Molecular surveillance of measles and rubella in the WHO European Region: new challenges in the elimination phase

BACKGROUND

The WHO European Region (EUR) has adopted the goal of eliminating measles and rubella but individual countries perform differently in achieving this goal. Measles virus spread across the EUR by mobile groups has recently led to large outbreaks in the insufficiently vaccinated resident population. As an instrument for monitoring the elimination process and verifying the interruption of endemic virus transmission, molecular surveillance has to provide valid and representative data. Irrespective of the country's specific situation, it is required to ensure the functionality of the laboratory surveillance that is supported by the WHO Global Measles and Rubella Laboratory Network.

AIMS

To investigate whether the molecular surveillance in the EUR is adequate for the challenges in the elimination phase, we addressed the quality assurance of molecular data, the continuity and intensity of molecular monitoring, and the analysis of transmission chains.

SOURCES

Published articles, the molecular External Quality Assessment Programme of the WHO, the Centralized Information System for Infectious Diseases of the WHO EUR and the WHO Measles and Rubella Nucleotide Surveillance databases served as information sources.

CONTENT

Molecular proficiency testing conducted by the WHO in 2016 has shown that the expertise for measles and rubella virus genotyping exists in all parts of the EUR. The analysis of surveillance data reported nationally to the WHO in 2013-2016 has revealed some countries with outbreaks but not sufficiently representative molecular data. Long-lasting supranational MV transmission chains were identified.

IMPLICATIONS

A more systematic molecular monitoring and recording of the transmission pattern for the whole EUR could help to create a meaningful picture of the elimination process.

Challenges of measles and rubella laboratory diagnostic in the era of elimination

The Member States of the WHO European Region adopted the goal of measles and rubella elimination more than 10 years ago, but so far only 21 of 53 countries have reached this target. Laboratory investigation of suspected cases is essential to support disease elimination efforts. Therefore, WHO maintains a network of accredited laboratories providing high-quality testing. Laboratory investigation heavily relies on specific IgM serology and increasingly on virus detection by reverse transcription (RT)-PCR, but other methods such as IgG avidity testing and genetic characterization of virus strains have gained in importance. In elimination settings, often few samples from suspected cases are available for testing, but testing proficiency must be maintained. The predictive value of an IgM-positive result decreases and other rash-fever disease aetiologies become more important. In addition, cases with a rash after measles/rubella vaccination or with mild disease after waning of vaccine-induced antibodies are seen more often. Thus, it is necessary to perform comprehensive and potentially time-consuming and costly investigations of every suspected case using quality-controlled laboratory methods. At the same time rapid feedback to public health officers is required for timely interventions. The introduction of new laboratory methods for comprehensive case investigations requires training of staff under the supervision of WHO-accredited reference laboratories and the definition of appropriate test algorithms. Clinical, laboratory, and epidemiological data are essential for final case classification and investigation of chains of transmission in the endgame of measles and rubella elimination.

Low and disparate seroprotection after pentavalent childhood vaccination in the Lao People's Democratic Republic: a cross-sectional study

OBJECTIVE

In Lao People's Democratic Republic, the high burden of vaccine-preventable diseases is thought to be mainly due to low vaccine coverage. We investigated the seroprotective response against diphtheria-tetanus-whole cell pertussis-hepatitis B-Haemophilus influenzae type b (DTPw-HepB-Hib) vaccine in children.

METHODS

Serum was collected from 1131 children aged 9 to 50 months and their mothers in a cross-sectional study between December 2013 and July 2014. All children had records of three injections of the DTPw-HepB-Hib vaccine. Serum was analysed for hepatitis B surface antigen (HBsAg), anti-HBsAg (anti-HBs), anti-hepatitis B virus core antigen (anti-HBc), anti-diphtheria and anti-tetanus antibodies. Stool samples were collected for detection of parasites. Demographic and nutritional information were also obtained.

RESULTS

Protective levels of anti-HBs antibodies were found in 394 (37.9%) of 1039 children; 529 (55.7%) of 950 and 809 (85.2%) of 950 children were seroprotected against diphtheria and tetanus. Time since vaccination, age, home birth and malnutrition only partially explained the poor vaccine responses. Overall, 81 (7.8%) of 1039 children and 445 (40.3%) of 1105 of mothers were anti-HBc positive. Ten (1.0%) of 1039 of the children and 77 (7.0%) of 1105 of the mothers were HBsAg carriers.

CONCLUSIONS

After a full documented course of vaccination, seroprotective rates were unusually low and disparate against components of the pentavalent vaccine. These can only partially be explained by the negative predictors identified. Although many children had been infected, only few were chronic carriers of HBsAg. Our study demonstrates an urgent need to monitor the serologic response to vaccination, particularly in resource-poor countries.

Epidemiologic and laboratory surveillance of the measles outbreak in the Federation of Bosnia and Herzegovina, February 2014-April 2015

A measles outbreak with two epidemic waves involving 4649 probable and laboratory-confirmed cases was recorded in six out of ten cantons of the Federation of Bosnia and Herzegovina between February 2014 and April 2015. The majority of the patients had never received measles vaccination (3115/4649, 67.00%), and the vaccination status of another 23% was unknown (1066/4649). A total of 281 blood samples were tested serologically. Virus detection was performed using 44 nasopharyngeal swabs. About 57% (161/281) of the laboratory-investigated sera were immunoglobulin M positive, and 95% (42/44) of the swabs were reverse transcriptase-PCR positive. Phylogenetic analysis of sequences obtained from 30 swab samples showed circulation of two variants of genotype D8, but no genotype D4 strains as detected in 2007. Similar involvement of all age groups indicates a problem with vaccine refusal resulting from antivaccination activities in addition to gaps in immunization coverage during the war and postwar period (1992-1998). Differences in ethnicity, vaccine coverage, compliance with review policies of vaccination records and potentially also travel habits may partially explain why only six of ten cantons were affected by the outbreak. The second epidemic wave may in part be due to large-scale migrations due to catastrophic floods in 2014. As a result of the epidemic, 6- to 12-month-old children may now be vaccinated against measles during outbreaks, and public health recommendations for interventions have been strengthened. Additional efforts are required to implement the measures throughout the cantons.

