Enterovirus RNA in longitudinal blood samples and risk of islet autoimmunity in children with a high
轮状病毒胃肠炎的免疫预防

•述评•轮状病毒胃肠炎的免疫预防刘娜中国疾病预防控制中心病毒病预防控制所,北京102206基金项目:世界卫生组织项目(WH02019/901646-0)DOI:10.3760/cma.j.issn.1673-4092.2021.02.001A组轮状病毒(rotavirus,RV)是导致5岁以下儿童 重症脱水性胃肠炎的最主要病原,所有5岁以下儿童至少 感染一次轮状病毒m,其中50%的儿童会因RV感染而发 生胃肠炎m。
无RV疫苗干预的情况下,5岁以下儿童重症 腹泻中40%由RV感染引起,发达国家与发展中国家RV 的检出率相似。
RV每年导致全球5岁以下儿童死亡18.5万,死亡主要发生在非洲、南亚和东南亚地区|3]。
1轮状病毒病原学和临床特征RV属于呼肠孤病毒科轮状病毒属,无包膜,直径 lOOnm,为分节段双链RNA病毒|41,1丨个片段编码6个 结构蛋白(VP1~VP4、VP6和VP7)和6个非结构蛋白(NSP1-NSP6 )w。
根据VP6的抗原性分为A~J 10个组, 其中A、B、C及H组可感染人类,5岁以下儿童对A组 RV普遍易感,所致胃肠炎症状重,最受关注'VP4和 VP7为主要的中和抗原表位,决定了 RV不同的G(VP7) 血清型和P(VP4)血清型。
目前有27种G型、37种P 型,全球最主要流行的毒株为:G1P[8】、G2P[4]、G3P[8]、G9P[8]和G12P[8],占所有流行毒株的90%141。
RV感染主要引起胃肠道症状,某些病人也有肠道外 的表现(惊厥、肺炎、肝炎、心肌炎、I型糖尿病等)。
胃肠炎症状可以从轻度到中重度,主要表现为腹泻、呕吐,1/3的患儿伴有发热(体温& 38.3丈)。
通常症状较其他 病原重,易导致脱水及水电解质平衡紊乱,如不及时纠正 易导致死亡。
呕吐和发热持续2~3d,腹泻持续3~5d,在 免疫抑制病人中,症状持续时间更长|61。
2轮状病毒流行特征R V潜伏期1~3d|71,轮状病毒胃肠炎(rotavirus gastroenteritis,RVGE)患者及隐性感染者均为传染源,主 要通过粪-口途径传播,也可通过呼吸道传播|81。
新型冠状病毒肺炎患者实验室检测指标研究进展

预防医学论坛2020年12月第26卷第12期Prev Med Trib, Vol. 26,No. 12,Dec. 2020• 957 ••综述•新型冠状病毒肺炎患者实验室检测指标研究进展*程惠玲1,房元勋2,张丽(通讯作者Y1.山东第一医科大学第一附属医院/山东省千佛山医院,山东济南250014;2.山东农业工程学院,山东济南250100摘要:新型冠状病毒肺炎(COVICM9)患者实验室检测指标在C C)Vir>19诊断及治疗有重要作用。
实时荧光RT-PCR病毒核酸检测及基因测序为疑似病例确诊的病原学证据;病毒特异性Ig M和Ig G抗体联合及动态监测,为病毒核酸检测假阴性结果的有效互补。
感染从普通型进展为重型、危重型过程中,患者出现肝功、心脏功能及肾功的异常比例及程度逐渐增高,如谷草转氨酶、乳酸脱氢酶、肌酸激酶,超敏肌钙蛋白I、尿素及肌酐进行性升高、低白蛋白血症等。
重症感染者伴随炎症加重,甚至“炎症风暴”发生,外周血中性粒细胞计数、中性粒细胞与淋巴细胞比值增加,单核细胞、嗜酸性粒细胞和嗜碱性粒细胞的百分比急剧下降;淋巴细胞数量进行性减少但过度激活;同时“炎症风暴”相关细胞/趋化因子增高,如:^"-2、IL-6、IL-7、IL-10、G■CSF、IP10、M CPl、M丨P lA和TNF-a进行性升高;其他炎症指标如C反应蛋白、血清淀粉样蛋白A、铁蛋白和降钙素原,随着病情进展呈逐步升高趋势。
重症感染及炎症,触发凝血功能紊乱,血浆二聚体进行性升高是患者重症/危重症预警信号,大于1Hg/m l是住院患者死亡独立危险因素。
COVII>19患者,特别是年长,或伴有高血压、糖尿病及心血管疾病患者,宜动态监测,提前预防,降低重症发生。
关键词:严重急性呼吸综合征冠状病毒;新型冠状病毒肺炎;实验室检测中图分类号:R511 文献标识码:A文章编号:1672 —9153(2020)12 —0957 —05新型冠状病毒肺炎(Coronavirus virus disease 2019,COVII>19)由严重急性呼吸综合征冠状病毒2 (Severe Acute Respiratory Syndrome Coronavirus 2, SARS-CoV-2)感染引发,SARS-CoV-2传染性强,传 播快,疫情对人类生命健康构成了重大威胁。
严重急性呼吸系统综合症冠状病毒-2与横纹肌溶解症

