Etiological and epidemiological features of acute meningitis or encephalitis in China: a nationwide active surveillance study.

BACKGROUND: Acute meningitis or encephalitis (AME) results from a neurological infection causing high case fatality and severe sequelae. AME lacked comprehensive surveillance in China. METHODS: Nation-wide surveillance of all-age patients with AME syndromes was conducted in 144 sentinel hospitals of 29 provinces in China. Eleven AME-causative viral and bacterial pathogens were tested with multiple diagnostic methods. FINDINGS: Between 2009 and 2018, 20,454 AME patients were recruited for tests. Based on 9,079 patients with all-four-virus tested, 28.43% (95% CI: 27.50%‒29.36%) of them had at least one virus-positive detection. Enterovirus was the most frequently determined virus in children <18 years, herpes simplex virus and Japanese encephalitis virus were the most frequently determined in 18-59 and ≥60 years age groups, respectively. Based on 6,802 patients with all-seven-bacteria tested, 4.43% (95% CI: 3.94%‒4.91%) had at least one bacteria-positive detection, Streptococcus pneumoniae and Neisseria meningitidis were the leading bacterium in children aged <5 years and 5-17 years, respectively. Staphylococcus aureus was the most frequently detected in adults aged 18-59 and ≥60 years. The pathogen spectrum also differed statistically significantly between northern and southern China. Joinpoint analysis revealed age-specific positive rates, with enterovirus, herpes simplex virus and mumps virus peaking at 3-6 years old, while Japanese encephalitis virus peaked in the ≥60 years old. As age increased, the positive rate for Streptococcus pneumoniae and Escherichia coli statistically significantly decreased, while for Staphylococcus aureus and Streptococcus suis it increased. INTERPRETATION: The current findings allow enhanced identification of the predominant AME-related pathogen candidates for diagnosis in clinical practice and more targeted application of prevention and control measures in China, and a possible reassessment of vaccination strategy. FUNDING: China Mega-Project on Infectious Disease Prevention and the National Natural Science Funds.

Etiological and epidemiological features of acute respiratory infections in China.

Nationwide prospective surveillance of all-age patients with acute respiratory infections was conducted in China between 2009‒2019. Here we report the etiological and epidemiological features of the 231,107 eligible patients enrolled in this analysis. Children <5 years old and school-age children have the highest viral positivity rate (46.9%) and bacterial positivity rate (30.9%). Influenza virus, respiratory syncytial virus and human rhinovirus are the three leading viral pathogens with proportions of 28.5%, 16.8% and 16.7%, and Streptococcus pneumoniae, Mycoplasma pneumoniae and Klebsiella pneumoniae are the three leading bacterial pathogens (29.9%, 18.6% and 15.8%). Negative interactions between viruses and positive interactions between viral and bacterial pathogens are common. A Join-Point analysis reveals the age-specific positivity rate and how this varied for individual pathogens. These data indicate that differential priorities for diagnosis, prevention and control should be highlighted in terms of acute respiratory tract infection patients' demography, geographic locations and season of illness in China.

Etiological, epidemiological, and clinical features of acute diarrhea in China.

National-based prospective surveillance of all-age patients with acute diarrhea was conducted in China between 2009‒2018. Here we report the etiological, epidemiological, and clinical features of the 152,792 eligible patients enrolled in this analysis. Rotavirus A and norovirus are the two leading viral pathogens detected in the patients, followed by adenovirus and astrovirus. Diarrheagenic Escherichia coli and nontyphoidal Salmonella are the two leading bacterial pathogens, followed by Shigella and Vibrio parahaemolyticus. Patients aged <5 years had higher overall positive rate of viral pathogens, while bacterial pathogens were more common in patients aged 18‒45 years. A joinpoint analysis revealed the age-specific positivity rate and how this varied for individual pathogens. Our findings fill crucial gaps of how the distributions of enteropathogens change across China in patients with diarrhea. This allows enhanced identification of the predominant diarrheal pathogen candidates for diagnosis in clinical practice and more targeted application of prevention and control measures.

Yersinia pseudotuberculosis Exploits CD209 Receptors for Promoting Host Dissemination and Infection.

