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Human Metapneumovirus Circulation in the United States, 2008 to 2014 Amber K Human Metapneumovirus Circulation in the United States, 2008 to 2014 Amber K. Haynes, MPH, a Ashley L. Fowlkes, MPH, b Eileen Schneider, MD,a Jeffry D. Mutuc, MPH,a Gregory L. Armstrong, MD, c Susan I. Gerber, MDa BACKGROUND: Human metapneumovirus (HMPV) infection causes respiratory illness, including abstract bronchiolitis and pneumonia. However, national HMPV seasonality, as it compares with respiratory syncytial virus (RSV) and influenza seasonality patterns, has not been well described. METHODS: Hospital and clinical laboratories reported weekly aggregates of specimens tested and positive detections for HMPV, RSV, and influenza to the National Respiratory and Enteric Virus Surveillance System from 2008 to 2014. A season was defined as consecutive weeks with ≥3% positivity for HMPV and ≥10% positivity for RSV and influenza during a surveillance year (June through July). For each virus, the season, onset, offset, duration, peak, and 6-season medians were calculated. RESULTS: Among consistently reporting laboratories, 33 583 (3.6%) specimens were positive for HMPV, 281 581 (15.3%) for RSV, and 401 342 (18.2%) for influenza. Annually, 6 distinct HMPV seasons occurred from 2008 to 2014, with onsets ranging from November to February and offsets from April to July. Based on the 6-season medians, RSV, influenza, and HMPV onsets occurred sequentially and season durations were similar at 21 to 22 weeks. HMPV demonstrated a unique biennial pattern of early and late seasonal onsets. RSV seasons (onset, offset, peak) were most consistent and occurred before HMPV seasons. There were no consistent patterns between HMPV and influenza circulations. CONCLUSIONS: HMPV circulation begins in winter and lasts until spring and demonstrates distinct seasons each year, with the onset beginning after that of RSV. HMPV, RSV, and influenza can circulate simultaneously during the respiratory season. Divisions of aViral Diseases, and bInfl uenza, National Center for Immunization and Respiratory Diseases, and WHAT’S KNOWN ABOUT THIS SUBJECT: Human c Offi ce of Advanced Molecular Detection, National Center for Emerging and Zoonotic Infectious Diseases, metapneumovirus is a respiratory virus that causes Centers for Disease Control and Prevention, Atlanta, Georgia upper and lower respiratory infections. Clinical Ms Haynes helped conceptualize and design the study and drafted the initial manuscript; presentation, populations most severely impacted, Mr Mutuc carried out preliminary analyses; Mr Mutuc and Dr Armstrong reviewed the and circulation patterns are similar to those of manuscript; Ms Fowlkes served as infl uenza virus subject matter expert; Ms Fowlkes and respiratory syncytial virus; however, national human Dr Schneider helped design the study; Ms Fowlkes and Drs Schneider and Gerber critically metapneumovirus circulation has not been well reviewed the manuscript; Dr Schneider served as human metapneumovirus subject matter described. expert; Dr Armstrong conceptualized the study analysis; Drs Armstrong and Gerber revised the manuscript; Dr Gerber guided the study concept and design; and all authors approved the fi nal WHAT THIS STUDY ADDS: This study describes manuscript as submitted. national human metapneumovirus circulation The fi ndings and conclusions in this report are those of the authors and do not necessarily using laboratory detections reported to a national represent the offi cial position of the Centers for Disease Control and Prevention. surveillance system from 2008 to 2014. Defi ning periods of elevated human metapneumovirus DOI: 10.1542/peds.2015-2927 circulation may guide virus detection and clinical Accepted for publication Jan 27, 2016 management, aiding in identifying illness and Address correspondence to Amber K. Haynes, MPH, National Center for Immunization and outbreaks. Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, MS A-34, Atlanta, GA 30329. E-mail: [email protected] To cite: Haynes AK, Fowlkes AL, Schneider E, et al. Human Metapneumovirus Circulation in the United States, 2008 to 2014. Pediatrics. 