肠道病毒A组71型在人脐静脉血管内皮细胞中的增殖及对细胞骨架的影响

目的研究肠道病毒A组71型(Enterovirus group A type 71,EV-A71)在人脐静脉血管内皮细胞(Human umbilical vein endothelial cells,HUVECs)中的增殖及对细胞骨架造成的影响,初步探讨其与病毒血症发生的关系。方法采用qRT-PCR技术及免疫荧光技术检测EV-A71在HUVECs中的复制和增殖,用免疫荧光双染色技术观察三种细胞骨架在EV-A71感染后的变化。结果 EV-A71能够有效感染HUVECs,且感染后24 h在细胞内复制达到高峰。病毒感染后微丝骨架完全解聚,微管骨架排列方式发生改变,而中间纤维结构模糊不清;同时检测到微管及中间纤维与病毒抗原共存。结论 EV-A71可以感染HUVECs并在其内有效复制增殖,同时诱导HUVECs三种细胞骨架发生改变,提示细胞骨架可能参与EV-A71感染HUVECs的过程。     

人肠道病毒A71型分离株全基因组序列及毒力相关位点分析

为了解人肠道病毒A71型(Enterovirus A71,EV-A71)的基因重组和遗传进化特征,探索其毒力相关位点。本研究通过对郴州市3株EV-A71分离株进行全基因组序列测定和分析,应用RDP软件(版本4.1.6)将其与231条EV-A71全基因组序列进行比较分析,检测可能的重组事件及重组位点;采用SimPlot软件(版本号3.5.1)对重组序列、2条亲本序列和其他A组肠道病毒(EV-A)代表株序列进行相似性分析;采用MEGA软件(版本5.2)构建系统发生树;结果发现郴州市3株EV-A71毒株均检测到重组信号,其共同的亲本主序列为广东省2009年毒株,亲本亚序列为中国台湾地区2008年毒株;我国C4b进化分支EV-A71代表株(分离于1998年的SHZH98株)和C4a进化分支EV-A71代表株(分离于2008年的安徽阜阳株)均与CVA4、CVA14及CVA16原型株在3D区域检测到型间重组信号。采用SPSS软件(版本19.0)对不同病例类型的变异位点作卡方检验以筛选出可能的毒力相关位点。发现死亡病例组与重症病例组间未找到具有统计学意义的突变位点;而死亡与重症病例合并组与一般病例组进行比较,共发现18个突变位点具有统计学意义,这些突变位点仅分布于P2区和P3区,而P1区未见。我国大陆的EV-A71流行株与EV-A其他毒株的型间重组早在1998年前即已经发生,并且在2008~2012年的手足口病暴发疫情中,EV-A71的型内重组频繁发生。此外,EV-A71毒力的改变可能与非衣壳蛋白区的变异相关,因此应该关注非衣壳蛋白基因改变对病毒毒力的影响。     

肠道病毒A71型3C蛋白结构、功能及抗3C蛋白药物的研究进展

肠道病毒A71型(Enterovirus A71,EV-A71)可引起手足口病(Hand,foot,and mouth disease,HFMD),严重者伴有神经系统并发症,如无菌性脑膜炎、神经源性肺水肿等。EV-A71引起的HFMD自2007年以来在全世界,尤其是亚太地区多次暴发,已成为亚太地区公共健康的主要威胁之一。目前尚无有效的抗病毒药物或疫苗。EVA71的致病机制尚未完全研究清楚,而非结构蛋白3C在病毒的复制和抑制天然免疫方面发挥了不可替代的作用。EV-A71 3C蛋白的研究在进一步了解EV-A71的致病机制以及研制抗病毒药物方面发挥着重要的作用。本文将对EV-A71 3C蛋白的结构、功能以及抗3C蛋白病毒药物的研究进展做出综述。     