Yersinia pseudotuberculosis is a Gram-negative enteropathogen and causes gastrointestinal infections. It disseminates from gut to mesenteric lymph nodes (MLNs), spleen, and liver of infected humans and animals. Although the molecular mechanisms for dissemination and infection are unclear, many Gram-negative enteropathogens presumably invade the small intestine via Peyer's patches to initiate dissemination. In this study, we demonstrate that Y. pseudotuberculosis utilizes its lipopolysaccharide (LPS) core to interact with CD209 receptors, leading to invasion of human dendritic cells (DCs) and murine macrophages. These Y. pseudotuberculosis-CD209 interactions result in bacterial dissemination to MLNs, spleens, and livers of both wild-type and Peyer's patch-deficient mice. The blocking of the Y. pseudotuberculosis-CD209 interactions by expression of O-antigen and with oligosaccharides reduces infectivity. Based on the well-documented studies in which HIV-CD209 interaction leads to viral dissemination, we therefore propose an infection route for Y. pseudotuberculosis where this pathogen, after penetrating the intestinal mucosal membrane, hijacks the Y. pseudotuberculosis-CD209 interaction antigen-presenting cells to reach their target destinations, MLNs, spleens, and livers.

[Investigation on distribution of Yersinia enterocolitica in Henan province between 2005 and 2011].

OBJECTIVE: To investigate the distribution of Yersinia enterocolitica in Henan province from 2005 to 2011. METHODS: A total of 6700 samples of stool specimen were collected from diarrhea patients and different domestic animals between 2005 and 2011 from Zhengzhou, Suixian and Dengfeng, as well as flies and the daub specimens of raw and cooked meat products. The bacteria were isolated by cold enrichment method, analyzed by the systematic biochemistry to determine the serotypes and bio-types, and tested the virulence genes by PCR method. RESULTS: A total of 216 strains of Yersinia enterocolitica were isolated from 11 kinds of animal hosts and foods, while 29.63% (64/216) of them were from swine. The dominant epidemic serotypes of the Yersinia enterocolitica were O: 5 and O: 8, accounted for 23.2% (50/216) and 20.4% (44/216), respectively; type 1A was the dominant bio-type, accounted for 84.7% (183/216). The dominant serotype and bio-type differed a lot among various hosts.16 pathogenic strains were isolated from swine, followed by diarrhea patients (6 strains) and dogs (6 strains). CONCLUSION: The distribution of the host of Yersinia enterocolitica was widespread, while swine was the dominant animal host.

[An etiological survey on a foodborne disease epidemic outbreak caused by Salmonella enteritidis].

OBJECTIVE: To conduct an etiological molecular epidemiological survey and laboratory test on a foodborne disease epidemic outbreak to make clear of the cause and implement effective prevention and control on it. METHODS: On May 12th 2012, 135 kindergarten children were sent to Xuzhou City People's Hospital and Children's Hospital with gastrointestinal infection disease. A total of 34 anus swab samples and 4 vomit samples were collected from the patients. Real-time PCR rapid detection, strains separation and cultivation, phage lysis experiments, ATB automated identification system were used to make etiological detection and identification. The genomic DNA of salmonella enteritidis were typed with the pulsed-field gel electrophoresis (PFGE), cluster analysis were carried out together with the patterns of local Salmonella infections. RESULTS: Children in 20 classes were suffered from the gastrointestinal infection among the 21 classes. There were no significant aggregation of class distribution. Among the 135 patients, 76 were boys (56.3%) and 59 were girls (43.7%). The main symptoms were fever (above 38°C), diarrhea and bellyache. Through real-time PCR detection and strains separation, 19 salmonella enteritidis were isolated from 34 anus swab samples of suspected cases and the detection rate was 56%. There were no strains detected from vomit samples. All of the 19 salmonella enteritidis showed the same serological subtype, biochemical reaction, drug sensitivity and phage lysis pattern. The salmonella enteritidis had the identical PFGE pattern (100% similarity), and were different from the pattern of local sporadic infection cases. CONCLUSION: It was confirmed that this was an epidemic outbreak of foodborne disease caused by homologous salmonella enteritidis by epidemiological survey, clinical information, lab etiological test and molecular typing.

Comparison of lipopolysaccharide and protein immunogens from pathogenic Yersinia enterocolitica bio-serotype 1B/O:8 and 2/O:9 using SDS-PAGE.

