including molecular targeted agents. Anticancer drug costs and hospital fees accounted for 50 to 77 % and 11 to 25 % of the overall costs of chemotherapy, respectively.The costs of irinotecan-based regimens were lower than those of oxaliplatin-based regimens and regimens including molecular targeted agents in Japan. Using a lower cost regimen for first-line treatment can potentially reduce the overall cost of chemotherapy. The main cost drivers were the anticancer drug costs and hospitalization costs.The online version of this article (doi:10.1186/s12913-015-1253-x) contains supplementary material, which is available to authorized users. Colorectal cancer is currently one of the most common cancers worldwide . In JapaA combination of 5-fluorouracil (5-FU) and leucovorin (LV) was the standard regimen for advanced colorectal cancer during the 1980s and 1990s. After the year 2000, FOLFOX  and FOLFIRI (irinotecan plus 5-FU and LV) were developed and modified over the course of several years. These regimens extended progression-free survival to more than 8 months . FurtherDespite the usefulness of various regimens for the treatment of advanced colorectal cancer, the development of new combination regimens has also attracted the attention of payers as well as physicians owing to the high costs of chemotherapy for colorectal cancer. The national medical expenditure in Japan reached 39.2 trillion JPY in 2011 . Above aWe have recently reported the results of a cost-minimization analysis comparing S-1-based regimens with 5FU-based regimens for advanced colorectal cancer in Japan . In the We undertook a real-world cost analysis to compare the detailed costs of different chemotherapy regimens used for advanced colorectal cancer from first-line treatment to the end of chemotherapy in a practical setting. The analysis was retrospectively performed from a payer’s perspective. The costs of healthcare-related services were calculated from the payer side using billing data obtained from Showa University Hospital. Showa University Hospital is a general hospital located in Tokyo that has approximately 800 beds as well as outpatient clinics. The fees are the same for all payers and virtually all providers in Japan and are set by the government in the national fee schedule . The stuWe retrospectively collected clinical and claim data on patients with advanced colorectal cancer in this observational study. Because most of the patients died before this study began, it was difficult to obtain written consent from the patients. We analyzed the data after removing all personal information to protect privacy. This approach was in accordance with the Japanese Ethical Guidelines for Epidemiological Studies ; moreoveThe study group comprised patients who were given a diagnosis of advanced colorectal cancer and received chemotherapy until the end of the final line of chemotherapy in the Department of Surgery, Showa University Hospital during the period from July 2004 through October 2010. We extracted data on all lines of chemotherapy given to all patients and classified the regimens into the following three groups: oxaliplatin-based regimens, irinotecan-based regimens, and regimens including molecular targeted agents.Resource utilization data on each chemotherapy regimen was extracted from Showa University Hospital billing data. The following costs were calculated on a monthly basis and were summed up on the basis of the Japanese National Health Insurance fee-for-service system (reimbursement price) in 2010: costs related to outpatient visits (physician consultations and outpatient visits); costs for hospitalization ; costs for operations and procedures (including transfusions); costs for laboratory tests and diagnostic imaging tests ; costs for drugs and administration . Costs unrelated to cancer, such as costs required for the management of hypertension and hyperlipidemia, and operation fees, such as those required for the creation of an artificial anus, were not considered. Extra bed fees and meal fees were collected from billing data as a reference.In this study, we collected data on regimens regardless of the treatment line, and then found that the duration of each regimen was influenced by the treatment line. The duration of the first line of treatment was longer than those of second and third lines. Therefore, the costs of each chemotherapy regimen were compared on a monthly basis to avoid the effects of the different durations of treatment.The monthly average costs of all chemotherapy regimens from first-line to the end of the final line of treatment were analyzed over the course of time. Treatments costs during the period of terminal care were not considered because it was difficult to collect relevant data during that period, and the costs varied depending on the status of individual patients during terminal care, regardless of the regimens used previously. Trends in the breakdown of costs were also analyzed in detail. Costs for more than 1 year were discounted by 3 %.The uncertainty of the results was explored by sensitivity analyses of uncertain factors. Several qualitative, one-way sensitivity analyses were conducted to explore the impact of alternative parametric assumptions on the results.The characteristics of the 30 patients identified from the patient database of Showa University Hospital are shown in Table The numbers of regimens and the durations of each treatment line are shown in Table The monthly total costs are shown in Table The average  monthly cost during the overall period from the beginning of treatment to the end of treatment was 308,363  JPY. The monthly costs varied over time. The first cost peak occurred in the first month, and the cost gradually increased from the fifth to the twelfth month. During this period, some patients started to receive expensive second-line treatments. The second cost peak occurred in the twelfth month and overlapped with the peak in the first month of third-line treatment. The average  monthly costs were 256,149  JPY for first-line treatment, 518,897  JPY for second-line, and 416,251  JPY for third-line.The average  monthly costs of oxaliplatin-based regimens, irinotecan-based regimens, and regimens