[Genetic evolution of poliovirus: success and difficulties in the eradication of paralytic poliomyelitis]

Poliovirus, the aetiological agent of poliomyelitis, is an enterovirus of the Picronaviridae family. Despite the success of the World Health Organisation (WHO) worldwide vaccination campaign against poliomyelitis, poliovirus remains a public health problem in several developing countries, in Africa and Asia in particular. This is partly due to the considerable capacity of poliovirus strains to circulate and spread in populations with insufficient vaccine coverage. In addition, the attenuated strains of the oral polio vaccine (OPV) may rapidly evolve a neurovirulent phenotype, causing rare cases of paralytic poliomyelitis. The recent occurrence of epidemics associated with vaccine-derived poliovirus (VDPV) has highlighted the emergence of recombinant strains with genomes constituted of sequences from OPV strains together with sequences from non-polio enteroviruses. In this review, after briefly describing the molecular biology of poliovirus and the pathogenesis of poliomyelitis, we will provide an overview of the current situation concerning poliomyelitis prophylaxis and the strategies developed to fight this disease. We will also deal with the issue of the possible re-emergence of poliovirus after declaration of the eradication of wildtype poliovirus.

Genetic features of polioviruses isolated in Tunisia, 1991-2006

BACKGROUND

Genetic characterisation of polioviruses remains highly important even in countries where wild poliovirus circulation has been interrupted. Sequence data on representative wild strains from all geographical regions is required for surveillance purposes and surveillance for vaccine-related isolates with increased potential for transmissibility in humans should continue.

OBJECTIVE

To report the genetic characteristics of wild and vaccine-related polioviruses isolated in Tunisia from 1991 to 2006.

STUDY DESIGN

Wild isolates were sequenced in the VP1 genomic region and compared to each other. Vaccine-related isolates were assessed for genetic recombination by PCR/RFLP and sequence analysis of the 3D region. Recombinant viruses were assessed for genetic drift in the VP1 region.

RESULTS

The VP1 sequences of the last wild isolates, all from serotype3, showed 97.7-98.7% nucleotide homology. Nineteen percent of vaccine-related isolates were vaccine/vaccine intertypic recombinants. No recombinant with non-poliovirus enteroviruses was identified. Mutational differences in the VP1 sequences of recombinant viruses ranged from 0.0% to 0.7% indicating a limited replication period.

CONCLUSIONS

This study provides sequence data on wild polioviruses from Tunisia/North Africa and shows that in countries with continuous high vaccine coverage transmission of vaccine-related polioviruses is time-limited.

Circulation of a type 1 recombinant vaccine-derived poliovirus strain in a limited area in Romania

After intensive immunisation campaigns with the oral polio vaccine (OPV) as part of the Global Polio Eradication Initiative, poliomyelitis due to wild viruses has disappeared from most parts of the world, including Europe. Here, we report the characterization of a serotype 1 vaccine-derived poliovirus (VDPV) isolated from one acute flaccid paralysis (AFP) case with tetraplegia and eight healthy contacts belonging to the same small socio-cultural group having a low vaccine coverage living in a small town in Romania. The genomes of the isolated strains appeared to be tripartite type 1/type 2/type 1 vaccine intertypic recombinant genomes derived from a common ancestor strain. The presence of 1.2% nucleotide substitutions in the VP1 capsid protein coding region of most of the strains indicated a circulation time of about 14 months. These VDPVs were thermoresistant and, in transgenic mice expressing the human poliovirus receptor, appeared to have lost the attenuated phenotype. These results suggest that small populations with low vaccine coverage living in globally well-vaccinated countries can be the origin of VDPV emergence and circulation. These results reaffirm the importance of active surveillance for acute flaccid paralysis and poliovirus in both polio-free and polio-endemic countries.

[Intense campaign for vaccination with the oral polio vaccine: what are the repercussions on the enterovirus world?]

