Evaluation of a New Norovirus Genogroups GI and GII In Vitro Molecular Diagnostic Assay Using Clinical Specimens Collected from Acute Diarrheal Outbreaks.

Norovirus is a leading cause of acute gastroenteritis (AGE) in Taiwan. To improve diagnosis as part of laboratory surveillance, AGE surveillance was conducted using a new fluorescent probe hydrolysis-based insulated isothermal polymerase chain reaction (PCR) method, the POCKIT system, and the results were compared with those obtained from conventional methods. A total of 119 clinical stool samples from reported AGE outbreaks were collected for this study. From 83 real-time reverse transcription PCR (rRT-PCR) norovirus-positive cases, the POCKIT system identified 78 with a sensitivity of 90.3% in GI genogroup and 96.7% in GII genogroup. The specificity for both GI and GII genogroups was 100%. Overall, the POCKIT system is faster and easier to use than the conventional rRT-PCR method, and because of its high sensitivity and specificity, this system is a promising alternative for the detection of norovirus in patients with AGE, and would benefit public health laboratories for near real-time surveillance of AGE epidemic outbreaks.

Norovirus Genogroup II Epidemics and the Potential Effect of Climate Change on Norovirus Transmission in Taiwan.

The activity of norovirus varies from season to season, and the effect of climate change on the incidence of norovirus outbreaks is a widely recognized yet poorly understood phenomenon. Investigation of the possible association between climatic factors and the incidence of norovirus is key to a better understanding of the epidemiology of norovirus and early prediction of norovirus outbreaks. In this study, clinical stool samples from acute gastroenteritis outbreaks were collected from January 2015 to June 2019 in Taiwan. Data analysis from our study indicated that more than half of the cases were reported in the winter and spring seasons, including those caused by norovirus of genotypes GII (genogroup II).2, GII.3, GII.6, and GII.17, and 45.1% of the patients who tested positive for norovirus were infected by the GII.4 norovirus in autumn. However, GII.6 norovirus accounted for a higher proportion of the cases reported in summer than any other strain. Temperature is a crucial factor influencing patterns of epidemic outbreaks caused by distinct genotypes of norovirus. The results of this study may help experts predict and issue early public warnings of norovirus transmission and understand the effect of climate change on norovirus outbreaks caused by different genotypes and occurring in different locations.

Molecular Epidemiology of GI.3 Norovirus Outbreaks from Acute Gastroenteritis Surveillance System in Taiwan, 2015-2019.

Norovirus is the leading cause of food-borne disease outbreaks. We conducted this study to examine the incidence and molecular characteristics of norovirus genogroup I infections from acute gastroenteritis outbreaks in Taiwan. Between January 2015 and June 2019, 2121 acute gastroenteritis clusters were reported to Taiwan CDC, of which 351 (16.5%) clusters were positive for NoV GI, and GI.3 was the most prevalent (36.8%) during the study period. The GI.3 infections were significantly higher than non-GI.3 infections in the age groups of 0-5 and 6-18 years. The phylogenetic analysis of the MCC tree revealed that VP1 genes were divided into 3 groups: the GI.P3-GI.3 strains in Taiwan were genetically close to Japan and the GI.Pd-GI.3 strains were segregated into 2 other groups which were genetically closely related to China. In addition, 7 GI.Pd-GI.3 recombinants were identified circulating in Taiwan between 2018 and 2019, and the prevalence of GI.Pd-GI.3 should be monitored to assess whether this could become the new predominant strains in neighboring Asian countries or other parts of the world. Both GI.P3-GI.3 and GI.Pd-GI.3 strains cocirculate, the recombination among these two lineages occurs frequently, contributing to the genetic diversity and multiple occurrences of different norovirus lineages, and their rapid evolution makes future control more difficult. Continued surveillance and timely interventions are critical to understand the complexity of norovirus gene variation and to monitor the new emerging norovirus strains.

Genetic Diversity and Phylogenetic Analysis of Human Bocavirus 2 in Pediatric Patients with Acute Gastroenteritis in Taiwan.

