Progress in understanding norovirus epidemiology:

Molecular epidemiology of noroviruses in children and adults with acute gastroenteritis in Wuhan, China, 2007-2010

To study epidemiological features and genetic characteristics of noroviruses in children and adults with acute gastroenteritis, fecal specimens were collected in three hospitals from Jan. 2007 to May 2010 in Wuhan, China. Noroviruses were detected in 25.9 % (286/1103) and 24.6 % (202/822) of the specimens from children and adults, respectively, with genogroup II (GII) being predominant (99.2 %). The most frequent genotype among GII strains was GII.4 (2006b variant) (77.3 %) (72.0 % in children and 87.9 % in adults), followed by GII.3 (15.0 %) and GII.6 (3.4 %). Potential recombinant genotypes (polymerase/capsid) were detected in 51 GII strains (15.9 %), including the most frequent type, GII.12/GII.3 (28 strains), and GII.16/GII.2, detected for the first time in China, which were found in only children. The results indicated that genetically similar noroviruses were circulating among children and adults as a cause of gastroenteritis, except for some recombinant genotypes.

Norovirus diagnostics: options, applications and interpretations

Noroviruses are a frequent cause of both acute gastroenteritis and outbreaks of gastroenteritis. Infection is usually self-limiting although it has been associated with mortality in children in the developing world and in vulnerable groups such as immunodeficient or immunosuppressed and elderly patients elsewhere. Diagnostic tests may be useful in preventing or limiting the spread and duration of outbreaks, and are needed to define norovirus-associated morbidity and mortality. However, the interpretation of test results should take account of the limitations of the different tests currently available. Therefore, the clinical, immunological and molecular tests available for norovirus detection have been reviewed. Early recognition of cases (clinical diagnoses) together with confirmation by sensitive and specific laboratory tests may contribute to reducing the spread of norovirus within hospitals. Syndromic testing that includes multiple or multiplex assays for the detection of viral, bacterial and parasitic pathogens with the inclusion of control groups are likely to better define norovirus-associated morbidity and mortality in low- and middle-income countries.

Antiviral activity of a small molecule deubiquitinase inhibitor occurs via induction of the unfolded protein response

Ubiquitin (Ub) is a vital regulatory component in various cellular processes, including cellular responses to viral infection. As obligate intracellular pathogens, viruses have the capacity to manipulate the ubiquitin (Ub) cycle to their advantage by encoding Ub-modifying proteins including deubiquitinases (DUBs). However, how cellular DUBs modulate specific viral infections, such as norovirus, is poorly understood. To examine the role of DUBs during norovirus infection, we used WP1130, a small molecule inhibitor of a subset of cellular DUBs. Replication of murine norovirus in murine macrophages and the human norovirus Norwalk virus in a replicon system were significantly inhibited by WP1130. Chemical proteomics identified the cellular DUB USP14 as a target of WP1130 in murine macrophages, and pharmacologic inhibition or siRNA-mediated knockdown of USP14 inhibited murine norovirus infection. USP14 is a proteasome-associated DUB that also binds to inositol-requiring enzyme 1 (IRE1), a critical mediator of the unfolded protein response (UPR). WP1130 treatment of murine macrophages did not alter proteasome activity but activated the X-box binding protein-1 (XBP-1) through an IRE1-dependent mechanism. In addition, WP1130 treatment or induction of the UPR also reduced infection of other RNA viruses including encephalomyocarditis virus, Sindbis virus, and La Crosse virus but not vesicular stomatitis virus. Pharmacologic inhibition of the IRE1 endonuclease activity partially rescued the antiviral effect of WP1130. Taken together, our studies support a model whereby induction of the UPR through cellular DUB inhibition blocks specific viral infections, and suggest that cellular DUBs and the UPR represent novel targets for future development of broad spectrum antiviral therapies.

Deubiquitinases (DUBs) are enzymes, which are implicated in many cellular processes but their functions during virus infection are not well understood. We used WP1130, a small molecule inhibitor of a subset of DUBs, as a probe to unravel the functions of DUBs during norovirus infections. We identified USP14 as a cellular DUB target of WP1130 that is required for optimal norovirus infection. Furthermore, we demonstrated that chemical induction of the unfolded protein response can significantly inhibit viral progeny production of several RNA viruses, including noroviruses. These results suggest that chemical inhibition of cellular DUBs and/or modulation of the unfolded protein response could represent novel targets for therapy against a variety of viral pathogens.

Unusual norovirus and rotavirus genotypes in Ethiopia

BACKGROUND

Gastro-enteritis is associated with significant mortality in low- and middle-income countries, and rotavirus and norovirus are the principal viral agents implicated.

AIMS

To investigate the molecular epidemiology and burden of disease associated with rotavirus and norovirus in children attending a health centre in Ethiopia.

METHODS

A cross-sectional study was conducted in children attending a health centre in Awassa, southern Ethiopia. Children with diarrhoea (cases) and without diarrhoea (controls) were recruited over a 6-month period from December 2008 to May 2009. Rotavirus was detected by ELISA and genotyped by RT-PCR, and norovirus was amplified by RT-PCR with genotyping by sequence analysis of RT-PCR products.

RESULTS

Rotavirus was detected in 44/200 (22%) cases and in none of the controls, with genotypes G3P[6] (48%), G1P[8] (27%) and G2P[4] (7%) being the strains most commonly identified. Norovirus was detected in 16 (8%) of 200 cases and in 4 (7%) of 57 controls. Norovirus GII.3 was the strain most commonly detected (40%: 8/20) and ten other genotypes were also detected.

