Cancer stage.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"172",leadTitle:null,fullTitle:"Power Quality Harmonics Analysis and Real Measurements Data",title:"Power Quality",subtitle:"Harmonics Analysis and Real Measurements Data",reviewType:"peer-reviewed",abstract:"Nowadays, the increasing use of power electronics equipment origins important distortions. The perfect AC power systems are a pure sinusoidal wave, both voltage and current, but the ever-increasing existence of non-linear loads modify the characteristics of voltage and current from the ideal sinusoidal wave. This deviation from the ideal wave is reflected by the harmonics and, although its effects vary depending on the type of load, it affects the efficiency of an electrical system and can cause considerable damage to the systems and infrastructures. Ensuring optimal power quality after a good design and devices means productivity, efficiency, competitiveness and profitability. Nevertheless, nobody can assure the optimal power quality when there is a good design if the correct testing and working process from the obtained data is not properly assured at every instant; this entails processing the real data correctly. In this book the reader will be introduced to the harmonics analysis from the real measurement data and to the study of different industrial environments and electronic devices.",isbn:null,printIsbn:"978-953-307-335-4",pdfIsbn:"978-953-51-4395-6",doi:"10.5772/699",price:119,priceEur:129,priceUsd:155,slug:"power-quality-harmonics-analysis-and-real-measurements-data",numberOfPages:292,isOpenForSubmission:!1,isInWos:1,isInBkci:!0,hash:"f35bec1bed8ccb6a099567bbf197b48c",bookSignature:"Gregorio Romero Rey and Luisa Martinez Muneta",publishedDate:"November 23rd 2011",coverURL:"https://cdn.intechopen.com/books/images_new/172.jpg",numberOfDownloads:56725,numberOfWosCitations:19,numberOfCrossrefCitations:13,numberOfCrossrefCitationsByBook:1,numberOfDimensionsCitations:15,numberOfDimensionsCitationsByBook:2,hasAltmetrics:1,numberOfTotalCitations:47,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 11th 2010",dateEndSecondStepPublish:"November 15th 2010",dateEndThirdStepPublish:"March 15th 2011",dateEndFourthStepPublish:"April 14th 2011",dateEndFifthStepPublish:"June 13th 2011",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7,8",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"964",title:"Dr.",name:"Gregorio",middleName:null,surname:"Romero",slug:"gregorio-romero",fullName:"Gregorio Romero",profilePictureURL:"https://mts.intechopen.com/storage/users/964/images/1793_n.jpg",biography:"Dr. Gregorio Romero Rey (Spain, 1974) received his Industrial Technical Engineering degree from the ICAI in 1996 and his Mechanical Engineering degree from the UNED in 2000. After the analysis of mathematical systems corresponding to multi-domain models, he was awarded his PhD Degree by the Universidad Politécnica de Madrid in 2005, the university in which he works as Associated Professor. Since 1997, he has worked mainly on simulation models and the virtual reality area, developing his research activity in the Research Group in Railway Technology and Advanced Simulation (CITEF) collaborating on European and National Projects, apart from works with private companies. He has been involved in different technical committees and has received two prizes associated with his research and education activity. At present he is the manager of an electrical simulator designed for a Spanish company and has published more than 70 technical papers in different international journals, books and conferences.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"Technical University of Madrid",institutionURL:null,country:{name:"Spain"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"121611",title:"Prof.",name:"Luisa",middleName:null,surname:"Martinez",slug:"luisa-martinez",fullName:"Luisa Martinez",profilePictureURL:"https://mts.intechopen.com/storage/users/121611/images/1795_n.jpg",biography:"Dr. Luisa Martinez Muneta received her Mechanical Engineer degree from the Universidad Politécnica de Madrid (UPM) in 1990. She got her PhD Degree in 1997 working on variational geometry. Since 1990 she started to work as Associate Professor at UPM. She usually works in the field of computer graphics, simulation and virtual reality, developing her research activity in the Research Group in Railway Technology and Advanced Simulation (CITEF) from 1997. During this time she has been involved in different industrial projects and pilot activities promoted by the European Commission and other Spanish institutions, and has received some prizes associated with her activity. 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Kothari Postdoctoral Research Fellowship Award from UGC, India and MI-MIT collaborated Postdoctoral Research Fellowship by Masdar Institute of Science and Technology (A part of Khalifa University of Science and Technology), Abu Dhabi, UAE. He is Editor and Reviewer of several International Journals of Materials Sciences, Polymer composites, Mechanical Engineering and Water Technology. Dr Gupta has over 30 research publications in SCI indexed journals, over 15 presentations in conferences including Invited Lecture and book chapters to his credit. 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Many cancer patients also have physical dysfunction and experience deficits in muscle strength, flexibility, and endurance as a result of chemotherapy, radiation therapy, and surgery [2]. Physical therapy is a comprehensive, multidisciplinary approach to the evaluation and treatment of patients diagnosed with various forms of cancer. Physical therapy can improve functional problems such as weakness, soft tissue tightness, joint stiffness, fatigue, and swelling or edema [3, 4]. Physical therapy allows experts to find the best ways for cancer patients to stay active. Physical therapy-led exercise is clinically effective and can help cancer patients improve their quality of life (QOL) [5]. Physical therapy includes stretching, strengthening, and aerobic exercises for the inpatients, outpatients, and cancer survivors. It often helps patients regain strength, physical functioning, quality of life, and independence in activities of daily living (ADL) that they may have lost due to cancer or its treatment. Physical therapists are available in multiple treatment settings, including preoperative, postoperative, acute care, nursing home, and inpatient and outpatient rehabilitation. Physical therapists also work in conjunction with the rehabilitation team to design components of a survivorship care plan in order to optimize overall functional outcomes (Figure 1) [6]. Cancer has four stages, and cancer patients have differences in disease and disabilities during each stage (Table 1). Physical therapists often use four cancer rehabilitation stages and identify the stage before physical therapy for cancer patients (Table 2) [7]. There are different approaches for therapy of cancer patients during each stage.
\nRehabilitation team for cancer patients.
Stage | \nCharacteristics |
---|---|
Stage 1 | \nCancer is relatively small and contained within the organ it originated from. This stage describes cancer in situ, which means “in place.” Stage 1 cancers have not spread to nearby tissues. This stage of cancer is often highly curable, usually by removing the entire tumor with surgery |
Stage 2 | \nCancer has not started to spread into surrounding tissue but the tumor is larger than in Stage 1. Sometimes, Stage 2 means that cancer cells have spread into lymph nodes close to the tumor. At this stage, cancer or tumor is relatively small and has not grown deeply into the nearby tissues. It also has not spread to the lymph nodes or other parts of the body. It is often called an early-stage cancer |
Stage 3 | \nCancer is larger. It may have started to spread into surrounding tissues, and cancer cells may be present in the lymph nodes of the area. This stage indicates larger cancers or tumors |
Stage 4 | \nCancer has spread from where it started to another organs or parts of the body. This is also called a secondary, advanced, or metastatic cancer |
Cancer stage.
Stage |
---|
(1) Preventive |
Intervention focused on improving the patient’s level of function prior to the onset of the effects of the cancer and its treatment, patient education, and psychological support |
(2) Restorative rehabilitation |
Intervention focused on returning the patient to a previous level of function and addressing impairments from cancer and its treatment |
(3) Supportive rehabilitation |
Intervention is meant to assist the cancer patient to function at the highest level within the context of his or her impairments, activity limitations, and participation restrictions |
(4) Palliative rehabilitation |
Intervention focused on minimizing complications such as pressure ulcers, contractures, and muscle deconditioning ensuring adequate pain control and emotional support for the family |
Four cancer rehabilitation stages.
This chapter introduces overview, treatment, common dysfunctions, physical therapy assessment, physical therapy, key points in diagnosis, and palliative care of following cancer types: breast cancer, gynecologic cancers, brain tumor, head and neck cancer, lung cancer, esophagus cancer, bone cancer, and blood cancer. This chapter also shows the important role of physical therapy in cancer patients.
\nPhysical therapists must undergo assessment based on the International Classification of Functioning, Disability and Health (ICF) model before, during, and after physical therapy for each cancer patient (Figure 2). ICF enables physical therapist to provide cancer patients with therapy. Cancer patients have many problems caused by cancer treatment or cancer itself. Physical therapy assessment should include manual muscle testing (MMT), range of motion (ROM), balance test, endurance test, and ADL test. Performance status (PS; Table 3) [8], Palliative Performance Scale (PPS; Table 4) [9], Barthel index (BI) [10], functional independence measure (FIM) [11, 12], and QOL are also used as assessment tools for cancer patients. Physical therapists should be aware that cancer patients are exposed to various risks such as infectious diseases due to immunosuppressive effects of the treatment. Thus, physical therapists must manage risks that are related to cancer and its treatment (Table 5) [13]. Additionally, physical therapists must recognize that cancer is a progressive disease. In general, cancer patients have a gradual decline in their physical function. Once a goal is set, physical therapists must be aware of cancer progression and patients’ prognosis [14]. Physical therapists also must know a variety of other problems that occur in cancer patients. Cancer patients might not only have physical function problems but may also develop depression and anxiety in the future [15]. Cancer patients might feel the fear of cancer recurrence or death. Physical therapy may be effective in reducing fatigue, increasing muscle strength and exercise capacity, and improving QOL in various cancer patients.
\nInternational Classification of Functioning, Disability, and Health.
Grade | \nECOG performance status |
---|---|
0 | \nFully active, able to carry on all pre-disease performance without restriction |
1 | \nRestricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work |
2 | \nAmbulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours |
3 | \nCapable of only limited self-care, confined to bed or chair more than 50% of waking hours |
4 | \nCompletely disabled. Cannot carry on any self-care. Totally confined to bed or chair |
5 | \nDead |
Performance status (PS).
