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Erickson DE, Simmons KM, Barrand ZA, Ridenour CL, Hawkinson PB, Lemke L, Sellner SP, Brock BN, Rivas AN, Sheridan K, Lemmer D, Yaglom HD, Porter WT, Belanger M, Torrey RM, Stills AJR, McCormack K, Black M, Holmes W, Rostain D, Mikus J, Sotelo K, Haq E, Neupane R, Weiss J, Johnson J, Collins C, Avalle S, White C, Howard BJ, Maltinsky SA, Whealy RN, Gordon NB, Sahl JW, Pearson T, Fofanov VY, Furstenau T, Driebe EM, Caporaso JG, Barber J, Terriquez J, Engelthaler DM, Hepp CM. Pan-Enterovirus Characterization Reveals Cryptic Circulation of Clinically Relevant Subtypes in Arizona Wastewater. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.11.20.23297677. [PMID: 38562876 PMCID: PMC10984038 DOI: 10.1101/2023.11.20.23297677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Most seasonally circulating enteroviruses result in asymptomatic or mildly symptomatic infections. In rare cases, however, infection with some subtypes can result in paralysis or death. Of the 300 subtypes known, only poliovirus is reportable, limiting our understanding of the distribution of other enteroviruses that can cause clinical disease. Objective The overarching objectives of this study were to: 1) describe the distribution of enteroviruses in Arizona during the late summer and fall of 2022, the time of year when they are thought to be most abundant, and 2) demonstrate the utility of viral pan-assay approaches for semi-agnostic discovery that can be followed up by more targeted assays and phylogenomics. Methods This study utilizes pooled nasal samples collected from school-aged children and long-term care facility residents, and wastewater from multiple locations in Arizona during July-October of 2022. We used PCR to amplify and sequence a region common to all enteroviruses, followed by species-level bioinformatic characterization using the QIIME 2 platform. For Enterovirus-D68 (EV-D68), detection was carried out using RT-qPCR, followed by confirmation using near-complete whole EV-D68 genome sequencing using a newly designed tiled amplicon approach. Results In the late summer and early fall of 2022, multiple enterovirus species were identified in Arizona wastewater, with Coxsackievirus A6, EV-D68, and Coxsackievirus A19 composing 86% of the characterized reads sequenced. While EV-D68 was not identified in pooled human nasal samples, and the only reported acute flaccid myelitis case in Arizona did not test positive for the virus, an in-depth analysis of EV-D68 in wastewater revealed that the virus was circulating from August through mid-October. A phylogenetic analysis on this relatively limited dataset revealed just a few importations into the state, with a single clade indicating local circulation. Significance This study further supports the utility of wastewater-based epidemiology to identify potential public health threats. Our further investigations into EV-D68 shows how these data might help inform healthcare diagnoses for children presenting with concerning neurological symptoms.
