福建省脊髓灰质炎疫苗转换前后AFP病例病原学监测结果分析

自2016年5月1日起,我国与全球另外154个国家和地区同步实施脊髓灰质炎(以下简称"脊灰")疫苗免疫策略转换,停用三价口服脊灰减毒活疫苗,改用二价口服脊灰减毒活疫苗.为探讨脊灰疫苗转换对福建省急性弛缓性麻痹(Acute flaccid paralysis,AFP)病例监测结果产生的变化,本研究收集2012-2018年福建省AFP病例的流行病学及实验室监测数据,对脊灰疫苗转换前后AFP病例的监测结果进行描述性分析,采集AFP病例及其接触者粪便标本,并使用RD细胞和L20B细胞进行病毒分离;对L20B阳性分离物进行脊灰病毒(Poliovirus,PV)的型内鉴别(Intratypic differentiation,ITD),对PV衣壳蛋白VP1编码区核苷酸序列测定和分析.使用SPSS 21.0软件对数据进行统计检验,比较采用X2检验.结果显示,2012-2018年福建省累计报告AFP病例1 776例,根据AFP病例分类流程确诊的AFP病例1 283例,排除的非AFP病例493例,疫苗转换前后报告发病率平均为2.83/10万和2.71/10万.实验室共检测3123份粪便标本(包括AFP病例、非AFP病例及接触者),其中合格标本采集率为92.42％,7日及时送检率为97.85％,14日内病毒分离完成率接近100％,疫苗转换前后PV平均分离率分别为1.91％(38/1986)、1.58％(18/1137),非脊灰肠道病毒平均分离率分别为10.22％(203/1 986)、5.45％(62/1 137).2016年5月1日之前分离出Ⅰ型PV6株,Ⅱ型PV 13株,Ⅲ型PV 19株;2016年5月1日之后分离出Ⅰ型PV 6株,Ⅲ型PV 12株.本研究结果提示,脊灰疫苗转换前后福建省AFP监测系统运转正常,始终保持较高的敏感性和及时性.2012-2018年福建省分离出的PV均为脊灰疫苗株,毒株血清型别以Ⅲ型为主,VP1编码区核苷酸以低变异为主,未发现疫苗衍生脊灰病毒及脊灰野病毒,疫苗转换后再未检出Ⅱ型PV,提示Ⅱ型脊灰疫苗株病毒可能已被阻断.     

云南省1例疫苗衍生株脊髓灰质炎病毒病例的调查分析

本调查旨在了解2010年云南省昭通市1株脊髓灰质炎Ⅱ型疫苗衍生毒株(Vaccine-derived poliovirus,VDPV)引起的病例的流行病学特征、该病例的排毒情况及其周围健康儿童的肠道病毒(EV)携带情况和病毒型别特征。在该病例的发生地进行现场流行病学调查,连续采集病例粪便标本,采集密切接触者及病例居住地健康儿童粪便标本进行病毒分离和型别鉴定。经省级专家组最终分类诊断为VDPV病例;实验室结果显示病例标本中未再检出VDPV;密切接触者及周围健康儿童标本中均未检测到脊灰疫苗株病毒及VDPV,AFP病例入户主动搜索未发现类似病例,表明该病毒未在当地造成循环;在健康儿童中检测到NPEV 21株,病毒携带率为20.0%;经VP1区核苷酸序列测定,21株NPEV分别属于HEV-A组(11株,3个血清型,占52.4%)和HEV-B组(10株,4个血清型,47.6%)。     