Lower seroreactivity to European than to North American H3N2 swine influenza viruses in humans, Luxembourg, 2010

Seroreactivity to H3N2 swine influenza viruses (SIVs) was evaluated in serum samples collected from 843 people aged 0 to 100 years in 2010 in Luxembourg. Sera were analysed by haemagglutination inhibition (HI) and virus neutralisation (VN) assays targeting a European H3N2 SIV, a North American H3N2 variant of swine origin (H3N2v) and human seasonal H3N2 viruses isolated in 1975, 1995 and 2005. HI antibodies (titre?≥?10) against European H3N2 SIV were almost exclusively detected in those born before 1990, of whom 70% were seropositive. HI antibodies against H3N2v were predominantly found in those born before 2000, with 86% seropositive. Titres against the North American H3N2v were higher than against the European H3N2 SIV. VN patterns were similar, but with higher rates and titres. We also demonstrated lower seroreactivity to European H3N2 SIV than to North American H3N2v virus. Finally, we found a strong correlation between HI titres against the European H3N2 SIV and H3N2v and their respective human ancestors, A/Victoria/3/75 and A/Nanchang/933/95. This finding and the minimal contacts between humans and pigs in Luxembourg suggest that anti-SIV antibodies in human serum samples reflect serological cross-reactivity with historical human H3N2 viruses. Our findings help assess the pandemic risk of H3N2 SIV.

Mumps outbreak in the Federation of Bosnia and Herzegovina with large cohorts of susceptibles and genetically diverse strains of genotype G, Bosnia and Herzegovina, December 2010 to September 2012

A mumps outbreak reported from the Federation of Bosnia and Herzegovina involved 7,895 cases between December 2010 and September 2012. This was the largest outbreak in the country since the introduction of the measles, mumps and rubella vaccine in 1980. The highest disease incidence was found among 15 to 19 year-olds. About 39% (3,050/7,895) of cases reported to be unvaccinated; the vaccination status of 31% (2,426/7,895) was unknown. A seroprevalence study among 150 asymptomatic contacts to mumps cases showed that about one third (45/150) were susceptible to mumps. Among 105 clinically suspected mumps patients hospitalised at the Clinical Centre of the University of Sarajevo, orchitis (60% of all males: 51/85) and meningitis (9%: 9/105) were the most common complications. Among 57 outbreak sequences obtained for the small hydrophobic gene, eight different variants of genotype G viruses were identified. The outbreak affected mainly age groups comprising individuals who were not vaccinated during or after the Bosnian war, as well as cantons with single dose immunisation policies until 2001. In addition to issues related to vaccination of individuals, differential responses to vaccines and vaccine strains, waning of antibodies and potentially also the genetically diverse variants of genotype G may have compounded the size and duration of the outbreak. Our report emphasizes the need for supplementary immunisation programmes in particular for adolescents and young adults.

High prevalence of mumps in Lao People's Democratic Republic

In the Lao People's Democratic Republic (PDR), mumps is not a notifiable disease and mumps vaccine is currently not included in the routine childhood immunization programme. In order to assess the burden of disease, we investigated the seroprevalence of mumps-specific IgG antibodies across four provinces. In addition, we genetically characterized mumps viruses from the past 3 years from several outbreaks and single cases. Blood and/or throat swabs from suspected cases were investigated for specific IgM antibodies or viral RNA. Mumps cases occurred between March and November in 2011-2013 and 5- to 15-year-olds were most affected. Four sequences from an outbreak in the north of Lao PDR in 2011 were identical and belonged to genotype G. Eight sequences from two outbreaks and two individual cases from 2012 and 2013 belonged to genotype J. In addition, sera collected from 2379 healthy infants and school pupils aged between 9 months and 19 years and from pregnant women aged between 16 and 46 years were investigated for mumps-specific IgG. Overall, 58.2% were positive, 39.5% were negative and the remaining 2.3% were equivocal. The seropositivity increased with age, with the lowest percentage found in <1-year-old infants (9.1%) and the highest in the cohort of pregnant women (69.2%). More female subjects than male subjects were seropositive (60.4 vs. 54.9%). There were some differences between the locations. Mumps should be a notifiable disease in Lao PDR in order to get more accurate case numbers and cost estimates for public health-care, and vaccination of children and high-risk groups should be considered.

Identification of enolases and aldolases as important fish allergens in cod, salmon and tuna: component resolved diagnosis using parvalbumin and the new allergens

BACKGROUND

The majority of fish-allergic patients are sensitized to parvalbumin, known to be the cause of important IgE cross-reactivity among fish species. Little is known about the importance of fish allergens other than parvalbumin.

OBJECTIVE

The aim of this study was to characterize hitherto undefined fish allergens in three commonly consumed fish species, cod, salmon and tuna, and to evaluate their importance for in vitro IgE-diagnosis in addition to parvalbumin and fish gelatin.

METHODS

Sixty-two patients were diagnosed by clinical history, skin prick tests and specific IgE to fish extracts. Two new fish allergens from cod, salmon and tuna were identified by microsequencing. These proteins were characterized by immunoblot, ELISA and mediator release assay. Purified parvalbumin, enolase, aldolase and fish gelatin were used for quantification of specific IgE in ELISA.

RESULTS

Parvalbumin and two other allergens of 50 and 40 kDa were detected in IgE-immunoblots of cod, salmon and tuna extracts by most patient sera. The 50 and 40 kDa proteins were identified as beta-enolase and fructose-bisphosphate aldolase A respectively. Both purified enzymes showed allergenic activity in the mediator release assay. Indeed, 72.6% of the patients were sensitized to parvalbumin, 20% of these had specific IgE to salmon parvalbumin only. IgE to enolases were found in 62.9% (0.5-95.0 kUA /L), to aldolases in 50.0% (0.4-26.0 kUA /L) and to fish gelatin in 19.3% (0.4-20.0 kUA /L) of the patients. Inter-species cross-reactivity, even though limited, was found for enolases and aldolases by IgE-inhibition ELISA.

CONCLUSIONS AND CLINICAL RELEVANCE

Fish enolase and aldolase have been identified as important new fish allergens. In fish allergy diagnosis, IgE to enolase and aldolase are especially relevant when IgE to parvalbumin are absent.

Occult hepatitis B infections among blood donors in Lao PDR

BACKGROUND AND OBJECTIVES

In Lao People's Democratic Republic, hepatitis B virus is highly endemic. However, blood donations are only screened for HBsAg, leaving a risk of transmission by HBsAg-negative occult infected donors. Here, we characterized first-time blood donors to assess prevalence of hepatitis B virus infections and occult infected donors.