OBJECTIVE: Yersinia enterocolitica is an extracellular pathogen and its related antigens interact with the host immune system. We investigated the difference in immunological characteristics between a highly pathogenic and poorly pathogenic strain of Y. enterocolitica. METHODS: We used SDS-PAGE and western blotting to characterize lipopolysaccharide (LPS), Yersinia outer membrane proteins (Yops), membrane proteins, and whole-cell proteins from poorly pathogenic Y. enterocolitica bio-serotype 2/O:9, isolated from China, and highly pathogenic bio-serotype 1B/O:8, isolated from Japan. RESULTS: These two strains of Y. enterocolitica had different LPS immune response patterns. Comparison of their Yops also showed differences that could have accounted for their differences in pathogenicity. The membrane and whole-cell proteins of both strains were similar; immunoblottting showed that the 35 kD and perhaps the 10 kD proteins were immunogens in both strains. CONCLUSION: The major antigens of the two strains eliciting the host immune response were the LPS and membrane proteins, as shown by comparing protein samples with reference and purified preparations.

[Molecular analysis on non-O1 and non-O139 Vibrio cholerae isolates].

OBJECTIVE: According to results from the two-month consecutive surveillance program in Maanshan, six suspected cases of non-O1 non-O139 Vibrio (V.) cholerae infection, were found that called for identification of pathogens as well as molecular-epidemiological analysis to determine the aggregation of the epidemic situation. METHODS: Biochemical and serotype identification, hemolysis test, and drug sensitive test were used to detect the drug resistance spectrum. Real-time PCR and conventional PCR were used to detect the presence of V. cholerae specific genes, virulent genes and its related genes, including ompW, ctx, tcpA, toxR, hlyA, zot, ace, rstR and gIII(CTX). Pulsed-field gel electrophoresis (PFGE) was used to analyze the molecular type of strains. RESULTS: All the six isolates of non-O1 non-O139 V. cholerae were identified by biochemical and serologic tests, and appeared to be ß hemolytic. Twelve out of the 14 kinds of drugs showed 100% sensitive. All isolates were positive of ompW gene by real-time PCR, but negative for ctx, tcpA, zot, ace, rstR and gIII(CTX). Five of the six isolates were positive for toxR and hlyA, except for strain 1001434446. All strains had different PFGE types, but two strains had similar types. All strains had a low similarity compared to the toxigenic V. cholerae. CONCLUSION: Six cases of non-O1 and non-O139 nontoxigenic V. cholerae infection appeared in the same period. Along with epidemiological information, we noticed that these cases had a sporadic nature, but frequently appeared in the same area. We got the impression that public health measurements should be strengthened, with special attention paid to those diarrhea outbreaks caused by non-O1/non-O139 strains since V. cholerae had appeared in low incidence.

[Analysis of the variation and changes of Yersinia enterocolitica in Ningxia area from 1984 to 2011].

OBJECTIVE: To analyze the genetic evolution and bacterial type changes of Yersinia enterocolitica in the Ningxia area between year 1984 and 2011. METHODS: A total of 296 strains of Yersinia enterocolitica was collected from diarrhea patients, pig, rodents, sheep and dogs between year 1984 and 2011. The serotype, biotype, ail, ystA, ystB, yadA, virF and other toxic genes were detected. The PFGE subtypes of serotype O:3 and O:9 strains and the cluster features were analyzed. RESULTS: Out of 296 Yersinia enterocolitica strains, pig was the main host, accounting for 65.20% (193/296), followed by rodents, accounting for 32.43% (96/296). Serotype and biotype had their own respective dominant types in different periods. During 1984 and 1985, 2 strains of serotype O:3 and 3 strains of serotype O:9 were isolated, all belonged to biotype 3. Because of lack of strains, there were no obvious dominant types found. Between 1997 and 1999, 177 strains of serotype O:9 Yersinia enterocolitica were isolated as the dominant strain; and there were 178 strains of biotype 2 Yersinia enterocolitica were found. During 2007 and 2011, 54 strains of serotype O:3 Yersinia enterocolitica were isolated as dominant strain; followed by 26 strains of serotype O:5. There were separately 44 and 59 strains of biotype 1A and biotype 3. The PCR test divided the 248 strains into 4 types, including pathogenic strains as type I (ail(+), ystA(+), ystB(-), yadA(+), virF(+)). The PFGE divided the serotype O:3 into 12 types, in which K6GN11C30021 and K6GN11C30012 were the dominant types, accounting for 63.64% (42/66). The serotype O:9 were divided into 14 types, in which K6GN11C90010, K6GN11C90008, K6GN11C30018 and K6GN11C90003 were the dominant types, accounting for 89.01% (162/182). CONCLUSION: The different serotypes of isolated strains in Ningxia district showed different dominant bacteria in different periods; while the biotypes also changed with serotypes. The Yersinia enterocolitica isolated from different years showed great variation.

