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Ikuse T, Aizawa Y, Kachikawa R, Kamata K, Osada H, Win SMK, Di Ja L, Win NC, Thein KN, Thida A, Tun A, Ito A, Kyaw Y, Tin HH, Shobugawa Y, Watanabe H, Saito R, Saitoh A. Detection of enterovirus D68 among children with severe acute respiratory infection in Myanmar. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:238-245. [PMID: 38233293 DOI: 10.1016/j.jmii.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 12/05/2023] [Accepted: 01/02/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND Enterovirus D68 (EV-D68) is an important reemerging pathogen that causes severe acute respiratory infection and acute flaccid paralysis, mainly in children. Since 2014, EV-D68 outbreaks have been reported in the United States, Europe, and east Asia; however, no outbreaks have been reported in southeast Asian countries, including Myanmar, during the previous 10 years. METHODS EV-D68 was detected in nasopharyngeal swabs from children with acute lower respiratory infections in Myanmar. The samples were previously collected from children aged 1 month to 12 years who had been admitted to the Yankin Children Hospital in Yangon, Myanmar, between May 2017 and January 2019. EV-D68 was detected with a newly developed EV-D68-specific real-time PCR assay. The clade was identified by using a phylogenetic tree created with the Bayesian Markov chain Monte Carlo method. RESULTS During the study period, nasopharyngeal samples were collected from 570 patients. EV-D68 was detected in 42 samples (7.4 %)-11 samples from 2017 to 31 samples from 2018. The phylogenetic tree revealed that all strains belonged to clade B3, which has been the dominant clade worldwide since 2014. We estimate that ancestors of currently circulating genotypes emerged during the period 1980-2004. CONCLUSIONS To our knowledge, this is the first report of EV-D68 detection in children with acute lower respiratory infections in Yangon, Myanmar, in 2017-2018. Detection and detailed virologic analyses of EV-D68 in southeast Asia is an important aspect of worldwide surveillance and will likely be useful in better understanding the worldwide epidemiologic profile of EV-D68 infection.
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Affiliation(s)
- Tatsuki Ikuse
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, 1-754, Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Yuta Aizawa
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, 1-754, Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Ryotaro Kachikawa
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, 1-754, Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Kazuhiro Kamata
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, 1-754, Asahimachi-dori, Chuo-ku, Niigata, Japan; Infectious Diseases Research Center of Niigata University in Myanmar, 35, Maw Koon Tike St., Pyay (East) Ward, Dagon, Yangon, Myanmar
| | - Hidekazu Osada
- Infectious Diseases Research Center of Niigata University in Myanmar, 35, Maw Koon Tike St., Pyay (East) Ward, Dagon, Yangon, Myanmar
| | - Su Mon Kyaw Win
- Infectious Diseases Research Center of Niigata University in Myanmar, 35, Maw Koon Tike St., Pyay (East) Ward, Dagon, Yangon, Myanmar
| | - Lasham Di Ja
- Infectious Diseases Research Center of Niigata University in Myanmar, 35, Maw Koon Tike St., Pyay (East) Ward, Dagon, Yangon, Myanmar
| | - Nay Chi Win
- Infectious Diseases Research Center of Niigata University in Myanmar, 35, Maw Koon Tike St., Pyay (East) Ward, Dagon, Yangon, Myanmar
| | - Khin Nyo Thein
- Yankin Children Hospital, 90, Thitsar Rd., Kanbe, Yankin Township, Yangon, Myanmar
| | - Aye Thida
- University of Medicine 2, Khaymar Thi Rd, Yangon, Myanmar
| | - Aye Tun
- Ministry of Health, Office No.4, Nay Pyi Taw, Myanmar
| | - Ai Ito
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, 1-754, Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Yadanar Kyaw
- University of Medicine 2, Khaymar Thi Rd, Yangon, Myanmar
| | - Htay Htay Tin
- University of Medical Technology, Insein Township, Yangon Yangon Division, Myanmar
| | - Yugo Shobugawa
- Division of International Health, Graduate School of Medical and Dental Science, Niigata University, 1-754, Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Hisami Watanabe
- Division of International Health, Graduate School of Medical and Dental Science, Niigata University, 1-754, Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Reiko Saito
- Division of International Health, Graduate School of Medical and Dental Science, Niigata University, 1-754, Asahimachi-dori, Chuo-ku, Niigata, Japan
| | - Akihiko Saitoh
- Department of Pediatrics, Niigata University Graduate School of Medical and Dental Sciences, 1-754, Asahimachi-dori, Chuo-ku, Niigata, Japan.
