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Kabue JP, Khumela R, Meader E, Baroni de Moraes MT, Traore AN, Potgieter N. Norovirus-Associated Gastroenteritis Vesikari Score and Pre-Existing Salivary IgA in Young Children from Rural South Africa. Viruses 2023; 15:2185. [PMID: 38005863 PMCID: PMC10674611 DOI: 10.3390/v15112185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/16/2023] [Accepted: 10/24/2023] [Indexed: 11/26/2023] Open
Abstract
Norovirus (NoV) is the leading cause of viral gastroenteritis, mostly affecting young children worldwide. However, limited data are available to determine the severity of norovirus-associated AGE (acute gastroenteritis) and to correlate it with the NoV-specific IgA antibodies' level. Between October 2019 and September 2021, two hundred stool samples were randomly collected from symptomatic cases for the vesikari score and NoV-specific IgA assessment in young children from rural South Africa. Additionally, one hundred saliva specimens were concomitantly sampled within the same cohort to evaluate the NoV-specific salivary IgA levels. In addition, 50 paired saliva and stool samples were simultaneously collected from asymptomatic children to serve as controls. NoV strains in stool samples were detected using real-time RT-PCR, amplified, and genotyped with RT-PCR and Sanger sequencing. ELISA using NoV VLP (virus-like particles) GII.4 as antigens was performed on the saliva specimens. Dehydrated children were predominantly those with NoV infections (65/74, 88%; p < 0.0001). NoV-positive infections were significantly associated with the severe diarrhea cases having a high vesikari score (55%, 33/60) when compared to the non-severe diarrheal score (29.3%, 41/140; p < 0.0308). NoV of the GII genogroup was mainly detected in severe diarrhea cases (50.9%, 30/59; p = 0.0036). The geometric means of the NoV-specific IgA level were higher in the asymptomatic NoV-infected group (0.286) as compared to the symptomatic group (0.174). This finding suggests that mucosal immunity may not protect the children from the NoV infection. However, the findings indicated the contribution of the pre-existing NoV-specific IgA immune response in reducing the severity of diarrheal disease. A high vesikari score of AGE associated with the NoV GII genogroup circulating in the study area underscores the need for an appropriate treatment of AGE based on the severity level of NoV-associated clinical symptoms in young children.
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Affiliation(s)
- Jean-Pierre Kabue
- Department of Biochemistry and Microbiology, Faculty of Science, Engineering and Agriculture, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa; (R.K.); (A.N.T.); (N.P.)
| | - Ronewa Khumela
- Department of Biochemistry and Microbiology, Faculty of Science, Engineering and Agriculture, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa; (R.K.); (A.N.T.); (N.P.)
| | - Emma Meader
- Clinical Microbiology, Pathology Department, East Kent Hospitals University NHS Foundation Trust, Ashford TN24 OLZ, UK;
| | - Marcia Terezinha Baroni de Moraes
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Avenida Brazil, 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil;
| | - Afsatou Ndama Traore
- Department of Biochemistry and Microbiology, Faculty of Science, Engineering and Agriculture, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa; (R.K.); (A.N.T.); (N.P.)
| | - Natasha Potgieter
- Department of Biochemistry and Microbiology, Faculty of Science, Engineering and Agriculture, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa; (R.K.); (A.N.T.); (N.P.)
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Khumela R, Kabue JP, de Moraes MTB, Traore AN, Potgieter N. Prevalence of Human Norovirus GII.4 Sydney 2012 [P31] between 2019 and 2021 among Young Children from Rural Communities in South Africa. Viruses 2023; 15:1682. [PMID: 37632024 PMCID: PMC10458076 DOI: 10.3390/v15081682] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 08/27/2023] Open
Abstract
Acute gastroenteritis (AGE) accounts for considerable morbidity and mortality in the paediatric population worldwide, especially in low-income countries. Human norovirus (HNoV), particularly GII.4 strains, are important agents of AGE. This study aimed to detect and characterise HNoV in children with and without AGE. Between 2019 and 2021, 300 stool samples (200 AGE and 100 without AGE) were collected from children below 5 years of age referred to the healthcare facilities of the rural communities of Vhembe District, South Africa. After detection using real-time RT-PCR, HNoV positive samples were subjected to RT-PCR and Sanger sequencing. Partial nucleotide sequences (capsid/RdRp) were aligned using the Muscle tool, and phylogenetic analysis was performed using MEGA 11. The nucleotides' percent identity among HNoV strains was compared using ClustalW software. A significant difference in HNoV prevalence between AGE children (37%; 74/200) and non-AGE (14%; 14/100) was confirmed (p < 0.0001). Genogroup II (GII) HNoV was predominant in AGE children (80%; 59/74), whereas most non-AGE children were infected by the GI norovirus genogroup (64%; 9/14). GII.4 Sydney 2012 [P31] strains were dominant (59%; 19/32) during the study period. A phylogenetic analysis revealed a close relationship between the HNoV strains identified in this study and those circulating worldwide; however, ClustalW showed less than 50% nucleotide similarity between strains from this study and those from previously reported norovirus studies in the same region. Our findings indicate significant changes over time in the circulation of HNoV strains, as well as the association between high HNoV prevalence and AGE symptoms within the study area. The monitoring of HuNoV epidemiology, along with stringent preventive measures to mitigate the viral spread and the burden of AGE, are warranted.
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Affiliation(s)
- Ronewa Khumela
- Department of Biochemistry and Microbiology, Faculty of Science, Engineering and Agriculture, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa; (J.-P.K.); (A.N.T.); (N.P.)
| | - Jean-Pierre Kabue
- Department of Biochemistry and Microbiology, Faculty of Science, Engineering and Agriculture, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa; (J.-P.K.); (A.N.T.); (N.P.)
| | - Marcia Terezinha Baroni de Moraes
- Laboratory of Comparative and Environmental Virology, Oswaldo Cruz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Avenida Brazil, 4365-Manguinhos, Rio de Janeiro 21040-360, RJ, Brazil;
| | - Afsatou Ndama Traore
- Department of Biochemistry and Microbiology, Faculty of Science, Engineering and Agriculture, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa; (J.-P.K.); (A.N.T.); (N.P.)
| | - Natasha Potgieter
- Department of Biochemistry and Microbiology, Faculty of Science, Engineering and Agriculture, University of Venda, Private Bag X5050, Thohoyandou 0950, South Africa; (J.-P.K.); (A.N.T.); (N.P.)