MATERIALS AND METHODS

Sera were screened for HBsAg, HBeAg and anti-HBs, anti-HBc and anti-HBe antibodies. Occult HBV infections (OBIs) were assessed in HBsAg-negative sera by PCR, and sera of HBsAg positive and occult infected donors were phylogenetically characterized.

RESULTS

9·6% of the donors were HBsAg positive, and 45.5% were positive for at least one of the hepatitis B virus serum markers. More than 40% HBsAg carriers were HBeAg positive, with HBeAg seroconversion occurring around 30 years of age. Furthermore, 10·9% of HBsAg-negative, anti-HBc and/or anti-HBs-positive donors were occult infected with hepatitis B virus. Thus, at least 3·9% of blood donations would potentially be unsafe, but hepatitis B virus DNA copy numbers greatly varied between donors.

CONCLUSION

In Lao People's Democratic Republic, a sizable proportion of HBsAg-negative and anti-HBc antibody-positive blood donations are potentially DNA positive and infective for hepatitis B.

Identification of enolases and aldolases as important fish allergens in cod, salmon and tuna: component resolved diagnosis using parvalbumin and the new allergens

BACKGROUND

The majority of fish-allergic patients are sensitized to parvalbumin, known to be the cause of important IgE cross-reactivity among fish species. Little is known about the importance of fish allergens other than parvalbumin.

OBJECTIVE

The aim of this study was to characterize hitherto undefined fish allergens in three commonly consumed fish species, cod, salmon and tuna, and to evaluate their importance for in vitro IgE-diagnosis in addition to parvalbumin and fish gelatin.

METHODS

Sixty-two patients were diagnosed by clinical history, skin prick tests and specific IgE to fish extracts. Two new fish allergens from cod, salmon and tuna were identified by microsequencing. These proteins were characterized by immunoblot, ELISA and mediator release assay. Purified parvalbumin, enolase, aldolase and fish gelatin were used for quantification of specific IgE in ELISA.

RESULTS

Parvalbumin and two other allergens of 50 and 40 kDa were detected in IgE-immunoblots of cod, salmon and tuna extracts by most patient sera. The 50 and 40 kDa proteins were identified as beta-enolase and fructose-bisphosphate aldolase A respectively. Both purified enzymes showed allergenic activity in the mediator release assay. Indeed, 72.6% of the patients were sensitized to parvalbumin, 20% of these had specific IgE to salmon parvalbumin only. IgE to enolases were found in 62.9% (0.5-95.0 kUA /L), to aldolases in 50.0% (0.4-26.0 kUA /L) and to fish gelatin in 19.3% (0.4-20.0 kUA /L) of the patients. Inter-species cross-reactivity, even though limited, was found for enolases and aldolases by IgE-inhibition ELISA.

CONCLUSIONS AND CLINICAL RELEVANCE

Fish enolase and aldolase have been identified as important new fish allergens. In fish allergy diagnosis, IgE to enolase and aldolase are especially relevant when IgE to parvalbumin are absent.

High genetic diversity including potential new subtypes of hepatitis C virus genotype 6 in Lao People's Democratic Republic

Sera from 105 anti-HCV-positive first-time blood donors collected in 2004, 2005 and 2008 in different provinces in Laos were investigated by PCR. Forty-five samples were positive for HCV (42.86%); two belonged to subtype 1b (2/45, 4.4%) and all others to genotype 6 (43/45, 95.6%), including subtypes 6b, 6h, 6k, 6l, 6n and 6q. Three groups of sequences were not clearly attributable to any genotype 6 subtype, two of which may be regarded as candidates for new subtypes of genotype 6. Two samples were mixed infected with different subtypes or clusters of genotype 6 viruses.

Ongoing large mumps outbreak in the Federation of Bosnia and Herzegovina, Bosnia and Herzegovina, December 2010 to July 2011

Binary file ES_Abstracts_Final_ECDC.txt matches

Ongoing large mumps outbreak in the Federation of Bosnia and Herzegovina, Bosnia and Herzegovina, December 2010 to July 2011

From December 2010 until the end of July 2011, 5,261 mumps cases were recorded in the Federation of Bosnia and Herzegovina, Bosnia and Herzegovina, leading to an incidence of 225.8 per 100,000. Fifteen to 19 year-olds (43%) were most affected and 62% of cases were male. Mumps-specific IgM antibodies were found in about 70% of sera investigated, complications were reported in 41% of 81 hospitalised patients. The outbreak affected mainly those unvaccinated or unaware of their vaccination status and is probably due to vaccination failures during the war and postwar period (1992–1998).

Detection of a new subgenotype of hepatitis B virus genotype A in Cameroon but not in neighbouring Nigeria

To further investigate the genetic diversity of hepatitis B virus (HBV) genotype A in Africa, we analysed 263 HBV strains from Nigeria (n=163) and Cameroon (n=100). Phylogenetic analysis of S fragment sequences attributed 175 strains (66.5%) to genotype E and 88 (33.5%) to genotype A. In Cameroon, genotype A strains were the most prevalent (79/100, 79.0%), whereas, in Nigeria, genotype E was highly dominant (154/163, 94.5%). The genotype A strains grouped with reference strains of subgenotype A3 (n=8), the provisional subgenotype A5 (n=43), a recently reported new variant from Rwanda (n=35), or as outliers (n=2). Ten complete genome sequences obtained from strains that clustered with the new variant from Rwanda formed a separate group supported by a bootstrap value of 96. The between-group distance to other potential or recognized subgenotypes of genotype A was at least 3.81%. Thus, the new group of strains could be considered as a new subgenotype of HBV genotype A, tentatively named 'A7'. Interestingly, the 'A7' strains from Rwanda and Cameroon showed an interspersed clustering, but essentially no other (sub)genotypes were shared between the two countries, suggesting that 'A7' may have evolved in a yet unknown place and may have only relatively recently spread to Rwanda and Western Cameroon. Strains attributed to provisional subgenotype A5 were found for the first time in Cameroon (n=36) and Central Nigeria (n=2), indicating that A5 is more widespread than previously thought.

