key: cord-0993185-z22hq84i
authors: Gray, Gregory C.; Erdman, Dean D.
title: Adenovirus Vaccines
date: 2017-07-17
journal: Plotkin's Vaccines
DOI: 10.1016/b978-0-323-35761-6.00010-9
sha: 94f2b8e4e38271c71839accf460f12199f65ceb4
doc_id: 993185
cord_uid: z22hq84i

nan

In the 1950s, multiple researchers 1,2 identified new viruses as the cause of acute respiratory disease (ARD), pharyngitis, conjunctivitis, and pneumonitis. Soon afterward, these viruses were recognized to be a related group of viruses and given their present name: adenoviruses. 3 

The adenoviruses are often the cause of respiratory illness among U.S. military trainees 4,5 and children. [6] [7] [8] [9] [10] [11] [12] [13] In the 1960s, adenoviruses were recognized to infect as many as 80% of trainees, with 20% requiring hospitalization. 5 Median attack rates for trainees ranged from 6 to 16.7/100 per month at the most affected northern and Midwestern U.S. military bases, and from 2.3 to 2.6/100 per month for posts in the South and West. 14 Up to 40% of the trainees in a unit were lost to illness within a 2-week period, and many who were hospitalized had to restart training. 15 Adenoviruses were also recognized to cause as much as 15% of instances of gastroenteritis in infants and children, and up to 10% of instances of pneumonia among hospitalized children. [16] [17] [18] Adenovirus morbidity can be severe and lead to death, especially in young children, transplantation recipients, and other immunocompromised patients.

The search for vaccines against adenoviruses was driven by adenovirus morbidity among military trainees, their disruption to military training, and their medical care costs. 15 In 1971, after a series of misstarts, military recruits began routinely receiving live oral enteric-coated vaccines for adenovirus types 4 and 7 (Ad4 and Ad7), which were safe and effective. 19 With few exceptions, adenovirus morbidity was markedly controlled. However, in 1996, the sole manufacturer of these vaccines ceased production. As vaccine stores were depleted, U.S. military trainees again experienced large outbreaks of adenovirus disease, with some deaths reminding public health officials of the impact of adenoviruses. [20] [21] [22] In one comprehensive 2006 study, Russell and colleagues documented 98% Ad4 attack rates among 180 susceptible military recruits during 4 weeks of training. 23 The importance of these pathogens has been further emphasized through the recent emergence of multiple novel Ad3, Ad7, and Ad14 strains and the subsequent epidemics and deaths they caused. [24] [25] [26] [27] [28] [29] 

Human adenoviruses have been classically grouped into seven species (A through G) containing as many as 68 unique types (Ad1 through Ad68) and multiple more genotypes 10 often determined by restriction enzyme digests (Ad7a, Ad7d2, etc). However, the nomenclature and classification system is undergoing change. In 2013, the International Committee of Taxonomy of Viruses added a genus prefix (eg, human adenovirus A has become human mastadenovirus A). 30 A number of investigators have additionally argued that it is time to move away from neutralization and hemagglutination assays in determining serotype and to chiefly use a genetic classification approach. 31 Such virologists have used large DNA sequence comparisons to describe as many as 68 novel adenovirus types, 32, 33 although this approach has met with some debate. [34] [35] [36] [37] No matter which adenovirus nomenclature or classification system is agreed upon, it is clear that adenoviruses affect most organ systems. Individual adenovirus types often have different tissue tropisms that lead to specific signs and symptoms (Table 10 .1). 39, 40 Endemic Respiratory Adenovirus in Children Although most children become infected with many of the common adenoviruses early in life, only approximately 50% of these infections result in disease. 39, 41, 42 Isolation studies have indicated that Ad1, Ad2, Ad5, Ad3, and Ad6 are most prevalent types detected, 39, 43 and often manifest by pharyngitis, bronchitis, bronchiolitis, croup, or pneumonia. 43, 44 The incidence of adenovirus disease is higher in late winter, spring, and early summer, and both sexes are equally affected. 41, 45 glands may be observed. 39 Epidemic keratoconjunctivitis (EKC) is associated with Ad8, Ad19, Ad37, and, rarely, other types. [70] [71] [72] [73] [74] In addition, Ad19 and Ad37 have been isolated from the genital tract of young adults with EKC, and the possibility of sexual transmission has been considered. 75, 76 Numerous epidemics of EKC have been associated with ophthalmology practices, where spread from contaminated ophthalmic solutions, fingers, and instruments has been implicated. 70, 72, 74, 77, 78 Hemorrhagic Cystitis Hemorrhagic cystitis syndrome in children is caused by adenovirus infections in 23% to 51% of cases in the United States and Japan. 79 Although the specific route of spread is unknown, Ad11 and Ad21 were the most frequently isolated adenoviruses. 79 Boys were two to three times more often affected than girls. Clinical findings included gross hematuria of 3 days' duration. Dysuria, microscopic hematuria, and urinary frequency lasted a few days longer. 79, 80 No viremia or structural abnormalities were found. Adenoviral antigen in exfoliated bladder epithelial cells can be demonstrated by immunofluorescence. 79 Cases of acute hemorrhagic cystitis after renal and bone marrow transplantation are increasingly being reported. [81] [82] [83] Ad34 and Ad35, as well as species B adenoviruses, were first isolated from renal transplantation recipients, but neither was associated with symptoms of hemorrhagic cystitis. 84 Gastroenteritis Adenoviruses are also recognized to cause watery diarrhea with fever. Ad40 and Ad41 are the most prevalent strains, but Ad50, Ad51, and Ad52 have been detected among the immunocompromised. AdV52 has been associated with one outbreak cluster of acute gastroenteritis. 124 These strains often require special cells lines for culture and they may not demonstrate cytopathic effect. 85 Electron micrography or special assays are often necessary for their study. 85 Numerous outbreaks have been described, and adenoviruses may account for up to 12% of all infant diarrhea. [86] [87] [88] Rare Acute Manifestations A number of case or outbreak reports document other, more unusual manifestations of human adenovirus infection. These occur most frequently among children. Although the studies recognized Ad55 (Ad11 and Ad14 recombinant) has been documented to have caused significant ARD morbidity among military trainees in China. 57 Typical ARD is a febrile disease with symptoms of sore throat, fever, cough, coryza, rhinorrhea, headache, and chest pain. 2, 39, 58 With extension into the lungs, physical examinations can reveal rales and rhonchi with little evidence of consolidation, and chest radiography often shows patchy interstitial infiltrates, principally in the lower lung fields. 2, 53, 59 Symptoms last 3 to 10 days. 39 The infection is often selflimited, but occasionally deaths occur. 2, 60 Routes of transmission are thought to include direct contact or aerosolized virus inhaled into the lung. The virus has been isolated from the oropharynx more than 2 weeks after exposure. 2 

This syndrome is characterized by pharyngitis, conjunctivitis, and spiking fever. 62 First described in the 1920s as associated with swimming, the cause has been subsequently linked to insufficient chlorination. [63] [64] [65] One or both eyes are affected, and diarrhea, coryza, tonsillar exudates, and lymphadenopathy may be observed. The most frequently identified types have been Ad3 and Ad7, but other types, such as Ad1, Ad4, and Ad14, are also associated with pharyngoconjunctival fever. 62 The disease is associated with summer camps, swimming pools, and lakes; occurs in children and young adults; and often spreads to other family members. 62, 66, 67 The incubation period is 6 to 9 days, and the virus may be isolated from pool water. 62, 65 There is little bacterial superinfection and no permanent damage to the eye. 59 

Epidemics of conjunctivitis in adults caused by adenoviruses were first described as "shipyard eye." 68, 69 The disease was observed at industrial settings where shipbuilding took place and was probably transmitted because of inadequate infection control practices when workers sought care for chemical irritation and minor trauma from paint and rust chips. 68 The disease has an incubation time of 8 to 10 days and is characterized by conjunctivitis, edema of the eye, pain, photophobia, and lacrimation. Superficial erosions and subepithelial infiltrates of the cornea may occur. 39 Preauricular lymph gland swelling and involvement of cervical and submaxillary lymph 

Thanks often to molecular techniques, human adenoviruses have been associated with a number of chronic disease conditions, including chronic airway obstruction, 101 pulmonary dysplasia, 116 myocarditis, and cardiomyopathy. 117 Although the results of studies are mixed, an intriguing series of human and animal studies associate a number of human adenovirus types with obesity. [118] [119] [120] [121] Virology Human adenoviruses are nonenveloped, double-stranded DNA viruses belonging to the genus Mastadenovirus, family Adenoviridae. 122 They are classified by species (A-G) through hemagglutination properties and by serotype (1-51) with horse or rabbit antisera (Table 10. 2). 40, 59, 123 Different strains within serotypes are further distinguished by whole-genome restriction-enzyme digest patterns. However, as typing serum samples are difficult to acquire and sequencing costs are decreasing, virologists are considering full genome sequencing as a more modern and accurate method to detect unique strains and have described as many as 68 unique adenovirus types. [124] [125] [126] [127] [128] Adenoviruses are considered large viruses, with an estimated diameter of approximately 920 Å. 129 The viruses have an icosahedral capsid shell that is made up of 240 hexon bases, 12 penton bases, and 12 fibers that are associated with the penton bases ( Fig. 10 .2). Four minor proteins (IIIa, VI, VIII, are inconsistent, adenovirus is implicated as a possible fetal pathogen. 89, 90 Adenovirus infections among children are associated with sudden infant death, 91 encephalitis, meningoencephalitis, 92,93 cerebral edema, 94 acute flaccid paralysis, 95  pertussis-like syndromes, 96,97 mononucleosis-like syndromes, 98 and neonatal disseminated infections. 99 Among adults, adenovirus infections have been associated with a toxic shock-like syndrome, 100 encephalitis, genital lesions, orchitis, urethritis, and cervicitis. 101 Nosocomial transmission to susceptible healthcare workers and patients has been reported. This is likely related to the long periods of viral shedding among adenovirus-infected immunocompromised hosts, the possible aerosolization of the virus, and fomite transmission in the hospital setting. 40, 95, 102 Complications

Adenoviruses have been implicated as opportunistic agents in patients with immune deficiency states, such as patients with AIDS, patients receiving cancer chemotherapy, bone marrow transplant recipients, and patients undergoing solid organ transplantation. 11, 12, 82, [103] [104] [105] [106] The patients are prone to pneumonia and disseminated adenoviral infection. They have also developed parotitis 107 and urinary tract disease. 108 A number of the more recently described types, such as Ad43 through Ad51, have been recovered from people with AIDS. 108, 109 A review of 201 bone marrow recipients over a 4-year period indicated that adenovirus infections occurred in 20.9% of patients, with a higher incidence in children than in adults (31.3% vs 13.6%). 110 Ad35 was the most common type identified. 110 In 1992, Hierholzer reported that adenovirus infections in immunocompromised patients with pneumonia were associated with case fatality rates as high as 60%, compared with only 15% among immunocompetent hosts with pneumonia. 9 Radiographs of adenovirus-infected patients often demonstrate patchy interstitial infiltrates, usually in the lower lung fields. 111 originated from nonhuman primates. 124, 141, 142 Hence, some virologists have recently reviewed the probability that adenoviruses may be zoonotic. 143 Some adenovirus types have been determined to be oncogenic in animals and to transform cell lines, but oncogenicity has not been observed in humans. Hybridization or genetic recombination of multiple strains of adenovirus may occur. Sometimes, these recombinant strains or other emergent novel adenovirus strains lead to epidemics. A number of recent examples have been reported in the medical literature. 26, 27, 29, [144] [145] [146] [147] [148] 

Depending on the route of inoculation, the type of virus, and the immune state of the host, adenoviruses can cause diseases or asymptomatic infections. Respiratory infection is presumed to result from inhalation of aerosolized virus, whereas ocular infection, gastroenteritis, and nosocomial infections may arise from fomites, water, or fecal-oral contact. Reactivation of latent adenovirus is also believed to occur. 53 Some 50% to 80% of tonsils removed surgically may have adenoviruses isolated from the tissue, suggesting that these viruses may remain in a latent state for years. 149, 150 Virus has been also isolated from lymphocytes, kidney, blood, cerebrospinal fluid, and most body organs. 9, 11, 12, 54, 55, 93, [151] [152] [153] In the lungs, extensive pathology has been found with microscopic necrosis of the tracheal and bronchial epithelium. 39 Acidophilic intranuclear inclusions are seen in bronchial epithelial cells in addition to the basophilic masses of cells surrounded by clear halos, which may indicate aggregations of viral material. 54 A mononuclear infiltrate, rosette formation, and focal necrosis of mucous glands are characteristically seen.