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Messacar K, Matzinger S, Berg K, Weisbeck K, Butler M, Pysnack N, Nguyen-Tran H, Davizon ES, Bankers L, Jung SA, Birkholz M, Wheeler A, Dominguez SR. Multimodal Surveillance Model for Enterovirus D68 Respiratory Disease and Acute Flaccid Myelitis among Children in Colorado, USA, 2022. Emerg Infect Dis 2024; 30:423-431. [PMID: 38407198 PMCID: PMC10902548 DOI: 10.3201/eid3003.231223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Abstract
Surveillance for emerging pathogens is critical for developing early warning systems to guide preparedness efforts for future outbreaks of associated disease. To better define the epidemiology and burden of associated respiratory disease and acute flaccid myelitis (AFM), as well as to provide actionable data for public health interventions, we developed a multimodal surveillance program in Colorado, USA, for enterovirus D68 (EV-D68). Timely local, state, and national public health outreach was possible because prospective syndromic surveillance for AFM and asthma-like respiratory illness, prospective clinical laboratory surveillance for EV-D68 among children hospitalized with respiratory illness, and retrospective wastewater surveillance led to early detection of the 2022 outbreak of EV-D68 among Colorado children. The lessons learned from developing the individual layers of this multimodal surveillance program and how they complemented and informed the other layers of surveillance for EV-D68 and AFM could be applied to other emerging pathogens and their associated diseases.
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Clark EC, Neumann S, Hopkins S, Kostopoulos A, Hagerman L, Dobbins M. Changes to Public Health Surveillance Methods Due to the COVID-19 Pandemic: Scoping Review. JMIR Public Health Surveill 2024; 10:e49185. [PMID: 38241067 PMCID: PMC10837764 DOI: 10.2196/49185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/06/2023] [Accepted: 12/07/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Public health surveillance plays a vital role in informing public health decision-making. The onset of the COVID-19 pandemic in early 2020 caused a widespread shift in public health priorities. Global efforts focused on COVID-19 monitoring and contact tracing. Existing public health programs were interrupted due to physical distancing measures and reallocation of resources. The onset of the COVID-19 pandemic intersected with advancements in technologies that have the potential to support public health surveillance efforts. OBJECTIVE This scoping review aims to explore emergent public health surveillance methods during the early COVID-19 pandemic to characterize the impact of the pandemic on surveillance methods. METHODS A scoping search was conducted in multiple databases and by scanning key government and public health organization websites from March 2020 to January 2022. Published papers and gray literature that described the application of new or revised approaches to public health surveillance were included. Papers that discussed the implications of novel public health surveillance approaches from ethical, legal, security, and equity perspectives were also included. The surveillance subject, method, location, and setting were extracted from each paper to identify trends in surveillance practices. Two public health epidemiologists were invited to provide their perspectives as peer reviewers. RESULTS Of the 14,238 unique papers, a total of 241 papers describing novel surveillance methods and changes to surveillance methods are included. Eighty papers were review papers and 161 were single studies. Overall, the literature heavily featured papers detailing surveillance of COVID-19 transmission (n=187). Surveillance of other infectious diseases was also described, including other pathogens (n=12). Other public health topics included vaccines (n=9), mental health (n=11), substance use (n=4), healthy nutrition (n=1), maternal and child health (n=3), antimicrobial resistance (n=2), and misinformation (n=6). The literature was dominated by applications of digital surveillance, for example, by using big data through mobility tracking and infodemiology (n=163). Wastewater surveillance was also heavily represented (n=48). Other papers described adaptations to programs or methods that existed prior to the COVID-19 pandemic (n=9). The scoping search also found 109 papers that discuss the ethical, legal, security, and equity implications of emerging surveillance methods. The peer reviewer public health epidemiologists noted that additional changes likely exist, beyond what has been reported and available for evidence syntheses. CONCLUSIONS The COVID-19 pandemic accelerated advancements in surveillance and the adoption of new technologies, especially for digital and wastewater surveillance methods. Given the investments in these systems, further applications for public health surveillance are likely. The literature for surveillance methods was dominated by surveillance of infectious diseases, particularly COVID-19. A substantial amount of literature on the ethical, legal, security, and equity implications of these emerging surveillance methods also points to a need for cautious consideration of potential harm.