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Vielot NA, François R, Huseynova E, González F, Reyes Y, Gutierrez L, Nordgren J, Toval-Ruiz C, Vilchez S, Vinjé J, Becker-Dreps S, Bucardo F. Association between breastfeeding, host genetic factors, and calicivirus gastroenteritis in a Nicaraguan birth cohort. PLoS One 2022; 17:e0267689. [PMID: 36240197 PMCID: PMC9565698 DOI: 10.1371/journal.pone.0267689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 09/16/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Norovirus and sapovirus are important causes of childhood acute gastroenteritis (AGE). Breastfeeding prevents AGE generally; however, it is unknown if breastfeeding prevents AGE caused specifically by norovirus and sapovirus. METHODS We investigated the association between breastfeeding and norovirus or sapovirus AGE episodes in a birth cohort. Weekly data on breastfeeding and AGE episodes were captured during the first year of life. Stools were collected from children with AGE and tested by RT-qPCR for norovirus and sapovirus. Time-dependent Cox models estimated associations between weekly breastfeeding and time to first norovirus or sapovirus AGE. FINDINGS From June 2017 to July 2018, 444 newborns were enrolled in the study. In the first year of life, 69 and 34 children experienced a norovirus and a sapovirus episode, respectively. Exclusive breastfeeding lasted a median of 2 weeks, and any breastfeeding lasted a median of 43 weeks. Breastfeeding in the last week did not prevent norovirus (HR: 1.09, 95% CI: 0.62, 1.92) or sapovirus (HR: 1.00, 95% CI: 0.82, 1.21) AGE in a given week, adjusting for household sanitation, consumption of high-risk foods, and mother's and child's histo-blood group phenotypes. Maternal secretor-positive phenotype was protective against norovirus AGE, whereas child's secretor-positive phenotype was a risk factor for norovirus AGE. INTERPRETATION Exclusive breastfeeding in this population was short-lived, and no conclusions could be drawn about its potential to prevent norovirus or sapovirus AGE. Non-exclusive breastfeeding did not prevent norovirus or sapovirus AGE in the first year of life. However, maternal secretor-positive phenotype was associated with a reduced hazard of norovirus AGE.
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Affiliation(s)
- Nadja Alexandra Vielot
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Ruthly François
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Emilya Huseynova
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Fredman González
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua–León, León, Nicaragua
| | - Yaoska Reyes
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua–León, León, Nicaragua
| | - Lester Gutierrez
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua–León, León, Nicaragua
| | - Johan Nordgren
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Christian Toval-Ruiz
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua–León, León, Nicaragua
| | - Samuel Vilchez
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua–León, León, Nicaragua
| | - Jan Vinjé
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Sylvia Becker-Dreps
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua–León, León, Nicaragua
| | - Filemon Bucardo
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua–León, León, Nicaragua
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Ottosson L, Hagbom M, Svernlöv R, Nyström S, Carlsson B, Öman M, Ström M, Svensson L, Nilsdotter-Augustinsson Å, Nordgren J. Long Term Norovirus Infection in a Patient with Severe Common Variable Immunodeficiency. Viruses 2022; 14:v14081708. [PMID: 36016330 PMCID: PMC9413339 DOI: 10.3390/v14081708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/24/2022] [Accepted: 07/25/2022] [Indexed: 11/29/2022] Open
Abstract
Norovirus is the most common cause of acute non-bacterial gastroenteritis. Immunocompromised patients can become chronically infected, with or without symptoms. In Europe, common variable immunodeficiency (CVID) is one of the most common inborn errors of immunity. A potentially severe complication is CVID-associated enteropathy, a disorder with similar histopathology to celiac disease. Studies suggest that chronic norovirus infection may be a contributor to CVID enteropathy, and that the antiviral drug ribavirin can be effective against norovirus. Here, a patient with CVID-like disease with combined B- and T-cell deficiency, had chronic norovirus infection and enteropathy. The patient was routinely administered subcutaneous and intravenous immunoglobulin replacement therapy (SCIg and IVIg). The patient was also administered ribavirin for ~7.5 months to clear the infection. Stool samples (collected 2013–2016) and archived paraffin embedded duodenal biopsies were screened for norovirus by qPCR, confirming a chronic infection. Norovirus genotyping was done in 25 stool samples. For evolutionary analysis, the capsid (VP1) and polymerase (RdRp) genes were sequenced in 10 and 12 stool samples, respectively, collected before, during, and after ribavirin treatment. Secretor phenotyping was done in saliva, and serum was analyzed for histo-blood group antigen (HBGA) blocking titers. The chronic norovirus strain formed a unique variant subcluster, with GII.4 Den Haag [P4] variant, circulating around 2009, as the most recent common ancestor. This corresponded to the documented debut of symptoms. The patient was a secretor and had HBGA blocking titers associated with protection in immunocompetent individuals. Several unique amino acid substitutions were detected in immunodominant epitopes of VP1. However, HBGA binding sites were conserved. Ribavirin failed in treating the infection and no clear association between ribavirin-levels and quantity of norovirus shedding was observed. In conclusion, long term infection with norovirus in a patient with severe CVID led to the evolution of a unique norovirus strain with amino acid substitutions in immunodominant epitopes, but conservation within HBGA binding pockets. Regularly administered SCIg, IVIg, and ~7.5-month ribavirin treatment failed to clear the infection.
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Affiliation(s)
- Loa Ottosson
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, 58185 Linköping, Sweden; (L.O.); (M.H.); (S.N.); (B.C.); (M.Ö.); (L.S.)
| | - Marie Hagbom
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, 58185 Linköping, Sweden; (L.O.); (M.H.); (S.N.); (B.C.); (M.Ö.); (L.S.)
| | - Rikard Svernlöv
- Department of Gastroenterology and Hepatology, Linköping University, 58185 Linköping, Sweden; (R.S.); (M.S.)
| | - Sofia Nyström
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, 58185 Linköping, Sweden; (L.O.); (M.H.); (S.N.); (B.C.); (M.Ö.); (L.S.)
- Department of Clinical Immunology and Transfusion Medicine and Department of Biomedical and Clinical Sciences, Linköping University, 58185 Linköping, Sweden
| | - Beatrice Carlsson
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, 58185 Linköping, Sweden; (L.O.); (M.H.); (S.N.); (B.C.); (M.Ö.); (L.S.)
| | - Mattias Öman
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, 58185 Linköping, Sweden; (L.O.); (M.H.); (S.N.); (B.C.); (M.Ö.); (L.S.)
| | - Magnus Ström
- Department of Gastroenterology and Hepatology, Linköping University, 58185 Linköping, Sweden; (R.S.); (M.S.)
| | - Lennart Svensson
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, 58185 Linköping, Sweden; (L.O.); (M.H.); (S.N.); (B.C.); (M.Ö.); (L.S.)
- Division of Infectious Diseases, Department of Medicine, Karolinska Institute, 17111 Stockholm, Sweden
| | - Åsa Nilsdotter-Augustinsson
- Infectious Diseases/Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, 58185 Linköping, Sweden;
| | - Johan Nordgren
- Division of Molecular Medicine and Virology, Department of Biomedical and Clinical Sciences, Linköping University, 58185 Linköping, Sweden; (L.O.); (M.H.); (S.N.); (B.C.); (M.Ö.); (L.S.)
