Coxsackievirus B4: an underestimated pathogen associated with a hand, foot, and mouth disease outbreak.

In order to discover the causes of a coxsackievirus B4 (CV-B4)-associated hand, foot, and mouth disease (HFMD) outbreak and to study the evolutionary characteristics of the virus, we sequenced isolates obtained during an outbreak for comparative analysis with previously sequenced strains. Phylogenetic and evolutionary dynamics analysis was performed to examine the genetic characteristics of CV-B4 in China and worldwide. Phylogenetic analysis showed that CV-B4 originated from a common ancestor in Shandong. CV-B4 strains isolated worldwide could be classified into genotypes A-E based on the sequence of the VP1 region. All CV-B4 strains in China belonged to genotype E. The global population diversity of CV-B4 fluctuated substantially over time, and CV-B4 isolated in China accounted for a significant increase in the diversity of CV-B4. The average nucleotide substitution rate in VP1 of Chinese CV-B4 (5.20 × 10-3 substitutions/site/year) was slightly higher than that of global CV-B4 (4.82 × 10-3 substitutions/site/year). This study is the first to investigate the evolutionary dynamics of CV-B4 and its association with an HFMD outbreak. These findings explain both the 2011 outbreak and the global increase in CV-B4 diversity. In addition to improving our understanding of a major outbreak, these findings provide a basis for the development of surveillance strategies.

Two Coxsackievirus B3 outbreaks associated with hand, foot, and mouth disease in China and the evolutionary history worldwide.

BACKGROUND: Coxsackievirus B3 (CV-B3) is usually associated with aseptic meningitis and myocarditis; however, the association between CV-B3 and hand, foot, and mouth disease (HFMD) has not been clearly demonstrated, and the phylogenetic dynamics and transmission history of CV-B3 have not been well summarized. METHOD: Two HFMD outbreaks caused by CV-B3 were described in Hebei Province in 2012 and in Shandong Province in 2016 in China. To analyze the epidemiological features of two CV-B3 outbreaks, a retrospective analysis was conducted. All clinical specimens from CV-B3 outbreaks were collected and disposed according to the standard procedures supported by the WHO Global Poliovirus Specialized Laboratory. EV genotyping and phylogenetic analysis were performed to illustrate the genetic characteristics of CV-B3 in China and worldwide. RESULTS: Two transmissible lineages (lineage 2 and 3) were observed in Northern China, which acted as an important "reservoir" for the transmission of CV-B3. Sporadic exporting and importing of cases were observed in almost all regions. In addition, the global sequences of CV-B3 showed a tendency of geographic-specific clustering, indicating that geographic-driven adaptation plays a major role in the diversification and evolution of CV-B3. CONCLUSIONS: Overall, our study indicated that CV-B3 is a causative agent of HFMD outbreak and revealed the phylogenetic dynamics of CV-B3 worldwide, as well as provided an insight on CV-B3 outbreaks for effective intervention and countermeasures.

Protective Efficacies of Formaldehyde-Inactivated Whole-Virus Vaccine and Antivirals in a Murine Model of Coxsackievirus A10 Infection.