including molecular targeted agents were respectively 418,463  JPY, 215,499  JPY, and 705,460  JPY. The costs of irinotecan-based regimens were lower than those of oxaliplatin-based regimens and regimens including molecular targeted agents.The monthly component costs of each regimen group up to the twelfth month of treatment are shown in Table The cost drivers were anticancer drugs and hospitalization. The costs of anticancer drugs were 228,539 JPY  for oxaliplatin-based regimens, 96,853 JPY (50 %) for irinotecan-based regimens, and 535,214 JPY (77 %) for regimens including molecular targeted agents. The costs were lower for irinotecan-based regimens than for oxaliplatin-based regimens and regimens including molecular targeted agents. The hospital fees were 89,935 JPY (21 %) for oxaliplatin-based regimens, 53,584 JPY (25 %) for irinotecan-based regimens, and 77,752 JPY (11 %) for regimens including molecular targeted agents. Next to the costs of anticancer drugs, hospital fees were second highest costs for all regimen groups.The costs of other components were as follows. The administration costs for drug administration were 19,882 JPY for oxaliplatin-based regimens and 16,133 JPY for regimens including molecular targeted agents, which were higher than the 12,543 JPY for irinotecan-based regimens. The diagnostic imaging cost for irinotecan-based regimens was 24,039 JPY, which was higher than the costs in the other regimen groups. The operation fees were 37,353 JPY for oxaliplatin-based regimens and 38,222 JPY for regimens including molecular targeted agents, which were higher than the operation fees for irinotecan-based regimens.The results of sensitivity analysis are shown in Table Current clinical guidelines for colorectal cancer –8, recomIn the present study, the average duration of the entire course of chemotherapy was longer than 1 year, and the average monthly total cost during the entire period was 308,363 JPY, which nearly equals the average wage in Japan . The burThe costs of oxaliplatin-based regimens such as FOLFOX were higher than those of irinotecan-based regimens such as IRIS and FOLFIRI. Regimens including molecular targeted agents such as Bev and Cet were the most expensive. Many economic evaluations of colorectal cancer chemotherapy have been performed in the world Table . MiyazakHospital fees were thought to be one of the cost drivers. However, the results of sensitivity analysis showed that the hospital fees did not influence the total costs. The base-case costs of oxaliplatin-based regimens and regimens including molecular targeted agents were higher than the cost of the scenario assuming 3 days of hospitalization. The management of adverse effects was apparently more difficult for oxaliplatin-based regimens and regimens including molecular targeted agents than for other regimens and thus required a longer hospitalization period.The cost characteristics of other components were as follows. The costs associated with drug administration were higher for oxaliplatin-based regimens  than for irinotecan-based regimens  because IRIS regimens did not require continuous infusion of 5-FU. The diagnostic imaging costs for irinotecan-based regimens, used mainly as first-line treatment, were higher than those for other regimens because diagnostic imaging was frequently performed during first-line treatment. Operation fees for placement of a central venous access port for continuous infusion of 5-FU were high for oxaliplatin-based regimens, because most FOLFOX regimens were used before FOLFIRI in this study. The costs of antiemetics did not differ among the regimens.As reference information, we also collected data on the extra bed fee paid by patients, which was not included in total costs in this study. The price depended on the type of room, irrespective of the type of regimen. Such out-of-pocket costs paid by the patient, however, were a great burden in a practical setting. We need to consider such out-of-pocket costs from a societal perspective in future studies.Our analysis had several important limitations. First, a small sample of claim data was collected from a single institution in this study. It seems to be difficult to generalize the results of this study. However, standard dosages and schedules of the regimens in Showa University Hospital were used. In addition, by grouping the regimens to compensate for the small numbers of patients who received each regimen, we could obtain convincing results to some extent. Second, the treatment line differed among the regimens. However, we did not attempt to balance the background characteristics of the patients according to each regimen, because treatment dosages and schedules did not differ between the lines. With regard to this point, the durations and total costs of each regimen group varied according to the treatment line. Therefore, we compared the regimen groups on a monthly basis to eliminate potential effects related to differences in the duration of each treatment. Ideally, however, we have to directly compare total costs in a clinical trial. Third, we calculated only direct costs because our analysis was performed from a payer’s perspective.As mentioned above, the most widely used regimen in this study was oral S-1-based IRIS. Several economic evaluations of regimens including oral preparations such as capecitabine and tegafur-uracil have shown that such regimens are more cost effective than regimens comprising only injectable preparations , 30–32. The cost of the entire course of chemotherapy for advanced colorectal cancer was considerably expensive in Japan. The costs of irinotecan-based regimens such as IRIS and FOLFIRI were lower than those of oxaliplatin-based regimens, such as FOLFOX, and regimens including molecular targeted agents, such as FOLFOX + Bev and FOLFIRI + Bev or Cet. Using lower cost regimens such as IRIS as first-line chemotherapy can lead to a reduction in overall costs for the entire course of chemotherapy, because the duration of first-line treatment was longer than the duration of second and subsequent lines of chemotherapy. The main cost drivers of treatment for advanced colorectal cancer were anticancer drug costs and hospital expenses.


