Seroprevalence studies using a recombinant Norwalk virus protein enzyme immunoassay

Molecular epidemiology analysis of symptomatic and asymptomatic norovirus infections in Chinese infants

BACKGROUND

Norovirus is a leading cause of acute gastroenteritis among children. Previous studies based on symptomatic infections indicated that mutations, rather than recombination drove the evolution of the norovirus ORF2. These characteristics were found in hospital-based symptomatic infections, whereas, asymptomatic infections are frequent and contribute significantly to transmission.

METHODS

We conducted the first norovirus molecular epidemiology analysis covering both symptomatic and asymptomatic infections derived from a birth cohort study in the northern China.

RESULTS

During the study, 14 symptomatic and 20 asymptomatic norovirus infections were detected in 32 infants. Out of the 14 strains that caused symptomatic infections, 12 strains were identified as GII.3[P12], and others were GII.4[P31]. Conversely, 17 asymptomatic infections were caused by GII.4[P31], two by GII.2[P16], and one by GII.4[P16]. Regardless of symptomatic and asymptomatic infections, the mutations were detected frequently in the ORF2 region, and almost all recombination were identified in the RdRp-ORF2 region. The majority of the mutations were located around the predefined epitope regions of P2 subdomain indicating a potential for immune evasion.

CONCLUSION

The role of symptomatic as well as asymptomatic infections in the evolution of norovirus needs to be evaluated continuously.

Profiling of humoral immune responses to norovirus in children across Europe

Norovirus is a leading cause of epidemic acute gastroenteritis. More than 30 genotypes circulate in humans, some are common, and others are only sporadically detected. Here, we investigated whether serology can be used to determine which genotypes infect children. We established a multiplex protein microarray with structural and non-structural norovirus antigens that allowed simultaneous antibody testing against 30 human GI and GII genotypes. Antibody responses of sera obtained from 287 children aged < 1 month to 5.5 years were profiled. Most specific IgG and IgA responses were directed against the GII.2, GII.3, GII.4, and GII.6 capsid genotypes. While we detected antibody responses against rare genotypes, we found no evidence for wide circulation. We also detected genotype-specific antibodies against the non-structural proteins p48 and p22 in sera of older children. In this study, we show the age-dependent antibody responses to a broad range of norovirus capsid and polymerase genotypes, which will aid in the development of vaccines.

Breadth and Dynamics of Human Norovirus-Specific Antibodies in the First Year of Life

We measured antibody binding to diverse norovirus virus-like particles over 12 months in 16 children. All had maternal antibodies at 2 months, with estimated lowest levels at 5 months of age. Antibody increases after 3 months suggested natural infections. This information could guide the timing of future norovirus vaccines.

Serological Humoral Immunity Following Natural Infection of Children with High Burden Gastrointestinal Viruses

Acute gastroenteritis (AGE) is a major cause of morbidity and mortality worldwide, resulting in an estimated 440,571 deaths of children under age 5 annually. Rotavirus, norovirus, and sapovirus are leading causes of childhood AGE. A successful rotavirus vaccine has reduced rotavirus hospitalizations by more than 50%. Using rotavirus as a guide, elucidating the determinants, breath, and duration of serological antibody immunity to AGE viruses, as well as host genetic factors that define susceptibility is essential for informing development of future vaccines and improving current vaccine candidates. Here, we summarize the current knowledge of disease burden and serological antibody immunity following natural infection to inform further vaccine development for these three high-burden viruses.

Norovirus infections and seroprevalence of genotype GII.4-specific antibodies in a Spanish population

Genotype II.4 noroviruses (NoVs) are a leading cause of epidemic acute gastroenteritis in children and adults worldwide. The prevalence of different NoV genotypes causing outbreaks and sporadic cases of acute gastroenteritis in the region of Valencia, Spain, during a 4-year period (2008-11) was investigated. NoVs were detected in 42 out of 55 (76.3%) outbreaks and in 26 out of 332 (7.8%) sporadic cases of acute gastroenteritis. Genogroup GII strains were predominant in outbreaks and sporadic cases. Different genotype GII.4 variants were found (Yerseke_2006a, Den Haag_2006b, Apeldoorn_2007, and New Orleans_2009), with the latter variant detected most frequently (35.3%). A recombinant P domain of the NoV GII.4 Apeldoorn_2007 variant was produced in Escherichia coli and used as the coating antigen in an enzyme immunoassay to survey the IgG antibody seroprevalence against NoV GII.4 in a Spanish population. Baculovirus-expressed virus-like particles (VLPs) of NoV GII.4 Den Haag_2006b variant were also produced and used as antigen to compare seroreactivity. Of the 434 serum specimens analyzed, 429 (98.6%) had antibodies against the P domain. The comparison of reactivities of 30 serum samples to the NoV GII.4 P polypeptide and VLP showed reproducible results with a correlation coefficient of r = 0.794. Titers of antibodies to the P domain increased gradually and significantly with age, reaching the highest levels at the age group of 41-50 years. These results confirm the high prevalence of NoV GII.4 infections in Valencia from early childhood.

Progress toward norovirus vaccines: considerations for further development and implementation in potential target populations

Human norovirus infection causes significant medical and financial costs in the USA and abroad. Some populations, including young children, the elderly, and the immunocompromised, are at heightened risk of infection with this virus and subsequent complications, while others, such as healthcare workers and food handlers are at increased risk of transmitting it, and some are at risk of both. Human noroviruses are heterogeneous with new strains emerging periodically. In addition to viral diversity, incompletely understood characteristics, such as virus-host cell binding and duration of immunity after infection add to the challenges of creating a norovirus vaccine. Although much progress has been made in recent years, many questions remain to be answered. In this review, we discuss the important areas and relevant literature in considering human norovirus vaccine development and potential targets for implementation.

