Encephalitis temporally associated with live attenuated Japanese encephalitis vaccine: four case reports.

BACKGROUND: Japanese encephalitis (JE) vaccination is the most effective measure for preventing JE disease. The live attenuated JE vaccine, which has shown good efficacy and safety, has been widely used in China. CASE PRESENTATIONS: We report four laboratory-confirmed JE cases detected in JE-endemic areas during the JE virus (JEV) transmission season, who all received a first dose of live attenuated JE vaccine within 2 weeks prior to the onset of illness. All cases presented with acute encephalitis and rapidly reduced consciousness. All cerebrospinal fluid (CSF) samples from the patients were positive for JEV-specific immunoglobulin M (IgM) antibodies, but viral isolation and polymerase chain reaction (PCR) detection of JEV were both negative. CONCLUSIONS: It is difficult to identify a causal link between the disease and the vaccination, as the source of positive CSF JEV IgM antibodies might be natural JEV infection or possibly due to a traumatic lumbar puncture. Our observations highlight the need for public health officers and doctors to consider reasonable vaccination policies during the JE season. In addition, continued surveillance as well as thorough investigation of any events that occur after JE vaccination is necessary.

Infection with severe fever with thrombocytopenia virus in healthy population: a cohort study in a high endemic region, China.

BACKGROUND: Severe fever with thrombocytopenia (SFTS) caused by SFTS virus (SFTSV) was a tick-borne hemorrhagic fever that posed significant threat to human health in Eastern Asia. The study was designed to measure the seroprevalence of SFTSV antibody in healthy population residing in a high endemic region. METHODS: A cohort study was performed on healthy residents in Shangcheng County in Xinyang City from April to December in 2018, where the highest SFTS incidence in China was reported. Anti-SFTSV IgG was measured by indirect enzyme-linked immunosorbent assay and neutralizing antibody (NAb) was detected by using PRNT50. The logistic regression models were performed to analyze the variables that were associated with seropositive rates. RESULTS: Totally 886 individuals were recruited. The baseline seroprevalence that was tested before the epidemic season was 11.9% (70/587) for IgG and 6.8% (40/587) for NAb, which was increased to 13.4% (47/350) and 7.7% (27/350) during the epidemic season, and further to 15.8% (80/508) and 9.8% (50/508) post epidemic. The IgG antibody-based seropositivity was significantly related to the patients aged ≥ 70 years old [adjusted odds ratio (OR) = 2.440, 95% confidence interval (CI): 1.334-4.461 compared to the group of < 50 years old, P = 0.004], recent contact with cats (adjusted OR = 2.195, 95% CI: 1.261-3.818, P = 0.005), and working in tea garden (adjusted OR = 1.698, 95% CI: 1.002-2.880, P = 0.049) by applying multivariate logistic regression model. The NAb based seropositivity was similarly related to the patients aged ≥ 70 years old (adjusted OR = 2.691, 95% CI: 1.271-5.695 compared to the group of < 50 years old, P = 0.010), and recent contact with cats (OR = 2.648, 95% CI: 1.419-4.941, P = 0.002). For a cohort of individuals continually sampled with 1-year apart, the anti-SFTSV IgG were maintained at a stable level, while the NAb level reduced. CONCLUSIONS: Subclinical infection might not provide adequate immunity to protect reinfection of SFTSV, thus highlighting the ongoing threats of SFTS in endemic regions, which called for an imperative need for vaccine development. Identification of risk factors might help to target high-risk population for public health education and vaccination in the future.

Mapping the global potential transmission hotspots for severe fever with thrombocytopenia syndrome by machine learning methods.

