First molecular detection of a novel Babesia species from Haemaphysalis hystricis in Taiwan

Newly recorded ticks and emerging tick-borne pathogens have recently been reported in subtropical and tropical East Asia. In this study, a total of 1,615 ticks (259 Haemaphysalis hystricis, 1334 Rhipicephalus microplus, 19 H. flava, and 3 R. haemaphysaloides) were collected by flagging from vegetation in Taiwan during 2019-2021. All 1,615 captured tick samples tested negative for SFTSV and Borrelia, but 12 of 356 tick samples tested positive for PCR amplification of a fragment of the 18S rRNA gene of Babesia spp., with an infection rate of 3.37 % (12/356) and a minimum infection rate of 0.74 % (12/1,615). Among the 12 detected Babesia spp., 11 were identified as Babesia bigemina in R. microplus, and the other one, detected in H. hystricis, was classified as an unnamed novel Babesia sp. Interestingly, the 18S rRNA sequence from the isolate detected in H. hystricis shared 98.79 % to 99.50 % identity with those of recent isolates from Japan, China and Nigeria. The exact origin of the Babesia species is not known, but the findings highlight the importance of international cooperation and the exchange of information on ticks and tick-borne pathogens. This represents a rare report of a Babesia sp. identified in H. hystricis, a tick species that has been proposed as a novel vector for some Babesia spp. This study supports H. hystricis as a possible vector of Babesia spp.

Delayed correlation between the incidence rate of indigenous murine typhus in humans and the seropositive rate of Rickettsia typhi infection in small mammals in Taiwan from 2007–2019

Murine typhus is a flea-borne zoonotic disease with acute febrile illness caused by Rickettsia typhi and is distributed widely throughout the world, particularly in port cities and coastal regions. We observed that murine typhus was an endemic disease (number of annual indigenous cases = 29.23±8.76) with a low incidence rate (0.13±2.03*10⁻⁴ per 100,000 person-years) in Taiwan from 2007–2019. Most (45.79%, 174/380) indigenous infections were reported in May, June, and July. The incidence rates in both May and June were statistically higher than those in other months (p<0.05). Correspondingly, sera collected from small mammals (rodents and shrews) trapped in airports and harbors demonstrated anti-R. typhi antibody responses (seropositive rate = 8.24±0.33%). Interestingly, the ports with the highest seropositivity rates in small mammals are all inside/near the areas with the highest incidence rates of indigenous murine typhus. In addition, incidence rates in humans were positively correlated with the 1-month and 2-month prior seropositive rates in small mammals (R = 0.31 and 0.37, respectively). As early treatment with appropriate antibiotics for murine typhus could effectively shorten the duration of illness and reduce the risk of hospitalization and fatality, flea-related exposure experience should be considered in clinics during peak seasons and the months after a rise in seropositivity rates in small mammals. Surveillance in small mammals might be helpful for the development of real-time reporting or even early reminders for physicians of sporadic murine typhus cases based on the delayed correlation observed in this study.

Murine typhus is a flea-borne zoonotic disease with acute febrile illness caused by Rickettsia typhi and is distributed widely throughout the world, particularly in port cities and coastal regions. Early treatment with appropriate antibiotics for murine typhus could effectively shorten the duration of illness and reduce the risk of hospitalization and fatality. However, it presents with nonspecific symptoms and is oftentimes misdiagnosed. In Taiwan, murine typhus has been designated a notifiable disease since 2007. Meanwhile, surveillance of R. typhi infection of small mammals was also launched at 25 international airports and harbors. Since then, we observed that indigenous murine typhus patients have been detected in Taiwan annually and sera collected from small mammals trapped in ports also demonstrated anti-R. typhi antibody responses. Correspondingly, the ports with the highest seropositivity are all inside/near the areas with the highest incidence rate of indigenous murine typhus in Taiwan. We further found that incidence rates in humans were positively correlated with the 1-month and 2-month prior seropositive rates in small mammals. Surveillance in small mammals might be helpful for the development of real-time reporting or even early reminders of sporadic murine typhus cases based on the delayed correlation observed in this study.