Three types of interaction of adenovirus with infected cells can occur. A lytic infection may take place during which the virus completes an entire replicative cycle. 59 Between 10 5 to 10 6 progeny viruses per cell are produced, of which only 1% to 5% are actually infectious. 59 The second type of interaction is chronic or latent infection, in which small amounts of virus are produced, and an inapparent infection results. Viral shedding from the gastrointestinal tract may occur for years. 39 In fact reactivation of such latent infection likely explains much adenovirus disease in the severely compromised. Correspondingly, monitoring viral loads in the stool of transplant patients has predicted disseminated disease and been useful in guiding antiviral therapy. 154 In addition to aerosolization, intestinal shedding of respiratory virus is an important factor to consider in the prevention of nosocomial spread in hospitals and chronic care homes. 39, 145, 155 Persistent infection has been reported in epithelial cells from monkeys. 156 Lymphoid cells are thought to be the reservoir for these persistent infections. 157, 158 The third type of interaction is oncogenic transformation, whereby the viral DNA is integrated into the host genome and replicated with the cellular host DNA, but only the early steps in the viral cycle occur and no infectious virions are produced. 159 The genes from adenoviruses are expressed in the cell nucleus in two phases: "early" (E), which precedes viral DNA replication, and "late." 157 Early genes encode proteins that function to thwart immunosurveillance, especially those from the E3 transcription unit. 157 The late genes primarily encode viral structural proteins. The functions of the E1 proteins include the induction of DNA synthesis in quiescent cells, immortalization of primary cells in cooperation with activated ras or with the E1B proteins, transactivation of delayed early genes, induction or repression of several cellular genes, and induction of apoptosis. These proteins modulate the sensitivity of adenovirus-infected cells to tumor necrosis factor (TNF), and IX) add to the complexity of the capsid. The pentons and hexons are each derived from different viral polypeptides.

Adenovirus hexons are both type-specific and speciesspecific antigens, primarily inducing species-specific complement-fixing antibodies, whereas the pentons are especially active in hemagglutination. 130 The fibers also evoke typespecific antibodies, vary in length among human strains, and are sometimes absent in particular animal strains. [131] [132] [133] [134] The genome core of the virus is composed of five more proteins (V, VII, u, Iva2, and terminal protein) and a single molecule of linear, double-stranded DNA of 26 × 106 to 45 × 106 molecular weight. The G + C base compositions of the human virus genomes range from 47% to 60%. 110, 122, 135, 136 Adenoviruses are unusually stable to physical and chemical agents, as well as adverse pH, and, thus, survive for long periods outside the host, making them available for transmission to others. They can be destroyed by heat at 56°C for 30 minutes, UV irradiation, 0.25% sodium dodecyl sulfate, chlorine at 0.5 µg/mL, and formalin, but are resistant to ether and chloroform.

Adenoviruses replicate in the cell nucleus and tend to be very host-specific. However, there is mounting evidence that humans and animals have exchanged adenoviruses. In 2009, a simian adenovirus epidemic occurred among nonhuman primates at a U.S. research center and subsequently infected the primate caretakers with some evidence of humanto-human transmission. 137, 138 A 2011 report documented the recent detection of 45 distinct adenovirus in nonhuman primates most of which mapped phylogenetically very closely to human adenovirus species. 139 In 2012, human infections with a novel avian adenovirus were associated with avian chlamydiosis outbreak in Hong Kong. 140 Finally, it is also important to recognize that Ad4 and Ad52 are thought to have and the suspected type. 101 Adenoviruses can be detected in a variety of specimens, including nasal and throat secretions, conjunctival scrapings and swabs, stool, blood, cerebrospinal fluid, and biopsied tissue specimens. Specimens should be collected early in the illness and shipped promptly at 4°C or on dry ice if prompt testing is not possible. Swab and fresh tissue specimens must be transported in appropriate viral transport media 40, 58, 84, 101 whereas fluid samples like urine, stool, and cerebrospinal fluid should not be diluted in transport media. For culture, nonsterile specimens should be treated with antibiotics prior to inoculation. Stool specimens are brought to 10% to 20% suspensions with buffered saline and clarified by low-speed centrifugation. Blood for culture or molecular testing should be collected with an anticoagulant to prevent clotting. Serum separated from clotted blood samples can be used for serological diagnosis (see below).

Cell Culture. Through biological amplification, cell culture offers a sensitive method for adenovirus detection by monitoring for cytopathic effect (CPE). Because adenoviruses are hostspecific, isolation of human adenoviruses is most easily accomplished in human cells. 169 Most human adenoviruses have been successfully isolated in cell culture. Several diploid and continuous cell lines, including A549, HeLa, HEp-2, KB, MRC-5 and commercial mixed cell lines with A549 cells, reportedly give good overall recovery and produce typical CPE. 170, 171 However, the fastidious enteric adenoviruses Ad40 and Ad41 are an exception. For efficient recovery, most Ad40 and Ad41 strains require the Graham-293 Ad5-transformed secondary HEK (human embryo kidney) cell line for primary isolation.

CPE may develop slowly in monolayers of inoculated cells necessitating several subpassages before becoming visible. Infected cells become rounded, enlarged, and refractile and aggregate into irregular "grape-like" clusters. 40 A 4-week incubation with blind passage is recommended. A rapid procedure for culture identification of adenovirus is the shell vial technique. Here, cell monolayers prepared in glass vials or multiwell plastic culture plates are inoculated with the clinical specimen, centrifuged, and stained after 2 to 3 days incubation with commercial monoclonal antibodies. 172 Cell culture is declining as a routine diagnostic method for detection and identification of human adenoviruses as a result of cost and delays. Antigen and molecular detection techniques have supplanted culture in many laboratories (see below). 169 However, while direct detection methods offer important diagnostic benefits, culture is the only means available for obtaining sufficient virus for immunotyping, assessing virus susceptibility to antivirals, and identifying infectious virus in clinical and environmental specimens.

Electron and immunoelectron microscopy 173 were once commonly used to detect and identify the fastidious adenoviruses in stool specimens from young children, thereby establishing their association with acute gastroenteritis. 40, 102, [174] [175] [176] [177] These methods are still used to localize virus in cells from biopsy and autopsy specimens to confirm disease association and to study disease pathology.

Antigen Assays. Detection of adenovirus antigenic proteins can be accomplished by reacting with virus-specific polyclonal or monoclonal antibodies labeled with various reporter systems. Examples include enzyme immunoassay, immunofluorescence assay, time-resolved fluoroimmunoassay, and latex agglutination. [178] [179] [180] [181] These assays can be used to detect adenovirus proteins directly in clinical specimens or to a key inflammatory cytokine with antiviral properties. 157 None of the E3 genes are required for adenovirus replication in cultured cells, but several of the E3-coded proteins (10.4 K, 14.5 K, and 14.7 K) inhibit TNF cytolysis. 157, 160, 161 Because a major function of TNF may be to prevent viral replication, the inhibition of TNF by these viral proteins may be a significant mechanism of pathogenesis.

Another significant E3-coded protein is Gp 19 K. This glycoprotein is located in the endoplasmic reticulum and forms a complex with class I antigens of the major histocompatibility complex (MHC), preventing cells from being killed by cytotoxic T lymphocytes. 157 A cotton rat animal model was used by Ginsberg and colleagues and Ginsberg and Prince to study the pathogenesis of Ad2 and Ad5, which cause pneumonia similar to that seen in humans. 160, 162 Two phases of infection were seen; the initial phase, characterized by the infiltration of monocytes and neutrophils, and a later phase associated with the infiltration of lymphocytes. The pathology seemed to reflect the response by host immune defenses to viral infection. The Gp 19 K markedly reduced the transport of the class I MHC to the surface of the infected cells and impeded the attack of cytotoxic T cells. 157, 160, 161 It is now known that only the early genes are required to induce the complete pathogenesis of adenovirus infection in cotton rats. 161 Although several cytokines, such as TNF-α, interleukin-1, and interleukin-6, were elaborated during the first 2 to 3 days of the infection in the cotton rat model, only TNF-α had a major role in pathogenesis. 161 Steroids almost completely eliminated the pneumonic inflammatory response to infection. 161 Pathology caused by latent infection with adenoviruses has been linked to chronic obstructive pulmonary disease (COPD). 158, 162 Some have suggested that childhood viral diseases represent an independent risk factor for COPD. 163 The adenoviral E1A proteins can stimulate the transcription of many heterologous viral and cellular genes. These proteins have the ability to interact with the DNA binding domains of several cellular transcription factors and activate a wide variety of genes. 164, 165 The adenoviral genome has been found to be present in the lungs of more patients with COPD than in control subjects. 166 E1A proteins are expressed in epithelial cells of human lung tissue, and by increasing the expression of several genes important in controlling the inflammatory process, these may contribute to the pathogenesis of COPD. The events described may amplify the airway inflammation associated with cigarette smoking. 161 The isolation and cloning of a 46-kDa protein adenovirus receptor, which mediates attachment and infection of group B viruses, may facilitate the development of new strategies to limit diseases caused by adenoviruses. 167 The more common receptor is referred to as CAR. This protein has been identified as the receptor for the coxsackie B virus and adenoviruses. Recently, another receptor, desmoglein 2, was identified for Ad3, Ad7, Ad11, and Ad14 strains. 168

Adenoviral infections generally cannot be diagnosed on clinical grounds alone because the clinical signs and symptoms of these infections are variable and often resemble those caused by other microorganisms. 101 Traditionally, laboratory support and qualified personnel are necessary to accurately diagnose adenoviruses infections. Considerations include specimen type and timing, collection and storage procedures, types of laboratory tests performed, including serological assays, and availability of newer types of diagnostic assays.

Specimen Collection. The optimal specimen for diagnosis of adenovirus infection depends on the clinical presentation on specific hypervariable regions of the virus genome, potentially important virus strains resulting from recombinations or mutations can be missed. McCarthy and colleagues proposed a molecular typing algorithm that combined examinations of the hexon and fiber genes. 212 Restriction enzyme analysis (REA) of whole-virus genomes can be used to identify genetic variants of a serotype, aiding epidemiologic studies and outbreak investigations. 213, 214 Extensive studies of Ad3, Ad4, and Ad7 using REA have been described 20,215-218 and a number of novel viruses have thus been identified. 26 However, REA is work intensive, dependent on virus isolation to recover genomic DNA and requires expertise to perform and interpret, and is therefore restricted to a few experienced laboratories.