基于反向遗传学技术获取具有精确末端的EV-A71

目的基于反向遗传学技术,设计可获取具有精确末端的肠道病毒A71(enterovirus A71, EV-A71)的方法,并在病毒感染能力研究和抗病毒药物筛选中进行应用。方法利用同源重组方法,在病毒基因组5′末端,引入具有顺式酶切活性的锤头状核酶(cis-active hammerhead ribozyme)序列;在病毒3′末端的poly(A)尾后,引入限制性核酸内切酶NsiⅠ酶切位点(ATGCA↓T),构建含有EV-A71全长感染性克隆的质粒(pBR322-EV-A71)。pBR322-EV-A71经体外转录获得EV-A71感染性RNA,用该RNA转染横纹肌肉瘤细胞(rhabdomyo-sarcoma cells, RD),以获取具有精确末端的EV-A71颗粒。通过检测病毒RNA拷贝数、病毒蛋白的表达量等指标,验证拯救病毒的感染能力和抗病毒药物的抑制作用。结果 pBR322-EV-A71经体外转录所得RNA,在转染进入RD细胞后,观察到细胞病变效应(cytopathic effect,CPE)并检测到病毒负链RNA,表明成功合成了EV-A71颗粒;拯救病毒颗粒在连续传代过程中,病毒增殖能力得以逐步提升,第4代病毒(R4 EV-A71)的感染能力强于第1、2、3代病毒(R1、R2、R3 EV-A71)(P<0.001),且已趋近于野毒株(wild-type EV-A71, wt EV-A71)水平(P>0.05);U0126和sorafenib两种ERK通路抑制剂可以有效抑制R4 EV-A71的增殖(P<0.001),且R4 EV-A71与wt EV-A71表现出同等程度的抑制作用。结论 pBR322-EV-A71可拯救出具有精确末端的EV-A71病毒颗粒,且其子代病毒可代替wt EV-A71进行病毒感染能力的评价和抗病毒药物的筛选。     

肠道病毒A71型致人扁桃体上皮细胞系UT-SCC-60B凋亡和S期阻滞的研究

肠道病毒A71型(Enterovirus A71,EV-A71)是手足口病的重要病原体,为研究EV-A71感染人扁桃体上皮细胞后对细胞凋亡和细胞周期的影响,确定ERK1/2、JNK1/2、PI3K/Akt和含半胱氨酸的天冬氨酸蛋白水解酶(Cysteinyl aspartate specific proteinase,Caspase)的作用,本文以人扁桃体上皮细胞系UT-SCC-60B为细胞模型,CCK-8试剂盒检测EV-A71对UT-SCC-60B的抑制率、流式细胞仪检测EV-A71感染组和抑制剂处理组的凋亡和细胞周期、Caspase活力检测试剂盒测定Caspase-3,Caspase-8,Caspase-9活力。EV-A71以感染剂量和感染时间依赖方式抑制UT-SCC-60B增殖;EV-A71感染致UT-SCC-60B发生细胞凋亡,抑制ERK1/2、JNK1/2和PI3K/Akt能够降低UT-SCC-60B细胞凋亡比例;EV-A71感染UT-SCC-60B后发生S期阻滞,抑制ERK1/2、JNK1/2、PI3K/Akt和Caspase阻止UT-SCC-60B发生S期阻滞;EV-A71感染UT-SCC-60B能够活化Caspase-3,Caspase-8,Caspase-9且ERK1/2、JNK1/2和PI3K/Akt调控Caspase-3,Caspase-8,Caspase-9活力。因此,EV-A71能够导致人扁桃体上皮细胞UT-SCC-60B发生凋亡和S期阻滞,并且ERK1/2、JNK1/2、PI3K/Akt和Caspase参与凋亡和S期阻滞的调控。     