PPS level | \nAmbulation | \nActivity and evidence of disease | \nSelf-care | \nIntake | \nConscious level |
---|---|---|---|---|---|
100 | \nFull | \nNormal activity and work no evidence of disease | \nFull | \nNormal | \nFull |
90 | \nFull | \nNormal activity and work Some evidence of disease | \nFull | \nNormal | \nFull |
80 | \nFull | \nNormal activity with effort Some evidence of disease | \nFull | \nNormal or reduced | \nFull |
70 | \nReduced | \nUnable normal job/work Significant disease | \nFull | \nNormal or reduced | \nFull |
60 | \nReduced | \nUnable hobby/house work Significant disease | \nOccasional assistance necessary | \nNormal or reduced | \nFull or confusion |
50 | \nMainly sit/lie | \nUnable to do any work Extensive disease | \nConsiderable assistance required | \nNormal or reduced | \nFull or confusion |
40 | \nMainly in bed | \nUnable to do most activity Extensive disease | \nMainly assistance | \nNormal or reduced | \nFull or drowsy ± confusion |
30 | \nTotally bed bound | \nUnable to do any activity Extensive disease | \nTotal care | \nNormal or reduced | \nFull or drowsy ± confusion |
20 | \nTotally bed bound | \nUnable to do any activity Extensive disease | \nTotal care | \nMinimal to sips | \nFull or drowsy ± confusion |
10 | \nTotally bed bound | \nUnable to do any activity Extensive disease | \nTotal care | \nMouth care only | \nDrowsy or coma ± confusion |
0 | \nDeath | \n\n | \n | \n |
Palliative Performance Scale (PPSv2).
1PPS scores are determined by reading horizontally at each level to find a “best fit” for the patient who is then assigned as the PPS% score.
2Begin at the left column, read downward until the appropriate ambulation level is reached, and then read across to the next column and downward again until the activity/evidence of disease is located. These steps are repeated until all five columns are covered before assigning the actual PPS for that patient. In this way, “leftward” columns (columns to the left of any specific column) are “stronger” determinants and generally take precedence over others.
3PPS scores are in 10% increments only. Sometimes, there are several columns easily placed at one level but one or two which seem better at a higher or lower level. One then needs to make a “best fit” decision. Choosing a “halfwit” value of PPS 45%, for example, is not correct. The combination of clinical judgment and “leftward precedence” is used to determine whether 40% or 50% is the more accurate score for that patient.
1. Hematologic profile: hemoglobin <7.5 g, platelets <20,000, white blood cell count <3000 |
2. Metastatic bone disease |
3. Compression of a hollow viscous (bowel, bladder, or ureter) vessel or spinal cord |
4. Fluid accumulation in the pleura, pericardium, abdomen, or retroperitoneum associated with persistent pain, dyspnea, or problems with mobility |
5. CNS depression or coma or increased intracranial pressure |
6. Hypokalemia/hyperkalemia, hyponatremia, or hypocalcemia/hypercalcemia |
7. Orthostatic hypotension |
8. Heart rate in excess 110 beat/min or ventricular arrhythmia |
9. Fever greater than 101°F |
Precaution rehabilitation for cancer patients.
Breast cancer is the most common invasive cancer in women worldwide [16]. Breast cancer alone accounts for 25% of all cancer cases and 15% of all cancer deaths among women [17]. Breast cancer starts when cells in the breast begin to grow out of control. These cells usually form a tumor that can be often seen on an X-ray or felt as a lump. Breast cancer can develop following changes in genetic material leading to cellular changes that causes cells to start multiplying in an uncontrolled fashion, forming lumps or nodules.
\nIn general, breast cancer patients have few treatment options such as surgery (breast-conserving surgery and mastectomy), radiation therapy, chemotherapy, and hormone therapy [18, 19]. In some cases, lymph nodes located close to the affected breast need to be surgically removed.
\nMuscle weakness around the shoulder joint, decline of ADL using upper extremities, dizziness, loss of appetite, shortness of breath, depression are present in a substantial majority of patients during or after their initial treatment (surgery, radiation, and/or chemotherapy) [20, 21]. Physical therapists must pay attention to the occurrence of musculoskeletal disorders and lymph vascular disorders following breast surgery. Musculoskeletal disorders include postsurgical pain, rotator cuff disease, and adhesive capsulitis [22]. Lymph vascular disorders are common after removal of lymph nodes [23]. As a result, breast cancer patients have limited range of motion, muscle weakness, pain, and ADL decline such as difficulties while brushing hair or taking off the jacket. In some cases of breast cancer, cellulitis occurs that can become a potentially serious bacterial skin infection [21, 24].
\nPhysical therapy assessment of cancer patients includes the ICF, examination of shoulder ROM, MMT, pain levels, fatigue, upper limb volume, an upper limb disability questionnaire, and QOL evaluation. Additionally, in the cases of breast cancer patients, physical therapists assess exercise tolerance.
\nMany previous studies showed that physical therapy has effectiveness in breast cancer patients [25, 26]. In general, combined physical therapy is effective to treat postoperative lymphedema, pain, and impaired ROM after treatment for breast cancer [26]. Physical therapy for breast cancer patients includes lymphatic drainage massage, vantage, manual stretching, myofascial therapy, relaxation massage, stretching, strengthening, resisted exercise, proprioceptive neuromuscular facilitation (PNF) exercises, isometric exercises, aerobic exercises, transcutaneous electrical nerve stimulation (TENS), heat and cold, patient education, and behavioral training. Breast cancer patients also receive ADL training such as bathing, showering (washing the body), and dressing.
\nPhysical therapists should improve mobility of upper extremities with a reduction of their volume. This should be followed by an attempt to recover upper limb function in ADL.
\nGynecologic cancers accounted for 19% of the 5.1 million estimated new cancer cases and 13 million 5-year prevalent cancer cases among women in the world in 2002 [27]. Gynecologic cancer is described as the uncontrolled growth and spread of abnormal cells originating in the female reproductive organs. They are found in different places within a woman’s pelvis, which is the area below the stomach and in between the hip bones. Five main types of gynecologic cancers are present: cervical, ovarian, uterine, vaginal, and vulvar.
\nIn general, gynecologic cancers can be cured with aggressive treatment involving surgery, chemotherapy, and/or radiation. Treatment goal in recurrent and metastatic cancer is to decrease progression of the disease [28, 29].
\nWeakness of pelvic floor muscles, decline in ADL, dizziness, loss of appetite, shortness of breath, depression are the symptoms present in a substantial majority of patients during or after their initial treatment (surgery, radiation, and/or chemotherapy) [30]. Lower extremity weakness often occurs in gynecologic cancer patients; thus, locomotion disability is common [31]. Physical therapists must pay attention to occurrence of musculoskeletal and lymph vascular disorders at the lower extremities following gynecologic surgery [32]. Lymphovascular disorders cause problems after removal of lymph nodes [33]. As a result, patients experience limited ROM, muscle weakness, pain, and decline in ADL.
\nFirst, physical therapists should assess pelvic floor muscle strength as gynecologic cancers have urinary incontinence after the treatment [34, 35]. Second, physical therapists should assess ICF category: lower extremities such as hip, knee, and ankle ROM; MMT; assessment of pain levels; fatigue; upper limb volume; locomotion ability such as gait speed; balance function; QOL; ADL; and sexual function [36]. Additionally, physical therapists should assess exercise tolerance.
\nA few previous reports showed that physical therapy has a positive effect on gynecologic cancer patients [37]. Physical therapists should perform pelvic floor physical therapy as a tool to aid in addressing pelvic floor symptoms [37]. In general, physical therapy for gynecologic cancer patients includes locomotion ability exercises such as standing and walking, lymphatic drainage massage, vantage, manual stretching, myofascial therapy, relaxation massage, stretching, strengthening, resisted exercise, PNF, aerobic exercise, TENS, patient education, and behavioral training.
\nPhysical therapists should improve muscle strength of lower extremities and reduce their volume as soon as possible. This should be followed by acquiring locomotion.
\nThe worldwide cancer incidence of a malignant brain tumor is 3.4 per 100,000 for men and 3.0 per 100,000 for women [38]. Brain tumor is the most common neurological complication related to cancer [39]. Brain tumors can originate from the patient’s brain (primary brain tumors) or from other parts of the patient’s body (secondary or metastatic brain tumors) [40, 41]. Brain tumors can destroy brain cells, increase inflammation, and elevate brain pressure. Brain tumors may cause a wide range of neurological dysfunctions, including disorders of the nervous system.
\nIn general, treatment options include surgery, radiation therapy, chemotherapy, targeted biological agents, or a combination of these [42]. Surgical resection is commonly the first recommended treatment in order to rapidly reduce brain pressure.
\nBrain tumor patients commonly experience weakness, sensory loss, and abnormal muscle tone. These include spasticity, visuospatial deficits, hemi-neglect or bilateral visual deficits, ataxia, cognitive deficits (thought processes, memory changes, apraxia, etc.), speech difficulties, dysphagia, bowel and bladder dysfunction, psychological problems, and fatigue. As a result, ADL decline and lower QOL are common in brain tumor patients [43, 44].
\nPhysical therapists often assess ICF category, Glasgow Coma Scale, Mini-Mental State Exam-ination, Fugl-Meyer, Motor Assessment Scale, Motricity Index, Berg Balance Assessment, Beck Depression Inventory (BDI), and Hospital Anxiety and Depression Scale (HADS). They examine pain levels and locomotion ability such as gait speed, QOL, and sexual function. Additionally, physical therapists should assess exercise tolerance in brain tumor patients [45, 46].
\nTo date, no previous study has reported positive effects of physical therapy in adult brain tumor patients. However, a few reports showed that physical therapy may be effective in pediatric brain tumor patients [47]. In general, physical therapy performed in brain tumor patients is also performed in stroke patients [48]. It includes neurofacilitation techniques such as Bobath, PNF, Brunnstrom, motor relearning, functional electrical stimulation (FES), biofeedback, balance retraining, gait reeducation, and use of supportive equipment. Physical therapists must be aware of the progress of paralysis in brain tumor patients as a result of increasing tumor size. Physical therapists should know how to improve convalescence of the brain. Additionally, cognitive dysfunction, apraxia, and aphasia should be assessed [49].
\nPhysical therapists should aim to treat paralysis and improve ADL as soon as possible. Attention should be paid to progressive paralysis in brain tumor patients.
\nOverall, the annual incidence of head and neck cancer worldwide is more than 550,000 cases with around 300,000 deaths [50]. Men are affected significantly more than women [51]. Head and neck cancer includes cancers of the mouth, nose, sinuses, salivary glands, throat, and lymph nodes in the neck. Most originate from the moist tissues that line the mouth, nose, and throat. Head and neck cancers can also originate within the salivary glands. Salivary glands contain many different types of cells that can become cancerous leading to many different types of salivary gland cancers.