Progress in combatting zoonoses that emerge from wildlife is often constrained by limited knowledge of the biology of pathogens within reservoir hosts. We focus on the host–pathogen dynamics of four emerging viruses associated with bats: Hendra, Nipah, Ebola, and Marburg viruses. Spillover of bat infections to humans and domestic animals often coincides with pulses of viral excretion within bat populations, but the mechanisms driving such pulses are unclear. Three hypotheses dominate current research on these emerging bat infections. First, pulses of viral excretion could reflect seasonal epidemic cycles driven by natural variations in population densities and contact rates among hosts. If lifelong immunity follows recovery, viruses may disappear locally but persist globally through migration; in either case, new outbreaks occur once births replenish the susceptible pool. Second, epidemic cycles could be the result of waning immunity within bats, allowing local circulation of viruses through oscillating herd immunity. Third, pulses could be generated by episodic shedding from persistently infected bats through a combination of physiological and ecological factors. The three scenarios can yield similar patterns in epidemiological surveys, but strategies to predict or manage spillover risk resulting from each scenario will be different. We outline an agenda for research on viruses emerging from bats that would allow for differentiation among the scenarios and inform development of evidence-based interventions to limit threats to human and animal health. These concepts and methods are applicable to a wide range of pathogens that affect humans, domestic animals, and wildlife. Long identified as potential sources of zoonotic pathogens ,2, bats Pteropus lylei in Thailand, Hendra virus in Pteropus sp. in Australia, and Marburg virus in Rousettus aegyptiacus in Uganda [Spillover of bat viruses is often associated with discrete temporal and spatial pulses of virus excretion from the bats that function as reservoir hosts –6. Outbrn Uganda –12.Markedly different underlying mechanisms can yield similar spatial and temporal patterns in prevalence and seroprevalence data. We outline three distinct scenarios that could generate pulses of viral excretion in bats Figs  and 2. AEven though the different scenarios can lead to similar observed dynamics, strategies to predict or manage spillover risk will be different for the different underlying mechanisms (and mechanisms would be expected to vary between virus types). Strategies that confront dynamics driven by transmission between hosts are likely to focus on population density, connectivity among populations, or herd immunity . By contAs part of the international focus on surveillance of zoonoses and bat-borne viruses such as Ebola virus, understanding the dynamics of pathogens within animal reservoir hosts should be a research priority ,20. HoweHere, we establish a framework to assess the evidence for the different mechanisms that could drive the observed epidemiological patterns of emerging bat viruses. We highlight the strengths and limitations of potential investigation methods and recommend ways to distinguish between scenarios, which require ambitious, interdisciplinary research . We explThree hurdles have constrained understanding of within-host dynamics of emerging viruses in bats. First, although serological assays often indicate high levels of exposure in bat populations, few studies have isolated the corresponding live virus. For example, Ebola virus  and AfriExperimental infections of Hendra, Nipah, and Marburg viruses in bats have suggested that, after a short incubation period, bats have an acute systemic phase of viral replication . RNA froThe sequelae to the acute period of viral infection and shedding in bats are less well characterized. Although virus was not isolated from bats at the conclusion of any experiment, RNA was frequently detected in tissues at necropsy . For insAlthough there is no direct evidence that the henipaviruses or filoviruses persist within individual bats, it is commonly assumed that bats host persistent infections . This asIf bats do not clear infections, there are at least two mechanisms by which viruses may persist within bat hosts . First, Latent and recrudescent Hendra and Nipah encephalitis cases were observed in humans, and, therefore, recrudescence was proposed as a mechanism of persistence in bats. However, recrudescent virus in humans was not transmitted and, therefore, did not contribute to epidemiological dynamics e.g., ,50–52. NPteropus scapulatus over six months [Experimental evidence for protective immunity following viral infection in bats is inconsistent and suggests differences among species and viruses . In the x months , and wanx months ,56,57, bx months .As is the case with most wildlife diseases, the process by which bat viruses are transmitted in the wild is poorly understood. Transmission events cannot be observed directly, viral infections of reservoir hosts may be asymptomatic, and sampling of individuals through time is difficult. Therefore, inferences must be drawn from multiple sources of indirect evidence. Bat