CONCLUSION

Rotavirus is a common cause of severe gastro-enteritis in children in Ethiopia; however, norovirus occurred with a similar frequency in cases and controls. A globally uncommon strain type, G3P[6], predominated within the rotavirus strains detected.

Transmission of viruses through shellfish: when specific ligands come into play

Shellfish are known as vectors for human pathogens and despite regulation based on enteric bacteria they are still implicated in viral outbreaks. Among shellfish, oysters are the most common vector of contamination, and the pathogens most frequently involved in these outbreaks are noroviruses, responsible for acute gastroenteritis in humans. Analysis of shellfish-related outbreak data worldwide show an unexpected high proportion of NoV GI strains. Recent studies performed in vitro, in vivo and in the environment indicate that oysters are not just passive filters, but can selectively accumulate norovirus strains based on viral carbohydrate ligands shared with humans. These observations contribute to explain the GI bias observed in shellfish-related outbreaks compared to other outbreaks.

Canine noroviruses

Noroviruses are recognized as emerging enteric pathogens of humans and have been identified in recent years in a number of mammalian species. The role of noroviruses as pathogens in immune-competent animals and under natural conditions remains uncertain, although both homologous and heterologous animal models are now available to investigate the pathogenesis, the immune response, and the molecular mechanism regulating norovirus infection. Recently, evidence has been gathered that noroviruses may also circulate in domestic carnivores. The zoonotic implications of these novel viruses deserve more attention, due to the strict social interactions between humans and pets.

First outbreak of norovirus in Albania

AIMS

Noroviruses (NoVs) represent the most important enteric viruses responsible for acute gastroenteritis world-wide. This study objective is to characterize the first outbreak of NoV that occurred in Ballsh, a small city in Albania.

METHODS AND RESULTS

Stool specimens were collected from people attending to the hospital. Samples were also collected from the aqueduct for bacteriological and virological tests. Overall 33 stools and five drinking water samples were collected, respectively, from the hospital in Ballsh and from the municipal aqueduct. No water samples were scored positive whereas ten stool samples (30.3%) were scored GGII NoV positive. All the GGII isolates were identified as GGII·4 genotype, and no GGI was identified. The alignment and protein analysis were performed using, respectively, ClustalV and the mega 4 software.

CONCLUSIONS

This is the first report of NoV GGII·4 in Albania causing an outbreak. The genetic analysis showed several point mutations and amino acid substitutions with respect to the international strains.

SIGNIFICANCE AND IMPACT OF STUDY

Over the last decades, Albania has suffered from different outbreaks as cholera, poliomyelitis, hepatitis A and now, for the first time, it has been documented an outbreak of NoV.

Norovirus gastroenteritis successfully treated with nitazoxanide

Infectious diarrhea is a common occurrence in the immunosuppressed population. We present a 43-year-old individual with large-volume stool output Norovirus acute gastroenteritis in the setting of relapsed refractory acute myelogenous leukemia, hematopoietic stem cell transplantation, and biopsy-proven cutaneous and pulmonary graft-versus-host disease. Therapeutic options such as intravenous immunoglobulin or reduction of immunosuppressants were not a feasible choice. A prompt clinical cure was achieved with nitazoxanide, a broad-spectrum antimicrobial agent. Nitazoxanide may be a safe therapeutic alternative, in which a reduction in immunosuppression may not be a viable option.

Food poisoning and diarrhea: small intestine effects

Transmission of foodborne pathogens remains a growing concern despite increasing public awareness and heightened federal measures to control infection. Over 76 million cases of acute diarrhea secondary to ingestion of contaminated food occur annually in the United States. Fortunately, most are self-limited and resolve without therapy, but up to 6000 deaths occur on an annual basis. Mechanisms of infection include consumption of a preformed toxin, formation of toxin following ingestion, and direct invasion of intestinal epithelial cells by the infecting organism. Diagnosis is most often confirmed through an accurate history, as cultures are often of low yield.

Norovirus infections in children under 5 years of age hospitalized due to the acute viral gastroenteritis in northeastern Poland

The primary aim of this study was to evaluate the frequency and seasonality of norovirus infection in hospitalized Polish children under 5 years of age, and a secondary aim was to compare the clinical severity of norovirus and rotavirus disease. The prospective surveillance study was carried out from July 2009 through June 2010. Stool samples from 242 children hospitalized due to acute viral gastroenteritis were tested for rotavirus group A and adenovirus with commercial immunochromatographic test and for norovirus with EIA assay. Single norovirus infection was found in 35/242 (14.5%) patients and in a further 5 (2.1%) children as co-infection with rotavirus. Overall, norovirus was detected in 16.5% of stool specimens. Norovirus infections tended to peak from October to November and again from February to March. In autumn months and in February, the proportion of norovirus gastroenteritis cases was equal or even surpassed those of rotavirus origin. Both norovirus and rotavirus infections most commonly affected children between 12 and 23 months of age. The low-grade or no fever was significantly more common in children infected with norovirus (94.3%) compared to rotavirus cases (52.9%). Overall, norovirus gastroenteritis was less severe than rotavirus disease with regard to 20-point severity scale (p < 0.05). Noroviruses have emerged as a relevant cause of acute gastroenteritis in Polish children. There is a great need for introducing routine norovirus testing of hospitalized children with gastroenteritis.