Classical and next generation sequencing technologies are increasingly being used to obtain full genomic sequences of human adenoviruses. Genome sequences are available for all human adenovirus prototype types and sequences of newly identified genomic variants are now routinely placed in public domain providing reference data for adenovirus identification. 126 A new whole genome-based characterization system for adenoviruses is under consideration to replace immunotyping for designating new adenovirus types. 31, 36 Serological Assays. Acute adenovirus infection can also be diagnosed by serological demonstration of a fourfold or greater rise in antibody titer between paired acute-phase and convalescent-phase sera. The first acute specimen should be collected as early as possible after onset of illness and the convalescent specimen should be collected 2 to 4 weeks later. Serologic tests for adenoviruses have included complement fixation (CF), HI, SN, indirect immunofluorescence, and enzyme immunoassay (EIA). 169 The classical CF test measures adenovirus-group specific antibodies, and though once widely used, lacks sensitivity. The EIA also measures adenovirus group-specific antibodies, but is more sensitive than the CF test and is readily automated and therefore more widely used today. 40, 101, 219 HI and SN assays also are more sensitive than CF, but because they measure type-specific antibodies, they are not suitable for routine diagnosis and most reagents are not commercially available. 40 Although valuable for outbreak investigations and essential for seroprevalence and vaccine efficacy studies, serology is rarely used today for clinical diagnosis because of the inconvenience of serum collection and the 2-to 4-week delay needed to obtain convalescent serum.

Currently, there are no FDA-approved treatment or prophylaxis therapies against adenovirus infections. There are numerous off-label therapeutic case or case series reports, but their results are mixed. There are few, if any, controlled, prospective therapeutic studies. 220 In the 1960s, γ-globulin was studied as prophylaxis against adenovirus infections without good effect. 221 However, Maisch and colleagues found a positive effect of intravenous immunoglobulin therapy in patients with adenovirusassociated inflammatory cardiomyopathy. 222 Some studies suggest that interferon-β may have a beneficial effect on EKC and viral cardiomyopathies. 223, 224 More recently, adoptive transfer of adenovirus-specific T-cells has been explored with some success but this is now reserved for immunocompromised patients who do not respond to antiviral therapy. 225 Off-label antiviral use reports of the antivirals ribavirin, cidofovir, ganciclovir, acyclovir, and vidarabine 220, 226 have also been disappointing. Only ribavirin and cidofovir have been used often enough to be worthy of discussion. Nebulized ribavirin was used with some success for two children with pneumonia caused by adenovirus. 227 Intravenous ribavirin has identify virus isolates. Immunoassays are simple to perform, less costly and provide results more quickly than culture or molecular tests, but are generally less sensitive. 181, 182 The immunofluorescence assay is often used in the clinical diagnostic laboratory for rapid identification of adenovirus in cells from unfrozen specimens. Point-of-care antigen immunoassays 181, 183 for rapid adenovirus detection and immunohistological staining for adenovirus antigens in biopsy and autopsy specimens are still in common use 182, 184 Molecular Assays. Molecular methods are rapidly replacing classical culture and antigen detection for diagnosis of adenovirus infection. The PCR assay in particular has become a popular diagnostic alternative for these viruses, offering the potential for rapid and sensitive detection and being easily tailored for species-specific and type-specific identification as described below. PCR assays 185 using adenovirus group-specific primers individually 185, 186 or combined in assays for multiple human pathogens 187 have proven comparable or better than cell culture or immunodiagnostic methods for detection of adenoviruses in clinical samples. Several commercial multiplex assays for respiratory pathogens including adenovirus have been cleared by the U.S. Food and Drug Administration (FDA) for clinical diagnostic use. 188 Use of quantitative real-time PCR assays have the added benefit of allowing monitoring of adenovirus levels that can be used to predict patient prognosis, manage chemotherapy and monitor efficacy of antiviral therapy. 189 Adenovirus Typing Assays. Once detected, further identification of adenoviruses to species and type can be accomplished by a variety of immunologic and molecular methods to support outbreak investigations and patient clinical management. For example, adenovirus infections in bone marrow or lung transplant recipients can be rapidly fatal. It is in the patients' interest that healthcare providers determine the species and type of any infecting adenovirus as some are more sensitive to specific antiviral therapy. 190 It is also important to learn if the adenovirus represents a community-acquired strain, a healthcare-acquired strain, a donor-associated strain, or the reactivation of a latent virus. Efforts to further identify adenoviruses have led to the discovery of cross-species infections with simian adenoviruses acquired from nonhuman primate reservoirs. 138, 191 Serum neutralization (SN) using defined hyperimmune animal antisera is the gold standard method used for classifying human adenovirus types. 40 SN targets type-specific neutralizing epitopes on the adenovirus hexon and fiber proteins and to a lesser extent on the penton protein. Hemagglutination inhibition (HI) has also been used of immunotyping adenoviruses. HI targets type-specific epitopes on the adenovirus fiber protein, and when used in combination with SN, can identify hexon/fiber recombinant viruses. Because immunotyping methods require reference antisera that are difficult to obtain and standardize and often difficult to interpret, molecular methods have generally replaced immunotyping for rapid routine adenovirus typing.

Numerous molecular methods for species and type-specific identification of adenoviruses have been described, including conventional [192] [193] [194] and real-time PCR 195, 196 assays using species-specific and type-specific primers and probes, PCR amplification coupled with restriction endonuclease analysis, 197,198 microarrays, 199 and mass spectrometry 200 and, increasingly, PCR-coupled sequence-based typing strategies that target hypervariable regions of the adenovirus hexon or fiber genes or both. 194, [201] [202] [203] [204] [205] [206] [207] [208] Several commercial assays have been marketed that use PCR to identify human adenovirus to species. [209] [210] [211] As molecular typing strategies often focus only younger than 2 years; persons with chronic disease; and persons infected with Ad3a2, Ad3a50, or multiple or rare strains were at increased risk of severe Ad3 clinical disease. Similarly, beginning in 1986, Chile, Uruguay, and Argentina experienced the emergence of a novel Ad7h strain that supplanted the endemic Ad7c strains. 239, 240 Among pediatric patients, the Ad7h strain was associated with longer hospitalizations, higher patient temperatures, greater oxygen requirements, and 55% secondary attack rates among siblings, and it explained 94% of adenovirus mortality. 241, 242 Similarly, first detected in 1992 in Israel, Ad7d2 spread to the United States in 1996 and since then has been associated with three of the five documented U.S. civilian outbreaks of Ad7 24 and at least one military outbreak. 20 These Ad7d2 outbreaks led to at least 19 deaths and the suggestion that this new genotype was a more virulent strain. In a 2005 report from Iowa, Ad7d2 had displaced other Ad7 strains. 243 Most recently, a novel genotype of a seldom-detected Ad14 strain (classified as Ad14p1) emerged in the United States and has spread to other countries causing considerable morbidity and death. 28, 146, 147, [244] [245] [246] [247] [248] [249] It differs from the Ad14p prototype strain by markedly greater epithelial cell binding, cell cytotoxicity, plaque morphology, and minor mutations in the fiber knob and E1A genes. 250,251,251a

As noted, virtually all children have adenovirus infections, and, occasionally, these infections are severe and lead to death. Additionally, adenovirus infections are quite common among the immunocompromised and often associated with significant morbidity. Adenovirus epidemics often occur at intensive care units or long-term care facilities. For instance, in 1999 a novel Ad7b variant caused 84% of the 50 residents (age range: 1-46 years) of a New York long-term care facility to become ill, 26 were hospitalized, and 7 died. 252 In a 2007 national U.S. adenovirus study, the authors found risk factors for severe clinical adenovirus disease included age younger than 7 years, chronic disease, recent transplantation, and infection with Ad5 or Ad21. 177 Epidemics among military populations, especially when adenovirus vaccines were not available, have been particularly well documented. 4 Before the use of vaccines in the U.S. military, Ad4 and Ad7 accounted for 60% of all ARD among hospitalized recruits. Ad3, Ad14, and Ad21 also occurred, but less commonly. 14 Up to 80% of recruits became infected with adenovirus, while seasoned military personnel experienced lower rates. 4 Such outbreaks have also been reported among military recruits in China, Finland, The Netherlands, The United Kingdom, Turkey, Singapore, and South Korea. [253] [254] [255] [256] [257] [258] [259] [260] [261] 

The disease characteristics of the adenoviruses vary by species and type (see Table 10 .1). 39 The reasons for these differences are not well understood. Adenoviruses are transmitted by direct contact, aerosolized virus, the fecal-oral route, and via water. Although recent data suggest that human Ad4 and Ad52 may have simian origins, 124,141 and a novel adenoviruses may have crossed species between humans and animals, 137, 262 humans are thought to be by far the primary reservoir for human adenovirus. 263

The most common environment for adenovirus transmission is the home. However, high rates of adenovirus transmission been reportedly used in immunocompromised patients and in patients with hemorrhagic cystitis and disseminated disease. 219, [228] [229] [230] [231] Intravenous ribavirin was given to 12 adult blood and marrow transplant recipients without appreciable benefit. 232 The mixed reports may be explained by a recent finding that only human adenoviruses of species C are susceptible to ribavirin. 190 In contrast, all species of human adenovirus appear to be susceptible to cidofovir. 190 Perhaps this finding explains the better results with this antiviral drug. In a retrospective study of 45 bone marrow transplant recipients treated with cidofovir for adenovirus infections, 31 (69%) had successful outcomes; however, in 18 (40%) of the 45 patients, cidofovirassociated toxicity developed. 233 A new experimental oral antiviral therapy against DNA viruses, brincidofovir (formerly CMX001), shows great promise against adenoviruses. 225, 234, 235 An analog of cidofovir, it does not have cidofovir's renal toxicity profile. Currently, brincidofovir is being evaluated against DNA viruses including adenoviruses. It has been awarded "Fast Track Designation" by the FDA.

Because only approximately 50% of childhood adenovirus infections result in disease, prevalence as detected by antibody studies is high. 42, 236, 237 Those in species C (Ad1, Ad2, Ad5, and Ad6) are usually endemic and acquired in early childhood, often before 2 years of age. 39 By school age, most children have been exposed to several types of adenoviruses. Infections caused by Ad4, Ad7, Ad14, and Ad21 may occur at a later age. Many of the other types occur sporadically or in epidemics. Many adenovirus infections are subclinical or asymptomatic, especially those in species A and D. Conversely, Ad4, Ad7, and Ad21 usually cause symptomatic respiratory disease. 39 Most types of adenoviruses are thought to be endemic worldwide. 45 In 1983, Schmitz and colleagues 45 summarized 10 years of adenovirus reports sent to the World Health Organization. They noted an increasing prevalence of Ad7, Ad8, and Ad19 and a declining prevalence of Ad3 and Ad4. 45 Age predilections were highly significant for infants for species A (Ad12, Ad18, and Ad31); for infants and small children for species C (Ad1, Ad2, Ad5, and Ad6); for school children for Ad3; for school children and adults for Ad7; and for adults for Ad4, Ad8, and other types of species B, D, and E. 45 A predilection for males was observed for all types in species B and C and in Ad4 and Ad19. 45 A summary of 2237 clinical adenovirus submissions to 22 U.S. laboratories during a 25-month period (2004) (2005) (2006) revealed that Ad3 (prevalence: 34.6%), Ad2 (prevalence: 24.3%), Ad1 (prevalence: 17.7%), and Ad5 (prevalence: 5.3%) explained most illnesses among children. The authors noted an increasing prevalence of Ad21 over time. 177 Even though most types of adenovirus can be found throughout the world, sometimes marked differences are observed in the geographical distribution of specific genotypes. Of particular note are the distributions of Ad3, Ad4, and Ad7 genotypes, with anecdotal suggestions that some genotypes may be more virulent and have competitive advantage. 238 As yet, no clear markers of increased adenovirus virulence have been identified.

