Norovirus Outbreak Surveillance, China, 2016-2018

Measures for preventing norovirus outbreaks on campus in economically underdeveloped areas and countries: evidence from rural areas in Western China

Background

The outbreak of norovirus represents a significant public health emergency within densely populated, impoverished, and underdeveloped areas and countries. Our objective is to conduct an epidemiology study of a norovirus outbreak that occurred in a kindergarten located in rural western China. We aim to raise awareness and garner increased attention towards the prevention and control of norovirus, particularly in economically underdeveloped regions.

Methods

Retrospective on-site epidemiological investigation results, including data on school layout, case symptoms, onset time, disposal methods and sample testing results, questionnaire surveys, and case-control study were conducted in a kindergarten to analyze the underlying causes of the norovirus outbreak.

Results

A total of 15 cases were identified, with an attack rate of 44.12% (15/34). Among them, 10 cases were diagnosed through laboratory tests, and 5 cases were diagnosed clinically. Vomiting (100%, 15/15) and diarrhea (93.33%, 14/15) were the most common symptoms in the outbreak. Case control study revealed that cases who had close contact (<1 m) with the patient's vomitus (OR = 5.500) and those who had close contact with similar patients (OR = 8.000) had significantly higher ORs compared to the control participants. The current study demonstrated that improper handling of vomitus is positively associated with norovirus outbreak. The absence of standardized disinfection protocols heightens the risk of norovirus outbreaks.

Conclusion

To our knowledge, this study represents the first investigation into a norovirus outbreak in rural areas of western China. We aspire that amidst rapid economic development, a greater emphasis will be placed on the prevention and control of infectious diseases in economically underdeveloped areas and countries.

Molecular Epidemiology of Human Norovirus Variants from Outbreaks in Zhejiang Province, China, during 2021

Background

Noroviruses are the most frequent cause of epidemic acute viral gastroenteritis in China.

Objectives

The aim of this study was to determine the molecular epidemiological characteristics of norovirus outbreaks and the molecular genetic features of norovirus in Zhejiang Province during 2021.

Methods

First, the local Centers for Disease Control and Prevention in the outbreak area conducted on-site epidemiologic investigations and collected samples from ill patients for initial testing. The general epidemiologic characteristics of the demographic information are presented through descriptive analysis. Positive samples were sent to the Microbiology Laboratory of Zhejiang Provincial Center for Disease Control and Prevention for further verification. The presence of norovirus genogroups I (GI) and II (GII), along with sapovirus, was detected. Subsequently, the specimens positive for norovirus were sequenced for genotyping purposes. Furthermore, the whole genomes of positive samples were sequenced, enabling the characterization of both nucleotide and amino acid differences within the virus. Finally, phylogenetic trees were constructed to further analyze and understand the genetic relationships among the detected viruses.

Result

227 norovirus outbreaks were reported in Zhejiang Province, China, during 2021. Schools were the main setting while January was the peak month for outbreaks. A total of 17 diverse genotypes of norovirus were identified in 2021, and GII.P16-GII.2 was the most frequent genotype (30.19%). Seven genomes (five GI.P4-GI.5 and two GII.P16-GII.2) were obtained. Although GI.P4-GI.5 is considered to be a rare genotype of norovirus, the prevalence might have been underestimated. Capsid microvariation of GII.2 displayed histo-blood group antigen binding patterns compared to the GII.2 prototype, although VP1 sequences were considered to have a minimal impact on antigenicity.

Conclusion

This study revealed the diversity of norovirus strains' genotypes circulating in Zhejiang Province in 2021. Continued molecular surveillance of noroviruses should be strengthened in our further efforts to the development of vaccines.

A narrative review of norovirus epidemiology, biology, and challenges to vaccine development

Norovirus is a leading cause of acute gastroenteritis (AGE) globally. AGE resulting from norovirus causes significant morbidity and mortality in countries of all income levels, particularly among young children and older adults. Prevention of norovirus AGE represents a unique challenge as the virus is genetically diverse with multiple genogroups and genotypes cocirculating globally and causing disease in humans. Variants of the GII.4 genotype are typically the most common genotype, and other genotypes cause varying amounts of disease year-to-year, with GII.2, GII.3, and GII.6 most prevalent in recent years. Noroviruses are primarily transmitted via the fecal-oral route and only a very small number of virions are required for infection, which makes outbreaks of norovirus extremely difficult to control when they occur. Settings like long-term care facilities, daycares, and hospitals are at high risk of outbreaks and can have very high attack rates resulting in substantial costs and disease burden. Severe cases of norovirus AGE are most common in vulnerable patient populations, such as infants, the elderly, and immunocompromised individuals, with available treatments limited to rehydration therapies and supportive care. To date, there are no FDA-approved norovirus vaccines; however, several candidates are currently in development. Given the substantial human and economic burden associated with norovirus AGE, a vaccine to prevent morbidity and mortality and protect vulnerable populations could have a significant impact on global public health.

Identifying SNP threshold from P2 sequences for investigating norovirus transmission

Noroviruses are a group of non-enveloped single-stranded positive-sense RNA virus belonging to Caliciviridae family. They can be transmitted by the fecal-oral route from contaminated food and water and cause mainly acute gastroenteritis. Outbreaks of norovirus infections could be difficult to detect and investigate. In this study, we developed a simple threshold detection approach based on variations of the P2 domain of the capsid protein. We obtained sequences from the norovirus hypervariable P2 region using Sanger sequencing, including 582 pairs of epidemiologically-related strains from 35 norovirus outbreaks and 6402 pairs of epidemiologically-unrelated strains during the four epidemic seasons. Genetic distances were calculated and a threshold was performed by adopting ROC (Receiver Operating Characteristic) curve which identified transmission clusters in all tested outbreaks with 80 % sensitivity. In average, nucleotide diversity between outbreaks was 67.5 times greater than the diversity within outbreaks. Simple and accurate thresholds for detecting norovirus transmissions of three genotypes obtained here streamlines molecular investigation of norovirus outbreaks, thus enabling rapid and efficient responses for the control of norovirus.

Prediction of Foodborne Norovirus Outbreaks in Coastal Areas in China in 2008-2018

Foodborne norovirus outbreak usually poses high risks in coastal areas in China. Owing to the influence of multiple climatic factors, it demonstrates typical seasonality and the hotspots gradually expanded northwards from 2008 to 2018. However, the complex mechanism of the onset of outbreaks makes accurate prediction difficult. Thus, it is in necessity to construct a predictive model for foodborne norovirus outbreaks in coastal areas based on environmental and geographical variables. A novel predictive nonlinear autoregressive model with exogenous inputs model was developed using 11 years of environmental and foodborne norovirus outbreak data collected from coastal areas in China. Five input variables (temperature, precipitation, elevation, latitude, and longitude) were screened through stepwise regression analysis. The predicted model developed in this study was able to reproduce 88.53% of outbreaks reported to the National Public Health Emergency Event Surveillance System (PHEESS) in the model development and 100% of outbreaks reported in the independent cross-validation since the system was first launched in China. In particular, foodborne norovirus outbreaks might occur when the probability is >0.6. The findings of this study suggest that foodborne norovirus outbreaks could be accurately predicted in coastal areas in China using the developed predictive model on a daily basis. The model output is most sensitive to temperature, followed by precipitation, and locations. The application of this predictive model is promising to improve local hygiene management levels, prevent foodborne norovirus outbreaks, and reduce the disease and economic costs in coastal areas in China.

Spatial Distribution and Enrichment Dynamics of Foodborne Norovirus in Oyster Tissues

The prevalence of norovirus in oysters poses a significant threat to food safety, necessitating a comprehensive understanding of contamination patterns. This study explores the temporal dynamics of norovirus distribution in various oyster tissues over a contamination period ranging from 6 to 96 h. Four tissues-the gill, palp, digestive gland, and stomach-were subjected to systematic monitoring using RT-qPCR for absolute quantification. Results revealed rapid norovirus detection in all tissues six hours post-contamination, with subsequent variations in detection rates. Gill and digestive gland tissues exhibited a peak in detection at 12-24 h, aligning with the oyster's gastrointestinal circulatory system. The digestive gland, distinguished by specific enrichment and adsorption capabilities, demonstrated the highest virus concentration at 48 h. In contrast, the stomach displayed a reemergence of norovirus. Beyond 72 h, detection remained exclusive to the digestive gland, with Ct values comparable to earlier time points. At 96 h, a limited amount of norovirus was detected in the digestive gland, emphasizing the importance for timely monitoring. In addition to providing critical insights into optimal detection strategies, these findings highlight the time-related characteristics of norovirus contamination in oysters. The study identifies the digestive gland as a key target for reliable monitoring, providing valuable data to improve protocols for reducing hazards associated with oyster consumption and foodborne norovirus infections. This research contributes to the understanding of norovirus dynamics in oyster tissues and reinforces current efforts aimed at ensuring food safety and public health.