Experimental human infection with Norwalk virus elicits a surrogate neutralizing antibody response with cross-genogroup activity

The human noroviruses (NoVs) are genetically diverse, rapidly evolving RNA viruses and are the major cause of epidemic gastroenteritis of humans. Serum antibodies that block the interaction of NoVs and NoV viruslike particles (VLPs) with host attachment factors are considered surrogate neutralizing antibodies in the absence of cell culture and small-animal replication models for the human NoVs. A serological assay for NoV-blocking antibodies was used to assess the breadth of the heterotypic antibody response in the context of an experimental challenge study with a human NoV. Heterotypic histo-blood group antigen (HBGA)-blocking activity against GI.4, GI.7, and GII.4 NoVs increased significantly in the serum of individuals (n = 18) infected with Norwalk virus (GI.1). Although the fold increases and peak titers of heterotypic antibody were more modest than titers of antibody reactive with the challenge antigen, Norwalk virus infection elicited a serological rise even against the novel Sydney variant of GII.4 NoVs. These observations indicate that the development of a broadly cross-protective NoV vaccine containing a limited number of genotypes may be possible.

Duration of immunity to norovirus gastroenteritis

The duration of immunity to norovirus (NoV) gastroenteritis has been believed to be from 6 months to 2 years. However, several observations are inconsistent with this short period. To gain better estimates of the duration of immunity to NoV, we developed a mathematical model of community NoV transmission. The model was parameterized from the literature and also fit to age-specific incidence data from England and Wales by using maximum likelihood. We developed several scenarios to determine the effect of unknowns regarding transmission and immunity on estimates of the duration of immunity. In the various models, duration of immunity to NoV gastroenteritis was estimated at 4.1 (95% CI 3.2-5.1) to 8.7 (95% CI 6.8-11.3) years. Moreover, we calculated that children (<5 years) are much more infectious than older children and adults. If a vaccine can achieve protection for duration of natural immunity indicated by our results, its potential health and economic benefits could be substantial.

Immunology of Norovirus Infection

Noroviruses are the leading cause of epidemic non-bacterial gastroenteritis worldwide. Despite their discovery over three decades ago, little is known about the host immune response to norovirus infection. The purpose of this chapter is to review the field of norovirus immunology and discuss the contributions of outbreak investigations, human and animal challenge studies and population-based studies. This chapter will survey both humoral and cellular immunity as well as recent advances in norovirus vaccine development.

Humoral immune responses against norovirus infections of children

In 2 infants with gastroenteritis associated with Norovirus (NoV), serum immunoglobulin (Ig) G, IgM, IgA, and fecal IgA antibody responses against NoV were examined by enzyme-linked immunosorbent assay using 11 different antigenic and genetic types of NoV virus-like particles expressed in insect cells. These two cases were putative primary single NoV infections, because antibodies against NoVs were not detected in acute-phase serums. In one of two cases, long-term excretion of virus RNA for 33 days was observed. Serum IgG responses demonstrated strong seroresponse to the homologous type, and weak seroresponse to the heterologous types within the genogroup. After more than 2 years, the IgG antibody titer remained high to the homologous type and low to the heterologous type within the genogroup. IgM and IgA were specific to the homologous type. IgM was short lived and the serum IgA antibody titer remained low to the homologous type for a long period. These results improve our understanding of the humoral immune response to NoV infection.

Prolonged norovirus shedding in infants <or=6 months of age with gastroenteritis

BACKGROUND

Noroviruses (NV) are one of the leading causes of gastroenteritis in young children; however, the duration of NV shedding in young children is not well known.

METHODS

Fecal specimens were collected from children with acute gastroenteritis at a pediatric clinic during the period from November to December 2002 and tested for NV by reverse transcription-polymerase chain reaction.

RESULTS

Of 71 children infected with NV, 60 (84.5%) were less than 3 years old. Among children aged <2 years and those aged 2 to 5 years, the duration of illness was longer (7 days versus 3.5 days, P = 0.0069), the maximum number of stools in a 24-hour period was greater (7 versus 3, P = 0.0078) and a 20-point severity score was higher (11 versus 8, P = 0.0031) in patients aged <2 years than in patients aged 2 to 5 years. Among the 23 children whose follow-up specimens were obtained, the median duration of NV shedding was 16 days (range, 5-47 days). Virus shedding for more than 2 weeks after onset was observed in 75% (6 of 8), 71.4% (5 of 7) and 25% (2 of 8) of children aged <1 year, 1 year and 2 to 3 years, respectively. Three infants aged <or=6 months continued to excrete NV for an extremely long period (more than 42, 44 and 47 days from onset) after recovery.

CONCLUSION

Long-term virus shedding after the disappearance of clinical symptoms was observed. Caution should be exercised when handling the excrement of infants and young children infected with NV.

Porcine enteric caliciviruses: genetic and antigenic relatedness to human caliciviruses, diagnosis and epidemiology

Porcine enteric caliciviruses include sapoviruses and noroviruses. Porcine sapoviruses infect pigs of all ages and cause diarrhea in young pigs, whereas porcine noroviruses were detected exclusively from adult pigs without clinical signs. Importantly, certain porcine norovirus strains were genetically and antigenically related to human noroviruses. This raises public health concerns that pigs may be reservoirs for emergence of epidemic human norovirus strains. This article reviews the discovery of porcine noroviruses and sapoviruses, their classification, diagnosis, epidemiology and genetic and antigenic relatedness to human caliciviruses.