Severe fever with thrombocytopenia syndrome (SFTS) is an emerging infectious disease with increasing spread. Currently SFTS transmission has expanded beyond Asian countries, however, with definitive global extents and risk patterns remained obscure. Here we established an exhaustive database that included globally reported locations of human SFTS cases and the competent vector, Haemaphysalis longicornis (H. longicornis), as well as the explanatory environmental variables, based on which, the potential geographic range of H. longicornis and risk areas for SFTS were mapped by applying two machine learning methods. Ten predictors were identified contributing to global distribution for H. longicornis with relative contribution ≥1%. Outside contemporary known distribution, we predict high receptivity to H. longicornis across two continents, including northeastern USA, New Zealand, parts of Australia, and several Pacific islands. Eight key drivers of SFTS cases occurrence were identified, including elevation, predicted probability of H. longicornis presence, two temperature-related factors, two precipitation-related factors, the richness of mammals and percentage coverage of water bodies. The globally model-predicted risk map of human SFTS occurrence was created and validated effective for discriminating the actual affected and unaffected areas (median predictive probability 0.74 vs. 0.04, P < 0.001) in three countries with reported cases outside China. The high-risk areas (probability ≥50%) were predicted mainly in east-central China, most parts of the Korean peninsula and southern Japan, and northern New Zealand. Our findings highlight areas where an intensive vigilance for potential SFTS spread or invasion events should be advocated, owing to their high receptibility to H. longicornis distribution.

Correlation between thrombocytopenia and host response in severe fever with thrombocytopenia syndrome.

Severe Fever with Thrombocytopenia Syndrome (SFTS) is an emerging infectious disease caused by a novel bunyavirus, SFTS virus (SFTSV), with fatal outcome developed in approximately 17% of the cases. Thrombocytopenia is a hallmark feature of SFTS, and associated with a higher risk of fatal outcome, however, the pathophysiological involvement of platelet in the clinical outcome of SFTS remained under-investigated. In the current study, by retrospectively analyzing 1538 confirmed SFTS patients, we observed that thrombocytopenia was associated with enhanced activation of the cytokine network and the vascular endothelium, also with a disturbed coagulation response. The platelet phenotypes were also extensively altered in the process of thrombocytopenia development of SFTS patients. More importantly, all these disturbed host responses were related to the severity of thrombocytopenia, thus were considered to play in a synergistic way to influence the disease outcome. Moreover, the clinical effect of platelet transfusion was assessed by comparing two groups of patients with or without receiving this therapy. As a result, we observed no therapy effect in altering frequencies of fatal outcome, clinical bleeding development, or dynamic change of platelet count during the hospitalization. It's suggested that platelet supplementation alone acted a minor role in improving disease outcome, therefore new therapeutic intervention to regulate host response should be proposed. The current results revealed some evidence of interrelationship between platelet count and clinical outcome of SFTS disease from the perspective of activation of the cytokine network, the vascular endothelium, and the coagulation/fibrinolysis system. These evaluations might help to attain a better understanding of the pathogenesis and therapy choice in SFTS.

Genomic sequence of a Japanese encephalitis virus isolate from southern China.

We determined the complete nucleotide sequence of a Japanese encephalitis virus (JEV) isolate (designated SH17M-2007) from a pool of Culex tritaeniorhynchus collected in southern China in 2007. The genome consisted of 10,965 nucleotides and included a single open reading frame (10,296 nucleotides) that encodes a 3,432-amino-acid polyprotein. The SH17M-2007 had 97.3 to 98.4% nucleotide identity with two Korean strains (KV1899, K94P05) and two Japanese strains (Ishikawa, JEV/sw/Mie/40/2004), but only 88.8% identity with the Chinese vaccine strain SA14-14-2. Five unique amino acid substitutions including one in the envelope (E) protein (Glu(E-306)-Lys) were found in the SH17M-2007 strain. Phylogenetic relationships based on the full-length nucleotide sequences were similar to those based on the E gene.

Genetic Diversity and the Spatio-Temporal Analyses of Hantaviruses in Shandong Province, China.