[Molecular epidemiology of parvovirus infection in Belarus]

The paper analyzes a 994 nucleotide fragment of the NS1/VP1u region junction of 84 parvovirus B19 samples obtained from the sera of erythema infectiosum patients in Belarus in 2006. All the strains belong to genotype 1 as defined by Servant et al. (2002) and form two major clusters within this genotype (1A and 1B) with a clearly distinct geographic distribution. Cluster 1A mainly included B19 strains from Minsk where an outbreak of erythema infectiosum was observed during sample collection. Cluster 1B comprises parvovirus B19 strains obtained from sporadic cases in different parts of the country. The nucleotide variability within cluster 1B (1.1%) was almost two times higher than that within cluster 1A (0.6%). The comparison of the Belarus strains with all parvovirus B19 sequences from the GenBank revealed 22 unique nucleotide substitutions in the new strains, 18 (81.8%) of which were nonsynonymous. A high percentage of parvovirus B19 IgM positive sera were also PCR positive (94.0%; n = 63/67) indicating that both methods are suitable for diagnosis of the infection.

Ongoing rubella outbreak in Bosnia and Herzegovina, March-July 2009--preliminary report

Between 24 March and 31 July 2009, 342 clinically diagnosed cases of rubella were notified in five municipalities in Republika Srpska, Bosnia and Herzegovina. Fourteen cases were laboratory-confirmed by positive IgG against rubella virus. Four virus isolates were obtained and identified as genotype 2B strains, with one isolate differing by a single mutation in the region of the E1 gene. This ongoing outbreak revealed gaps in the immunisation programme during the war in BiH (1992-1995) and highlights the need to revise legislation to permit immunisation of children above 14 years of age with measles, mumps, rubella (MMR) vaccine and to introduce supplemental immunisation activities.

Avian metapneumovirus subtype A in China and subtypes A and B in Nigeria

In order to detect and characterize avian metapneumovirus, organs or swabs were collected from 697 chicken and 110 turkeys from commercial farms in Southwestern Nigeria and from 107 chickens from live bird markets in Southeastern China. In Nigeria, 15% and 6% of the chicken and turkey samples, respectively, and 39% of the chicken samples from China, were positive for aMPV genome by PCR. The sequence of a 400 nt fragment of the attachment protein gene (G gene) revealed the presence of aMPV subtype A in both Nigeria and Southeastern China. Essentially identical subtype A viruses were found in both countries and were also previously reported from Brazil and the United Kingdom, suggesting a link between these countries or a common source of this subtype. In Nigeria, subtype B was also found, which may be a reflection of chicken importations from most major poultry-producing countries in Europe and Asia. In order to justify countermeasures, further studies are warranted to better understand the metapneumoviruses and their impact on poultry production.

Genetic variability and mRNA editing frequencies of the phosphoprotein genes of wild-type measles viruses

The sequences of the nucleoprotein (N) and hemagglutinin (H) genes are routinely used for molecular epidemiologic studies of measles virus (MV). However, the amount of genetic diversity contained in other genes of MV has not been thoroughly evaluated. In this report, the nucleotide sequences of the phosphoprotein (P) genes from 34 wild-type strains representing 15 genotypes of MV were analyzed and found to be almost as variable as the H genes but less variable than the N genes. Deduced amino acid sequences of the three proteins encoded by the P gene, P, V and C, demonstrated considerably higher variability than the H proteins. Phylogenetic analysis showed the same tree topography for the P gene sequences as previously seen for the N and H genes. RNA editing of P gene transcripts affects the relative ratios of P and V proteins, which may have consequences for pathogenicity. Wild-type isolates produced more transcripts with more than one G insertion; however, there was no significant difference in the use of P and V open reading frames, suggesting that the relative amounts of P and V proteins in infected cells would be similar for both vaccine and wild-type strains.

Multiple genotypes and subtypes of hepatitis B and C viruses in Belarus: similarities with Russia and western European influences

The Republic of Belarus reports a seroprevalence of 4.8% for hepatitis B virus (HBV) and 1.26% for hepatitis C virus (HCV), but little is known about the molecular characteristics of the circulating viruses. This study analysed 69 HBV surface antigen (HBsAg)-positive and 113 anti-HCV-positive donors attending a national reference hospital in Minsk. Among the HCV patients, 70% were co-infected with human immunodeficiency virus (HIV). Phylogenetic analysis of 12 complete genomes and 31 partial HBV sequences, as well as 78 core/E1 HCV sequences, revealed that multiple genotypes and subtypes of both viruses were circulating in Belarus. Of the HBV strains, 11.6% were genotype A2 and 88.6% were genotype D. The genotype D strains segregated into four recently described subtypes, with D2 being the most prevalent (58.1%), followed by D3 (16.3%), D1 (11.6%) and D4 (2.3%), but with inter-subtypic distances lower than the minimal 4% distance proposed to define subtypes. The 78 HCV strains belonged to subtypes 1b (53.8%), 3a (38.5%), 1a (5.1%), 4a (1.3%) and 4d (1.3%). Subtype 1b was less prevalent (45.1% vs. 70.4%) among HCV/HIV co-infected donors, while subtype 3a was more prevalent (29.6% vs. 43.1%). The relative prevalence of HBV and HCV genotypes in Belarus corresponded to the prevalence in Russia, although with a clear European influence that reflected the socio-political context of the country.

Molecular and antigenic evolution and geographical spread of H5N1 highly pathogenic avian influenza viruses in western Africa

In Africa, highly pathogenic avian influenza H5N1 virus was first detected in northern Nigeria and later also in other regions of the country. Since then, seven other African countries have reported H5N1 infections. This study reports a comparison of full-length genomic sequences of H5N1 isolates from seven chicken farms in Nigeria and chicken and hooded vultures in Burkina Faso with earlier H5N1 outbreaks worldwide. In addition, the antigenicity of Nigerian H5N1 isolates was compared with earlier strains. All African strains clustered within three sublineages denominated A (south-west Nigeria, Niger), B (south-west Nigeria, Egypt, Djibouti) and C (northern Nigeria, Burkina Faso, Sudan, Côte d'Ivoire), with distinct nucleotide and amino acid signatures and distinct geographical distributions within Africa. Probable non-African ancestors within the west Asian/Russian/European lineage distinct from the south-east Asian lineages were identified for each sublineage. All reported human cases in Africa were caused by sublineage B. Substitution rates were calculated on the basis of sequences from 11 strains from a single farm in south-west Nigeria. As H5N1 emerged essentially at the same time in the north and south-west of Nigeria, the substitution rates confirmed that the virus probably did not spread from the north to the south, given the observed sequence diversity, but that it entered the country via three independent introductions. The strains from Burkina Faso seemed to originate from northern Nigeria. At least two of the sublineages also circulated in Europe in 2006 as seen in Germany, further suggesting that the sublineages had already emerged outside of Africa and seemed to have followed the east African/west Asian and Black Sea/Mediterranean flyways of migratory birds.

