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Indiana University-Purdue University Indianapolis (IUPUI) / Enteric viruses are infectious human pathogens that initiate infection in the gastrointestinal tract. They follow a fecal-oral route of transmission and are spread by contamination of food, water, or contact between individuals. Furthermore, enteric viruses also cause significant morbidity, mortality, and economic burdens yearly. Coxsackievirus (CV) is commonly isolated among enteric viruses and is an etiological agent of hand, foot, and mouth disease, hemorrhagic conjunctivitis, and myocarditis. The virus predominantly infects infants and young children and accounts for 11% of the fatality rate in neonates. Despite CV’s impact on human health, there are no treatments or vaccines for CV infections. Using a mouse model to study a key CV, Coxsackievirus B3 (CVB3), our laboratory has found two critical factors that impact CVB3 replication and pathogenesis. First, we have demonstrated that intestinal bacteria enhance intestinal CVB3 replication. We found that certain specific bacteria (Salmonella enterica) and its cell wall components, like lipopolysaccharides (LPS), enhanced CVB3 stability and infectivity in vitro. Additionally, we found that particular constituents of LPS are required for stability to occur. These data suggest that specific bacteria may be integral in maintaining CVB3 infectivity in the intestine. Besides virus-microbiome interaction, CVB3 is also impacted by sex hormones. Using castrated mice models, we observed a sex bias to CVB3 infection, with male mice succumbing to CVB3-induced disease at an increased rate compared to female mice. Our data suggest that testosterone, a predominant male sex hormone, enhanced CVB3 intestinal replication and viral dissemination to organs in male and female mice, but lethality only in male mice. Moreover, testosterone also affected the immune response by reducing the activation of the CD8+ T cells. CD8+ T cells are required to clear the viral infection and are integral in vaccine development. In contrast, we found an enhanced CD8+ T cell response in female mice to CVB3 infection, suggesting a sex-dependent T cell response that may underlie the sex bias in disease. Overall, these data represent an essential advancement in the CV field and will help develop future therapeutics and aid in vaccine design to limit CV infections.

No description available.

CoxsackievirusB3 (CVB3), a member of the Picornaviridae family is the causative agent of Virus-induced Myocarditis and Dilated Cardiomyopathy. The 5’UTR contains an Internal Ribosome Entry Site or IRES element that recruits ribosomes in a cap-independent manner. The ribosomes are recruited upstream of the AUG triplet at 591 (AUG591), also called as the cryptic AUG, after which they scan downstream for about 150 nucleotide, before initiating at the initiator AUG or AUG741. The 3’UTR of CVB3 is 99 nts long, highly structured RNA containing conserved domains, and is followed by a poly (A) tail of variable lengths. We have investigated possible involvement of host proteins which may interact with CVB3 IRES and influence its activity. We have demonstrated the role of Poly-pyrimidine tract binding protein (PTB) and established PTB as a bona-fide ITAF for CVB3, by characterizing the effect of partial silencing of PTB ex-vivo in HeLa cells. The IRES activity in BSC-1 cells, reported to have very low level of endogenous PTB, is found to be significantly low compared to that in HeLa cells. PTB is observed to interact with both the 5’ and 3’ UTR of CVB3, although with different affinities. Finer mapping of the interaction between PTB and the UTRs showed that the protein interacts with multiple regions of both UTRs. We have also shown the cis-acting effect of the CVB3-3’UTR on IRES mediated translation. The PTB contact points on the 3’UTRwas found to map to conserved regions, the deletion of which abrogates the 3’UTR mediated enhancement of the IRES activity. The possible role played by PTB in enhancing IRES activity by CVB3 3’UTR suggests that PTB protein might help in circularization of the CVB3 RNA by bridging the ends necessary for efficient translation of the viral RNA. In the second part, we have investigated possible role of some of the cis-acting element present in the CVB3 5’UTR RNA particularly the cryptic AUG. We have shown that mutation in cryptic