Fever with thrombocytopenia associated with a novel bunyavirus in China.

BACKGROUND: Heightened surveillance of acute febrile illness in China since 2009 has led to the identification of a severe fever with thrombocytopenia syndrome (SFTS) with an unknown cause. Infection with Anaplasma phagocytophilum has been suggested as a cause, but the pathogen has not been detected in most patients on laboratory testing. METHODS: We obtained blood samples from patients with the case definition of SFTS in six provinces in China. The blood samples were used to isolate the causal pathogen by inoculation of cell culture and for detection of viral RNA on polymerase-chain-reaction assay. The pathogen was characterized on electron microscopy and nucleic acid sequencing. We used enzyme-linked immunosorbent assay, indirect immunofluorescence assay, and neutralization testing to analyze the level of virus-specific antibody in patients' serum samples. RESULTS: We isolated a novel virus, designated SFTS bunyavirus, from patients who presented with fever, thrombocytopenia, leukocytopenia, and multiorgan dysfunction. RNA sequence analysis revealed that the virus was a newly identified member of the genus phlebovirus in the Bunyaviridae family. Electron-microscopical examination revealed virions with the morphologic characteristics of a bunyavirus. The presence of the virus was confirmed in 171 patients with SFTS from six provinces by detection of viral RNA, specific antibodies to the virus in blood, or both. Serologic assays showed a virus-specific immune response in all 35 pairs of serum samples collected from patients during the acute and convalescent phases of the illness. CONCLUSIONS: A novel phlebovirus was identified in patients with a life-threatening illness associated with fever and thrombocytopenia in China. (Funded by the China Mega-Project for Infectious Diseases and others.).

[Characteristics of Yersinia enterocolitica genes isolated in Ningxia Hui autonomous region from 1997 to 2010].

OBJECTIVE: To investigate the distribution of virulent genes of Yersinia enterocolitica (Y. enterocolitica) in Ningxia Hui autonomous region and the characteristics of the molecular patterns of Y. enterocolitica. METHODS: 283 strains of Y. enterocolitica were isolated in Ningxia Hui autonomous region between year 1997 and 2010. The genes ail, ystA, ystB, yadA and virF were analyzed by PCR method; the chromosomal DNA of Y. enterocolitica was digested by restriction endonucleases NotI and processed by pulsed-field gel electrophoreses (PFGE); and then the cluster analysis were conducted by BioNumeric computer software towards the above results. RESULTS: Of all, 209 strains of serotypes O:3 and O:9 Y.enterocolitica showed positive virulence of genes ail, ystA, yadA and virF; 97.6% (204/209) of which, the ystB virulence were negative. The virulence of all genes in serotype O:8 and serum-unclassified strains were negative. 9 out of 11 strains of serotype O:5 Y. enterocolitica showed negative virulence of the above five genes. By PFGE, according to the NotI Macrorestriction Map on chromosomal DNA, the 29 strains of serotype O:3 Y. enterocolitica were divided into 12 PFGE patterns, 2 of which were dominant patterns which could be found in over 5 strains; and the 180 strains of serotype O:9 Y. enterocolitica were divided into 13 patterns, 4 of which were dominant patterns which existed in over 10 strains; which were isolated individually from pigs and house mouse, pigs and dogs as well as pigs and wild rabbits. CONCLUSION: Y.enterocolitica serotypes O:3 and O:9 were pathogenic in Ningxia, and serotype O:3 becomes predominant gradually. O:5, O:8 and serum-unclassified serotypes were non-pathogenic.