Multiple introductions of H5N1 in Nigeria

As the avian influenza virus H5N1 swept from Asia across Russia to Europe, Nigeria was the first country in Africa to report the emergence of this highly pathogenic virus. Here we analyse H5N1 sequences in poultry from two different farms in Lagos state and find that three H5N1 lineages were independently introduced through routes that coincide with the flight paths of migratory birds, although independent trade imports cannot be excluded.

Seroprevalence of Avian Influenza Virus, Infectious Bronchitis Virus, Reovirus, Avian Pneumovirus, Infectious Laryngotracheitis Virus, and Avian Leukosis Virus in Nigerian Poultry

Eight poultry farms in Nigeria, including chickens from nine breeder, 14 broiler, 28 pullet, 11 layer, and three cockerel flocks, were tested for antibody seroprevalence to the following poultry viruses of potential economic importance: infectious bronchitis virus (IBV), avian reovirus, avian pneumovirus (APV), infectious laryngotracheitis virus (ILTV), avian influenza virus (AIV), and avian leukosis virus (ALV). Serum samples were collected between 1999 and 2004 and were tested for antibodies using commercial enzyme-linked immunosorbent assay (ELISA) kits. Seroprevalence was very high for IBV (84%); intermediate for reovirus (41%), APV (40%), and ILTV (20%); and very low for ALV (<5%) antibodies. By commercial ELISA, the seroprevalence of antibodies against AIV was, in some flocks, up to 63%. However, more specific assays did not confirm AIV antibodies, indicating that all flocks tested were free of avian influenza antibodies. Birds seemed to be first infected by IBV (at about 7 wk of age), then by reovirus at 12 wk, before they became infected by APV (week 25) and ILTV (week 30). This is the first report of serological evidence of the above viruses in West Africa. Further studies are necessary to assess economic losses due to these avian viruses and the costs and benefits of countermeasures.

Molecular epidemiology of chicken anemia virus in Nigeria

Between February 2002 and May 2004, chicken anemia virus (CAV) was detected by PCR in organ samples from 14 flocks of poultry farms in Lagos, Ogun and Oyo States in Southwestern Nigeria. The farms reported low (<5%) to high mortalities (up to 100%) with various lesions at necropsy. The complete VP1 gene of 30 of these positive strains was sequenced. Strains that diverged by up to 4.4% on a nucleotide level differed only by up to 2.5% at the amino acid level (7 aa) as a result of clustered silent mutations. No amino acid substitutions specific for Nigerian strains were observed. Some birds had a CAV mixed infection. Genetic clustering of the VP1 gene did not correlate with differences in flock mortality but the co-infection of CAV with IBDV may be particularly lethal. This first molecular epidemiological study of CAV in Africa shows that the Nigerian strains cluster with viruses from very diverse geographic origins and were almost as diverse (4.4%) as all other strains combined (5.8%).

Passive immunity to measles in the breastmilk and cord blood of some nigerian subjects

Maternal and cord blood collected from 33 Nigerian mother-child pairs were tested for measles-sepcific IgG. All 33 had protective measles antibodies at the time of delivery with a positive correlation of r = 0.87. Determination of the rate of waning of these antibodies revealed that 58 per cent of these children had lost the protective maternal antibody by the age of 4 months and only 3 per cent of the children had enough antibody to protect them between the ages of 6-9 months. Fifty-five colostrum samples from the same mothers and 347 breastmilk samples collected at various periods of breastfeeding also showed that anti-measles IgA had dropped below the protective cut-off within the first 2 weeks of birth. It is evident that the Nigerian child is born with solid anti-measles antibody but the rate of waning has left a large number unprotected before the first dose of the vaccine. There is an urgent need to review the measles vaccination programme in Nigeria to protect these susceptible infants.

Serologic evidence of chicken infectious anemia in commercial chicken flocks in southwest Nigeria

Sera samples from seven poultry farms in southwest Nigeria consisting of 7 broiler, 10 pullet, 1 layer, 1 cockerel, and 1 broiler breeder flocks were tested for the presence of chicken infectious anemia virus (CIAV) antibodies using a commercial enzyme-linked immunosorbent assay kit. Eleven of the 20 flocks (55%) and six out of seven (86%) farms were positive for CIAV antibodies. The seroprevalence largely depended on the age of the flocks. Seroprevalence was higher within the older pullet and layer flocks (83%-100%) than in the younger broiler flocks (0%-83%). In essence, all flocks older than 6 to 8 wk became infected. This is the first report of serologic evidence of CIAV in Subsaharan Africa. Since Southwest Nigeria is the main port of entry of imported chicken and the hub of major poultry breeders, the disease can probably be found throughout the country and beyond. Further studies are necessary to assess economic losses due to CIAV and the cost benefit of countermeasures.

High sequence diversity in infectious bursal disease virus serotype 1 in poultry and turkey suggests West-African origin of very virulent strains

Fifty-eight outbreaks of Infectious bursal disease virus (IBDV) were observed in vaccinated chicken flocks in four Southwestern states of Nigeria between 1995 and 2000. Bursa samples from 40 flocks were found virus-positive in VP2-specific nested RT-PCR. Sequences of the hypervariable region of VP2 were compared to reference strains of the different IBDV variants including also 1988 isolates from Nigeria. Sequence analysis revealed that all 40 Nigerian isolates belonged to the very virulent (vv) variant. The maximum sequence diversity of 5.7% was higher than in all other vvIBDV sequences listed in Genbank (3.6%). Two clusters within Nigerian isolates are unique to this region. Serotype 1 IBDV was also detected in four symptomatic turkey flocks. The turkey isolates were found within 2 of the 3 VV-clusters of chicken isolates. Full length sequence of a turkey isolate (NIE009t) confirmed its close relation to vvIBDV strain D6948NET for both segment A (1.4% sequence diversity) and segment B (2.1%). Thus, turkeys should be considered susceptible to vvIBDV infection. The unusually high sequence diversity of vvIBDV may be an indication of a West-African origin of this virus, from where it spread to other continents.