Coxsackievirus A10 (CVA10) is one of the major pathogens associated with hand, foot, and mouth disease (HFMD). CVA10 infection can cause herpangina and viral pneumonia, which can be complicated by severe neurological sequelae. The morbidity and mortality of CVA10-associated HFMD have been increasing in recent years, particularly in the pan-Pacific region. There are limited studies, however, on the pathogenesis and immunology of CVA10-associated HFMD infections, and few antiviral drugs or vaccines have been reported. In the present study, a cell-adapted CVA10 strain was employed to inoculate intramuscularly 5-day-old ICR mice, which developed significant clinical signs, including reduced mobility, lower weight gain, and quadriplegia, with significant pathology in the brain, hind limb skeletal muscles, and lungs of infected mice in the moribund state. The severity of illness was associated with abnormally high expression of the proinflammatory cytokine interleukin 6 (IL-6). Antiviral assays demonstrated that ribavirin and gamma interferon administration could significantly inhibit CVA10 replication both in vitro and in vivo In addition, formaldehyde-inactivated CVA10 whole-virus vaccines induced immune responses in adult mice, and maternal neutralizing antibodies could be transmitted to neonatal mice, providing protection against CVA10 clinical strains. Furthermore, high-titer antisera were effective against CVA10 and could relieve early clinical symptoms and improve the survival rates of CVA10-challenged neonatal mice. In summary, we present a novel murine model to study CVA10 pathology that will be extremely useful in developing effective antivirals and vaccines to diminish the burden of HFMD-associated disease.IMPORTANCE Hand, foot, and mouth disease cases in infancy, arising from coxsackievirus A10 (CVA10) infections, are typically benign, resolving without any significant adverse events. Severe disease and fatalities, however, can occur in some children, necessitating the development of vaccines and antiviral therapies. The present study has established a newborn-mouse model of CVA10 that, importantly, recapitulates many aspects of human disease with respect to the neuropathology and skeletal muscle pathology. We found that high levels of the proinflammatory cytokine interleukin 6 correlated with disease severity and that ribavirin and gamma interferon could decrease viral titers in vitro and in vivo Whole-virus vaccines produced immune responses in adult mice, and immunized mothers conferred protection on neonates against challenge from CVA10 clinical strains. Passive immunization with high-titer antisera could also improve survival rates in newborn animals.

The color removal and fate of organic pollutants in a pilot-scale MBR-NF combined process treating textile wastewater with high water recovery.

A combination of membrane bioreactor (MBR) and nanofiltration (NF) was tested at pilot-scale treating textile wastewater from the wastewater treatment station of a textile mill in Wuqing District of Tianjin (China). The MBR-NF process showed a much better treatment efficiency on the removal of the chemical oxygen demand, total organic carbon, color and turbidity in comparison with the conventional processes. The water recovery rate was enhanced to over 90% through the recycling of NF concentrate to the MBR, while the MBR-NF showed a stable permeate water quality that met with standards and could be directly discharged or further reused. The recycled NF concentrate caused an accumulation of refractory compounds in the MBR, which significantly influenced the treatment efficiency of the MBR. However, the sludge characteristics showed that the activated sludge activity was not obviously inhibited. The results of fluorescence spectra and molecular weight distribution indicated that those recalcitrant pollutants were mostly protein-like substances and a small amount of humic acid-like substances (650-6,000 Da), which contributed to membrane fouling of NF. Although the penetrated protein-like substances caused the residual color in NF permeate, the MBR-NF process was suitable for the advanced treatment and reclamation of textile wastewater under high water yield.

Comparison of NF membrane fouling and cleaning by two pretreatment strategies for the advanced treatment of antibiotic production wastewater.

The nanofiltration (NF) membrane fouling characteristics and cleaning strategies were investigated and compared for treating membrane bioreactor (MBR) effluent and MBR-granular activated carbon (GAC) effluent of an antibiotic production wastewater by DK membrane. Results showed that the fouling of treating MBR effluent was more severe than that of treating MBR-GAC effluent. After filtering for 216 h, the difference of membrane flux decline was obvious between MBR effluent and MBR-GAC effluent, with 14.9% and 10.3% flux decline, respectively. Further study showed that organic fouling is the main NF membrane fouling in the advanced treatment of antibiotic production wastewater for both of the two different effluents. Soluble microbial by-product like and tyrosine-like substances were the dominant components in the foulants, whereas humic-like substances existing in the effluents had little contribution to the NF membrane fouling. A satisfactory efficiency of NF chemical cleaning could be obtained using combination of acid (HCl, pH 2.0-2.5) and alkali (NaOH + 0.3 wt% NaDS, pH 10.0-10.5). The favorable cleaning strategy is acid-alkali for treating the MBR-GAC effluent, while it is alkali-acid for treating the MBR effluent.

Fate of organic pollutants in a pilot-scale membrane bioreactor-nanofiltration membrane system at high water yield in antibiotic wastewater treatment.