\nTreatment options include surgery, radiation therapy, chemotherapy, and targeted therapy [52]. Surgery or radiation therapy alone or a combination of these treatments may be part of a patient’s treatment plan [53]. Tracheostomy is performed when there are concerns about breathing due to airway obstruction associated with a throat cancer or treatment side effects [54]. Nutritional status of patients declines following tracheostomy. As patients are not able to eat, they usually receive intravenous feeding.
\nAspiration pneumonia after concurrent chemoradiation therapy and surgery is seen in head and neck cancer patients [55]. Most patients have dysphagia and are at increased risk of having aspiration and subsequent pneumonia [56]. Additionally, physical therapists must be aware of the decline in nutritional status after surgery or chemoradiation in these patients [57]. Paralysis of accessory nerve that causes trapezius muscle dysfunction is often seen following neck dissection [58]. This dysfunction leads to shoulder syndrome with adhesive capsulitis. Muscle weakness, decline of ADL, dizziness, loss of appetite, shortness of breath, depression are observed in a substantial majority of patients during or after their initial treatment (surgery, radiation, and/or chemotherapy) [59]. Upper and lower extremities tend to be weaker following long-term bedridden and sedentary treatment.
\nGeneral pulmonary function tests are performed: spirometry; breathing pattern and cough; breath sounds including wheezing, coarse crackles, fine crackles, and rhonchi; and posture deformities in the chest or the spine; dysphagia evaluation; and ADL. Additionally, physical therapists should perform exercise tolerance test in gynecologic cancer patients. Furthermore, physical therapists should assess shoulder function including strength, mobility, and pain after surgery or chemoradiotherapy. Physical therapists often assess ICF category and lower and upper joint ROM; perform MMT; and evaluate pain levels, fatigue, and locomotion ability such as gait speed, balance function, and QOL.
\nPhysical therapy of the arms is performed to improve locomotion and pulmonary dysfunction. Some previous reports showed that physical therapy has effectiveness in head and neck cancer patients [60, 61]. When patients have paralysis of the accessory nerve, physical therapists perform exercises for the trapezius muscle to reduce its dysfunction [62]. Additionally, physical therapy of head and neck cancer patients includes locomotion ability exercises such as standing and walking, massage, manual stretching, myofascial therapy, relaxation massage, stretching, strengthening, resisted exercise, PNF, aerobic exercise, TENS, patient education, and behavioral training [63, 64]. However, if patients are fasting and have aspiration, they may have lower nutritional status requiring physical function recovery to be delayed.
\nPhysical therapists must recognize that head and neck cancer patients tend to experience decline of the pulmonary function and paralysis of accessory nerve following the neck surgery. Physical therapists should recover pulmonary and shoulder function and improve ADL in such patients.
\nLung cancer is the most frequently diagnosed cancer worldwide with about 1.35 million new cases diagnosed each year [65]. Lung cancer starts with uncontrollable growth of abnormal cells in the lung. These cells can invade nearby tissues and form tumors. Lung cancer can start anywhere in the lungs and affect any part of the respiratory system. Cancer cells can spread, or metastasize, to the lymph nodes and other parts of the body. There are two main types of lung cancer: small-cell lung cancer (SCLC) and non-small-cell lung cancer (NSCLC). Small-cell lung cancers usually grow quicker and are more likely to spread to other body parts. Non-small-cell lung cancer accounts for about 85% of all lung cancer cases, whereas small-cell lung cancer accounts for about 15% of all lung cancer cases [50, 66].
\nLung cancer treatment depends on its type. Small-cell lung cancer is mostly treated with chemotherapy [67]. Non-small-cell lung cancer can be treated with surgery, chemotherapy, radiotherapy, or a combination of these depending on the stage at which the cancer is diagnosed [68, 69].
\nWhen lung cancer treatment involves chemotherapy only, patients experience a decrease in physical function including decreased muscle strength and flexibility, which is also observed before the treatment. However, if lung cancer patients receive surgery, they encounter more problems than without the surgery. These problems include pulmonary dysfunction and decline of locomotion and ADL. Additionally, lung cancer patients experience pain of a surgical wound following thoracotomy and costectomy. Muscle weakness, decline of ADL, dizziness, loss of appetite, shortness of breath, and depression occur in a substantial majority of patients during or after their initial treatment (surgery, radiation, and/or chemotherapy). Upper and lower extremity and trunk muscle strength decreases following long-term bedridden and sedentary treatment.
\nGeneral pulmonary function tests include spirometry; breathing pattern and cough; breath sounds like wheezing, coarse crackles, fine crackles, and rhonchi; postural deformities in the chest or the spine; and dysphagia evaluation on ADL [70, 71]. Additionally, physical therapists should assess exercise tolerance and shoulder function including its strength, mobility, and pain following surgery or chemoradiotherapy in patients with lung cancer. Physical therapists often assess ICF category and lower and upper joint ROM; perform MMT; and assess pain levels, fatigue, and locomotion ability such as gait speed, balance function, and QOL.
\nPhysical therapy of the arms is done in order to improve locomotion and pulmonary dysfunction after the treatment [72]. Some previous studies reported that preoperative physical therapy has effectiveness in lung cancer patients [73, 74]. Intensive physical therapy appears to increase oxygen saturation, reduce hospital stay, and change ventilation/perfusion distribution in lung cancer patients [73]. Following surgery with resection, physical therapists promote mobilization starting at the intensive care unit (ICU) because lung cancer patients tend to be sedentary leading to progressive decline in their physical function. Physical therapy for lung cancer patients includes massage, manual stretching, myofascial therapy, relaxation massage, stretching, strengthening, resisted exercise, PNF, aerobic exercise, TENS, patient education, and behavioral training.
\nPhysical therapists should prevent development of further weakness after the treatment. Following surgery, physical therapists must make lung cancer patients perform pulmonary and mobilization exercises as soon as possible.
\nEsophageal carcinoma affects more than 450,000 people worldwide, and the incidence is rapidly increasing [75]. Esophageal cancer is a disease in which malignant (cancer) cells form in the tissues of the esophagus. The most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma. Smoking and heavy alcohol use increase the risk of esophageal squamous cell carcinoma [76]. Esophageal cancer is often diagnosed at an advanced stage because there are no early signs or symptoms. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. Esophageal cancer can also spread into the lungs, liver, stomach, and other parts of the body.
\nChemotherapy, radiotherapy, and surgery are often used as treatments for esophageal cancers [77]. Chemotherapy by itself rarely is effective. It is often combined with radiation therapy. Chemoradiation is often used before the surgery aiming to remove the cancer and some of the normal surrounding tissues. In some cases it might be combined with other treatments, such as chemotherapy and/or radiation therapy [78].
\nIf esophageal cancer patients receive chemotherapy or radiotherapy alone, they tend to have decreased physical function including loss of muscle strength and flexibility which is also observed before treatment. However, if surgery is performed, patients have more problems than without surgery, including pulmonary dysfunction and decline of locomotion and ADL. Following surgery, patients have to stay in ICU for few days. During this period, patients may develop a decline in pulmonary function and as a result, they may be intubated for a long time. Additionally, fasting is common for a few weeks until patients can eat food without aspiration. Muscle weakness, decline of ADL, dizziness, loss of appetite, shortness of breath, depression are observed in a substantial majority of patients during or after their initial treatment (surgery, radiation, and/or chemotherapy). Upper and lower extremity and trunk muscle strength decreases following long-term bedridden and sedentary treatment.
\nGeneral pulmonary function tests should be performed in cancer patients. This includes spirometry; breathing pattern and cough; breath sounds like wheezing, coarse crackles, fine crackles, and rhonchi; and postural deformities in the chest or the spine. Evaluation of dysphagia on ADL should be also often assessed. Additionally, physical therapists should assess exercise tolerance in esophageal cancer patients and shoulder function including strength, mobility, and pain after surgery or chemoradiotherapy in patients with esophageal cancers. Physical therapists often assess ICF category and lower and upper joint ROM; perform MMT; and assess pain levels, fatigue, and locomotion ability such as gait speed, balance function, and QOL [79].
\nTo date, there are no previous studies reporting that physical therapy is effective in esophageal cancer patients. In general, physical therapy has few aims in these patients. First, performance of pulmonary exercises including positioning and breathing exercises promotes weaning of the ventilator and extubating. Second, improvement of locomotion promotes mobilization in patient’s bedside [80]. Third, physical therapy aims to improve muscle strength and exercise tolerance during hospitalization. Physical therapy often includes massage, manual stretching, myofascial therapy, relaxation massage, stretching, strengthening, resisted exercise, PNF, aerobic exercise, TENS, patient education, and behavioral training.
\nPhysical therapists should aim to prevent further weakness after the treatment. Following surgery, physical therapists must make patients perform pulmonary exercise and mobilization as soon as possible.
\nThe age-adjusted incidence rate of primary malignant bone tumors in the United States is 0.9 per 100,000 persons per year, accounting for approximately 0.2% of all malignancies [81]. Bone cancer is a rare form of cancer that can affect any bone in the body. Bone cancer is a cancer that arises from the cells that make up the bones. When cancer is detected in the bone, it most often has started somewhere else (e.g., in another organ) and then spread to the bones. This is known as cancer that has metastasized to the bone and is named after the site where the original cancer began. Bone cancer can vary widely from person to person depending on its location and size. The most common type of malignant bone tumor is osteosarcoma, which most often develops in the bones of the arms, legs, and pelvis. Other types of bone cancer include the following: chondrosarcoma, Ewing’s tumor, chordoma, fibrosarcoma, giant cell tumor, and malignant fibrous histiocytoma [82].
\nTreatment includes surgery, chemotherapy, and radiation therapy [83, 84]. Amputation may be necessary if limb-sparing surgery is not possible or had no positive outcomes [85].
\nChemotherapy or radiotherapy alone results in and improvement of physical function including muscle strength and flexibility. However, if bone cancer patients received surgery, they could develop some problems. Patients may have pain and weakness of the affected limb and may have restricted weight bearing and movement of limbs or the spine. In addition, when amputation of the arm, leg, hand, or foot is performed, patients become more physically disabled. Bone cancer patients with spine tumor, paraplegia, or quadriplegia have declined motor and sensory function in addition to bladder and bowel dysfunction [86].