肠道病毒A71型亚单位蛋白对RD细胞自噬活化的影响

肠道病毒A71型（Enterovirus-A71, EV-A71）能够活化宿主细胞的自噬并依赖自噬促进其复制,然而EV-A71的亚单位蛋白对自噬的活化目前仍不清楚。为探讨EV-A71亚单位蛋白对人横纹肌肉瘤（Human rhabdomyosarcoma, RD）细胞自噬活化的影响,将EV-A71的亚单位蛋白重组真核质粒转染至RD细胞,采用抑制剂MK-2206阻断PI3K/Akt途径,共聚焦显微镜和免疫印迹检测自噬活化。过表达EV-A71亚单位蛋白的RD细胞中PI3K/Akt途径、p38、JNK和ERK途径均呈现不同程度活化,同时RD细胞呈现出绿色荧光表明自噬发生活化,特别是EV-A71的VP2和2A。EV-A71亚单位蛋白使LC3-II/LC3-I的转化水平提升,EV-A71亚单位蛋白（VP2、VP3、VP4、2A、2B和2C）显著提升p62的表达水平,EV-A71 VP1显著下调p62的表达水平但显著上调LAMP-1和LAMP-2的表达水平。阻断PI3K/Akt途径后,过表达EV-A71亚单位蛋白的RD细胞绿色荧光强度显著减弱、自噬被阻断,同时LC3-II/LC3-I的转化水平显著降...     

肠道病毒A71型VP1-E98K突变对hSCARB2-KI小鼠致病性的影响

目的 探究肠道病毒A71型(enterovirus A71, EV-A71)VP1-E98K突变对人清道夫受体B2敲入(human scavenger receptor class B member 2 knock-in, hSCARB2-KI)小鼠致病性的影响。方法 利用pSVA-EV-A71-Isehara感染性克隆重组质粒获取拯救的EV-A71 Isehara株,分别在人恶性胚胎横纹肌瘤(human rhabdomyosarcoma, RD)细胞和转染hSCARB2的RD细胞(RD-hSCARB2)中传代并收获病毒,感染小鼠后建立hSCARB2-KI小鼠感染模型。研究中还采用了感染小鼠的临床评分指标、RT-qPCR、HE染色和免疫荧光技术、ELISA、病毒滴定等方法研究病毒的致病性。结果 用RD细胞中连续传代获得的EV-A71 Isehara株攻击hSCARB2-KI小鼠,未观察到预期的体质量减少、行动迟缓、肢体瘫痪等临床表现;经测序确定该病毒株衣壳蛋白发生了VP1-E98K突变,故称之为VP1-98K突变株。而野毒型EV-A71 Isehara株(VP1-98E野毒株)感染的h...     

EV-A71感染导致的重症手足口病的机制及防控研究进展

手足口病(Hand,foot and mouth disease,HFMD)是一种具有高度传染性的病毒性传染病,通常夏秋季高发于幼儿和儿童;若患儿并发呼吸和循环功能障碍、神经系统受累等临床症状称为重症HFMD。少数重症病例可出现肺水肿、脑炎和急性弛缓性麻痹等罕见的神经或循环系统并发症,甚至导致患儿死亡。引起HFMD最常见的病原是肠道病毒A71型(EV-A71)和柯萨奇病毒A16型(CV-A16),而EV-A71是引起重症HFMD的主要病原体。EV-A71导致的重症HFMD已成为全球重要的公共卫生问题,减少EV-A71流行范围和预防EV-A71重症HFMD非常重要。EV-A71疫苗是目前最有效的预防重症HFMD发生的措施;中国已经批准了三个厂家的灭活EV-A71疫苗上市并已开展适龄儿童接种,以期预防EV-A71感染引起的重症HFMD,但这种疫苗不能预防其它肠道病毒如CV-A16,CV-A6和CV-A10等引起的HFMD。据文献报道,小分子抑制剂芦平曲韦可以通过阻止EV-A71的3C pro蛋白活性来抑制EV-A71复制;小干扰RNA和单克隆抗体也可抑制EV-A71复制。研制EV-A71和CVA16双价灭活疫苗是防控HFMD的策略之一,而小分子抑制剂、小干扰RNA和单克隆抗体的研制和应用等也是临床防治HFMD的探索。     