AUG reduces the efficiency of translation mediated by the CVB3 IRES. Mutation in cryptic AUG moiety also reduces the interaction of mutant RNA with La protein. We have demonstrated that binding of 48S ribosomal complex with mutant IRES RNA was weaker compared to wt IRES RNA. We have investigated the possible alteration in secondary structure in the mutant RNA by chemical and enzymatic modification, which suggests that there is marginal alteration in the local structure due to mutation. It appears that integrity of cryptic AUG is important for efficient translation initiation by the CVB3 IRES. Results suggest that cryptic AUG plays a significant role in mediating internal initiation of translation of CVB3 RNA by mediating precise La binding and correct positioning of the 48S ribosomal complex. Finally, we have investigated the importance of a conserved hexa-nucleotide stretch in the apical loop within stem loop C (SLC, nt104-180), upstream of the ribosome landing site, on CVB3 IRES function. It has been already shown from our laboratory that the deletion at this apical loop resulted in significant decrease in IRES activity. This deletion mutant was shown to alter the secondary structure of the CVB3 5’UTR RNA. Here we have investigated the effect of point mutation in the apical loop SLC/c on CVB3 IRES activity by generating substitution mutation in the apical loop SLC/c in order to avoid possible alteration in secondary structure. Both the deletion or substitution mutation at this apical loop resulted in significant decrease in IRES activity. Both the mutant IRES RNAs (deletion and substitution mutant) failed to interact with certain trans-acting factors. Furthermore, expression of CVB3 2A protease significantly enhanced IRES activity of the wild type, but the effect was not so pronounced on the mutant IRESs. It is possible that the mutant RNAs were unable to interact with some trans-acting factors critical for enhanced IRES function. We have short-listed three proteins of approximate molecular mass of 56, 64 and 90 kDa, which showed reduced binding with mutant IRESs. By using RNA affinity column with biotinylated UTP labeled RNA we have purified couple of proteins and identified p64 as Cyto Keratin 1 protein by performing in-gel trypsin digestion followed by MALDI analysis. Overall, the results characterize the CVB3 IRES structurally and functionally, which could be useful in targeting critical RNA-protein interactions to develop candidate antiviral agent against Coxsackievirus infection.

Der Großteil MHC Klasse I restringierter Epitope wird bei der Proteindegradation durch das Ubiquitin Proteasom System (UPS) generiert. In der vorliegenden Arbeit wurde die Rolle des UPS in der Antigenpräsenation in einer Coxsackievirus B3 (CVB3) induzierten akuten und chronischen Myokarditis untersucht. Für in vitro Degradationsexperimente mit isolierten 20S Proteasomen wurden CVB3 Polypeptide synthetisiert und die Degradationsprodukte massenspektrometrisch analysiert. Eine erhöhte Substratumsatzrate und eine Verschiebung von Schnittpräferenzen durch Immunoproteasomen oder unter dem Einfluss von PA28 führten zu einer verbesserten Generierung immunrelevanter CVB3 Fragmente. Inflammatorische Kardiomyopathien können in Mäusen durch eine CVB3 Infektion ausgelöst werden. Resistente Stämme (C57BL/6) eliminieren das Virus vollständig, in anfälligen Mäusen (A.BY/SnJ) erfolgt keine vollständige Elimination. In Herzen gesunder Mäuse werden vorwiegend konstitutive 20S Proteasomen exprimiert. Eine myokardiale Entzündung, ausgelöst durch eine CVB3 Infektion, führte in den Herzen beider Mausstämme zu der Bildung von Immunoproteasomen, was zu einer gesteigerten Generierung immunrelevanter CVB3 Fragmente führte. Die größte Menge immunrelevanter Fragmente wurden durch Proteasomen gebildet, die am Tag vier aus den Herzen akut erkrankender C57BL/6 Mäuse und am Tag acht aus chronisch erkrankenden A.BY/SnJ Mäusen isoliert wurden. Dies korrelierte mit der Inkorporation von Immunountereinheiten in de novo assemblierende Proteasomen und einer unterschiedlichen Interferon (IFN) Typ I Kinetik. In Geweben lymphatischen Ursprungs hingegen waren Zusammensetzung und proteolytische Aktivität der Proteasomen im Verlauf der Infektion in beiden Mausstämmen unverändert. Die vorliegende Arbeit unterstreicht die Bedeutung einer zeitlich optimalen IFN Sekretion an der Infektionsstelle, die zu der Anpassung des