- Correspondence:
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Zambrana JV, Bustos Carrillo FA, Ojeda S, Lopez Mercado B, Latta K, Schiller A, Kuan G, Gordon A, Reingold A, Harris E. Epidemiologic Features of Acute Pediatric Diarrhea in Managua, Nicaragua, from 2011 to 2019. Am J Trop Med Hyg 2022; 106:1757-1764. [PMID: 35895434 PMCID: PMC9209918 DOI: 10.4269/ajtmh.21-0793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 02/18/2022] [Indexed: 11/12/2022] Open
Abstract
Diarrhea remains a leading cause of death in children in developing countries, including Nicaragua, but little is known about patterns of diarrhea occurrence in Central America over long periods of time. The purpose of this study was to determine the incidence, risk factors, long-term trends, and seasonality of diarrhea in children age 2 to 14 years in Managua, Nicaragua. From 2011 to 2019, we examined episodes of diarrhea among 6,485 children who participated in a prospective cohort study and presented for care in a primary care facility. We performed a longitudinal analysis considering time-varying variables and the intra-subject correlation of outcomes. In addition, we analyzed the weekly incidence of diarrhea, applying seasonal trend decomposition to extract secular and seasonal patterns. The overall incidence rate of diarrhea was 133.4 episodes per 1,000 person-years (95% CI, 128.3–138.7). We observed a slight increase in the incidence of diarrhea from 2011 to 2019. Younger age was the strongest predictor of the risk of diarrhea, and incidence increased with every additional hour without running water in the household per day. Diarrhea incidence in Managua was seasonal, with high peaks each year between May and July. Despite reductions in childhood mortality since 1990 in Nicaragua, diarrheal morbidity remains a major problem in Managua.
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Affiliation(s)
| | - Fausto Andres Bustos Carrillo
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, California
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, California
| | - Sergio Ojeda
- Sustainable Sciences Institute, Managua, Nicaragua
| | | | - Krista Latta
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Amy Schiller
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Guillermina Kuan
- Centro de Salud Sócrates Flores Vivas, Ministry of Health, Managua, Nicaragua
| | - Aubree Gordon
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Arthur Reingold
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, California
| | - Eva Harris
- Division of Infectious Diseases and Vaccinology, School of Public Health, University of California, Berkeley, California
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Hasan H, Nasirudeen NA, Ruzlan MAF, Mohd Jamil MA, Ismail NAS, Wahab AA, Ali A. Acute Infectious Gastroenteritis: The Causative Agents, Omics-Based Detection of Antigens and Novel Biomarkers. CHILDREN (BASEL, SWITZERLAND) 2021; 8:1112. [PMID: 34943308 PMCID: PMC8700514 DOI: 10.3390/children8121112] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 12/25/2022]
Abstract
Acute infectious gastroenteritis (AGE) is among the leading causes of mortality in children less than 5 years of age worldwide. There are many causative agents that lead to this infection, with rotavirus being the commonest pathogen in the past decade. However, this trend is now being progressively replaced by another agent, which is the norovirus. Apart from the viruses, bacteria such as Salmonella and Escherichia coli and parasites such as Entamoeba histolytica also contribute to AGE. These agents can be recognised by their respective biological markers, which are mainly the specific antigens or genes to determine the causative pathogen. In conjunction to that, omics technologies are currently providing crucial insights into the diagnosis of acute infectious gastroenteritis at the molecular level. Recent advancement in omics technologies could be an important tool to further elucidate the potential causative agents for AGE. This review will explore the current available biomarkers and antigens available for the diagnosis and management of the different causative agents of AGE. Despite the high-priced multi-omics approaches, the idea for utilization of these technologies is to allow more robust discovery of novel antigens and biomarkers related to management AGE, which eventually can be developed using easier and cheaper detection methods for future clinical setting. Thus, prediction of prognosis, virulence and drug susceptibility for active infections can be obtained. Case management, risk prediction for hospital-acquired infections, outbreak detection, and antimicrobial accountability are aimed for further improvement by integrating these capabilities into a new clinical workflow.
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Affiliation(s)
- Haziqah Hasan
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
| | - Nor Ashika Nasirudeen
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
| | - Muhammad Alif Farhan Ruzlan
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
| | - Muhammad Aiman Mohd Jamil
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
| | - Noor Akmal Shareela Ismail
- Department of Biochemistry, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia;
| | - Asrul Abdul Wahab
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia;
| | - Adli Ali
- Department of Pediatric, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Kuala Lumpur 56000, Malaysia; (H.H.); (N.A.N.); (M.A.F.R.); (M.A.M.J.)
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Boonyos P, Boonchan M, Phattanawiboon B, Nonthabenjawan N, Tacharoenmuang R, Gunpapong R, Singchai P, Upchai S, Rungnobhakhun P, Mekmullica J, Towayunanta W, Chuntrakool K, Ngaopravet K, Ruchusatsawat K, Sangkitporn S, Uppapong B, Mekada E, Matsuura Y, Tatsumi M, Mizushima H. Spread of genetically similar noroviruses in Bangkok, Thailand, through symptomatic and asymptomatic individuals. Heliyon 2021; 7:e08250. [PMID: 34761137 PMCID: PMC8566885 DOI: 10.1016/j.heliyon.2021.e08250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/16/2021] [Accepted: 10/21/2021] [Indexed: 11/29/2022] Open
Abstract
Norovirus infection is a major cause of acute gastroenteritis, although some infected individuals are asymptomatic. GII.4 is the predominant genotype worldwide and, since 2000, has been the most prevalent in patients in Thailand with acute gastroenteritis. We screened stool samples for norovirus in 786 patients with acute gastroenteritis who were admitted to a hospital in Bangkok from 2017 to early 2019 and detected it in 136 specimens (17.3%). Eight and 124 specimens were positive for the GI and GII genogroups, respectively, and the remaining 4 specimens were double-positive. Nine genotypes (GI.3, GI.5, GII.2, GII.3, GII.4, GII.6, GII.8, GII.13, and GII.17) were identified from 140 strains, and 72 strains (51.4%) were GII.4. We had previously conducted a one-year survey of norovirus infection in residents of a community in Bangkok from May 2018 to April 2019 and found that a substantial portion of the residents were infected asymptomatically. The 9 genotypes identified in the patients were also commonly identified in the community residents. To investigate the relationship between noroviruses identified in the acute gastroenteritis patients and those identified in the community residents, phylogenetic tree analysis was conducted. Of the 9 genotypes, 8 showed similarities in both their genomic sequences and their deduced amino acid sequences. In addition, strain replacement of GI.3 was observed in both the patients and the community residents within the overlapping period. These results suggested that norovirus spreads efficiently to the community by simultaneously causing symptomatic and asymptomatic infections. GII.4 Sydney predominated in gastroenteritis patients of Bangkok during 2017–2019. Common norovirus genotypes spread in symptomatic and asymptomatic individuals. Noroviruses in symptomatic and asymptomatic individuals share genetical similarity.
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Affiliation(s)
- Patcharaporn Boonyos
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Michittra Boonchan
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Benjarat Phattanawiboon
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Nutthawan Nonthabenjawan
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Ratana Tacharoenmuang
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Ratigorn Gunpapong
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Phakapun Singchai
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Sompong Upchai
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | | | | | | | | | | | - Kriangsak Ruchusatsawat
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Somchai Sangkitporn
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Ballang Uppapong
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Eisuke Mekada
- Research and Education Promotion Foundation, Bangkok, Thailand
| | - Yoshiharu Matsuura
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Masashi Tatsumi
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Hiroto Mizushima
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
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8
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Zweigart MR, Becker-Dreps S, Bucardo F, González F, Baric RS, Lindesmith LC. Serological Humoral Immunity Following Natural Infection of Children with High Burden Gastrointestinal Viruses. Viruses 2021; 13:2033. [PMID: 34696463 PMCID: PMC8538683 DOI: 10.3390/v13102033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Mark R. Zweigart
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27599, USA; (M.R.Z.); (S.B.-D.)
| | - Sylvia Becker-Dreps
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27599, USA; (M.R.Z.); (S.B.-D.)