To eradicate poliomyelitis and poliovirus, intensive vaccination campaigns with oral polio-vaccine (OPV) have been organised. Eradication campaigns may well be successful because the antiviral immunity and the local intestinal immunity due to OPV in particular avoids and/or limits poliovirus circulation. These campaigns give interesting opportunities for studying the impact of viral vaccines on the viral world in terms of ecological and genetic virology. The pre-eradication phase we are now entering brings with it two kinds of problems. First, the major disadvantage of OPV is the genetic and phenotypic variability of the vaccine strains. This variability leads to the spread of potentially pathogenic strains, which can be implicated in vaccine-associated paralytic poliomyelitis (VAPP). Genetic changes are characterised by point mutations and by genetic exchanges among OPV strains, between OPV and wild strains and perhaps between poliovirus and non-polio enteroviruses (ENPV). The fact that a few OPV mutant strains have been shown to multiply and/or to circulate for long periods suggests that OPV could sustain a reservoir of pathogenic poliovirus strains. Second, there are ecological considerations. The disappearance of wild poliovirus through OPV vaccination could be due not only to antiviral local immunity but also to competition between OPV strains and wild strains for infecting the digest tract. Moreover, a competition between OPV and other enteroviruses may take place in a common ecological niche. To our knowledge, the possible impact of intensive OPV vaccination campaigns on the ENPV populations has never been considered. Because the goal of poliovirus eradication may be reached in the near future, there is worry as to the possible evolution of ENPV towards highly epidemic and pathogenic strains. This is leading those laboratories involved in poliomyelitis surveillance not only to search for remaining wild poliovirus strains but also to study the possible long-term circulation of OPV strains and to develop efficient ENPV surveillance.

Evolution of the Sabin type 1 poliovirus in humans: characterization of strains isolated from patients with vaccine-associated paralytic poliomyelitis

Attenuated strains of the Sabin oral poliovirus vaccine replicate in the human gut and in rare cases cause vaccine-associated paralytic poliomyelitis (VAPP). Reversion of vaccine strains toward a pathogenic phenotype is probably one of the main causes of VAPP, a disease most frequently associated with type 3 and type 2 strains and more rarely with the type 1 (Sabin 1) strain. To identify the determinants and mechanisms of safety versus pathogenicity of the Sabin 1 strain, we characterized the genetic and phenotypic changes in six Sabin 1-derived viruses isolated from immunocompetent patients with VAPP. The genomes of these strains carried either few or numerous mutations from the original Sabin 1 genome. As assessed in transgenic mice carrying the human poliovirus receptor (PVR-Tg mice), all but one strain had lost the attenuated phenotype. Four strains presented only a moderate neurovirulent phenotype, probably due at least in part to reversions to the wild-type genotype, which were detected in the 5' noncoding region of the genome. The reversions found in most strains at nucleotide position 480, are known to be associated with an increase in neurovirulence. The construction and characterization of Sabin 1 mutants implicated a reversion at position 189, found in one strain, in the phenotypic change. The presence of 71 mutations in one neurovirulent strain suggests that a vaccine-derived strain can survive for a long time in humans. Surprisingly, none of the strains analyzed were as neurovirulent to PVR-Tg mice as was the wild-type parent of Sabin 1 (Mahoney) or a previously identified neurovirulent Sabin 1 mutant selected at a high temperature in cultured cells. Thus, in the human gut, the Sabin 1 strain does not necessarily evolve toward the genetic characteristics and high neuropathogenicity of its wild-type parent.

Random selection: a model for poliovirus infection of the central nervous system

Mixed infections occur in the natural environment, and also result from the use of mixed live vaccines. Some recipients of the trivalent oral poliovirus vaccine develop vaccine-associated paralytic poliomyelitis (VAPP). Numerous serotypes and recombinant genotypes of vaccine-derived polioviruses may be found in stool samples from such cases. To investigate the relationship between the multiplication of various genotypes at the primary replication site in the gut and the infection outcome in the central nervous system (CNS), the viruses excreted on consecutive days by two patients with VAPP were compared with the viruses isolated from the CNS. The genotypes from stools were numerous and varied with time in both cases, suggesting a multiplication of the viruses in multiple foci in the gut. Where the CNS isolated virus clearly corresponded to one of the many viruses detected in stool, this virus was unexpectedly less neurovirulent than others isolated from stool. To assess the mechanism by which viruses with different degrees of neurovirulence are selected in the CNS, transgenic mice sensitive to poliovirus infection were inoculated extraneurally with mixtures of two phenotypically different viruses at different neuropathogenic doses. The virus(es) inducing neurological disease was then isolated from the CNS. At less than 100% input neuropathogenic dose of both inoculated viruses, individual mice were affected stochastically by the virus variants from the mixture. Extrapolated to humans, this selection pattern might explain the occurrence of CNS infections with less neurotropic viruses derived from an extraneural pool containing also highly neurotropic viruses.