Pathogenesis of a genogroup II human norovirus in gnotobiotic pigs

We evaluated the gnotobiotic (Gn) pig as a model to study the pathogenesis of human norovirus (HuNoV) and to determine the target cells for viral replication. Sixty-five Gn pigs were inoculated with fecal filtrates of the NoV/GII/4/HS66/2001/US strain or with pig-passaged intestinal contents (IC) and euthanized acutely (n = 43) or after convalescence (n = 22). Age-matched Gn piglets (n = 14) served as mock-inoculated controls. Seventy-four percent (48/65) of the inoculated animals developed mild diarrhea compared to 0 of 14 controls. Pigs from postinoculation days (PID) 1 to 4 tested positive for HuNoV by reverse transcription-PCR of rectal swab fluids (29/65) and IC (9/43) and by antigen (Ag) enzyme-linked immunosorbent assay (ELISA) using antiserum to virus-like particles of HuNoV GII/4. No control pigs were positive. Histopathologic examination showed mild lesions in the proximal small intestine of only one pig (1/7). Seroconversion after PID 21 was detected by antibody ELISA in 13 of 22 virus-inoculated pigs (titers, 1:20 to 1:200) but not in controls. Immunofluorescent microscopy using a monoclonal antibody to HuNoV GII capsid revealed patchy infection of duodenal and jejunal enterocytes of 18 of 31 HuNoV-inoculated pigs with a few stained cells in the ileum and no immunofluorescence (IF) in mock-inoculated controls. Immunofluorescent detection of the viral nonstructural N-terminal protein antigen in enterocytes confirmed translation. Transmission electron microscopy of intestines from HuNoV-inoculated pigs showed disrupted enterocytes, with cytoplasmic membrane vesicles containing calicivirus-like particles of 25 to 40 nm in diameter. In summary, serial passage of HuNoV in pigs, with occurrence of mild diarrhea and shedding, and immunofluorescent detection of the HuNoV structural and nonstructural proteins in enterocytes confirm HuNoV replication in Gn pigs.

Development of an enzyme immunoassay for detection of sapovirus-specific antibodies and its application in a study of seroprevalence in children

Sapoviruses (SVs) are an important cause of acute pediatric gastroenteritis. Due to the lack of appropriate diagnostic methods, the epidemiology of SV-associated illness remains poorly understood. Baculovirus and Escherichia coli expression systems were evaluated for the development of antibody detection enzyme immunoassays (EIA). Age-related antibody prevalence in children was studied using the new EIA. Because of the low yield of the baculovirus system, the E. coli-expressed SV capsid proteins were used to develop the EIA. The antigenic specificities of the E. coli-expressed SV capsid proteins were demonstrated using hyperimmune antisera raised in animals and sera collected from patients. A high prevalence (>90%) of antibodies to both SV (strain Mex340) and norovirus (strain VA387) was observed in children involved in a birth cohort at 20 to 24 months of age; however, at 1 to 3 months of age, <25% of the children possessed anti-SV antibodies versus >90% with anti-NV antibodies. The E. coli-derived SV proteins are an excellent source of antigens for the EIA. SV infection is common in the first 2 years of life. The low prevalence of maternal antibodies detected in Mexican children against SVs in this study is unique and needs to be addressed in future studies.

Characterization of the homo- and heterotypic immune responses after natural norovirus infection

Noroviruses (NoV) are a genetically and antigenically diverse group of viruses that are common causes of outbreaks of gastroenteritis in humans of all ages. Limited information has been obtained on type specificity of the NoV immune response. In this study, we characterized the homologous and heterologous antibody responses in adults from 13 outbreaks, representing 4 different NoV genotypes. NoV specific IgG and IgA antibodies were determined as well as the increase of antibody avidity. In addition, antibody-mediated blocking of NoV binding to its putative receptor was evaluated. Both homologous and heterologous serological responses were detected after NoV infection. The avidity of antibodies could not be used to distinguish between homologous and heterologous antibody responses. However, a homologous blocking response but not a heterologous response was detected after infection with NoV belonging to genogroup II.4 by a NoV ligand binding inhibition assay. Infection with NoV induces antibodies that can block virus ligand interactions. In contrast with all currently known antibody detection assays for NoV, this can be used as a type specific assay and may be an alternative for studying neutralizing antibodies.

Expression and antigenicity of virus-like particles of norovirus and their application for detection of noroviruses in stool samples

Human noroviruses (NoVs), members of the genus Norovirus in the family Caliciviridae, are the leading agents of nonbacterial acute gastroenteritis worldwide. Human NoVs are currently divided into at least two genogroups, genogroup I (GI) and genogroup II (GII), each of which contains at least 14 and 17 genotypes. To explore the genetic and antigenic relationship among NoVs, we expressed the capsid protein of four genetically distinct NoVs, the GI/3 Kashiwa645 virus, the GII/3 Sanbu809 virus, the GII/5 Ichikawa754 virus, and the GII/7 Osaka10-25 virus in baculovirus expression system. An antigen enzyme-linked immunosorbent assay (ELISA) with hyperimmune serum against the four recombinant capsid proteins and characterized previously three capsid proteins derived from GI/1, GI/4, and GII/12 was developed to detect the NoVs antigen in stools. The antigen ELISA was highly specific to the homotypic strains, allowing assignment of a strain to a Norovirus genetic cluster within a genogroup.