UPS an die inflammatorischen Bedingungen führt. / The recognition of viral antigens bound to major histocompatibility complex (MHC) class I molecules by CD8+ T cells is crucial for virus elimination. Most MHC class I restricted antigenic peptides are produced by the Ubiquitin Proteasome System (UPS). In the present study, the impact of the UPS in antigen presentation during Coxsackievirus B3 (CVB3) induced acute and chronic myocarditis has been investigated. To examine whether the proteasome is involved in the generation of MHC class I ligands derived from the CVB3 polyprotein, polypeptides were synthesized for in vitro processing by 20S proteasomes. Mass spectrometry analysis demonstrated an enhanced generation of immunorelevant CVB3 fragments due to an increased substrate degradation rate and altered cleavage site preferences by immunoproteasomes or in the presence of PA28. Murine models of CVB3 induced myocarditis mimic human disease pattern with diverse outcomes. Permissive mice (A.BY/SnJ) develop chronic myocarditis with cardiac CVB3 persistence whereas resistant mice (C57BL/6) recover and eliminate the virus after acute infection. Constitutive 20S proteasomes are mainly expressed in hearts of healthy mice. Myocardial inflammation, caused by a CVB3 infection, resulted in immunoproteasome formation in hearts of both, resistant C57BL/6 and susceptible A.BY/SnJ mice, and was correlated with enhanced generation of immunorelevant CVB3 peptides. In concurrence with distinctive type I interferon kinetics, immunoproteasome formation and improved epitope generation peaked on day 4 post infection in resistant mice, and was delayed in susceptible mice. No alterations were observed in assembly and proteolytic activity of 20S proteasomes in lymphatic tissues during CVB3 infection, independent from mouse strain. The results emphasise the impact of a rapid adjustment of the UPS to viral infection due to early secretion of type I interferon at site of infection.

Background / Hand, foot, and mouth disease (HFMD), in particular those associated with enterovirus 71 (EV71), has caused large outbreaks in the Western Pacific and Southeast Asian countries in the past three decades. There is currently no effective chemoprophylaxis or vaccination for HFMD or EV71 infection. Public health strategies rest on good understanding of the epidemiological features of HFMD. The present series of studies examined the epidemiological characteristics of HFMD in Hong Kong, with a view to better understand the disease epidemiology so as to guide public health actions. / Methods and results of individual studies / Study (1)--characterizing the changing epidemiological features identified from various surveillance systems for HFMD / The trend of HFMD activities from 2001-2009 was analyzed using the sentinel surveillance statistics and HFMD outbreaks. The type of institutions reporting HFMD over time, incidences of outbreaks in 18 districts, and age and sex distribution of affected persons of HFMD outbreaks were analyzed. The clinical presentation, hospitalization rate, complication rate and case fatality of outbreaks were examined. The circulating enterovirues each year were determined by laboratory surveillance findings from 2001-2009 and test for morbidity caused by EV71. Seasonal peak was detected from warmer months of May through July but a smaller winter peak was found from October to December since 2006. An increasing trend of more older children aged above 5 years were infected, from 25.4% in 2001 to 33.0% in 2009 (p=0.01, Mantel-Haenszel Chi-square test). Laboratory surveillance detected a cyclical high activity of EV71 in every 3 to 4 years, which was associated with a higher average hospitalization rate among patients of the HFMD outbreaks reported in corresponding year, although it was only marginally significant (p=0.09, linear regression test). / Study (2)--analyzing the characteristics of EV71 epidemic in 2008 / All EV71 cases diagnosed by PHLC from 1998-2008 were analyzed. The complication and case fatality rates, percentage requiring hospitalization, median duration of hospital care, and the likelihood of being associated with an HMFD outbreak in institution in 2008 were compared with the corresponding rates calculated from cases reported from 1998-2007. Phylogenetic tree was constructed by using the neighbour-joining method and the molecular epidemiology of EV71 detected in 2008 was compared with the past years’ trends. Ninety-eight EV71 cases were reported in 2008, highest in the past decade. The annual incidence was 1.4/100 000 in general population, with highest incidence reported in children aged 0-4 years old (27.9/100 000). 