Thermostabilization of live virus vaccines by heavy water (D2O)

Eradication of poliomyelitis is based on the mass administration of oral poliovirus vaccine (OPV). Delivery of effective vaccines in the developing world, especially in tropical areas, is compromised when refrigeration cannot be assured. The OPV, prepared with three live attenuated polioviruses (Sabin strains, serotypes 1, 2 and 3), is considered to be the most thermolabile of vaccines in the World Health Organization's Expanded programme on Immunization. To be effective, the initial concentration (potency of each of the three component serotypes, measured in tissue culture infective doses, should not decrease by more than 0.5 log10 before vaccine delivery. High concentration (1 M) of MgCl2 is currently used as stabilizer for OPV. The stabilizing effect of D2O was tested here on OPV strains. By diluting the viral suspension with D2O-based salt and buffer solutions, in a manner similar to that involved in OPV production an 87% concentration of D2O in the final viral preparation was achieved. In severe conditions of testing (incubation for 3 days at 45 degrees C), the Sabin 3 virus lost an average of 2.7 log10 potency in the presence of 87% D2 as compared to 3.0 log10 in H2O-based 1 M MgCl2, and to 5.7 log10 in the H2O-based control solutions. When tested in a combined 87% D2O and 1 M MgCl2 treatment, the Sabin 3 virus lost only 1.3 log10 potency after 3 days at 45 degrees C. Similar thermostabilizing effects were obtained for Sabin 1 and Sabin 2 strains, but the level of stabilization was slightly lower. Tested in standard conditions at 37 degrees C for 7 days, the infectivity of the three D2O MgCl2-treated OPV strains remained in the limit of requirements ( < or = 0.5 log10). The stabilizing effect of D2O was also demonstrated on yellow fever 17D vaccine virus strain.

High diversity of poliovirus strains isolated from the central nervous system from patients with vaccine-associated paralytic poliomyelitis

To establish the etiology of vaccine-associated paralytic poliomyelitis (VAPP), isolates from the central nervous system (CNS) from eight patients with VAPP were compared with stool isolates from the same patients. The vaccine (Sabin) origin was checked for all of the available isolates. Unique and similar strains were recovered from paired stool and CNS samples for five of the eight VAPP cases and the three wild-type cases included in the study. In the remaining three VAPP cases, the stool samples and, in one case, the CNS samples contained mixtures of strains. In two of these cases an equivalent of the CNS isolate was found among the strains separated by plaque purification from stool mixtures, and in one case different strains were isolated from CNS and stool. This shows that the stool isolate in VAPP might not be always representative of the etiologic agent of the neurological disease. A wide variety of poliovirus vaccine genomic structures appeared to be implicated in the etiology of VAPP. Of nine CNS vaccine-derived strains, four were nonrecombinant and five were recombinant (vaccine/vaccine or even vaccine/nonvaccine). The neuropathogenic potential of the isolates was evaluated in transgenic mice sensitive to poliovirus. All of the CNS-isolated strains lost the attenuated phenotype of the Sabin strains. However, for half of them, the neurovirulence was lower than expected, suggesting that the degree of neurovirulence for transgenic mice is not necessarily correlated with the neuropathogenicity in humans.

Polioviruses with natural recombinant genomes isolated from vaccine-associated paralytic poliomyelitis