In 2009, Lebeck and colleagues 26 reported on 516 clinical Ad3 isolates from 15 U.S. laboratories with restriction enzyme digests. The most prevalent types were Ad3a2 (36.9%), Ad3a50 (27.1%), Ad3a51, (18.0%), and Ad3a17 (4.6%). Ad3a50 and Ad3a51 were newly described strains that became more prevalent in 2006. Multivariable modeling revealed that children rates, with only a 52% reduction in hospital illnesses caused by adenoviruses. 274 Even this low rate of protection was reported in 1965 to have saved the Army approximately $5 million a year. 274 Adenovirus seed lots were found to be contaminated with simian virus 40 (SV40), a virus oncogenic in animals, and in 1963, the license for the vaccine was rescinded. 15 Although this caused considerable concern at the time, an epidemiologic study of 1959-1961 era U.S. Army male veterans showed no evidence of an increased risk of various cancers that plausibly could be the result of an SV40 exposure. 275 Use of a live vaccine for ARD caused by Ad7 was investigated, and oral administration was reported to induce high antibody levels in 1960. 276 Couch and colleagues 277 and Chanock and colleagues 278 demonstrated that some adenoviruses infect the gastrointestinal tract but do not produce symptoms in adults. This finding led to the administration of the virus as a vaccine in an enteric-coated capsule, which produced an asymptomatic, intestinal infection and neutralizing antibodies. 277, 278 Many safety studies were performed in human volunteers, including the administration of Ad4 and Ad7 vaccines separately and simultaneously. 277 Neutralizing antibodies were elicited, and asymptomatic infections were evidenced by the recovery of virus from rectal specimens. Initial vaccine virus production using HEK cells was later modified to use human diploid fibroblast strains WI-26 and WI-38 because the primary cells were not suitable for large-scale production and there was concern of their contamination with other human pathogens. 278 Because some adenoviruses are oncogenic in animals, much attention was given to safety studies in hamsters and the transformation of cell lines by adenoviruses. 279, 280 Additional field trials for the Ad4 vaccine were conducted at Parris Island, SC, and Great Lakes, IL, indicating that the vaccine was highly protective, safe, and antigenic and showed no evidence of transmission among military trainees. Vaccine use led to reductions in ARD rates by 50%. 281, 282 Intrinsic vaccine efficacy was as high as 82%. 282 Use of the monotypic Ad4 vaccine was followed by the appearance of ARD caused by Ad7 at Fort Dix, NJ. 15 The Army Adenovirus Surveillance Program was initiated to identify the agents of ARD and to assess fluctuations in disease patterns. 14 Before an Ad7 vaccine could be developed and licensed, numerous studies addressed the oncogenicity potential of Ad7 to humans. [283] [284] [285] [286] A trial of the Ad7 vaccine demonstrated safety, infectivity, antigenicity, and lack of communicability similar to that observed for the Ad4 vaccine. 287 Additional trials indicated that when the Ad4 and Ad7 vaccines were given simultaneously, no decrease in immunogenicity occurred, and with mass immunization, there was 95% suppression of Ad7associated disease. [287] [288] [289] Numerous outbreaks of Ad21 in military populations in the United States and Europe led to the initiation of studies using an Ad21 prototype vaccine in safety and immunogenicity trials. [290] [291] [292] [293] [294] Trials of Ad1, Ad2, and Ad5 vaccines were also conducted with the goal of protecting children. 295 However, Ad1, Ad2, Ad5, and Ad21 vaccine production was never pursued.

Beginning in 1971, live, enteric-coated, oral vaccines for Ad4 and Ad7 were routinely administered, and adenovirus morbidity was greatly reduced. 19 Ad4 and Ad7 vaccines were licensed by the FDA in 1980 and produced by Wyeth Laboratories. In 1994, the Department of Defense was notified that the sole producer of Ad4 and Ad7 vaccines, Wyeth Laboratories Inc, Marietta, PA, would stop production permanently. Beginning in 1984, Wyeth repeatedly notified the Department of Defense of the need to negotiate a contract that would consider the renovation of the existing vaccine production facility. 296 The contract was not renegotiated. 296 Bulk vaccine production ceased in 1995, and the last vaccine was placed in occur wherever large groups of susceptible people gather. Transmission rates are higher in children's institutions and daycare centers, and in lower socioeconomic groups. 46, 47 Enteric adenoviruses may be an important pathogen in the daycare setting. 264 Epidemics associated with Ad3 often occur in association with swimming activities. 66 Ad8 has been associated with transmission in physicians' offices. 70 Nosocomial outbreaks of adenovirus keratoconjunctivitis have been reported from the accident and emergency department of a major eye hospital in the United Kingdom. [265] [266] [267] Nosocomial conjunctivitis, pharyngitis, and pneumonia caused by adenoviruses have been noted in hospital intensive care units. 17, 268, 269 With increasing numbers of immunocompromised patients in hospitals, adenovirus infections have become of more frequent cause of severe disease. 9 In addition, reactivation of a latent infection could possibly initiate a nosocomial outbreak. Persons with deficient cell-mediated immunity are at greatest risk for adverse outcomes. 39 Bone marrow transplant recipients are especially susceptible to adenovirus infections. 82, 110 The death rate among immunodeficient patients with pneumonia may be as high as 60%. 9 Chronic diarrhea in patients with AIDS is often a diagnostic problem. A prospective study using extensive diagnostic techniques, such as duodenal, jejunal, and rectal biopsies, demonstrated that 6.5% of the patients had adenovirus infections. 270 Although the civilian experience has not established a requirement for a vaccine, the epidemic nature and extensive morbidity experienced by military recruits during the 1960s demonstrated an overwhelming need for adenovirus vaccines for military use. One well-studied and typical epidemic at Fort Dix, NJ, exemplified this requirement. 15 A platoon of 48 men was followed up prospectively for their 8 weeks of basic training. Of 92 episodes of respiratory illness, 24 required hospitalization. The documented hospitalization rate for ARD due to adenovirus Ad4 was 5/100 soldiers per week. 15 At large basic training posts, this rate translated to approximately 500 to 800 ARD admissions per week, which had a devastating impact on military hospitals. 15, 19 Excess medical costs and the fact that soldiers had to be "recycled" owing to lost training time resulted in significant economic loss to the military. Serious disruptions to training schedules led to administrative attempts to control epidemics, such as sleeping head-to-foot and keeping military units separated (cohorting). 19 The impact of adenovirus infections in the military led to the development of adenovirus vaccines.

While years ago immunoglobulin therapy was not found to be particularly useful in preventing adenovirus infections among military trainees, 220 modern passive immunization strategies may prove helpful. In particular, recently isolating Ad-specific T cells from stem cell donors have been effective in treating hematopoietic stem cell transplantation recipients who develop severe adenovirus that is nonresponsive to antivirals. 37

The first adenovirus vaccine prototype was an injectable bivalent Ad4 and Ad7 vaccine grown in monkey kidney cells and formalin-inactivated. 19 After safety tests, a small trial in 1957 reduced admissions for adenoviruses by 98%, and a large trial of 8238 soldiers was 90% effective in reducing hospitalization. 271, 272 A trivalent vaccine, which also included Ad3, was also tested. 273 Large-scale production of vaccine lots led to variation in antigenicity, resulting in a lowering of protection 25%, 9%, and 7% of the isolates, 302 respectively (although the prevalence of Ad7 detections has markedly declined in recent years). 303 Russell 304 The aggregate number of adenovirus infections among U.S. military trainees has fluctuated with the availability of vaccines and season (Fig. 10.3) . In some winter months, more than 2200 preventable clinical infections were documented. Realizing that the detected adenovirus illnesses greatly underestimated true clinical disease, Russell and colleagues 304 posited that the true count of clinical adenovirus disease occurring in these camps was an estimated 45,000 cases per year, 90% of which would be prevented were the adenovirus vaccines available. This realization of preventable morbidity was not lost to public health officials inside and outside the U.S. Department of Defense, with many calling for reacquisition and use of the vaccines. [305] [306] [307] [308] On September 25, 2001, 7 years after Wyeth announced permanent cessation of production of the adenovirus vaccines, two widely publicized adenovirus-associated deaths in nonimmunized recruits, 309 and strongly worded letters from the Institute of Medicine and the Armed Forces Epidemiological Board to expedite contract efforts, induced the Department of Defense to contract for production of adenovirus vaccines. 296, 306, 310, 311 The decision to resume production was based on a continuing low prevalence of antibodies to Ad4 and Ad7 in people coming into the military, 300 the occurrence of documented outbreaks when the vaccines were not given, [20] [21] [22] 302 and almost 30 years of experience of not having ARD outbreaks when potent adenovirus vaccines were being tablet form in 1996. Through requests for extensions of expiration dates and use of vaccines only during September through March, rather than year-round, the U.S. Department of Defense attempted to obtain maximum benefit from the remaining supply. By 1999, all vaccine supplies were depleted.

After the loss of the manufacture of the Ad4 and Ad7 vaccines, there were many documented outbreaks of ARD due to adenoviruses in U.S. military training centers. The first recorded epidemic took place during April-May 1995, at Fort Jackson, SC, during a lapse of vaccine administration that occurred because of a logistical error that temporarily interrupted vaccine production. 21 Ad4 was identified as the etiologic agent in unvaccinated soldiers who experienced hospitalization rates of 11.6% during basic training. 21 Numerous additional outbreaks occurred at the other U.S. military camps, 20, 22, 297 some causing large numbers of hospitalizations 22, 297, 298 and some spreading to more advanced training camps. 299 Results of a nationwide seroprevalence survey among unimmunized U.S. Army trainees confirmed the lack of protective neutralization antibodies to Ad4 and Ad7, with nearly 90% being susceptible to at least one type. 299, 300 Evaluation of the epidemic, clinical, and immunological risk factors for adenovirus infection was performed for a subset of patients, demonstrating that anti-Ad4 immunity was low in new recruits, risk of illness was higher in smokers, and 81% of patients from whom paired serum samples were collected demonstrated a fourfold or higher increase in anti-Ad4 titer after infection. 301 Gray and colleagues provided a concise overview of population-based surveillance for respiratory disease at four U.S. military training centers as the last of the stores of vaccines were depleted. 302 Between October 1996 and June 1998,53.1% of 1,814 throat cultures from symptomatic trainees yielded adenoviruses. 302 Ad4, Ad7, Ad3, and Ad21 accounted for 57%, 

outer layer of inactive excipients, and a protective enteric coating consisting of cellulose acetate phthalate, alcohol, acetone, and castor oil (Fig. 10.4) . 318 The Ad7 vaccine tablet also contains FD&C Yellow #6 aluminum lake dye to give it a distinguishing yellow color.

The Teva adenovirus vaccines contain live nonattenuated Ad4 or Ad7 in the form of enteric-coated tablets. They are produced similarly to how the Wyeth vaccines (described above) were produced. The final vaccine is composed of two tablets (one tablet of Ad4 and one tablet of Ad7) designed to pass intact through the stomach and release the live virus in the intestine. Each enteric-coated tablet contains an inner core tablet containing anhydrous lactose, microcrystalline cellulose, polacrilin potassium, magnesium stearate, and live adenovirus, either Type 4 or Type 7, at a potency of no fewer than 32,000 tissueculture infective doses (4.5 log 10 TCID 50 ) per tablet. The outer tablet layer contains microcrystalline cellulose, magnesium stearate, and anhydrous lactose, with an enteric coating consisting of cellulose acetate phthalate, alcohol, acetone, and castor oil. The Ad7 tablet also contains FD&C Yellow #6 aluminum lake dye. The Ad4 vaccine (white tablets) and the Ad7 vaccine (yellow tablets) are packaged in separate bottles and the bottles are combined in a single package. 318 The tablets can be administered simultaneously but have to be swallowed without chewing. Vomiting and diarrhea may interfere with vaccine effectiveness. These vaccines are indicated for military populations shown to be at risk of ARD from the specific adenovirus types represented in the tablets.