[Study on the integration site and arrangement of SfII and SfX prophages in Shigella flexneri serotype 2b strains].

OBJECTIVE: To study the integration site and arrangement of SfII and SfX prophages in Shigella flexneri serotype 2b strains. METHODS: A series of primers were designed based on potential integration site of SfII and SfX prophages in Shigella flexneri serotype 2b strains, and PCR were performed for 50 serotype 2b strains to amplify special genes located in host and prophages. PCR products were sequenced to identify integration sites and arrangement of SfII and SfX. RESULTS: In all the serotype 2b strains, prophage SfII and SfX were adjacent to each other, and integrated into the thrW tRNA gene of the host, which were located between genes proA and yaiC of host. Prophage SfX was located immediately upstream of prophage SfII in all the detected 50 serotype 2b strains exception for strain 51251. CONCLUSION: This was the first report on the integration site and arrangement of serotype-converting prophages SfII and SfX in Shigella flexneri 2b strains.

[Development of a protocol on pulsed field gel electrophoresis analysis for Streptococcus suis].

OBJECTIVE: To develop a PFGE protocol for Streptococcus suis. METHODS: We developed and optimized a PFGE protocol for S. suis, in terms of plug preparation, choice of restriction endonucleases and optimized electrophoresis parameters. By analyzing the genome sequences of S. suis P1/7 with Mapdraw of DNAStar, we found three restriction enzymes, Swa I, Sma I and Apa I, were more suitable than others. RESULTS: Analysis of 100 isolates of S. suis including 34 of 35 serotypes identified, 59, 53 and 43 patterns were obtained from Swa I, Sma I and Apa I restriction, respectively. The enzyme Swa I had the greatest power for discrimination ability. CONCLUSION: By optimization of the protocol at various conditions, a rapid, reproducible, economic and practical PFGE method for S. suis was developed.

[Clone and express ctb-stx2b fusion gene in Enterohemrrhagic escherichia coli O157:H7 Shigeal toxin 2B subunit and V cholera toxin B subunit and the detection of their immunogenicity].

OBJECTIVE: To clone and express the fusion gene encoding Enterohemrrhagic escherichia coli O157 : H7 (EHEC O157 : H7) Shigela toxin 2B subunit (Stx2B) and vibrio cholera toxin B subunit (CTB) as well as to detect the immunogenicity and GM1-binding ability of fusion protein. METHODS: To design a primer to amplify stx2b gene and ctb-stx2b fusion gene encoding Stx2B and CTB-Stx2B respectively and to clone the genes into express plasmid pET30a(+)C in order to construct pET30a-ctb-stx2b after T-A sequencing was varified, then to transform constructed plasmid into E. coli BL21 (DE3) induced by IPTG and purified by a purify kit and to detect molecular weight and immunogenicity by SDS-PAGE and Western-blot. RESULTS: The amplified ctb-stx2b fragments appeared to be 750 bp and gene sequence was identical to designed sequence. The prokaryotic expression system pET30a-ctb-stx2b/BL21 could express protein weight about M(r) 20 x 10(3) and the expressed protein could react to CTB monoclone anti-body. The fusion protein CTB-Stx2B could bind GM1. CONCLUSION: CTB-Stx2B had successfully been expressed in prokaryotic while the expressed protein had good immunogenicity and GM1-Binding ability. This study provided information on further EHEC O157 : H7 vaccine research.

[Molecular epidemiology of enterohaemorrhagic Esacherichia coli O157 in some areas in China].

OBJECTIVE: To understand the epidemiological characteristics of enterohaemorrhagic Escherichia coli (EHEC) O157 and to determine the degree of its genetic relations. METHODS: Polymerase chain reaction (PCR) techniques and chromosomal DNA digested by restriction enzyme Xba I according to PulseNet directions by pulsed field gel electrophoresis (PFGE) method were applied to 300 E. coli O157 strains isolated from patients and animal sources from 1988 to 2005 from Henan, Jiangsu and Anhui provinces. RESULTS: Very high prevalence of stx2 gene in EHEC O157:H7 strains isolated from some provinces of China was found and variation existed in some strains. We got 161 PFGE patterns from 300 strains. The stx2-producing strains could be clearly separated from stx2 variation-producing strains. CONCLUSION: The variability of restriction enzyme-digestion patterns of O157 genomes suggested that the presence of some genomic diversity among the strains did exist.