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沙库巴曲缬沙坦治疗急性心肌梗死合并Ⅱ~Ⅲ期慢性肾脏病患者的短期效果

·临床研究·基金项目:安徽省安庆市科技局基金项目(2021Z2001)作者简介:沈国秀,主治医师,Email:1158710529@qq.com通信作者:项学军,主任医师,Email:guangf4508@163.com
沙库巴曲缬沙坦治疗急性心肌梗死合并Ⅱ~Ⅲ期慢性肾脏病患者的短期效果
沈国秀,王贤进,顾崇怀,项学军安庆市立医院心血管内科,安庆246000
[摘要] 目的 探讨沙库巴曲缬沙坦治疗急性心肌梗死合并Ⅱ~Ⅲ期慢性肾脏病患者住院期间的治疗效果。方法 回顾性分析2019年1月1日至2022年3月31日于安庆市立医院住院的急性心肌梗死合并Ⅱ~Ⅲ期慢性肾脏病患者病历资料,依据其使用不同种类肾素-血管紧张素-醛固酮系统(RAAS)抑制剂将其分组为沙库巴曲缬沙坦组96例,缬沙坦组126例,共计222例患者。分别记录入院及出院时估算的肾小球滤过率(eGFR)、左室射血分数(LVEF),疗效值及安全效应值分别为出院LVEF、eGFR水平与入院时比较的差值,同时使用1∶1倾向性评分匹配(PSM)比较均衡基线资料后效应量的改变。结果 2组出院LVEF、eGFR较入院时均有改善,差异有统计学意义(P<0.05),组间比较显示沙库巴曲缬沙坦组出院LVEF、eGFR改善程度更大,差异有统计学意义(P<0.05);
在进行PSM均衡基线后(匹配后2组各70例),沙库巴曲缬沙坦组出院LVEF、eGFR较入院时仍有改善,差异有统计学意义(P<0.05);缬沙坦组出院LVEF较入院时有改善,差异有统计学意义(P<0.05),eGFR水平出院与入院比较,差异无统计学意义(P>0.05);PSM后LVEF改善程度2组比较,差异无统计学意义(P>0.05)。结论 沙库巴曲缬沙坦能够改善急性心肌梗死合并Ⅱ~Ⅲ期慢性肾脏病患者住院期间心、肾功能,使用安全有效。[关键词] 心肌梗死;沙库巴曲缬沙坦;肾功能不全DOI:10.3969/J.issn.16726790.2022.03.017
探索二甲双胍减少系统性红斑狼疮患者感染事件的作用一项Met-Lupus研究的事后分析