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Affiliation(s)
- Daryn E Erickson
- Translational Genomics Research Institute, Flagstaff, AZ, USA
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Kyle M Simmons
- Translational Genomics Research Institute, Flagstaff, AZ, USA
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Zachary A Barrand
- Translational Genomics Research Institute, Flagstaff, AZ, USA
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Chase L Ridenour
- Translational Genomics Research Institute, Flagstaff, AZ, USA
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
| | - Paige B Hawkinson
- Translational Genomics Research Institute, Flagstaff, AZ, USA
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Lacey Lemke
- Northern Arizona Healthcare, Flagstaff, AZ, USA
| | - Shayne P Sellner
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Breezy N Brock
- Translational Genomics Research Institute, Flagstaff, AZ, USA
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Alexis N Rivas
- Translational Genomics Research Institute, Flagstaff, AZ, USA
| | | | - Darrin Lemmer
- Translational Genomics Research Institute, Flagstaff, AZ, USA
| | - Hayley D Yaglom
- Translational Genomics Research Institute, Flagstaff, AZ, USA
| | - W Tanner Porter
- Translational Genomics Research Institute, Flagstaff, AZ, USA
| | | | - Rachel M Torrey
- City of Flagstaff, Water Services Division, Flagstaff, AZ, USA
| | | | - Kiley McCormack
- City of Flagstaff, Water Services Division, Flagstaff, AZ, USA
| | - Matt Black
- City of Flagstaff, Water Services Division, Flagstaff, AZ, USA
| | - Wydale Holmes
- City of Tempe, Municipal Utilities Department, Tempe, AZ, USA
| | - Drew Rostain
- City of Tempe, Municipal Utilities Department, Tempe, AZ, USA
| | - Jeremy Mikus
- City of Tempe, Municipal Utilities Department, Tempe, AZ, USA
| | - Kimberly Sotelo
- City of Tempe, Municipal Utilities Department, Tempe, AZ, USA
| | - Emmen Haq
- City of Tempe, Municipal Utilities Department, Tempe, AZ, USA
| | | | - Joli Weiss
- Arizona Department of Health Services, Phoenix, AZ, USA
| | | | | | - Sarah Avalle
- Arizona Department of Health Services, Phoenix, AZ, USA
| | - Chelsi White
- Maricopa County Department of Public Health, Phoenix, AZ, USA
| | | | - Sara A Maltinsky
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Ryann N Whealy
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Nathaniel B Gordon
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Jason W Sahl
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Talima Pearson
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Viacheslav Y Fofanov
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Tara Furstenau
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
| | | | - J Gregory Caporaso
- Translational Genomics Research Institute, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
| | - Jarrett Barber
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
| | | | | | - Crystal M Hepp
- Translational Genomics Research Institute, Flagstaff, AZ, USA
- School of Informatics, Computing, and Cyber Systems, Northern Arizona University, Flagstaff, AZ, USA
- Pathogen and Microbiome Institute, Northern Arizona University, Flagstaff, AZ, USA
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Frost J, Rudy MJ, Leser JS, Tan H, Hu Y, Wang J, Clarke P, Tyler KL. Telaprevir Treatment Reduces Paralysis in a Mouse Model of Enterovirus D68 Acute Flaccid Myelitis. J Virol 2023; 97:e0015623. [PMID: 37154751 PMCID: PMC10231134 DOI: 10.1128/jvi.00156-23] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/09/2023] [Indexed: 05/10/2023] Open
Abstract
In 2014, 2016, and 2018, the United States experienced unprecedented spikes in pediatric cases of acute flaccid myelitis (AFM), which is a poliomyelitis-like paralytic illness. Accumulating clinical, immunological, and epidemiological evidence has identified enterovirus D68 (EV-D68) as a major causative agent of these biennial AFM outbreaks. There are currently no available FDA-approved antivirals that are effective against EV-D68, and the treatment for EV-D68-associated AFM is primarily supportive. Telaprevir is an food and drug administration (FDA)-approved protease inhibitor that irreversibly binds the EV-D68 2A protease and inhibits EV-D68 replication in vitro. Here, we utilize a murine model of EV-D68 associated AFM to show that early telaprevir treatment improves paralysis outcomes in Swiss Webster (SW) mice. Telaprevir reduces both viral titer and apoptotic activity in both muscles and spinal cords at early disease time points, which results in improved AFM outcomes in infected mice. Following intramuscular inoculation in mice, EV-D68 infection results in a stereotypic pattern of weakness that is reflected by the loss of the innervating motor neuron population, in sequential order, of the ipsilateral (injected) hindlimb, the contralateral hindlimb, and then the forelimbs. Telaprevir treatment preserved motor neuron populations and reduced weakness in limbs beyond the injected hindlimb. The effects of telaprevir were not seen when the treatment was delayed, and toxicity limited doses beyond 35 mg/kg. These studies are a proof of principle, provide the first evidence of benefit of an FDA-approved antiviral drug with which to treat AFM, and emphasize both the need to develop better tolerated therapies that remain efficacious when administered after viral infections and the development of clinical symptoms. IMPORTANCE Recent outbreaks of EV-D68 in 2014, 2016, and 2018 have resulted in over 600 cases of a paralytic illness that is known as AFM. AFM is a predominantly pediatric disease with no FDA-approved treatment, and many patients show minimal recovery from limb weakness. Telaprevir is an FDA-approved antiviral that has been shown to inhibit EV-D68 in vitro. Here, we demonstrate that a telaprevir treatment that is given concurrently with an EV-D68 infection improves AFM outcomes in mice by reducing apoptosis and viral titers at early time points. Telaprevir also protected motor neurons and improved paralysis outcomes in limbs beyond the site of viral inoculation. This study improves understanding of EV-D68 pathogenesis in the mouse model of AFM. This study serves as a proof of principle for the first FDA-approved drug that has been shown to improve AFM outcomes and have in vivo efficacy against EV-D68 as well as underlines the importance of the continued development of EV-D68 antivirals.