[Immunoproteomic assay of secretive proteins from Streptococcus suis type 2 strain SC84].

OBJECTIVE: To identify antigenic proteins secreted by Streptococcus suis (S. suis) type 2 strain SC84. METHODS: Two-dimensional electrophoresis (2-DE), western-blot assay and matrix-assisted laser desorption/ionization-time of flight-mass spectrometry (MALDI-TOF-MS) analysis were performed to search and identify antigenic proteins secreted by S. suis strain SC84, which triggered an outbreak of the disease in Sichuan province,China, in 2005. RESULTS: A total number of 14 western blot spots were found on PVDF membrane. 11 spots which could be found the existence of matching protein on coomassie G-250-stained 2-DE gel were identified by MALDI-TOF MS. The 11 proteins, all located at extra-cellular or cell wall, were classified into 8 kinds of proteins. Among of them, muramidase-released protein (MRP), suilysin (Sly) and extra-cellular factor (EF) were the known antigenic proteins, but several proteins such as putative 5'-nucleotidase, ribo-nucleases G and E, and predicted metal-loendo-peptidase were newly found antigenic proteins. All the identified protein were found to have had the coding gene in genomic of S. suis strain 05ZYH33, isolated from patients in Sichuan province, China in 2005. CONCLUSION: The newly found proteins could be used as voluntary antigens for detection and vaccination of S. suis.

Pleiotropic effect of tatC mutation on metabolism of pathogen Yersinia enterocolitica.

OBJECTIVE: To analyze the impact of depletion of the twin arginine translocation (TAT) system on virulence and physiology of Yersinia enterocolitica for a better understanding of its pathogenicity. METHODS: We constructed a DeltatatC::SpR mutant of Yersinia enterocolitica by P1 phage mediated transduction using Escherichia coli K-12 DeltatatC::SpR strain as a donor. RESULTS: A P1-mediated genetic material transfer was found between the two species of enterobacteria, indicating a great potential of acquisition of antibiotic resistance in emergency of a new threatening pathogen by genetic material exchanges. Periplasmic trimethylamine N-oxidase reductase activity was detected in the wild type Y. enterocolitica strain and translocation of this enzyme was completely abolished by the DeltatatC::SpR mutation. In addition, the DeltatatC::SpR mutation showed a pleiotropic effect on the metabolism of Y. enterocolitica. However, the tat mutation did not seem to affect the mobility and virulence of Y. enterocolitica under the conditions used. CONCLUSION: Unlike other pathogenic bacteria studied, the TAT system of Y. enterocolitica might play an important role in the pathogenic process, which is distinct from other pathogens, such as Pseudomonas aeruginosa and enterohemorrhagic E. coli O157:H7.

[Identification of harboring stx2::IS1203 Escherichia coli O157:H7 strains isolated in China].

OBJECTIVE: To understand the variation of Shiga toxin (stx) genes of Escherichia coli O157:H7 strains isolated in China. METHODS: Polymerase chain reaction (PCR) was used to identity the types of stx genes and the nucleotide sequences of the amplified stex variants genes were determined. Compare to the cytotoxicity of Stx,variants were tested by HeLa cell assay. RESULTS: We found novel stx2 genes in 3 of 289 strains of Shiga toxin-producing E. coli O157:H7 isolated from 1999 to 2002 in China. The novel stx2 genes were inserted by a 1.3-kb insertion sequence (IS) and the nucleotide sequences of IS showed 100% homology with that of IS1203 variant (IS1203v). The IS1203v inserted in the stx2 genes of three E. coli O157:H7 strains at different sites and the direction of the open reading frames (ORFs) of IS1203v of each strain was different. In addition to the above mentioned findings, the nucleotide sequences of three stx2 genes were completely identical and the type of the three Stx2 was Stx2 prototype. Compare to the cytotoxicity of Stx2 prototype, the novel Stx2 was found to be obviously lower. CONCLUSION: E. coli O157:H7 strains harboring stx2::IS1203v genes were isolated in China. Consequently, the results of HeLa cell assay showed that the insertion of IS1203v could lead to low cytotoxicity of Stx2.