Hemorrhagic fever with renal syndrome (HFRS) is a serious public health problem in Shandong Province, China. We conducted an epizootiologic investigation and phylogeographic and phylodynamic analyses to infer the phylogenetic relationships of hantaviruses in space and time, and gain further insights into their evolutionary dynamics in Shandong Province. Our data indicated that the Seoul virus (SEOV) is distributed throughout Shandong, whereas Hantaan virus (HTNV) co-circulates with SEOV in the eastern and southern areas of Shandong. Their distribution showed strong geographic clustering. In addition, our analyses indicated multiple evolutionary paths, long-distance transmission, and demographic expansion events for SEOV in some areas. Selection pressure analyses revealed that negative selection on hantaviruses acted as the principal evolutionary force, whereas a little evidence of positive selection exists. We found that several positively selected sites were located within major functional regions and indicated the importance of these residues for adaptive evolution of hantaviruses.

A new hantavirus from the stripe-backed shrew (Sorex cylindricauda) in the People's Republic of China.

Inspired by the recent discovery of genetically distinct hantaviruses from insectivore species worldwide, we performed a small-scale search for insectivore-borne hantaviruses. In this paper, we report the discovery of a new hantavirus, which was designated the Qian Hu Shan virus (QHSV). This virus was detected in the lung tissues of three stripe-backed shrews (Sorex cylindricauda), which were captured in the Yunnan Province, China. The full-length S genomic segment of the representative QHSV strain YN05-284 was 1661 nucleotides and is predicted to encode a nucleocapsid protein of 429 amino acids that starts at nucleotide position 48. It exhibited the highest similarity with other Sorex-related hantaviruses, with 68.1%-72.8% nucleotide and 71.9%-84.4% amino acid sequence identities. An analysis of a 1430-nucleotide region of the partial M segment exhibited approximately 54.4%-79.5% nucleotide and 43.2%-90.8% amino acid sequence identities to other hantaviruses. A comparison of a 432-nucleotide region of the L segment also showed similar degrees of identity, with 68.9%-78.4% nucleotide and 71.1%-93.8% amino acid sequence identities to other hantaviruses. Phylogenetic analyses using Bayesian methods indicated that QHSV shared the most recent common ancestor with other Sorex-related hantaviruses. The host was identified using a morphological assessment and verified using mitochondrial cytochrome b (mt-Cyt b) gene sequencing. A pair-wise comparison of the 1140-nucleotide mt-Cyt b gene sequence from the host demonstrated that the host was close to S. cylindricauda from Nepal with 94.3% identity. The virus-host association tanglegram, which was constructed using the Dendroscope software, indicated that the QHSV phylogeny and the host phylogeny were approximately matched, which suggests no evidence of host switching for QHSV. Our results contribute to a wider viewpoint regarding the heterogeneity of viruses that infect shrews.

Cytokine and chemokine responses to Japanese encephalitis live attenuated vaccine in a human population.

OBJECTIVES: The SA14-14-2 Japanese encephalitis (JE) live attenuated vaccine is licensed for use only in China, and has provided excellent efficacy in reducing the incidence of JE. The humoral immune response related to the JE vaccination has been well characterized, however cellular immune responses are less well known. METHODS: Thirty-four healthy males who had recently received inoculation with the SA14-14-2 live attenuated vaccine were recruited. Serum samples from these subjects were analyzed for cytokine and chemokine levels using the FlowCytomix method. RESULTS: Eighteen of 34 subjects were positive for JE virus-specific IgG antibodies. Levels of interleukin (IL)-8, monocyte chemoattractant protein (MCP)-1, macrophage inflammatory protein (MIP)-1α, and MIP-1ß were significantly higher in the vaccinees than in a control group (p<0.0001, p<0.0001, p=0.021, and p<0.0001, respectively). IL-6 was detectable in 64.7% of vaccinees, but was not detectable in any of the controls. IL-1ß, IL-2, IL-4, IL-5, IL-9, IL-10, IL-12p70, IL-13, IL-17A, IL-22, tumor necrosis factor (TNF)-α, and interferon (IFN)-γ were detected in very few subjects or were undetectable in both groups. CONCLUSIONS: IL-6, IL-8, MCP-1, MIP-1α, and MIP-1ß may play important roles in the immune response to JE live attenuated vaccine.