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Affiliation(s)
- Emily C Clark
- National Collaborating Centre for Methods and Tools, Hamilton, ON, Canada
| | - Sophie Neumann
- National Collaborating Centre for Methods and Tools, Hamilton, ON, Canada
| | - Stephanie Hopkins
- National Collaborating Centre for Methods and Tools, Hamilton, ON, Canada
| | - Alyssa Kostopoulos
- National Collaborating Centre for Methods and Tools, Hamilton, ON, Canada
| | - Leah Hagerman
- National Collaborating Centre for Methods and Tools, Hamilton, ON, Canada
| | - Maureen Dobbins
- National Collaborating Centre for Methods and Tools, Hamilton, ON, Canada
- School of Nursing, McMaster University, Hamilton, ON, Canada
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Jobling K, Quintela-Baluja M, Hassard F, Adamou P, Blackburn A, Research Team T, McIntyre-Nolan S, O'Mara O, Romalde JL, Di Cesare M, Graham DW. Comparison of gene targets and sampling regimes for SARS-CoV-2 quantification for wastewater epidemiology in UK prisons. JOURNAL OF WATER AND HEALTH 2024; 22:64-76. [PMID: 38295073 PMCID: wh_2023_093 DOI: 10.2166/wh.2023.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Prisons are high-risk settings for infectious disease transmission, due to their enclosed and semi-enclosed environments. The proximity between prisoners and staff, and the diversity of prisons reduces the effectiveness of non-pharmaceutical interventions, such as social distancing. Therefore, alternative health monitoring methods, such as wastewater-based epidemiology (WBE), are needed to track pathogens, including SARS-CoV-2. This pilot study assessed WBE to quantify SARS-CoV-2 prevalence in prison wastewater to determine its utility within a health protection system for residents. The study analysed 266 samples from six prisons in England over a 12-week period for nucleoprotein 1 (N1 gene) and envelope protein (E gene) using quantitative reverse transcriptase-polymerase chain reaction. Both gene assays successfully detected SARS-CoV-2 fragments in wastewater samples, with both genes significantly correlating with COVID-19 case numbers across the prisons (p < 0.01). However, in 25% of the SARS-positive samples, only one gene target was detected, suggesting that both genes be used to reduce false-negative results. No significant differences were observed between 14- and 2-h composite samples, although 2-h samples showed greater signal variance. Population normalisation did not improve correlations between the N1 and E genes and COVID-19 case data. Overall, WBE shows considerable promise for health protection in prison settings.
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Affiliation(s)
- Kelly Jobling
- School of Engineering, Newcastle University, Newcastle upon Tyne NE1 7RU, UK; The authors contributed equally to the manuscript. E-mail:
| | - Marcos Quintela-Baluja
- School of Engineering, Newcastle University, Newcastle upon Tyne NE1 7RU, UK; The authors contributed equally to the manuscript
| | - Francis Hassard
- Cranfield Water Science Institute, Cranfield University, Cranfield MK43 0AL, UK
| | - Panagiota Adamou
- School of Engineering, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Adrian Blackburn
- School of Engineering, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | | | | | | | - Jesus L Romalde
- CRETUS, Departamento de Microbiología y Parasitología, Universidade de Santiago de Compostela, Santiago de Compostela, Spain
| | | | - David W Graham
- School of Engineering, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
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5
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Kevill JL, Farkas K, Ridding N, Woodhall N, Malham SK, Jones DL. Use of Capsid Integrity-qPCR for Detecting Viral Capsid Integrity in Wastewater. Viruses 2023; 16:40. [PMID: 38257740 PMCID: PMC10819219 DOI: 10.3390/v16010040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
Quantifying viruses in wastewater via RT-qPCR provides total genomic data but does not indicate the virus capsid integrity or the potential risk for human infection. Assessing virus capsid integrity in sewage is important for wastewater-based surveillance, since discharged effluent may pose a public health hazard. While integrity assays using cell cultures can provide this information, they require specialised laboratories and expertise. One solution to overcome this limitation is the use of photo-reactive monoazide dyes (e.g., propidium monoazide [PMAxx]) in a capsid integrity-RT-qPCR assay (ci-RT-qPCR). In this study, we tested the efficiency of PMAxx dye at 50 μM and 100 μM concentrations on live and heat-inactivated model viruses commonly detected in wastewater, including adenovirus (AdV), hepatitis A (HAV), influenza A virus (IAV), and norovirus GI (NoV GI). The 100 μM PMAxx dye concentration effectively differentiated live from heat-inactivated viruses for all targets in buffer solution. This method was then applied to wastewater samples (n = 19) for the detection of encapsulated AdV, enterovirus (EV), HAV, IAV, influenza B virus (IBV), NoV GI, NoV GII, and SARS-CoV-2. Samples were negative for AdV, HAV, IAV, and IBV but positive for EV, NoV GI, NoV GII, and SARS-CoV-2. In the PMAxx-treated samples, EV, NoV GI, and NoV GII showed -0.52-1.15, 0.9-1.51, and 0.31-1.69 log reductions in capsid integrity, indicating a high degree of potentially infectious virus in wastewater. In contrast, SARS-CoV-2 was only detected using RT-qPCR but not after PMAxx treatment, indicating the absence of encapsulated and potentially infectious virus. In conclusion, this study demonstrates the utility of PMAxx dyes to evaluate capsid integrity across a diverse range of viruses commonly monitored in wastewater.