Immunodominant domains of the Measles virus hemagglutinin protein eliciting a neutralizing human B cell response

The most important neutralizing and protective antibodies against Measles virus (MeV) are directed against the hemagglutinin protein (MeV-H). To define the MeV binding domains recognized by human antibodies a set of 10 non-redundant MeV-H-specific monoclonal antibodies (mabs) was used to block their binding in a competition ELISA. Sera from both naturally infected and vaccinated individuals showed similar competition patterns. Two distinct domains were identified as the main target of human antibodies. One domain corresponded to the region of the previously described hemagglutinin noose epitope (HNE, aa 380-400) [35], which is recognized by hemagglutination-inhibiting, neutralizing and protective mabs. The second region is defined by a mab with strong neutralizing but weak hemagglutination-inhibiting activity. Mabs with a strong neutralizing capacity with respect to wild-type viruses seemed to displace more human antibodies than those with a weaker neutralizing activity. Human antibodies seem to react more weakly with the hemagglutinin regions that bind the CD46 and the fusion protein and more strongly with the putative CD150 binding site and the top loops of beta-sheet 2 and 3 of the hemagglutinin.

Neutralizing immunogenicity of transgenic carrot (Daucus carota L.)-derived measles virus hemagglutinin

Although edible vaccines seem to be feasible, antigens of human pathogens have mostly been expressed in plants that are not attractive for human consumption (such as potatoes) unless they are cooked. Boiling may reduce the immunogenicity of many antigens. More recently, the technology to transform fruit and vegetable plants have become perfected. We transformed carrot plants with Agrobacterium tumefaciens to generate plants (which can be eaten raw) transgenic for an immunodominant antigen of the measles virus, a major pathogen in man. The hemagglutinin (H) glycoprotein is the principle target of neutralizing and protective antibodies against measles. Copy numbers of the H transgene were verified by Southern blot and specific transcription was confirmed by RT-PCR. The H protein was detected by western blot in the membrane fraction of transformed carrot plants. The recombinant protein seemed to have a 8% lower molecular weight than the viral protein. Although this suggests a different glycosylation pattern, proper folding of the transgenic protein was confirmed by conformational-dependent monoclonal antibodies. Immunization of mice with leaf or root extracts induced high titres of IgG1 and IgG2a antibodies that cross-reacted strongly with the measles virus and neutralized the virus in vitro. These results demonstrate that transgenic carrot plants can be used as an efficient expression system to produce highly immunogenic viral antigens. Our study may pave the way towards an edible vaccine against measles which could be complementary to the current live-attenuated vaccine.

Phylogenetic analysis of new hepatitis B virus isolates from Nigeria supports endemicity of genotype E in West Africa

Isolates of hepatitis B viruses were collected from 20 acute and chronic hepatitis patients in a highly endemic region of Nigeria. Sequencing classified the isolates to the ayw4, as they all contained the amino acid variations characteristic for that serotype. In the pre-S2 region of five isolates, three to seven amino acids were deleted, suggesting that immune escape mutations previously associated only with chronic HBV infection may be observed also in acute disease. Phylogenetic analysis of the complete pre-S2/S (large S) genes (831 nt) demonstrated that all the viruses belonged to the same genotype E. So far, no isolates of genotype E have been found in any other region of the world, including the Americas. This may suggest a relatively recent introduction of this genotype into humans and would explain the relatively low genetic diversity of viruses belonging to this genotype. One genotype E virus had been found previously in a chimpanzee, and viruses belonging to the CHIMP genotype are related to other genotype E viruses. These findings are compatible with a transmission of genotype E viruses from chimpanzees to humans.

Heteroduplex mobility assay (HMA) pre-screening: an improved strategy for the rapid identification of inserts selected from phage-displayed peptide libraries

Phage-displayed peptide libraries represent an efficient tool to isolate peptides that bind a given target molecule. After several selection rounds, generally a large pool of target binding phages is obtained. Conventional analysis of the selected phage population involves extensive sequencing of many clones, most of which can be identical. We have adapted the Heteroduplex Mobility Assay (HMA) for pre-screening of phage inserts that were amplified by direct colony PCR of ELISA-positive clones. This strategy allowed for the rapid and reproducible assignment of insert sequences to different 'heteroduplex migration groups'. Sequence analysis of only one representative of each HMA migration group then completes the characterisation of the binding phage population. In our model experiments, only 16% of HMA pre-screened clones required further sequence analysis.

Genetic analysis of Asian measles virus strains--new endemic genotype in Nepal

In many parts of Asia measles virus (MV) continues to be endemic. However, little is known about the genetic characteristics of viruses circulating on this continent. This study reports the molecular epidemiological analysis based on the entire nucleocapsid (N) and hemagglutinin (H) genes of the first isolates from Nepal and Taiwan, as well as of recent MV strains from India, Indonesia, and China. Four isolates collected in various regions in Nepal during 1999 belonged to a new genotype, tentatively called D8. Another Nepalese isolate and one from India belonged to genotype D4. The diversity of the Nepalese strains indicated that measles continues to be endemic in this country. The isolate from Taiwan grouped with D3 viruses and one Chinese strain isolated in The Netherlands was assigned to the previously described clade H, known to be endemic in Mainland China. Molecular characterization emerges as an important tool for monitoring virus endemicity and vaccination efforts.

Measles elimination: old and new challenges?

Life attenuated measles vaccines have dramatically reduced measles morbidity and mortality world-wide. Despite high vaccination coverage, measles outbreaks continue to occur both in developed and developing countries. While secondary vaccine failure may be responsible for disease in some seroconverted individuals, evidence suggests that many more vaccinees who are protected against disease may not be fully protected against virus infection. In low-income developing countries protection by maternal antibodies seems to erode faster than previously estimated especially in infants who were born to vaccinated mothers. Problems of infectivity and susceptibility of vaccinees will be compounded in case wild-type viruses become less sensitive to vaccine induced immunity. These observations suggest that elimination may be more easily achieved as long as large proportions of populations are protected by wild-type virus-induced immunity.

New strategies for closing the gap of measles susceptibility in infants: towards vaccines compatible with current vaccination schedules

Peptides representing epitopes of the measles virus glycoproteins have been designed to induce neutralizing and protective antibodies. Those that escape recognition by passively acquired anti-whole virus antibodies could potentially be used as components of a 'pre-vaccine' that could be given during early childhood irrespective of persisting maternal antibodies. Unlike vaccines based on recombinant proteins, epitope-based vaccines can be designed to be compatible with a subsequent boost with the standard life attenuated vaccine. Although synthetic peptides may induce only short-term immunity they have the potential to close in young infants the gap of vulnerability until the standard live attenuated vaccine can be given at 9 or 15 months of age.