Investigation of two norovirus outbreaks linked to drinking water contaminated with multiple GII strains in a rural county-Chongqing, China, 2021

Backgrounds

Norovirus is leading cause of non-bacterial gastroenteritis outbreaks globally, characterized by different strains prevalent in different countries and regions.

Methods

Cases were defined as individuals experiencing diarrhea ≥3 times/24 h, and/or vomiting ≥2 times/24 h in two villages between January 28 and February 9, 2021. Investigations were conducted to identify causes. Cases were interviewed using a standardized in-person form to collect data on potential risk factors. A retrospective cohort study was conducted to investigate the role of the spring water supply as the outbreak source. Residents from neighboring villages with different water sources served as the unexposed population. Stool specimens, rectal swabs, and water samples were tested using quantitative real-time Polymerase Chain Reaction, with subsequent sequencing performed on pathogen-positive specimens.

Results

Village-specific attack rates were 21.93% (123/561) and 26.99% (88/326), respectively. Evidence from both epidemiological and laboratory tests was consistent. Drinking spring water was statistically associated with the two outbreaks (RR = 41.8 and 79.2, respectively). In both outbreaks, stool specimens, rectal swabs, and water samples tested positive for norovirus. Specifically, GII.2 (P16) and GII.17 (P17) were identified in outbreak A, and GII.4 Sydney (P16) and GII.1 (P16) in outbreak B.

Conclusion

These two independent gastroenteritis outbreaks share similarities, both being linked to norovirus GII strains. The contaminated spring drinking water was identified as the probable source and was promptly closed and subjected to disinfection procedures. These findings reinforce the importance of implementing sanitation and environmental disinfection measures in rural areas, especially during the periods of increased rainfall.

Molecular epidemiology and genetic diversity of norovirus among hospitalized patients with acute gastroenteritis in Shandong, China, 2016-2018

Norovirus (NoV) infection is a leading cause of acute gastroenteritis (AGE) for people of all ages. Here, we reported the molecular epidemiology and genetic diversity of NoVs among hospitalized patients with AGE between 2016 and 2018 in Shandong Province, China. Two thousand sixty-nine AGE patients from sentinel hospitals were enrolled. The stool samples were collected and tested for NoVs by real-time RT-PCR. The RNA-dependent RNA polymerase (RdRp) and capsid gene of 163 strains were amplified and sequenced for genotyping. Phylogenetic analyses and genomic characterization were conducted with the VP1 and RdRp region of the full genome sequences. Four hundred seventy two (21.76%) samples were NoV-positive. The positive rate in 2016 was higher than those of 2017 and 2018. We observed diverse NoV genotypes. GII.2[P16] emerged in January 2017 and became the dominant genotype between May and June 2017. Phylogenetic analyses showed that our GII.2[P16] genomes clustered in the SC1 in VP1 region, while they belonged to the Emerging GⅡ.P16 (2015-2017) clade in RdRp region. Our GⅡ.4 strains displayed two amino acid mutations, positions R297H and D372N, in epitope A of the VP1 region. Our study highlighted that NoV is an important pathogen of viral AGE in Shandong and, therefore, it is necessary to strengthen its surveillance.

Norovirus outbreaks in hospitals in China: a systematic review

BACKGROUND

Norovirus outbreaks in hospitals can potentially impair patient care and result in significant financial expenses. There is currently limited information on hospital norovirus outbreaks in the Chinese mainland.

AIM

To systematically review the published literature to describe the characteristics of norovirus outbreaks in Chinese mainland hospitals to facilitate prompt identification and control of outbreaks.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis standards. Databases including PubMed, Web of Science, and Chinese Journals Online databases (China National Knowledge Infrastructure (CNKI), Chinese Wan Fang digital database (WANFANG) were searched from inception to July 18th, 2022.

FINDINGS

A total of 41 norovirus Chinese hospital outbreaks occurring before July 18th, 2022 were reported in 32 articles. Most reported outbreaks were from Shanghai and Beijing, and occurred in December and January. Cases were mainly adults. The male:female ratio was 1.22:1. The majority of cases in norovirus outbreaks were hospitalized patients (56.82%); medical staff were affected in 15 outbreaks. Norovirus outbreaks occurred in both private and public hospitals, and in secondary and tertiary care centres, and occurred mainly in internal medicine and geriatric departments. Person-to-person transmission was the primary transmission mode and GII was more prevalent.

CONCLUSION

Norovirus outbreaks in hospitals can affect both patients and healthcare workers, sometimes causing serious financial losses. In order to have a more complete understanding of the disease burden caused by norovirus outbreaks, surveillance needs to be established in hospitals.

Vaccine value profile for norovirus

Norovirus is attributed to nearly 1 out of every 5 episodes of diarrheal disease globally and is estimated to cause approximately 200,000 deaths annually worldwide, with 70,000 or more among children in developing countries. Noroviruses remain a leading cause of sporadic disease and outbreaks of acute gastroenteritis even in industrialized settings, highlighting that improved hygiene and sanitation alone may not be fully effective in controlling norovirus. Strengths in global progress towards a Norovirus vaccine include a diverse though not deep pipeline which includes multiple approaches, including some with proven technology platforms (e.g., VLP-based HPV vaccines). However, several gaps in knowledge persist, including a fulsome mechanistic understanding of how the virus attaches to human host cells, internalizes, and induces disease.

Changing predominance of norovirus strains in children with acute gastroenteritis in Shanghai, 2018-2021

Norovirus (NoV) is a major pathogen that causes acute gastroenteritis (AGE) in people of all ages, especially in children. In this study, we investigated the molecular epidemiological characteristics of NoV in children with AGE in Shanghai from 2018 to 2021. The overall detection rate of NoV was 11.9% (181/1545), with annual detection rates of 9.4% (36/381), 13.6% (29/213), 5.8% (13/226) and 14.2% (103/725), respectively. Of note, the prevalence of NoV in 2020 was significantly lower than that in 2018-2019 (10.9%, 65/594) (P ​= ​0.023) and 2021 (14.2%, 103/725) (P ​= ​0.000). The 181 NoV strains identified in this study were classified into the GI group (1.1%, 2/181), GII group (98.3%, 178/181) and GIX group (0.6%, 1/181) according to the VP1 gene. The most common NoV VP1 genotype was GII.4 Sydney_2012 (63.5%, 115/181), followed by GII.3 (19.9%, 36/181) and GII.2 (9.4%, 17/181). For P genotypes, 174 strains were sequenced successfully according to the RdRp gene, and the predominant genotype was GII.P16 (44.8%, 78/174), followed by GII.P31 (25.9%, 45/174) and GII.P12 (21.3%, 37/174). Among the 174 cases, GII.4 Sydney_2012[P16] (36.8%, 64/174) was the dominant genotype, followed by GII.4 Sydney_2012[P31] (25.3%, 44/174), GII.3[P12] (20.1%, 35/174) and GII.2[P16] (8.0%, 14/174). In particular, the dominant genotypes in Shanghai changed from GII.4 Sydney_2012[P31] in 2018-2019 to GII.4 Sydney_2012[P16] in 2020-2021. This is the first report to describe the epidemiological changes in NoV infection before and during the COVID-19 pandemic in Shanghai. These data highlight the importance of continuous surveillance for NoV in children with AGE in Shanghai.

Transmissibility quantification of norovirus outbreaks in 2016-2021 in Beijing, China

The transmissibility is a crucial feature for norovirus, yet its quantitative estimation has been limited. Our objective was to estimate the basic reproduction number (R0 ) of norovirus and investigate its variation characteristics. Norovirus outbreaks reported from September 2016 to August 2021 in Beijing were analyzed. The susceptible-infected-removed compartment model was established to estimate R0 . Linear regression models and logistic regression models were used to explore the factors affecting the transmissibility of norovirus. The overall median R0 of norovirus was estimated as 2.1 (interquartile range [IQR] 1.8-2.5), with 650 norovirus outbreaks. The transmissibility of norovirus varied by year, outbreak setting and genotype. The R0 of norovirus during September 2019 to August 2020 (median 2.1, IQR 1.8-2.4) and September 2020 to August 2021 (median 2.0, IQR 1.7-2.3) was lower than that of September 2016 to August 2017 (median 2.3, IQR 1.8-2.7) (β = 0.94, p = 0.05; β = 0.93, p = 0.008). The R0 of norovirus for all other settings was lower than that for kindergarten (median 2.4, IQR 2.0-2.9) (primary school: median 2.0, IQR 1.7-2.4, β = 0.94, p = 0.001; secondary school: median 1.7, IQR 1.5-2.0, β = 0.87, p < 0.001; college: median 1.7, IQR 1.5-1.8, β = 0.89, p = 0.03; other closed settings: median 1.8, IQR 1.5-2.0, β = 0.90, p = 0.004). GⅡ.2[P16] outbreaks had a median R0 of 2.2 (IQR 1.8-2.7), which was higher than that for GⅡ.6[P7] outbreaks (median 1.8, IQR: 1.8-2.0, odds ratio = 0.19, p = 0.03; GⅡ.2[P16] as reference) and mixed-genotype outbreaks (median 1.7, IQR: 1.5-1.8, β = 0.92, p = 0.02; mixed-genotype as reference). In kindergartens and primary schools, norovirus shows increased transmissibility, emphasizing the vulnerable population and high-risk settings. Furthermore, the transmissibility of norovirus may change over time and with virus evolution, necessitating additional research to uncover the underlying mechanisms.