Human bocavirus (HBoV) is a causative agent of respiratory and gastrointestinal diseases worldwide. Four HBoV species (HBoV1-4) have been identified so far. Although a previous report has documented the HBoV association with acute gastroenteritis (AGE) in Taiwan, their epidemiology, genetic diversity, and phylogenetic relationships remain unclear. In this study, we focused on an investigation of these unsolved issues, which will help to reveal molecular epidemiology and phylogeny of the circulating HBoV2 in Taiwan. A total of 176 stool samples were collected from children with AGE for this study. PCR amplification and sequencing on the VP1 gene region were used to identify species. Phylogenetic analysis was conducted by maximum-likelihood and neighbor-joining methods. Selection pressure was also estimated to obtain HBoV evolutionary information. Our results showed the prevalence of HBoV in AGE children was 8.5%, of which HBoV1 was the predominant species (6.3%), followed by HBoV2 (2.3%). Phylogenetic analysis showed those Taiwanese HBoV2 strains have significant genetic variability and can be divided into two clusters. One belongs to HBoV2 genotype A and the other forms an independent unclassified cluster. The nucleotide distance between that independent cluster and the known HBoV2 genotypes was more than 5%, suggesting a new HBoV2 genotype. No positive selection site was found and the virus was under purifying selection. This is the first report to reveal HBoV2 genetic diversity and phylogenetic relationships among AGE children in Taiwan. We find that HBoV2 may have been introduced into the country by multiple origins, and a potential new HBoV2 genotype is proposed.

Surveillance of upper respiratory infections using a new multiplex PCR assay compared to conventional methods during the influenza season in Taiwan.

OBJECTIVES: To improve diagnosis as part of laboratory surveillance in Taiwan, influenza-like illness (ILI) surveillance was conducted using a new multiplex PCR assay (FilmArray) and the results compared to those of conventional methods The study was performed during the winter months. METHODS: Throat swabs from patients with an ILI presenting to physicians in sentinel practices were collected during the 2016-2017 influenza season. RESULTS: A total of 52 samples tested positive by FilmArray Respiratory Panel. Forty percent were influenza A virus, and subtype H3N2 virus was the major epidemic strain. However, nearly 60% of ILI cases seen at sentinel sites were caused by non-influenza pathogens. The results of the FilmArray assay and cell culture were identical, and this assay was more sensitive than a rapid influenza diagnostic test. Genetic analyses revealed new influenza A H3N2 variants belonging to a novel subclade 3C.2a2. CONCLUSIONS: The FilmArray assay facilitates urgent testing and laboratory surveillance for common viral and bacterial respiratory pathogens. This study demonstrated the use of a highly sensitive assay using clinical samples that is feasible for application worldwide. This may lead to an increased rate of diagnosis of viral infections and to improved patient outcomes, and in particular to a reduction in the overuse of antibiotics and antivirals.

Molecular epidemiological analysis of Saffold cardiovirus genotype 3 from upper respiratory infection patients in Taiwan.

BACKGROUND: Saffold cardiovirus (SAFV) belongs to the Cardiovirus genus of Picornaviridae family, and may be a relevant new human pathogen; Thus far, eleven genotypes have been identified. The SAFV type 3 (SAFV-3) is thought to be the major genotype and is detected relatively frequently in children with acute gastroenteritis and respiratory illness. The epidemiology and pathogenicity of SAFV-3 remain unclear. OBJECTIVES: To investigate the genomic and epidemiologic profiles of SAFV-3 infection in Taiwan. STUDY DESIGN: Virus was detected in respiratory samples from children suffering for URI. SAFV-3 isolates were detected by isolation on cell culture and IF assay. The molecular typing was performed by RT-PCR and was sequenced to compare with reference strains available in the NCBI GeneBank. Serum samples were collected from 2005 to 2013 in Taiwan for seroprevalence investigation. RESULTS: A total of 226 specimens collected from children with URIs, 22 (9.73%) were positive for SAFV-3. The majority of SAFV-3 infections were found in children less than 6 years of age (14 of 22, 63.6%). Genetic analysis of VP1 coding region of Taiwanese isolates shown an 83.2-97.7% difference from other available SAFV-3 sequences in NCBI GenBank. Phylogenetic analysis revealed there is three genetic groups of SAFV-3 co-circulated in Taiwan during the study period. In addition, seroprevalence investigation results indicated that SAFV-3 infection occurs early in life and 43.7-77.8% of children aged between 6 months to 9 years old, had neutralizing antibodies against SAFV-3. CONCLUSION: SAFV-3 may have circulated in Taiwan for some time and it appears to be one of the etiological agents responsible for URIs in children.

Molecular epidemiologic and clinical characteristics of influenza B-associated complications among hospitalized patients during an outbreak in Taiwan.