The adenovirus vaccines are routinely given to military recruits and U.S. Coast Guard cadets along with numerous other vaccines in the first 8 days after entering training. Typespecific neutralizing antibodies to the adenovirus vaccines are produced in the vaccinated trainees and were associated with protection against ARD. Interference with immune responses when the adenovirus vaccines were given with other vaccines has not been identified. 319 administered. 19 A genomic analysis of the Wyeth Ad4 and Ad7 vaccine strains show no evidence of attenuation. 312 In 2001 the contract was awarded and seed viruses strains from Wyeth were transferred to Barr Laboratories Inc. (now part of Teva Pharmaceuticals Industries, Inc.).

In the fall of 2004, the Teva Ad4 and Ad7 vaccines were studied in a Phase I double-blind, placebo-controlled trial involving 58 Army medic trainees who had just completed U.S. Army basic training. 313 Among the subjects who had been previously exposed to adenovirus during basic training and before enrollment, 79% and 78% were seropositive to Ad4 or Ad7, respectively. For the trial, 58 initially seronegative subjects were selected. Both vaccines were given to 30, and 28 received placebo tablets. For 32 subjects, final follow-up was permitted at day 180. The participants were closely followed up with cultures, symptom diaries, and clinical examinations during a 56-day period for evidence of vaccine reactions and adenoviral disease. The most commonly reported adverse events in the vaccine recipients were nasal congestion (33%) and dry cough (33%), sore throat (27%), headache (20%), abdominal pain (17%), arthralgia (13%), nausea (13%), and diarrhea (13%). Symptom reporting did not differ between vaccine and placebo groups. Vaccine virus was shed in the stools of 73% and 71% of volunteers seronegative to Ad4 and Ad7, respectively, for as long as 21 days after vaccination. By day 28 after vaccination, 73% of vaccine recipients seroconverted to Ad4, while 63% seroconverted to Ad7. A randomized, double-blind, placebocontrolled Phase II/III trial (NCT00382408) of these vaccines was conducted in 2006-2007 at two military training facilities. Ad4 and Ad7 vaccine or placebo was administered to 4040 U.S. military trainees in a 3 : 1 ratio. As described above the vaccine was found to have excellent efficacy (99.3% for Ad4) and safety profiles similar to the previously manufactured Wyeth vaccine.

In March 2011, after an arduous 10-year vaccine development process, eight likely preventable adenovirus-associated deaths, 314 thousands of hospitalizations, and more than $100 million in funding, 315, 316 Teva was awarded FDA licensure for their Ad4 and Ad7 vaccines. The vaccines are indicated for military personnel ages 17 to 50 years of age and contraindicated for persons who are pregnant, who cannot swallow the vaccine tablets without chewing, or who have a severe reaction to the vaccines.

Wyeth vaccine tablets contained live viruses, materials added for the growth and maintenance of viruses and cells, and other pharmaceutical materials. Human-diploid fibroblast cells (strain WI-38) were used for virus preparation, and growth was maintained in Minimal Essential Medium, Eagle solution, antibiotics (neomycin sulfate, gentamicin sulfate, and amphotericin B), fetal bovine serum, and sodium bicarbonate. After harvesting, the viral growth was freed of particulate material by filtration and dried by lyophilization. During drying, additives were used to preserve viability. Before processing into tablets, the virus preparation was diluted with lactose powder. 317 Using the same Wyeth master seed viruses and a manufacturing process similar to the process Wyeth used, Teva is now producing the Ad4 and Ad7 vaccines. Teva's tablets consist of three layers: a central core containing at least 4.5 log 10 tissue culture infective dose (TCID 50 ) of lyophilized formulated adenovirus mixed with anhydrous lactose, microcrystalline cellulose, polacrilin potassium, and magnesium stearate, an 

A SN assay value of 1 : 4 against a specific virus is considered as protective. 315 A fourfold rise in titer is considered as evidence of infection.

Although some early Ad1, Ad2, Ad4, and Ad5 vaccine trials were conducted among civilians, 320, 326, 327 the Teva vaccines have not been used in groups other than healthy military trainees.

Military recruits who received Ad4 vaccine exhibited increased resistance to respiratory disease caused by this virus. 278, 281, 328 A number of major well-controlled studies of more than 42,000 soldiers were performed from 1963 to 1966. 329 Use of the vaccine reduced ARD by 50% and adenovirus infection in recruits by more than 90%.

Field trials began in 1969 for the Ad7 vaccine. The trials indicated protection against disease in susceptible persons. 288, 289, 330 In addition, it was found that the two vaccines (for Ad4 and Ad7) could be administered simultaneously without interference or loss of efficacy. 288, 289, 331 As a result of using the vaccines at one large Air Force base during a 9-year period, ARD caused by adenovirus disappeared. 332 The adenovirus surveillance program demonstrated that the combination of the two adenovirus vaccines was highly effective in controlling epidemic ARD. 14 From 1971 to 1999, the live enteric-coated Ad4 and Ad7 vaccines were administered to new military recruits and successfully controlled ARD caused by adenoviruses.

The Phase III double-blind, placebo-controlled efficacy trial of the Teva Ad4 and Ad7 vaccines conducted in 2006 found the vaccines to be 99.3% effective in reducing Ad4caused ARD. 324 Two years after their reintroduction, the Teva vaccines were credited with a 100-fold decline in military trainee adenovirus cases and with the prevention of 1100 to 2700 hospitalizations each year. 303

The duration of immunity and persistence of circulating antibody following immunization has not been well studied. The adenovirus vaccines were developed to protect new members of the military (recruits) against Ad4 and Ad7 respiratory disease during the first months of military service. The adenovirus vaccines were very effective in accomplishing that objective, and immunity beyond 56 days has not been studied.

Four study groups were followed up for inpatient and outpatient episodes of illness during vaccine safety and immunogenicity trials at Lackland Air Force Base, TX, in 1976. In addition to the placebo group, one group received three vaccines simultaneously (Ad4, Ad7, and Ad21), another group received two vaccines simultaneously (Ad4 and Ad7), and the last group received one vaccine only (Ad21). 294 No appreciable differences were noted in the inpatient or outpatient experiences of the different groups. 294 Studies of the various live adenovirus vaccines have documented fecal and pharyngeal shedding of vaccine virus and

The initial oral Ad4 vaccine was developed using dried virus contained in enteric-coated capsules and found to be effective in preventing infections. 278 Original trials for Ad7 vaccine were conducted using 0.05 mL of a 1 : 10 dilution of the Ad7 pool (10 6 TCID 50 ) within a hard gelatin capsule and given orally. 277 Time of disintegration within the intestine was assayed roentgenographically using a barium sulfate-containing capsule and varied between 1 and 5 hours. 277 Two small dose ranging studies using vaccine capsules suggested that for both types, nearly 100% seroconversion was achieved by approximately 10 4 TCID 50 per capsule. 289, 313 A 1969 dose-ranging study used three Ad7 doses: 10 6.8 TCID 50 ,10 4.8 TCID 50 , and less than 10 TCID 50 per capsule. 277, 289 There was 100% antibody response with the highest dose, 95% response with the intermediate dose, and 56% response with the lowest dose. Another study evaluated the response when both vaccines were given individually at doses of 10 5.4 TCID 50 for Ad7 and 10 4 TCID 50 for Ad4, and simultaneously for both vaccines at the same doses. 287 There was no decrease in the immunogenicity of the Ad4 vaccine when it was given with the Ad7 vaccine. 289 In the mid 1960s, Wyeth Laboratories took over production of the adenovirus vaccines, which were converted to enteric-coated tablets.

The currently licensed Teva vaccines are stored between 2°C and 8°C with a shelf life of 30 months.

Oral adenovirus vaccine recipients routinely shed virus fecally, which can potentially continue for up to 6 weeks. 292, 320 Wyeth vaccine recipients developed neutralizing humoral antibody (immunoglobulin [Ig] G, IgM, and IgA). 292 In soldiers who were free of preexisting antibody, an average of 80% to 95% developed a neutralizing antibody level of greater than 1 : 8, while fewer than 50% demonstrated complement-fixing antibody. 289, 321 Neutralizing antibody responses were detected 2 to 3 weeks after vaccination. In general, antibody titers were less than titers achieved after natural infection. 8, 282 Local secretory IgA antibody was not induced by the oral vaccine, and reinfection of the respiratory tract was possible, but usually mild or asymptomatic. 322 Since viremia and viruria could occur in patients with febrile disease, invasiveness beyond mucosal surfaces could be important in the pathogenesis of the disease and infection. 323 The serum-neutralizing antibody produced as a result of vaccination may have prevented the typical febrile disease associated with natural infection. 321 Local IgA antibody could be produced experimentally by the intranasal inoculation of an Ad4 vaccine in liquid. 322 A Phase I/II study of the Teva oral Ad4/7 vaccine showed 73% and 63% of immunonaïve subjects seroconverted to Ad4 and Ad7 at 28 days postvaccination. 313 A Phase III study of the same vaccines documented seroconversion at 94.5% (Ad4) and 95% (Ad7). 324

The cellular response to Wyeth Ad4 and Ad7 vaccines has not been well studied. However, the cellular immune responses to some adenovirus-vectored vaccines have been excellent. 325 and a high risk of subsequent infection and disease. Adenovirus vaccines were recommended for use in military populations at risk of developing ARD from adenoviruses. Use of these vaccines was not recommended for other populations. Current and future studies of virus transmission and disease occurrence in pediatric populations, chronic care, and other civilian institutional settings; high-level healthcare organizations; and colleges may identify other potential indications for adenovirus vaccines.

In 1971, the U.S. military began routinely administering both vaccines to males reporting to recruit training centers, but only during the winter months. 15 The incoming recruits were given the vaccines within hours of arrival at a training center to obtain protection as early as possible in the training program. Initially, women were not given the vaccines because ARD outbreaks caused by adenoviruses had never been documented among military women, and there was concern about the possibility of administering the vaccines to women who were pregnant. 19 The program of administering the vaccines only during the high-risk winter months was directed at control, rather than eradication of ARD caused by adenoviruses. 15 With this schedule, late spring and early fall outbreaks occurred. These outbreaks prompted the U.S. Army and the U.S. Navy to adopt policies of year-round administration of both adenovirus vaccines in 1983. 19 Taking a different course, the U.S. Air Force stopped the administration of adenovirus vaccines at its only recruit training center in Texas in the mid-1980s and adopted a program of surveillance with use of the vaccines only as indicated. 19 When the military started immunizations to protect against ARD caused by adenoviruses, training programs were segregated by gender. These separate training programs have since been combined, leading to concern that the risk for ARD caused by adenoviruses would be the same for men and women. The U.S. military regulation for immunizations required that, based on risk, Ad4 and Ad7 vaccines be administered simultaneously and only once to Army, Navy, and Marine Corps recruits. 335 In the Air Force and Coast Guard, the vaccines were administered when directed by the appropriate authority. 335 The same regulation described precautions to be taken to avoid unintentional administration of the vaccines during pregnancy and counseling instructions regarding the possibility of pregnancy within 3 months following immunization. 335 In response to the cessation of adenovirus vaccine production in 1996, the Army, Navy, and Marine Corps modified their policies of year-round vaccine administration to conserve the remaining vaccine for use in higher-risk months only. The modified policies directed that the vaccines be given to arriving military recruits only during the period of September 1 through March 31 until all vaccine stocks were exhausted in 1999.