\nPhysical therapists should often assesses ICF category; pain levels; affected bone tumor; ROM; MMT; fatigue; ADL; and locomotion ability such as gait speed, balance function, and QOL. Physical therapists should be aware of motion and weight-bearing restrictions that occur after the surgery. In case of amputation, physical therapists should assess phantom limb pain, muscle strength, and mobility of the affected limb. Patients with spine tumor have paralysis; hence, physical therapists should use the American Spinal Injury Association (ASIA) scores for evaluation of sensory function, strength, mobility, and pain after the surgery or chemoradiotherapy.
\nTo date, there are no previous studies reporting that physical therapy is effective in bone cancer patients. In general, physical therapists must pay attention to fragile bones. Bone tumors make bones easy to fracture with vigorous movements. Physical therapy differs depending on the treatment of bone cancer. When bone cancer patients receive chemotherapy and radiotherapy only, muscle strengthening and endurance exercises are performed. However, when patients receive surgery, physical therapists must pay attention to contraindicative exercises. When patients receive amputation, limb prosthetics should be considered by the physiotherapist together with a prosthetist and an orthotist. In bone cancer patients with paraplegia such as bone tumor in the spinal cord, physical therapy is carried out in accordance with physical therapy of spinal cord injury. Otherwise, physical therapy often includes stretching, strengthening, resisted exercise, PNF, aerobic exercise, patient education, and behavioral training.
\nPhysical therapists must know the location and progression of bone tumor as it is an important factor allowing improvement of physical function after treatment.
\nThe number of new cases of leukemia is 4.5–9.1 per 100,000 men and 3.6–6.0 per 100,000 women per year [50]. Blood cancer affects the blood and lymph systems. Bone marrow has a function of producing blood cells such as red blood cells, white blood cells, and platelets. Bone marrow is a flexible soft tissue found in the hollow interior of the bones. Blood cancer may begin in blood-forming tissue (e.g., bone marrow) or in the cells of the immune system. There are different types of hematological cancers including leukemia, non-Hodgkin lymphoma, Hodgkin lymphoma, and multiple myeloma. Leukemia is a cancer that originates in the white blood cells and affects people of all ages [87].
\nIn general, blood cancer treatment includes chemotherapy, corticosteroids, radiation, and HSCT.
\nFirst, blood cancer patients that have received chemotherapy experience a decrease in physical function including muscle strength and endurance capacity. Second, if complete remission is not achieved after chemotherapy, HSCT has to be chosen. In this case, patients experience even more decreased muscle strength and endurance capacity as they have to stay in a hospital for a few weeks [88, 89]. Hospitalized patients often have graft-versus-host disease (GVHD). GVHD normally affects the skin, liver, and gastrointestinal system resulting in further dysfunctions. Furthermore, following HSCT treatment, patients must stay in the isolation room to prevent infection; hence, a decrease in physical activity during these days will occur [90].
\nPhysical therapists should assess muscle strength, body composition, mobility, and endurance capacity in blood cancer patients. Physical therapists often assess ICF category, lower and upper joint ROM, balance function, MMT, fatigue, and locomotion ability such as gait speed, balance function, and QOL [91–94].
\nPhysical therapy focused on the arms is performed in order to improve locomotion and muscle strength after treatment. Some previous reports showed that physical therapy is effective in pediatric leukemia patients [95, 96]. Additionally, some previous reports showed that physical therapy is effective in patients with HSCT [90, 97]. Following HSCT, physical therapists must wear a mask, plastic grove, and apron during physical therapy. The most common physical therapy of blood cancer includes massage, manual stretching, myofascial therapy, relaxation massage, stretching, strengthening, resisted exercise, PNF, aerobic exercise, balance training, TENS, patient education, and behavioral training.
\nPhysical therapists should aim to increase muscle strength and exercise capacity in blood cancer patients. Additionally, physical therapists must be aware that patients may have myelosuppression as a result of chemotherapy. Physical therapy should be performed in such a way that it prevents infection in these patients.
\nPalliative care helps people cope with the symptoms of cancer and cancer treatment [98]. Palliative care aims to improve the quality of life of patients who have serious or life-threatening diseases [99]. The goal of palliative care is to prevent or treat the symptoms and side effects of the disease and its treatment in addition to related psychological, social, and spiritual problems [100]. However, the main goal is not to cure patients [101]. When many different treatments have been tried and showed no control over cancer, it could be the time to weigh the benefits and risks of continuing trying new treatments. Palliative care provides patients of any age or disease stage with relief from symptoms, pain, and stress and should be provided along curative treatment. Palliative care focuses on helping people get relief from symptoms caused by serious illness (e.g., nausea, pain, fatigue, or shortness of breath) [102].
\nPalliative treatment is designed to relieve symptoms and often includes medication, nutritional support, relaxation techniques, spiritual support, emotional support, and other therapies [103, 104]. Palliative treatment improves patient’s quality of life. It can be used at any stage of an illness and also if there are troubling symptoms such as pain or sickness. Palliative treatment can also mean using medicines to reduce or control side effects of cancer treatments.
\nCancer patients have many problems making palliative care a good additional treatment option. Patients have many symptoms including pain, fatigue, loss of appetite, nausea, vomiting, shortness of breath, insomnia, thirst, dry mouth, bad taste, and difficulty swallowing. Gradually, patients may become bedridden and sedentary. Patients usually have a bigger decrease in muscle strength, pulmonary function, ADL, and locomotion after they received palliative care. In some cases, cancer patients have lymphedema. Unfortunately, patients may die in a few weeks or months.
\nPhysical therapists should often assess ICF category, pain levels, ROM, MMT, fatigue, ADL, and QOL. Additionally, physical therapists should perform pulmonary function tests including spirometry; breathing pattern; cough; breath sounds such as wheezing, coarse crackles, fine crackles, and rhonchi; and postural deformities in the chest or the spine and evaluate dysphagia on ADL. If cancer patients become bedridden for a long time, physical therapists should assess pressure ulcers at the sacrum and coccyx.
\nA few previous reports showed that physical therapy may be effective in cancer patients who receive palliative care [105, 106]. In general, physical therapy helps to maintain mobility and improves body movements [7, 107]. Physical therapists improve locomotion ability by exercises that include standing and walking, massage, manual stretching, strengthening, resisted exercises, aerobic exercises, patient education, and behavioral training. If patients have severe pain related to cancer, physical therapy includes myofascial therapy, relaxation massage, TENS, heat and cold, and positioning. If patients are bedridden or sedentary for a long time, physical therapists should relieve pressure to prevent pressure ulcers on bones such as the sacrum and coccyx.
\nPhysical therapists must be aware that cancer patients experience more fatigue and pain while improving their locomotion. When cancer patients cannot receive progressive physical therapy, physical therapists should use myofascial therapy, relaxation massage, TENS, heat and cold, and positioning to relieve pain.
\nCancer patients have some physical impairment. Physical therapy is helpful and contributes to patients’ recovery. Cancer patients are exposed to some risk factors during physical therapy. Therefore, physical therapists must pay attention and manage those risk factors. Cancer survivors increase 5 years of survival in various cancer diseases. Physical therapy may have an important role to improve physical function, ADL, and QOL of cancer patients and cancer survivors.
\nBacteria, fungi (yeasts and molds), mycobacteria, prions, protozoa, and viruses are common pathogens infecting humans and animals. They typically exist within the host or in the environment. It has been observed that these microorganisms exhibit a notable difference in the natural survivability in the environment, as well as susceptibility to chemical and physical inactivation. For example, under ambient and dried conditions, human coronaviruses seem to lose their infectivity in a matter of several hours to several days [1], whereas endospores and prions may remain infectious for years to decades or even indefinitely [2, 3].
As more and more data have become available regarding the survivability and susceptibility of pathogens to microbicides, it has been observed that the pathogens seem to demonstrate an order of susceptibility to chemical and physical inactivation. E. H. Spaulding first proposed a classification system for the sterilization and disinfection of medical instruments based on the infection risk in 1939 [4]. On the basis of this classification, the concept of a hierarchy of pathogen susceptibility was proposed, in which microorganisms are placed into several groups and ranked from least susceptible to most susceptible. In this hierarchy concept, bacterial spores were ranked the least susceptible, followed by mycobacteria, non-enveloped viruses, fungi, vegetative bacteria, and enveloped viruses. The susceptibility hierarchy was also believed to be related to the biochemical and biophysical characteristics of a pathogen [5, 6].
This hierarchy concept has been slightly modified and expanded over the years. For example, prions were added and considered less susceptible to inactivation by microbicides than bacterial spores; small non-enveloped viruses were considered less susceptible than large non-enveloped viruses; and the order between mycobacteria and small non-enveloped viruses was sometimes reversed (Figure 1) [7, 8, 9, 10]. Additionally, it has been suggested that the hierarchy concept may be applied either “vertically” (i.e., ranking of susceptibility
Proposed hierarchy of susceptibility of pathogens to microbicides. Note: slightly different versions of the hierarchy concept have been proposed in the literature. Mycobacteria have been placed above small non-enveloped viruses, and molds have been placed above large non-enveloped viruses in certain versions. In some versions, the small and large non-enveloped viruses are combined; and yeasts and molds may be combined.
The hierarchy concept has been quite useful for enabling scientists to better understand the innate difference among various types of pathogens. In the case of newly emerged pathogens, especially, the hierarchy concept has helped stakeholders design and implement a disinfection strategy swiftly with a reasonable level of confidence. The concept also helps the contaminant control for food, pharmaceutical, and biopharmaceutical products, as it is impractical to test every possible contaminating pathogen, and a robust infectivity assay system may be lacking for certain pathogens (e.g., hepatitis E virus).
Despite its usefulness, the hierarchy concept should be interpreted with caution, as it may oversimply the differences and trending of pathogen susceptibilities. Further examination and refinement of the concept may be necessary; and several important questions should be answered. For example, how often do exceptions to the hierarchy occur and what are the underlying reasons? Could a trending be specific to a given type of chemistry? Is the hierarchy the same between susceptibility to both chemical and physical inactivation? Why do pathogens in the same group, or even the same family or genus, sometimes exhibit striking differences in susceptibility? Is there a way to identify and separate reliable/consistent trending versus blurred/variable trending? A deeper look at the efficacy data for various types of microbicidal actives, especially for non-enveloped viruses, may help stakeholders understand the scope, reliability, and limitation of the hierarchy concept so that it can be best utilized.