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Affiliation(s)
- Jessica L. Kevill
- School of Environmental and Natural Sciences, Bangor University, Bangor, Gwynedd LL57 2UW, UK; (K.F.); (N.R.); (N.W.); or (D.L.J.)
| | - Kata Farkas
- School of Environmental and Natural Sciences, Bangor University, Bangor, Gwynedd LL57 2UW, UK; (K.F.); (N.R.); (N.W.); or (D.L.J.)
| | - Nicola Ridding
- School of Environmental and Natural Sciences, Bangor University, Bangor, Gwynedd LL57 2UW, UK; (K.F.); (N.R.); (N.W.); or (D.L.J.)
| | - Nicholas Woodhall
- School of Environmental and Natural Sciences, Bangor University, Bangor, Gwynedd LL57 2UW, UK; (K.F.); (N.R.); (N.W.); or (D.L.J.)
| | - Shelagh K. Malham
- School of Ocean Sciences, Bangor University, Menai Bridge, Anglesey LL59 5AB, UK;
| | - Davey L. Jones
- School of Environmental and Natural Sciences, Bangor University, Bangor, Gwynedd LL57 2UW, UK; (K.F.); (N.R.); (N.W.); or (D.L.J.)
- Centre for Sustainable Farming Systems, Food Futures Institute, Murdoch University, Murdoch, WA 6150, Australia
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6
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Hooi YT, Balasubramaniam VRMT. In vitro and in vivo models for the study of EV-D68 infection. Pathology 2023; 55:907-916. [PMID: 37852802 DOI: 10.1016/j.pathol.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/03/2023] [Accepted: 08/14/2023] [Indexed: 10/20/2023]
Abstract
Enterovirus D68 (EV-D68) is one of hundreds of non-polio enteroviruses that typically cause cold-like respiratory illness. The first EV-D68 outbreak in the United States in 2014 aroused widespread concern among the public and health authorities. The infection was found to be associated with increased surveillance of acute flaccid myelitis, a neurological condition that causes limb paralysis in conjunction with spinal cord inflammation. In vitro studies utilising two-dimensional (2D) and three-dimensional (3D) culture systems have been employed to elucidate the pathogenic mechanism of EV-D68. Various animal models have also been developed to investigate viral tropism and distribution, pathogenesis, and immune responses during EV-D68 infection. EV-D68 infections have primarily been investigated in respiratory, intestinal and neural cell lines/tissues, as well as in small-size immunocompetent rodent models that were limited to a young age. Some studies have implemented strategies to overcome the barriers by using immunodeficient mice or virus adaptation. Although the existing models may not fully recapitulate both respiratory and neurological disease observed in human EV-D68 infection, they have been valuable for studying pathogenesis and evaluating potential vaccine or therapeutic candidates. In this review, we summarise the methodologies and findings from each experimental model and discuss their applications and limitations.
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Affiliation(s)
- Yuan Teng Hooi
- Infection and Immunity Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia.
| | - Vinod R M T Balasubramaniam
- Infection and Immunity Research Strength, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia.
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Boehm AB, Wadford DA, Hughes B, Duong D, Chen A, Padilla T, Wright C, Moua L, Bullick T, Salas M, Morales C, White BJ, Glaser CA, Vugia DJ, Yu AT, Wolfe MK. Trends of Enterovirus D68 Concentrations in Wastewater, California, USA, February 2021-April 2023. Emerg Infect Dis 2023; 29:2362-2365. [PMID: 37877593 PMCID: PMC10617337 DOI: 10.3201/eid2911.231080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
In this retrospective study, we measured enterovirus D68 (EV-D68) genomic RNA in wastewater solids longitudinally at 2 California, USA, wastewater treatment plants twice per week for 26 months. EV-D68 RNA was undetectable except when concentrations increased from mid-July to mid-December 2022, which coincided with a peak in confirmed EV-D68 cases.