OBJECTIVES: To study the resurgence of influenza B/Yam in Taiwan and summarize clinical findings of influenza B-associated complications among hospitalized patients, in particular the link between clinical and molecular epidemiologic characteristics. METHODS: Clinical information and isolates were collected through the national surveillance system of the Taiwan Centers for Disease Control. Potential risk factors associated with severe illness were analyzed. Antigenic and genetic analysis of representative hemagglutinin (HA) nucleotide sequences was performed. RESULTS: Of 326 patients admitted to the intensive care unit (ICU), 63.2% were aged ≤18 years or ≥65 years and 12.9% were adults aged 19-49 years. Most of the cases had underlying medical conditions before admission, and more fatal cases had chronic medical conditions than those who convalesced in the ICU. Results of the phylogenetic analysis showed that the majority of isolates from fatal cases in Taiwan were in group 2 (represented by B/Massachusetts/2/2012-like) rather than group 3, which was the predominant group of strains circulating in other Asian countries. CONCLUSIONS: Our findings suggest a regional trend of influenza B viruses and showed that new phylogenetic lineages and antigenic variants emerging in neighboring countries were likely to be the progenitors of the epidemic strains in the following seasons.

Multiple models of porcine teschovirus pathogenesis in endemically infected pigs.

Porcine teschoviruses (PTVs) belong to the genus Teschovirus within the family Picornaviridae. PTVs are universal contaminants in pig herds in endemic and multi-infection status. To further the understanding of PTV pathogenesis in endemically infected pigs, a set of samples was studied by real time reverse transcription PCR (qRT-PCR) to quantitate viral loads in tissues and by in situ hybridization (ISH) to locate PTV signals in target cells, both targeting the 5'-NTR. cRNA of PTV-1 and PTV-7, in vitro transcribed from cloned fragments of 5'-NTR of 2 viruses, was used to construct standard curves and to run parallel in qRT-PCR, which had detection limits of 10(1) copies/per reaction, with a linearity in between 10(1) and 10(7) copies/per reaction and correlation coefficients of 0.997-0.9988. The qRT-PCR specifically amplified RNA from PTV-1 to -11, while excluding those of Sapelovirus, PEV-9 and PEV-10. Inguinal lymph node (LN) had the highest viral load of all (assuming 100%), followed by ileac LN (89-91%), tonsil (66-68%), ileum (59-60%), spleen (38-40%), and kidney (30-31%), with the least in brain (22.9%) of the inguinal LN. The 22.9% load in brain was higher than that anticipated from a simple fecal-oral-viremia operative model. The results suggested in addition that intranasal infection and retrograding axonal infection from the tonsils were equally operative and significant. ISH revealed PTV signals in a wider variety of tissue cell types than before. PTV signals were noted most impressively in neurons of the cerebral cortex and hippocampus and in the dark zone of the germinal center and adjacent paracortex of regional LN. Multiple operative models indicated that PTVs seemed to have no difficulty invading the brain. The key to whether encephalitis would ensue resided in the animal's immune status and topographic differences of neurons' susceptibilities to PTVs. When common co-infected agents are present, as is typical in the field, PTVs may synergize in causing diseases.

Exploring the molecular epidemiology and evolutionary dynamics of influenza A virus in Taiwan.

The evolution and population dynamics of human influenza in Taiwan is a microcosm of the viruses circulating worldwide, which has not yet been studied in detail. We collected 343 representative full genome sequences of human influenza A viruses isolated in Taiwan between 1979 and 2009. Phylogenetic and antigenic data analysis revealed that H1N1 and H3N2 viruses consistently co-circulated in Taiwan, although they were characterized by different temporal dynamics and degrees of genetic diversity. Moreover, influenza A viruses of both subtypes underwent internal gene reassortment involving all eight segments of the viral genome, some of which also occurred during non-epidemic periods. The patterns of gene reassortment were different in the two subtypes. The internal genes of H1N1 viruses moved as a unit, separately from the co-evolving HA and NA genes. On the other hand, the HA and NA genes of H3N2 viruses tended to segregate consistently with different sets of internal gene segments. In particular, as reassortment occurred, H3HA always segregated as a group with the PB1, PA and M genes, while N2NA consistently segregated with PB2 and NP. Finally, the analysis showed that new phylogenetic lineages and antigenic variants emerging in summer were likely to be the progenitors of the epidemic strains in the following season. The synchronized seasonal patterns and high genetic diversity of influenza A viruses observed in Taiwan make possible to capture the evolutionary dynamic and epidemiological rules governing antigenic drift and reassortment and may serve as a "warning" system that recapitulates the global epidemic.