- Department of Family Medicine, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Filemón Bucardo
- Department of Microbiology, National Autonomous University of Nicaragua, León 21000, Nicaragua; (F.B.); (F.G.)
| | - Fredman González
- Department of Microbiology, National Autonomous University of Nicaragua, León 21000, Nicaragua; (F.B.); (F.G.)
| | - Ralph S. Baric
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27599, USA; (M.R.Z.); (S.B.-D.)
| | - Lisa C. Lindesmith
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC 27599, USA; (M.R.Z.); (S.B.-D.)
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9
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Virological and Epidemiological Features of Norovirus Infections in Brazil, 2017-2018. Viruses 2021; 13:v13091724. [PMID: 34578304 PMCID: PMC8472875 DOI: 10.3390/v13091724] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/09/2021] [Accepted: 08/13/2021] [Indexed: 12/19/2022] Open
Abstract
Noroviruses are considered an important cause of acute gastroenteritis (AGE) across all age groups. Here, we investigated the incidence of norovirus, genotypes circulation, and norovirus shedding in AGE stool samples from outpatients in Brazil. During a two-year period, 1546 AGE stool samples from ten Brazilian states were analyzed by RT-qPCR to detect and quantify GI and GII noroviruses. Positive samples were genotyped by dual sequencing using the ORF1/2 junction region. Overall, we detected norovirus in 32.1% of samples, with a massive predominance of GII viruses (89.1%). We also observed a significant difference between the median viral load of norovirus GI (3.4×105 GC/g of stool) and GII (1.9×107 GC/g). The most affected age group was children aged between 6 and 24 m old, and norovirus infection was detected throughout the year without marked seasonality. Phylogenetic analysis of partial RdRp and VP1 regions identified six and 11 genotype combinations of GI and GII, respectively. GII.4 Sydney[P16] was by far the predominant genotype (47.6%), followed by GII.2[P16], GII.4 Sydney[P31], and GII.6[P7]. We detected, for the first time in Brazil, the intergenogroup recombinant genotype GIX.1[GII.P15]. Our study contributes to the knowledge of norovirus genotypes circulation at the national level, reinforcing the importance of molecular surveillance programs for future vaccine designs.
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10
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Lo M, Mitra S, De P, Banerjee A, Deb AK, Miyoshi SI, Manna A, Ghosh SK, Okamoto K, Dutta S, Chawla-Sarkar M. Genetic characterization and evolutionary analysis of norovirus genotypes circulating among children in eastern India during 2018-2019. Arch Virol 2021; 166:2989-2998. [PMID: 34383167 PMCID: PMC8358548 DOI: 10.1007/s00705-021-05197-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/11/2021] [Indexed: 01/13/2023]
Abstract
Noroviruses are significant etiological agents of acute gastroenteritis (AGE) across all age groups, especially in children under 5 years of age. Although the prevalence of norovirus infection is known to have increased in various countries, in India there are few reports pertaining to the norovirus disease burden. We investigated the epidemiology and molecular characteristics of noroviruses in children seeking health care at two hospitals in Kolkata, Eastern India. Faecal specimens were collected between January 2018 and December 2019 from 2812 children under 5 years of age with acute gastroenteritis. Noroviruses were detected in 6.04% (170/2812) of the samples, and 12.9% (22/170) of these were cases of coinfection with rotavirus. Among children (≤5 years), a higher infection rate (8.2%, n = 94/1152) was observed in the 6 to 12 month age group. GII.4 Sydney 2012 was the dominant norovirus capsid genotype (n = 75/90, 83.3%), followed by GII.3 (n = 10/90, 11.1%). Other capsid types GII.13 (n = 4/90, 4.4%) and GII.17 (n = 1/90; 1.1%) were also detected at low frequency. Phylogenetic analysis showed that the GII.P16 polymerase of strains in this region clustered with those of the phylogenetically distinct monophyletic clade of GII.P16 strains, whose members have been circulating worldwide since 2014. Inter-genotypic norovirus recombinants such as GII.P16-GII.3 (n = 10) and GII.P16-GII.13 (n = 4) were also observed among the circulating strains. In comparison to previous studies from eastern India, the present study shows a higher detection rate of norovirus infection in the paediatric population suffering from acute gastroenteritis. Continuous surveillance is required for predicting the emergence of novel genotypes and recombinant strains and for future vaccine development.
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Affiliation(s)
- Mahadeb Lo
- Division of Virology, ICMR-National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road Scheme-XM, Beliaghata, Kolkata, 700010, India
| | - Suvrotoa Mitra
- Division of Virology, ICMR-National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road Scheme-XM, Beliaghata, Kolkata, 700010, India
| | - Papiya De
- Division of Virology, ICMR-National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road Scheme-XM, Beliaghata, Kolkata, 700010, India
| | - Anindita Banerjee
- Division of Virology, ICMR-National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road Scheme-XM, Beliaghata, Kolkata, 700010, India
| | - Alok Kumar Deb
- Division of Epidemiology, ICMR-National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road Scheme-XM, Beliaghata, Kolkata, 700010, India
| | - Shin-Ichi Miyoshi
- Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan.,Collaborative Research Centre of Okayama University for Infectious Disease, ICMR-National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road Scheme-XM, Beliaghata, Kolkata, 700010, India
| | - Asis Manna
- Infectious diseases and Beliaghata General (ID & BG) Hospital, Beliaghata, Kolkata, 700010, India
| | - Sanat Kumar Ghosh
- Dr. B.C. Roy Post Graduate Institute of Pediatric Sciences, Kolkata, 700054, India
| | - Keinosuke Okamoto
- Collaborative Research Centre of Okayama University for Infectious Disease, ICMR-National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road Scheme-XM, Beliaghata, Kolkata, 700010, India
| | - Shanta Dutta
- Regional Virus Research and Diagnostic Laboratory, ICMR-National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road Scheme-XM, Beliaghata, Kolkata, 700010, India
| | - Mamta Chawla-Sarkar
- Division of Virology, ICMR-National Institute of Cholera and Enteric Diseases, P-33, C.I.T. Road Scheme-XM, Beliaghata, Kolkata, 700010, India.