Perinatal outcomes and congenital abnormalities in the newborns of women affected by the 2009 pandemic influenza A (H1N1) in Beijing, China.

OBJECTIVE: To investigate the pregnancy complications, perinatal outcomes, and congenital abnormalities (CAs) that occurred in Beijing, China, when pregnant women became infected with the 2009 pandemic influenza A (H1N1) (H1N1 pdm). METHODS: Pregnancy complications, perinatal outcomes, and CAs were compared among 3 groups of pregnant women. The 23 women in group 1 were confirmed to harbor viral RNA; the 23 in group 2 had serum levels of virus-specific antibodies against H1N1 pdm, meaning that they were suspected of being infected with the virus; and the 93 in group 3 had no detectable virus-specific antibodies. RESULTS: Perinatal outcomes and pregnancy complications were not significantly different in groups 1 and 3. Higher percentages of stillbirths (12.0%) and placental disorders (13.0%) were observed in group 2 than in group 3. Many women in group 2 (62.5%) experienced symptoms of having a cold during pregnancy and most took no medication. Two cases of CA occurred in group 1, in the offspring of women infected in the second trimester. CONCLUSION: When left untreated, infection with the 2009 H1N1 pdm virus during pregnancy appears to have increased fetal mortality and morbidity. Because CAs are traumatic for all concerned, their possible association with the virus should be further evaluated.

Isolation and genetic characteristics of human genotype 1 Japanese encephalitis virus, China, 2009.

BACKGROUND: Several studies have shown that the predominant genotype of Chinese Japanese encephalitis virus (JEV) is evolving from genotype 3 to genotype 1. However, in recent years, almost all genotype 1 isolates were from mosquitoes, and genotype 1 has been less associated with human disease than genotype 3. This study reports the isolation of human genotype 1 JEV and its genetic characteristics to provide additional insights into human JE pathogens that are currently circulating in China. METHODS AND RESULTS: In 2009, 31 cerebrospinal fluid samples were collected from patients living in Yunnan and Shanxi provinces and were used to inoculate Aedes albopictus C6/36 cells for virus isolation. The JEV strains were identified using immunofluorescent assays and the reverse transcription-polymerase chain reaction. Phylogenetic analyses based on the partial capsid/pre-membrane and full envelope (E) sequences were performed using Clustalx 1.8 software. Three JEV isolates were obtained from a 4-year-old girl and a 2-year-old boy living in Yunnan and an 82-year-old woman in Shanxi. The boy had been immunized with one dose of JE live attenuated vaccine. New isolates were grouped into genotype 1. Amino acid sequence for the viral E protein indicated 95% to 100% identity with each other and with other JEV strains. When compared with a consensus sequence of E protein, two amino acid substitutions were found: Ser(E-123)-Asn in the two Yunnan isolates and Lys(E-166)-Arg in the Shanxi isolate. CONCLUSIONS: Our findings indicate that the genotype 1 of JEV is causing human infections in China. Our observation of a previously vaccinated boy developing JE from genotype 1 virus infection also calls for more detailed studies, both in vitro and in vivo neutralization tests as well as active surveillance, to examine the possibility of a lack of complete protection conferred by the live attenuated JE vaccine against genotype 1 virus.

Genetic analysis of a hantavirus strain carried by Niviventer confucianus in Yunnan province, China.

Hantavirus genome sequences were recovered from lung tissues of Chinese white-bellied rats (Niviventer confucianus) captured in Yunnan province, China. Pairwise comparison of the nucleotide and deduced amino acid sequences of the entire S and partial M and L segments indicated that the newly discovered virus strain, which was designated as strain YN509, was very different from other rodent-borne hantaviruses. Phylogenetic analysis showed that the new strain fit into a clade containing Da Bie Shan virus (DBSV) (also carried by N. confucianus), which is mainly found in Anhui Province in mainland China. Strain YN509 appears to be in a sister taxa of the DBSV group described previously. These data suggest that strain YN509 is a new subtype of DBSV, which appears to be widely distributed in China with a higher genetic diversity than expected.