This chapter reviews the inactivation efficacy data from the literature against non-enveloped viruses for several commonly used types of chemistries, either in formulated or unformulated form, in an effort to generate a separate relative order of susceptibility among these non-enveloped viruses for each type of chemistry and to differentiate consistent versus variable trending. Physical inactivation approaches are not covered in this chapter, although a significant degree of variation also exists for physical treatments. It is not clear that the physical inactivation approaches, in general, are governed by the same hierarchy to susceptibility as is observed for chemical inactivation approaches [12].
Currently, there are a total of 21 families of viruses (including enveloped and non-enveloped) identified for humans [13], which represent only a small part of the entire paradigm of viruses in nature, whose host ranges extend from vertebrates to plants to bacteria. The most common families of non-enveloped viruses for humans and animals include
Family | Example virus | Abbreviation | Genus | Genome | Size (nm) |
---|---|---|---|---|---|
Adenovirus type 2 | AdV-2 | ds DNA | 70–90 | ||
Adenovirus type 5 | AdV-5 | ds DNA | 70–90 | ||
Adenovirus type 8 | AdV-8 | ds DNA | 70–90 | ||
Human astrovirus | HAstV | ss RNA | 28–35 | ||
Feline calicivirus | FCV | ss RNA | 28–40 | ||
Human norovirus | HuNoV | ss RNA | 28–40 | ||
Murine norovirus | MNV | ss RNA | 28–40 | ||
Tulane virus | TuV | ss RNA | 28–40 | ||
Porcine circovirus | PCV | ss DNA | ∼17 | ||
Hepatitis E virus | HEV | ss DNA | 32–34 | ||
Human papillomavirus | HPV | ds DNA | 50–60 | ||
Bovine parvovirus | BPV | ss DNA | 20–28 | ||
Canine parvovirus | CPV | ss DNA | 20–25 | ||
Human parvovirus B19 | B19V | ss DNA | 23–26 | ||
Minute virus of mice | MVM (MMV) | ss DNA | 20–25 | ||
Porcine parvovirus | PPV | ss DNA | 20–25 | ||
Bovine enterovirus | BEV | ss RNA | 30–32 | ||
Coxsackievirus | Cox | ss RNA | 30–32 | ||
Echovirus 11 | Echo11 | ss RNA | 30–32 | ||
Encephalomyocarditis virus | EMCV | ss RNA | 30–32 | ||
Enterovirus 71 | EV-71 | ss RNA | 30–32 | ||
Enterovirus D68 | EV-D68 | ss RNA | 30–32 | ||
Foot and mouth disease virus | FMDV | ss RNA | 30–32 | ||
Hepatitis A virus | HAV | ss RNA | 30–32 | ||
Poliovirus type 1 | PV1 | ss RNA | 30–32 | ||
Rhinovirus | RV | ss RNA | 30–32 | ||
Seneca Valley virus | SVV | ss RNA | 30–32 | ||
Bovine polyomavirus | BPyV | ds DNA | 40–50 | ||
Simian virus 40 | SV40 | ds DNA | 40–50 | ||
Bluetongue virus | BTV | ds RNA | 60–80 | ||
Reovirus type 3 | REO-3 | ds RNA | 60–80 | ||
Rotavirus | Rota | ds RNA | 60–80 |
Common families of human and animal non-enveloped viruses.
Among these, the
It is worth noting that viruses are typically classified taxonomically on the basis of virion properties (size, shape, envelope, physical, and chemical properties, etc.), genome organization, replication mechanism, antigenic properties, and biological properties [13, 14, 15]. The final classification is a combined consideration of these properties. However, the stability and susceptibility to inactivation of a virus may not relate to all of these properties and, as such, may not always align with the taxonomic classification system. For example, the susceptibility of a virus to surfactants may primarily be related to the envelope of the virion and not related to the genome structure or mode of replication.
The susceptibilities of non-enveloped viruses to chemicals have been found to be highly variable and somewhat hard to predict, since they do not always agree with the hierarchy concept. For example, according to the hierarchy concept as modified by Sattar [8], small non-enveloped viruses should be less susceptible than large non-enveloped viruses. Additionally, if there is a fixed hierarchy, all small non-enveloped viruses should either display similar levels of susceptibility or should demonstrate a definitive trend of relative susceptibility, regardless of the type of microbicide. Based on the literature, neither of these predictions appear to hold in every case. The relative order of susceptibility seems chemistry-dependent; and sometimes viruses within the same family or even genus have been found to exhibit unequivocal differences in their susceptibilities (reviewed in [16]). Any trending or hierarchy, therefore, must be reviewed in the context of the type of chemistry, and it should not be assumed that non-enveloped viruses within the same family or genus will always display similar susceptibilities to a given microbicide.
Viral inactivation may be achieved by chemical and/or physical methods. The subset of chemicals commonly used for inactivation of non-enveloped viruses includes alcohols, oxidizers, halogen compounds, quaternary ammonium compounds, phenolics, aldehydes, acids, and alkalines [17, 18, 19]. These differ with respect to efficacy, stability, toxicity, material or surface compatibility, cost, and sensitivity to organic soil load. Soil load is a term used to signify an organic matrix used to challenge the inactivating efficacy of a microbicide. It is intended to mimic secretions or excretions in which the virus would be released from an infected person or animal. Some chemistries (e.g., sodium hypochlorite, phenolics, and aldehydes) are mostly used for environmental or medical device disinfection. Other chemistries (e.g., ethanol) are more commonly used for hand hygiene, while some others (e.g., quaternary ammonium compounds) may be used for both environmental disinfection and skin antisepsis (Table 2).
Class | Chemical | Typical conc. | Usage | Mechanism of viral inactivation | Sensitivity to soil load |
---|---|---|---|---|---|
Alcohols | Ethanol | 50–95% | Disinfection; Antisepsis | Protein denaturation | + |
Isopropanol | 70–90% | Disinfection | Protein denaturation | + | |
Oxidizers | Sodium hypochlorite | 0.01–0.5% | Disinfection | Protein/genome damage | ++ |
Chlorine dioxide | 0.1–1 mg/L | Disinfection; Water treatment | Protein/genome damage | — | |
Hydrogen peroxide | 0.1–10% | Disinfection; Antisepsis | Lipid/protein/genome damage | + | |
Hypochlorous acid | 0.002–0.1% | Disinfection; Water treatment | Protein/genome damage | ++ | |
Peracetic acid | 0.01–1% | Disinfection; Sterilization | Protein denaturation | — | |
Povidone-iodine | 0.02–8% | Disinfection; Antisepsis | Protein/genome damage | ++ | |
Chlorohexidine | 0.02–0.2% | Antisepsis | Protein denaturation | + | |
QAC | BKC, DDAC, etc. | 0.01–0.2% | Disinfection | Lipid/protein damage | + |
Low pH | Acids | ≤ pH 4 | Sanitization; Biomanufacturing | Capsid/protein damage | — |
High pH | NaOH, etc. | ≥ pH 10 | Disinfection; Tissue processing | Capsid/genome damage | — |
Aldehydes | Glutaraldehyde | 0.02–2% | HLD; Sterilization | Crosslinking/protein & genome damage | — |
Formaldehyde | 0.1–5% | Disinfection/Preservation | Alkylating/protein & genome damage | — | |
OPA | 0.02–2% | HLD; Sterilization | Crosslinking/protein damage | — | |
Phenolics | Phenylphenol, etc. | 0.05–5% | Disinfection | Protein damage | — |
Common types of chemistries used for non-enveloped viral inactivation.
Abbreviations used: BKC, benzalkonium chloride; Conc, concentration; DDAC, didecyldimethylammonium chloride; HLD, high-level disinfection; NaOH, sodium hydroxide; OPA, ortho-phthaldehyde; QAC, quaternary ammonium compounds.
The virucidal efficacy of a product is not only determined by the type and concentration of the chemical, but is also heavily influenced by the formulation, pH, exposure (contact or dwell) time, organic soil load, temperature, and surface characteristics (as applicable), etc. [10, 20, 21, 22]. Given the differences between various testing methods, as well as the intrinsic variability of viral infectivity (titration) assays, a general conclusion on the efficacy of a particular type of active ingredient will be enhanced if the efficacy is derived from multiple sets of data and under various application conditions (such as the concentration of the microbicidal active(s), contact time, formulation matrix (as applicable), and organic soil load, etc.) Additionally, in order best to explore the relative ranking of susceptibility between viruses, or the lack thereof, efficacy data from side-by-side studies wherein the same test methodologies and conditions were used would be preferable. Care should be taken when comparing data from different studies, especially if the formulations, test methods, and test conditions were different.
Alcohols, primarily ethanol and isopropanol, are widely used for hand hygiene and environmental disinfection, and their efficacies against bacteria and viruses have been extensively studied [23, 24, 25]. Ethanol at a concentration of 70–90% and isopropanol at 70% have been broadly shown to be effective against enveloped viruses; however, their efficacies against non-enveloped viruses are much more variable.
The trending of the degree of susceptibility of non-enveloped viruses to ethanol and isopropanol is generally clearer and more consistent than it is for many other types of chemistries, thanks to the large amount of data in the literature. The relative ranking of susceptibility of non-enveloped viruses seems to differ between ethanol and isopropanol; and the ranking does not appear to align well with the classical virological taxonomy.