The role of porcine teschovirus in causing diseases in endemically infected pigs.

Porcine teschoviruses (PTVs) belong to the genus Teschovirus within the family Picornaviridae. Hitherto, PTVs have had 13 serotypes associated with a variety of clinical diseases. The virulent PTV-1 strains were associated with highly fatal, nonsuppurative encephalomyelitis of pigs (Teschen disease) in the 1930-1950s. Today, less virulent Talfan strains of PTV-1 are more widespread, and PTVs have contaminated swine herds worldwide (endemic or enzootic) together with a variety of common swine pathogens (multi-infection status). The aim of this study was to investigate the extent to which PTVs play a role in causing diseases in the field, under the endemic and multi-infection situation, when most pigs in the herds are infected and immune. Based on the fecal-oral model of pathogenesis, a set of 15 organs were collected from 30 culled post-weanling piglets of 4-8 weeks old. For nested RT-PCR targeted on the 5'-NTR, the PTV detection rate was 96.7% (by heads), confirming the endemic status, and infection was most commonly detected in the intestines (averaged 61%) and lymphoid organs (averaged 59%), followed by visceral organs (averaged 37%) and the CNS (different parts varied from 17 to 47%). The correlation of PTVs detected by nested RT-PCR and a histological lesion were analyzed by Chi-square test showing that in the field situation only non-suppurative encephalitis in the caudal part of the brain (P=0.054) may be marginal significantly attributed to infection by PTVs. By genotyping based on partial VP1 sequences, 5 serotypes, namely PTV-1, -4, -6, -7, and -11, were identified, with some animals having two serotypes co-existed in different organs.

Phylodynamics and molecular evolution of influenza A virus nucleoprotein genes in Taiwan between 1979 and 2009.

BACKGROUND: Many studies concentrate on variation in the hemagglutinin glycoprotein (HA) because of its significance in host immune response, the evolution of this virus is even more complex when other genome segments are considered. Recently, it was found that cytotoxic T lymphocytes (CTL) play an important role in immunity against influenza and most CTL epitopes of human influenza viruses were remarkably conserved. The NP gene has evolved independently in human and avian hosts after 1918 flu pandemic and it has been assigned a putative role as a determinant of host range. METHODS AND FINDINGS: Phylodynamic patterns of the genes encoding nucleoprotein (NP) of influenza A viruses isolated from 1979-2009 were analyzed by applying the Bayesian Markov Chain Monte Carlo framework to better understand the evolutionary mechanisms of these Taiwanese isolates. Phylogenetic analysis of the NP gene showed that all available H3 worldwide isolates collected so far were genetically similar and divided into two major clades after the year 2004. We compared the deduced amino acid sequences of the NP sequences from human, avian and swine hosts to investigate the emergence of potential adaptive mutations. Overall, selective pressure on the NP gene of human influenza A viruses appeared to be dominated by purifying selection with a mean d(N)/d(S) ratio of 0.105. Site-selection analysis of 488 codons, however, also revealed 3 positively selected sites in addition to 139 negatively selected ones. CONCLUSIONS: The demographic history inferred by Bayesian skyline plot showed that the effective number of infections underwent a period of smooth and steady growth from 1998 to 2001, followed by a more recent rise in the rate of spread. Further understanding the correlates of interspecies transmission of influenza A virus genes from other host reservoirs to the human population may help to elucidate the mechanisms of variability among influenza A virus.

Emergence and spread of oseltamivir-resistant A(H1N1) influenza viruses in Oceania, South East Asia and South Africa.

The neuraminidase inhibitors (NAIs) are an effective class of antiviral drugs for the treatment of influenza A and B infections. Until recently, only a low prevalence of NAI resistance (<1%) had been detected in circulating viruses. However, surveillance in Europe in late 2007 revealed significant numbers of A(H1N1) influenza strains with a H274Y neuraminidase mutation that were highly resistant to the NAI oseltamivir. We examined 264 A(H1N1) viruses collected in 2008 from South Africa, Oceania and SE Asia for their susceptibility to NAIs oseltamivir, zanamivir and peramivir in a fluorescence-based neuraminidase inhibition assay. Viruses with reduced oseltamivir susceptibility were further analysed by pyrosequencing assay. The frequency of the oseltamivir-resistant H274Y mutant increased significantly after May 2008, resulting in an overall proportion of 64% (168/264) resistance among A(H1N1) strains, although this subtype represented only 11.6% of all isolates received during 2008. H274Y mutant viruses demonstrated on average a 1466-fold reduction in oseltamivir susceptibility and 527-fold reduction in peramivir sensitivity compared to wild-type A(H1N1) viruses. The mutation had no impact on zanamivir susceptibility. Ongoing surveillance is essential to monitor how these strains may spread or persist in the future and to evaluate the effectiveness of treatments against them.