Seroprevalence of antibodies against noroviruses among students in a Chinese military medical university

Noroviruses (NVs) are important causes of nonbacterial gastroenteritis in humans, but the role of NVs as a cause of diseases in the Chinese people, particularly in Chinese military personnel, remains unclear. This study investigated antibody prevalence and factors that associate with the prevalence of antibody to NVs among students attending a military medical university. Serum specimens were tested by an enzyme-linked immunosorbent assay for immunoglobulin G antibody to recombinant capsid antigens of three NVs (rNorwalk, rMxV, and rVA387). Of 588 serum samples tested, the antibody prevalence was 88.9, 54.1, or 90.0% for the three antigens, respectively. There were significant differences in the prevalence of antibody to rMxV between blood types (P < 0.05); the prevalence for type O was the highest (62.5%), and the prevalence for type B was the lowest (49.1%). The average optical density values for antibody to rNorwalk and rMxV were lowest among students with type B. The number of students who did not have antibody to any of the three antigens was the highest for blood type B (6.9%) compared to other blood types (0.8 to 3.4% [P < 0.006]). The antibody prevalence also varied with the hometown residencies of the students before joining the military, with the highest rates for students from rural areas, lower rates for students from small towns or villages, and the lowest rates for students from large cities. The numbers of students who did not have antibody to any of the three antigens were highest for students from the large cities, lower for students from small towns or villages, and lowest for students from rural areas. The distribution of ABO blood types did not differ among the three groups. These data suggest that NVs are prevalent in China and that both genetic and environmental factors play a role in NV infection.

Human caliciviruses and pediatric gastroenteritis

Surveillance using molecular diagnostic methods developed in the past decade shows that human caliciviruses, particularly the Noroviruses, are the most important cause of pediatric acute gastroenteritis, next to rotavirus. Noroviruses also cause severe gastroenteritis in children, requiring hospitalization. The Sapovirus, a morphologically and genetically distinct genus of calicivirus, cause mainly milder endemic pediatric gastroenteritis. Noroviruses and Sapoviruses are genetically and antigenetically diverse, and multiple genetic types cocirculate in the same community. Human caliciviruses still cannot be cultivated in cell culture or in an animal model. Significant progress has been made in the past decade in the classification, diagnosis, and vaccine development, as well as in the recent discovery of Norovirus recognizing human histoblood group antigens as receptors. Major developments in this field are expected to occur in the near future.

Norovirus capture with histo-blood group antigens reveals novel virus-ligand interactions

Noroviruses are genetically diverse, uncultivable, positive-sense RNA viruses and are the most common cause of epidemic acute gastroenteritis in humans in the United States. Recent studies of norovirus attachment in vitro by using recombinant virus-like particles (VLPs) suggest that various norovirus strains exhibit different patterns of attachment to ABH histo-blood group antigens, which are carbohydrate epitopes present in high concentrations on mucosal cell surfaces of the gut. However, attachment of live norovirus strains to histo-blood group antigens has not been investigated to date. Utilizing a newly designed magnetic bead-virus capture method, we characterized histo-blood group antigen attachment properties of various norovirus strains obtained from clinical stool specimens to compare the attachment properties of wild-type virus and VLPs and to further map norovirus attachment. Consistent with previous reports using VLPs, various strains of noroviruses exhibited different patterns of attachment to histo- blood group antigens. Norwalk virus bound specifically to H type 1, H type 3, and Le(b). Two genogroup II noroviruses, one representing the Toronto genotype and the other from a novel genotype, bound specifically to Le(b). A Desert Shield-like strain did not attach to H types 1, 2, or 3, H type 1 and 3 precursors, Le(a), or Le(b). Surprisingly, wild-type Snow Mountain virus (SMV) attached specifically to H type 3, which contradicted previous findings with SMV VLPs. On further investigation, we found that stool components promote this attachment, providing the first known observation that one or more components of human feces could promote and enhance norovirus attachment to histo-blood group antigens.

Cross-reactivity among several recombinant calicivirus virus-like particles (VLPs) with monoclonal antibodies obtained from mice immunized orally with one type of VLP

Human caliciviruses (HuCVs) are classified into the Norwalk-like viruses (NLV) and Sapporo-like viruses (SLV) as genera within the family CALICIVIRIDAE: The NLV genus is further classified into genogroups I and II, based on sequence similarities. To study the antigenic determinants on the HuCV capsid protein and develop new diagnostic tools for field samples, we established and characterized monoclonal antibodies (MAbs) against baculovirus-expressed recombinant HuCV virus-like particles (VLPs). Hybrid clones producing MAbs were obtained from cultures of PAI myeloma cells fused with spleen or mesenteric lymph node cells from mice immunized orally with either a single type of recombinant Norwalk virus (rNV), Kashiwa 47 virus (rKAV), Snow Mountain agent (rSMA), or Sapporo virus (rSV) VLP or with mixtures of two types of VLPs from different genogroups. Twenty MAbs, obtained as mouse ascites, were characterized and classified into six groups according to their enzyme-linked immunosorbent assay (ELISA) and Western blotting (WB) cross-reactivity patterns to VLPs. Five groups of MAbs reacted by both WB and ELISA and were classified as follows: common cross-reactive MAbs for four genogroup I and six genogroup II VLPs (group A), genogroup I-specific MAbs (group B), genogroup II-specific MAbs (group C), and strain-specific MAbs (groups D and E). One MAb group (group F) reacted only by ELISA. The group A MAbs, which showed broad cross-reactivity with VLPs of both NLV genogroups, were obtained from mice immunized orally with a single type of VLP (either rNV or rKAV). Two MAbs, which were obtained from mice immunized with rSV, reacted with rSV but not with any NLV VLP. These are the first MAbs to be reported for any SLV. These strain-, genogroup-, and genus-reactive MAbs will be useful tools for further study of the antigenic and structural topography of the HuCV virion and for diagnostic assays for HuCVs.