11.2% had complications including meningitis or encephalitis (6.1%), pneumonia (3.1%), acute flaccid paralysis (1.0%), and shock (1.0%). There was only one fatal case (CFR: 1.0%) attributed to interstitial pneumonitis. 45.9% had concurrent HFMD outbreaks in their schools or institutions, and six schools required temporarily class suspension for 14 days. Both the complication rate and CFR werenot significantly different from the corresponding rates of the past 10 years (p=0.12 and 1.00 respectively). Phylogenetic analysis found that most cases reported in 2008 were C4 strains, which were the predominant circulating strains in the past ten years. / Study (3)--examining the association between meteorological parameters and HFMD activity / The sentinel consultation rate of HFMD was tested for any association with the meteorological parameters obtained from the Hong Kong Observatory from 2000-2004. Different regression models were examined to find the best model for predicting HFMD consultation rates from 2005-2009. In multivariate regression analysis, model M2 (in which mean temperature, diurnal difference in temperature, relative humidity and wind speed were positively associated with HFMD) was found to have a higher R2 (0.119) than M0 and M1 models with an R2 of 0.079 and 0.062 respectively, indicating that HFMD consultation rates were better explained using meteorological parameters measured 2 weeks earlier. The predicted trend of HFMD consultation rates for 2005 to 2009 matched well with the observed one (Spearman’s rank correlation coefficient=0.276, P=0.000). Sensitivity analysis showed that the estimated HFMD consultation rates were mostly affected by varying the relative humidity and least affected by wind speed. / Study (4)--determining the basic reproduction number of coxsackievirus A16 and enterovirus 71 using mathematical model / The basic reproduction numbers (R0) of EV71 and CoxA16 from laboratory confirmed HFMD outbreaks reported to DH from 2004-2009 were determined using mathematical model. Thirty four outbreaks were analyzed, 27 due to CoxA16 and seven due to EV71. The median R0 of EV71 was 5.48 with an inter-quartile range of 4.206.51 while median R0 of CoxA16 was 2.50 with an inter-quartile range of 1.963.67. In the sensitivity analysis, R0 of EV71 was significantly higher than that of CoxA16 in whole range of incubation periods, p≦0.025. R0was not associated with outbreak setting, size of the institution or number of persons affected. / Study (5)--assessing the impact of SARS and pandemic influenza H1N1 on transmission of HFMD in Hong Kong / I compared the observed HFMD consultation rates and the projected rates, which were constructed using mathematical model, in defined periods of 2003 and 2009 during which territory-wide public health interventions (including school closure) against Severe Acute Respiratory Syndrome (SARS) and pandemic influenza H1N1 were implemented. There was a reduction of 57.2% (95% C.I.:53.0-60.7%) in observed HFMD consultation rates during SARS period in 2003 and a reduction of 26.7% (95% C.I.:19.5-32.7%) during pandemic influenza H1N1 period in 2009. In 2003, the projected rates were still lower than the observed rates beyond week 31 until almost the end of the year. On the contrary, in 2009, the observed HFMD consultation rates became comparable to that of the projected rates in August, before the end of the defined intervention period. / Conclusions / This thesis bridges the knowledge gaps regarding epidemiological characteristics of HFMD. The changing epidemiology of HFMD, including the cyclical high activity of EV71 warrants vigilant surveillance of its activity in order to guide preventive measures. I have demonstrated that climate parameters may help predict HFMD activity, which could assist in explaining the winter peak detected in recent years and issuing early warning in the future. The R0 of EV71 and CoxA16 were first determined in the literature and I found that R0 of EV71 was higher than R0 of CoxA16. The reduction of transmission of HFMD during the SARS and H1N1 periods suggested that public health measures are effective in reducing the transmission of enteroviruses. / Ma, Siu Keung. / Thesis (M.