2016;137(5):e20152927 Downloaded from www.aappublications.org/news by guest on September 30, 2021 PEDIATRICS Volume 137 , number 5 , May 2016 :e 20152927 ARTICLE First identified in 2001, 1 human evaluate national trends in HMPV test results. For RSV analysis, we metapneumovirus (HMPV) is a circulation. included laboratories reporting cause of both upper and lower ≥10 RSV antigen detection tests/ In the United States, surveillance respiratory tract infections, including week annually and ≥1 RSV antigen for several respiratory viruses is bronchiolitis and pneumonia, detection test for 30 of 52 weeks conducted annually through the particularly among young children of the NREVSS year; for influenza National Respiratory and Enteric (<5 years), the elderly, and analysis, we included laboratories Virus Surveillance System (NREVSS). immunocompromised patients.2–5 reporting influenza by PCR to In this study, we describe national Infection with HMPV has been the World Health Organization HMPV circulation patterns and associated with an estimated 20 000 collaborating laboratories;14 and compare with patterns of RSV and U.S. hospitalizations annually among for HMPV analysis, we included influenza activity reported to NREVSS children aged <5 years.6 However, laboratories reporting ≥1 HMPV PCR during 6 seasons from 2008 to 2014. the infrequent testing and low index or antigen detection test for 36 of 52 of suspicion associated with HMPV weeks of the NREVSS year. These are may have limited the assessment METHODS standard laboratory inclusion criteria of temporal trends in HMPV for RSV and influenza; no standard circulation. Also, many studies have NREVSS is a passive surveillance inclusion criteria exist for HMPV. demonstrated that HMPV causes a network established in 1984 that collects specimen test results respiratory tract infection clinically For each virus, we calculated the for several respiratory viruses, indistinguishable from infections weekly proportion-positive. To including HMPV, RSV, and influenza. caused by respiratory syncytial virus define the season for RSV13 and Approximately 300 clinical and (RSV) and influenza.1–5 In contrast, influenza, 14 we used the widely public health laboratories in the the specific prevention options and accepted 10% weekly proportion- United States report ≥1 specimen some populations severely affected positive threshold. Specifically, test result on average for 44 weeks vary for HMPV, RSV, and influenza.7 the RSV or influenza seasons were in a surveillance year.13 Laboratories Currently there is no vaccine for defined as the first of 2 consecutive report weekly aggregates of the HMPV. Thus, describing HMPV weeks when the proportion of number of tests performed and circulation in the United States in the positive weekly aggregates exceeded positive detections by antigen context of RSV and influenza may 10% positivity, and the season detection, polymerase chain reaction help clinicians to prioritize diagnostic offset, as the last of 2 consecutive (PCR), and viral isolation. The type of testing, identify an etiologic agent, weeks when the proportion of assay reported can vary depending manage patients clinically, and weekly aggregates exceeded 10% on the respiratory virus and year. choose appropriate prevention positivity. To define the season for For RSV, we analyzed antigen strategies. HMPV, we selected a 3% weekly detection reports; for influenza, proportion-positive threshold. We we analyzed PCR reports; and for Many studies have demonstrated a defined the HMPV season onset HMPV, we analyzed both antigen winter-to-spring circulation period as the first of 2 consecutive weeks detection and PCR reports. The for HMPV in temperate climates, 8–10 when the proportion of positive NREVSS surveillance year is defined but determination of national HMPV weekly aggregates exceeded 3% as July of the starting year through trends and comparison of HMPV positivity, and the season offset, the end of the following June to seasonality to RSV and influenza as the last of 2 consecutive weeks capture the typical national onset in multiple sites throughout the when the proportion of weekly and offset of several respiratory United States have not yet been aggregates exceeded 3% positivity. viruses. Surveillance for RSV and done. A study conducted in 3 U.S. At a threshold of 3%, 84% to 94% influenza through NREVSS is well sites identified HMPV circulation in of HMPV detections by antigen established and ongoing since 1984 winter and spring months;6 however, detection tests were captured and 1989, respectively. The first it remains unclear if this pattern each year, and 80% to 92% of HMPV diagnostic test was reported reflects trends in national HMPV HMPV detections by PCR tests to NREVSS in July 2005, but reports circulation. The increased availability were captured. For each virus, we were insufficient for robust analysis and use of molecular diagnostic calculated the onset, offset, peak, until 2008 to 2009, when test reports assays to detect respiratory viruses11 and duration (onset to offset) for to NREVSS exceeded 70 000. in recent years has highlighted each individual season and the several HMPV-associated outbreaks Laboratories included in this analysis median for the 6 seasons. A 4-season throughout the United States12 and were selected based on annual median rather than a 6-season has enhanced the opportunity to duration and volume of reported median was calculated for influenza;
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