Clinical and genetic analysis of Human Bocavirus in children with lower respiratory tract infection in Taiwan.

BACKGROUND: Human Bocavirus (HBoV) is a likely etiologic agent of acute respiratory disease in children. The prevalence of this virus has been studied in several sites worldwide. We conducted the first clinical and molecular study of HBoV in Taiwan at the Centers for Diseases Control, Taiwan. OBJECTIVES: To investigate the genomic and epidemiologic profiles of HBoV infection in Taiwan. STUDY DESIGN: Throat swabs or nasopharyngeal aspirates were obtained from hospitalized pediatric patients with acute lower respiratory tract infections. Specimens negative for other respiratory viruses by molecular screening were examined for HBoV. RESULTS: HBoV was the only virus detected in 30 (5.6%) of 531 samples. Of these positive cases, 56.7% were from children less than 2 years old. Two groups of HBoV co-circulated in Taiwan during the study. Results of evolutionary networks evaluation suggest that HBoV might have had an opportunity for interbreeding of viruses and genetic recombinations among the different genes. CONCLUSION: HBoV may have circulated in Taiwan for some time and it appears to be one of the etiological agents responsible for lower respiratory tract infection in children.

Genetic and antigenic analysis of epidemic influenza viruses isolated during 2006-2007 season in Taiwan.

Influenza viruses are some of the most active pathogens in Taiwan. The monitoring influenza activity has been coordinated by the Centers for Diseases Control, Taiwan, and the surveillance is based on integrated clinical and virological surveillance components. Data from sentinel physician networks and other sources, mainly hospitals were collected. During 2006-07 season, a total of 1724 cases of laboratory-confirmed influenza were reported by collaborating laboratories and sentinels, which was five fold higher than during the corresponding part of the 2005-06 season. Of the Taiwan isolates analyzed using post-infection ferret antisera, 1.5% were H1N1 (A/Hi), 21.5% H3N2 (A/H3), and 77.0% influenza B viruses. This reflects the predominance of influenza B viruses during 2006-07 season. In addition, continued antigenic drift was seen with the A/I-B viruses compared with the previous season's reference strains. However, an increasing number of recent A/H3 isolates characterized in our report were amantadine sensitive. Preparation for an influenza pandemic is presently a high priority in Taiwan. Laboratory-based surveillance systems must be timely in order to be effective. The data presented here highlights the need to characterize the circulating strains both antigenically and genetically during regular surveillance. Any contribution of individual genes or gene combinations to usual or unusual epidemic characteristics might thus be identified ensuring that virus strains can be selected for vaccine formulation that will most closely match the circulating viruses.

Characterization of the epidemic influenza B viruses isolated during 2004-2005 season in Taiwan.

To characterize the antigenic and genetic relationships of influenza B viruses isolated during the 2004-2005 season, a total of 11,707 clinical respiratory samples were tested of which 1572 (13.5%) were positive for influenza (463 type A and 1109 type B influenza). Of the type B viruses, 348 isolates collected in different parts of Taiwan were further analyzed. Viruses belonging to both influenza B lineages, B/Yamagata/16/88 (B/Yam) and B/Victoris/2/87 (B/Vic) were detected, although an increasing number of B/Vic lineage isolates was obtained as the season progressed. Recent B/Vic-lineage isolates were found to have additional amino acid substitutions compared to isolates from previous seasons, indicating that viruses of this lineage continue to evolve significantly and may have the capacity to become the dominant influenza B viruses worldwide. Results presented in this report demonstrate that antigenically and genetically distinct viruses within both B/Vic and B/Yam lineages co-circulate and that reassortment among these two lineages occurs frequently contributing to the genetic diversity of the circulating strains.

Laboratory-based surveillance and molecular epidemiology of influenza virus in Taiwan.