联合IFN-α与U0126的抗EV-A71作用及其机制研究

目的在细胞学水平明确IFN-α和胞外信号调节激酶(extracellular signal-regulated kinase, ERK)通路抑制剂U0126联合用药对肠道病毒A71(EV-A71)感染的作用及其可能机制。方法利用病毒致细胞病变效应、病毒终点滴定实验以及Western blot,确定IFN-α和U0126联合用药对EV-A71抗病毒效果,对细胞干扰素(interferon, IFN)受体及其下游信号通路重要蛋白水平、ERK通路活性的影响。结果 IFN-α和U0126联合用药能有效发挥抗EV-A71增殖的作用(P0.01),同时也能有效抑制ERK通路磷酸化活性、阻断EV-A71 2A~(pro)介导的I型干扰素受体1(interferon alpha receptor 1, IFNAR1)表达水平下调(P0.001),并上调IFN信号通路重要分子eIF2α磷酸化(P0.001)。此外,利用ERK抑制剂(U0126和sorafenib)或特异性siRNA分别阻断ERK磷酸化活性后,可显著阻断肠道病毒2A~(pro)介导的eIF4GI切割和IFNAR1表达下调的作用,同时受染细胞EV-A71复制也显著下降。结论 IFN-α和U0126联合用药可通过有效地抑制ERK通路,抑制2A~(pro)依赖的切割eIF4GI和下调IFNAR1表达的作用,使得外源IFN-α能更有效与细胞膜上IFNAR结合,有效激活IFN抗病毒信号通路,从而发挥IFN抗EV-A71蛋白翻译及增殖作用。     

安徽省2017-2018年手足口病柯萨奇病毒A6型基因进化特征分析

人肠道病毒A组71型(Enterovirus A71,EV-A71)和柯萨奇病毒A组16型(Coxsackievirus A16,CV-A16)是引起手足口病(Hand,foot,and mouth disease,HFMD)的主要病原体.近年来非EV-A71和非CV-A16的其他肠道病毒(Enterovirus,EV)已成为HFMD流行或暴发疫情的优势病原体.安徽省HFMD监测数据显示,2017-2018年HFMD样本非EV-A71和非CV-A16其他EV核酸阳性率超过50％,其中大部分为柯萨奇病毒A组6型(Coxsackievirus A6,CV-A6).为了解安徽省2017-2018年HFMD其他肠道病毒构成和CV-A6基因进化特征,本研究收集2017-2018年HFMD咽拭子EV核酸阳性标本,采用人横纹肌肉瘤(RD)细胞进行病毒分离培养,对分离到的CV-A6毒株VP1全长序列基因扩增及核苷酸序列测定.从NCBI GenBank数据库下载CV-A6原型株和代表性毒株基因参考序列,运用生物软件MEGA 6.0构建VP1基因序列系统进化树,分析其基因遗传特征.结果 显示,安徽省2017-2018年HFMD实验室确诊病例其他EV占66.1％,CV-A16占23.5％,EV-A71占10.4％.52株CV-A6毒株均为D3a基因亚型,其VP1区核苷酸序列间相似度为93.7％～100％,编码的氨基酸序列相似度为98.3％～100％;与CV-A6 Gdula原型株核苷酸相似度为78％～82.3％,氨基酸相似度为94.6％～96.3％.VP1区15个氨基酸位点有变异,氨基酸位点Q98L和G160S的变异发生率为100％.其他EV已成为安徽省引起HFMD流行的重要病原体,D3基因型CV-A6为优势流行毒株.持续加强其他EV的病原学监测与分析,对安徽省HFMD防控策略制定与疫情处置具有重要意义.     

Mitochondria Redistribution in Enterovirus A71 Infected Cells and Its Effect on Virus Replication

Enterovirus A71(EV-A71) is one of the main causative agents of hand, foot and mouth disease(HFMD) and it also causes severe neurologic complications in infected children. The interactions between some viruses and the host mitochondria are crucial for virus replication and pathogenicity. In this study, it was observed that EV-A71 infection resulted in a perinuclear redistribution of the mitochondria. The mitochondria rearrangement was found to require the microtubule network, the dynein complex and a low cytosolic calcium concentration. Subsequently, the EV-A71 non-structural protein 2 BC was identified as the viral protein capable of inducing mitochondria clustering. The protein was found localized on mitochondria and interacted with the mitochondrial Rho GTPase 1(RHOT1) that is a key protein required for attachment between the mitochondria and the motor proteins, which are responsible for the control of mitochondria movement.Additionally, suppressing mitochondria clustering by treating cells with nocodazole, EHNA, thapsigargin or A23187 consistently inhibited EV-A71 replication, indicating that mitochondria recruitment played a crucial role in the EV-A71 life cycle. This study identified a novel function of the EV-A71 2 BC protein and provided a potential model for the regulation of mitochondrial motility in EV-A71 infection.     

