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National surveillance for emerging adenovirus infections

National Surveillance for

Emerging Adenovirus Infections

Picture courtesy of Central Microscopy Research Facility, University of Iowa



Hypervariable regions defined: Crawford-Miksza J Virology 1996;70:1936-44

image from J Gen Virology August 13, 2003 online



Materials & Methods




Gregory C. Gray, MD, MPH,1 Troy McCarthy,1 Mark LeBeck,1 Dean D. Erdman, DrPH,2

David P. Schnurr, PhD,3 Kevin L. Russell, MD, MTM&H,4 Adriana E. Kajon, PhD,5

Jeffrey D. Dawson, ScD,6 Gary V. Doern, PhD,7 Leta K. Crawford-Miksza, PhD, MPH8

for the US National Adenovirus Surveillance Team

Background- The epidemiology of human adenovirus infections is changing. New, possibly more virulent, strains have emerged and caused epidemics. We sought to epidemiologically study US clinical adenovirus isolates and to determine risk factors for adenovirus disease.

Methods - From July 2004 through March 2005, adenovirus viral specimens and corresponding clinical data were collected from 23 US sites (8 military). Adenoviruses were typed using PCR (hexon gene) and sequencing protocols developed by the Centers for Disease Control and Prevention. Sequences were compared to those available from GenBank and to in-house sequence data from the 51 recognized human prototype strains. Identification of adenovirus field isolates was based on achieving identification scores ≥90% (both datasets) for a given prototypic strain. A blinded systematic-derived sample of 101 adenovirus field isolates was studied by a collaborating laboratory using established serotyping techniques.

Results - Of 1259 adenovirus isolates examined(411 military and 848 civilian), 99.7% were successfully typed using the PCR and sequencing method. Among military specimens, adenovirus serotypes 4 (96.6%), 21(1.2%), and 3 (2.2%) were the most prevalent. Adenoviruses obtained from civilians were more diverse: adenovirus serotype 1 (15.9%), 2 (22.8%), 3 (39.9%), 4 (5.1%), 5 (6.1%), 6 (0.6%), 7 (1.1%), 11 (0.5%), 12 (0.8%), 14 (0.4%), 19 (0.2%), 21 (1.8%), 22 (0.2%), 25 (0.1%), 31 (0.9%), 34 (0.7%), 35 (0.7%), 41 (2.0%) and 45 (0.1%). Adenoviruses from civilian subjects were often associated with hospitalization (43%) or intensive care unit stay (6%). The blinded serotyping validation study demonstrated 100% agreement among the 98 isolates that were typable by serum neutralization.

Conclusion - The hexon gene sequencing approach appears to be a very useful method in typing human adenovirus and it may eventually supplant traditional serotyping methods. However, alternative sequence typing gene targets are needed to supplement the hexon gene approach in order to identify novel recombinant viruses. (Revised)

  • Of 694 adenovirus isolates examinedthus far,93% were successfully typed using gene sequencing.

  • Type 4 was the most prevalent among military populations.

  • Type 3 was the most prevalent among civilian populations.

  • Adenoviruses from civilian subjects were often associated with hospitalization (43%) or intensive care unit stay (6%).

  • Gene typing may be useful in investigating nosocomial infections and in determining antiviral therapy (Antivir Ther 2005;10:225-9).

  • The hexon gene sequencing approach appears to be a very useful method in typing human adenovirus and it may eventually supplant traditional serotyping methods.