Synergistic Effects of Rotavirus and Co-Infecting Viral Enteric Pathogens on Diarrheal Disease - Guangzhou City, Guangdong Province, China, 2019

What is already known about this topic?

Diarrhea represents a substantial public health issue, contributing globally to a high number of pediatric medical consultations, hospital admissions, and mortality rates.

What is added by this report?

An increase in diarrheal frequency serves as a critical benchmark for evaluating severity. The predominant pathogens associated with pediatric diarrhea are rotavirus and norovirus, with co-infections exerting a notable compounding effect that leads to more severe diarrhea.

What are the implications for public health practice?

Implementing sensitive diagnostic techniques and comprehensive monitoring is paramount in identifying co-infections. Such strategies can provide physicians with critical insights into disease progression, thus considerably reducing the burden of diarrhea.

Development and evaluation of a new luciferase immunosorbent assay to detect GII.6 norovirus-specific IgG in different domestic and wild animals

Noroviruses (NoVs) are the leading viral pathogens globally causing acute gastroenteritis (AGE) in humans, posing a significant global health threat and economic burden. Recent investigations revealed that human NoVs had been detected in different animals, which raises concerns about whether NoVs are potential zoonotic diseases. This study developed a novel luciferase immunosorbent assay (LISA) to detect GII.6 NoV IgG based on P protein of VP1. The LISA showed high specificity (99.20%) and sensitivity (92.00%) with 4-16 times more sensitivity compared with an ELISA. NoV-LISA was reproducible with human serum regarding the inter- and intra-assay coefficient of variance values. Potential cross-reactivity was also evaluated using mice serum immunized by other antigens, which showed that NoV-LISA could differentiate GII.6 NoV from rotavirus and various genotypes of NoV. Specific GII.6 NoV IgG was widely detected in different domestic and wild animals, including dogs, pigs, bats, rats, and home shrews, with various IgG-positive rates ranging from 2.5 to 74.4%. In conclusion, our newly developed NoV-LISA assay is suitable for NoV-specific IgG detection in humans and animals. The wide distribution of IgG antibodies against human NoV indicates potential zoonotic transmission between humans and animals.

Pathogenetic characteristics of infectious diarrhea in Yantai City, Shandong Province, 2018-2019

Background

Analysis of the pathogenic spectrum, epidemiological characteristics and molecular epidemiological features of important pathogens of infectious diarrhea in Yantai City, Shandong Province, 2018-2019, were analyzed to provide a reference basis for the prevention and control of infectious diarrhea.

Methods

A total of 1514 stool specimens were collected within 3 days of the onset of diarrhea in secondary or higher hospitals in Yantai from 2018-2019, and all specimens were tested for the presence of seven major viruses and three major bacteria by employing reverse transcription ploymeraer chain reaction (RT-PCR). Population and seasonal analyses were also performed on positive samples for infectious diarrhea. The top two ranked rotavirus and norovirus were focused on genotyping and analysis of geographical distribution.

Results

The study showed that the high prevalence of infectious diarrhea in Yantai, Shandong Province, for two consecutive years in 2018 and 2019 was in young children aged 1-5 years, accounting for 48.6% of the total number of cases. Viral diarrhea was distributed throughout the year with no obvious seasonal distribution, while bacterial diarrhea was predominant in summer. Of 1514 stool specimens, the total positive rate of specimens was 43.92% (665/1514). One pathogen was detected in 507 specimens, two pathogens in 107 specimens, and three pathogens in 44 specimens, with mixed infections accounting for 22.71% of positive specimens (151/665). Viral diarrheal pathogens accounted for 93.23% (620/665) of positive samples. The percentages of positive samples for Rotavirus (RV), Norovirus GI, Norovirus GII, Enterovirus universal (EV), Enteroadenovirus (EAdV), Sapovirus (SaV), Astrovirus (Astv), Salmonella (SE), Listeria monocytogenes (LiMo), and Vibrio parahaemolyticus (VP) were 48.57%, 3.61%, 15.34%, and 10.68% of the total positive samples.

Conclusions

This study analyzed in detail the composition of infectious diarrhea pathogen spectrum, pathogen alternation pattern, seasonal distribution and population distribution of pathogens in Yantai City, Shandong Province, 2018-2019, to provide a basis for improving relevant local preventive measures and reducing the disease burden.

Prevalence and Etiological Characteristics of Norovirus Infection in China: A Systematic Review and Meta-Analysis

Norovirus is a common cause of sporadic cases and outbreaks of gastroenteritis worldwide, although its prevalence and the dominant genotypes responsible for gastroenteritis outbreaks remain obscure. A systematic review was conducted on norovirus infection in China between January 2009 and March 2021. A meta-analysis and beta-binomial regression model were used to explore the epidemiological and clinical characteristics of norovirus infection and the potential factors contributing to the attack rate of the norovirus outbreaks, respectively. A total of 1132 articles with 155,865 confirmed cases were included, with a pooled positive test rate of 11.54% among 991,786 patients with acute diarrhea and a pooled attack rate of 6.73% in 500 norovirus outbreaks. GII.4 was the predominant genotype in both the etiological surveillance and outbreaks, followed by GII.3 in the etiological surveillance, and GII.17 in the outbreaks, with the proportion of recombinant genotypes increasing in recent years. A higher attack rate in the norovirus outbreaks was associated with age group (older adults), settings (nurseries, primary schools, etc.) and region (North China). The nation-wide pooled positive rate in the etiological surveillance of norovirus is lower than elsewhere in the global population, while the dominant genotypes are similar in both the etiological surveillance and the outbreak investigations. This study contributes to the understanding of norovirus infection with different genotypes in China. The prevention and control of norovirus outbreaks during the cold season should be intensified, with special attention paid to and enhanced surveillance performed in nurseries, schools and nursing homes from November to March.

Epidemiological characteristics of norovirus infection in pediatric patients during the COVID-19 pandemic

To assess the epidemiological characteristics of norovirus infection. We included 5564 patients under the age of 18 years who visited the hospital in which the study took place from December 2020 to November 2022 with a primary diagnosis of acute diarrhea. Clinical information was extracted from the electronic health record system. We calculated the prevalence of norovirus infection by age, gender, season, year, and type of patients. A nonlinear association between age and prevalence rates was assessed using a restricted cubic spline regression model. A total of 5564 patients completed the test for human norovirus, among whom 1442 (25.9%) tested positive. The prevalence of norovirus infection was significantly lower in 2022 than in 2021 (35.9% vs. 53.7%, p < 0.001), and the highest prevalence was observed in winter (35.1%) and then followed by autumn (27.5%). Regarding the age pattern, the highest rate was seen in children aged 1-3 years (37.5%). Children at age 1.5 years may have the highest risk of having norovirus infection (Pnonlinear  < 0.001). The prevalence of norovirus infection of norovirus during the COVID-19 pandemic was similar to that before the pandemic shown in literatures. A relatively high rate was observed in cool seasons and in younger children (i.e., 1-3 years).

Spatio-temporal distribution and influencing factors of norovirus outbreaks in Beijing, China from 2016 to 2020

BACKGROUND

Noroviruses are a leading cause of acute gastroenteritis (AGE) worldwide. The geographical characteristics of norovirus outbreaks in Beijing and their influencing factors remain unknown. This study aimed to explore the spatial distributions, geographical characteristics, and influencing factors of norovirus outbreaks in Beijing, China.

METHODS

Epidemiological data and specimens were collected through the AGE outbreak surveillance system in all 16 districts of Beijing. Data on spatial distribution, geographical characteristics, and influencing factors of norovirus outbreaks were analyzed using descriptive statistics methods. We measured spatial, geographical clustering of high- or low-value deviance from random distribution using Z-scores and P-values as statistical significance measures with Global Moran's I statistics and Getis-Ord Gi in ArcGIS. Linear regression and correlation methods were used to explore influencing factors.