TAR DNA-Binding Protein 43 is Cleaved by the Protease 3C of Enterovirus A71

Enterovirus A71(EV-A71) is one of the etiological pathogens leading to hand, foot, and mouth disease(HFMD), which can cause severe neurological complications. The neuropathogenesis of EV-A71 infection is not well understood. The mislocalization and aggregation of TAR DNA-binding protein 43(TDP-43) is the pathological hallmark of amyotrophic lateral sclerosis(ALS). However, whether TDP-43 was impacted by EV-A71 infection is unknown. This study demonstrated that TDP-43 was cleaved during EV-A71 infection. The cleavage of TDP-43 requires EV-A71 replication rather than the activated caspases due to viral infection. TDP-43 is cleaved by viral protease 3 C between the residues 331 Q and332 S, while mutated TDP-43(Q331 A) was not cleaved. In addition, mutated 3 C which lacks the protease activity failed to induce TDP-43 cleavage. We also found that TDP-43 was translocated from the nucleus to the cytoplasm, and the mislocalization of TDP-43 was induced by viral protease 2 A rather than 3 C. Taken together, we demonstrated that TDP-43 was cleaved by viral protease and translocated to the cytoplasm during EV-A71 infection, implicating the possible involvement of TDP-43 in the pathogenesis of EV-A71 infection.     

Immunodominant IgM and IgG Epitopes Recognized by Antibodies Induced in Enterovirus A71-Associated Hand,Foot and Mouth Disease Patients

Enterovirus A71 (EV-A71) is one of the main causative agents of hand, foot and mouth disease (HFMD). Unlike other enteroviruses that cause HFMD, EV-A71 is more frequently associated with severe neurological complications and fatality. To date, no effective licensed antivirals are available to combat EV-A71 infection. Little is known about the immunogenicity of viral non-structural proteins in humans. Previous studies have mainly focused on characterization of epitopes of EV-A71 structural proteins by using immunized animal antisera. In this study, we have characterized human antibody responses against the structural and non-structural proteins of EV-A71. Each viral protein was cloned and expressed in either bacterial or mammalian systems, and tested with antisera by western blot. Results revealed that all structural proteins (VP1-4), and non-structural proteins 2A, 3C and 3D were targets of EV-A71 IgM, whereas EV-A71 IgG recognized all the structural and non-structural proteins. Sixty three synthetic peptides predicted to be immunogenic in silico were synthesized and used for the characterization of EV-A71 linear B-cell epitopes. In total, we identified 22 IgM and four IgG dominant epitopes. Synthetic peptide PEP27, corresponding to residues 142–156 of VP1, was identified as the EV-A71 IgM-specific immunodominant epitope. PEP23, mapped to VP1 41–55, was recognized as the EV-A71 IgG cross-reactive immunodominant epitope. The structural protein VP1 is the major immunodominant site targeted by anti-EV-A71 IgM and IgG antibodies, but epitopes against non-structural proteins were also detected. These data provide new understanding of the immune response to EV-A71 infection, which benefits the development of diagnostic tools, potential therapeutics and subunit vaccine candidates.     