Sequence diversity of human caliciviruses recovered from children with diarrhea in Mendoza, Argentina, 1995-1998

Human caliciviruses were detected by EIA and/or RT-PCR in stool specimens from children with diarrhea treated at out- or in-patient facilities between 1995 and 1998 in Mendoza, Argentina. Mexico virus-like strains detected by primers NV36/51 were transiently prevalent in 1995/1996. Significantly more human caliciviruses were detected when primers were designed from contemporaneously circulating strains. Nucleotide sequences of a highly conserved region in the RNA polymerase gene of 10 selected human caliciviruses were determined. Eight strains were Norwalk-like viruses and two strains were Sapporo-like viruses. Seven of the eight Norwalk-like viruses also were positive by the recombinant Mexico virus antigen EIA. The seven Mexico virus EIA-positive strains revealed two patterns in the RNA polymerase sequences: two strains were closest to Mexico virus and the other five strains were closest to Lordsdale virus. One of the five "Lordsdale" viruses was found to be a naturally occurring recombinant between the Mexico virus and Lordsdale human calicivirus genetic clusters [Jiang et al., (1999b) Archives of Virology 144:2377-2387]. The Mexico virus EIA-negative strain had 73-77% nucleotide identity with the closest related Norwalk-like viruses, indicating it might belong to a new genetic cluster of the Norwalk-like virus genus. The two Sapporo-like viruses were distinct genetically; one belonged to the Houston/90 or Parkville cluster and the other to a new cluster. Some strains appeared to have short periods of prevalence and locally adapted primer pairs significantly increased detection rates. The finding of high diversity of circulating strains, including recombinant strains and strains with previously unrecognized genetic identities, highlights a need for studies of human caliciviruses in these children and other populations.

Human caliciviruses in Europe

Caliciviruses are single-stranded RNA viruses, which are divided into four genera based on their morphology and genomic structure. Viruses from two genera, the Norwalk like viruses and Sapporo like viruses, are a common cause of acute, nonbacterial gastroenteritis in humans. Although the first human calicivirus discovered nearly 30 years ago, much of the epidemiological and biological character of these viruses is only now beginning to unfold. Investigation has been difficult due to a number of factors, the viruses cannot be amplified by in vitro cell culture or animal models and electron microscopy (EM) is often not sensitive enough to detect the viruses in stool samples. Recent advances in molecular diagnostic techniques and the advent of a baculovirus expression system have highlighted the clinical and public health importance of calicivirus in all age groups, their ability to cause infection via a number of transmission routes as well as their considerable genetic diversity. These characteristics, in conjunction with the inability of humans to develop long-term immunity make HuCV an important public health issue in Europe and worldwide.

Outbreaks of acute gastroenteritis associated with Norwalk-like viruses in campus settings

Norwalk-like viruses (NLVs) are transmitted by fecally contaminated food, water, fomites, and person-to-person contact. They are a leading cause of acute gastroenteritis epidemics in industrialized countries. NLV outbreaks are characterized by a 12- to 48-hour incubation period; nausea, vomiting, and diarrhea for 24 to 72 hours; and high secondary attack rates. NLV infections spread rapidly on college and university campuses because of close living quarters, shared bathrooms and common rooms, many food handlers, popular self-service salad bars in dining halls, and person-to-person contact through sports and recreational activities. The illness is generally mild and self-limited but an outbreak can strain the resources of campus health services and cause high absenteeism among both students and staff. Treatment is primarily through antiemetic medication and oral rehydration. Prevention and control of NLV outbreaks rests on promoting hand washing; enforcement of strict hygiene in all food preparation areas; and prompt, rigorous cleaning of potentially contaminated areas where someone has been ill.

Expression of recombinant capsid proteins of chitta virus, a genogroup II Norwalk virus, and development of an ELISA to detect the viral antigen

The second open reading frame (ORF2) gene of the Chitta virus (CHV) was cloned to construct a recombinant baculovirus. The CHV ORF2 is predicted to encode a capsid protein of 535 amino acids (aa). CHV showed a high aa identity in the capsid region with genogroup II Norwalk virus (NV) (65-85%), but a low aa identity with genogroup I NV (44-46%). Phylogenetic analysis of the ORF2 gene demonstrated that CHV is genetically closely related to the Hawaii virus included in genogroup II NV. The recombinant capsid protein of CHV (rCHV) self-assembled to form empty virus-like particles (VLPs) when expressed in insect cells with the recombinant baculovirus. An enzyme-linked immunosorbent assay (ELISA) based on antisera to rCHV was developed to detect CHV antigen in stools. The antigen ELISA appeared to be highly specific to both rCHV and CHV-like strains. In addition, combined use of antigen ELISAs using antibodies against two antigenically distinct recombinant VLPs, the recombinant Chiba virus (rCV) and recombinant Seto virus (rSEV), enabled us to determine the genetic as well as antigenic relationship among these three viruses.

Diagnosis of noncultivatable gastroenteritis viruses, the human caliciviruses

Gastroenteritis is one of the most common illnesses of humans, and many different viruses have been causally associated with this disease. Of those enteric viruses that have been established as etiologic agents of gastroenteritis, only the human caliciviruses cannot be cultivated in vitro. The cloning of Norwalk virus and subsequently of other human caliciviruses has led to the development of several new diagnostic assays. Antigen detection enzyme immunoassays (EIAs) using polyclonal hyperimmune animal sera and antibody detection EIAs using recombinant virus-like particles have supplanted the use of human-derived reagents, but the use of these assays has been restricted to research laboratories. Reverse transcription-PCR assays for the detection of human caliciviruses are more widely available, and these assays have been used to identify virus in clinical specimens as well as in food, water, and other environmental samples. The application of these newer assays has significantly increased the recognition of the importance of human caliciviruses as causes of sporadic and outbreak-associated gastroenteritis.