Norovirus-host interaction: multi-selections by human histo-blood group antigens

The discovery of human histo-blood group antigens (HBGAs) as receptors or ligands of noroviruses (NoVs) raises a question about the potential role of host factors in the evolution and diversity of NoVs. Recent structural analysis of selected strains in the two major genogroups of human NoVs (GI and GII) demonstrated highly conserved HBGA binding interfaces within the two groups but not between them, indicating convergent evolution of GI and GII NoVs. GI and GII NoVs are probably introduced to humans from different non-human hosts with the HBGAs as a common niche. Each genogroup has further diverged into multiple sub-lineages (genotypes) through selections by the polymorphic HBGAs of the hosts. An elucidation of such pathogen-host interaction, including determination of the phenotypes of NoV-HBGAs interaction for each genotype, is important in understanding the epidemiology, classification and disease control and prevention of NoVs. A model of this multi-selection of NoVs by HBGAs is proposed.

Noroviruses as a major cause of acute gastroenteritis in children in Finland, 2009-2010

Noroviruses are, after rotaviruses, the second most common cause of acute gastroenteritis in young children. In a prospective study conducted in 2009-2010 at the Tampere University Hospital, 195 stool specimens were collected from cases of acute gastroenteritis in children and examined for noroviruses, sapoviruses, and rotaviruses, using a reverse transcriptase polymerase chain reaction (RT-PCR). Noroviruses were found in 49 (25%) of the cases and sapoviruses in 12 (6%). The norovirus genotype GII.4 dominated with a 76% share; other genotypes detected were GII.7/GII.6 (16%), GII.g/GII.12, GII.e/GII.4, and GII.7 (2% each). For comparison, 47 (24%) cases of rotavirus gastroenteritis were diagnosed in the same period. In conclusion, after the introduction of rotavirus vaccination in Finland in September 2009, noroviruses have become as common as rotaviruses as the causative agents of acute gastroenteritis in young children, and are likely to become the leading cause. Norovirus GII.4 continues to be the dominant genotype.

Targeting norovirus infection-multivalent entry inhibitor design based on NMR experiments

Noroviruses attach to their host cells through histo blood group antigens (HBGAs), and compounds that interfere with this interaction are likely to be of therapeutic or diagnostic interest. It is shown that NMR binding studies can simultaneously identify and differentiate the site for binding HBGA ligands and complementary ligands from a large compound library, thereby facilitating the design of potent heterobifunctional ligands. Saturation transfer difference (STD) NMR experiments, spin-lock filtered NMR experiments, and interligand NOE (ILOE) experiments in the presence of virus-like particles (VLPs), identified compounds that bind to the HBGA binding site of human norovirus. Based on these data two multivalent prototype entry-inhibitors against norovirus infection were synthesized. A surface plasmon resonance based inhibition assay showed avidity gains of 1000 and one million fold over a millimolar univalent ligand. This suggests that further rational design of multivalent inhibitors based on our strategy will identify potent entry-inhibitors against norovirus infections.

The dynamics of norovirus outbreak epidemics: recent insights

Noroviruses are a major cause of gastroenteritis outbreaks worldwide. Norovirus outbreaks frequently occur as epidemics which appear to be related to both genetic and environmental factors. This review considers recent progress in understanding these factors. The norovirus genome undergoes continuous change and this appears to be important in the persistence of the virus in the community. Studies on the common GII.4 genotype have shown that some norovirus outbreak epidemics involving this genotype are correlated with specific changes in the genome. In contrast to the growing understanding of the role of genetic factors in norovirus outbreak epidemics, the role of environmental factors is less well understood. Topics reviewed here include long term excretion of norovirus in some individuals, long term survivability of norovirus in the environment, the role of meteorological factors in the control of norovirus outbreaks and the possible zoonotic transmission of the virus.

Noroviruses: a challenge for military forces

For military forces, the control of infectious acute gastroenteritis constitutes an old, constant and unsolved concern. Recent epidemiological studies suggest that the common bacterial causes are being overtaken by viruses. Norviruses are the most alarming group and norovirus outbreaks in military forces are regularly reported. Illness is generally mild and characterised by acute vomiting and diarrhoea, which lasts for a few days on average, but may be severe and potentially life-threatening in subjects who are already dehydrated due to daily activity. Moreover, outbreaks may diminish operational effectiveness. Prevention of norovirus infection currently relies on strict application of personal and collective hygiene rules including isolation of the cases, to the greatest possible extent. Although noroviruses are frequently mentioned as the cause of gastroenteritis outbreaks in troops deployed overseas, laboratory diagnosis is rarely done. So their real burden in military forces remains unclear and further epidemiological studies are required to determine the full impact of norovirus gastroenteritis on troops.

Genetic characterization of a novel calicivirus from a chicken

We describe the identification and genetic characterization of a novel enteric calicivirus, detected by transmission electron microscopy and RT-PCR in two clinically normal chickens and in a chicken with runting and stunting syndrome from different flocks in southern Germany. Positive findings were confirmed by sequencing. The complete nucleotide sequence and genome organization of one strain (Bavaria/04V0021) was determined. The genome of the Bavaria virus is 7,908 nt long and contains two coding open reading frames. Phylogenetic analysis of the deduced partial 2C helicase/NTPase, 3C cysteine protease, RNA-dependent RNA polymerase and complete VP1 capsid protein amino acid sequences showed that the virus is genetically related to but distinct from sapoviruses and lagoviruses. Morphologically, the Bavaria virus particles are 37-42 nm in diameter and exhibit characteristic cup-shaped surface depressions.