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Affiliation(s)
| | | | - Bridgette Hughes
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Dorothea Duong
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Alice Chen
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Tasha Padilla
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Chelsea Wright
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Lisa Moua
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Teal Bullick
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Maria Salas
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Christina Morales
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Bradley J. White
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Carol A. Glaser
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Duc J. Vugia
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Alexander T. Yu
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
| | - Marlene K. Wolfe
- Stanford University, Stanford, California, USA (A.B. Boehm)
- California Department of Public Health, Richmond, California, USA (D.A. Wadford, A. Chen, T. Padilla, C. Wright, L. Moua, T. Bullick, M. Salas, C. Morales, C.A. Glaser, D.J. Vugia, A.T. Yu)
- Verily Life Sciences, South San Francisco, California, USA (B. Hughes, D. Duong, B.J. White)
- Emory University Rollins School of Public Health, Atlanta, Georgia, USA (M.K. Wolfe)
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Shi Y, Liu Y, Wu Y, Hu S, Sun B. Molecular epidemiology and recombination of enterovirus D68 in China. INFECTION, GENETICS AND EVOLUTION : JOURNAL OF MOLECULAR EPIDEMIOLOGY AND EVOLUTIONARY GENETICS IN INFECTIOUS DISEASES 2023; 115:105512. [PMID: 37827347 DOI: 10.1016/j.meegid.2023.105512] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/05/2023] [Accepted: 10/09/2023] [Indexed: 10/14/2023]
Abstract
Enterovirus D68 (EV-D68), a member of Enterovirus genus of the Picornaviridae family, mainly causes respiratory system-related diseases as well as neurological complications in some patients. At present, there is no effective vaccine or treatment for the virus. The aim of this research was to systematically analyse the molecular epidemiology, recombination and changes in the epitope of EV-D68 in China from 2008 to 2022. Through phylogenetic analysis based on VP1 sequences, it was found that there was limited information about EV-D68 infection before 2011 and that EV-D68 infection was dominated by the A2 gene subtype from 2011 to 2013 and the B3 genotype from 2014 to 2018, during which A2 and B3 were coprevalent and alternately prevalent. We also constructed a phylogenetic tree using the EV-D68 full-length genome sequences, and the genotype of each sequence was consistent with that of the VP1 sequence evolutionary tree. Recombination analysis showed that MH341715 underwent intertypic recombination with the A2 genotype MH341729 at the 5' untranslated region (5'UTR) and that P1-P3 underwent recombination with the B3 genotype MH341712. The capsid protein VP1 is one of the most important structural proteins. In VP1, the BC-loop (89-105 amino acids) and DE-loop (140-152 amino acids) are the most variable domains on the surface of the virus and are associated with epitopes. In this study, it was found that the dominant amino acid composition of the BC-loop and DE-loop continued to change with the epidemic of the virus; the amino acid composition also differed in different regions of the same genotypes. The ongoing genomic and molecular epidemiology of EV-D68 remains important for predicting emergence of new viruses and preventing major outbreaks of respiratory diseases.
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Affiliation(s)
- Yingying Shi
- Department of Immunology, School of Medicine, Jianghan University, Wuhan, Hubei 430056, China
| | - Yongjuan Liu
- Department of Central Laboratory, the Affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, Jiangsu 222002, China
| | - Yanli Wu
- Department of Immunology, School of Medicine, Jianghan University, Wuhan, Hubei 430056, China
| | - Song Hu
- Wuhan Institute of Biomedical Sciences, School of Medicine, Jianghan University, Wuhan, China
| | - Binlian Sun
- Wuhan Institute of Biomedical Sciences, School of Medicine, Jianghan University, Wuhan, China.
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Galitska G, Jassey A, Wagner MA, Pollack N, Miller K, Jackson WT. Enterovirus D68 capsid formation and stability requires acidic compartments. mBio 2023; 14:e0214123. [PMID: 37819109 PMCID: PMC10653823 DOI: 10.1128/mbio.02141-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/14/2023] [Indexed: 10/13/2023] Open
Abstract
IMPORTANCE The respiratory picornavirus enterovirus D68 is a causative agent of acute flaccid myelitis, a childhood paralysis disease identified in the last decade. Poliovirus, another picornavirus associated with paralytic disease, is a fecal-oral virus that survives acidic environments when passing from host to host. Here, we follow up on our previous work showing a requirement for acidic intracellular compartments for maturation cleavage of poliovirus particles. Enterovirus D68 requires acidic vesicles for an earlier step, assembly, and maintenance of viral particles themselves. These data have strong implications for the use of acidification blocking treatments to combat enterovirus diseases.