RESULTS

Between September 2016 and August 2020, 1,193 norovirus outbreaks were laboratory-confirmed. The number of outbreaks varied seasonally, typically peaking in spring (March to May) or winter (October to December). Outbreaks primarily occurred around central districts at the town level, and spatial autocorrelation was evident in both the entire study period and in individual years. Hotspots of norovirus outbreaks in Beijing were primarily found in contiguous areas between three central districts (Chaoyang, Haidian, Fengtai) and four suburban districts (Changping, Daxing, Fangshan, Tongzhou). The average population numbers, mean number of all schools, and mean number of kindergartens and primary schools for towns in central districts and hotspot areas were higher than those in suburban districts and non-hotspot areas respectively. Additionally, population numbers and densities of kindergartens and primary schools were influencing factors at the town level.

CONCLUSIONS

Hotspots of norovirus outbreaks in Beijing were in contiguous areas between central and suburban districts with high populations, and high kindergarten and primary school densities were the likely driving forces. Outbreak surveillance needs to focus on contiguous areas between central and suburban districts with increased monitoring, medical resources, and health education.

Use of Zebrafish Embryos To Reproduce Human Norovirus and To Evaluate Human Norovirus Infectivity Decay after UV Treatment

This study reports an essential improvement of the method for replication of human norovirus (HNoV) with the use of zebrafish (Danio rerio) embryos. With three HNoV genotypes and P-types GII.2[P16], GII.4[P16], and GII.17[P31], we demonstrated that this tool had higher efficiency and robustness than the zebrafish larvae as reported previously. When zebrafish larvae were injected with virus (1.6 ± 0.3 log genome copies/10 larvae), a significant increase of virus genome copies was detected at 2 days postinfection (dpi; 4.4 ± 0.8 log genome copies/10 larvae, P < 0.05) and the viral loads started to decrease gradually from 3 dpi. In comparison, when the viruses were injected into the zebrafish embryos, significant virus replication was noticed from 1 dpi and lasted to 6 dpi (P < 0.05). The virus levels detected at 3 dpi had the highest mean value and the smallest variation (7.7 ± 0.2 log genome copies/10 larvae). The high levels of virus replication enabled continuous passaging for all three strains up to four passages. The zebrafish embryo-generated HNoVs showed clear patterns of binding to human histo-blood group antigens (HBGAs) in human saliva by a simple saliva-binding reverse transcription-quantitative PCR (RT-qPCR). Last, in a disinfection study, it was shown that a dose of 6 mJ/cm2 UV254 was able induce a >2-log reduction in HNoV infectivity for all three HNoV strains tested, suggesting that HNoVs were more UV susceptible than multiple enteric viruses and commonly used HNoV surrogates as tested before. IMPORTANCE HNoVs are a leading cause of gastroenteritis outbreaks worldwide. The zebrafish embryo tool as developed in this study serves as an efficient way to generate viruses with high titers and clean background and a straightforward platform to evaluate HNoV inactivation efficacies. It is expected that this tool will not only benefit epidemiological research on HNoV but also be used to generate HNoV inactivation parameters which are highly needed by the water treatment and food industries.

Asymptomatic Norovirus Infection Among Children in Kindergartens and Primary Schools - Beijing Municipality, China, 2021

What is already known about this topic?

Children in kindergartens and primary schools are the high-incidence groups of norovirus acute gastroenteritis. However, asymptomatic norovirus infection among them is seldom reported.

What is added by this report?

The norovirus positive rate was 3.48% among asymptomatic children in kindergartens and primary schools in Beijing Municipality in June 2021, the most common genotype was GII.4 Sydney, and no acute gastroenteritis outbreak was reported over the study period.

What are the implications for public health practice?

The asymptomatic norovirus infection was relatively low among kindergarten children and primary school students in summer. Norovirus genotypes in asymptomatic children were similar to those circulating in the symptomatic cases. Asymptomatic norovirus infection may play a limited role in causing acute gastroenteritis outbreaks.

First report of coinfection and whole-genome sequencing of norovirus and sapovirus in an acute gastroenteritis patient from Pakistan

Acute gastroenteritis is one of the most common diseases in infants and children in developing countries including Pakistan. In Pakistan, rotavirus (RVA) is known to contribute significantly to pediatric diarrheal illness, but the contribution of other viruses is still unclear. In the current study we have identified a case of mixed infection of norovirus (NoV) and sapovirus (SaV) in a 2-year-old child with acute gastroenteritis. The sample was initially processed for the detection of group A RVA through ELISA followed by NoV using RT-PCR assay. The sample tested positive for NoV RNA and was later subjected to whole-genome sequencing using meta-genome approach on Miseq (Illumina) platform. Sequencing results revealed GII.15 genotype of NoV that clustered with viruses from China and USA from 2017 to 2021. We also retrieved the complete genome of SaV (GI.1 genotype) from the same sample and phylogenetic analysis showed clustering with strains reported from Japan, South Korea, US, and Taiwan during 2012-2016. This is the first report from Pakistan that confirms coinfection of NoV and SaV and elucidates their whole genomes. We recommend initiation of NoV and SaV surveillance program to ascertain disease burden and explore genetic diversity, especially as RVA vaccines have been included in national immunization program.

Functional and structural characterization of Norovirus GII.6 in recognizing histo-blood group antigens

Noroviruses (NoVs) are the primary cause of acute gastroenteritis worldwide. Histo-blood group antigens (HBGAs) are receptors or attachment factors that affect the prevalence and host susceptibility of NoVs. GII.6 NoV is one of the predominant genotypes in humans, which recognizes the type ABO secretor of HBGAs. However, the structural basis of GII.6 NoV's interaction with HBGAs receptors remains elusive. In this study, we investigated the binding features of the GII.6 strain to HBGAs using saliva- and glycan-ELISA assays and characterized the molecular basis of the GII.6 virus that recognizes H disaccharide. We showed that the GII.6 ​P domain recognized some A and O secretor's saliva samples, most B secretor's saliva samples, and H disaccharide antigen, but did not bind non-secretors' saliva. Further, we determined the crystal structures of GII.6 and its complex with H disaccharides at 1.7 ​Å, revealing that the P domain of GII.6 shares the conventional binding interface and mode of GII HBGAs. Single residue mutations at the GII.6-H binding sites could inhibit the binding of GII.6 to HBGAs, demonstrating that the interaction residues were crucial in maintaining NoV-glycan integrity. Finally, structural and sequence analyses showed that the major residues of the GII.6-H interaction were conserved among NoVs in the GII genogroup. Taken together, our study characterized the functional and structural features of GII.6 that allow it to interact with HBGAs, and shed light on NoV evolution, epidemiology, and anti-viral drug development.

Evaluation of the transmissibility of norovirus and the effectiveness of prevention and control measures for schools in Jiangsu Province

OBJECTIVE

This study aims to estimate the transmissibility of norovirus outbreaks in schools by different transmission routes, and to evaluate the effects of isolation, school-closure and disinfection measures under different intervention intensities, finally, scientific prevention and control suggestions are proposed.

METHOD

23 outbreaks of norovirus infectious diarrhea occurring in Jiangsu Province's school from 2012-2018 were selected and fitted to the model. The data includes various types of school places and pathogen genotype. A 'SEIAQRW' model with two transmission routes was established. The transmissibility of each outbreak was assessed using effective reproduction number, the efficacy of different intervention measures and intensities were evaluated by calculating the total attack rate and peak incidence.

RESULTS

The mean effective reproduction number of noroviruses was estimated to be 8.92 for the human-to-human route of transmission and 2.19 for the water or food-to-human route of transmission. When all symptomatic cases were isolated, the median peak incidence for both transmission routes both being less than 1.8%. There was a smaller reduction in total attack rate compared to peak incidence, the median total attack rate for the two transmission routes decreased by 17.59% and 42.09%, respectively. When the effect of school-closure or disinfection is more than 90%, the total attack rate and peak incidence in the human-to-human route are reduced by more than 90% compared to no intervention, and the peak incidence in the water or food-to-human routes can be reduced to less than 1.4%, but the reduction in the total attack rate is only 50% or so.

CONCLUSION

Norovirus outbreaks have a high rate of transmission in schools. In the case of norovirus outbreaks, isolation should be complemented by other interventions, and the implementation of high-intensity school closures or disinfection of the external environment can be effective in reducing the spread of the virus.

Identification and genetic characterization of a minor norovirus genotype, GIX.1[GII.P15], from China

Background

Human noroviruses, single-stranded RNA viruses in the family Caliciviridae, are a leading cause of nonbacterial acute gastroenteritis in people of all ages worldwide. Despite three decades of genomic sequencing and epidemiological norovirus studies, full-length genome analyses of the non-epidemic or minor norovirus genotypes are rare and genomic regions other than ORF2 and 3′-end of ORF1 have been largely understudied, which hampers a better understanding of the evolutionary mechanisms of emergence of new strains. In this study, we detected a rare norovirus genotype, GIX.1[GII.P15], in a vomit sample of a 60 year old woman with acute gastroenteritis using Raji cells and sequenced the complete genome.