Monitoring of measles elimination using molecular epidemiology

The different measles virus genotypes are confined to more or less distinct geographic regions. Molecular characterization of virus isolates has been successfully used to determine epidemiological links between cases and the geographic origin of imported viruses. In Europe, indigenous measles has been eliminated in some countries, but in others the disease is still endemic. Intra-outbreak variability can be used to differentiate between sporadic endemic cases and a 'pseudo-outbreak' of unrelated imported cases. The interruption of virus circulation by mass vaccination campaigns could be demonstrated by comparing the variability of pre-campaign viruses with post-campaign isolates. Simplified tools are being developed that could bring genotyping within reach of laboratories that do not have the possibility of sequencing.

An outbreak of African Swine Fever in Nigeria: virus isolation and molecular characterization of the VP72 gene of a first isolate from West Africa

The isolation of 98/ASF/NG, a strain of African Swine Fever Virus (ASFV) associated with a 1998 epizootic in Nigeria, is reported. This first isolate of the virus from West Africa was identified through a successful polymerase chain reaction (PCR) amplification and sequencing of a 280 base pair (bp) fragment of the Major Capsid Protein (VP72) gene. Further amplification and sequence analysis of a 1.9 kilobase pair (kbp) fragment encompassing the complete VP72 gene showed that the isolate has a 92.2%, 92.4%, and 97.2% homology with previously sequenced Ugandan, Dominican Republican and Spanish isolates respectively. Of the 50 nucleotide changes observed in this highly conserved gene, 45 were found to result in 40 amino acid changes clustered around the central region (position 426 to 516) of the VP 72 protein while changes at the remaining 5 positions were silent. These changes also led to the loss of two out of the seven potential N-glycosylation sites which are in this gene conserved among all isolates. The possible epizootiological implications of such mutations in a highly conserved gene of a DNA virus is discussed in relation to this outbreak.

Antigenic and immunogenic phage displayed mimotopes as substitute antigens: applications and limitations

The most exciting potential of phage displayed peptide libraries is to obtain small peptide molecules that mimic an antigen, at least with respect to a particular epitope. In addition to their interest as research tools, such mimotopes could in principle be useful as diagnostic tools or for eliciting antibodies to a predefined epitope. However, the reduction of the phage insert sequence to a short peptide that can compete with the antigenic and in particular with the immunogenic properties of the natural antigen faces considerable difficulties. This review assesses critically the antigenicity of phage displayed peptides as free peptides and in different molecular environments. The difficulties to use mimotopes to induce antibodies that bind to the natural antigen (crossreactive immunogenicity) and the considerable discrepancy between antigenicity and immunogenicity of phage-derived peptides are discussed. Peptides selected with antibodies from phage displayed random peptide libraries have raised considerable expectations as low molecular weight substitutes of the natural antigen. This review will focus on the results of phage displayed random peptide libraries screened with antibodies specific for proteins, carbohydrates and nucleic acids and critically examine how the above expectations have been met.

Resistance of recent measles virus wild-type isolates to antibody-mediated neutralization by vaccinees with antibody

The neutralization capacity of sera from Luxembourgian adolescent vaccinees and from Nigerian women with measles-induced immunity to a number of measles virus strains was compared. Although both cohorts were matched for their hemagglutination inhibition and standard neutralization titers, 12 of the 22 late convalescent sera, and only 6 of 24 vaccinees neutralized all viruses. Similarly, only 2 of 20 viruses were not neutralized by at least 75% of late convalescent sera, in comparison to 10 of 20 viruses that resisted neutralization by at least 75% of the vaccinees. The more resistant viruses were not limited to a certain clade. One Nigerian virus was resistant to neutralization by 30% of the late convalescent women and by 75% of vaccinees. These results suggest that qualitative differences in neutralizing antibodies may reduce further protection of infants by passively acquired immunity against wild-type viruses when vaccinated girls become mothers.

Differential antigenicity of recombinant polyepitope-antigens based on loop- and helix-forming B and T cell epitopes

To investigate a strategy for the design of chimeric antigens based on B cell epitopes (BCEs) we have genetically recombined multiple copies of loop- (L) and helix-forming (H) sequential and protective BCEs of the measles virus hemagglutinin protein (MVH) in a number of high-molecular-weight polyepitope constructs (24.5-45.5 kDa). The BCE cassettes were combined semi-randomly together with a promiscuous T cell epitope (TCE; tt830-844) to yield 13 different permutational constructs. When expressed in mammalian cells, all constructs were detectable by Western blot as distinct bands of predicted molecular weight. Flow cytometry with conformation-specific antibodies revealed the Cys-loop in two [(L(4)T(4))(2) and (L(2)T(2))(4)] and the helix conformation in one [(H(2)T(2))(4)] of the different permutational constructs. The larger constructs, containing 16 epitope cassettes, seemed more likely to express the BCEs in their native conformation than the 8-mers. In the T cell proliferation assay, constructs with a higher copy number of TCEs, such as (L(2)T(2))(4), were more antigenic, as long as tandem repeats were separated by spacers. Since the conformation of even sequential BCEs and the processing of TCEs are both sensitive to their molecular environment it is difficult to predict the antigenic properties of polyepitopes. However, with the permutational approach we have developed several polyepitope constructs [(L(4)T(4))(2), (L(2)T(2))(4), (H(2)T(2))(4)] based on complex sequential BCEs that are antigenic for both T and B cells. Several constructs induced sera that reacted with reporter peptides, demonstrating that the sequential nature of the viral epitopes was conserved in the polyepitopes. Although several sera contained antibodies directed against amino acids critical for neutralization, only one construct induced antibodies that cross-reacted with the virus. Our results show the difficulty of designing chimeric antigens based on B cell epitopes mimicking their antigenic and immunologic properties even when these are sequential in nature.

Placental transfer and decay of maternally acquired antimeasles antibodies in Nigerian children

BACKGROUND

In developing countries vaccination against measles virus (MV) is generally administered at 9 months of age, although it is well-documented that protection of most infants by passively acquired maternal MV antibodies is waning before immunization is given. The purpose of this study was to investigate the decay of maternally derived MV antibodies in Nigerian infants as well as to compare a German and Nigerian cohort of paired mothers and newborns regarding the placental transfer efficiency of MV-specific IgG and total IgG antibodies.