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11
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Misumi M, Nishiura H. Long-term dynamics of Norovirus transmission in Japan, 2005-2019. PeerJ 2021; 9:e11769. [PMID: 34306831 PMCID: PMC8280881 DOI: 10.7717/peerj.11769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 06/22/2021] [Indexed: 11/20/2022] Open
Abstract
Norovirus continues to evolve, adjusting its pathogenesis and transmissibility. In the present study, we systematically collected datasets on Norovirus outbreaks in Japan from 2005 to 2019 and analyzed time-dependent changes in the asymptomatic ratio, the probability of virus detection, and the probability of infection given exposure. Reports of 1,728 outbreaks were published, and feces from all involved individuals, including those with asymptomatic infection, were tested for virus in 434 outbreaks. We found that the outbreak size did not markedly change over this period, but the variance in outbreak size increased during the winter (November–April). Assuming that natural history parameters did not vary over time, the asymptomatic ratio, the probability of virus detection, and the probability of infection given exposure were estimated to be 18.6%, 63.3% and 84.5%, respectively. However, a model with time-varying natural history parameters yielded better goodness-of-fit and suggested that the asymptomatic ratio varied by year. The asymptomatic ratio was as high as 25.8% for outbreaks caused by genotype GII.4 noroviruses. We conclude that Norovirus transmissibility has not changed markedly since 2005, and that yearly variation in the asymptomatic ratio could potentially be explained by the circulating dominant genotype.
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Affiliation(s)
- Megumi Misumi
- Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan.,Rumoi City Hospital, Rumoi, Hokkaido, Japan
| | - Hiroshi Nishiura
- Graduate School of Medicine, Hokkaido University, Sapporo, Hokkaido, Japan.,School of Public Health, Kyoto University, Kyoto, Japan
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12
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Cannon JL, Bonifacio J, Bucardo F, Buesa J, Bruggink L, Chan MCW, Fumian TM, Giri S, Gonzalez MD, Hewitt J, Lin JH, Mans J, Muñoz C, Pan CY, Pang XL, Pietsch C, Rahman M, Sakon N, Selvarangan R, Browne H, Barclay L, Vinjé J. Global Trends in Norovirus Genotype Distribution among Children with Acute Gastroenteritis. Emerg Infect Dis 2021; 27:1438-1445. [PMID: 33900173 PMCID: PMC8084493 DOI: 10.3201/eid2705.204756] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Noroviruses are a leading cause of acute gastroenteritis (AGE) among adults and children worldwide. NoroSurv is a global network for norovirus strain surveillance among children <5 years of age with AGE. Participants in 16 countries across 6 continents used standardized protocols for dual typing (genotype and polymerase type) and uploaded 1,325 dual-typed sequences to the NoroSurv web portal during 2016-2020. More than 50% of submitted sequences were GII.4 Sydney[P16] or GII.4 Sydney[P31] strains. Other common strains included GII.2[P16], GII.3[P12], GII.6[P7], and GI.3[P3] viruses. In total, 22 genotypes and 36 dual types, including GII.3 and GII.20 viruses with rarely reported polymerase types, were detected, reflecting high strain diversity. Surveillance data captured in NoroSurv enables the monitoring of trends in norovirus strains associated childhood AGE throughout the world on a near real-time basis.
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13
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Reyes Y, González F, Gutierrez L, Blandon P, Centeno E, Zepeda O, Toval-Ruíz C, Lindesmith LC, Baric RS, Vielot N, Diez-Valcarce M, Vinjé J, Svensson L, Becker-Dreps S, Nordgren J, Bucardo F. Secretor status strongly influences the incidence of symptomatic norovirus infection in a genotype-dependent manner in a Nicaraguan birth cohort. J Infect Dis 2021; 225:105-115. [PMID: 34129046 DOI: 10.1093/infdis/jiab316] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The role of histo-blood group on the burden and severity of norovirus gastroenteritis in young infants has not been well documented. METHODS Norovirus gastroenteritis was assessed in 443 Nicaraguan children followed from birth until 3 years of age. Stool samples were tested for norovirus by RT-qPCR and histo-blood group antigens (HBGA) were determined by phenotyping of saliva and blood. Hazards ratios (95% CI) and predictors of norovirus AGE outcome stratified by HBGA were estimated using Cox proportional hazards models. RESULTS Of 1,353 AGE episodes experienced by children, 229 (17%) tested positive for norovirus with an overall incidence of 21.9/100 child-years. Secretor children were infected as early as 2 months old and had a higher incidence of norovirus GII compared to non-secretor children (15.4 vs 4.1/100 child-years, P = 0.006). Furthermore, all GII.4 AGE episodes occurred in secretor children. Children infected with GI (adjusted OR=0.09, 95% CI 0.02-0.33) or non-GII.4 viruses (adjusted OR=0.2, 95% CI: 0.07-0.6) were less likely to have severe AGE compared to GII.4 infected children. CONCLUSION Secretor status in children strongly influences the incidence of symptomatic norovirus infection in a genogroup or genotype-dependent manner and provides evidence that clinical severity in children depends on norovirus genotypes.
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Affiliation(s)
- Yaoska Reyes
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua - León, León, Nicaragua.,Division of Molecular Medicine and Virology, Linköping University, Linköping, Sweden
| | - Fredman González
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua - León, León, Nicaragua
| | - Lester Gutierrez
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua - León, León, Nicaragua
| | - Patricia Blandon
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua - León, León, Nicaragua
| | - Edwing Centeno
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua - León, León, Nicaragua
| | - Omar Zepeda
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua - León, León, Nicaragua
| | - Christian Toval-Ruíz
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua - León, León, Nicaragua
| | - Lisa C Lindesmith
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ralph S Baric
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Nadja Vielot
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Marta Diez-Valcarce
- Centers for Disease Control and Prevention, Division of Viral Diseases, Atlanta, GA, United States of America.,Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Jan Vinjé
- Centers for Disease Control and Prevention, Division of Viral Diseases, Atlanta, GA, United States of America
| | - Lennart Svensson
- Division of Molecular Medicine and Virology, Linköping University, Linköping, Sweden.,Division of Medicine, Karolinska Institute, Sweden
| | - Sylvia Becker-Dreps
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.,Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Johan Nordgren
- Division of Molecular Medicine and Virology, Linköping University, Linköping, Sweden
| | - Filemón Bucardo
- Department of Microbiology and Parasitology, National Autonomous University of Nicaragua - León, León, Nicaragua
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14
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Bhavanam S, Freedman SB, Lee BE, Zhuo R, Qiu Y, Chui L, Xie J, Ali S, Vanderkooi OG, Pang XL. Differences in Illness Severity among Circulating Norovirus Genotypes in a Large Pediatric Cohort with Acute Gastroenteritis. Microorganisms 2020; 8:E1873. [PMID: 33256234 PMCID: PMC7760397 DOI: 10.3390/microorganisms8121873] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/20/2020] [Accepted: 11/23/2020] [Indexed: 12/12/2022] Open
Abstract
Norovirus is a major pathogen identified in children with acute gastroenteritis (AGE), little is known about the strain's diversity and their clinical severity. Stool and/or rectal swabs were collected from children ≤18 years of age recruited at emergency departments (ED), and a provincial nursing advice phone line due to AGE symptoms in the province of Alberta, Canada between December 2014 and August 2018. Specimens were tested using a reverse transcription real time PCR and genotyped by Sanger sequencing. The Modified Vesikari Scale score (MVS) was used to evaluate the disease severity. The objectives are to identify the Genogroup and Genotype distribution and to compare illness severity between the GI and GII genogroups and to complete further analyses comparing the GII genotypes identified. GII.4 was the genotype most commonly identified. Children with GII.4 had higher MVS scores (12.0 (10.0, 14.0; p = 0.002)) and more prolonged diarrheal (5 days (3.0, 7.8)) and vomiting (3.2 days (1.7, 5.3; p < 0.001)) durations compared to other non GII.4 strains. The predominant strain varied by year with GII.4 Sydney[P31] predominant in 2014/15, GII.4 Sydney[P16] in 2015/16 and 2017/18, and GII.3[P12] in 2016/17. Genogroup II norovirus strains predominated in children with AGE with variance between years; clinical severity associated with different strains varied with episodes being most severe among GII.4 infected children.