viruses have been detected in urine, feces, saliva, and soiled fruit, indicating the potential for virus transmission via excreta between bats in the wild ,59. HoweDisease dynamics within populations are primarily driven by interactions among the processes of pathogen transmission and clearance, immunity, and host population dynamics. We focus on three different scenarios—representing different combinations of these within- and between-host processes—that could generate pulses of viral excretion in bat populations . AlthougThe first scenario is that pulses of infection are driven by transmission of short-lived infections that provide long-lasting immunity  . Age-strLongitudinal sampling of the infection status of individuals can help distinguish between scenarios if four conditions are met: (1) Prevalence of the infection must be high enough to detect pathogen within a small number of sampled individuals but must not approach 100% so that variations can be observed. (2) The period over which individuals are resampled must exceed that of the infectious period (and therefore the infectious period must be known). (3) The host’s lifetime must far exceed the infectious period. (4) Pathogen must be detectable without lethal sampling. It is our contention that, if these conditions are met, it should be possible to distinguish among scenarios. In a population with waning immunity and cyclical reinfection, the probability that a given individual becomes infected is expected to be equal to the prevalence of infection among other individuals of similar age and the same sex. Therefore, past infection status is not expected to predict present infection status. In contrast, if individuals are persistently infected but shed episodically, the prevalence of infection among previously positive individuals will be higher than among the population, and past infection increases the likelihood of positive infection status . HoweverEidolon helvum (the reservoir hosts of henipaviruses and Lagos bat virus) migrate across continents [Pteropus alecto (the reservoir host of Hendra virus), recapture of individuals within populations that include tens of thousands of individuals is difficult if not impossible. In contrast to studies in migratory canopy-dwelling species, capture-mark-recapture methods have been implemented in cave-dwelling species. For example, Frick et al. [Myotis lucifugusi, and Smith et al. [Myotis macropus.A caveat to this method is that longitudinal, systematic sampling of wild animals, particularly highly mobile or migratory species, requires major effort. For example, large populations of ntinents . Even ink et al.  reportedh et al.  reportedIf recapture is possible, generating a consistent time-series of recaptures may be challenging, affecting the ability to make inferences on the temporal resolution of the underlying processes. Nevertheless, some mechanisms may be ruled out even with incomplete time-series data. For example, SIR dynamics are unlikely in an animal in which virus is detected, not detected, and then detected again. However, genomics still is necessary to differentiate SIRS from SILI dynamics.We hypothesize that pulses of infection arising from reactivation of persistent viruses or reintroduction of acute viruses may leave distinguishable evolutionary signatures in viral genomes at the population and individual levels . Viral rIn the absence of comprehensive, landscape-level data, other features of viral evolution may help distinguish reactivating from recolonizing viruses. Because viral evolutionary rates can be estimated for many species or can be approximated from better-studied related viruses , internaRepeated sampling of individuals, although challenging and sometimes impossible, may also provide powerful insights. In pulses of reintroduced viruses, the individual viruses sampled at different points in time might be paraphyletic , whereas reactivated viruses are expected to be monophyletic, with differences among pulses attributable to within-host evolution . CombiniViral sequence data may therefore help to distinguish the mechanisms driving pulses of viral infection in bats; however, several aspects of viral evolution present challenges. First, patterns of evolution within and between hosts are just beginning to be understood and different processes can generate similar patterns ,75. For Rousettus aegyptiacus bats, Hayman [In the face of incomplete data, modeling is regularly applied to explore the dynamics that would be expected given different scenarios for within- and between-host processes. For example, Blackwood et al.  compared, Hayman  investig, Hayman  used mod, Hayman ,79.Effective interventions to limit threats to human health from emerging infectious diseases rely on understanding the connections among observed pathogen dynamics, the underlying transmission mechanisms, and their ecological and environmental drivers. We propose that multiple processes can lead to similar spatial and temporal patterns in prevalence and seroprevalence data, and, to our knowledge, existing empirical data often are insufficient to identify the underlying mechanisms. We encourage researchers to collect appropriate