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Affiliation(s)
- Ganna Galitska
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Alagie Jassey
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Michael A. Wagner
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Noah Pollack
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Katelyn Miller
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - William T. Jackson
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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10
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Bubba L, Benschop KSM, Blomqvist S, Duizer E, Martin J, Shaw AG, Bailly JL, Rasmussen LD, Baicus A, Fischer TK, Harvala H. Wastewater Surveillance in Europe for Non-Polio Enteroviruses and Beyond. Microorganisms 2023; 11:2496. [PMID: 37894154 PMCID: PMC10608818 DOI: 10.3390/microorganisms11102496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Wastewater surveillance (WWS) was developed in the early 1960s for the detection of poliovirus (PV) circulation in the population. It has been used to monitor several pathogens, including non-polio enteroviruses (NPEVs), which are increasingly recognised as causes of morbidity in children. However, when applying WWS to a new pathogen, it is important to consider the purpose of such a study as well as the suitability of the chosen methodology. With this purpose, the European Non-Polio Enterovirus Network (ENPEN) organised an expert webinar to discuss its history, methods, and applications; its evolution from a culture-based method to molecular detection; and future implementation of next generation sequencing (NGS). The first simulation experiments with PV calculated that a 400 mL sewage sample is sufficient for the detection of viral particles if 1:10,000 people excrete poliovirus in a population of 700,000 people. If the method is applied correctly, several NPEV types are detected. Despite culture-based methods remaining the gold standard for WWS, direct methods followed by molecular-based and sequence-based assays have been developed, not only for enterovirus but for several pathogens. Along with case-based sentinel and/or syndromic surveillance, WWS for NPEV and other pathogens represents an inexpensive, flexible, anonymised, reliable, population-based tool for monitoring outbreaks and the (re)emergence of these virus types/strains within the general population.
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Affiliation(s)
- Laura Bubba
- European Non-Polio Enterovirus Network (E.N.P.E.N.), 1207 Geneva, Switzerland
| | - Kimberley S. M. Benschop
- National Institute for Public Health and the Environment (RIVM), 3721 MA Bilthoven, The Netherlands; (K.S.M.B.); (E.D.)
| | - Soile Blomqvist
- Finnish Institute for Health and Welfare, P.O. Box 95, 70701 Kuopio, Finland;
| | - Erwin Duizer
- National Institute for Public Health and the Environment (RIVM), 3721 MA Bilthoven, The Netherlands; (K.S.M.B.); (E.D.)
| | - Javier Martin
- Division of Vaccines, Medicines and Healthcare Products Regulatory Agency, Potters Bar EN6 3QG, UK;
| | - Alexander G. Shaw
- MRC Centre for Global Infectious Disease Analysis, London SW7 2AZ, UK;
- Abdul Latif Jameel Institute for Disease and Emergency Analytics, School of Public Health, Imperial College London, London SW7 2BX, UK
| | - Jean-Luc Bailly
- Laboratoire Micro-Organismes Genome Environnement (LMGE), Université Clermont Auvergne CNRS, 63001 Clermont-Ferrand, France;
| | - Lasse D. Rasmussen
- Virus Surveillance and Research Section Department of Virus and Microbiological Special Diagnostics Statens Serum Institut, DK-2300 Copenhagen, Denmark;
| | - Anda Baicus
- Enteric Viral Infections Laboratory, Cantacuzino National Institute for Medical-Military Research and Development, 020123 Bucharest, Romania;
| | - Thea K. Fischer
- Department of Clinical Research, University Hospital of Nordsjaelland, 3400 Hilleroed, Denmark
- Department of Public Health, University of Copenhagen, 1172 Copenhagen, Denmark
| | - Heli Harvala
- Microbiology Services National Health Service (NHS) Blood and Transplant, London NW9 5BG, UK;
- Division of Infection and Immunity, University College London, London WC1E 6BT, UK
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11
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Singh B, Arora S, Sandhu N. Emerging trends and insights in acute flaccid myelitis: a comprehensive review of neurologic manifestations. Infect Dis (Lond) 2023; 55:653-663. [PMID: 37368373 DOI: 10.1080/23744235.2023.2228407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 06/08/2023] [Accepted: 06/18/2023] [Indexed: 06/28/2023] Open
Abstract
Acute Flaccid Myelitis (AFM) is a neurological condition in the anterior portion of the spinal cord and can be characterised as paraplegia (paralysis of the lower limbs), and cranial nerve dysfunction. These lesions are caused by the infection due to Enterovirus 68 (EV-D68); a member of the Enterovirus (EV) family belongs to the Enterovirus species within the Picornavirus family and a Polio-like virus. In many cases, the facial, axial, bulbar, respiratory, and extraocular muscles were affected, hence reducing the overall quality of the patient's life. Moreover, severe pathological conditions demand hospitalisation and can cause mortality in a few cases. The data from previous case studies and literature suggest that the prevalence is high in paediatric patients, but careful clinical assessment and management can decrease the risk of mortality and paraplegia. Moreover, the clinical and laboratory diagnosis can be performed by Magnetic resonance imaging (MRI) of the spinal cord followed by Reverse transcription polymerase chain reaction (rRT-PCR) and VP1 seminested PCR assay of the cerebrospinal fluid (CSF), stool, and serum samples can reveal the disease condition to an extent. The primary measure to control the outbreak is social distancing as advised by public health administrations, but more effective ways are yet to discover. Nonetheless, vaccines in the form of the whole virus, live attenuated, sub-viral particles, and DNA vaccines can be an excellent choice to treat these conditions. The review discusses a variety of topics, such as epidemiology, pathophysiology, diagnosis/clinical features, hospitalisation/mortality, management/treatment, and potential future developments.