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 121-149). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Table of content --- p.ii / Acknowledgements --- p.iv / Abbreviations --- p.v / Caption for Tables --- p.vi / Caption for Figures --- p.viii / Précis --- p.1 / Chapter PART I: --- LITERATURE REVIEW ON HFMD --- p.5 / Chapter Chapter 1. --- Current Understanding of Epidemiology of HFMD --- p.6 / Chapter 1.1 --- Causative agents and virology --- p.6 / Chapter 1.2 --- Clinical presentation and management --- p.8 / Chapter 1.3 --- Geographical distribution and past epidemics --- p.14 / Chapter 1.4 --- Host susceptibility and molecular determinants of neruovirulence --- p.26 / Chapter 1.5 --- Routes of transmission and transmission dynamics --- p.27 / Chapter 1.6 --- Knowledge gap identified from literature review --- p.29 / Chapter PART II: --- STUDIES ON EPIDEMIOLOGY OF HFMD IN HONG KONG --- p.33 / Chapter Chapter 2. --- Study Objectives and Main data source for analysis --- p.34 / Chapter 2.1 --- Aim and objectives of this thesis --- p.34 / Chapter 2.2 --- Sentinel surveillance system for monitoring HFMD activity --- p.35 / Chapter 2.3 --- Institutional outbreaks of HFMD reported to DH . --- p.37 / Chapter 2.4 --- EV 71 infection reported to Department of Health --- p.37 / Chapter 2.5 --- Laboratory surveillance for monitoring enteroviruses --- p.37 / Chapter Chapter 3. --- Study (1)--Characterizing the changing epidemiological features identified from various surveillance systems for HFMD --- p.38 / Chapter Chapter 4. --- Study (2)--Analyzing the epidemic of enterovirus 71 in 2008 and its public health implication to Hong Kong --- p.52 / Chapter Chapter 5. --- Study (3)--Examining the association between meteorological parameters and HFMD activity --- p.67 / Chapter Chapter 6. --- Study (4)--Determining the basic reproduction number of coxsackievirus A16 and enterovirus 71 using mathematical model --- p.85 / Chapter Chapter 7. --- Study (5)--Impact of SARS and Pandemic Influenza H1N1 on transmission of HFMD in Hong Kong --- p.100 / Chapter Chapter 8. --- Conclusion --- p.111 / List of publications related to this thesis --- p.119 / References --- p.121

This thesis focuses on enteroviral effects on human pancreatic islets. Most knowledge of viral effects on host cells relies on studies of immortalized cell lines or animal models. The islets represent a fundamentally different and less well studied cellular host. Also, enterovirus has been implicated in the etiology of type 1 diabetes (T1D). We show that when enterovirus replicates in human islets it activates innate immunity genes and induces secretion of the chemokines MCP-1 and IP-10. An important difference in activation of innate immunity by replicating EV and synthetic dsRNA is suggested, since the chemokine secretion induced by EV infection but not by dsRNA is reduced by female sex hormone. We also demonstrate a direct antiviral effect of nicotinamide, and even though this substance failed to prevent T1D in a large-scale study, this finding could have implications for the treatment/prevention of virus- and/or immune-mediated disease. We also had access to human pancreata from two organ donors with recent onset T1D and several donors with T1D-related autoantibodies, which gave us the opportunity to study ongoing pathogenic processes at and before the onset of T1D. Despite this, we could neither confirm nor reject the hypothesis that EV is involved in T1D development. Several observations, such as ultrastructural remodeling of the beta cell, activation of innate immunity, and immunopositivity to EV capsid protein 1, supported an ongoing virus infection, but direct evidence is still lacking. An interesting finding in the donors with recent onset T1D was that the islets were positively stained for insulin, but did not secrete insulin in response to glucose-stimulation. A similar effect was observed in EV-infected islets in vitro; EV destroyed islet function and insulin gene expression, but the islets still stained positive for insulin. This may be indicative of that a functional block in addition to beta cell destruction is involved in T1D pathogenesis. In conclusion, these studies of EV in isolated human islets in vitro support that this virus can cause T1D in vivo, but future studies will have to show if and how frequently this happens.