贵州省贞丰县疫苗衍生脊髓灰质炎病毒循环的病毒学分析

为及时发现和阻断疫苗衍生脊髓灰质炎（脊灰）病毒（vaccine-derived polioviruses, VDPVs）循环、脊灰野病毒的输入和能够引起临床脊灰的其它脊灰疫苗相关病毒,做好贵州省无脊灰状态下脊灰病毒学监测工作,采用病毒分离、鉴定与核苷酸序列测定和分析方法,对贵州省贞丰县及周围10个县2003～2004年报告的急性弛缓性麻痹（AFP）病例及2004年接触者粪便标本的病毒学监测的结果进行了分析. 对收集到的105例AFP病例和47例密切接触者的278份便标本进行了病毒学监测,结果从66例中共分离到肠道病毒（EV）66株,阳性率为43.4%,其中脊灰病毒（PV）29例,分离率为19.1%,非脊灰肠道病毒（NPEV）37例,分离率为24.3%.29例PV经中国疾病预防控制中心病毒病预防控制所国家脊灰实验室鉴定,24例为疫苗相似株,5例为脊灰Ⅰ型VDPVs,这5例均为2004年从贞丰县所分离到.贞丰县及周围县EV阳性检出率（43.4%）高于2003～2004年全省水平（22.9%～24.6%）,2004年PV分离率比2003年高达2.6倍,29株PV中单个Ⅰ型占34.5%,明显高于往年（2000～2002年全省平均4.1%）.本研究提示,Ⅰ型VDPVs在贞丰县引起了循环（cVDPVs）,通过口服脊灰疫苗强化免疫已经阻断cVDPVs的传播.人群中PV和NPEV带毒率明显增高,非VDPVs引起的临床符合脊灰病例不容忽视;应加强脊灰病毒学监测数据的分析和早期疫情预警工作.     

深圳市2005—2012年脊髓灰质炎疫苗相关病例流行病学分析

目的了解深圳市脊髓灰质炎疫苗相关病例(VAPP)发生情况及流行病学特征,为消灭脊髓灰质炎后期脊灰疫苗免疫策略的研究提供基础数据。方法采用流行病学方法对深圳市2005—2012年残留麻痹急性弛缓性麻痹AFP病例个案资料、病原学检测结果、VAPP病例进行分析。结果 2005—2012年共报告残留麻痹病例55例,其中VAPP病例8例,占15.54%;深圳市VAPP病例均为小年龄组小于6月龄的儿童,总发生率0.20/10万,无接触者VAPP病例,其中首次服苗的VAPP发生率为0.51/10万;无明显的地区和时间分布聚集性。结论 VAPP的发生是接种脊髓灰质炎减毒活疫苗难以克服的弱点,为减少VAPP病例及防止脊灰疫苗衍生病毒的发生,应在消灭脊髓灰质炎后期科学、合理地调整消灭脊髓灰质炎的免疫策略。     

中国首例iVDPVs病例粪便标本中病毒血清型分布和Ⅲ型iVDPVs VP1区基因特征

分析中国首例免疫缺陷疫苗衍生脊髓灰质炎病毒(immunodeficient vaccine-derived polioviruses,iVDPVs)急性弛缓性麻痹(acute flaccid paralysis,AFP)病例(实验室编号为9230)12份便标本中病毒血清型分布和分离物中Ⅲ型VP1区的基因特征。31个省的疾病预防控制中心脊髓灰质炎(脊灰)实验室网络,在2005年采用细胞培养、病毒分离和微量中和试验从5231例AFP病例中的293例的便标本中分离到脊灰病毒,其中从1例编号为9230的AFP病例发病2~150天的12份便标本中分离到17株脊灰病毒株,包括Ⅱ型12株,Ⅲ型5株。用PCR-RFLP和ELISA两种方法对送检的293例AFP病例中分离的病毒进行型内鉴定,VP1区序列测定和分析发现:从9230号病例粪便标本中分离的12株Ⅱ型为混合不同变异数目的Ⅱ型iVDPVs,5株Ⅲ型病毒为单一Ⅲ型iVDPVs;除9230号病例外未发现其它iVDPVs或疫苗衍生脊灰病毒(vaccine-derived polioviruses,VDPVs)。5株Ⅲ型iVDPVs的VP1区基因和SabinⅢ相比有22~24个碱基突变,同源性为97.33%~97.56%,是中国至今发现变异最大的Ⅲ型VDPVs。9230号病例临床诊断为X-连锁低/无丙种球蛋白血症,是在中国首次发现的iVDPVs病例,该病例的病毒分离物中同时存在Ⅱ型和Ⅲ型iVDPVs,Ⅲ型iVDPVs在患者体内至少复制2.5年以上,iVDPVs病例的持续排毒已经给中国维持无脊灰状态提出了新的挑战。     