Human SCARB2-dependent infection by coxsackievirus A7, A14, and A16 and enterovirus 71

Human enterovirus species A (HEV-A) consists of at least 16 members of different serotypes that are known to be the causative agents of hand, foot, and mouth disease (HFMD), herpangina, and other diseases, such as respiratory disease and polio-like flaccid paralysis. Enterovirus 71 (EV71) and coxsackievirus A16 (CVA16) are the major causative agents of HFMD. CVA5, CVA6, CVA10, and CVA12 mainly cause herpangina or are occasionally involved with sporadic cases of HFMD. We have previously shown that human scavenger receptor class B, member 2 (SCARB2) is a cellular receptor for EV71 and CVA16. Using a large number of clinical isolates of HEV-A, we explored whether all clinical isolates of EV71 and other serotypes of HEV-A infected cells via SCARB2. We tested this possibility by infecting L-SCARB2 cells, which are L929 cells expressing human SCARB2, by infecting human RD cells that had been treated with small interfering RNAs for SCARB2 and by directly binding the viruses to a soluble SCARB2 protein. We showed that all 162 clinical isolates of EV71 propagated in L-SCARB2 cells, suggesting that SCARB2 is the critical receptor common to all EV71 strains. In addition, CVA7, CVA14, and CVA16, which are most closely related to each other, also utilized SCARB2 for infection. EV71, CVA14, and CVA16 are highly associated with HFMD, and EV71 and CVA7 are occasionally associated with neurological diseases, suggesting that SCARB2 plays important roles in the development of these diseases. In contrast, another group of viruses, such as CVA2, CVA3, CVA4, CVA5, CVA6, CVA8, CVA10, and CVA12, which are relatively distant from the EV71 group, is associated mainly with herpangina. None of these clinical isolates infected via the SCARB2-dependent pathway. HEV-A viruses can be divided into at least two groups depending on the use of SCARB2, and the receptor usage plays an important role in developing the specific diseases for each group.     

A Consistent Orally-Infected Hamster Model for Enterovirus A71 Encephalomyelitis Demonstrates Squamous Lesions in the Paws,Skin and Oral Cavity Reminiscent of Hand-Foot-and-Mouth Disease

Enterovirus A71 (EV-A71) causes self-limiting, hand-foot-and-mouth disease (HFMD) that may rarely be complicated by encephalomyelitis. Person-to-person transmission is usually by fecal-oral or oral-oral routes. To study viral replication sites in the oral cavity and other tissues, and to gain further insights into virus shedding and neuropathogenesis, we developed a consistent, orally-infected, 2-week-old hamster model of HFMD and EV-A71 encephalomyelitis. Tissues from orally-infected, 2-week-old hamsters were studied by light microscopy, immunohistochemistry and in situ hybridization to detect viral antigens and RNA, respectively, and by virus titration. Hamsters developed the disease and died after 4–8 days post infection; LD₅₀ was 25 CCID₅₀. Macroscopic cutaneous lesions around the oral cavity and paws were observed. Squamous epithelium in the lip, oral cavity, paw, skin, and esophagus, showed multiple small inflammatory foci around squamous cells that demonstrated viral antigens/RNA. Neurons (brainstem, spinal cord, sensory ganglia), acinar cells (salivary gland, lacrimal gland), lymphoid cells (lymph node, spleen), and muscle fibres (skeletal, cardiac and smooth muscles), liver and gastric epithelium also showed varying amounts of viral antigens/RNA. Intestinal epithelium, Peyer’s patches, thymus, pancreas, lung and kidney were negative. Virus was isolated from oral washes, feces, brain, spinal cord, skeletal muscle, serum, and other tissues. Our animal model should be useful to study squamous epitheliotropism, neuropathogenesis, oral/fecal shedding in EV-A71 infection, person-to-person transmission, and to test anti-viral drugs and vaccines.     

The Combination Effects of LiCl and the Active Leflunomide Metabolite,A771726, on Viral-Induced Interleukin 6 Production and EV-A71 Replication

Enterovirus 71 (EV-A71) is a neurotropic virus that can cause severe complications involving the central nervous system. No effective antiviral therapeutics are available for treating EV-A71 infection and drug discovery efforts are rarely focused to target this disease. Thus, the main goal of this study was to discover existing drugs with novel indications that may effectively inhibit EV-A71 replication and the inflammatory cytokines elevation. In this study, we showed that LiCl, a GSK3β inhibitor, effectively suppressed EV-A71 replication, apoptosis and inflammatory cytokines production (Interleukin 6, Interleukin-1β) in infected cells. Furthermore, LiCl and an immunomodular agent were shown to strongly synergize with each other in suppressing EV-A71 replication. The results highlighted potential new treatment regimens in suppressing sequelae caused by EV-A71 replication.     