A Molecular Approach Applied to Enteroviruses Surveillance in Northern Taiwan, 2008-2012

Traditional methods for detection and serotyping of enterovirus infections are virus isolation and immunofluorescence assay (VI-IFA), which are labor-intensive and time-consuming. Recently, VP1 gene has been targeted to develop a CODEHOP-based RT-PCR (VP1-CODEHOP) for the same purpose. In this study, we conducted a 5-year enterovirus surveillance comparing the VI-IFA and VP1-CODEHOP tests. Throat swabs were collected from 431 pediatric patients and 208(48%) and 250(58%) were tested positive by the VI-IFA and VP1-CODEHOP tests, respectively. Among the 47 cases who had inconsistent results between the VI-IFA and VP1-CODEHOP tests and provided paired sera for serological verifications, correct diagnosis for the VI-IFA and VP1-CODEHOP were 5(11%) and 40(85%) cases, respectively. Therefore, the VP1-CODEHOP is more reliable for detection of human enteroviruses than the VI-IFA. Based on serological verifications for the eight cases who had inconsistent serotypes between the two tests and provided paired sera, five and two showed consistent serotypes with the VP1-CODEHOP and VI-IFA tests, respectively. CVA16, CVA6 and EV71 were the most prevalent serotypes in northern Taiwan, 2008~2012. Moreover, variant CVA2, CVA6 and EV71 viruses were further identified based on phylogenetic analysis of partial VP1 sequences. In conclusion, the VP1-CODEHOP test could be used as the primary method for enterovirus surveillance to support decision-making for outbreak control.

Epidemiology of enterovirus 71 infections in Taiwan

Enterovirus 71 (EV71) was first described in USA in 1969 but retrospective studies in The Netherlands further detected EV71 in the clinical specimens collected in 1963. EV71 has one single serotype measured by using hyperimmune animal antisera but can be phylogenetically classified into three genogroups (A, B, and C) including 11 genotypes (A, B1-B5, C1-C5). In Taiwan, EV71 caused a large-scale nationwide epidemic in 1998. Retrospective studies further detected EV71 in clinical specimens collected from hand-foot-mouth disease patients in 1980 and 1986. Therefore, EV71 may have circulated in Taiwan prior to 1980. Since 1998, EV71 has cyclically caused nationwide epidemics with different predominant genotypes in 1998 (genotype C2), 2000-2001 (B4), 2005 (C4), 2008 (B5), and 2012 (B5). Phylogenetic analysis revealed that C4 viruses isolated in 2005 were probably from China, B5 viruses isolated in 2008 were probably from South Eastern Asia, and B5 viruses isolated in 2012 were probably from Xiamen, China. Several studies have collected postinfection sera from children to measure cross-reactive neutralizing antibody titers against different EV71 genotypes and found that antigenic differences between genogroup B and C viruses did not have a clear pattern but that genotype A virus was antigenically different from genogroup B and C viruses. In conclusion, EV71 cyclically caused nationwide epidemics through international importations. EV71 surveillance in Taiwan should combine genetic and serological methods.

Monitoring antigenic variations of enterovirus 71: implications for virus surveillance and vaccine development