Results

Using electron microscopy, a morphology of spherical and lace-like appearance of norovirus virus particles with a diameter of approximately 30 nm were observed. Phylogenetic analysis of VP1 and the RdRp region indicated that the KMN1 strain could be genotyped as GIX.1[GII.P15]. In addition, the VP1 region of KMN1 strain had 94.15% ± 3.54% percent nucleotide identity (PNI) compared to 26 genomic sequences available in GenBank, indicating a higher degree similarity between KMN1 and other GIX.1[GII.P15] strains. Further analysis of the full genome sequence of KMN1 strain showed that a total of 96 nucleotide substitutions (63 in ORF1, 25 in ORF2, and 8 in ORF3) were found across the genome compared with the consensus sequence of GIX.1[GII.P15] genome, and 6 substitutions caused amino acid changes (4 in ORF1, 1 in ORF2, and 1 in ORF3). However, only one nucleotide substitution results in the amino acid change (P302S) in the VP1 protein and the site was located near one of the predicted conformational B epitopes on the dimer structure.

Conclusions

The genomic information of the new GIX.1[GII.P15] strain KMN1, which was identified in Kunming, China could provide helpful insights for the study of the genetic evolution of the virus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12863-022-01066-6.

Molecular characteristics of norovirus in sporadic and outbreak cases of acute gastroenteritis and in sewage in Sichuan, China

Background

Norovirus is highly diverse and constant surveillance is essential for the prevention and control of norovirus gastroenteritis.

Methods

From 2015 to 2019, fecal samples were collected from sporadic cases and outbreaks of acute gastroenteritis reported to Sichuan center for disease control and prevention. Sewage samples were collected from a wastewater treatment plant in Sichuan. All samples were tested for norovirus by real-time reverse transcription polymerase chain reaction. Norovirus-positive clinical samples were sequenced by Sanger sequencing. Sewage samples were sequenced by amplicon and virome sequencing.

Results

A total of 1462 fecal samples were collected and 11 different norovirus genotypes were detected. GII.4 Sydney 2012[P31] and GII.3[P12] were the dominant genotypes in sporadic cases whereas GII.2[P16] and GII.17[P17] were the dominant genotypes in outbreaks. GII.3 was predominant in children 0–6 months of age during spring and summer, while GII.4 was predominant in children older than 6 months and in the autumn. The detection rate of GII.17[P17] increased with age. In sewage, 16 genotypes were detected. GII.3, GII.4, GI.1, and GI.2 were the dominant genotypes.

Conclusion

This study demonstrated that multiple norovirus genotypes co-circulate in Sichuan. It is vital to continuously trace the genetic diversity of norovirus to give a future perspective on surveillance needs and guide vaccine design and policy decisions.

Early evolution and transmission of GII.P16-GII.2 norovirus in China

Norovirus is the most common cause of acute gastroenteritis worldwide. During 2016-2017, a novel recombinant GII.P16-GII.2 genotype of norovirus suddenly appeared and over the next several years became the predominant strain in both China and worldwide. To better understand the origin and diffusion of the GII.P16-GII.2 genotype in China, we conducted molecular evolutionary analyses, including phylodynamics and phylogeography. Moreover, to trace person-to-person transmission of GII.P16-GII.2 norovirus, we applied the novel method, TransPhylo, to a historical phylogeny using sequences obtained from a publicly available database. A time-scaled phylogenetic tree indicated that the time to the most recent common ancestor of the GII.P16-GII.2 major capsid protein (VP1) gene diverged from the GII.P2-GII.2 VP1 gene at 2,001.03 with an evolutionary rate of 3.32 × 10-3 substitutions/site/year. The time to the most recent common ancestor of the GII.P16-GII.2 RNA-dependent RNA polymerase region diverged from the GII.P16-GII.4 RNA-dependent RNA polymerase region at 2,013.28 with an evolutionary rate of 9.44 × 10-3 substitutions/site/year. Of these 2 genomic regions, VP1 gene sequence variations were the most influenced by selective pressure. A phylogeographic analysis showed that GII.P16-GII.2 strains in China communicated most frequently with those in the United States, Australia, Thailand, and Russia, suggesting import from Australia to Taiwan and from the United States to Guangdong. TransPhylo analyses indicated that the basic reproductive number (R0) and sampling proportion (pi) of GII.P16-GII.2 norovirus were 1.99 (95% confidence interval: 1.58-2.44) and 0.76 (95% confidence interval: 0.63-0.88), respectively. Strains from the United States and Australia were responsible for large spread during the evolution and transmission of the virus. Coastal cities and places with high population densities should be closely monitored for norovirus.

Cluster of Norovirus Genogroup IX Outbreaks in Long-Term Care Facilities, Utah, USA, 2021

We report 5 clustered acute gastroenteritis outbreaks in long-term care facilities in Utah, USA, that were linked to healthcare employees working at multiple facilities. Four outbreaks were caused by norovirus genotype GIX. We recommend continued norovirus surveillance and genotyping to determine contributions of this genotype to norovirus outbreaks.

Norovirus outbreaks in China, 2000-2018: A systematic review

To understand epidemiological characteristics of norovirus outbreaks in China from 2000 to 2018 the literature on norovirus outbreaks was identified by searching WANFANG, CNKI, PubMed, and Web of Science databases before 31 December 2018. Statistical analyses were performed using Statistical Product Service Solutions software. RStudio1.4.1717 and ArcGIS trial version were used for plotting bar graphs and maps. A total of 419 norovirus outbreaks were reported in the 394 included articles, which occurred between June 2000 and October 2018, showing an overall increasing trend. The majority of outbreaks occurred in schools (52.28%, 218/417) and kindergartens (55/417, 13.19%). Person-to-person transmission (41.64%, 137/329) was most common, followed by food-borne transmission (75/329, 22.80%) and water-borne transmission (72/329, 21.88%). GII was the most predominant norovirus genogroup, with GII.4, GII.17 and GII.2 being the dominant genotypes in 2007-2013, 2014-2015, 2016-2017, respectively. Increased outbreaks were associated with the prevalence of new variants. Most norovirus outbreaks were reported in the southeast of the country. The number of norovirus outbreaks was positively associated with the per capita gross domestic product and the year-end resident population. Norovirus outbreaks have become an important public health problem in China. It is necessary to establish surveillance in hospitals and nursing homes. Genotyping of noroviruses is important for monitoring the circulating strains and improving the vaccine design, so it should be carried out in more regions.

Genetic diversity of norovirus associated with outbreaks in school children with acute gastroenteritis in Changzhou, China, 2018-2019

OBJECTIVE

Norovirus is one of the major causes of outbreaks and sporadic cases of acute gastroenteritis in school children. Obtaining local genotype diversity information regarding norovirus is important for developing and evaluating prevention strategies of the transmission of this virus in school children.

METHODS

Clinical specimens, obtained from the routine acute gastroenteritis surveillance network from 2018 to 2019, were primarily tested using commercial real-time PCR Kit. Samples with Ct value less than 25 were selected and used for complete genome sequencing and those with Ct value between 25 and 30 were selected and used for he partial VP1 and RdRp regions sequencing. Phylogenetic trees of the viral genome were constructed by using the neighbor-joining method with bootstrap analysis of 1,000 replicates in MEGA 6.0 RESULTS: Epidemiological surveillance of acute intestinal infections (n=384) showed high-level detection (73.18%) of human norovirus in school endemic acute gastroenteritis events in Changzhou, with obvious epidemic characteristics in autumn and winter. Through genotyping, it was found that 93.12% of norovirus were GII, including GII.2, GII.3, GII.4, GII.6, GII.7 and GII.17. By October 2019, two norovirus genotypes, GII.4[P31] and GII.17[P17], became the preponderant epidemic strains. Phylogenetic analysis of the new GII.17[P17] complete genomes showed close relationship with Miyagi strain identified in Japan in 2015, and GII.4[P31] showed close relationship with Jinan strain indentified in China in 2017.

CONCLUSION

The study highlights the emerging role of GII.4[P31] and GII.17[P17] in causing endemic acute gastroenteritis outbreaks at school children, in Changzhou, China in 2019. This article is protected by copyright. All rights reserved.