Teva uses no antibiotics in the virus propagation steps. The vaccine is contraindicated for pregnant women, immunocompromised patients, persons outside the target age range of 17 to 50 years, persons who cannot swallow the tablets whole, or persons who are allergic to the vaccines.

In the prevaccine era, ARD from adenoviruses caused significant morbidity at military training centers. These outbreaks transmission to nonvaccinated study participants. 295, 320, 321, 324, 333 Although recent trials of the Teva vaccine demonstrated sparse transmission among military personnel, 324 the possibility of transmission of vaccine virus to other susceptible personnel should be considered for up to 4 weeks after receipt of modern vaccines.

In 1973, a Navy trainee was hospitalized with fever, malaise, and dyspnea for 11 days after receiving the Ad4 and Ad7 vaccines. 334 The patient died on the 10th hospital day with the diagnosis of Ad7 pneumonia, based on the isolation of the virus by cell culture. However, it was not possible at the time to determine whether his infection was caused by a wild Ad7 before the development of vaccine-induced immunity or to an Ad7 vaccine strain. 334 

As adenoviruses may cause severe disease among immunocompromised persons, when HIV was first discovered, concern grew among U.S. military public health officials that adenovirus vaccine might cause severe disease among HIV-infected military trainees. Subsequently, a study was conducted among HIV-infected and uninfected military trainees. Although significantly fewer HIV-infected subjects responded to the Ad4 vaccine than did soldiers without HIV infection, no clinically apparent adverse reactions were detected. 319 Response to the Ad7 vaccine was difficult to define because many vaccine recipients in both groups had high neutralizing antibody titers at the time of vaccination. 319 More severely immunocompromised persons, who might inadvertently be infected with adenovirus vaccine virus through fecal shedding from "normal" vaccine recipients, have not been studied.

The live, oral adenovirus vaccines were never subjected to animal reproduction studies because of the lack of a suitable animal model. Therefore, it is not known if these vaccines had the potential to cause fetal damage if given to a pregnant woman or to affect reproductive capacity. Female military trainees are screened with pregnancy tests before they received the adenovirus vaccines. During the recent Teva vaccine trials four of the subjects were found to be pregnant after they had received the Ad4 and Ad7 vaccines. 318 All four subjects delivered healthy babies at 36 to 40 weeks' gestation. Unusual morbidity among pregnant vaccine recipients has not been reported.

Because the virus may be shed fecally for up to 6 weeks, the virus may be spread to family members or very close contacts. 320, 326 Hence, vaccine recipients are instructed to maintain good hygiene and to avoid contact with children younger than 7 years of age, the immunocompromised, and pregnant women for 28 days following vaccination. 318 The spread of vaccine virus has not been well studied. In the recent Phase II trial of the Teva vaccines, participants were followed shedding on days 0, 7, 14, 21, 28, and 56. Periodic fecal shedding was noted 7 to 21 days following vaccination. 313 

Adenovirus vaccines have been indicated for the prevention and control of specific adenovirus-associated ARD in populations with a high risk of exposure, a high level of susceptibility,

The excess morbidity caused by ARD and associated costs are of significant concern to the U.S. military. A number of costto-benefit analyses have been performed each showing significant benefit in using the vaccines. [336] [337] [338] Using an estimated cost for receipt of both vaccines at $150 and using the vaccines year-round in approximately 200,000 trainees per year, Radin and colleagues, 303 estimated the U.S. Department of Defense would prevent approximately 6000 to 13,000 clinical adenovirus cases and 1100 to 2700 hospitalizations per year, saving the U.S. government approximately $20 million per year in training and medical costs.

In 1963, soluble viral subunit antigens were found to be highly immunogenic on parenteral administration in animals. 321, 343 Crystalline hexon and fiber antigens from Ad5 have been shown to induce neutralizing antibody and protection in human volunteers who were challenged. 344 There has been no additional development of these antigens as potential vaccines. However, adenovirus vaccines consisting of soluble viral subunit antigens would be free of DNA and could alleviate fear of the oncogenic potential of adenoviruses. 321

Advances in molecular biology have permitted the in vivo and in vitro gene transfer into mammalian cells using various adenovirus constructs. Genetically engineered adenoviruses have been altered to carry genes from a wide array of other pathogens including influenza A virus, 345 Ebola virus, 346 and Middle East respiratory syndrome-coronavirus, 347 and to introduce genes as a therapy against various chronic diseases. Adenovirus vaccine construct research is quite dynamic. A detailed description is beyond the scope of this textbook. However, excellent reviews have been published discussing the advantages and drawbacks of recombinant adenovirus vaccine strategies. [348] [349] [350] [351] [352] [353] [354] [355] were extremely costly in terms of medical care requirements and time lost from training. 19 The routine administration of the Ad4 and Ad7 vaccines, which began in 1971, resulted in an extremely efficacious, cost-effective, and safe immunization program. 19, [336] [337] [338] Initially, the vaccines were administered only during the high-risk winter months. The occurrence of spring and fall outbreaks prompted a modification of the program to administration of the vaccines year-round. 19 From 1971 to 1999, except for a period in the 1970s when ineffective vaccines thought to be contaminated with solvent were used, 15 there has never been a reported outbreak of ARD caused by Ad4 or Ad7 in U.S. military units that received the vaccines. Outbreaks of ARD caused by Ad14 and Ad21 have occurred, but these have been sporadic. 19, 294, 339 A problem in the administrative system used to procure vaccines for the U.S. military resulted in an adenovirus vaccine production delay that began in the spring of 1994 and lasted until late February 1995. 19 There was only one outbreak of ARD caused by adenoviruses reported in conjunction with that production delay. 21 When Wyeth Laboratories announced in 1994 that it would no longer produce the adenovirus vaccines, many in the U.S. Department of Defense and the different military services asked if the vaccines were still needed. Some thought that improved military barracks with modern heating, ventilation, and air-conditioning systems may have significantly reduced the risk of transmission of the adenoviruses and subsequent disease in susceptible people. The assessment of current risk was hampered by the lack of modern seroprevalence data for Ad4 and Ad7 among new military entrants and the lack of studies of adenovirus carriage, transmission, infection, and disease because the vaccines had been so successful. The U.S. Department of Defense also found it had lost the capability to perform serologic studies for adenovirus infections. Unfortunately, with the loss of the vaccines, adenovirus-associated ARD increased in all uniformed services, including the U.S. Air Force.

Ad4 and Ad7 vaccines have been the primary means for controlling adenovirus-induced ARD among U.S. military trainees. Secondary control measures have included reducing crowding, aligning trainees' beds head-to-foot, making frequent hand washing a requirement, increasing air exchanges, and keeping contact between different cohorts of recruits to a minimum (cohorting). [340] [341] [342] Although interventions like frequent hand washing 340 caused a 45% reduction in upper respiratory tract infections among trainees, the numerous attempted interventions fell far short of the effectiveness of administering adenovirus vaccines in reducing ARD.

Isolation of a cytopathogenic agent from human adenoids undergoing spontaneous degeneration in tissue culture

Recovery of new agent from patients with acute respiratory illness

Adenoviruses: group name proposed for new respiratory tract viruses

Epidemiology of acute, respiratory disease in military recruits

Appraisal of occurrence of adenovirus-caused respiratory illness in military populations

Severe and fatal pneumonia in infants and young children associated with adenovirus infections

Genome analysis of adenovirus type 31 strains from immunocompromised and immunocompetent patients

Immunoglobulin responses in serum and nasal secretions after natural adenovirus infections

Adenoviruses in the immunocompromised host

Fatal neonatal pneumonia caused by adenovirus type 35

New human adenovirus (candidate adenovirus type 35) causing fatal disseminated infection in a renal transplant recipient

Adenoviruses from patients with AIDS: a plethora of serotypes and a description of five new serotypes of subgenus D

Hemorrhagic cystitis associated with adenovirus infection in bone marrow transplantation

Acute respiratory disease in military trainees: the adenovirus surveillance program, 1966-1971

Control of adenovirus acute respiratory disease in U.S. Army trainees

Severe and fatal pneumonia in infants associated with adenovirus infections

Type 3 adenoviral pneumonia occurring in a respiratory intensive care unit

Enteric adenoviruses. Brief review

Adenovirus vaccines in the U.S. military

Large epidemic of respiratory illness due to adenovirus types 7 and 3 in healthy young adults

Reemergence of adenovirus type 4 acute respiratory disease in military trainees: report of an outbreak during a lapse in vaccination

Large, persistent epidemic of adenovirus type 4-associated acute respiratory disease in U.S. army trainees

Transmission dynamics and prospective environmental sampling of adenovirus in a military recruit setting

Molecular epidemiology of adenovirus type 7 in the United States

Molecular and serological characterization of adenovirus genome type 7h isolated in Japan

Emergent US adenovirus 3 strains associated with an epidemic and serious disease

Adenovirus type 3 outbreak in Connecticut associated with a novel variant

Molecular epidemiology and brief history of emerging adenovirus 14-associated respiratory disease in the United States

Outbreak of acute respiratory infection among infants in Lisbon, Portugal, caused by human adenovirus serotype 3 and a new 7/3 recombinant strain

Using the whole-genome sequence to characterize and name human adenoviruses

Human adenovirus: viral pathogen with increasing importance

Molecular evolution of human adenoviruses

Characterizing, typing, and naming human adenovirus 55 n the era of whole genome data

Designation of human adenovirus types based on sequence data: an unfinished debate

Toward an integrated human adenovirus designation system that utilizes molecular and serological data and serves both clinical and fundamental virology

Adenovirus infections in immunocompetent and immunocompromised patients

Antigenic characterization of intermediate adenovirus 14-11 strains associated with upper respiratory illness in a military camp

Viral Infections of Humans

Infections in 18,000 infants and children in a controlled study of respiratory tract disease. II. Variation in adenovirus infections by year and season

The virus watch program: a continuing surveillance of viral infections in metropolitan New York families. VI. Observations of adenovirus infections: virus excretion patterns, antibody response, efficiency of surveillance, patterns of infections, and relation to illness

Viral and mycoplasmal pneumonia in a prepaid medical care group during an eight-year period

Infections in 18,000 infants and children in a controlled study of respiratory tract disease. I. Adenovirus pathogenicity in relation to serologic type and illness syndrome

Worldwide epidemiology of human adenovirus infections

Adenovirus infections and respiratory illnesses in children in group day care

Illness and microbial experiences of nursery children at Junior Village

Outbreak of adenoviral infections in a long-term paediatric facility

Outbreak of adenovirus genome type 7d2 infection in a pediatric chronic-care facility and tertiary-care hospital

Adenovirus 7a: a community-acquired outbreak in a children's hospital

Re-emergent human adenovirus genome type 7d caused an acute respiratory disease outbreak in Southern China after a twenty-one year absence

Experimental transmission of minor respiratory illness to human volunteers by filter-passing agents. Demonstration of two types of illness characterized by long and short incubation periods and different clinical features

The isolation of adenovirus type 7 from a fatal case of pneumonia and disseminated disease

Type 7 adenovirus pneumonia

Adenovirus type 7b in a children's hospital

In vitro characterization of human adenovirus type 55 in comparison with its parental adenoviruses, types 11 and 14

Clinical picture and epidemiology of adenovirus infections

Principles and Practice of Infectious Diseases

Fatal pneumonia associated with adenovirus type 7 in three military trainees

Effect of route of inoculation on experimental respiratory viral disease in volunteers and evidence for airborne transmission