Enterovirus 71 (EV71) causes life-threatening epidemics in Asia and can be phylogenetically classified into three major genogroups (A∼C) including 11 genotypes (A, B1∼B5, and C1∼C5). Recently, EV71 epidemics occurred cyclically in Taiwan with different genotypes. In recent years, human studies using post-infection sera obtained from children have detected antigenic variations among different EV71 strains. Therefore, surveillance of enterovirus 71 should include phylogenetic and antigenic analysis. Due to limitation of sera available from children with EV71 primary infection, suitable animal models should be developed to generate a panel of antisera for monitoring EV71 antigenic variations. Twelve reference strains representing the 11 EV71 genotypes were grown in rhabdomyosarcoma cells. Infectious EV71 particles were purified and collected to immunize rabbits. The rabbit antisera were then employed to measure neutralizing antibody titers against the 12 reference strains and 5 recent strains. Rabbits immunized with genogroup B and C viruses consistently have a lower neutralizing antibody titers against genogroup A (≧8-fold difference) and antigenic variations between genogroup B and C viruses can be detected but did not have a clear pattern, which are consistent with previous human studies. Comparison between human and rabbit neutralizing antibody profiles, the results showed that ≧8-fold difference in rabbit cross-reactive antibody ratios could be used to screen EV71 isolates for identifying potential antigenic variants. In conclusion, a rabbit model was developed to monitor antigenic variations of EV71, which are critical to select vaccine strains and predict epidemics.

Enterovirus 71 (EV71) has caused several life-threatening epidemics in children in the Asia-Pacific region since 1997. EV71 has one single serotype as measured using hyper-immune animal antisera but can be phylogenetically classified into three major genogroups (A, B and C) and eleven genotypes (A, B1–B5, and C1–C5). Recently, epidemiological studies in the Asia-Pacific region have found that large-scale EV71 epidemics occurred cyclically with different genotypes. This observation of genotype replacement, in conjunction with the observed antigenic variations among different EV71 genogroups in human studies, has kindled the interest to establish animal models to monitor the antigenic variations of EV71. In this study, we developed a rabbit model to monitor antigenic variations of EV71, which could be further integrated into national enterovirus surveillance systems.

Cross-reactive neutralizing antibody responses to enterovirus 71 infections in young children (P4319)

Recently, enterovirus 71 (EV71) has caused life-threatening outbreaks involving neurological and cardiopulmonary complications in Asian children with unknown mechanism. EV71 has one single serotype but can be phylogenetically classified into 3 main genogroups (A, B and C) and 11 genotypes (A, B1~B5 and C1~C5). In Taiwan, nationwide EV71 epidemics with different predominant genotypes occurred in 1998 (C2), 2000-2001 (B4), 2004-2005 (C4), and 2008 (B5). In this study, sera were collected to measure cross-reactive neutralizing antibody titers against different genotypes. We collected historical sera from children who developed an EV71 infection in 1998, 2000, 2005, 2008, or 2010 and measured cross-reactive neutralizing antibody titers against all 11 EV71 genotypes. In addition, we aligned and compared the amino acid sequences of P1 proteins of the tested viruses. Serology data showed that children infected with genogroups B and C consistently have lower neutralizing antibody titers against genogroup A (&gt;4-fold difference). The sequence comparisons revealed that five amino acid signatures (N143D in VP2; K18R, H116Y, D167E, and S275A in VP1) are specific for genogroup A and may be related to the observed antigenic variations. In conclusion, this study documented antigenic variations among different EV71 genogroups and identified potential immunodominant amino acid positions. Enterovirus surveillance and vaccine development should monitor these positions.

Comparing molecular methods for early detection and serotyping of enteroviruses in throat swabs of pediatric patients

Background

Enteroviruses include over 100 serotypes and usually cause self-limited infections with non-specific symptoms in children, with the exceptions of polioviruses and enterovirus 71 which frequently cause neurologic complications. Therefore, early detection and serotyping of enteroviruses are critical in clinical management and disease surveillance. Traditional methods for detection and serotyping of enteroviruses are virus isolation and immunofluorescence assay, which are time-consuming. In this study, we compare virus isolation and two molecular tests for detection and serotyping of enteroviruses in clinical samples.

Methods

One hundred and ten throat swabs were collected from pediatric outpatients with enterovirus-like illnesses (hand-foot-mouth disease, herpangina, and non-specific febrile illness). Virus isolation was conducted using multiple cell lines and isolated viruses were serotyped using immunofluorescent assay. In the molecular tests, a semi-nested RT-PCR and a novel CODEHOP platform were used to detect the 5′UTR and VP1 genes of enteroviruses, respectively. Amplified nucleotides were sequenced and genotyped.