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Affiliation(s)
- Sudha Bhavanam
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
| | - Stephen B. Freedman
- Divisions of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T3B 6A8, Canada;
| | - Bonita E. Lee
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children’s Health Research Institute, Stollery Children’s Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (B.E.L.); (S.A.)
| | - Ran Zhuo
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
| | - Yuanyuan Qiu
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
| | - Linda Chui
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
- Public Health Laboratories (ProvLab), Alberta Precision Laboratories (APL), Edmonton, AB T6G 2J2, Canada
| | - Jianling Xie
- Departments of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB T3B 6A8, Canada;
| | - Samina Ali
- Department of Pediatrics, Faculty of Medicine & Dentistry, Women and Children’s Health Research Institute, Stollery Children’s Hospital, University of Alberta, Edmonton, AB T6G 2R3, Canada; (B.E.L.); (S.A.)
| | - Otto G. Vanderkooi
- Departments of Pediatrics, Microbiology, Immunology and Infectious Diseases, Pathology & Laboratory Medicine and Community Health Sciences, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB T3B 6A8, Canada;
| | - Xiaoli L. Pang
- Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, AB T6G 2R3, Canada; (S.B.); (R.Z.); (Y.Q.); (L.C.)
- Public Health Laboratories (ProvLab), Alberta Precision Laboratories (APL), Edmonton, AB T6G 2J2, Canada
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15
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Nonthabenjawan N, Boonyos P, Phattanawiboon B, Towayunanta W, Chuntrakool K, Ngaopravet K, Ruchusatsawat K, Uppapong B, Sangkitporn S, Mekada E, Matsuura Y, Tatsumi M, Mizushima H. Identification of GII.14[P7] norovirus and its genomic mutations from a case of long-term infection in a post-symptomatic individual. INFECTION GENETICS AND EVOLUTION 2020; 86:104612. [PMID: 33137471 DOI: 10.1016/j.meegid.2020.104612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/24/2020] [Accepted: 10/27/2020] [Indexed: 11/17/2022]
Abstract
Norovirus is a leading cause of acute gastroenteritis worldwide. Norovirus shedding typically lasts one week to one month after the onset of diarrhea in immunocompetent hosts. The occurrence of mutations in the genome during infection has contributed to the evolution of norovirus. It has been suggested that genomic mutations in the P2-domain of capsid protein VP1, the major antigenic site for virus clearance, are involved in the evasion of host immunity and prolonged shedding of norovirus. In our previous study, we found a case of long-term shedding of GII.14 norovirus in a post-symptomatic immunocompetent individual that lasted about three months. In this study, we characterized the genomic sequence of the GII.14 strain to gain insight into the context of long-term shedding. By sequencing a 4.8 kb region of the genome corresponding to half of ORF1 and the entire ORF2 and ORF3, which encode several non-structural proteins and the structural proteins VP1 and VP2, the GII.14 strain was found to be classified as recombinant GII.14[P7]. Six point-mutations occurred during the three-month period of infection in a time-dependent manner in the genomic regions encoding RNA-dependent RNA polymerase, VP1, and VP2. Three of the six mutations were sense mutations, but no amino acid substitution was identified in the P2-domain of VP1. These results suggest that there is a mechanism by which long-term shedding of norovirus occurs in immunocompetent individuals independent of P2-domain mutations.
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Affiliation(s)
- Nutthawan Nonthabenjawan
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Patcharaporn Boonyos
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Benjarat Phattanawiboon
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | | | | | | | - Kriangsak Ruchusatsawat
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Ballang Uppapong
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Somchai Sangkitporn
- National Institute of Health, Department of Medical Sciences, Ministry of Public Health, Nonthaburi, Thailand
| | - Eisuke Mekada
- Research and Education Promotion Foundation, Bangkok, Thailand
| | - Yoshiharu Matsuura
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Masashi Tatsumi
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Hiroto Mizushima
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand.
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16
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Phattanawiboon B, Nonthabenjawan N, Boonyos P, Jetsukontorn C, Towayunanta W, Chuntrakool K, Ngaopravet K, Ruchusatsawat K, Uppapong B, Sangkitporn S, Mekada E, Matsuura Y, Tatsumi M, Mizushima H. Norovirus transmission mediated by asymptomatic family members in households. PLoS One 2020; 15:e0236502. [PMID: 32702014 PMCID: PMC7377487 DOI: 10.1371/journal.pone.0236502] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022] Open
Abstract
The transmission of human norovirus excreted from infected persons occasionally causes sporadic infections and outbreaks. Both symptomatic patients and asymptomatic carriers have been reported to contribute to norovirus transmission, but little is known about the magnitude of the contribution of asymptomatic carriers. We carried out a 1-year survey of residents of a district of Bangkok, Thailand to determine the percentage of norovirus transmissions originating from asymptomatic individuals. We screened 38 individuals recruited from 16 families from May 2018 to April 2019 for GI and GII genotypes. Norovirus was detected every month, and 101 of 716 stool samples (14.1%) from individuals with no symptoms of acute gastroenteritis were norovirus-positive. The average infection frequency was 2.4 times per person per year. Fourteen genotypes were identified from the positive samples, with GII.4 being detected most frequently. Notably, 89.1% of the norovirus-positive samples were provided by individuals with no diarrhea episode. Similar to cases of symptomatic infections in Thailand, asymptomatic infections were observed most frequently in December. We detected 4 cases of NV infection caused by household transmission, and 3 of the 4 transmissions originated from asymptomatic individuals. We also identified a case in which norovirus derived from an asymptomatic individual caused diarrhea in a family member. These results suggest that asymptomatic individuals play a substantial role in both the maintenance and spreading of norovirus in a community through household transmission.