Pharyngoconjunctival fever; epidemiological studies of a recently recognized disease entity

Adenoidalpharyngeal-conjunctival agents: a newly recognized group of common viruses of the respiratory system

Swimming bath conjunctivitis

Pharyngoconjunctival fever caused by adenovirus type 4: report of a swimming pool-related outbreak with recovery of virus from pool water

Adenovirus type 3 epidemic associated with intermittent chlorination of a swimming pool

Infection and disease with respect to age, immunologic status, race and sex

The story of shipyard eye

Epidemic keratoconjunctivitis superficial punctate keratitis, keratitis sub-epithelialis, keratitis maculosa, keratitis nummularis

Epidemic keratoconjunctivitis caused by adenovirus type 8: epidemiologic and laboratory aspects of a large outbreak

Epidemiology of adenovirus respiratory infections in military recruit populations

Clinical and epidemiological features of adenovirus keratoconjunctivitis in London

Epidemic keratoconjunctivitis: a community outbreak of mixed adenovirus type 8 and type 19 infection

The changing etiology of epidemic keratoconjunctivitis: antigenic and restriction enzyme analyses of adenovirus types 19 and 37 isolated over a 10-year period

Adenovirus 37: identification and characterization of a medically important new adenovirus type of subgroup D

Human adenoviruses types associated with non-gonococcal urethritis

Epidemic keratoconjunctivitis. A severe industrial outbreak due to adenovirus type 8

Keratoconjunctivitis associated with adenovirus type 37: an extended outbreak in an ophthalmologist's office

A review of adenoviruses in the etiology of acute hemorrhagic cystitis

Further study on acute hemorrhagic cystitis due to adenovirus type 11

Acute hemorrhagic cystitis caused by adenovirus following renal transplantation: review of the literature

Hemorrhagic cystitis due to adenovirus infection following bone marrow transplantation

PCR detection of adenovirus in a bone marrow transplant recipient: hemorrhagic cystitis as a presenting manifestation of disseminated disease

Adenoviridae and their replication

Development of plaque assays for adenoviruses 40 and 41

Outbreak of infantile gastroenteritis due to type 40 adenovirus

Fecal adenoviruses from a longitudinal study of families in metropolitan Washington, D.C.: laboratory, clinical, and epidemiologic observations

Importance of enteric adenoviruses 40 and 41 in acute gastroenteritis in infants and young children

Is adenovirus a fetal pathogen?

Viral studies on amniotic fluid from fetuses with and without abnormalities detected by prenatal sonography

Detection and significance of adenoviruses in cases of sudden infant death

Encephaloningitis in children associated with an adenovirus type 7 epidemic

Adenovirus meningoencephalitis

Isolation and characterization of adenovirus 5 from the brain of an infant with fatal cerebral edema

Adenovirus type 21-associated acute flaccid paralysis during an outbreak of hand-foot-and-mouth disease in Sarawak, Malaysia

Viruses and whooping-cough

The role of adenoviruses in the pertussis syndrome

Involvement of adenovirus in clinical mononucleosis-like syndromes in young children

Neonatal adenovirus infection: four patients and review of the literature

Adenovirus Type 3 Viremia in an Adult with Toxic Shock-Like Syndrome

Clinical Virology

Manual of Clinical Microbiology

Adenovirus isolates from urine of patients with acquired immunodeficiency syndrome

Comparison of neutralization and DNA restriction enzyme methods for typing clinical isolates of human adenovirus

Adenovirus hepatitis in an immunosuppressed adult patient

Adenovirus pneumonia in lung transplant recipients

Adenovirus parotitis in patients with AIDS

Molecular epidemiology of adenovirus type 35 infections in immunocompromised hosts

Two new candidate adenovirus serotypes

Increasing incidence of adenovirus disease in bone marrow transplant recipients

Viral pneumonia

Prediction of severe disseminated adenovirus infection by serum PCR

Necrotizing tubulointerstitial nephritis associated with adenovirus infection

Adenovirus nephritis in hematopoietic stem-cell transplantation

Adenovirus infections in hematopoietic stem cell transplant recipients

Detection of microorganisms in the tracheal aspirates of preterm infants by polymerase chain reaction: association of adenovirus infection with bronchopulmonary dysplasia

Detection of viruses in myocardial tissues by polymerase chain reaction. evidence of adenovirus as a common cause of myocarditis in children and adults

Adenovirus 36 and obesity in children and adolescents

Adenovirus 36 seropositivity is strongly associated with race and gender, but not obesity, among US military personnel

Infectobesity": viral infections (especially with human adenovirus-36: Ad-36) may be a cause of obesity

Adenovirus 36 infection and obesity

International Union of Microbiological Societies. Virology Division. Virus taxonomy: classification and nomenclature of viruses: eighth report of the International Committee on Taxonomy of Viruses

Antigenic relationships among the 47 human adenoviruses determined in reference horse antisera

New adenovirus species found in a patient presenting with gastroenteritis

Evidence of molecular evolution driven by recombination events influencing tropism in a novel human adenovirus that causes epidemic keratoconjunctivitis

Computational analysis identifies human adenovirus type 55 as a re-emergent acute respiratory disease pathogen

Computational analysis and identification of an emergent human adenovirus pathogen implicated in a respiratory fatality

The revolution in viral genomics as exemplified by the bioinformatic analysis of human adenoviruses

Atomic structure of human adenovirus by cryo-EM reveals interactions among protein networks

Molecular biology of adenoviruses

A proposed terminology for the adenovirus antigens and virion morphological subunits

The icosahedral form of an adenovirus

The polypeptides of adenovirus. I. Evidence for multiple protein components in the virion and a comparison of types 2, 7A, and 12

Molecular composition of the adenovirus type 2 virion

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Adenoviridae: the adenoviruses

Cross-species transmission of a novel adenovirus associated with a fulminant pneumonia outbreak in a new world monkey colony

Cross-species transmission of a novel adenovirus associated with a fulminant pneumonia outbreak in a New World monkey colony

Novel adenoviruses in wild primates: a high level of genetic diversity and evidence of zoonotic transmissions

Efficacy of CMX001 as a post exposure antiviral in New Zealand White rabbits infected with rabbitpox virus, a model for orthopoxvirus infections of humans

Phylogenetic analysis of the main neutralization and hemagglutination determinants of all human adenovirus prototypes as a basis for molecular classification and taxonomy

Computational analysis of four human adenovirus type 4 genomes reveals molecular evolution through two interspecies recombination events

Efficacy of CMX001 as a prophylactic and presymptomatic antiviral agent in New Zealand white rabbits infected with rabbitpox virus, a model for orthopoxvirus infections of humans

Outbreak of adenovirus 14 respiratory illness-Prince of

Nosocomial adenovirus infections: molecular epidemiology of an outbreak due to adenovirus 3a

Outbreak of severe respiratory disease associated with emergent human adenovirus serotype 14 at a US air force training facility in 2007

Acute respiratory disease associated with adenovirus serotype 14-four states

Epidemiology of human adenovirus and molecular characterization of human adenovirus 55 in China

Latent adenovirus infections of the human respiratory tract

Latent species C adenoviruses in human tonsil tissues

Persistent infection with adenovirus types 5 and 6 in lymphoid cells from humans and woolly monkeys

Adenovirus infection in the immunocompromised patient

Infectious gastroenteritis in bone-marrow-transplant recipients

Monitoring of adenovirus load in stool by real-time PCR permits early detection of impending invasive infection in patients after allogeneic stem cell transplantation

Infection of staff during an outbreak of viral gastroenteritis in an elderly persons' home

Persistent adenovirus infections of nonpermissive monkey cells

Adenovirus genes that modulate the sensitivity of virus-infected cells to lysis by TNF

Group C adenovirus DNA sequences in human lymphoid cells

Oncogenic effects in hamsters of human adenovirus types 12 and 18

Role of early region 3 (E3) in pathogenesis of adenovirus disease

The molecular basis of adenovirus pathogenesis

Immunodetection of adenoviral E1A proteins in human lung tissue

Acute lower respiratory illness in childhood as a predictor of lung function and chronic respiratory symptoms

Promoter targeting by adenovirus E1a through interaction with different cellular DNA-binding domains

Transcriptional and transforming activities of the adenovirus E1A proteins

Latent adenoviral infection in the pathogenesis of chronic airways obstruction

Isolation of a common receptor for Coxsackie B viruses and adenoviruses 2 and 5

Desmoglein 2 is a receptor for adenovirus serotypes 3, 7, 11 and 14

Manual of Clinical Microbiology

Alternative cell line for virus isolation

Use of A-549 cells in a clinical virology laboratory

Rapid diagnosis of respiratory viral infections by using a shell vial assay and monoclonal antibody pool

Modern uses of electron microscopy for detection of viruses

The emerging role of adenoviruses as inducers of gastroenteritis

Diagnosis of fastidious enteric adenoviruses 40 and 41 in stool specimens

Stool viruses, coinfections, and diarrhea in HIV-infected patients. Berlin Diarrhea/ Wasting Syndrome Study Group

Genotype prevalence and risk factors for severe clinical adenovirus infection, United States

The utility of latex agglutination assays in the diagnosis of pediatric viral gastroenteritis

Routine diagnosis of seven respiratory viruses and Mycoplasma pneumoniae by enzyme immunoassay

Development and preliminary evaluation of an enzyme immunosorbent assay for the detection of adenovirus type 8

Rapid diagnosis of adenovirus respiratory tract infections using the chromatographic immunoassay test in the pediatric outpatient setting

Late fatal adenovirus pneumonitis in a lung transplant recipient. Transplantation

Performance evaluation of detecting adenovirus by using rapid diagnostic kits among Japanese people

Intussusception associated with adenovirus

Detection of a broad range of human adenoviruses in respiratory tract samples using a sensitive multiplex real-time PCR assay

Pring-Akerblom P. Rapid and quantitative detection of human adenovirus DNA by real-time PCR

Comparison of multiplex PCR assays and conventional techniques for the diagnostic of respiratory virus infections in children admitted to hospital with an acute respiratory illness

Comparison of the Biofire FilmArray RP, Genmark eSensor RVP, Luminex xTAG RVPv1, and Luminex xTAG RVP fast multiplex assays for detection of respiratory viruses

Adenoviruses in immunocompromised hosts

In vitro susceptibility of adenovirus to antiviral drugs is species-dependent

A novel adenovirus species associated with an acute respiratory outbreak in a baboon colony and evidence of coincident human infection

Species-specific identification of human adenoviruses by a multiplex PCR assay

Type-and group-specific polymerase chain reaction for adenovirus detection

Identification of subgenus C adenoviruses by fiber-based multiplex PCR

Quantitative realtime PCR assay panel for detection and type-specific identification of epidemic respiratory human adenoviruses

Real-time qualitative PCR for 57 human adenovirus types from multiple specimen sources

PCR and restriction endonuclease analysis for rapid identification of human adenovirus subgenera

Rapid typing of human adenoviruses by a general PCR combined with restriction endonuclease analysis

Use of oligonucleotide microarrays for rapid detection and serotyping of acute respiratory disease-associated adenoviruses

Rapid identification and strain-typing of respiratory pathogens for epidemic surveillance

Comprehensive detection and serotyping of human adenoviruses by PCR and sequencing

Comparative sequence analysis of the hexon gene in the entire spectrum of human adenovirus serotypes: phylogenetic, taxonomic, and clinical implications

Heterogeneity of the fibre sequence in subgenus C adenoviruses

Molecular typing of human adenoviruses by PCR and sequencing of a partial region of the hexon gene

Type-specific identification of human adenovirus 3, 7, and 21 by a multiplex PCR assay