METHODS

MV-specific IgG antibodies were measured with a commercially available MV-enzyme-linked immunosorbent assay, a recombinant hemagglutinin enzyme-linked immunosorbent assay as well as a neutralization assay. Total IgG values were determined with a standard immunoturbidimetric test.

RESULTS

Anti-MV IgG titers were twice as high in German newborns as in Nigerian newborns. An increased concentration of immunoglobulins transferred via the placenta was found only in the German cohort. High concentrations of total maternal IgG reduced the concentration of MV-specific as well as total IgG that crossed the placenta. Furthermore only 17% of the 4-month-old Nigerian infants were still protected against measles. Antibodies had a biologic half-life of 33 days and a biochemical half-life of 48 days.

CONCLUSIONS

Our findings demonstrate that the decay of passively acquired MV antibodies occurred even more rapidly than expected resulting in susceptibility to MV in most of the 4-month-old infants in Nigeria. Furthermore transfer of maternal anti-MV IgG and total IgG antibodies to the newborn was more efficient in the German cohort compared with the Nigerian group. These findings suggest the use of alternative vaccination strategies in developing countries to possibly reduce the window of susceptibility against measles.

Genetic variability of measles viruses circulating in the Benelux

In Europe measles incidence remains high and in some parts the disease is likely to be still endemic due to insufficient vaccination. Luxembourg experienced an outbreak with at least 110 cases in 1996, and cases continued to be reported throughout 1997. We used molecular epidemiology to investigate this apparent endemicity. On the basis of their N gene sequences, the isolates were assigned to the typical European C2 and D6 genotypes. Sequence diversity within the outbreak was 0.2%. The nucleotide distance between the C2-viruses of the outbreak and the other C2 isolates was at least three or four times higher, suggesting an independent origin of the latter viruses. Similarly, the four D6 viruses found in Luxembourg were thought to be of at least two or three origins. Thus, we propose here to use intra-outbreak sequence diversity to differentiate between sporadic endemic cases and a "pseudo-outbreak" of multiple unrelated imported cases.

Estimation of the basic reproduction number of measles during an outbreak in a partially vaccinated population

From March to July 1996 a measles outbreak occurred in northern Luxembourg with 110 reported cases centered around two primary schools (85 cases) and the surrounding community (25 cases). Eighty four suspected cases were confirmed serologically. Vaccine coverage was estimated from questionnaire-based surveys at the two primary schools to be 70 and 76%, respectively. Vaccine efficacy during the outbreak was estimated to be 94.6% [95% confidence interval (CI) 90.4-97.0]. Using the information from the, school surveys, we obtained estimates of the basic reproduction number of measles of 7.7 (95% CI 4.4-11.0) and 6.2 (95% CI 3.5-8.9), respectively. Assuming a 95% vaccine efficacy, these estimates correspond to minimal vaccine coverages of 91.6% (95% CI 81.4-95.7) and 88.3% (95% CI 75.5-93.4) which would have been necessary to minimize the chances of a major outbreak occurring. We can confirm that major outbreaks in similar school settings can only be prevented if vaccination coverage exceeds 90%.

Expression of measles virus antigens in Streptococcus gordonii

The measles virus proteins haemagglutinin (HA) and fusion protein (F), which together mediate attachment and penetration of the virus in the host cell and can elicit production of neutralising antibodies in the course of natural infection were expressed in the vaccine vector Streptococcus gordonii, a Gram-positive bacterium normally present in the human oral cavity. HA and F were expressed as fusion proteins attached to the bacterial surface, and were both found to be immunogenic when the recombinant S. gordonii were inoculated subcutaneously in mice.

Neutralization of measles virus wild-type isolates after immunization with a synthetic peptide vaccine which is not recognized by neutralizing passive antibodies

The sequence H379-410 of the measles virus haemagglutinin (MV-H) protein forms a surface-exposed loop and contains three cysteine residues (Cys-381, Cys-386 and Cys-394) which are conserved among all measles isolates. It comprises the minimal sequential B cell epitope (BCE) (H386-400) of the neutralizing and protective MAb BH6 that neutralizes all wild-type viruses tested. The aim of this study was to design synthetic peptides which induce neutralizing antibodies against MV wild-type isolates. Peptides containing one or two copies of T cell epitopes (TCE) and BCEs of different lengths (H386-400, B(CC); H379-400, B(CCC)), in different combinations and orientations were produced and iteratively optimized for inducing neutralizing antibodies. Peptides with the shorter BCE induced sera that cross-reacted with MV but did not neutralize. The longer BCE containing the three cysteines (B(CCC)) and two homologous TCE were required for neutralization activity. These sera neutralized wild-type strains of different clades and geographic origins. Neutralizing serum was also obtained after immunization with human promiscuous TCEs. Furthermore B(CCC)-based peptides were fully immunogenic even in the presence of pre-existing MV-specific antibodies. The results suggest that subunit vaccines based on such peptides could potentially be used to actively protect infants against wild-type viruses irrespective of persisting maternal antibodies.

Evaluation of different measles IgG assays based on recombinant proteins using a panel of low-titre sera

During the WHO campaign to eradicate measles, accurate discrimination between immune and non-immune individuals will become increasingly important. Due to waning immunity in vaccinated populations, the performance of a measles IgG assay depends mainly on its ability to detect reliably seronegative individuals among many vaccinees with low antibody levels. New serological tests based on recombinant proteins detect only a fraction of the total measles virus (MV) specific antibodies. Therefore, several assays based on recombinant MV-haemagglutinin (ELISA and flow cytometry) or MV-fusion protein (flow cytometry) as well as neutralisatlon and haemagglutination test have been evaluated using a large panel of low-titre and negative sera. Since such an evaluation is highly dependent on threshold values for positivity, the receiver operating characteristic curve analysis was applied. The H-FACS and the H-ELISA showed the best performing characteristics (specificity: 97.4 and 96.1%, respectively; sensitivity: 88.1 and 89.6%, respectively) and may be an alternative to the neutralisation assay. The number of undefined/grey zone sera was significantly lower compared to a commercial whole virus-based ELISA and therefore fewer individuals would be vaccinated unnecessarily.

Measles in a Dutch hospital introduced by an immuno-compromised infant from Indonesia infected with a new virus genotype

A fatal measles case in an immunocompromised Indonesian child was associated with nosocomial transmission to health care workers. The virus isolated proved to represent a new genotype within clade G.