For ethanol, parvoviruses and the polyomavirus simian virus 40 have low susceptibility, while rotavirus (a reovirus) is susceptible (Table 3). Viruses in the
Virusa | Method | Soil/Matrixb | Log10 Reduction after | References | |||
---|---|---|---|---|---|---|---|
30 s | 1 min | 5 min | 10 min | ||||
PPV | Stainless steel | Erythrocytes + BSA | 0.3 | 0.6 | [26] | ||
MVM | Stainless steel | Erythrocytes + BSA | 0.3 | 0.7 | [26] | ||
HEV71 | Suspension test | Medium | < 1 | [27] | |||
HAV | Suspension test | Medium | 0.4 | [28] | |||
HAV | Suspension test | 20% fecal | 0.4 | [28] | |||
HuNoV | Suspension test | 20% stool | <0.5 | [29] | |||
TuV | Suspension test | Medium | <0.5 | [30] | |||
PV1 | Suspension test | 20% fecal | 0.3 | [28] | |||
PV1 | Suspension test | Medium | 0.4 | [31] | |||
PV1 | Glass | Medium | 2.3 | 1.0 | 5.0 | [31] | |
PV1 | Stainless steel | Erythrocytes + BSA | 2.1 | 1.8 | [26] | ||
PV1 | Suspension test | Medium | 4 | [28] | |||
FCV | Suspension test | Medium | 1.7 | 2.2 | [30] | ||
AdV-8 | Suspension test | Medium | 1.9 | [33] | |||
AdV-5 | Stainless steel | Erythrocytes + BSA | 2.4 | >4.1 | [26] | ||
AdV-5 | Stainless steel | Medium | ∼5 | [34] | |||
MNV | Suspension test | Medium | 5 | [30] | |||
Rotavirus | Suspension test | Medium | > 3.1 | [28] | |||
CPV | Stainless steel | Medium | 0.1 | [36] | |||
SV40 | Suspension test | Medium | <1 | [37] | |||
PV1 | Glass | Medium | 2.9 | 2.9 | 5.4 | [31] | |
TuV | Suspension test | Medium | <0.5 | [30] | |||
FCV | Suspension test | Medium | <0.5 | [30] | |||
HEV71 | Suspension test | Medium | <1 | [27] | |||
PV1 | Suspension test | medium | <1 | [37] | |||
PV1 | Glass | Medium | 1.2 | 1.3 | 1.0 | [31] | |
AdV-5 | Stainless steel | Medium | ∼1 | [34] | |||
AdV-8 | Suspension test | Medium | 2.0 | [33] | |||
MNV | Suspension test | Medium | 1.8 | 3.1 | [30] | ||
SV40 | Suspension test | Medium | >4 | [37] | |||
Rotavirus | Suspension test | Medium | > 4 | [42] |
Efficacy of alcohols against non-enveloped viruses.
See Table 1 for abbreviations used for viruses.
BSA, bovine serum albumin; medium, culture medium; RT, room temperature.
Entries in purple font indicate results from undiluted or diluted formulations with the indicated microbicidal active ingredients.
Interestingly, the above order of susceptibility does not appear to hold the same for isopropanol (Table 3). For example, the polyomavirus simian virus 40 is much more susceptible to isopropanol than many other non-enveloped viruses; and poliovirus appears to display a lower susceptibility, similar to that of hepatitis A virus and human enterovirus 71. Murine norovirus is still more susceptible than feline calicivirus to isopropanol, but not as susceptible as simian virus 40 or rotavirus. The apparent difference between adenovirus 5 and adenovirus 8 that has been observed for ethanol has not been observed for isopropanol.
An oxidizer or oxidizing agent is a chemical that has the ability to oxidize other molecules, i.e., to accept their electrons. Common oxidizing agents used for disinfection, sterilization, or antisepsis include hydrogen peroxide, peracetic acid, ozone, and halogen-containing compounds such as sodium hypochlorite (bleach), hypochlorous acid, povidone-iodine, chlorohexidine, and chlorine dioxide, etc. These compounds can react with and alter the proteins and nucleic acids of non-enveloped viruses and render them noninfectious. Oxidizers comprise a large group of chemicals, and the relative order of susceptibility of non-enveloped viruses to oxidizers seems to vary by specific type of active ingredient (Table 4).
Virusa | Method | Soil/Matrixb | Log10 Reduction after | References | |||
---|---|---|---|---|---|---|---|
≤ 1 min | 2 min | 5 min | 10 min | ||||
FCV | Suspension test | Medium | 3 | [29] | |||
FCV | Suspension test | 20% stool | 0.5 | [29] | |||
MNV | Suspension test | Medium | 3 | [29] | |||
MNV | Suspension test | 20% stool | 0.0 | [29] | |||
CPV | Stainless steel | 90% plasma | < 1 | [43] | |||
CPV | Stainless steel | 5% serum | 5 | [43] | |||
HAV | Stainless steel | 5% serum | 5 | [43] | |||
HAV | Stainless steel | 90% plasma | <1 | 5 | [43] | ||
HAV | Suspension test | PBS/20% fecal | 4 | [28] | |||
PV1 | Suspension test | PBS/20% fecal | 4 | [28] | |||
PPV | Stainless steel | Erythrocytes + BSA | 0.6 | 1.0 | [26] | ||
MVM | Stainless steel | Erythrocytes + BSA | 3.0 | 4.4 | [26] | ||
PV1 | Stainless steel | Erythrocytes + BSA | 2.8 | 4.5 | [26] | ||
AdV-5 | Stainless steel | Erythrocytes + BSA | 4 | [26] | |||
PV1 | Glass | Medium | 0.4 | 0.9 | [16] | ||
RV14 | Glass | Medium | >4.9 | [16] | |||
PPV | Stainless steel | Erythrocytes + BSA | 0.5 | [26] | |||
MVM | Stainless steel | Erythrocytes + BSA | 1.5 | [26] | |||
PV1 | Stainless steel | Erythrocytes + BSA | 3.9 | [26] | |||
AdV-5 | Stainless steel | Erythrocytes + BSA | 2.3 | [26] | |||
MNV | Suspension test | Medium | ∼3 | [52] | |||
HAV | Suspension test | Medium | ∼3 | [53] | |||
PV | Suspension test | Medium | >3 | [53] | |||
CPV | Stainless steel | BSA | 1.6 | [34] | |||
MVM | Stainless steel | BSA | 2.3-2.9 | [34] | |||
PPV | Stainless steel | BSA | 3.8-5.5 | [34] | |||
AdV-5 | Stainless steel | BSA | 4.9-5.8 | [34] |
Efficacy of oxidizers against non-enveloped viruses.
See Table 1 for abbreviations used for viruses.
BSA, bovine serum albumin; PBS, phosphate buffered saline; medium, culture medium; RT, room temperature.
Viral-inoculated lettuce was washed with PAA solution for a defined period of time.
Entries in purple font indicate results from undiluted original or diluted formulations with microbicidal active ingredients.
Parvoviruses are generally among the least susceptible viruses to various types of oxidizers, including sodium hypochlorite, hydrogen peroxide, and peracetic acid. However, for sodium hypochlorite, minute virus of mice appears to be more susceptible than porcine parvovirus and canine parvovirus. All picornaviruses appear to exhibit a similar degree of susceptibility to sodium hypochlorite; but within the family of
The trending for hydrogen peroxide seems more complex than that for sodium hypochlorite. For example, there seems a higher level of variability within the
For peracetic acid, hepatitis A virus also seems less susceptible than poliovirus. Both feline calicivirus and murine norovirus are susceptible to peracetic acid and so is adenovirus.
Quaternary ammonium compounds (QAC) are widely used as active ingredients for disinfectants. Among the advantages of QAC are good stability, dual function of disinfection and cleaning, surface activity, low toxicity, and lack of odor, etc. The potential limitation in the microbicidal efficacy and possible effect in promoting antimicrobial resistance of QAC have also been discussed in the literature [54, 55].
Quaternary ammonium compounds are generally efficacious on most vegetative bacteria and enveloped viruses. Their efficacies against non-enveloped viruses, however, are generally much weaker. Nevertheless, several non-enveloped viruses, such as rotavirus, rhinovirus, and coxsackievirus A11, have been shown to be susceptible to QAC. The susceptibility levels among the
Virusa | Method | Soil/matrixb | Log10 reduction after | References | |||
---|---|---|---|---|---|---|---|
30 s | 1 min | 10 min | 60 min | ||||
PPV | Stainless steel | Erythrocytes + BSA | 0.4 | [26] | |||
MVM | Stainless steel | Erythrocytes + BSA | 0.5 | [26] | |||
PV1 | Stainless steel | Erythrocytes + BSA | 0.5 | [26] | |||
AdV-5 | Stainless steel | Erythrocytes + BSA | 1.8 | [26] | |||
AdV-8 | Suspension test | Medium | 1.0-1.8 | [57] | |||
AdV-5 | Suspension test | Medium | 3.7-5.3 | [57] | |||
TuV | Suspension test | Medium | <0.5 | [30] | |||
PV1 | Suspension test | BSA/yeast extract | 0.0 | [58] | |||
AdV-25 | Suspension test | BSA/yeast extract | 0.3 | [58] | |||
Cox A11 | Suspension test | BSA/yeast extract | >5.1 | [58] | |||
FCV | Suspension test | Medium | <0.5 | [29] | |||
MNV | Suspension test | Medium | <0.5 | [29] | |||
Rhinovirus | Glass | Medium | >3.0 | >3.3 | [16] |
Efficacy of QAC against non-enveloped viruses.
See Table 1 for abbreviations used for viruses.
BSA, bovine serum albumin; medium, culture medium; QAC, quaternary ammonium compound.
Entries in purple font indicate results from original or diluted formulations with microbicidal active ingredients.
Acids and alkalines, either used alone or in combination with other active ingredients in formulated products, can be an effective means for viral inactivation. Acids may be used for disinfection, sanitization, textile or face mask pretreatment, or viral clearance during biopharmaceutical manufacturing. Alkalines may also be used for disinfection, sanitization, and viral clearance during biopharmaceutical manufacturing and can be effective against even the least susceptible of pathogens, the prions [58].