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Affiliation(s)
- Baljinder Singh
- Centre for Pharmaceutical Innovation, University of South Australia, North Terrace, Adelaide, SA, Australia
| | - Sanchit Arora
- Department of Pharmaceutics, Delhi Institute of Pharmaceutical Sciences and Research (DIPSAR), Delhi Pharmaceutical Sciences and Research University (DPSRU), New Delhi, India
| | - Navjot Sandhu
- Department of Quality Assurance, ISF College of Pharmacy, Moga, Affiliated to IK Gujral Punjab Technical University, Jalandhar, India
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12
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Galitska G, Jassey A, Wagner MA, Pollack N, Jackson WT. Enterovirus D68 capsid formation and stability requires acidic compartments. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.06.12.544695. [PMID: 37398138 PMCID: PMC10312662 DOI: 10.1101/2023.06.12.544695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Enterovirus D68 (EV-D68), a picornavirus traditionally associated with respiratory infections, has recently been linked to a polio-like paralytic condition known as acute flaccid myelitis (AFM). EV-D68 is understudied, and much of the field's understanding of this virus is based on studies of poliovirus. For poliovirus, we previously showed that low pH promotes virus capsid maturation, but here we show that, for EV-D68, inhibition of compartment acidification during a specific window of infection causes a defect in capsid formation and maintenance. These phenotypes are accompanied by radical changes in the infected cell, with viral replication organelles clustering in a tight juxtanuclear grouping. Organelle acidification is critical during a narrow window from 3-4hpi, which we have termed the "transition point," separating translation and peak RNA replication from capsid formation, maturation and egress. Our findings highlight that acidification is crucial only when vesicles convert from RNA factories to virion crucibles.
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Affiliation(s)
- Ganna Galitska
- Department of Microbiology and Immunology, University of Maryland School of Medicine, 685 W. Baltimore St, Baltimore, MD 21201, USA
| | - Alagie Jassey
- Department of Microbiology and Immunology, University of Maryland School of Medicine, 685 W. Baltimore St, Baltimore, MD 21201, USA
| | - Michael A Wagner
- Department of Microbiology and Immunology, University of Maryland School of Medicine, 685 W. Baltimore St, Baltimore, MD 21201, USA
| | - Noah Pollack
- Department of Microbiology and Immunology, University of Maryland School of Medicine, 685 W. Baltimore St, Baltimore, MD 21201, USA
| | - William T Jackson
- Department of Microbiology and Immunology, University of Maryland School of Medicine, 685 W. Baltimore St, Baltimore, MD 21201, USA
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13
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Fall A, Han L, Abdullah O, Norton JM, Eldesouki RE, Forman M, Morris CP, Klein E, Mostafa HH. An increase in enterovirus D68 circulation and viral evolution during a period of increased influenza like illness, The Johns Hopkins Health System, USA, 2022. J Clin Virol 2023; 160:105379. [PMID: 36652754 DOI: 10.1016/j.jcv.2023.105379] [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: 10/17/2022] [Revised: 11/30/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND An increase in influenza like illness in children and adolescents at the Johns Hopkins Health system during summer 2022 was associated with increased positivity for enterovirus/ rhinovirus. We sought to characterize the epidemiology and viral evolution of enterovirus D68 (EV-D68). METHODS A cohort of remnant respiratory samples tested at the Johns Hopkins Microbiology Laboratory was screened for EV-D68. EV-D68 positives were characterized by whole genome sequencing and viral loads were assessed by droplet digital PCR (ddPCR). Genomic changes and viral loads were analyzed along with patients' clinical presentations. RESULTS Of 566 screened samples, 126 were EV-D68 (22.3%). The median age of EV-D68 infected patients was four years, a total of 52 required supplemental oxygen (41.3%), and 35 (27.8%) were admitted. Lung disease was the most frequent comorbidity that was associated with hospitalization. A total of 75 complete and 32 partial genomes were characterized that made a new cluster within the B3 subclade that was closest to US genomes from 2018. Amino acid changes within the BC and DE loops were identified from 31 genomes (29%) which correlated with an increase in average viral load in respiratory specimens and the need for supplemental oxygen. CONCLUSIONS EV-D68 outbreaks continue to cause influenza like illness that could be overwhelming for the health system due to a significant demand for high flow oxygen. Viral evolution and an increase in the susceptible population are likely driving the trends of the increased EV-D68 infections.