巴彦淖尔市2008—2015年急性弛缓性麻痹病例的监测结果分析

目的分析内蒙古巴彦淖尔市2008—2015年急性弛缓性麻痹(acute flaccid paralysis,AFP)病例的流行病学特征,评价AFP信息监测管理报告系统,为制定本地区预防AFP提供科学依据。方法采用描述性流行病学方法,对巴彦淖尔市2008—2015年15岁以下儿童AFP病例监测数据进行流行病学特征分析,并对AFP监测系统进行评价。结果巴彦淖尔市2008—2015年共报告15岁以下儿童AFP病例65例,年平均报告发病率3.20/10万,无脊髓灰质炎野毒株检出和脊髓灰质炎病例报告;发病时间以夏秋6—9月为多;临河区位居报告病例数首位,占总报告病例数的52.3%;男性多于女性,男女性别比为1.24∶1;1~<5岁儿童占总报告病例数的53.8%;完成全程免疫的儿童占61.0%,未完成免疫史和免疫史不详者占39.0%。各项监测指标均达到国家监测方案要求。结论巴彦淖尔市AFP监测系统灵敏性较高,AFP病例的监测应关注重点地区和重点人群免疫接种情况,继续保持无脊灰状态。     

2010年山东省环境污水中脊髓灰质炎病毒的监测及其基因特征分析

本研究在山东省开展了脊髓灰质炎病毒(Poliovirus,PV)的外环境监测,从济南、临沂两地采集污水标本,浓缩处理后进行病毒分离,对分离到的PV采用中和试验进行血清定型,并对其VP1及3D区进行序列测定,分析其基因突变和重组情况。2010年,共采集污水标本32份,PV阳性10份,阳性率31.3%;分离到18株PV(PV1型3株,PV2型9株,PV3型6株),均为疫苗相关株,VP1完整编码区核苷酸变异数在0~4个之间,在3株PV2型病毒和4株PV3型病毒的基因组中发现重组;对VP1区影响神经毒力的减毒位点分析发现,PV1型病毒中有1株在nt 2 749发生突变(A→G),PV2型病毒中有1株在nt2 908发生A→G突变,3株在nt2 909发生U→C突变,6株PV3型病毒全部在nt2 493发生C→U突变。环境污水中可以分离到PV,其基因重组率和主要减毒位点的回复突变率较高,未发现脊灰野毒株和疫苗衍生株脊灰病毒(Vaccine-derived poliovirus,VDPV)。     

中国急性弛缓性麻痹(AFP)病例中脊髓灰质炎病毒疫苗株VP1区基因变异的研究

为研究中国急性弛缓性麻痹(AFP)病例中脊髓灰质炎(简称脊灰)病毒分离株的分子特征,为中国继续维持"无脊灰野毒状态"提供理论依据,对2002年所有省级疾病预防控制中心送检的脊灰分离株,用PCR-RFLP法及ELISA法进行型内鉴定.用PCR-RFLP法筛查出与疫苗株相比有异常酶切图谱的毒株共24株,其中Ⅰ型毒株1株,Ⅱ型毒株21株,Ⅲ型毒株2株;用ELISA法筛查出与疫苗株相比有不同的抗原抗体反应的毒株共22株,其中Ⅰ型毒株7株,Ⅱ型毒株4株,Ⅲ型毒株11株,在7株Ⅰ型毒株中有3株为非疫苗类似株(NSL),其余为双反应毒株(DRV).随后对这46株毒株进行了全VP1区的基因序列分析.结果表明:2002年脊灰分离株都是疫苗株或疫苗衍生株,没有发现野毒株,中国继续保持着"无脊灰野毒状态";口服减毒活疫苗(OPV)株与其它野毒株在稳定性性质方面是类似的,即通常是不稳定的,在人体肠道内有很强的选择性;在人体肠道内,病毒复制产生的基因变异导致毒力升高,是引起疫苗相关麻痹病例(VAPP)的重要原因,但宿主本身的因素也有很大的作用;在局部地区有疫苗株的循环或脊灰疫苗衍生株(VDPV)的存在;最终消除疫苗株引起的AFP病例可能还需要脊灰灭活疫苗(IPV)的介入.     