Trace elements are essential for the host defence against infections, and during common infections, the balance of trace elements is changed in serum and tissues. Supplementation with selenium (Se), an essential trace element, is known to decrease the severity of coxsackievirus B3 (CVB3) infection in mice. Even the non-essential trace element arsenic (As) seems to influence the replication of some viruses. During the course of an acute CVB3 infection in mice, Se concentrations decreased in most tissues and were negatively correlated to viral load in our study. However, As concomitantly decreased in most tissues. As has previously been shown to interfere with the balance of essential trace elements. However, in the present study As supplementation in healthy mice resulted in minor effects on seven studied trace elements in serum and tissues. The effects of As supplementation were more pronounced in CVB3-infected mice, with an increase in As, but a decrease in Se in most tissues when compared with non-infected mice. As supplementation during CVB3 infection in mice decreased viral RNA concentrations in the brain (97%) and pancreas (75%), two of the target organs of this infection. In vitro experiments indicate that As caused an impaired virion assembly or release. In vivo, infection-induced expression of the host defence-associated genes nuclear factor κB (NFκB) and interferon γ (IFN-γ) were unaffected by As supplementation, except for an earlier increase in IFN-γ in the brain. In conclusion, a clinically relevant dose of As decreased the replication of CVB3 in vitro and in vivo. This antiviral effect in vivo was not related to changes in specific trace elements or in the host’s immune-mediated defence. Although the mechanism underlying the observed effect on viral replication remains to be further elucidated, As seems to be an intriguing trace element to study in the pursuit of new antiviral drugs.

The Enterovirus genus within the family Picornaviridae contains over 100 serotypes, of which sixty-four are known to be human pathogens. Infection with this group of RNA viruses produces a myriad of clinical conditions including poliomyelitis, meningitis, encephalitis, respiratory illnesses, and hand-foot-and-mouth disease. Outbreaks have been documented worldwide; significant morbidity and mortality exist to warrant laboratory surveillance. Traditionally, enteroviruses have been identified to the level of serotype by the serum neutralization assay. However, numerous problems are associated with this assay. The serum neutralization assay is labor intensive, results are often ambiguous, and reagents are becoming difficult to obtain. Recently, molecular-based typing protocols have been described that are cost effective and produce results that are more reliable. The overall objective of this thesis was to implement a molecular-based typing protocol to replace the serum neutralization method currently used. Three specific aims were identified to reach this objective. First, a database cataloging all enteroviruses isolated at the Florida Department of Health - Tampa Branch Laboratory from 1981 through 2002 was created. Serotype prevalence, specimen submission rates, and temporal trends were analyzed to demonstrate the public health importance of enterovirus surveillance. Next, five oligonucleotide primer sets were compared with respect to sensitivity, specificity, and overall utility in molecular typing protocols developed to accurately determine enterovirus type. Finally, the most effective molecular assay was used to conduct two basic molecular epidemiological analyses of intratypic variation of Coxsackievirus B5 isolates, and of intratypic variation of successive Echovirus 9 passages. The results from this study show that implementation of a molecular-based typing system for enteroviruses would be an improvement over current enterovirus serotyping methods. Results are obtained more rapidly and are more reliable. The implementation of such a system would improve the surveillance capabilities of the State of Florida Department of Health.