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Affiliation(s)
- Amary Fall
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, United States
| | - Lijie Han
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, United States
| | - Omar Abdullah
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, United States
| | - Julie M Norton
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, United States
| | - Raghda E Eldesouki
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, United States
| | - Michael Forman
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, United States
| | - C Paul Morris
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, United States; National Institute of Allergy and Infectious Disease, National Institutes of Health, Bethesda, MD, United States
| | - Eili Klein
- Department of Emergency Medicine, Johns Hopkins School of Medicine, United States; Center for Disease Dynamics, Economics, and Policy, Washington DC, United States
| | - Heba H Mostafa
- Johns Hopkins School of Medicine, Department of Pathology, Division of Medical Microbiology, United States.
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14
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Cassidy H, Lizarazo-Forero E, Schuele L, Van Leer-Buter C, Niesters HGM. Off-season circulation and characterization of enterovirus D68 with respiratory and neurological presentation using whole-genome sequencing. Front Microbiol 2023; 13:1088770. [PMID: 36845975 PMCID: PMC9947850 DOI: 10.3389/fmicb.2022.1088770] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/19/2022] [Indexed: 02/11/2023] Open
Abstract
To explore an off-season enterovirus D68 (EV-D68) upsurge in the winter season of 2019/2020, we adapted a whole-genome sequencing approach for Nanopore Sequencing for 20 hospitalized patients with accompanying respiratory or neurological presentation. Applying phylodynamic and evolutionary analysis on Nextstrain and Datamonkey respectively, we report a highly diverse virus with an evolutionary rate of 3.05 × 10-3 substitutions per year (entire EV-D68 genome) and a positive episodic/diversifying selection with persistent yet undetected circulation likely driving evolution. While the predominant B3 subclade was identified in 19 patients, one A2 subclade was identified in an infant presenting with meningitis. Exploring single nucleotide variations using CLC Genomics Server showed high levels of non-synonymous mutations, particularly in the surface proteins, possibly highlighting growing problems with routine Sanger sequencing for typing enteroviruses. Surveillance and molecular approaches to enhance current knowledge of infectious pathogens capable of pandemic potential are paramount to early warning in health care facilities.
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Affiliation(s)
- Hayley Cassidy
- The University of Groningen, University Medical Centre Groningen, Department of Medical Microbiology and Infection Prevention, Division of Clinical Virology, Groningen, Netherlands
| | - Erley Lizarazo-Forero
- The University of Groningen, University Medical Centre Groningen, Department of Medical Microbiology and Infection Prevention, Division of Clinical Virology, Groningen, Netherlands
| | - Leonard Schuele
- The University of Groningen, University Medical Centre Groningen, Department of Medical Microbiology and Infection Prevention, Division of Clinical Virology, Groningen, Netherlands
| | - Coretta Van Leer-Buter
- The University of Groningen, University Medical Centre Groningen, Department of Medical Microbiology and Infection Prevention, Division of Clinical Virology, Groningen, Netherlands
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15
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Monitoring of Enterovirus D68 Outbreak in Israel by a Parallel Clinical and Wastewater Based Surveillance. Viruses 2022; 14:v14051010. [PMID: 35632752 PMCID: PMC9144596 DOI: 10.3390/v14051010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 04/30/2022] [Accepted: 05/03/2022] [Indexed: 11/16/2022] Open
Abstract
Enterovirus D68 (EVD68) was recently identified as an important cause of respiratory illness and acute flaccid myelitis (AFM), mostly in children. Here, we examined 472 pediatric patients diagnosed with severe respiratory illness and screened for EVD68 between April and October 2021. In parallel, samples collected from a wastewater treatment plant (WWTP) covering the residential area of the hospitalized patients were also tested for EVD68. Of the 472 clinical samples evaluated, 33 (7%) patients were positive for EVD68 RNA. All wastewater samples were positive for EVD68, with varying viral genome copy loads. Calculated EVD68 genome copies increased from the end of May until July 2021 and dramatically decreased at the beginning of August. A similar trend was observed in both clinical and wastewater samples during the period tested. Sequence analysis of EVD68-positive samples indicated that all samples originated from the same branch of subclade B3. This study is the first to use wastewater-based epidemiology (WBE) to monitor EVD68 dynamics by quantitative detection and shows a clear correlation with clinically diagnosed cases. These findings highlight the potential of WBE as an important tool for continuous surveillance of EVD68 and other enteroviruses.
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