云南省疫苗衍生脊髓灰质炎病毒全基因组序列遗传特征分析

为了解云南省疫苗衍生脊髓灰质炎病毒(Vaccine-derived Poliovirus,VDPV)的基因组特征,对2010年及2012年监测到的4株VDPV进行全基因组序列测定。结果显示,2株Ⅱ型VDPV的基因组全长均为7439nt,与Sabin Ⅱ疫苗株全基因组核苷酸和氨基酸的序列同源性分别为95.4%和97.7%;2株I型VDPV基因组全长均为7441nt,与Sabin I疫苗株全基因组核苷酸和氨基酸序列的同源性分别为93.9%和97.9%。减毒位点分析发现II型和I型VDPV毒株分别有两个(nt 481和nt 2909)和三个减毒位点(nt 480、nt 2795和nt 6203)发生了回复突变。VP1序列分析显示II型和I型VDPV毒株与相应Sabin株的变异分别为1%和2.3%,重组分析显示II型和I型VDPV的基因组结构分别为S2/S3和S1/S2/S1/S3,后者的重组次数高达3次,显示了重组的普遍性和复杂性,也表明了病毒在人体内复制和传播的持久性与重组的多样性成正相关。因此,从分子水平分析VDPV的特性,可掌握病毒的变异动态,为制定科学可行的VDPV控制策略提供理论依据。     

An Outbreak of Type Π Vaccine-Derived Poliovirus in Sichuan Province,China: Emergence and Circulation in an Under-Immunized Population

Background

During August 2011–February 2012, an outbreak of type Π circulating vaccine-derived poliovirus (cVDPVs) occurred in Sichuan Province, China.

Methods

A field investigation of the outbreak was conducted to characterize outbreak isolates and to guide emergency response. Sequence analysis of poliovirus capsid protein VP1 was performed to determine the viral propagation, and a coverage survey was carried out for risk assessment.

Results

One clinical compatible polio case and three VDPV cases were determined in Ngawa County, Ngawa Tibetan and Qiang Autonomous Prefecture, Sichuan Province. Case patients were unimmunized children, 0.8–1 years old. Genetic sequencing showed that the isolates diverged from the VP1 region of the type Π Sabin strain by 5–12 nucleotides (nt) and shared the same 5 nt VP1 substitutions, which indicate single lineage of cVDPVs. Of the 7 acute flaccid paralysis cases (all>6 months) reported in Ngawa Prefecture in 2011, 4 (57.1%) cases (including 2 polio cases) did not receive oral attenuated poliovirus vaccine. Supplementary immunization activities (SIAs) were conducted in February–May, 2012, and the strain has not been isolated since.

Conclusion

High coverage of routine immunization should be maintained among children until WPV transmission is globally eradicated. Risk assessments should be conducted regularly to pinpoint high risk areas or subpopulations, with SIAs developed if necessary.     

Isolation and Characterization of a Type 2 Vaccine-Derived Poliovirus from Environmental Surveillance in China, 2012

Environmental surveillance of poliovirus on sewage has been conducted in Shandong Province, China since 2008. A type 2 vaccine-derived poliovirus (VDPV) with 7 mutations in VP1 coding region was isolated from the sewage collected in the city of Jinan in December 2012. The complete genome sequencing analysis of this isolate revealed 25 nucleotide substitutions, 7 of which resulted in amino acid alteration. No evidence of recombination with other poliovirus serotypes was observed. The virus did not lose temperature sensitive phenotype at 40°C. An estimation based on the evolution rate of the P1 coding region suggested that evolution time of this strain might be 160–176 days. VP1 sequence analysis revealed that this VDPV strain is of no close relationship with other local type 2 polioviruses (n = 66) from sewage collected between May 2012 and June 2013, suggesting the lack of its circulation in the local population. The person who excreted the virus was not known and no closely related virus was isolated in local population via acute flaccid paralysis surveillance. By far this is the first report of VDPV isolated from sewage in China, and these results underscore the value of environmental surveillance in the polio surveillance system even in countries with high rates of OPV coverage.     