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Affiliation(s)
- Benjarat Phattanawiboon
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Nutthawan Nonthabenjawan
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Patcharaporn Boonyos
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Chanya Jetsukontorn
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | | | | | | | - Kriangsak Ruchusatsawat
- Department of Medical Sciences, National Institute of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Ballang Uppapong
- Department of Medical Sciences, National Institute of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Somchai Sangkitporn
- Department of Medical Sciences, National Institute of Health, Ministry of Public Health, Nonthaburi, Thailand
| | - Eisuke Mekada
- Research and Education Promotion Foundation, Bangkok, Thailand
| | - Yoshiharu Matsuura
- Research Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Masashi Tatsumi
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
| | - Hiroto Mizushima
- Thailand-Japan Research Collaboration Center on Emerging and Re-emerging Infections, Nonthaburi, Thailand
- * E-mail:
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17
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Genomic and biological characterization of a pandemic norovirus variant GII.4 Sydney 2012. Virus Genes 2020; 56:174-181. [PMID: 31912284 DOI: 10.1007/s11262-019-01729-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 12/28/2019] [Indexed: 02/03/2023]
Abstract
Genogroup II, genotype 4 noroviruses (GII.4 NoVs) are a leading cause of epidemic and sporadic acute non-bacterial gastroenteritis worldwide. In this study, we isolated a GII.4 NoV strain (designated 2015HN08) from a kid presenting with acute gastroenteritis and determined its near-complete genome sequence. We then performed sequence analysis by comparing this strain with the prototypical GII.4 strain. Virus-like particles (VLPs) derived from the major capsid protein (VP1) were expressed by using a recombinant-baculovirus expression system, and monoclonal antibodies (mAbs) were produced to compare changes in antigenic or histo-blood group antigens (HBGAs) binding sites with the previously characterized GII.4 NoV strain (JZ403). The genome of 2015HN08 was 7559 nucleotides (nt) long, excluding the poly(A) tail. Genotyping analysis indicated that this strain was a Sydney 2012 variant. In comparison with the prototype Sydney 2012 strain, there were 74, 35, and 16 differences in nucleotide sequences in ORF1, OFR2, and OFR3, causing 7, 10, and 6 amino acid (aa) changes, respectively. Expression of VP1 led to successful assembly of VLPs, as demonstrated by electron microscopy. Screening of hybridoma cell supernatants with an in vitro VLP-HBGAs binding blockade assay led to the identification of a cell clone 3G10 that exhibited HBGA-blocking effects. This mAb also exhibited blocking effects against JZ403 strain, suggesting maintenance of the antigenic site and/or HBGAs binding sites between the two strains. In summary, we determined the near-complete genome sequence of a GII.4 Sydney 2012 variant and produced an mAb with blocking effects that might be useful in evaluating the evolution of current Sydney 2012 NoV strains.
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The surface-exposed loop region of norovirus GII.3 VP1 plays an essential role in binding histo-blood group antigens. Arch Virol 2019; 164:1629-1638. [PMID: 30968211 DOI: 10.1007/s00705-019-04256-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/14/2019] [Indexed: 10/27/2022]
Abstract
Trypsin digestion promotes disassembly of GII.3 NoV virus-like particles (VLPs) and binding of VLPs to salivary histo-blood group antigens (HBGAs), but it is not clear which specific regions or residues mediate viral attachment to HBGAs. An earlier study indicated that arginine residues in the predicted surface-exposed loop region are susceptible to trypsin digestion. Here, we introduced single or multiple substitutions of four arginine residues located in the predicted surface-exposed loop region of the GII.3 NoV capsid protein (VP1) and observed their effects on susceptibility to trypsin digestion and binding to HBGAs. All of the mutations in VP1, including single substitutions (R287G, R292G, R296G or R307G) and quadruple substitutions (R287G, R292G, R296G and R307G), permitted successful VLP assembly. After tryptic digestion, all VP1 proteins bearing single point mutations were cleaved, resulting in complete digestion or single fragments with various molecular sizes (27-35 kDa), while the VP1 protein bearing four substitutions was cleaved into two fragments (27-55 kDa). Binding assays using synthetic and salivary HBGAs showed that none of the VP1 mutants (singly or quadruply substituted) exhibited detectable binding to HBGA before or after trypsin cleavage. These results indicated that arginine residues within the predicted surface loop region of GII.3 NoV VP1 were involved directly or indirectly in binding salivary HBGAs and could potentially mediate the HBGA-GII.3 NoV interactions through which host cells become infected.
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Norovirus Infections and Disease in Lower-MiddleandLow-Income Countries, 1997⁻2018. Viruses 2019; 11:v11040341. [PMID: 30974898 PMCID: PMC6521228 DOI: 10.3390/v11040341] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/05/2019] [Accepted: 04/08/2019] [Indexed: 12/25/2022] Open
Abstract
Noroviruses are a major cause of viral gastroenteritis. The burden of the norovirus in low-resource settings is not well-established due to limited data. This study reviews the norovirus prevalence, epidemiology, and genotype diversity in lower-middle-income countries (LMIC) and in low-income countries (LIC). PubMed was searched up to 14 January 2019 for norovirus studies from all LIC and LMIC (World Bank Classification). Studies that tested gastroenteritis cases and/or asymptomatic controls for norovirus by reverse transcription-polymerase chain reaction (RT-PCR) were included. Sixty-four studies, the majority on children <5 years of age, were identified, and 14% (95% confidence interval; CI 14–15, 5158/36,288) of the gastroenteritis patients and 8% (95% CI 7–9, 423/5310) of healthy controls tested positive for norovirus. In LMIC, norovirus was detected in 15% (95% CI 15–16) of cases and 8% (95% CI 8–10) of healthy controls. In LIC, 11% (95% CI 10–12) of symptomatic cases and 9% (95% CI 8–10) of asymptomatic controls were norovirus positive. Norovirus genogroup II predominated overall. GII.4 was the predominant genotype in all settings, followed by GII.3 and GII.6. The most prevalent GI strain was GI.3. Norovirus causes a significant amount of gastroenteritis in low-resource countries, albeit with high levels of asymptomatic infection in LIC and a high prevalence of coinfections.
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Nordgren J, Svensson L. Genetic Susceptibility to Human Norovirus Infection: An Update. Viruses 2019; 11:E226. [PMID: 30845670 PMCID: PMC6466115 DOI: 10.3390/v11030226] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 02/28/2019] [Accepted: 03/02/2019] [Indexed: 12/15/2022] Open
Abstract
Noroviruses are the most common etiological agent of acute gastroenteritis worldwide. Despite their high infectivity, a subpopulation of individuals is resistant to infection and disease. This susceptibility is norovirus genotype-dependent and is largely mediated by the presence or absence of human histo-blood group antigens (HBGAs) on gut epithelial surfaces. The synthesis of these HBGAs is mediated by fucosyl- and glycosyltransferases under the genetic control of the FUT2 (secretor), FUT3 (Lewis) and ABO(H) genes. The so-called non-secretors, having an inactivated FUT2 enzyme, do not express blood group antigens and are resistant to several norovirus genotypes, including the predominant GII.4. Significant genotypic and phenotypic diversity of HBGA expression exists between different human populations. Here, we review previous in vivo studies on genetic susceptibility to norovirus infection. These are discussed in relation to population susceptibility, vaccines, norovirus epidemiology and the impact on public health.
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Affiliation(s)
- Johan Nordgren
- Division of Molecular Virology, Department of Clinical and Experimental Medicine, Linköping University, 58185 Linköping, Sweden.
| | - Lennart Svensson
- Division of Molecular Virology, Department of Clinical and Experimental Medicine, Linköping University, 58185 Linköping, Sweden.
- Division of Infectious Diseases, Department of Medicine, Karolinska Institute, 17177 Stockholm, Sweden.