A laboratory-based surveillance network of 11 clinical virological laboratories for influenza viruses was established in Taiwan under the coordination of the Center for Disease Control and Prevention (CDC), Taiwan. From October 2000 to March 2004, 3,244 influenza viruses were isolated, including 1,969 influenza A and 1,275 influenza B viruses. The influenza infections usually occurred frequently in winter in the northern hemisphere. However, the influenza seasonality in Taiwan was not clear during the four seasons under investigation. For example, the influenza A viruses peaked during the winters of 2001, 2002, and 2003. However, some isolated peaks were also found in the summer and fall (June to November) of 2001 and 2002. An unusual peak of influenza B also occurred in the summer of 2002 (June to August). Phylogenetic analysis shows that influenza A isolates from the same year were often grouped together. However, influenza B isolates from the year 2002 clustered into different groups, and the data indicate that both B/Victoria/2/87-like and B/Yamagata/16/88-like lineages of influenza B viruses were cocirculating. Sequence comparison of epidemic strains versus vaccine strains shows that many vaccine-like Taiwanese strains were circulating at least 2 years before the vaccine strains were introduced. No clear seasonality of influenza reports in Taiwan occurred in contrast to other more continental regions.

Coupling multiplex RT-PCR to a gene chip assay for sensitive and semiquantitative detection of severe acute respiratory syndrome-coronavirus.

An early and accurate diagnostic assay for severe acute respiratory syndrome (SARS) is crucial for infection control. However, most of the diagnostic methods available today, such as real-time reverse transcriptase-polymerase chain reaction (RT-PCR), require a second detection method for confirmation because they detect a single sequence region of the SARS-coronavirus (SARS-CoV). For sensitive and accurate early diagnosis, we report a novel assay system combining multiplex RT-PCR and a diagnostic gene chip to detect multiple virus-specific genomic sequences of SARS-CoV. With 53 clinical specimens, we successfully demonstrate that this technique offers not only a high-accuracy diagnosis for early SARS infection but also a semiquantitative assay.

Serologic and molecular biologic methods for SARS-associated coronavirus infection, Taiwan.

Severe acute respiratory syndrome (SARS) has raised a global alert since March 2003. After its causative agent, SARS-associated coronavirus (SARS-CoV), was confirmed, laboratory methods, including virus isolation, reverse transcriptase-polymerase chain reaction (RT-PCR), and serologic methods, have been quickly developed. In this study, we evaluated four serologic tests ( neutralization test, enzyme-linked immunosorbent assay [ELISA], immunofluorescent assay [IFA], and immunochromatographic test [ICT]) for detecting antibodies to SARS-CoV in sera of 537 probable SARS case-patients with correlation to the RT-PCR. With the neutralization test as a reference method, the sensitivity, specificity, positive predictive value, and negative predictive value were 98.2%, 98.7%, 98.7%, and 98.4% for ELISA; 99.1%, 87.8%, 88.1% and 99.1% for IFA; 33.6%, 98.2%, 95.7%, and 56.1% for ICT, respectively. We also compared the recombinant-based western blot with the whole virus-based IFA and ELISA; the data showed a high correlation between these methods, with an overall agreement of >90%. Our results provide a systematic analysis of serologic and molecular methods for evaluating SARS-CoV infection.

Early detection of antibodies against various structural proteins of the SARS-associated coronavirus in SARS patients.

Severe acute respiratory syndrome (SARS), a new disease with symptoms similar to those of atypical pneumonia, raised a global alert in March 2003. Because of its relatively high transmissibility and mortality upon infection, probable SARS patients were quarantined and treated with special and intensive care. Therefore, instant and accurate laboratory confirmation of SARS-associated coronavirus (SARS-CoV) infection has become a worldwide interest. For this need, we purified recombinant proteins including the nucleocapsid (N), envelope (E), membrane (M), and truncated forms of the spike protein (S1-S7) of SARS-CoV in Escherichia coli. The six proteins N, E, M, S2, S5, and S6 were used for Western blotting (WB) to detect various immunoglobulin classes in 90 serum samples from 54 probable SARS patients. The results indicated that N was recognized in most of the sera. In some cases, S6 could be recognized as early as 2 or 3 days after illness onset, while S5 was recognized at a later stage. Furthermore, the result of recombinant-protein-based WB showed a 90% agreement with that of the whole-virus-based immunofluorescence assay. Combining WB with existing RT-PCR, the laboratory confirmation for SARS-CoV infection was greatly enhanced by 24.1%, from 48.1% (RT-PCR alone) to 72.2%. Finally, our results show that IgA antibodies against SARS-CoV can be detected within 1 week after illness onset in a few SARS patients.