Results

Among the 110 cases, 39(35%), 52(47%), and 46(42%) were tested positive with these three tests, respectively. Using the consensus results of these three tests as the gold standard, agreement of the VP1 CODEHOP test was 96%, which is higher than those of the virus isolation (89%) and the 5′-UTR test (88%). The VP1 CODEHOP test also has the best performance on serotyping confirmed with serum neutralization tests.

Conclusions

The VP1 CODEHOP test performed well for detection and serotyping of enteroviruses in clinical specimens and could reduce unnecessary hospitalization cares during enterovirus seasons.

Incidence rates of enterovirus 71 infections in young children during a nationwide epidemic in Taiwan, 2008-09

Objective

Enterovirus 71 (EV71) is causing life-threatening outbreaks in tropical Asia. In Taiwan and other tropical Asian countries, although nationwide EV71 epidemics occur cyclically, age-specific incidence rates of EV71 infections that are critical to estimate disease burden and design vaccine trials are not clear. A nationwide EV71 epidemic occurred in 2008–09 in Taiwan, which provided a unique opportunity to estimate age-specific incidence rates of EV71 infections.

Study Design

We prospectively recruited 749 healthy neonates and conducted follow-ups from June 2006 to December 2009. Sera were obtained from participants at 0, 6, 12, 24, and 36 months of age for measuring EV71 neutralizing antibody titers. If the participants developed suspected enterovirus illnesses, throat swabs were collected for virus isolation.

Results

We detected 28 EV71 infections including 20 symptomatic and 8 asymptomatic infections. Age-specific incidence rates of EV71 infection increased from 1.71 per 100 person-years at 0–6 months of age to 4.09, 5.74, and 4.97 per 100 person-years at 7–12, 13–24, and 25–36 months of age, respectively. Cumulative incidence rate was 15.15 per 100 persons by 36 months of age, respectively.

Conclusions

Risk of EV71 infections in Taiwan increased after 6 months of age during EV71 epidemics. The cumulative incidence rate was 15% by 36 months of age, and 29% of EV71 infections were asymptomatic in young children.

Enterovirus 71 (EV71) was first isolated in California, USA, in 1969. Since then, EV71 has been identified globally. Recently, EV71 caused several life-threatening outbreaks in young children in tropical Asia. Development of EV71 vaccines becomes national priority in several Asia countries including Taiwan. To design clinical trials of EV71 vaccines, age-specific incidence rates of EV71 infections are required to identify target populations, estimate disease burdens, select endpoints of clinical efficacy, and estimate sample size. In Taiwan, nationwide EV71 epidemics occurred every 3–4 years but age-specific incidences of EV71 infection are not available. In 2006, we initiated a prospective cohort study in northern Taiwan to recruit neonates and follow up them. In 2008–09, a nationwide EV71 epidemic occurred and we found that age-specific incidence rates of EV71 infection increased from 1.71 per 100 person-years at 0–6 months of age to 4.09, 5.74, and 4.97 per 100 person-years at 7–12, 13–24, and 25–36 months of age, respectively. The cumulative incidence rate was 15% by 36 months of age, and 29% of EV71 infections were asymptomatic in young children. These findings would be helpful to development of EV71 vaccines in Taiwan and other Asian tropical countries.

An investigation of epidemic enterovirus 71 infection in Taiwan, 2008: clinical, virologic, and serologic features

BACKGROUND

Enterovirus 71 (EV71) is causing life-threatening hand-foot-mouth disease in Asia. In Taiwan, EV71 epidemics with different predominant genotypes occurred in 1998 (C2), 2000-2001 (B4), and 2004-2005 (C4). This genotype replacement may have important implications for vaccine development and prediction of epidemics. A nationwide EV71 outbreak occurred again in 2008, which provided a unique opportunity to characterize clinical, virologic, and serologic features of this epidemic.