Evolutionary Analyses of Emerging GII.2[P16] and GII.4 Sydney [P16] Noroviruses

GII.2[P16] and GII.4 Sydney [P16] are currently the two predominant norovirus genotypes. This study sought to clarify their evolutionary patterns by analyzing the major capsid VP1 and RNA-dependent RNA polymerase (RdRp) genes. Sequence diversities were analyzed at both nucleotide and amino acid levels. Selective pressures were evaluated with the Hyphy package in different models. Phylogenetic trees were constructed by the maximum likelihood method from full VP1 sequences, and evolutionary rates were estimated by the Bayesian Markov Chain Monte Carlo approach. The results showed that (1) several groups of tightly linked mutations between the RdRp and VP1 genes were detected in the GII.2[P16] and GII.4[P16] noroviruses, and most of these mutations were synonymous, which may lead to a better viral fitness to the host; (2) although the pattern of having new GII.4 variants every 2–4 years has been broken, both the pre- and the post-2015 Sydney VP1 had comparable evolutionary rates to previously epidemic GII.4 variants, and half of the major antigenic sites on GII.4 Sydney had residue substitutions and several caused obvious changes in the carbohydrate-binding surface that may potentially alter the property of the virus; and (3) GII.4 Sydney variants during 2018–21 showed geographical specificity in East Asia, South Asia, and North America; the antigenic sites of GII.2 are strictly conserved, but the GII.2 VP1 chronologically evolved into nine different sublineages over time, with sublineage IX being the most prevalent one since 2018. This study suggested that both VP1 and RdRp of the GII.2[P16] and GII.4 Sydney [P16] noroviruses exhibited different evolutionary directions. GII.4[P16] is likely to generate potential novel epidemic variants by accumulating mutations in the P2 domain, similar to previously epidemic GII.4 variants, while GII.2[P16] has conserved predicted antigenicity and may evolve by changing the properties of nonstructural proteins, such as polymerase replicational fidelity and efficiency. This study expands the understanding of the evolutionary dynamics of GII.2[P16] and GII.4[P16] noroviruses and may predict the emergence of new variants.

Norovirus detection in wastewater and its correlation with human gastroenteritis: a systematic review and meta-analysis

Norovirus (NoV) is a major cause of sporadic cases and outbreaks of acute gastroenteritis (AGE), thereby imposing threat to health globally. It is unclear how quantitation of wastewater NoV reflects the incidence of human AGE infections; therefore, we conducted this systematic review and meta-analysis of published NoV wastewater surveillance studies. A literature search was performed, and all studies on NoV wastewater surveillance were identified. Quantitative results were evaluated. The results showed that the overall detection rate of NoV in wastewater was 82.10% (95% confidence interval [CI]: 74.22-89.92%); NoV concentration was statistically significant in terms of season (P < 0.001), with higher concentration in spring and winter. There were positive correlations between NoV GII concentration in wastewater and GII AGE cases (rs = 0.51, 95% CI: 0.18-0.74, I2 = 0%), total AGE cases (rs = 0.40, 95% CI: 0.15-0.61, I2 = 23%) and NoV outbreaks (rs = 0.47, 95% CI: 0.30-0.62, I2 = 0%). Results of cross-correlation analysis of partial data indicated that variations in GII concentration were consistent with or ahead of those in the number of AGE cases. The diversity of NoV genotypes in wastewater was elucidated, and the dominant strains in wastewater showed a consistent temporal distribution with those responsible for human AGE. Our study demonstrated the potential association of NoV detected in wastewater with AGE infections, and further studies are needed to confirm this conclusion.

Epidemiological and Genetic Characterization of Norovirus Outbreaks That Occurred in Catalonia, Spain, 2017–2019

Molecular characterization of human norovirus (HuNoV) genotypes enhances the understanding of viral features and illustrates distinctive evolutionary patterns. The aim of our study was to describe the prevalence of the genetic diversity and the epidemiology of the genotypes involved in HuNoV outbreaks in Catalonia (Spain) between 2017 and 2019. A total of 100 HuNoV outbreaks were notified with the predominance of GII (70%), followed by GI (27%) and mixed GI/GII (3%). Seasonality was observed for GII outbreaks only. The most prevalent genotypes identified were GII.4[P31] Sydney 2012, GII.4[P16] Sydney 2012 and GII.2[P16]. As compared to person-to-person (P/P) transmitted outbreaks, foodborne outbreaks showed significantly higher attack rates and lower duration. The average attack rate was higher in youth hostel/campgrounds compared to nursing homes. Only genotypes GI.4[P4], GII.2[P16], GII.4[P16], GII.4[P31] and GII.17[P17] were consistently detected every year, and only abundance of GII.2[P16] showed a negative trend over time. GII.4 Sydney 2012 outbreaks were significantly associated to nursing homes, while GII.2[P16] and GI.3[P3] were most frequently identified in youth hostel/campgrounds. The average attack rate was significantly higher when comparing GII.2[P16] vs. GI.4[P4], GII.2[P16] vs. GII.4[P31] Sydney 2012, and GII.6[P7] vs. GII.4[P31] Sydney 2012. No correlations were found between genotype and outbreak duration or age of affected individuals.

Study of Risk Factors for Total Attack Rate and Transmission Dynamics of Norovirus Outbreaks, Jiangsu Province, China, From 2012 to 2018

Objective: To describe the epidemiological characteristics of norovirus outbreaks in Jiangsu Province, utilize the total attack rate (TAR) and transmissibility (R_unc) as the measurement indicators of the outbreak, and a statistical difference in risk factors associated with TAR and transmissibility was compared. Ultimately, this study aimed to provide scientific suggestions to develop the most appropriate prevention and control measures.

Method: We collected epidemiological data from investigation reports of all norovirus outbreaks in Jiangsu Province from 2012 to 2018 and performed epidemiological descriptions, sequenced the genes of the positive specimens collected that were eligible for sequencing, created a database and calculated the TAR, constructed SEIAR and SEIARW transmission dynamic models to calculate R_unc, and performed statistical analyses of risk factors associated with the TAR and R_unc.

Results: We collected a total of 206 reported outbreaks, of which 145 could be used to calculate transmissibility. The mean TAR in was 2.6% and the mean R_unc was 12.2. The epidemiological characteristics of norovirus outbreaks showed an overall increasing trend in the number of norovirus outbreaks from 2012 to 2018; more outbreaks in southern Jiangsu than northern Jiangsu; more outbreaks in urban areas than in rural areas; outbreaks occurred mostly in autumn and winter. Most of the sites where outbreaks occurred were schools, especially primary schools. Interpersonal transmission accounted for the majority. Analysis of the genotypes of noroviruses revealed that the major genotypes of the viruses changed every 3 years, with the GII.2 [P16] type of norovirus dominating from 2016 to 2018. Statistical analysis of TAR associated with risk factors found statistical differences in all risk factors, including time (year, month, season), location (geographic location, type of settlement, type of premises), population (total number of susceptible people at the outbreak site), transmission route, and genotype (P < 0.05). Statistical analysis of transmissibility associated with risk factors revealed that only transmissibility was statistically different between sites.

Conclusions: The number of norovirus outbreaks in Jiangsu Province continues to increase during the follow-up period. Our findings highlight the impact of different factors on norovirus outbreaks and identify the key points of prevention and control in Jiangsu Province.

What is the Potential Cause for the Predominance of GII.2[P16] Norovirus in Acute Gastroenteritis Outbreaks in China?

GII.2[P16] noroviruses (NoV) reemerged and rapidly became the main epidemic strain in acute gastroenteritis (AGE) outbreaks in Asian countries since 2016. The current GII.2 [P16] NoV showed the same antigenicity to the ones before 2016, but several unique amino acid substitutions existed in the RNA dependent RNA polymerase (RdRp) and other non-structural proteins, and the viral load of the current GII.2[P16] NoV was higher than those of other genotypes, it was estimated that the viral replication ability may have improved. However, other genotypes, such as GII.1 and GII.3, also had recombination with the novel RdRp, were not prevalent in AGE-outbreaks; thus, it was inferred that the capsid proteins also played an important role in the enhanced replication process. The viral infection could also be affected by other factors, such as the population genetic background, the climate and environment, and people’s lifestyles. Continued surveillance on genetic diversity and evolutionary pattern for the GII.2[P16] NoV is necessary.

Molecular Epidemiological Characteristics of Gastroenteritis Outbreaks Caused by Norovirus GII.4 Sydney [P31] Strains - China, October 2016-December 2020

Introduction

Human noroviruses are the leading cause of acute viral gastroenteritis (AGE) worldwide in all age groups. GII.4 strains have been the predominant genotype circulating globally over the last 2 decades and since 2012. GII.4 Sydney viruses have emerged and caused the majority of AGE outbreaks worldwide.

Methods

Data from norovirus outbreaks from the laboratory-based surveillance of norovirus outbreaks in China (CaliciNet China) between October 2016-December 2020 were analyzed.