Hand,Foot, and Mouth Disease in China: Modeling Epidemic Dynamics of Enterovirus Serotypes and Implications for Vaccination

Background

Hand, foot, and mouth disease (HFMD) is a common childhood illness caused by serotypes of the Enterovirus A species in the genus Enterovirus of the Picornaviridae family. The disease has had a substantial burden throughout East and Southeast Asia over the past 15 y. China reported 9 million cases of HFMD between 2008 and 2013, with the two serotypes Enterovirus A71 (EV-A71) and Coxsackievirus A16 (CV-A16) being responsible for the majority of these cases. Three recent phase 3 clinical trials showed that inactivated monovalent EV-A71 vaccines manufactured in China were highly efficacious against HFMD associated with EV-A71, but offered no protection against HFMD caused by CV-A16. To better inform vaccination policy, we used mathematical models to evaluate the effect of prospective vaccination against EV-A71-associated HFMD and the potential risk of serotype replacement by CV-A16. We also extended the model to address the co-circulation, and implications for vaccination, of additional non-EV-A71, non-CV-A16 serotypes of enterovirus.

Methods and Findings

Weekly reports of HFMD incidence from 31 provinces in Mainland China from 1 January 2009 to 31 December 2013 were used to fit multi-serotype time series susceptible–infected–recovered (TSIR) epidemic models. We obtained good model fit for the two-serotype TSIR with cross-protection, capturing the seasonality and geographic heterogeneity of province-level transmission, with strong correlation between the observed and simulated epidemic series. The national estimate of the basic reproduction number, R ₀, weighted by provincial population size, was 26.63 for EV-A71 (interquartile range [IQR]: 23.14, 30.40) and 27.13 for CV-A16 (IQR: 23.15, 31.34), with considerable variation between provinces (however, predictions about the overall impact of vaccination were robust to this variation). EV-A71 incidence was projected to decrease monotonically with higher coverage rates of EV-A71 vaccination. Across provinces, CV-A16 incidence in the post-EV-A71-vaccination period remained either comparable to or only slightly increased from levels prior to vaccination. The duration and strength of cross-protection following infection with EV-A71 or CV-A16 was estimated to be 9.95 wk (95% confidence interval [CI]: 3.31, 23.40) in 68% of the population (95% CI: 37%, 96%). Our predictions are limited by the necessarily short and under-sampled time series and the possible circulation of unidentified serotypes, but, nonetheless, sensitivity analyses indicate that our results are robust in predicting that the vaccine should drastically reduce incidence of EV-A71 without a substantial competitive release of CV-A16.

Conclusions

The ability of our models to capture the observed epidemic cycles suggests that herd immunity is driving the epidemic dynamics caused by the multiple serotypes of enterovirus. Our results predict that the EV-A71 and CV-A16 serotypes provide a temporary immunizing effect against each other. Achieving high coverage rates of EV-A71 vaccination would be necessary to eliminate the ongoing transmission of EV-A71, but serotype replacement by CV-A16 following EV-A71 vaccination is likely to be transient and minor compared to the corresponding reduction in the burden of EV-A71-associated HFMD. Therefore, a mass EV-A71 vaccination program of infants and young children should provide significant benefits in terms of a reduction in overall HFMD burden.     

Cyclical Patterns of Hand,Foot and Mouth Disease Caused by Enterovirus A71 in Malaysia