1Center for Emerging Infectious Diseases, Dept. of Epidemiology, University of Iowa College of Public Health, Iowa City, IA

2Respiratory Virus Diagnostics Program, CDC/NCID/DVRD/REVB, Atlanta, GA

3Viral and Rickettsial Disease Lab., Div. of Communicable Disease Control, California Dept. of Health Services, Richmond, CA

4Respiratory Disease Laboratory, DoD Center for Deployment Health Research, Naval Health Research Center, San Diego, CA

5Lovelace Respiratory Research Institute, Albuquerque, NM

6Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA

7Department of Pathology, University of Iowa College of Medicine, Iowa City, IA

8Food and Drug Laboratory Branch, California Department of Health Services, Richmond, CA


The military samples came from 8 different bases in the United States. Samples were from military personnel ranging from age 17 to 34 years old with a mean age of 20.1± 2.4 years old and 88% were from males. Neither age (p=0.672) nor gender (p=0.594) are predictors of adenovirus infection in military personnel. Of the 291 samples sequenced so far, Ad4 (n=283) is the most prevalent. Ad4, Ad3, and Ad21 were the only other types found. There was no association of specific adenovirus types with specific military bases.

  • 23 viral labs linked across the United States submitting all adenoviral isolates x 3 years

  • All specimens were typed using a DNA hexon gene sequencing procedure that highly correlates with the more tedious classical serological typing systems.

Coinvestigators - Dean D. Erdman, DrPH; David P. Schnurr, PhD; Kevin L. Russell, MD, MTM&H; Adriana E. Kajon, PhD; Jeffrey D. Dawson, ScD; Gary V. Doern, PhD; Leta K. Crawford-Miksza, PhD, MPH

Site principal investigators - James Chappell, MD, PhD, Nashville, TN; Gail J. Demmler, MD, Houston, TX; Christine C. Ginocchio, PhD, Manhasset, NY; Diane C. Halstead, PhD, DABMM, FAAM, Jacksonville, FL; Nancy G. Henshaw, PhD, MPH, Durham, NC; Sue C. Kehl, PhD, Milwaukee, WI; Deanna L. Kiska, PhD, DABMM, Syracuse, NY; Marie L. Landry, MD, New Haven, CT; Diane S. Leland, PhD, Indianapolis, IN; Melissa Miller, MD, Chapel Hill, NC; Christine Robinson, PhD, Denver, CO; Michael A. Saubolle, PhD, Tempe, AZ; Rangaraj Selvarangan, BVSc, PhD, Kansas City, MO; Gregory A. Storch, MD, St. Louis, MO; and Danielle Zerr, MD, MPH, Seattle, WA

Collaborators - Howard Lehmkuhl, PhD, Kevin Knudson, PhDCEID Staff - Whitney Baker, Ana Capuano, Mark Lebeck, Ghazi Kayali, Troy McCarthy, Sharon Setterquist

Funding – NIH/NIAID R01 AI053034


Civilian isolates came from 15 sites. Civilian adenovirus patients ranged in age from 8 days to 78 years, with a mean age of 6.9 ± 12.1 yrs. 59% were from males. Age and gender were not predictors of specific adenovirus types. 43.4% of the civilian samples were adenovirus types 3, 4, 7 or 21 with Ad3 being most prevalent. Other types observed were Ad1, Ad11, Ad12, Ad14, Ad19, Ad22, Ad 31, Ad41, Ad5, and Ad6. No specific strains were strongly associated with hospitalization or ICU admission.

  • The wild type sequences were compared to the CEID adenovirus sequence library that we created by sequencing 51 prototypic adenovirus isolates.

  • Sites sent adenovirus positive specimens with associated data on supplied forms to be typed.


A panel of 101 blinded specimens was sent to CA’s Viral and Rickettsial Disease Laboratory. 98 were typed by classical serotyping method with 100% agreement with UI hexon gene sequencing method The other 3 specimens were sent to the Navy Respiratory Disease Laboratory for a PCR typing algorithm comparison where they found 100% agreement with UI hexon gene sequence method.

  • Why Study Human Adenovirus?

  • Recognition of emergent more virulent adenovirus strains

  • Recognition of adenovirus associations with numerous chronic diseases

  • Recognition of adenovirus as a major cause of morbidity among transplant patients

  • Recognition that some species of adenovirus may be responsive to antiviral therapy

  • Clinical data collected from populations at high risk of adv infection:

    • children <7 years of age

    • allogeneic stem cell or solid organ

    • transplant patients