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Affiliation(s)
- Joshua Frost
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael J. Rudy
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - J. Smith Leser
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Haozhou Tan
- Department of Medicinal Chemistry, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Yanmei Hu
- Department of Medicinal Chemistry, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Jun Wang
- Department of Medicinal Chemistry, Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey, USA
| | - Penny Clarke
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kenneth L. Tyler
- Department of Immunology & Microbiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Division of Infectious Disease, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Neurology Service, Rocky Mountain VA Medical Center, Aurora, Colorado, USA
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8
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Shah MM, Perez A, Lively JY, Avadhanula V, Boom JA, Chappell J, Englund JA, Fregoe W, Halasa NB, Harrison CJ, Hickey RW, Klein EJ, McNeal MM, Michaels MG, Moffatt ME, Otten C, Sahni LC, Schlaudecker E, Schuster JE, Selvarangan R, Staat MA, Stewart LS, Weinberg GA, Williams JV, Ng TFF, Routh JA, Gerber SI, McMorrow ML, Rha B, Midgley CM. Enterovirus D68-Associated Acute Respiratory Illness ─ New Vaccine Surveillance Network, United States, July-November 2018-2020. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2021; 70:1623-1628. [PMID: 34818320 PMCID: PMC8612514 DOI: 10.15585/mmwr.mm7047a1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Enterovirus D68 (EV-D68) is associated with a broad spectrum of illnesses, including mild to severe acute respiratory illness (ARI) and acute flaccid myelitis (AFM). Enteroviruses, including EV-D68, are typically detected in the United States during late summer through fall, with year-to-year fluctuations. Before 2014, EV-D68 was infrequently reported to CDC (1). However, numbers of EV-D68 detection have increased in recent years, with a biennial pattern observed during 2014-2018 in the United States, after the expansion of surveillance and wider availability of molecular testing. In 2014, a national outbreak of EV-D68 was detected (2). EV-D68 was also reported in 2016 via local (3) and passive national (4) surveillance. EV-D68 detections were limited in 2017, but substantial circulation was observed in 2018 (5). To assess recent levels of circulation, EV-D68 detections in respiratory specimens collected from patients aged <18 years* with ARI evaluated in emergency departments (EDs) or admitted to one of seven U.S. medical centers† within the New Vaccine Surveillance Network (NVSN) were summarized. This report provides a provisional description of EV-D68 detections during July-November in 2018, 2019 and 2020, and describes the demographic and clinical characteristics of these patients. In 2018, a total of 382 EV-D68 detections in respiratory specimens obtained from patients aged <18 years with ARI were reported by NVSN; the number decreased to six detections in 2019 and 30 in 2020. Among patients aged <18 years with EV-D68 in 2020, 22 (73%) were non-Hispanic Black (Black) persons. EV-D68 detections in 2020 were lower than anticipated based on the biennial circulation pattern observed since 2014. The circulation of EV-D68 in 2020 might have been limited by widespread COVID-19 mitigation measures; how these changes in behavior might influence the timing and levels of circulation in future years is unknown. Ongoing monitoring of EV-D68 detections is warranted for preparedness for EV-D68-associated ARI and AFM.
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