Rotavirus and norovirus infections in children in Sana'a, Yemen

OBJECTIVES

To describe the epidemiology of rotavirus and norovirus infection among children with acute gastroenteritis in Sana'a, Yemen.

METHODS

A cross-sectional study from November 2007 to March 2009 of children aged 1 month to 5 years attending the emergency and outpatient departments of two hospitals in Sana'a with acute gastroenteritis. Rotavirus was detected by ELISA and genotyped by RT-PCR. Norovirus was detected by End Point RT-PCR and nucleotide sequencing.

RESULTS

A total of 290 children (48% in the emergency department and 52% in the outpatient department of the children respectively) were enrolled. Rotavirus infections were detected in 78 (27%) and norovirus infections in 30 (10%). Rotavirus genotypes included G1P[8] (55%), G9P[8] (21%) and G2P[4] (12%) with G12 comprising 3% of strain types. The main norovirus genotype was GII.4 (27%) with >10 other genotypes detected.

CONCLUSIONS

Rotavirus and norovirus infections are common causes of gastroenteritis in Yemen. Rotavirus vaccines could play a significant role in the control of acute childhood diarrhoea in this setting.

Vesicular stomatitis virus as a vector to deliver virus-like particles of human norovirus: a new vaccine candidate against an important noncultivable virus

Human norovirus (HuNoV) is a major causative agent of food-borne gastroenteritis worldwide. Currently, there are no vaccines or effective therapeutic interventions for this virus. Development of an attenuated vaccine for HuNoV has been hampered by the inability to grow the virus in cell culture. Thus, a vector-based vaccine may be ideal. In this study, we constructed a recombinant vesicular stomatitis virus (rVSV-VP1) expressing VP1, the major capsid protein of HuNoV. Expression of the capsid protein by VSV resulted in the formation of HuNoV virus-like particles (VLPs) that are morphologically and antigenically similar to native virions. Recombinant rVSV-VP1 was attenuated in cultured mammalian cells as well as in mice. Mice inoculated with a single dose of rVSV-VP1 through intranasal and oral routes stimulated a significantly stronger humoral and cellular immune response than baculovirus-expressed VLP vaccination. Moreover, we demonstrated that mice inoculated with rVSV-VP1 triggered a comparable level of fecal and vaginal IgA antibody. Taken together, the VSV recombinant system not only provides a new approach to generate HuNoV VLPs in vitro but also a new avenue for the development of vectored vaccines against norovirus and other noncultivable viruses.

Norovirus as a foodborne disease hazard

Norovirus (NoV) is the most common cause of infectious gastroenteritis in the world. Gastroenteritis caused by bacterial and parasitic pathogens is commonly linked to food sources, but the link between NoV and contaminated foods has been more difficult to establish. Even when epidemiological information indicates that an outbreak originated with food, the presence of NoV in the suspect product may not be confirmed. If food is found to contain a common strain of NoV that circulates widely in the community, it is not possible to use strain typing to link the contamination to patient cases. Although food is certainly implicated in NoV spread, there are additional person-to-person and fomite transmission routes that have been shown to be important. NoV has an extremely low infectious dose, is stable in the environment, and resists disinfection. Cell culture methods are not available, so viability cannot be determined. Finally, many NoV outbreaks originate with when an infected food handler contaminates ready-to-eat food, which can be interpreted as foodborne or person-to-person transmission. This review will discuss both the physical characteristics of NoVs and the available epidemiological information with particular reference to the role of foods in NoV transmission.

Noroviruses in children seen in a hospital for acute gastroenteritis in Finland

Noroviruses (NoVs) are second only to rotaviruses (RVs) as causative agents of acute gastroenteritis (AGE) in children. The proportional role of NoVs is likely to increase after control of RV by vaccination. We investigated NoVs in children seen in Tampere University Hospital either treated as outpatients or hospitalized because of AGE before universal RV vaccination was implemented in Finland. This prospective study was conducted from September 2006 to August 2008. A total of 1,128 children <15 years of age with symptoms of AGE were enrolled either in the hospital clinic or in a ward, and stool samples for NoV studies were obtained from 759 children. NoVs were found in 196 (26%) cases. In the first year, NoVs were found in 116 (34%) out of 341, and in the second year, in 80 (19%) out of 418 cases. RVs were found respectively in 128 (38%) and 260 (62%) cases in these two seasons. Both RV and NoV were present in 24 cases. NoV genotype GII.4 predominated with a 96% share of the NoV cases in the first season and an 80% share in the second season. Other NoV genotypes seen infrequently were GII.7, GIIb, GI.6, GII.1, GII.2, and GIIc. The median clinical severity of NoV AGE was 14 compared to 16 for RV AGE on a 20-point scale.

CONCLUSION

NoVs were nearly as common as RVs as causative agents of severe AGE in children seen in hospital. After implementing universal RV vaccination, the importance of NoVs will still increase further.

Analytical performance of norovirus real-time RT-PCR detection protocols in Canadian laboratories

BACKGROUND

Noroviruses (NoVs) are the leading cause of infectious gastroenteritis worldwide. Real-time reverse transcription PCR (real-time RT-PCR) is the preferred method of NoV detection for the majority of testing laboratories. Although the accepted target region for molecular detection assays is the conserved ORF1/ORF2 junction, multiple variations have been published with differences in primers, probes, reagents, multiplexing, etc.

OBJECTIVES

We assessed the detection limit for GII.4 NoV real-time RT-PCR assays as well as the ability to detect the non-GII.4 NoV genotypes in each participating laboratory.