A double membrane system combining a membrane bioreactor (MBR) with a nanofiltration (NF) membrane at the pilot scale was tested to treat real antibiotic wastewater at a pharmaceutical company in Wuxi (China). The water yield of the pilot system reached over 92 ± 5.6% through recycling the NF concentrate to the MBR tank. Results showed that the pilot scale system operated in good conditions throughout the entire experiment period and obtained excellent water quality in which the concentrations of chemical oxygen demand and total organic carbon were stable at 35 and 5.7 mg/L, respectively. The antibiotic removal rates of both spiramycin (SPM) and new spiramycin in wastewater were over 95%. Organics analysis results showed that the main organics in the biological effluent were proteins, soluble microbial by-product-like, fulvic acid-like and humic-like substances. These organics could be perfectly rejected by the NF membrane. Most of the organics could be removed through recycling NF concentrate to the MBR tank and only a small part was discharged with NF concentrate and permeate.

Evolutionary Diversity of Coxsackievirus A6 Causing Severe Hand, Foot, and Mouth Disease - China, 2012-2023.

Introduction: Coxsackievirus A6 (CVA6) has emerged as a significant pathogen responsible for severe cases of hand, foot, and mouth disease (HFMD). This study aims to delineate the demographic characteristics and analyze the viral evolution of severe HFMD associated with CVA6, thereby assisting in its surveillance and management. Methods: In this investigation, 74 strains of CVA6 were isolated from samples collected from severe HFMD cases between 2012 and 2023. The VP1 gene sequences of CVA6 were amplified and analyzed to assess population historical dynamics and evolutionary characteristics using BEAST, DnaSP6, and PopART. Results: A significant portion (94.4%) of severe CVA6-associated HFMD cases (51 out of 54, with 20 lacking age information) were children under 5 years old. Among the 74 CVA6 strains analyzed, 72 belonged to the D3a sub-genotype, while only two strains were D2 sub-genotype. The average genetic distance between VP1 sequences prior to 2015 was 0.027, which increased to 0.051 when compared to sequences post-2015. Historical population dynamics analysis indicated three significant population expansions of severe CVA6-associated HFMD during 2012-2013, 2013-2014, and 2019-2020, resulting in the formation of 65 distinct haplotypes. Consistent with the MCC tree findings, transitioning between regional haplotypes required multiple base substitutions, showcasing an increase in population diversity during the evolutionary process (from 14 haplotypes in 2013 to 55 haplotypes over the subsequent decade). Conclusions: CVA6, associated with severe HFMD, is evolving and presents a risk of outbreak occurrence. Thus, enhanced surveillance of severe HFMD is imperative.

[Analysis of clinical features and early warning indicators of death from hand, foot and mouth disease in Shandong province].

OBJECTIVE: To understand the clinical features of death from hand, foot and mouth disease (HFMD) and to explore the early warning index of HFMD death. METHODS: A total of 41 HFMD death cases were collected as case group in Shandong province between 2009 and 2011, and another 123 serious HFMD cases were selected as control group according to the similar gender, place of origin and hospital level, with the ratio at 1:3. We investigated the general situation, clinical treatment, past medical history, clinical symptoms and signs of the ill children, and applied the conditional logistic regression to explore early warning index of HFMD death. RESULTS: The rate of patients who had symptoms in nervous system, digestive system, circulatory system and respiratory system were separately 90.2% (37/41), 58.5% (24/41), 53.7% (22/41) and 90.2% (37/41) in case group; and the proportions were 44.7% (55/123), 13.8% (17/123), 10.6% (13/123) and 12.2% (15/123) respectively in control group. The difference between the two groups showed statistical significance (χ(2) = 25.881, 32.791, 34.011, 86.505, P < 0.05). In case group, 37 patients had neurogenic pulmonary edema, 26 patients got encephalitis, 15 patients had respiratory and circulatory failure, 7 patients got pulmonary hemorrhage, 4 patients had multiple organ failure, 4 patients got myocarditis and 1 patient had cerebral hernia. According to multi-factor logistic regression analysis, the early warning indicators of HFMD death included neck resistance (case group: 34.1% (14/41), control group: 4.1% (5/123); OR = 7.145, 95%CI: 1.748 - 29.204), vomiting (case group: 58.5% (24/41), control group: 13.8% (17/123); OR = 5.632, 95%CI: 1.793 - 17.685) and increase of heart rate (case group: 53.7% (22/41), control group: 10.6% (14/123), OR = 6.370, 95%CI: 1.517 - 26.743). CONCLUSION: In the process of clinical treatment and care, we should interfere the serious HFMD patients with neck resistance, vomiting and increase of heart rate, and thereby reduce the death from HFMD.