Serotype-specific antigen ELISA for detection of Chiba virus in stools

Chiba virus (CV), a Norwalk-like virus (NLV), was first identified as a cause of oyster-associated outbreak of gastroenteritis that occurred in Chiba prefecture, Japan, in 1987. An enzyme-linked immunosorbent assay (ELISA), based on hyperimmune antisera to recombinant baculovirus-expressed capsid proteins of CV (rCV), was developed to detect CV antigen in stools. No cross-reactions were observed with other enteric viruses including enteroviruses, rotaviruses, astroviruses, or enteric adenoviruses. The ELISA was used to screen 101 stools collected from 16 oyster-associated outbreaks of acute gastroenteritis. Twelve stools (11.9%) from seven outbreaks were positive for CV antigen. Ten rCV ELISA-positive strains were confirmed by RT-PCR and nucleotide sequencing. ELISA-positive strains showed 96-100% nucleotide sequence identity to each other, though they were obtained nine years apart. Phylogenetic analysis demonstrated that all ten strains clustered with the prototype CV in genogroup I viruses. We concluded that the antigen ELISA described in this study is highly type-specific, and that this method should be useful for epidemiological surveys of Chiba virus infections.

Diagnosis of foodborne viral infections in patients

A significant global problem is the microbiological contamination of foods and water. The microorganisms associated with about half of the foodborne disease outbreaks still go unrecognized, primarily as a result of inadequate diagnostic methods and sampling. A significant amount of food- and waterborne diseases are associated with viruses, information that has been obtained only in recent years. Improved diagnostic methods have established that caliciviruses are the most important non-bacterial pathogens associated with food- and waterborne outbreaks, and are the major cause of seafood-associated gastroenteritis.

Seroprevalence and seroincidence of Norwalk-like virus infection among Brazilian infants and children

To determine the importance of Norwalk-like viruses (NLVs) as pediatric pathogens in a developing country, the seroprevalence and seroincidence of this group of viruses in a cohort of children less than 4 years of age in an urban shantytown in northeastern Brazil was examined. Serum samples were collected approximately every 6 months from 135 children who were surveyed three times each week for diarrhea and vomiting. NLV IgG was measured by an enzyme immunosorbent assay (EIA) with recombinant Norwalk virus capsid protein. Overall NLV seroprevalence was 71%, and the overall NLV seroconversion rate was 0.7 seroconversions per child-year. The highest age-specific NLV seroconversion rate (0.8 seroconversions per child-year) was observed in the 13-24-month age group. For all study children, the incidence of diarrhea and vomiting was significantly greater (P < 0.01) during time periods spanned by serum pairs that indicated NLV seroconversion compared with time periods without NLV seroconversion. However, NLV seroconversion was not associated with gastrointestinal symptoms during the first year of life.

Immunity to calicivirus infection

The evolution of our understanding of immunity to calicivirus infection, using Norwalk virus as the prototype, is discussed in three stages: (1) "ancient times (1972-1978), when human volunteer studies prevailed, (2) the "middle ages (1978-1990), which were characterized by the development and implementation of solid-phase immunoassays based on native viral antigens, and (3) "modern times (1990 to present), which began with the cloning of the genome of the noncultivatable 8FIIa strain of Norwalk virus and resulted in a readily available source of recombinant virus-like particles that have revolutionized the study of caliciviruses. Throughout these stages, it has been shown repeatedly that short-term immunity develops to homologous virus. However, the search for determinants of long-term immunity continues. These studies will likely be facilitated by the newest reagents-the noninfectious recombinant virus-like particles-used in the setting of human volunteer studies and large epidemiologic studies.

Diagnosis of human caliciviruses by use of enzyme immunoassays

The application of molecular technologies, such as the expression of viral proteins in baculovirus, has provided a powerful approach to the diagnosis of human calicivirus (HuCV) infections. The baculovirus-expressed HuCV capsid protein self-assembles into virus-like particles, providing excellent reagents for immunologic assays, such as enzyme immunoassays (EIAs). Following the expression of the capsid protein of Norwalk virus, the capsid proteins of 8 other HuCV strains have been expressed in baculovirus. The unlimited supply of baculovirus-produced reagents for HuCVs allows these EIAs to be applied in large-scale clinical and epidemiological studies. Both the antigen and antibody-detection EIAs are highly sensitive. The antigen-detection EIAs are highly specific, but the antibody-detection EIAs are more broadly reactive. This article reviews baculovirus expression techniques used to produce HuCV capsid antigens, development of EIAs using these antigens, and application of these EIAs in studies of HuCV infection and illness.

Norwalk-like virus infection in military forces: epidemic potential, sporadic disease, and the future direction of prevention and control efforts

The impact of Norwalk-like virus (NLV) infection on military forces is evaluated in this report. NLVs were a major cause of both outbreaks and sporadic disease among crowded US ground troops in the 1991 war with Iraq. NLVs also have been found to be a cause of acute gastroenteritis in other ground and shipboard deployments. Four large outbreaks of acute gastroenteritis were investigated aboard US Navy aircraft carriers between 1992 and 1997. In these outbreaks, NLVs were identified as the probable cause, and crowding was a major risk factor for transmission. An evaluation of a routine shipboard deployment also suggests that NLVs cause sporadic gastroenteritis. These data indicate that NLV infection is a major cause of acute morbidity in military forces. Because of the limitations of available prevention and control methods, development of a vaccine against these viruses may be the best solution in the military environment.