METHODS

We analyzed clinical and virologic data of 111 EV71 patients hospitalized in 2008 and prospectively conducted follow-ups of healthy children from June 2006 to December 2008.

RESULTS

Among the 111 EV71 inpatients, 21 (19%) developed complications. Among the 21 complicated cases, 15 had central nervous system complication only, 2 had acute heart failure, and 4 had central nervous system and pulmonary complications. In the prospective study, 11 symptomatic infections and 4 asymptomatic infections were detected. Twenty-two EV71 isolates were genotyped, and 21 of them belong to genotype B5, which is phylogenetically close to B5 viruses circulating in Southeast Asia. Serologic tests show that children infected with B5 viruses have lower geometric mean titers of neutralizing antibody against genotype C4 than those against genotype B5 (P = 0.004, t test).

CONCLUSIONS

The 2008 nationwide EV71 epidemic was caused by genotype B5 that was likely introduced to Taiwan from Southeast Asia. Clinical features of the 2008 epidemic were not different from those observed before in Taiwan. Potential antigenic variations between genotype C4 and B5 viruses could be detected and its long-term epidemiologic significance needs further investigation to clarify.

Development of a high-throughput assay for measuring serum neutralizing antibody against enterovirus 71

Enterovirus 71 (EV71) is the main etiologic agent of hand, foot, and mouth disease (HFMD) and causes frequently severe neurological complications and mortality in young children. The serum neutralizing antibody response is the major indicator of EV71 infection and protective immunity. The current serum neutralization test based on inhibition of cytopathic effect (Nt-CPE) requires manual microscopic examination, which is time-consuming and labor-intensive. In this study, a high-throughput neutralization assay which employs enzyme immunoassay for detecting growth of EV71 in Rhabdomyosarcoma (RD) cells and measuring serum neutralizing antibody (Nt-EIA) against EV71 was developed. RD cells infected with 100 TCID(50) of EV71 for 36-42h had the best performance and were selected for Nt-EIA. One hundred and twenty human sera (59 negative sera, 61 positive sera) were measured for EV71 neutralization antibody titers by Nt-CPE and Nt-EIA. Neutralization antibody titers against EV71 determined by Nt-EIA had a high sensitivity (100%), specificity (94.9%) and agreement (97.5%) by a qualitative comparison with Nt-CPE. In the quantitative comparison, the correlation coefficient between Nt-EIA and Nt-CPE was 0.91 after log transformation. Overall, the Nt-EIA is a suitable alternative assay for the quantitation of EV71 neutralizing antibody to EV71.

Determination of nalbuphine by high-performance liquid chromatography with ultraviolet detection: application to human and rabbit pharmacokinetic studies

A rapid, sensitive, precise and accurate high-performance liquid chromatographic assay with ultraviolet detection was developed for the determination of nalbuphine in human, rabbit, pig and dog plasma. It is comprised of only a one-step extraction procedure with hexane-isoamyl alcohol at pH 9.25 and reversed-phase chromatography on a micro Porasil column. The recoveries of nalbuphine and ethylmorphine (internal standard) were greater than 86%. Calibration graphs were linear over the concentration range 0.75-150 ng/ml with a coefficient of variation, both within-day and between-day, of less than 10% at any level. The limit of quantitation was 0.75 ng/ml of plasma based on a signal-to-noise ratio of 3. Seven other clinically used analgesics were investigated to check for potential interferences and their analytical conditions. The specificity of this assay was checked with a metabolite of nalbuphine (noroxymorphine). Nalbuphine in plasma did not decompose significantly at -20 degrees C for six weeks. Pharmacokinetic application in three surgical patients and four rabbits revealed that nalbuphine followed a linear three-compartment model with two distribution phases. The two distribution and one elimination half-lives and the plasma clearance of nalbuphine were 0.9, 5.8 and 157 min and 370 ml/min in human, and 3.5, 28 and 117 min and 21 166 ml/min in rabbits.