Results

During October 2016-December 2020, 1,954 norovirus outbreaks were reported, and positive fecal samples from 1,352 (69.19%) outbreaks were genotyped. GII.4 Sydney [P31] viruses accounted for 2.1% (October 2016-August 2017), 5.5% (September 2017-August 2018), 3.3% (September 2018-August 2018), 26.6% (September 2019-August 2020), and and 1.1% (September 2020-December 2020) of GII outbreaks, respectively. Compared to reference strains of GII.4 Sydney [P31] from 2012 to 2013, 7 amino acid mutations in epitopes[A (297, 372 and 373), B (333), E (414), and H (309 and 310)] and 1 in human histo-blood group antigens binding site at site II 372 were found by analyzing 9 GII.4 Sydney [P31] complete genomic sequences.

Conclusions

This report identified the genomic variation of GII.4 Sydney [P31] from CaliciNet China. Continued surveillance with prompt genotyping and genetic analysis is necessary to monitor the emergence of novel GII.4 variants.

Epidemiological characteristics and genetic diversity of norovirus infections among outpatient children with diarrhea under 5 years of age in Beijing, China, 2011-2018

Background

Human noroviruses are the leading cause of sporadic cases and outbreaks of viral acute gastroenteritis in all age groups worldwide.

Methods

Epidemiological data and fecal specimens were collected between January 2011 and December 2018 from 4911 children < 5 years of age with diarrhea in three districts of Beijing. From 2011 to 2013, One-Step Reverse Transcription Polymerase Chain Reaction (RT-PCR) was used to detect noroviruses, and from January 2014 to December 2018, norovirus GI and GII were screened using duplex quantitative real-time RT-PCR (qRT-PCR). One-Step RT-PCR and RT-seminested PCR were performed to amplify the RNA-dependent polymerase and capsid genes of noroviruses in positive sample. Amplified products were sequenced directly; norovirus was typed using the online Norovirus Genotyping Tool v2.0 and phylogenetic analyses were conducted using MEGA-X.

Results

From 2011 to 2018, noroviruses were detected in 16.5% of specimens from children with diarrhea. The highest prevalence was observed in children aged 12 to 23 months (22.4%, 319/1421), followed by children aged 6 to 11 months (17.6%, 253/1441). The highest prevalence of norovirus infections occurred in autumn followed by winter, spring, and summer. From 2011 to 2018, the most prevalent dual types (genotype and polymerase type) were GII.4 Sydney[P31] (51.6%, 239/463), followed by GII.3[P12] (24.0%, 111/463), GII.4 2006b[P4 2006b] (7.3%, 34/463), GII.2[P16] (5.0%, 23/463), GII.17[P17] (2.6%, 12/463) and GII.6[P7] (2.6%, 12/463). GII.4 2006b[P4 2006b] predominated in 2011 and 2012. GII.4 Sydney[P31] predominated from 2013 to 2018. In total, 15 genotypes, 15 P-types and 19 dual types were detected in this study, reflecting the genetic diversity.

Conclusions

There were significant epidemiological characteristics and genetic diversity among outpatient children with norovirus infections < 5 years of age in Beijing from 2011 to 2018. These characteristics differ from those of norovirus outbreaks in Beijing. The complete genome sequences of each genotype are needed to better understand norovirus evolutionary mechanisms.

Norovirus Vaccines: Current Clinical Development and Challenges

Noroviruses are the major viral pathogens causing epidemic and endemic acute gastroenteritis with significant morbidity and mortality. While vaccines against norovirus diseases have been shown to be of high significance, the development of a broadly effective norovirus vaccine remains difficult, owing to the wide genetic and antigenic diversity of noroviruses with multiple co-circulated variants of various genotypes. In addition, the absence of a robust cell culture system, an efficient animal model, and reliable immune markers of norovirus protection for vaccine evaluation further hinders the developmental process. Among the vaccine candidates that are currently under clinical studies, recombinant VP1-based virus-like particles (VLPs) that mimic major antigenic features of noroviruses are the common ones, with proven safety, immunogenicity, and protective efficacy, supporting a high success likelihood of a useful norovirus vaccine. This short article reviews the recent progress in norovirus vaccine development, focusing on those from recent clinical studies, as well as summarizes the barriers that are being encountered in this developmental process and discusses issues of future perspective.

Epidemiology and evolution of Norovirus in China

Norovirus (NoV) has been recognized as a leading cause of gastroenteritis worldwide. This review estimates the prevalence and genotype distribution of NoV in China to provide a sound reference for vaccine development. Studies were searched up to October 2020 from CNKI database and inclusion criteria were study duration of at least one calendar year and population size of >100. The mean overall NoV prevalence in individuals with sporadic diarrhea/gastroenteritis was 16.68% (20796/124649, 95% CI 16.63-16.72), and the detection rate of NoV was the highest among children. Non-GII.4 strains have replaced GII.4 as the predominant caused multiple outbreaks since 2014. Especially the recombinant GII.P16-GII.2 increased sharply, and virologic data show that the polymerase GII.P16 rather than VP1 triggers pandemic. Due to genetic diversity and rapid evolution, predominant genotypes might change unexpectedly, which has become major obstacle for the development of effective NoV vaccines.

Prevalence of GII.4 Sydney Norovirus Strains and Associated Factors of Acute Gastroenteritis in Children: 2019/2020 Season in Guangzhou, China

Norovirus, the leading cause of non-bacterial acute gastroenteritis (AGE) worldwide, is constantly mutating. Continuous monitoring of the evolution of epidemic genotypes and emergence of novel genotypes is, therefore, necessary. This study determined the prevalence and clinical characteristics of norovirus strains in AGE in Guangzhou, China in 2019/2020 season. This study included children aged 2-60 months diagnosed with AGE in Guangzhou Women and Children Hospital, from August 2019 to January 2020. Norovirus was detected by real-time polymerase chain reaction and clinical data were obtained. Genotyping and phylogenetic analyses were performed with partial gene sequence fragments located within the open reading frames 1 and 2. During the study period, 168 children (61.3% males) were confirmed as norovirus infectious AGE. The main symptoms were diarrhoea and vomiting and 38 patients (22.6%) had seizures. Norovirus was mainly prevalent in October and November, and GII.4 Sydney[P31] was the major genotype circulating in Guangzhou. The phylogenetic tree showed that the Guangzhou strains had high homology with the strains circulating in 2017-2019 worldwide. GII.4 Sydney was the main prevalent norovirus genotype in Guangzhou from August 2019 to January 2020, which had more severe diarrhoea than those of other genotypes. These findings provide a valuable reference for the prevention, control, and treatment of norovirus in the future.

Prevalence and Evolution of Noroviruses between 1966 and 2019, Implications for Vaccine Design

Noroviruses (NoVs), a group of single-stranded RNA viruses causing epidemic acute gastroenteritis in humans, are highly diverse, consisting of multiple genogroups with >30 genotypes. Their continual evolutions make NoV vaccine design and development difficult. Here, we report a study of NoV sequences obtained from a population-based diarrhea surveillance in Zhengding County of Hebei Province spanning from 2001 to 2019 and those available in the GenBank database from 1966 to 2019. NoV genotypes and/or variants that may evade immunity were screened and identified based on primary and conformational structures for vaccine design. We selected 366, 301, 139, 74 and 495 complete VP1-coding nucleotide sequences representing the predominant genotypes of GII.4, GII.2, GII.3, GII.6 and GII.17, respectively. A total of 16 distinct GII.4 variants were identified, showing a typical linear evolutionary pattern of variant replacement, while only 1–4 variants of the other genotypes were found to co-circulate over the 40–50-year period without typical variant replacement. The vaccine strain GII.4c is close to variant Sydney_2012 (0.053) in their primary structure, but they are distinct at epitopes A and E in conformations. Our data suggested GII.4 variant Sydney_2012, GII.2 variant A, a GII.3 strain, GII.6 variants B and C and GII.17 variant D are primary candidate strains for NoV vaccine development.

Advances in Human Norovirus Vaccine Research

Human norovirus (HuNoV) is the leading cause of acute gastroenteritis (AGE) worldwide, which is highly stable and contagious, with a few virus particles being sufficient to establish infection. Although the World Health Organization in 2016 stated that it should be an absolute priority to develop a HuNoV vaccine, unfortunately, there is currently no licensed HuNoV vaccine available. The major barrier to the development of an effective HuNoV vaccine is the lack of a robust and reproducible in vitro cultivation system. To develop a HuNoV vaccine, HuNoV immunogen alone or in combination with other viral immunogens have been designed to assess whether they can simultaneously induce protective immune responses against different viruses. Additionally, monovalent and multivalent vaccines from different HuNoV genotypes, including GI and GII HuNoV virus-like particles (VLPs), have been assessed in order to induce broad protection. Although there are several HuNoV vaccine candidates based on VLPs that are being tested in clinical trials, the challenges to develop effective HuNoV vaccines remain largely unresolved. In this review, we summarize the advances of the HuNoV cultivation system and HuNoV vaccine research and discuss current challenges and future perspectives in HuNoV vaccine development.