STUDY DESIGN

A panel of 25 RNA samples was circulated to 18 testing laboratories for comparison of their real-time RT-PCR procedures for NoV detection.

RESULTS

Multiple protocols with slight differences in reagents or conditions successfully detected 10 genome equivalents or fewer of NoV per reaction. Multiplex procedures were significantly associated (p=0.04) with false negative results, particularly for a GI.2 strain. Sensitive detection was associated with false positive results (p=0.03).

CONCLUSIONS

Overall, the data indicate that comparable results are produced under slightly different assay conditions.

[Survival strategies of human norovirus]

Human norovirus is a mutatable non-enveloped RNA virus capable of causing acute gastroenteritis in humans. Thus far, no experimental systems can propagate this virus in large amounts. Recent progresses in viral genomics and bioinformatics have led to a better understanding of molecular evolution of this virus in human populations. In addition, progresses in studies of the related noroviruses, those are replicable in laboratory systems, have led to a rapid accumulation of information on structural biology of norovirus. Furthermore, progresses in public health and water environment researches have led to a better understanding of viral ecology. In this review, I will first summarize fundamental characteristics of norovirus and its molecules. Then, I will summarize structure and molecular evolution of norovirus GII/4 subtype, which is now responsible for majorities of norovirus outbreaks in the world. Finally I will discuss survival strategies of human norovirus in nature by integrating the information.

Chronic shedders as reservoir for nosocomial transmission of norovirus

Norovirus (NoV) infection in immunocompromised patients may lead to prolonged norovirus shedding. Here, we demonstrate the involvement of three chronic shedders in hospital outbreaks. Combined epidemiological and molecular evidence suggests that in one case, NoV transmission occurred at least 17 days after the first diagnosis.

Prospective characterization of norovirus compared with rotavirus acute diarrhea episodes in chilean children

BACKGROUND

Rotavirus and more recently noroviruses are recognized as main causes of moderate to severe acute diarrhea episodes (ADE) in children < or =5 years of age. Comparing epidemiologic and clinical features of norovirus to rotavirus ADE will aid in the decision-making process required to develop norovirus vaccines.

METHODS

Surveillance for ADE occurring in children < or =5 years of age was implemented in the emergency department (ED) and ward of a large hospital in Santiago and Valparaiso, and in 4 outpatient clinics in Santiago. A stool sample was obtained within 48 hours of consultation for rotavirus detection by enzyme-linked immunosorbent assay and noroviruses by enzyme-linked immunosorbent assay or reverse transcription polymerase chain reaction. For ED and hospital rotavirus and norovirus ADE parents were instructed to monitor clinical findings associated with severity until the end of the episode. The 20-point Vesikari score was used to determine disease severity.

RESULTS

Between July 2006 and October 2008 rotavirus and noroviruses were detected in 331 (26%) and 224 (18%) of 1913 ADE evaluated. The proportion of rotavirus-positive samples in hospital ward, ED, and outpatient clinic was 40%, 26% to 30%, and 13% compared with 18%, 17% to 19%, and 14% for noroviruses. Mean age and 25%-75% interquartile interval of children with rotavirus and norovirus ADE were remarkably similar, 15.6 months (9-20), and 15.5 months (9-19), respectively. Rotavirus cases displayed an autumn-winter peak followed 2 to 3 months later by the norovirus peak. The mean (interquartile) for the Vesikari score was 12.9 (11-15) and 11.9 (9-14.5) for rotavirus (N = 331) and norovirus (N = 224) ADE, respectively, P = 0.003. Compared with norovirus, rotavirus ADE were more common in the 11 to 16 severity score interval (P = 0.006), had a higher maximum stool output in a given day (P = 0.01) and more frequent fever (P < 0.0001). Duration of diarrhea, presence, duration and intensity of vomiting, and intensity of fever did not differ between viruses. Mixed rotavirus and norovirus infections were uncommon (<1%) and not clinically more severe. Clinical severity of ADE in young infants was similar for rotavirus and lower (P = 0.03) for noroviruses compared with older children.

CONCLUSION

Noroviruses are a significant cause of moderate to severe endemic ADE in Chilean children. Although significantly less severe than rotavirus as a group, most norovirus episodes were moderate to severe clinically. An effective norovirus vaccine would be of significant additional benefit to the current rotavirus vaccine in decreasing disease burden associated with ADE.

Bovine norovirus: carbohydrate ligand, environmental contamination, and potential cross-species transmission via oysters

Noroviruses (NoV) are major agents of acute gastroenteritis in humans and the primary pathogens of shellfish-related outbreaks. Previous studies showed that some human strains bind to oyster tissues through carbohydrate ligands that are similar to their human receptors. Thus, based on presentation of shared norovirus carbohydrate ligands, oysters could selectively concentrate animal strains with increased ability to overcome species barriers. In comparison with human GI and GII strains, bovine GIII NoV strains, although frequently detected in bovine feces and waters of two estuaries of Brittany, were seldom detected in oysters grown in these estuaries. Characterization of the carbohydrate ligand from a new GIII strain indicated recognition of the alpha-galactosidase (α-Gal) epitope not expressed by humans, similar to the GIII.2 Newbury2 strain. This ligand was not detectable on oyster tissues, suggesting that oysters may not be able to accumulate substantial amounts of GIII strains due to the lack of shared carbohydrate ligand and that they should be unable to contribute to select GIII strains with an increased ability to recognize humans.