Sporadic Isolation of Sabin-Like Polioviruses and High-Level Detection of Non-Polio Enteroviruses during Sewage Surveillance in Seven Italian Cities,after Several Years of Inactivated Poliovirus Vaccination

Sewage surveillance in seven Italian cities between 2005 and 2008, after the introduction of inactivated poliovirus vaccination (IPV) in 2002, showed rare polioviruses, none that were wild-type or circulating vaccine-derived poliovirus (cVDPV), and many other enteroviruses among 1,392 samples analyzed. Two of five polioviruses (PV) detected were Sabin-like PV2 and three PV3, based on enzyme-linked immunosorbent assay (ELISA) and PCR results. Neurovirulence-related mutations were found in the 5′ noncoding region (5′NCR) of all strains and, for a PV2, also in VP1 region 143 (Ile > Thr). Intertypic recombination in the 3D region was detected in a second PV2 (Sabin 2/Sabin 1) and a PV3 (Sabin 3/Sabin 2). The low mutation rate in VP1 for all PVs suggests limited interhuman virus passages, consistent with efficient polio immunization in Italy. Nonetheless, these findings highlight the risk of wild or Sabin poliovirus reintroduction from abroad. Non-polio enteroviruses (NPEVs) were detected, 448 of which were coxsackievirus B (CVB) and 294 of which were echoviruses (Echo). Fifty-six NPEVs failing serological typing were characterized by sequencing the VP1 region (nucleotides [nt] 2628 to 2976). A total of 448 CVB and 294 Echo strains were identified; among those strains, CVB2, CVB5, and Echo 11 predominated. Environmental CVB5 and CVB2 strains from this study showed high sequence identity with GenBank global strains. The high similarity between environmental NPEVs and clinical strains from the same areas of Italy and the same periods indicates that environmental strains reflect the viruses circulating in the population and highlights the potential risk of inefficient wastewater treatments. This study confirmed that sewage surveillance can be more sensitive than acute flaccid paralysis (AFP) surveillance in monitoring silent poliovirus circulation in the population as well as the suitability of molecular approaches to enterovirus typing.     

Retrospective characterization of a vaccine-derived poliovirus type 1 isolate from sewage in Greece

Retrospective molecular and phenotypic characterization of a vaccine-derived poliovirus (VDPV) type 1 isolate (7/b/97) isolated from sewage in Athens, Greece, in 1997 is reported. VP1 sequencing of this isolate revealed 1.87% divergence from the VP1 region of reference strain Sabin 1, while further genomic characterization of isolate 7/b/97 revealed a recombination event in the nonstructural part of the genome between a vaccine strain and a nonvaccine strain probably belonging to Enterovirus species C. Amino acid substitutions commonly found in previous studies were identified in the capsid coding region of the isolate, while most of the attenuation and temperature sensitivity determinants were reverted. The ultimate source of isolate 7/b/97 is unknown. The recovery of such a highly divergent derivative of a vaccine strain emphasizes the need for urgent implementation of environmental surveillance as a supportive procedure in the polio surveillance system even in countries with high rates of OPV coverage in order to prevent cases or even outbreaks of poliomyelitis that otherwise would be inevitable.     

Environmental surveillance system to track wild poliovirus transmission

Eradication of poliomyelitis from large metropolis cities in India has been difficult due to high population density and the presence of large urban slums. Three paralytic poliomyelitis cases were reported in Mumbai, India, in 1999 and 2000 in spite of high immunization coverage and good-quality supplementary immunization activities. We therefore established a systematic environmental surveillance study by weekly screening of sewage samples from three high-risk slum areas to detect the silent transmission of wild poliovirus. In 2001, from among the 137 sewage samples tested, wild poliovirus type 1 was isolated from 35 and wild poliovirus type 3 was isolated from 1. Acute flaccid paralysis (AFP) surveillance indicated one case of paralytic poliomyelitis from the city. Phylogenetic analysis with complete VP1 sequences revealed that the isolates from environmental samples belonged to four lineages of wild polioviruses recently isolated from poliomyelitis cases in Uttar Pradesh and not to those previously isolated from AFP cases in Mumbai. Wild poliovirus thus introduced caused one case of paralytic poliomyelitis. The virus was detected in environmental samples 3 months before. It was found that wild polioviruses introduced several times during the year circulated in Mumbai for a limited period before being eliminated. Environmental surveillance was found to be sensitive for the detection of wild poliovirus silent transmission. Nucleotide sequence analysis helped identify wild poliovirus reservoir areas.