It has been widely reported that a low-pH treatment (typically at pH 4 and below) can effectively inactivate most enveloped viruses, although some enveloped viruses, such as bovine viral diarrhea virus, still exhibit a relatively low susceptibility to this treatment pH [22]. The range of susceptibilities of non-enveloped viruses to low pH seems quite scattered and often goes against the “conventional wisdom” that non-enveloped viruses are not susceptible to acidic pH (Table 6). For instance, in the family of
Virusa | Method | Soil/Matrixb | Log10 Reduction after | References | |||
---|---|---|---|---|---|---|---|
20 min | 30 min | 45 min | 1–2 hr | ||||
REO-3 | Suspension test | Medium | 1–3 | [59] | |||
PCV | Suspension test | Medium | >3 | [60] | |||
MVM | Suspension test | Medium | <1 | [61] | |||
MNV | Suspension test | Medium | <0.5 | [30] | |||
TuV | Suspension test | Medium | <0.5 | [30] | |||
PARV4 | Suspension test | Medium | 2–3 | [61] | |||
B19V | Suspension test | Medium | > 4 | [61] | |||
FCV | Suspension test | Medium | 6.3 | [30] | |||
FCV | Suspension test | Medium | >5 | [62] | |||
PV | Suspension test | Medium | <1 | [63] | |||
PV | Suspension test | Medium | <1 | [64] | |||
HAV | Suspension test | Medium | <1 | [64] | |||
MNV | Suspension test | Medium | <0.5 | [30] | |||
TuV | Suspension test | Medium | <0.5 | [30] | |||
Cox A9 | Suspension test | Medium | <1 | [65] | |||
FCV | Suspension test | Medium | ∼3 | [30] | |||
FCV | Suspension test | Medium | ∼4.7 | [62] | |||
RV | Suspension test | Medium | >3 | [65] | |||
FMDV | Suspension test | Medium | >3 | [65] | |||
MVM | Suspension test | Medium | <1 | [66] | |||
EV71 | Suspension test | Medium | <1 | [67] | |||
EV-D68 | Suspension test | Medium | ∼4–5 | <5 | [67] | ||
B19V | Suspension test | Medium | [66] |
Efficacy of low pH against non-enveloped viruses.
The
Feline calicivirus and murine norovirus in the family
Viruses, both enveloped and non-enveloped, are generally susceptible to high pH. At an environment of pH 12 or above, most if not all non-enveloped viruses would be inactivated, with extent depending both on temperature and contact time. Reovirus, simian virus 40, hepatitis A virus, canine parvovirus, poliovirus, murine norovirus, and Tulane virus seem to be less susceptible than minute virus of mice, feline calicivirus, adenovirus, rotavirus, and foot-and-mouth disease virus. It may be worth noting that the order of susceptibility to high pH seems to be in discord with the hierarchy concept by the greatest degree: in this case, an enveloped virus, bovine viral diarrhea virus, seems to be less susceptible than most, if not all, non-enveloped viruses [22]; parvoviruses are not necessarily less susceptible than many other non-enveloped viruses; and the size of the viral particle does not seem to matter much with regard to the degree of susceptibility (Table 7).
Virusa | Method | Soil/Matrixb | Log10 Reduction after | References | |||
---|---|---|---|---|---|---|---|
≤ 1 min | 10 min | 30 min | 1 hr | ||||
MNV | Suspension test | Medium | ∼2 | [30] | |||
TuV | Suspension test | Medium | ∼2.2 | [30] | |||
FCV | Suspension test | Medium | >5.5 | [30] | |||
REO-3 | Suspension test | Medium | 3 | [68] | |||
Cox B | Suspension test | Medium | 5 | [69] | |||
Echo 11 | Suspension test | Medium | 6 | [68] | |||
BVDV | Suspension test | Medium | 2.5 | [70] | |||
HAV | Suspension test | Medium | 2.7 | [59] | |||
SV40 | Suspension test | Medium | 3.9 | [70] | |||
HAV | Stainless steel | 5% serum | 3.0 | [43] | |||
HAV | Stainless steel | 90% plasma | 3.6 | [43] | |||
CPV | Stainless steel | 5% serum | 3.5 | [43] | |||
CPV | Stainless steel | 90% plasma | 5.2 | [43] | |||
MVM | Suspension test | Medium | >4.7 | [71] | |||
MVM | Suspension test | Medium | >4 | [66] | |||
CPV | Suspension test | Medium | 5.6 | [70] | |||
PV | Suspension test | Medium | 5.9 | [70] | |||
AdV-2 | Suspension test | Medium | >6.9 | [70] | |||
AdV-5 | Suspension test | Medium | >6 | [72] | |||
HAV | suspension test | Medium | 2.4 | [59] | |||
PV | suspension test | Medium | 4.1 | [63] | |||
Avian Reo | Suspension test | Medium | 4 | [73] | |||
PV | Suspension test | Medium | 5.1 | [73] | |||
Bovine Rota | Suspension test | Medium | >6 | [73] |
Efficacy of high pH against non-enveloped viruses.
Entries in purple font indicate results from undiluted or diluted formulations with microbicidal active ingredients.
Aldehydes, such as glutaraldehyde, formaldehyde, and
Virusa | Method | Soil/Matrixb | Log10 Reduction after | References | |||
---|---|---|---|---|---|---|---|
5 min | 10 min | 30 min | 60 min | ||||
HAV | Suspension test | Medium | 3.0 | [75] | |||
PPV | Stainless steel | BSA | 1.7–2.8 | [34] | |||
MVM | Stainless steel | BSA | 2.5–3.3 | [34] | |||
PV1 | Suspension test | Medium | >3 | [76] | |||
AdV-5 | Stainless steel | BSA | 4.9–6.3 | [34] | |||
PPV | Stainless steel | Erythrocytes + BSA | 3.6 | [26] | |||
MVM | Stainless steel | Erythrocytes + BSA | >4.4 | [26] | |||
AdV-5 | Suspension test | Medium | >5.0 | [77] | |||
Ortho-phthaldehyde, 0.55% | |||||||
PPV | Stainless steel | Erythrocytes + BSA | 3.6 | [26] | |||
MVM | Stainless steel | Erythrocytes + BSA | >4. | [26] |
Efficacy of aldehydes against non-enveloped viruses.
See Table 1 for abbreviations used for viruses.
BSA, bovine serum albumin; medium, culture medium; RT, room temperature.
Entries in purple font indicate results from original or diluted formulations with microbicidal active ingredients.
In the simplified hierarchy of susceptibility of pathogens to microbicides concept, small non-enveloped viruses are considered less susceptible than large non-enveloped viruses, and both groups of non-enveloped viruses are believed to be less susceptible than enveloped viruses. The hierarchy concept also assumes that the ranking applies to all types of microbicidal actives. Additionally, the hierarchy concept can generally lead to common notions that viruses that share similar virological properties (e.g., same family or genus of virus) may be expected to display similar degrees of susceptibility and that the smaller a virus is, the less susceptible it will be to microbicides in general.
These generalizations are correct, to a degree. For example, most enveloped viruses are indeed more susceptible than non-enveloped viruses to chemical inactivation. It should be noted though that exceptions to the hierarchy concept do exist, e.g., especially in the case of viral susceptibility to acids and alkalines [22], and exceptions are not uncommon for certain other chemistries. The hierarchy concept was never applied specifically to physical inactivation approaches, nor should it be. The evidence for heat inactivation, UV inactivation, and gamma irradiation indicates differing rankings of susceptibility to these modalities. Envelope status and particle size do not, in each case, relate to susceptibility for inactivation by these physical approaches [22, 78, 79, 80].
The validity of the hierarchy concept
The accuracy and usefulness of a hierarchy concept can be improved if the model is broken into separate chemistries for non-enveloped viruses, since many viruses do exhibit a reliable and consistent trend of susceptibility for a specific type of chemical. Table 9 and Figure 2 provide a summary of the relative order of susceptibility for selected non-enveloped viruses under specific types of chemistry.
Chemical | Lower susceptibility | Medium susceptibility | Higher susceptibility |
---|---|---|---|
Ethanol | Animal parvovirus | Poliovirus | Murine norovirus |
Simian virus 40 | Foot and mouth disease virus | Rhinovirus | |
Hepatitis A virus | Human norovirus | Adenovirus 5 | |
Enterovirus 71 | Feline calicivirus | Rotavirus | |
Adenovirus 2, 8 | |||
Isopropanol | Animal parvovirus | Adenovirus 5, 8 | Simian virus 40 |
Hepatitis A virus | Murine norovirus | Rotavirus | |
Enterovirus 71 | |||
Poliovirus | |||
Feline calicivirus | |||
NaOCl | Porcine parvovirus | Minute virus of mice | Feline calicivirus |
Hepatitis A virus | Hepatitis A virus | Adenovirus | |
Poliovirus | Rotavirus | ||
Enterovirus 71 | |||
Murine norovirus | |||
H2O2 | Animal parvovirus | Poliovirus | Rhinovirus |
Hepatitis A virus | Murine norovirus | Feline calicivirus | |
Adenovirus | Rotavirus | ||
PAA | Animal parvovirus | Poliovirus | Feline calicivirus |
Hepatitis A virus | Murine norovirus | ||
Adenovirus | |||
QAC | Animal parvovirus | Feline calicivirus | Rotavirus |
Poliovirus | Murine norovirus | Rhinovirus | |
Adenovirus 8, 25 | Adenovirus 5 | Coxsackievirus A11 | |
Low pH | Minute virus of mice | Human parvovirus 4 | Feline calicivirus |
Hepatitis A virus | Rhinovirus | ||
Poliovirus | Foot and mouth disease virus | ||
Enterovirus 71 | Enterovirus EV-D68 | ||
Coxsackievirus A9 | Human parvovirus B19 | ||
Murine norovirus | |||
Rotavirus | |||
Reovirus | |||
High pH | Bovine viral diarrhea virus | Reovirus | Murine minute virus |
Simian virus 40 | Feline calicivirus | ||
Hepatitis A virus | Adenovirus | ||
Canine parvovirus | Rotavirus | ||
Poliovirus | Foot and mouth disease virus | ||
Murine norovirus | |||
Tulane virus | |||
Aldehydes | Porcine parvovirus | Minute virus of mice | Poliovirus |
Hepatitis A virus | |||
Feline calicivirus | |||
Adenovirus | |||
Reovirus | |||
Rotavirus |
Relative order of susceptibility of non-enveloped viruses to chemical inactivation.
Abbreviations used: H2O2, hydrogen peroxide; NaOCl, sodium hypochlorite; PAA, peracetic acid; QAC, quaternary ammonium compound.
Relative order of susceptibility of non-enveloped viruses per microbicidal chemistry. Note: various types of adenoviruses exhibit different degrees of susceptibility to ethanol and quaternary ammonium compounds.