Diagnostic accuracy and analytical sensitivity of IDEIA Norovirus assay for routine screening of human norovirus

Noroviruses (NoVs) are recognized as the leading cause of epidemic and sporadic acute gastroenteritis. Early detection of NoV is crucial to control the spread of the disease. In this study, we evaluated the diagnostic accuracy, analytical sensitivity, and analytical reactivity of the IDEIA Norovirus assay (an enzyme immunoassay [EIA]) in a prospective and retrospective study design. A total of 557 prospectively collected fecal samples and a panel of 97 archived fecal samples, including 21 different GI and GII genotypes, were tested by conventional reverse transcription-PCR (RT-PCR)/bidirectional sequencing, real-time RT-PCR, and electron microscopy. The sensitivity and specificity of the EIA were 57.6% and 91.9%, respectively. The sensitivity for detecting NoV in fecal samples from outbreaks improved from 44.1% when three samples were tested to 76.9% when five samples per outbreak were tested. The EIA was able to detect strains from 7 GI and 11 GII genotypes. The analytical sensitivity of the EIA was 3.1 x 10(6) and 1.6 x 10(7) virus particles g(-1) of fecal sample for NoV GI and GII strains, respectively. Most GII samples positive by EIA had a threshold cycle (C(T)) of <26.5, and 50% of the GII samples negative by EIA had a C(T) of >25.6, suggesting that, although strains from genotypes GI.8, GII.10, and GII.16 were not detected, the low sensitivity of the EIA is primarily caused by low virus concentration. In conclusion, the current EIA may be of use as a rapid screening test during a norovirus outbreak investigation when multiple fecal samples are available; however, sporadic samples should be tested by molecular methods.

Genogroup IIb norovirus infections and association with enteric symptoms in a neonatal nursery in southern India

Noroviruses (NoVs) are increasingly recognized as an important cause of acute gastroenteritis in children worldwide. However, there are limited data on the role of NoVs in neonatal infections and disease. The objectives of the present study were to determine the prevalence of NoVs in neonates with gastrointestinal disease using a case-control study design and to characterize the NoV strains infecting neonates. A total of 309 fecal samples from 161 neonates with gastrointestinal symptoms and 148 asymptomatic controls were screened for genogroup II (GII) NoV using reverse transcription-PCR. A subset of PCR-positive amplicons for the polymerase and capsid regions was sequenced. NoV was detected in 26.2% of samples, with the rate of detection being significantly higher among symptomatic neonates (60/161, 37.2%) than asymptomatic neonates (24/148, 14.1%) (P < 0.001). On the basis of sequencing of 29 strains, a single NoV strain, GIIb, was identified to be the predominant (27/29, 93.1%) cause of neonatal infections. Coinfection with rotavirus was seen in nearly one-third of symptomatic neonates. The study demonstrates a high prevalence of NoV infections in neonates and indicates that coinfection with rotavirus may result in significantly more gastrointestinal disease in this population.

Complete genome sequence and phylogenetic analysis of a recombinant Korean norovirus, CBNU1, recovered from a 2006 outbreak

We have determined the complete nucleotide and deduced amino acid sequences of the RNA genome of CBNU1, a human norovirus (NoV) recovered from a 2006 outbreak in South Korea. The genome of 7547 nucleotides, excluding a 3'-poly(A) tail of 11-105 nucleotides, encodes three overlapping open reading frames (ORFs): ORF1 (nucleotides 5-5104), ORF2 (nucleotides 5085-6731), and ORF3 (nucleotides 6731-7495). In a comparison to 108 other currently available completely sequenced NoVs representing all five genogroups (GI-GV) except GIV, the CBNU1 strain was highly similar to GII.3 NoVs. Multiple sequence alignments of the completely sequenced NoV genomes revealed five hypervariable regions throughout their genomes: two in ORF1, one in ORF2, and two in ORF3. At both the nucleotide and amino acid levels, genome-based phylogenetic analyses invariably showed that the CBNU1 strain was most closely related to three GII.3 NoVs: the American Texas/TCH04-577 and the two Japanese Saitama U18 and Saitama U201 strains; furthermore, these genome-based phylogenetic topologies corresponded most closely to those based on the ORF2 genes, as compared to those based on the ORF1 and ORF3 genes. Subsequent ORF2-based phylogenetic analyses of a selection of 126 other NoVs representing all 19 GII genotypes, in combination with genome-based Simplot analyses, showed that the CBNU1 strain was a recombinant GII.3 NoV with a breakpoint at the ORF1/ORF2 junction between two putative parent-like strains, Guangzhou/NVgz01 and Texas/TCH04-577. Overall, the CBNU1 strain represents the first Korean human NoV whose genome has been completely sequenced and for which its relationship with a large panel of genetically diverse NoVs has been extensively characterized.

Norwalk virus-like particles as vaccines

Noroviruses (NoV) cause the great majority of epidemic nonbacterial gastroenteritis in humans. Expression of the capsid protein in recombinant systems, including insect and plant cells, yields assembly of virus-like particles (VLPs) that mimic the antigenic structure of authentic virions, and are relatively acid- and heat-stable. Norwalk virus (NV), the prototype NoV, has been studied extensively, and Norwalk virus-like particles (NVLPs) produced in insect cells and plants are immunogenic in mice and humans when delivered orally, stimulating the production of systemic and mucosal anti-NV antibodies. NVLPs are also highly immunogenic when delivered intranasally, provoking antibodies at levels similar to orally delivered VLP at much lower doses. Oral and nasal delivery of NVLPs efficiently produces antibodies at distal mucosal sites, which suggests that NVLPs could be used to deliver heterologous peptide antigens by production of genetic fusion chimeric capsid proteins. Examination of norovirus VLP surface structures and receptor binding motifs facilitates identification of potential sites for insertion of foreign peptides that will minimally affect the efficiency of VLP assembly and receptor binding. Thus, there is strong potential to use norovirus VLPs as vaccine-delivery vehicles.