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Ma S, Zheng L, Liu J, Wang W, Ma J, Cheng X, Ge L, Wang M, Huo Y, Shen S. Chimeric GII.3/GII.6 norovirus capsid (VP1) proteins: characterization by electron microscopy, trypsin sensitivity and binding to histo-blood group antigens. Arch Virol 2018; 163:3265-3273. [PMID: 30143876 DOI: 10.1007/s00705-018-4002-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/03/2018] [Indexed: 12/13/2022]
Abstract
GII.3 and GII.6 noroviruses (NoVs) are similar in several aspects, including the presence of a short sequence insertion in the P2 domain of the major capsid protein (VP1) and trypsin susceptibility of VP1-containing virus-like particles (VLPs). In this study, we generated two constructs with the S or P domains of VP1 from GII.3 and GII.6 NoV strains exchanged (GII.3S/GII.6P and GII.6S/GII.3P), and the resultant chimeric capsid proteins were expressed from recombinant baculoviruses. The assembly of VLPs was confirmed by electron microscopy, and the susceptibility of assembled VLPs to trypsin digestion was analyzed by SDS-PAGE. Salivary histo-blood group antigen (HBGA) binding and binding blockade assays were performed to determine the binding characteristics of chimeric VP1-containing VLPs with and without trypsin digestion. Our results indicated that both expressed GII.3S/GII.6P and GII.6S/GII.3P chimeric proteins successfully assembled into VLPs. Trypsin digestion of VLPs assembled from both chimeric proteins led to the generation of two fragments with molecular sizes similar to those of wild-type VP1-containing VLPs. An in vitro salivary HBGA binding assay demonstrated that VLPs assembled from both chimeric proteins exhibited enhanced binding after trypsin cleavage. An HBGA binding blockade assay indicated that the binding of GII.3S/GII.6P and GII.6S/GII.3P VLPs against salivary HBGAs could only be blocked by GII.3 and GII.6 NoV VLP-specific hyperimmune sera, respectively. For GII.6 and GII.3S/GII.6P VLPs, a difference in binding enhancement after trypsin cleavage was observed. Our results demonstrate that the S domains of GII.3 and GII.6 NoV VP1 are interchangeable and that the S domain affects the binding of the P domain to HBGAs.
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Affiliation(s)
- Shuhuan Ma
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, People's Republic of China
| | - Lijun Zheng
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, People's Republic of China
| | - Jinjin Liu
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, People's Republic of China
| | - Wenhui Wang
- Wuhan Institute of Biological Products, Wuhan, People's Republic of China
| | - Jie Ma
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, People's Republic of China
| | - Xuhui Cheng
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, People's Republic of China
| | - Lili Ge
- Zhengzhou Children's Hospital, Zhengzhou, People's Republic of China
| | - Mingchen Wang
- Zhengzhou University, Zhengzhou, People's Republic of China
| | - Yuqi Huo
- The Sixth People's Hospital of Zhengzhou, Zhengzhou, People's Republic of China.
| | - Shuo Shen
- Wuhan Institute of Biological Products, Wuhan, People's Republic of China
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Bucardo F. Understanding Asymptomatic Norovirus Infections. EClinicalMedicine 2018; 2-3:7-8. [PMID: 31193686 PMCID: PMC6537566 DOI: 10.1016/j.eclinm.2018.09.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 09/14/2018] [Indexed: 01/30/2023] Open
Affiliation(s)
- Filemón Bucardo
- Department of Microbiology, Faculty of Medical Science, National Autonomous University of Nicaragua, León (UNAN-León), Nicaragua
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23
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Genomic characterization of GII.3 noroviruses isolated from children in Zhengzhou city, China, 2015/16. Arch Virol 2018; 163:2737-2742. [PMID: 29909464 DOI: 10.1007/s00705-018-3905-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/29/2018] [Indexed: 02/08/2023]
Abstract
In this study, we isolated, amplified and sequenced GII.3 norovirus (NoV) strains from children admitted to a department of pediatric gastroenterology presenting with acute gastroenteritis from September 2015 to March 2016. A total of 35 stool samples were collected and eight were GII.3 NoV positive, based on sequencing. The complete genome sequences were determined for two strains while partial genome sequences, encompassing approximately 3.2 kb of the 3´end, were generated for the six other strains. Genotyping analysis of all strains indicated that they belonged to GII P12/GII.3. Phylogenetic analysis indicated that these isolated strains could be divided into two clusters. Strains in cluster IV were the most frequently isolated and exhibited less intra-cluster variation in nucleotide sequences. Our study demonstrated that the GII.P12/GII.3 recombinant strain was the dominant GII.3 NoVs in Zhengzhou city.
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Farsi M, Roodbari F, Nejati B, Arashkia A, Jalilvand S, Nateghian A, Rahbarimanesh A, Marashi SM, Shoja Z. Prevalence and genetic diversity of norovirus genogroup II in children less than 5 years of age with acute gastroenteritis in Tehran, Iran. Med Microbiol Immunol 2018; 207:201-210. [PMID: 29619604 DOI: 10.1007/s00430-018-0541-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 03/29/2018] [Indexed: 10/17/2022]
Abstract
Viral gastroenteritis is a major public health problem worldwide. In Iran, very limited studies have been performed with regard to the epidemiology of noroviruses. This study aimed to evaluate the prevalence and molecular epidemiology of GII noroviruses in hospitalized children less than 5 years of age with acute gastroenteritis (AGE). A total of 210 stool specimens were collected from Ali Asghar Children's Hospital and Bahrami Children's Hospital in Tehran, from June 2015 to June 2016. The samples were screened by real-time RT-PCR for genogroup II (GII). Positive samples were genotyped by semi-nested PCR followed by Sanger sequencing and phylogenetic analysis. Norovirus was identified in 36 (17.1%) of 210 specimens. Based on genetic analysis of RdRp and capsid sequences, the strains were clustered into eight RdRp-capsid genotypes: GII.P4-GII.4 Sydney_2012 (41.7%), GII.Pe-GII.4 Sydney_2012 (30.6%), GII.P21-GII.3 (13.9%), GII.P16-GII.4 Sydney_2012 (2.8%), GII.P16-GII.12 (2.8%), GII.P2-GII.4 Sydney_2012 (2.8%), GII.P7-GII.7 (2.8%) and GII.P2-GII.2 (2.8%). We determined several different co-circulating norovirus genotypes in children < 5 years of age with AGE in our hospital in Tehran, Iran. Continued molecular surveillance of noroviruses, including typing of both RdRp and capsid genes, is important for monitoring emerging strains in our continued efforts to reduce the overall burden of norovirus disease.
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Affiliation(s)
- Mahsa Farsi
- Biology Department, Faculty of Basic Sciences, University of Mazandaran, Babolsar, Iran
| | - Fatemeh Roodbari
- Biology Department, Faculty of Basic Sciences, University of Mazandaran, Babolsar, Iran
| | - Behrooz Nejati
- Biology Department, Faculty of Basic Sciences, University of Mazandaran, Babolsar, Iran
| | - Arash Arashkia
- Virology Department, Pasteur Institute of Iran, Tehran, Iran
| | - Somayeh Jalilvand
- Virology Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Nateghian
- Ali-Asghar Children's Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Aliakbar Rahbarimanesh
- Department of Pediatric Infectious Diseases, Bahrami Children Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Sayed Mahdi Marashi
- Virology Department, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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