Seroepidemiological study of genogroup I and II calicivirus infections in South and southern Africa

Diarrhoea is associated with the daily death of between 180 and 200 children under the age of 5 years in South Africa. Until recently, many cases and outbreaks of diarrhoea were not associated with a known aetiologic agent. Previous studies using baculovirus-expressed Norwalk virus (NV) and Mexico virus (MxV) capsid antigens have shown that human calicivirus infection is common in South Africa. In this study, our surveillance was extended to different populations, as well as to four other southern African countries: Namibia, Angola, Zimbabwe, and Mozambique. More than 1,700 specimens, some involved in previous cohort studies of infectious diseases, were enrolled in the surveillance. The overall seroprevalence of antibody against NV was >90% for all cohorts except for Mozambican refugees that had 83. 8% sero-positivity. The MxV antibody prevalence was higher than NV, with >95% positivity for all cohorts, except for one in Namibia that had 81% exposure. This study is one of only a few reporting on the concurrent incidence of NV and MxV infections in a cohort study, and has determined that small round structured viruses are prevalent in the local populations of South and Southern Africa. These agents may account for a number of previously unknown or unidentified causes of diarrhoeal illness, in both adults and children, in southern Africa.

Prevalence of antibodies to astrovirus types 1 and 3 in children and adolescents in Norfolk, Virginia

OBJECTIVE

To determine the prevalence of antibody to human astrovirus types 1 (HAstV-1) and 3 (HAstV-3) in children.

METHODS

Sera from children hospitalized in Norfolk, VA, for noninfectious conditions were collected for a 1-month period every 6 months from 1993 to 1996 and tested by enzyme immunoassay for antibody to HAstV-1 and HAstV-3 with the use of baculovirus-expressed recombinant capsid proteins as antigens.

RESULTS

The seroprevalence of 393 infants and children to HAstV-1 decreased from 67% in infants <3 months of age to 7% by 6 to 8 months of age, consistent with loss of transplacental antibodies. Children acquired HAstV-1 antibody with a peak prevalence of 94% at 6 to 9 years of age (P < 0.001). Antibodies to HAstV-3 exhibited a lower prevalence, with 26% positive at <3 months, 0% at 6 to 11 months and 42% by 6 to 9 years of age. HAstV-1 seroprevalence in children O to 2 months of age decreased from 89% in November, 1993, to 40% in November, 1996 (P = 0.009).

CONCLUSIONS

Astrovirus type-specific antibody prevalence can be measured by baculovirus-expressed capsid antigens in an enzyme immunoassay. Children developed antibody to HAstV-1 (94%) and to HAstV-3 (42%) by 6 to 9 years of age indicating frequent exposure to these enteric viruses in infancy and early childhood.

Prevalence of human calicivirus infections in Kenya as determined by enzyme immunoassays for three genogroups of the virus

An epidemiological survey on human calicivirus (HuCV) infections and associated gastroenteritis in infants was conducted to clarify the prevalence of HuCV infections in infants and adults in Kenya. Enzyme immunoassays (EIAs) for three genogroups of HuCVs, Norwalk virus (NV), Mexico virus (MXV), and Sapporo virus (SV), were used to detect antigen or antibody. We tested 1,431 stool samples obtained from children younger than 6 years old with acute gastroenteritis who visited outpatient clinics in three districts in Kenya from August 1991 to July 1994. Thirty-two (2.2%) of these stool samples were positive for SV antigen. Only one (0.1%) of 1,186 samples was positive for NV antigen and none of 246 samples was positive for MXV antigen. One hundred ninety-three serum samples were tested for antibodies to NV and MXV, and 64 of them were examined for antibody to SV. The pattern of the age-related prevalence of serum antibody to NV was different from that of antibodies to MXV and SV. The acquisition of serum antibodies to HuCVs in the three genogroups appeared in early childhood, at about 1 to 2 years of age. The prevalence of serum antibody to NV was low (about 60%) throughout adulthood compared with a high prevalence of antibody (approximately 80 to 90%) to MXV and SV. These data indicate that infections with viruses in the three genogroups of HuCVs are common in Kenya, and immunological responses to NV may be different from those to MXV and SV. The EIAs for the detection of NV and MXV antigens appear to be quite specific for prototype NV and MXV strains, respectively, so that they can detect only a few strains of HuCVs related to them. Alternatively, NV and MXV caused less severe infections that did not bring children to the outpatient clinics for gastroenteritis in Kenya.

The role of human caliciviruses in epidemic gastroenteritis

Members of the Caliciviridae family of small, positive-sense RNA viruses exhibit a broad host range. The Norwalk and Norwalk-like caliciviruses in this family are major etiologic agents of epidemic gastroenteritis in humans. This illness characteristically lasts 24-48 h and often occurs in group settings such as families, schools, institutions, or communities. The spread of the human caliciviruses is considered to be predominantly by person-to-person contact via the fecal-oral-route. However, the ingestion of calicivirus-contaminated food or water can result in large-scale common-source outbreaks. Many basic features concerning the biology and replication of the human caliciviruses are not known because they have not yet been grown in cell culture and the virus does not appear to replicate in animal models other than the chimpanzee. Sequence analysis of RT-PCR-generated DNA fragments derived from serotypically distinct reference strains (such as the Norwalk, Hawaii, and Snow Mountain viruses) and other circulating strains associated with gastroenteritis has provided evidence for marked genetic diversity among these viruses. Moreover, analysis of the antigenic relationships among these viruses using paired sera from individuals infected with well-characterized reference strains or from animals immunized with recombinant "virus-like particles" (VLPs) suggests that several serotypes of these viruses are circulating worldwide. The availability of molecular techniques for the detection of these fastidious viruses has enabled epidemiologic studies that have strengthened the association of human caliciviruses with acute gastroenteritis and has demonstrated a potential role for antigenic diversity in the natural history of these pathogens.