Norovirus disease associated with excess mortality and use of statins: a retrospective cohort study of an outbreak following a pilgrimage to Lourdes

Although norovirus infection is generally known to be a mild disease, there is some evidence for severe outcome. An outbreak in a Dutch psychiatric institution, originating from pilgrims returning from Lourdes (France), provided an opportunity for performing a retrospective cohort study in order to identify risk factors for norovirus disease and excess mortality. Relative risks (RR) including 95% confidence intervals (CI) showed that attending the pilgrimage (RR 2·0, 95% CI 1·4–3·0) and age >70 (RR 1·7, 95% CI 1·2–2·2) were risk factors for symptomatic infection. In a subset of patients, for whom more detailed information was available, the use of statins was associated with norovirus disease when adjusted for underlying condition (adjusted odds ratio 3·9, 95% CI 1·2–13·0). Mortality was higher in cases infected during the pilgrimage compared to other residents (RR 20·9, 95% CI 4·7–93·8). Norovirus disease can lead to severe outcome. The newly identified risk of statins for contracting norovirus disease may have considerable consequences for the Western world and needs prospective confirmation.

Norovirus RNA in the blood of a child with gastroenteritis and convulsions--A case report

Potential extra-intestinal spread is an important issue in understanding the pathogenesis of NoV disease. A previously healthy 14-month-old boy was admitted to the Pediatric Emergency Department of the University-Hospital of Parma, Italy, for afebrile convulsions in a gastroenteritis episode. Bacterial culture and microscopic examination on cerebrospinal fluid (CSF) yielded negative results as well as PCRs and reverse-transcription PCRs (RT-PCRs) for neurotropic viruses performed either on CSF or plasma. Stools were subjected to electron microscopy and conventional cell culture, yielding negative results. NoV was found in stools and plasma by nested RT-PCR targeting the NoV polymerase gene. The nucleotide sequences obtained from the two specimens showed 100% identity, demonstrating that the strain invading the blood stream was from the intestine, and, in comparison with GenBank sequences, they belonged to NoV genotype GII.4, "2006b" variant. The child had no abnormal electrolyte balance and no fever that could justify seizures, encouraging the hypothesis that NoV could be the cause of the neurologic disorder. These findings further induce to review the current concept of human NoV focused on intestinal infection.

Pathogenesis of noroviruses, emerging RNA viruses

Human noroviruses in the family Caliciviridae are a major cause of epidemic gastroenteritis. They are responsible for at least 95% of viral outbreaks and over 50% of all outbreaks worldwide. Transmission of these highly infectious plus-stranded RNA viruses occurs primarily through contaminated food or water, but also through person-to-person contact and exposure to fomites. Norovirus infections are typically acute and self-limited. However, disease can be much more severe and prolonged in infants, elderly, and immunocompromised individuals. Norovirus outbreaks frequently occur in semi-closed communities such as nursing homes, military settings, schools, hospitals, cruise ships, and disaster relief situations. Noroviruses are classified as Category B biodefense agents because they are highly contagious, extremely stable in the environment, resistant to common disinfectants, and associated with debilitating illness. The number of reported norovirus outbreaks has risen sharply since 2002 suggesting the emergence of more infectious strains. There has also been increased recognition that noroviruses are important causes of childhood hospitalization. Moreover, noroviruses have recently been associated with multiple clinical outcomes other than gastroenteritis. It is unclear whether these new observations are due to improved norovirus diagnostics or to the emergence of more virulent norovirus strains. Regardless, it is clear that human noroviruses cause considerable morbidity worldwide, have significant economic impact, and are clinically important emerging pathogens. Despite the impact of human norovirus-induced disease and the potential for emergence of highly virulent strains, the pathogenic features of infection are not well understood due to the lack of a cell culture system and previous lack of animal models. This review summarizes the current understanding of norovirus pathogenesis from the histological to the molecular level, including contributions from new model systems.

Viral multiplex quantitative PCR assays for tracking sources of fecal contamination

Human and animal fecal pollution of the environment presents a risk to human health because of the presence of pathogenic viruses and bacteria. To distinguish between human and animal sources of pollution, we designed specific real-time reverse transcription (RT)-PCR assays for human and animal enteric viruses, including norovirus genogroups I, II, and III; porcine adenovirus types 3 and 5; ovine adenovirus; atadenovirus; and human adenovirus species C and F, which are excreted by infected humans, pigs, cattle, sheep, deer, and goats, and for the detection of F+ RNA bacteriophage genogroups I to IV, which are associated with human and animal wastes. The sensitivity of this viral toolbox (VTB) was tested against 10-fold dilution series of DNA plasmids that carry the target sequences of the respective viruses and was shown to detect at least 10 plasmid copies for each assay. A panel of human and animal enteric and respiratory viruses showed these assays to be highly sensitive and specific to their respective targets. The VTB was used to detect viruses in fecal and environmental samples, including raw sewage and biosolids from municipal sewage treatment plants, abattoir sewage, and fecally contaminated shellfish and river water, which were likely to contain animal or human viruses.