Genomic Epidemiology and Transmission Dynamics of Global Coxsackievirus B4.

The aim of this study was to determine the global genetic diversity and transmission dynamics of coxsackievirus B4 (CVB4) and to propose future directions for disease surveillance. Next-generation sequencing was performed to obtain the complete genome sequence of CVB4, and the genetic diversity and transmission dynamics of CVB4 worldwide were analyzed using bioinformatics methods such as phylogenetic analysis, evolutionary dynamics, and phylogeographic analysis. Forty complete genomes of CVB4 were identified from asymptomatic infected individuals and hand, foot, and mouth disease (HFMD) patients. Frequent recombination between CVB4 and EV-B multiple serotypes in the 3Dpol region was found and formed 12 recombinant patterns (A-L). Among these, the CVB4 isolated from asymptomatic infected persons and HFMD patients belonged to lineages H and I, respectively. Transmission dynamics analysis based on the VP1 region revealed that CVB4 epidemics in countries outside China were dominated by the D genotype, whereas the E genotype was dominant in China, and both genotypes evolved at a rate of > 6.50 × 10-3 substitutions/site/year. CVB4 spreads through the population unseen, with the risk of disease outbreaks persisting as susceptible individuals accumulate. Our findings add to publicly available CVB4 genomic sequence data and deepen our understanding of CVB4 molecular epidemiology.

Genetic recombination in fast-spreading coxsackievirus A6 variants: a potential role in evolution and pathogenicity.

Hand, foot, and mouth disease (HFMD) is a common global epidemic. From 2008 onwards, many HFMD outbreaks caused by coxsackievirus A6 (CV-A6) have been reported worldwide. Since 2013, with a dramatically increasing number of CV-A6-related HFMD cases, CV-A6 has become the predominant HFMD pathogen in mainland China. Phylogenetic analysis based on the VP1 capsid gene revealed that subtype D3 dominated the CV-A6 outbreaks. Here, we performed a large-scale (near) full-length genetic analysis of global and Chinese CV-A6 variants, including 158 newly sequenced samples collected extensively in mainland China between 2010 and 2018. During the global transmission of subtype D3 of CV-A6, the noncapsid gene continued recombining, giving rise to a series of viable recombinant hybrids designated evolutionary lineages, and each lineage displayed internal consistency in both genetic and epidemiological features. The emergence of lineage -A since 2005 has triggered CV-A6 outbreaks worldwide, with a rate of evolution estimated at 4.17 × 10-3 substitutions site- 1 year-1 based on a large number of monophyletic open reading frame sequences, and created a series of lineages chronologically through varied noncapsid recombination events. In mainland China, lineage -A has generated another two novel widespread lineages (-J and -L) through recombination within the enterovirus A gene pool, with robust estimates of occurrence time. Lineage -A, -J, and -L infections presented dissimilar clinical manifestations, indicating that the conservation of the CV-A6 capsid gene resulted in high transmissibility, but the lineage-specific noncapsid gene might influence pathogenicity. Potentially important amino acid substitutions were further predicted among CV-A6 variants. The evolutionary phenomenon of noncapsid polymorphism within the same subtype observed in CV-A6 was uncommon in other leading HFMD pathogens; such frequent recombination happened in fast-spreading CV-A6, indicating that the recovery of deleterious genomes may still be ongoing within CV-A6 quasispecies. CV-A6-related HFMD outbreaks have caused a significant public health burden and pose a great threat to children's health; therefore, further surveillance is greatly needed to understand the full genetic diversity of CV-A6 in mainland China.

Emerging recombination of the C2 sub-genotype of HFMD-associated CV-A4 is persistently and extensively circulating in China.