Simvastatin Reduces Protection and Intestinal T Cell Responses Induced by a Norovirus P Particle Vaccine in Gnotobiotic Pigs

Noroviruses (NoVs) are a leading cause of acute gastroenteritis worldwide. P particles are a potential vaccine candidate against NoV. Simvastatin is a cholesterol-reducing drug that is known to increase NoV infectivity. In this study, we examined simvastatin’s effects on P particle-induced protective efficacy and T-cell immunogenicity using the gnotobiotic pig model of human NoV infection and diarrhea. Pigs were intranasally inoculated with three doses (100 µg/dose) of GII.4/VA387-derived P particles together with monophosphoryl lipid A and chitosan adjuvants. Simvastatin-fed pigs received 8 mg/day orally for 11 days prior to challenge. A subset of pigs was orally challenged with 10 ID₅₀ of a NoV GII.4/2006b variant at post-inoculation day (PID) 28 and monitored for 7 days post-challenge. Intestinal and systemic T cell responses were determined pre- and postchallenge. Simvastatin abolished the P particle’s protection and significantly increased diarrhea severity after NoV infection. Simvastatin decreased proliferation of virus-specific and non-specific CD8 T cells in duodenum and virus-specific CD4 and CD8 T cells in spleen and significantly reduced numbers of intestinal mononuclear cells in vaccinated pigs. Furthermore, simvastatin significantly decreased numbers of duodenal CD4+IFN-γ+, CD8+IFN-γ+ and regulatory T cells and total duodenal activated CD4+ and CD8+ T cells in vaccinated pigs pre-challenge at PID 28. Following challenge, simvastatin prevented the IFN-γ+ T cell response in spleen of vaccinated pigs. These results indicate that simvastatin abolished P particle vaccine-induced partial protection through, at least in part, impairing T cell immunity. The findings have specific implications for the development of preventive and therapeutic strategies against NoV gastroenteritis, especially for the elderly population who takes statin-type drugs.

Detection of Norovirus Variant GII.4 Hong Kong in Asia and Europe, 2017-2019

We report a new norovirus GII.4 variant, GII.4 Hong Kong, with low-level circulation in 4 Eurasia countries since mid-2017. Amino acid substitutions in key residues on the virus capsid associated with the emergence of pandemic noroviruses suggest that GII.4 Hong Kong has the potential to become the next pandemic variant.

Evolution of the GII.3[P12] Norovirus from 2010 to 2019 in Jiangsu, China

Objectives

Norovirus genotype GII.3[P12] strains have been an important pathogen for sporadic gastroenteritis infection. In previous studies of GII.3[P12], the number of specimens and time span are relatively small, which is difficult to truly reflect the infection and evolution of this type of norovirus. Here we report a molecular epidemiological study of the NoVs prevalent in Jiangsu between 2010 and 2019 to investigate the evolution of the GII.3[P12] strains in China.

Methods

In this study 60 GII.3[P12] norovirus strains were sequenced and analyzed for evolution, recombination, and selection pressure using bioanalysis software.

Results

The GII.3[P12] strains were continuously detected during the study period, which showed a high constituent ratio in males, in winter and among children aged 0–11 months, respectively. A time-scaled evolutionary tree showed that both GII.P12 RdRp and GII.3 VP1 sequences were grouped into three major clusters (Cluster I–III). Most GII.3[P12] strains were mainly located in sub-cluster (SC) II of Cluster III. A SimPlot analysis identified GII.3[P12] strain to be as an ORF1-intragenic recombinant of GII.4[P12] and GII.3[P21]. The RdRp genes of the GII.3[P12] showed a higher mean substitution rate than those of all GII.P12, while the VP1 genes of the GII.3[P12] showed a lower mean substitution rate than those of all GII.3. Alignment of the GII.3 capsid sequences revealed that three HBGA binding sites of all known GII.3 strains remained conserved, while several amino acid mutations in the predicted antibody binding sites were detected. The mutation at 385 was within predicted antibody binding regions, close to host attachment factor binding sites. Positive and negative selection sites were estimated. Two common positively selected sites (sites 385 and 406) were located on the surface of the protruding domain. Moreover, an amino acid substitution (aa204) was estimated to be near the active site of the RdRp protein.

Conclusions

We conducted a comprehensive analysis on the epidemic and evolution of GII.3[P12] noroviruses and the results suggested that evolution was possibly driven by intergenic recombination and mutations in some key amino acid sites.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13099-021-00430-8.

Molecular epidemiology and changes in genotype diversity of norovirus infections in acute gastroenteritis patients in Huzhou, China, 2018

Norovirus is an important causative agent of acute gastroenteritis worldwide, affecting people of all ages. Stool samples collected from patients with clinical symptoms of acute gastroenteritis in all age groups at the diarrhea outpatient department of the First People's Hospital in Huzhou were analyzed to gain insight into the prevalence and genetic characteristics of norovirus. From January to December 2018, a total of 551 specimens were screened for norovirus by real-time reverse transcription-polymerase chain reaction (RT-PCR). RT-PCR was used for genomic amplification and sequencing of the RNA-dependent RNA polymerase and capsid gene of the positive samples. Genotypes of norovirus were assigned using the norovirus Noronet typing tool and phylogenetic analysis. About 100 (18.1%) specimens were identified as norovirus positive. GII genogroup was the main genogroup identified (83.0%; 83/100). About 42 (42.0%) samples were successfully sequenced and genotyped by RT-PCR. Since one of the samples was dual infection, so we got 43 virus finally. Nine norovirus GII genotypes and four norovirus GI genotypes were detected in Huzhou during our research period. The main two norovirus GII genotypes were GII.2[P16] (54.8%; 23/43) and GII.17[P17] (11.9%; 5/43). We characterized the molecular epidemiology of norovirus infection in acute gastroenteritis patients during 2018. GII genogroup was the main genogroup identified. The dominance norovirus genotype circulating in the population of Huzhou was GII.2[P16] in 2018.

Single-step RT-PCR assay for dual genotyping of GI and GII norovirus strains

BACKGROUND

Noroviruses are the major cause of acute gastroenteritis (AGE) in people of all ages globally. Standardized genotyping is key for outbreak investigations and surveillance networks.

OBJECTIVE

Here we describe the validation of a one-step conventional RT-PCR assay for sequence-based dual typing of GI and GII noroviruses. This polymerase (P) and capsid (C) dual typing assay uses a combination of previously published oligonucleotide primers amplifying a genomic region spanning the 3'-end of ORF1 and 5'end of ORF2 resulting in a 579 bp product for GI and 570 bp product for GII viruses.

RESULTS

The limit of detection of the assay ranged from 5 to 50 copies of viral RNA per reaction for GI and GII. To validate the assay, we tested 2,663 noroviruspositive stool samples from outbreaks and sporadic cases of AGE in Bangladesh, Guatemala, Peru, and USA collected between 2010-2019, of which 2,392 (90 %) were genotyped successfully. Most of the known genotypes infecting humans (GI (n = 9) and GII (n = 23)) and P types (GI (n = 15), GII, (n = 20)) could be detected. The remaining 270 samples had low viral load (Ct > 30) by real-time RT-PCR. A panel of 166 samples positive for other enteric viruses (rotavirus, astrovirus, sapovirus, adenovirus type 40/41) tested negative.

CONCLUSION

The use of broadly reactive genotyping assays greatly strengthens exchange of standardized genotype data globally to monitor trends in genotype diversity which is important for both the development of vaccines and to measure their impact.

Recent advances in human norovirus research and implications for candidate vaccines

INTRODUCTION

Noroviruses are a leading cause of acute gastroenteritis worldwide. An estimated 21 million illnesses in the United States and upwards of 684 million illnesses worldwide are attributed to norovirus infection. There are no licensed vaccines to prevent norovirus, but several candidates are in development.

AREAS COVERED

We review recent advances in molecular epidemiology of noroviruses, immunology, and in-vitro cultivation of noroviruses using human intestinal enteroids. We also provide an update on the status of norovirus vaccine candidates.

EXPERT OPINION

Molecular epidemiological studies confirm the tremendous genetic diversity of noroviruses, the continuous emergence of new recombinant strains, and the predominance of GII.4 viruses worldwide. Duration of immunity, extent of cross protection between different genotypes, and differences in strain distribution for young children compared with adults remain key knowledge gaps. Recent discoveries regarding which epitopes are targeted by neutralizing antibodies using the novel in vitro culture of human noroviruses in human intestinal enteroids are enhancing our understanding of mechanisms of protection and providing guidance for vaccine development. A future norovirus vaccine has the potential to substantially reduce the burden of illnesses due to this ubiquitous virus.