Analysis of 15 adenovirus hexon proteins reveals the location and structure of seven hypervariable regions containing serotype-specific residues

Human adenoviruses in respiratory infections: sequencing of the hexon hypervariable region reveals high sequence variability

Molecular identification of adenovirus sequences: a rapid scheme for early typing of human adenoviruses in diagnostic samples of immunocompetent and immunodeficient patients

Development of a PCR-and hybridization-based assay (PCR Adenovirus Consensus) for the detection and the species identification of adenoviruses in respiratory specimens

Rapid detection and identification of human adenovirus species by adenoplex, a multiplex PCR-enzyme hybridization assay

Comparison of the GenMark Diagnostics eSensor respiratory viral panel to real-time PCR for detection of respiratory viruses in children

Molecular typing of clinical adenovirus specimens by an algorithm which permits detection of adenovirus coinfections and intermediate adenovirus strains

Molecular epidemiology of human adenoviruses

Molecular epidemiology and restriction site mapping of adenovirus 7 genome types

Analysis of 15 different genome types of adenovirus type 7 isolated on five continents

Genome type analysis of adenovirus type 4. Intervirology

Genome analysis of adenovirus 4 isolated over a six year period

New genome type of adenovirus serotype 4 caused nosocomial infections associated with epidemic conjunctivitis in Japan

Intravenous ribavirin therapy for disseminated adenovirus infection

Treatment of adenovirus infections in the immunocompromised host

The effect of gamma globulin on acute respiratory illness in military recruits

Treatment of inflammatory dilated cardiomyopathy and (peri)myocarditis with immunosuppression and i.v. immunoglobulins

Clinical effect of human fibroblast derived interferon in treatment of adenovirus epidemic keratoconjunctivitis and its complications

Detection of adenoviral genome in the myocardium of adult patients with idiopathic left ventricular dysfunction

Adenovirus: current epidemiology and emerging approaches to prevention and treatment

Activity of ganciclovir against human adenovirus type-5 infection in cell culture and cotton rat eyes

Nebulised ribavirin for adenovirus pneumonia

Intravenous ribavirin therapy for adenovirus cystitis after allogeneic bone marrow transplantation

Adenovirus-associated hemorrhagic cystitis treated with intravenous ribavirin

Intravenous ribavirin therapy for adenovirus gastroenteritis after bone marrow transplantation

Treatment of adenoviral pneumonitis with intravenous ribavirin and immunoglobulin

Adenovirus infections in adult recipients of blood and marrow transplants

Cidofovir for adenovirus infections after allogeneic hematopoietic stem cell transplantation: a survey by the Infectious Diseases Working Party of the European Group for Blood and Marrow Transplantation

Safety and efficacy of CMX001 as salvage therapy for severe adenovirus infections in immunocompromised patients

Development of CMX001 (Brincidofovir) for the treatment of serious diseases or conditions caused by dsDNA viruses

The Seattle virus watch. 3. Evaluation of isolation methods and summary of infections detected by virus isolations

The virus watch program: a continuing surveillance of viral infections in metropolitan New York families. IX. A comparison of infections with several respiratory pathogens in New York and New Orleans families

Adenovirus serotype evolution is driven by illegitimate recombination in the hypervariable regions of the hexon protein

Molecular epidemiology of adenovirus acute lower respiratory infections of children in the south cone of South America (1991-1994)

Sequence analysis of the E3 region and fiber gene of human adenovirus genome type 7h

Adenovirus surveillance on children hospitalized for acute lower respiratory infections in Chile (1988-1996)

Hospital-acquired adenovirus 7h infantile respiratory infection in Chile

Emergent strain of human adenovirus endemic in Iowa

Outbreak of pneumonia associated with emergent human adenovirus serotype 14-Southeast Alaska

A community-based outbreak of severe respiratory illness caused by human adenovirus serotype 14

Adenovirus serotype 14 pneumonia at a basic military training site in the United States, spring 2007: a case series

Transmission of adenovirus serotype 14 in the health care setting

Emergence of adenovirus type 14 in US military recruits-a new challenge

Outbreak of febrile respiratory illness associated with human adenovirus type 14p1 in Gansu Province, China. Influenza Other Respir Viruses

A comparison of viral fitness and virulence between emergent adenovirus 14p1 and prototype adenovirus 14p strains

Genome sequences of human adenovirus 14 isolates from mild respiratory cases and a fatal pneumonia, isolated during 2006-2007 epidemics in North America

Effective apical infection of differentiated human bronchial epithelial cells and induction of proinflammatory chemokines by the highly pneumotropic human adenovirus type 14p1

Adenovirus type 7 genomic-type variant

Patterns of infections with adenovirus types 4, 7 and 21 in military recruits during a 9-year survey

Efficacy of PCR and other diagnostic methods for the detection of respiratory adenoviral infections

Adenovirus infections in servicemen in Finland

Respiratory disease caused by a species B2 adenovirus in a military camp in Turkey

Outbreak of febrile respiratory illness caused by adenovirus at a South Korean military training facility: clinical and radiological characteristics of adenovirus pneumonia

Outbreak of acute respiratory disease caused by human adenovirus type 7 in a military training camp in Shaanxi

Outbreak of adenovirus infection in the Portsmouth Naval Command

Outbreak of febrile respiratory illness associated with adenovirus 11a infection in a Singapore military training cAMP

Prevalence of adenovirus types 3 and 7 antibodies in Singapore

A novel psittacine adenovirus identified during an outbreak of avian chlamydiosis and human psittacosis: zoonosis associated with virus-bacterium coinfection in birds

Lack of evidence of avian adenovirus infection among turkey workers

Acute gastroenteritis in Latin America

The role of a rapid diagnostic test (adenovirus immune dot-blot) in the control of an outbreak of adenovirus type 8 keratoconjunctivitis

Adenovirus cross-infection: a continuing problem

A large outbreak of keratoconjunctivitis due to adenovirus type 8

Nosocomial viral pneumonia in the intensive care unit

Hospital-associated epidemic of pharyngitis and conjunctivitis caused by adenovirus (21/H21 + 35)

Investigation of chronic diarrhoea in acquired immunodeficiency syndrome. A prospective study of 155 patients

Adenovirus (R1-APC-ARD) vaccine for prevention of acute respiratory illness: II. field evaluation

Second field evaluation of bivalent types 4 and 7 adenovirus vaccines

Adenovirus vaccine; a field evaluation of protective capacity against respiratory disease

Effects of adenovirus vaccine on acute respiratory disease in U. S. Army recruits

Case-control study of cancer among US Army veterans exposed to simian virus 40-contaminated adenovirus vaccine

Vaccination of man with attenuated live adenovirus

Immunization with types 4 and 7 adenovirus by selective infection of the intestinal tract

Immunization by selective infection with type 4 adenovirus grown in human diploid tissue cultures. I. Safety and lack of oncogenicity and tests for potency in volunteers

The oncogenicity of human adenoviruses in hamsters

In vitro transformation of hamster kidney cells by human adenovirus type 12

Immunization by selective infection with type 4 adenovirus grown in human diploid tissue culture. II. Specific protective effect against epidemic disease

Characteristics of vaccine-induced and natural infection with adenovirus type 4 in naval recruits

The problem of oncogenicity of adenoviruses The First International Conference on Vaccines Against Viral and Rickettsial Diseases of Man: PanAmerican Health Org

Serologic surveys of human cancer patients for antibody to adenovirus T antigens

Adenoviruses in human cancer

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Immunization with live types 7 and 4 adenovirus vaccines. I. Safety, infectivity, antigenicity, and potency of adenovirus type 7 vaccine in humans

Control of respiratory disease in recruits with types 4 and 7 adenovirus vaccines

Immunization with live types 7 and 4 adenovirus vaccines. II. Antibody response and protective effect against acute respiratory disease due to adenovirus type 7

Association of type 21 adenovirus with acute respiratory illness in military recruits

Enteric immunization with live adenovirus type 21 vaccine. I. Tests for safety, infectivity, immunogenicity, and potency in volunteers

Enteric immunization with live adenovirus type 21 vaccine. II. Systemic and local immune responses following immunization

Adenovirus ARD in basic combat trainees

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Clinical evaluation of live, oral types 1, 2, and 5 adenovirus vaccines

Remanufacture of adenovirus vaccines type 4 and 7. Depart of Defense Recruit and Trainee Healthcare Symposium

Adenovirus type 4 outbreak in military basic trainees: reemergence of disease due to lack of vaccine availability

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Epidemic spread of adenovirus type 4-associated acute respiratory disease between U.S. Army installations

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Dramatic decline of respiratory illness among US military recruits after the renewed use of adenovirus vaccines

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Urgent attention needed to restore lapsed adenovirus vaccine availability

A tale of two vaccines

Adenovirus infection is not trivial

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A double-blind, placebocontrolled study of the safety and immunogenicity of live, oral type 4 and type 7 adenovirus vaccines in adults

Adenovirusassociated deaths in US military during postvaccination period

History of the restoration of adenovirus type 4 and type 7 vaccine, live oral (Adenovirus Vaccine) in the context of the Department of Defense acquisition system

Restoring adenovirus vaccine. Contract Pharma

Type 4 adenovirus vaccine, live, prepared in human diploid cell system for oral administration

Package insert-adenovirus type 4 and adenovirus type 7 vaccine, live, oral

Safety and immunogenicity of multiple conventional immunizations administered during early HIV infection

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Communicability of enteric live adenovirus type 4 vaccine in families

Clinical evaluation of live, oral types 1, 2, and 5 adenovirus vaccines

Vaccination with live type 4 adenoviruses: evaluation of antibody responses and protective efficacy

Mass enteric live adenovirus vaccination during epidemic ARD

Recent experiences with live adenovirus vaccines in Navy recruits

Simultaneous oral administration of live adenovirus types 4 and 7 vaccines

Viral respiratory disease at Lowry Air Force Base in Denver, 1952-1982

Communicability of enteric live adenovirus type 4 vaccine in families

Fatal adenovirus pneumonia in a young adult associated with ADV-7 vaccine administered 15 days earlier

US Government Printing Office

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Cost-effectiveness analysis of reacquiring and using adenovirus types 4 and 7 vaccines in naval recruits

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Handwashing and respiratory illness among young adults in military training

Returning to the past: respiratory illness, vaccines, and handwashing

Selected nonvaccine interventions to prevent infectious acute respiratory disease

Production of specific neutralizing antibody with soluble antigens of type 5 adenovirus

Induction of immunity in man by crystalline adenovirus type 5 capsid antigens

Vaccines within vaccines: the use of adenovirus types 4 and 7 as influenza vaccine vectors

Adenovirus-vectored vaccine provides postexposure protection to Ebola virusinfected nonhuman primates

Systemic and mucosal immunity in mice elicited by a single immunization with human adenovirus type 5 or 41 vector-based vaccines carrying the spike protein of Middle East respiratory syndrome coronavirus

Progress on adenovirus-vectored universal influenza vaccines

Adenovirus-based vaccines for fighting infectious diseases and cancer: progress in the field

Prospects for oral replicating adenovirus-vectored vaccines

Oral adenoviral-based vaccines: historical perspective and future opportunity

Advances and future challenges in recombinant adenoviral vectored H5N1 influenza vaccines

First-in-human evaluation of the safety and immunogenicity of a recombinant adenovirus serotype 26 HIV-1 Env vaccine (IPCAVD 001)

Adenovirus-based vaccines for fighting infectious diseases and cancer: progress in the field

Adenovirus vectors for gene therapy, vaccination and cancer gene therapy

We thank John Shaw of Teva Pharmaceuticals, Inc., and Andrew Towle, PhD, AVP LLC, for their critical review of this work.