To determine how oral poliovirus vaccine (Sabin) strains evolve during replication in humans and to confirm the etiology of vaccine-associated paralytic poliomyelitis (VAPP), we examined 70 vaccine-derived strains isolated from VAPP cases. Two distant sequences of the poliovirus genome were targeted for a double restriction fragment length polymorphism assay (RFLP) of reverse-transcribed genomic segments amplified by PCR, an extension of the method that we described previously (Balanant et al., 1991). One (RFLP-1) was a 480-long nucleotide sequence coding for the N-terminal part of the VP1 capsid polypeptide, situated in the 5' third of the viral genome (nucleotides 2401-2880). The other (RFLP-3D1) was a 291-long nucleotide sequence coding for a part of the viral polymerase, situated near the 3' end of the genome (nucleotides 6086-6376). Strain-specific restriction profiles could be generated for different field isolates by using three restriction enzymes in each case: HaeIII, DdeI, and HpaII for RFLP-1 and HaeIII, DdeI and RsaI for RFLP-3D1. With few exceptions, the vaccine-specific RFLP profiles were found to be conserved in both regions during replication of these viruses in humans. Thus, RFLP could be used as a marker so as to identify the origin of viral isolates at both ends of their genome. Whether viral isolates were vaccine-derived was determined by using strain-specific monoclonal antibodies and RFLP-1. Among the 70 isolates, 21 of the 43 type 2 strains and 15 of the 22 type 3 strains had a recombinant genome. None of the 5 type 1 Sabin-derived isolates was found to be recombinant. Both intertypic vaccine/vaccine and vaccine/non-vaccine recombinants were detected. Partial nucleotide sequencing confirmed the RFLP results in all cases that were investigated. In one case, it was possible to predict the recombination junction site from the restriction profiles. This site was more precisely localized by sequencing. The C6203 > U nucleotide substitution, which is suspected to contribute to the reversion toward neurovirulence of the attenuated Sabin 1 strain, was detected in almost all the recombinant genomes containing Sabin 1-specific sequences at the 3' extremity. This mutation was detected by identification of the modified RsaI profile in the RFLP-3D1. The results presented in this paper suggest that recombination, alone or together with mutation, might be one of the mechanisms of the reversion toward neurovirulence of attenuated vaccine strains and of the natural evolution of poliovirus.

Molecular epidemiology of type 1 polioviruses isolated in Israel and defined by restriction fragment length polymorphism assay

The genomic variability of 27 type 1 polioviruses (PV-1) isolated in Israel during 1980-1991 was examined by restriction fragment length polymorphism (RFLP) analysis of a reverse-transcribed genomic fragment amplified by polymerase chain reaction. By using the restriction enzymes HaeIII, DdeI, and HpaII, strain-specific restriction profiles were generated for the PV-1/Mahoney and PV-1/Sabin strains and 27 wild-type isolates. The profile observed for PV-1 isolated during an outbreak in 1988 was also observed for PV-1 isolated from different places in Israel in 1982 and 1983, 1987, and 1991. This profile, characterized by the lack of the DdeI site, was different from the DdeI profile of PV-1 isolated in 1984 or in 1986 from sporadic cases of poliomyelitis. The diversity of circulating PV-1 in Israel was also confirmed by nucleotide sequence analysis. The epidemiologic information provided by the RFLP and sequence data establishes a clear epidemiologic link between epidemic and sporadic virus strains and demonstrates the power of this molecular approach to epidemiology.

The natural genomic variability of poliovirus analyzed by a restriction fragment length polymorphism assay

The genomic variability of poliovirus was examined by analyzing the restriction fragment length polymorphism of a reverse-transcribed genomic fragment amplified by the polymerase chain reaction. The fragment was a 480-nucleotide sequence of the poliovirus genome coding for the N-terminal half of the capsid protein VP1, including antigenic site 1. The identification of a pair of generic primers flanking this fragment allowed its amplification in practically all the poliovirus strains tested so far (more than 150). By using the restriction enzymes HaeIII, DdeI, and HpaII, strain-specific restriction profiles could be generated for the amplified genomic fragment of each of the six reference poliovirus strains tested: one representative wild poliovirus of each of the three serotypes (P1/Mahoney, P2/Lansing, and P3/Finland/23127/84) and the three Sabin vaccine strains. When 21 poliovirus field isolates previously identified as Sabin vaccine-related were tested, they showed restriction profiles identical to those of the originating homotypic Sabin virus, demonstrating the conservation of these profiles during virus replication in humans. These profiles could thus be used as markers for Sabin-derived genotypes. To compare the distribution of poliovirus genotypes in nature before and after the introduction of poliovirus vaccines, the restriction profiles of the amplified genomic fragment of a total of 72 strains of various geographic and temporal origins were determined. Strains isolated before the introduction of polio vaccines displayed a wide diversity of genotypes. In contrast, wild (Sabin unrelated) strains isolated after vaccine introduction, during a single epidemic in a particular geographic area, showed identical or very similar restriction profiles, indicating the circulation of predominant regional genotypes. Our results indicate that the assay we developed for the analysis of the restriction fragment length polymorphism of the poliovirus genome may be used to identify and characterize poliovirus genotypes circulating in nature.