Sporadic outbreaks caused by coxsackievirus A4 (CV-A4) have been reported worldwide. To further elucidate the detailed genetic characteristics and evolutionary recombination events of CV-A4, virus samples from nationwide hand, foot and mouth disease (HFMD) surveillance, encompassing 27 out of the 31 provinces in China, were investigated. Comprehensive and systematic phylogenetic analyses were performed by using 29 complete genomes, 142 complete CV-A4 VP1 sequences. Four genotypes (A, B, C and D) and five sub-genotypes (C1-C5) were re-identified based on the complete VP1 sequences. C2 is the predominant sub-genotype of CV-A4 associated with HFMD and has evolved into 3 clusters. Cluster 1 is a major cluster that has been persistently and extensively circulating in China since 2006 and has been associated with all severe cases. All the sequences showed high homology with the CV-A4 prototype in the P1 region, while higher identities with CV-A5, CV-14 and CV-16 in the P2 and P3 regions. Recombination analysis revealed that C2 had two specific genetic recombination patterns with other EV-A prototypes in the 5'-UTR and 3D region compared with C5. These recombination patterns might be associated with the increased transmissibility of C2 viruses, which were obtained due to their persistent and extensive circulation in populations.

Fouling characteristics and cleaning strategies of NF membranes for the advanced treatment of antibiotic production wastewater.

The nanofiltration (NF) membrane fouling characteristics and cleaning strategies were investigated through a laboratory-scale NF fouling test treating membrane bioreactor (MBR) effluent and MBR-granular activated carbon (GAC) effluent of an antibiotic production wastewater by DK and NF90 membranes, respectively. Results showed that organic fouling is the main NF membrane fouling for treating both the MBR effluent and MBR-GAC effluent. Soluble microbial by-product (SMP)-like and aromatic protein-like substances were the dominant components in the foulants, whereas humic-like substances had little contribution to the NF fouling. The fouling of DK was more severe than that of NF90. However, foulants respond by UV254 were more easily to foul NF90 membrane. It could get satisfactory effect using combined cleaning of acid (HCl, pH 2.0∼2.5) and alkali (NaOH + 0.3 wt% NaDS, pH 10.0∼10.5). The favorable cleaning strategy is "acid + alkali" for treating MBR-GAC effluent, while it is "alkali + acid" for treating MBR effluent.

Fouling analysis of membrane bioreactor treating antibiotic production wastewater at different hydraulic retention times.

Membrane fouling, including foulants and factors, was investigated during hydraulic retention time (HRT) optimization of a membrane bioreactor (MBR) that treated wastewater from the production of antibiotics. The results showed that HRT played an important role in membrane fouling. Trans-membrane pressure (TMP), membrane flux, and resistance were stable at -6 kPa, 76 L m-2 h-1 bar-1, and 4.5 × 1012 m-1 when HRT was at 60, 48, and 36 h, respectively. Using Fourier transform infrared spectroscopy, foulants were identified as carbohydrates and proteins, which correlated with effluent organic matter and effluent chemical oxygen demand (COD) compounds. Therefore, membrane fouling trends would benefit from low supernatant COD (378 mg L-1) and a low membrane removal rate (26 %) at a HRT of 36 h. Serious membrane fouling at 72 and 24 h was related to soluble microbial products and extracellular polymeric substances in mixed liquor, respectively. Based on the TMP decrease and flux recovery after physical and chemical cleaning, irremovable fouling aggravation was related to extracellular polymeric substances' increase and soluble microbial products' decrease. According to changes in the specific oxygen uptake rate (SOUR) and mixed liquor suspended solids (MLSSs) during HRT optimization in this study, antibiotic production wastewater largely inhibited MLSS growth, which only increased from 4.5 to 5.0 g L-1 when HRT was decreased from 72 to 24 h, but did not limit sludge activity. The results of a principal component analysis highlighted both proteins and carbohydrates in extracellular polymeric substances as the primary foulants. Membrane fouling associated with the first principal component was positively related to extracellular polymeric substances and negatively related to soluble microbial products. Principal component 2 was primarily related to proteins in the influent. Additional membrane fouling factors included biomass characteristics, operational conditions, and feed characteristics.

Seroprevalence of Enterovirus A71 and Coxsackievirus A16 in Healthy People in Shandong Province, China.