data to identify the scenarios driving pulses of excretion of emerging bat viruses because strategies to predict or reduce spillover risk should depend on the mechanisms’ underlying dynamics . CurrentIdentifying the mechanisms and drivers of pulses of virus excretion may be the greatest challenge to predicting, managing, and preventing spillover of emerging diseases. We suggest that genomics and longitudinal sampling of individuals be integrated into virus and antibody surveys, and that these data be analyzed with inferential models. These methods will allow for identification of the drivers of infection pulses and thus set the agenda for research on emerging viruses that originate from bats. Moreover, these techniques can be applied to a range of animal and human systems in which differentiating between- from within-host mechanisms is challenging.A limited knowledge of the biology of pathogens within reservoir hosts makes understanding, predicting, and managing zoonoses that emerge from wildlife very challenging.One challenge is that different mechanisms can yield similar patterns in epidemiological data, yet strategies to predict or manage spillover risk will be different for each. Therefore, distinguishing among mechanisms driving disease dynamics in reservoir hosts may be critical for developing public health interventions.Spillover of emerging bat viruses to humans often coincides with pulses of viral excretion from bat populations. We present three scenarios of within-host and between-host processes that can generate these pulses of virus excretion. Each scenario involves different underlying mechanisms, yet can produce similar patterns in prevalence data. Research efforts often do not use data collection methods that would allow these mechanisms to be distinguished.We show that understanding the connections among observed pathogen dynamics, the underlying mechanisms, and their ecological and environmental drivers requires ambitious, interdisciplinary research. We suggest a research agenda combining genomics, longitudinal sampling of individuals, virus and antibody surveys, and inferential models.Zhou P, Tachedjian M, Wynne JW, Boyd V, Cui J, Smith I, et al. Contraction of the type I IFN locus and unusual constitutive expression of IFN-α in bats. Proceedings of the National Academy of Sciences. 2016;113(10):2696–701. 10.1073/pnas.1518240113.Plowright RK, P. Eby, P. J. Hudson, I. L. Smith, D. Westcott, W. L. Bryden, et al. Ecological dynamics of emerging bat virus spillover. Proceedings of the Royal Society of London B: Biological Sciences. 2015;282(1798):20142124.PLoS Pathog. 2012;8(10):e1002877.Amman BR, Carroll SA, Reed ZD, Sealy TK, Balinandi S, Swanepoel R, et al. Seasonal pulses of Marburg virus circulation in juvenile Rousettus aegyptiacus bats coincide with periods of increased risk of human infection. Luby SP, Hossain MJ, Gurley ES, Ahmed B-N, Banu S, Khan SU, et al. Recurrent zoonotic transmission of Nipah virus into humans, Bangladesh, 2001–2007. Emerging infectious diseases. 2009;15(8):1229.Restif O, Hayman DTS, Pulliam JRC, Plowright RK, George DB, Luis AD, et al. Model-guided fieldwork: practical guidelines for multidisciplinary research on wildlife ecological and epidemiological dynamics. Ecology Letters. 2012;15(10):1083–94.S1 Table(XLSX)Click here for additional data file.


Aedes aegypti during a 2011 outbreak in Al Hodayda, Yemen, which resulted in significant human fatalities. Phylogenetic analysis demonstrated that this Yemeni isolate is most closely related to Indian Ocean strains of the east/central/south African genotype.Chikungunya virus is recognized as a serious public health problem. The complete genome was sequenced for a chikungunya virus isolated from the mosquito  Alphavirus genus, family Togaviridae  detected an outbreak of a dengue-like illness in Al-Hodayda, Yemen. Initially, 1,542 cases were reported, with 104 associated deaths   collected from an indoor environment during the 2011 Yemen outbreak.Chikungunya virus (CHIKV) is an enveloped, positive-sense, single-stranded RNA arthropod-borne virus, which is taxonomically classified as a member of the aviridae . CHIKV iCHIKV was isolated by cell culture . RNA wasWhole-genome analysis reveals the Yemeni CHIKV isolate is 99.5% similar to the Indian Oceans strains but only 96.7% similar to the S27 African CHIKV prototype (GenBank accession no. NC_004162). The Yemeni isolate has several unique amino acid substitutions in the nonstructural and structural protein regions: two in the nsP2 region (I447M and N667Y), 5 amino acid deletions in the nsP3 at positions 368 to 372, one in the nsP4 region (L385H), and one in the E2 region (V251A). A deletion observed in the nsP3 region is of particular interest, as this locus is involved in negative-strand RNA synthesis, a function critical to the virus. The biological effect, if any, of this deletion should be determined.A. albopictus (Phylogenetic trees were generated using MEGA (version 6.0)  with thebopictus .KC614648. The version described in this paper is the first version.The assembled complete genome sequence of the Yemeni CHIKV isolate was submitted to GenBank under the accession no.