Serological reports of human infections of H7 and H9 avian influenza viruses in northern China.

BACKGROUND: H7 and H9 subtype avian influenza viruses pose a similar threat to humans as H5 virus. OBJECTIVES: This study aims to identify the potential existence of H7 and H9 avian influenza infections in farmers and in poultry workers in northern China regions with highly pathogenic avian influenza (HPAI) H5N1 outbreaks. STUDY DESIGN: Sera were collected from farmers in Xinjiang Uygur autonomous region and Liaoning province and poultry workers in Shandong province. Sera from healthy residents in Shanxi province were used as the controls. H7 and H9 virus infections were examined by hemagglutination inhibition (HI) assay using horse erythrocytes. The titer equal to or greater than 1:160 was considered positive. RESULTS: A total of 583 sera collected from farmers in Xinjiang were tested, and 10 (1.7%) were positive for H9 virus infection. Out of 200 sera collected from Liaoning, two (1.0%) were infected by H9 virus. No H7 virus infection was detected in the above serum samples. Neither H7 nor H9 virus infection was identified in 277 poultry workers of Shandong and in 407 residents of Shanxi. CONCLUSIONS: Although H9 virus infection was limited in farmers from Xinjiang and Liaoning, a public health alert is needed as novel pandemic influenza strains may develop unnoticed given the presence of subclinical infections, and the possibility of re-assortment with prevailing H5N1 virus in these regions.

Failure of Japanese encephalitis vaccine and infection in inducing neutralizing antibodies against West Nile virus, People's Republic of China.

We examined whether live attenuated Japanese encephalitis (JE) vaccine is effective in preventing West Nile virus (WNV) infection in the People's Republic of China. Three groups were recruited into the study: patients with Japanese encephalitis (JE), healthy controls vaccinated with live attenuated 2 SA14-14-vaccine against JE virus (JEV), and unvaccinated healthy controls. Serum samples were collected and screened for IgG antibodies against JEV by an indirect immunofluorescence assay. Positive samples were then analyzed for levels of antibodies against JEV and neutralizing antibodies against West Nile virus (WNV) by a plaque-reduction neutralization test (PRNT). Although most persons had medium to high levels of JEV-reactive IgG and neutralizing antibodies, only 2 of the 82 unvaccinated control samples were positive for the WNV-reactive antibodies. These findings suggest that previous JEV infection or vaccination did not induce adequate levels of WNV-reactive antibodies in the population studied. However, how these persons would respond to a secondary flavivirus infection and whether their prior experience with wild-type or attenuated JE vaccine will provide some cross-protection against WNV disease still warrants further investigation.

[Comparison and discrimination of the biological characteristics between West Nile virus and Japanese encephalitis virus].

BACKGROUND: To compare the biological characteristics of West Nile virus (WNV) and Japanese encephalitis virus (JEV), including cells sensitivity, pathogenicity, viral morphology, as well as the results of immunological and molecular biological detection. METHODS: Cytopathic effect (CPE) and pathogenicity were observed in C6/36 cells and in suckling mice inoculated intracerebrally with the WNV or JEV, respectively. The sliced tissue samples for electron microscopic examination were prepared for the morphologic observation of the viruses. Serum antibody to WNV or JEV was detected using indirect immunofluorescence assay (IFA), and the viral RNA was analyzed by RT-PCR method. RESULTS: WNV or JEV-caused CPE was characterized by cell fusion and cell shedding, respectively. There was no significant difference in the pathogenicity to suckling mice between WNV and JEV. The morphologic observation showed that the shape and size of the two virions were similar. WNV and JEV were found to have antigenic cross-reactivity. The viral RNA could be detected from both WNV and JEV samples with universal primer set, but only nucleoside fragments of corresponding virus could be amplified when specific primers were used. CONCLUSION: CPE in C6/36 cell and detection of the viral RNA should be useful in discrimination of WNV and JEV, and simultaneously examining the titers of serum antibodies against WNV and JEV may be helpful to diagnosis of infection with these agents.