Enterovirus A71 (EV-A71) is an important emerging pathogen causing large epidemics of hand, foot and mouth disease (HFMD) in children. In Malaysia, since the first EV-A71 epidemic in 1997, recurrent cyclical epidemics have occurred every 2–3 years for reasons that remain unclear. We hypothesize that this cyclical pattern is due to changes in population immunity in children (measured as seroprevalence). Neutralizing antibody titers against EV-A71 were measured in 2,141 residual serum samples collected from children ≤12 years old between 1995 and 2012 to determine the seroprevalence of EV-A71. Reported national HFMD incidence was highest in children <2 years, and decreased with age; in support of this, EV-A71 seroprevalence was significantly associated with age, indicating greater susceptibility in younger children. EV-A71 epidemics are also characterized by peaks of increased genetic diversity, often with genotype changes. Cross-sectional time series analysis was used to model the association between EV-A71 epidemic periods and EV-A71 seroprevalence adjusting for age and climatic variables (temperature, rainfall, rain days and ultraviolet radiance). A 10% increase in absolute monthly EV-A71 seroprevalence was associated with a 45% higher odds of an epidemic (adjusted odds ratio, aOR1.45; 95% CI 1.24–1.69; P<0.001). Every 10% decrease in seroprevalence between preceding and current months was associated with a 16% higher odds of an epidemic (aOR = 1.16; CI 1.01–1.34 P<0.034). In summary, the 2–3 year cyclical pattern of EV-A71 epidemics in Malaysia is mainly due to the fall of population immunity accompanying the accumulation of susceptible children between epidemics. This study will impact the future planning, timing and target populations for vaccine programs.     

Prevalence of Multiple Enteroviruses Associated with Hand,Foot, and Mouth Disease in Shijiazhuang City,Hebei Province,China: Outbreaks of Coxsackieviruses A10 and B3

Hand, foot, and mouth disease (HFMD) has been one of the most common infectious diseases in Shijiazhuang City, as is the situation in China overall. In the National HFMD surveillance system, the pathogen detection was focused on EV-A71 and CVA16, and therefore, information on the other EVs is very limited. In order to identify the circulating EV serotypes in the HFMD outbreaks in Shijiazhuang City during 2010–2012, 4045 patients presented with HFMD were recruited in the study, and clinical samples were investigated. Typing of EV serotypes was performed using the molecular typing methods, and phylogenetic analyses based on entire VP1 sequences of human enterovirus 71 (EV-A71), coxsackievirus A16 (CVA16), CVA10 and CVB3 was performed. The results revealed that EV-A71 and CVA16 were the 2 most important pathogens but the circulating trends of the 2 viruses showed a shift, the spread of EV-A71 became increasingly weak, whereas the spread of CVA16 became increasingly stronger. CVA10 and CVB3 were the third and fourth most prevalent pathogens, respectively. Co-infection of two viruses at the same time was not found in these samples. Based on entire VP1 region sequences, the phylogenetic analysis revealed that C4a subgenotype EV-A71, B1a and B1b subgenotype CVA16 continued to evolve. The CVA10 strains were assigned to 4 genotypes (A–D), whereas the CVB3 strains were assigned to 5 genotypes (A–E), with clear geographical and temporal-specific distributions. The Shijiazhuang CVA10 sequences belonged to 4 epidemic lineages within genotype C, whereas the Shijiazhuang CVB3 sequences belonged to 2 epidemic lineages within genotype E, which may have the same origins as the strains reported in other part of China. CVA10 and CVB3, 2 pathogens that were previously infrequently detected, were identified as pathogens causing the HFMD outbreaks. This study underscores the need for detailed laboratory-based surveillances of HFMD in mainland China.     

Suppression of interleukin-6 increases enterovirus A71 lethality in mice

Background

Enterovirus A71 (EV-A71) infection can induce fatal encephalitis in young children. Clinical reports show that interleukin-6 (IL-6) levels in the serum and cerebrospinal fluid of infected patients with brainstem encephalitis are significantly elevated. We used a murine model to address the significance of endogenous IL-6 in EV-A71 infection.

Results

EV-A71 infection transiently increased serum and brain IL-6 protein levels in mice. Most importantly, absence of IL-6 due to gene knockout or depletion of IL-6 using neutralizing monoclonal antibody enhanced the mortality and tissue viral load of infected mice. Absence of IL-6 increased the damage in the central nervous system and decreased the lymphocyte and virus-specific antibody responses of infected mice.

Conclusions

Endogenous IL-6 functions to clear virus and protect the host from EV-A71 infection. Our study raises caution over the use of anti-IL-6 antibody or pentoxifylline to reduce IL-6 for patient treatment.