Study of Norwalk virus and Mexico virus infections at Ga-Rankuwa Hospital, Ga-Rankuwa, South Africa

Small round-structured viruses (SRSVs) or Norwalk-like viruses have been implicated as an important causative agent of gastroenteritis outbreaks. We used the relatively newly developed recombinant enzyme immunoassays (EIAs) to determine the seroprevalence of Norwalk virus (NV) and Mexico virus (MxV) in a family-based cohort and an antenatal clinic cohort at Ga-Rankuwa Hospital, Ga-Rankuwa, South Africa. High prevalences (96 to 99%) of anti-NV and anti-MxV antibodies were detected in both cohorts. We also investigated the pattern of antibody acquisition in a cohort of infants and young children without gastroenteritis and found that by 48 months of age all children had acquired adult antibody levels to both these viruses. Lastly, we tested 276 stool specimens collected from infants and young children with gastroenteritis for the presence of NV or MxV antigen by recombinant EIAs to each virus, by electron microscopy (EM), and by reverse transcription (RT)-PCR. NV and MxV antigens were present in 1.8 and 4.3% of the stool specimens, respectively, by the recombinant EIAs; 9.2% were positive for SRSVs by EM, and 25% of these SRSVs gave a positive result by RT-PCR for primer pair 35-36 directed to a region of the RNA-dependent RNA polymerase gene. The seroprevalence studies indicate a high level of exposure to these viruses in both children and adults. Although the viral antigens are not highly prevalent in diarrheal stools, it was determined by the two assays for NV and MxV that children are, nevertheless, infected early in life.

Seroprevalence of astrovirus types 1 and 6 in London, determined using recombinant virus antigen

We have developed a microimmunofluorescence test (IF) which uses cells infected with a recombinant baculovirus which expresses the capsid proteins of astrovirus types 1 or 6. The IF test was sensitive and specific and the results for human astrovirus type 1 (HAst-1) were comparable to those obtained by immune electronmicroscopy and radioimmunoassay. Application of the test to a panel of 273 sera collected from patients and staff at two childrens hospitals in London showed that over 50% of the population were infected by HAst-1 between the age of 5 and 12 months rising to 90% by 5 years, whereas human astrovirus type 6 (HAst6) was relatively uncommon (10-30%) in all age groups.

Prevalence of serum antibodies to Norwalk virus among Norwegian military recruits

The prevalence of serum antibodies against Norwalk virus among military recruits in Norway was investigated using an enzyme-linked immunosorbent assay (ELISA). A total of 1017 sera were assayed for anti-Norwalk virus total antibodies (ig), of which 300 (29.5%) were positive. Of 227 positive sera, 10.6 and 15.4% were positive for IgA and IgM, respectively, while 2.2% were positive for both. The prevalence of antibodies against Norwalk virus in south-east Norway was significantly higher than that in northern Norway.

An epidemiological investigation of Norwalk virus infection in South Africa

A study was carried out to determine the incidence and seroprevalence of Norwalk virus (NV) in the Pretoria area, South Africa, using a recombinant NV (rNV) immunoassay for the detection of serum IgG antibodies. Maternal antibody was detectable in infants' sera up to approximately 6 months of age. Infection with NV was detected serologically in the second year of life and the seroprevalence of NV IgG rose from 37.1% at 7-11 months of age to 62.1% by the age of 40 years. No significant differences in seroprevalence of NV IgG antibody was evident between subjects of European or African ethnic origin, where overall seroprevalence rates were 56.4% and 53.9% respectively.

Study on occurrence of human calicivirus (Mexico strain) as cause of sporadic cases and outbreaks of calicivirus-associated diarrhoea in the United Kingdom, 1983-1995

The use of a recently developed EIA using antisera raised against purified baculovirus expressed recombinant Mexico virus (rMx) capsid protein is described for screening for human calicivirus in stools. The results show that MX-like viruses have been circulating in the UK periodically since 1983 and were an occasional cause of sporadic cases of diarrhoea in infants and outbreaks of infection among elderly patients in hospitals and old people's homes. Further evidence is presented that some strains of caliciviruses with characteristic surface morphology (HuCVs) and some with an indistinct appearance, small round structured viruses (SRSVs) are antigenically related to MxV. Tests on SRSVs from four unrelated outbreaks typed as UK3 failed to react in the Mx EIA or recombinant Norwalk virus (rNV) EIA. A 2-month survey of 206 children treated in two London hospitals for diarrhoea showed that only one was positive for MxV, a child known to be infected with HIV-1. None of the samples reacted in the rNV EIA.

Genetic and antigenic diversity of human caliciviruses (HuCVs) using RT-PCR and new EIAs

RT-PCR using primers from conserved regions of calicivirus genomes, followed by sequencing, permits characterization of genetic variation within the family. EIAs based on baculovirus-expressed viral capsid proteins and hyperimmune antisera against the capsid proteins were developed to detect HuCV antigens and antibodies. Serologic surveys using recombinant Norwalk virus (rNV) and recombinant Mexico virus (rMX, a SMA-like virus) EIAs showed that infections by HuCVs are common and that children acquire antibodies to HuCVs at an early age in both developed and developing countries. Three HuCV genogroups have been described that are represented by Norwalk virus (NV), Snow Mountain agent (SMA), and Sapporo virus, although recently accumulated sequences of HuCV strains indicate these genogroups can be further divided. These genogroups also correspond to distinct antigenic groups based on the results of the recombinant EIAs. The three genogroups co-circulate and have a worldwide distribution, although the SMA genogroup seems to be predominant currently. Application of these new assays for further characterization of the genetic and antigenic properties of HuCVs remains an important task for HuCV research.