The Spaulding concept of the hierarchy of susceptibility of pathogens to microbicidal inactivation, along with its modifications, has been widely influential. Multiple industries as well as regulatory agencies have adopted or referenced this concept to various degrees [9, 10, 81, 82]. The concept does provide a good tool for understanding the innate differences and trending of susceptibility among various types of pathogens. For the most part, the hierarchy is insightful and valuable. It is particularly helpful when a pathogen is newly emerged, and limited or no knowledge is yet available regarding its level of susceptibility to microbicides [83, 84]. In fact, the United States Environmental Protection Agency (U.S. EPA) and Centers for Disease Control and Prevention (U.S. CDC) use the hierarchy concept as the basis of the Emerging Viral Pathogen Guidance for Antimicrobial Pesticides and public hygiene [10, 82, 85, 86] specifically to deal with just such a possibility.
It should be cautioned, however, that the hierarchy concept is largely oversimplified and by no means perfect [87]. For viruses, although enveloped viruses are usually more susceptible than non-enveloped viruses, certain enveloped viruses such as bovine viral diarrhea virus can be less susceptible than some non-enveloped viruses (e.g., feline calicivirus) under certain chemistries (e.g., low pH and high pH).
The accuracy and applicability of the hierarchy concept are more complex and limited among non-enveloped viruses. The trending is highly dependent on the type of chemistry; and the size of the virion is not always a primary determinant of viral susceptibility among non-enveloped viruses. If a clearer and more consistent trending can be identified among non-enveloped viruses, albeit only specific to a given type of chemistry, the knowledge should be useful.
To generalize an order of susceptibility, for a specific chemistry, data from side-by-side studies wherein viruses are evaluated concurrently by the same test method and under the same conditions should, ideally, be used. When results from different studies are used, caution should be taken to exclude conditional or case-specific differences that result from the test methodology and/or condition. For instance, a surface (carrier) test may give different log10 reduction results than a suspension test of the same microbicide or formulation under certain situations [88]. For example, the data of Kindermann et al. [47] and Tyler et al. [31] indicate that sodium hypochlorite causes a higher log10 reduction value (LRV) when tested in a suspension test than in a surface test. On the other hand, glutaraldehyde has been found to cause similar log reduction in either methodology, while hydrogen peroxide causes higher LRV in the surface test, which is thought to be likely related to the consumption of hydrogen peroxide by the protein in the virus-suspending solution [31].
The organic soil load in which the challenge virus is suspended prior to inoculation can also impact the viral inactivation outcome, especially for oxidizers, alcohols, and QAC. It would be inaccurate or even misleading if a result from a light organic load (e.g., 5% animal serum or phosphate-buffered saline) were to be directly compared with a test that used a heavier organic load (e.g., 90% blood or 20% fecal suspension). Tung
Other testing conditions may also affect the reduction results. For instance, a higher contact temperature may work in the favor of the virucide under investigation, which may result in a higher log reduction. Nemoto et al. [56] reported that a 0.125% glutaraldehyde solution completely inactivated rotavirus after 10 min under ambient temperature, but not when evaluated on ice. The pH and other components in the product formulation could also affect the viral reduction outcome, presumably by activating the chemical and/or by a synergistic or additive effect between the pH and the active chemical [22, 39, 89]. The efficacy of formulated versus non-formulated microbicides may differ even within the same type and concentration of active(s). For example, formulated QAC and ethanol products have been reported to exhibit strong activities against certain non-enveloped viruses albeit the efficacy may be weaker for non-formulated solutions [45, 54, 90, 91]. Therefore, the formulation of the microbicidal active must be considered. The viral stock (i.e., inoculum) preparation method and the challenge viral titer may also affect the reported viral reduction efficacy. For example, purified virus may be more susceptible than crude virus preparations [49]; viral clumps can make the virus less susceptible [92]; and a higher viral challenge titer could make the chemical harder to achieve an expected log10 reduction. Sometimes, viruses propagated in different host cell types may behave differently. It would therefore be ideal if all studies could use a standardized viral preparation and infectivity assay protocol. This is, of course, practically challenging. Last, but not least, the method for preparing the microbicide and the verification of the active concentration might also differ from lab to lab, thus potentially influencing the efficacy results obtained.
Despite these practically hard-to-avoid differences in test methodology and conditions, some generalizations on the pattern of susceptibility among non-enveloped viruses can still be made with confidence. For instance, it is quite apparent that the
The family
Different types of adenoviruses seem to exhibit varying degrees of susceptibility to ethanol and QAC. For example, adenovirus type 5 appears to be notably more susceptible to ethanol than are adenovirus types 2 and 8. In general, however, adenoviruses are more susceptible than many other non-enveloped viruses. Considering that adenovirus type 5 is listed as one of the allowable challenge viruses for a generic or “broad-spectrum” virucidal efficacy claim (i.e., a product that is effective for adenovirus type 5 may be considered effective against all viruses) [97, 98], this practice may not represent a challenge and lead to an insufficient safety margin, which is not supported by the published data.
Parvoviruses are among the smallest of non-enveloped viruses. The animal parvoviruses (e.g., minute virus of mice, porcine parvovirus, bovine parvovirus, canine parvovirus, etc.) are considered to exhibit very low susceptibility to chemical inactivation [99] and are commonly used as a worst-case model for viral inactivation studies. This literature review generally supports this notion, although it should be noted that the animal parvoviruses do not appear to represent a worst-case challenge for high-pH inactivation, and porcine parvovirus seems less susceptible than minute virus of mice at times. Additionally, human parvovirus B19 seems especially susceptible to acid treatment [100].
It has been observed that the particle size of a virus is not an exclusive or even a primary determinant of susceptibility to microbicides for non-enveloped viruses, albeit this characteristic may play a role. There are numerous reports demonstrating that larger non-enveloped viruses, such as adenoviruses and reoviruses, are less susceptible than some of the smaller non-enveloped viruses for certain chemistries. Interestingly though, rotavirus, a large non-enveloped virus, indeed seems to be the most susceptible among non-enveloped viruses, except to low pH.
The mechanisms underlying the large variation in susceptibility among non-enveloped viruses and the chemistry dependency are not always clear, but they could presumably be related to the physicochemical properties of the virus as well as the mechanisms of action of the chemical inactivants. For alcohols, for instance, it has been proposed that the hydrophobicity or hydrophilicity of the viral particles is an important determinant of susceptibility [101]. Poliovirus, which is hydrophilic, is more susceptible to ethanol than it is to isopropyl alcohol. This is attributed to the fact that ethanol is more hydrophilic than isopropanol. In comparison, the hydrophobic simian virus 40 is susceptible to isopropanol but not to ethanol [101]. Enterovirus 71 (EV71) and enterovirus EV-D68 (EV-D68) are both enteroviruses in the family
A review of the relative order of susceptibility for non-enveloped viruses under each chemistry reveals that the order for some chemicals (e.g. aldehydes) seems to fit the traditional hierarchy concept well (e.g., parvoviruses are less susceptible than larger viruses); but the order for some other chemistries (e.g., low pH) does not seem to agree with the concept as well.
The variability in viral susceptibility to physical treatments is not covered in this chapter; however, a marked degree of variation also exists for physical treatments, both within non-enveloped viruses and between enveloped and non-enveloped viruses [12, 16, 21, 49]. A comparison of the order of susceptibility of viruses to chemical versus physical treatments and an exploration of the underlying mechanisms would be interesting and revealing.
This chapter reviewed the literature on chemical inactivation of non-enveloped viruses, with an emphasis on the relative difference and trending of susceptibility among some relevant (from a public health perspective) non-enveloped viruses under each type of chemistry. The traditional concept of a hierarchy of susceptibility to microbicides provides a useful tool in understanding and predicting the susceptibility of a pathogen; however, the concept tends to be oversimplified. The order of susceptibility among non-enveloped viruses depends on the type of chemistry, and there is no universal order that holds true for all types of chemistries. Picornaviruses and caliciviruses exhibit a particularly high degree of intrafamily variation, and the order may even be reversed between viruses, depending on the chemistry. Additionally, larger non-enveloped viruses are not always more susceptible than some of the smaller non-enveloped viruses. It may be inappropriate to consider adenovirus type 5 as a worst-case non-enveloped virus; and even the animal parvoviruses, universally considered among the least susceptible to chemical inactivation, do not actually represent the least susceptible virus type for certain chemistries.
The author thanks Drs. Raymond Nims and M. Khalid Ijaz for the critical review of the manuscript and discussion.
The author declares no conflict of interest.
IntechOpen celebrates Open Access academic research of women scientists: Call Opens on February 11, 2018 and closes on March 8th, 2018.
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\\n\\nThe submissions are now closed. All applicants will be notified on the results in due time. Thank you for participating!
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\n\nThe submissions are now closed. All applicants will be notified on the results in due time. Thank you for participating!
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Rodriguez-Morales",hash:"61c627da05b2ace83056d11357bdf361",volumeInSeries:3,fullTitle:"Current Topics in Neglected Tropical Diseases",editors:[{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7064",title:"Current Perspectives in Human Papillomavirus",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7064.jpg",slug:"current-perspectives-in-human-papillomavirus",publishedDate:"May 2nd 2019",editedByType:"Edited by",bookSignature:"Shailendra K. 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Saxena",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",institutionURL:null,country:{name:"India"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},subseriesFiltersForPublishedBooks:[{group:"subseries",caption:"Bacterial Infectious Diseases",value:3,count:2},{group:"subseries",caption:"Parasitic Infectious Diseases",value:5,count:4},{group:"subseries",caption:"Viral Infectious Diseases",value:6,count:7}],publicationYearFilters:[{group:"publicationYear",caption:"2022",value:2022,count:2},{group:"publicationYear",caption:"2021",value:2021,count:4},{group:"publicationYear",caption:"2020",value:2020,count:3},{group:"publicationYear",caption:"2019",value:2019,count:3},{group:"publicationYear",caption:"2018",value:2018,count:1}],authors:{paginationCount:302,paginationItems:[{id:"280338",title:"Dr.",name:"Yutaka",middleName:null,surname:"Tsutsumi",slug:"yutaka-tsutsumi",fullName:"Yutaka Tsutsumi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/280338/images/7961_n.jpg",biography:null,institutionString:null,institution:{name:"Fujita Health University",country:{name:"Japan"}}},{id:"116250",title:"Dr.",name:"Nima",middleName:null,surname:"Rezaei",slug:"nima-rezaei",fullName:"Nima Rezaei",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/116250/images/system/116250.jpg",biography:"Professor Nima Rezaei obtained an MD from Tehran University of Medical Sciences, Iran. He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. 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