Utility of clinical-epidemiological profiles in outbreaks of foodborne disease, Catalonia, 2002 through 2006

The objective of this study was to evaluate the use of clinical-epidemiological profiles for classifying non-laboratory-confirmed outbreaks of foodborne disease (FBD) in Catalonia between 2002 and 2006 and for elucidating associations among factors contributing to these outbreaks. A total of 275 nonfamily outbreaks were studied, of which 190 (69.1%) were laboratory confirmed and 85 (30.9%) were not. In 176 (92.6%) of laboratory-confirmed outbreaks and 69 (81.2%) of non-laboratory-confirmed outbreaks, information was obtained on contributing factors (P = 0.009). In 72% of non-laboratory-confirmed outbreaks, the etiology was assigned by using clinical-epidemiological profiles; thus, 93% of outbreaks eventually were associated with an etiology. In laboratory-confirmed outbreaks, poor personal hygiene was positively associated with norovirus (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.47 to 4.89; P = 0.0007) and negatively associated with Salmonella and Campylobacter (OR, 0.54; 95% CI, 0.33 to 0.89; P = 0.01), and an unsafe source was positively associated with Salmonella and Campylobacter (OR, 4.07; 95% CI, 1.72 to 10.09; P = 0.001) and negatively associated with norovirus (OR, 0.14; 95% CI, 0.04 to 0.58; P = 0.001). No differences were found among contributing factors associated with outbreaks with a laboratory-confirmed etiology and those associated with outbreaks with an etiology assigned according to the clinical-epidemiological profiles. Clinical-epidemiological profiles are useful for determining what prevention and control strategies are appropriate to the agents involved in each community and for designing outbreak investigations.

Heterotypic humoral and cellular immune responses following Norwalk virus infection

Norovirus immunity is poorly understood as the limited data available on protection after infection are often contradictory. In contrast to the more prominent GII noroviruses, GI norovirus infections are less frequent in outbreaks. The GI noroviruses display very complex patterns of heterotypic immune responses following infection, and many individuals are highly susceptible to reinfection. To study the immune responses and mechanisms of GI.1 persistence, we built structural models and recombinant virus-like particles (VLPs) of five GI strains: GI.1-1968, GI.1-2001, GI.2-1999, GI.3-1999, and GI.4-2000. Structural models of four GI genotype capsid P domain dimers suggested that intragenotype structural variation is limited, that the GI binding pocket is mostly preserved between genotypes, and that a conserved, surface-exposed epitope may allow for highly cross-reactive immune responses. GI VLPs bound to histo-blood group antigens (HBGAs) including fucose, Lewis, and A antigens. Volunteers infected with GI.1-1968 (n = 10) had significant increases between prechallenge and convalescent reactive IgG for all five GI VLPs measured by enzyme immunoassay. Potential cross-neutralization of GI VLPs was demonstrated by convalescent-phase serum cross-blockade of GI VLP-HBGA interaction. Although group responses were significant for all GI VLPs, each individual volunteer demonstrated a unique VLP blockade pattern. Further, peripheral blood mononuclear cells (PBMCs) were stimulated with each of the VLPs, and secretion of gamma interferon (IFN-gamma) was measured. As seen with blockade responses, IFN-gamma secretion responses differed by individual. Sixty percent responded to at least one GI VLP, with only two volunteers responding to GI.1 VLP. Importantly, four of five individuals with sufficient PBMCs for cross-reactivity studies responded more robustly to other GI VLPs. These data suggest that preexposure history and deceptive imprinting may complicate PBMC and B-cell immune responses in some GI.1-1968-challenged individuals and highlight a potential complication in the design of efficacious norovirus vaccines.

Viral load and genotypes of noroviruses in symptomatic and asymptomatic children in Southeastern Brazil

BACKGROUND

Noroviruses (NoVs) are a major etiological agent of sporadic acute gastroenteritis worldwide.

OBJECTIVES

To detect, quantify and characterize genogroups and genotypes of NoVs in children with and without gastrointestinal symptoms.

STUDY DESIGN

NoVs were investigated by RT-PCR in a total of 319 fecal specimens from children up to three years old with (n=229) and without (n=90) acute diarrhea, between February 2003 and June 2004 in the emergency room in Vitória, Southeastern Brazil. NoVs were quantified by real-time PCR and genotyped.

RESULTS

NoVs were detected in 17% (40/229) and 13% (12/90) of symptomatic and asymptomatic children, respectively. Six NoV-rotavirus A mixed infections were observed. Fifty-one strains were characterized as NoV GII and one as GI. Twenty strains were characterized as GII/4 (9/13), GII/3 (1/13), GII/6 (2/13) and GII/14 (1/13) in symptomatic and GII/3 (6/7) and GII/8 (1/7) in asymptomatic children. The median RNA viral loads were 8.39 and 7.15log(10)copies/g of fecal specimens for symptomatic and asymptomatic children, respectively (p=0.011). NoV load was lower when it was present in a mixed infection with rotavirus A (p=0.0005).

CONCLUSIONS

This study demonstrates a diversity of NoV strains circulating in this geographic area, and reports GII/8 and GII/14 in the American Continent for the first time. In addition, it confirms GII/4 as the most prevalent genotype in symptomatic children and identified GII/3 in an important frequency, especially in asymptomatic children. Furthermore, preliminary results show that symptomatic patients present a viral load that is significantly greater than asymptomatic children (p=0.011).