BACKGROUND: Hand, foot, and mouth disease has become very common in mainland of China in recent years, and enterovirus A71 and coxsackievirus A16 are its major etiologic factors. Here we investigated the seroprevalence of enterovirus A71 and coxsackievirus A16 based on a large group of healthy individuals in Shandong province, China. METHODS: A total of 1378 healthy individuals were tested for serum neutralizing antibodies against enterovirus A71 and coxsackievirus A16 using a micro neutralization test. RESULTS: The overall seroprevalence of enterovirus A71 neutralizing antibodies was 74.75%. It increased significantly from 48.84% in children aged 0-1 years old to 88.64% in those aged 20-29 years (p < 0.01) and decreased to 85.71% in adults > 40 years old with a significant gender-specific difference (p < 0.01). The overall coxsackievirus A16 antibody prevalence was 71.77%. It increased significantly from 39.53% in children aged 0-1 years to 80.68% in those aged 10-19 years (p < 0.01) and decreased to 75.63% in adults >40 years without a gender-specific difference. Nearly 50% of the children <1 year were susceptible to enterovirus A71 infection versus 40% to coxsackievirus A16 infection. Sample collection time and place also played a role in the enterovirus A71 and coxsackievirus A16 positive rates. The overall rates in January were significantly lower than those in April and August (p < 0.01); enterovirus A71 positive rates in Jinan city (capital city of Shandong province) were lower than those in Jining city and Zibo city (p < 0.05); and oxsackievirus A16 positive rates in Jining city were significantly higher than those in Jinan city and Zibo city (p < 0.01). CONCLUSION: There were significant differences among age groups, locations, and time points in the seroprevalence rates of enterovirus A71 and coxsackievirus A16 neutralizing antibodies in healthy people in Shandong province.

Performance and fate of organics in a pilot MBR-NF for treating antibiotic production wastewater with recycling NF concentrate.

A double membrane system comprising a membrane bioreactor (MBR) combined with a nanofiltration (NF) membrane was investigated on a pilot scale for the treatment of antibiotic production wastewater over a three-month period at a pharmaceutical company in Wuxi, China. By recycling the NF concentrate, the combined MBR-NF process was shown to be effective for the treatment of antibiotic production wastewater, resulting in excellent water quality and a high water yield of 92±5.6%. The water quality of the pilot-scale MBR-NF process was excellent; e.g., the concentrations of TOC, NH4(+)-N, TP were stable at 5.52, 0.68, 0.34 mg L(-1), respectively, and the values of turbidity and conductivity of the NF permeate were 0.15 NTU and 2.5 mS cm(-1), respectively; these values meet China's water quality standard requirements for industrial use (GB21903-2008). Not only were the antibiotic removal rates of spiramycin (SPM) and new spiramycin (NSPM) over 95%, the acute toxicity was also drastically reduced by the MBR-NF pilot system. The main organics in the MBR effluent were proteins, polysaccharides, and humic-like substances; they were almost completely retained by the NF membrane and further biodegraded in the MBR because the NF concentrate was recycled. The microbial community of the MBR did not significantly change with the recycling of the NF concentrate.

Determination of benzimidazole residues in edible animal food by polymer monolith microextraction combined with liquid chromatography-mass spectrometry.

A sensitive method has been developed for the simultaneous determination of 10 benzimidazole residues and some of their metabolites in egg, milk, chicken, and pork. This method is based on the combination of polymer monolith microextraction (PMME) technique with liquid chromatography and electrospray ionization mass spectrometry (LC-ESI/MS). The extraction was performed with a poly(methacrylic acid-co-ethylene glycol dimethacrylate) (MAA-co-EGDMA) monolithic capillary column. Under the optimized extraction conditions, good extraction efficiencies for the targets were obtained with no matrix interference in the subsequent detection. The LODs (S/N=3) for 10 benzimidazoles were found to be 0.56-2.76 ng g(-1) in egg, 0.50-1.41 ng mL(-1) in milk, 0.09-0.28 ng g(-1) in chicken, and 0.08-0.15 ng g(-1) in pork. The recoveries in egg, milk, chicken, and pork matrices ranged from 75.2 to 116.8% spiked at different levels with analytes, with RSDs of <13.7%. The method was later successfully applied for the determination of primary and metabolite residues in eggs after oral administration of albendazole to hens.