Vol.41No.4Apr.2021上海交通大学学报(医学版)JOURNAL OF SHANGHAI JIAO TONG UNIVERSITY(MEDICAL SCIENCE)探索二甲双胍减少系统性红斑狼疮患者感染事件的作用:一项Met-Lupus研究的事后分析耿时凯1❋,张乐2,3❋,王慧静1,吕良敬3,万伟国4,孙芳芳1#,叶霜1#1.上海交通大学医学院附属仁济医院南院风湿科,上海201112;2.上海交通大学医学院附属仁济医院南院药剂科,上海201112;3.上海交通大学医学院附属仁济医院风湿科,上海200001;4.复旦大学附属华山医院风湿科,上海200041[摘要]目的·在一项多中心、随机、双盲、安慰剂对照临床研究(Met-Lupus)的基础上探索二甲双胍对中/低疾病活动度系统性红斑狼疮(systemic lupus erythematosus,SLE)患者的感染防护作用。
方法·Met-Lupus研究的140例受试者被随机分为二甲双胍组(67例)和安慰剂组(73例),分别在常规治疗的基础上加入二甲双胍或安慰剂;二甲双胍目标剂量为1500mg/d,分3次口服。
记录12个月随访期内SLE患者感染事件的发生情况,包括感染事件的类型、感染持续时间、感染严重程度,以及发生感染时实验室检查结果;比较发生和未发生感染事件受试者的临床特征,以及比较发生感染的患者中使用二甲双胍和使用安慰剂患者的临床特征。
多元Logistic回归分析二甲双胍与感染事件发生的相关性,生存分析比较二甲双胍组和安慰剂组患者的无感染生存时间。
结果·在12个月随访期末,未发生感染事件受试者的二甲双胍使用率(65.9%)显著高于发生感染事件的受试者(34.7%),差异有统计学意义(P=0.022),其他基线临床特征及治疗方案在感染和非感染患者间差异均无统计学意义。
多元Logistic回归分析显示,二甲双胍的使用是减少SLE患者感染的独立保护因素(OR=0.423,P=0.033)。
GⅠGⅡ型诺如病毒两联装甲RNA标准样品的研制

GI/GII型诺如病毒两联装甲RNA标准样品的研制王鸣秋1,2,杨俊2,常雨桐2,张涛1,刘丽娟2(1.湖北省食品质量安全监督检验研究院,湖北武汉 430075)(2.中国检验检疫科学研究院,北京 100176) 摘要:针对目前缺乏适配多项检测标准、稳定、安全的诺如病毒RNA标准样品的问题,研制基于MS2噬菌体内含常见GI/GII 型诺如病毒检测靶标两联装甲RNA标准参考样品。
人工合成MS2噬菌体成熟酶基因、衣壳蛋白基因、包装位点及GI/GII型诺如病毒靶标基因,克隆于表达载体pET-28a(+)中,构建重组质粒pET-MS2-NoV。
经大肠杆菌BL21诱导表达,先后利用PEG6000、酶处理和丙烯葡聚糖凝胶层析柱纯化表达产物。
SDS-PAGE和透射电镜鉴定产物大小及结构,荧光定量PCR检测有无残留核酸。
之后对纯化的病毒样颗粒(Virus-like particles,VLPs)开展定值、均匀性和短期稳定性研究。
SDS-PAGE结果表明重组质粒在BL21中表达出了目的蛋白,大小在10~15 ku之间,与预期一致;纯化后的VLPs无杂蛋白和残留核酸;透射电镜下呈结构完整、大小均一的球状,直径约25 nm。
纯化后AR-NoV中GI型和GII型靶标定值结果分别为(4.04±0.62)×107 copies/μL和(6.16±0.30)×107 copies/μL。
单因素方差检验证实样品均一性良好,F<F0.05(25,52);短期稳定性研究结果表明AR-NoV在37 ℃至少可稳定保存15 d,25 ℃至少稳定保存24 d。
本研究制备的诺如病毒GI/GII型两联装甲RNA标准样品稳定均一,拷贝数高,能够为GI/GII型诺如病毒核酸分子检测提供全过程质控。
关键词:诺如病毒;两联装甲RNA;MS2噬菌体;标准样品;实时荧光定量RT-PCR文章篇号:1673-9078(2021)03-286-293 DOI: 10.13982/j.mfst.1673-9078.2021.3.0835 Preparation of Coupled Armored RNA Reference Material for NorovirusGI/GIIW ANG Ming-qiu1,2, YANG Jun2, CHANG Yu-tong2, ZHANG Tao1, LIU Li-juan2(1.Hubei Provincial Institute for Food Supervision and Test, Wuhan 430075, China)(2.Chinese Academy of Inspection and Quarantine, Beijing 100176, China)Abstract: To provide a safe and stable reference material for Norovirus nucleic detection, the armored RNA containing target RNA of Norovirus GI and GII based on MS2 bacteriophage was developed in this work. DNA fragments including maturase coding gene, capsid protein coding gene and packing site of MS2 bacteriophage, target cDNA sequence of Norovirus GI and GII were synthesized artificially and then cloned into expression vector pET-28a(+) to construct recombinant plasmid pET-MS2-NoV. After expressed in E. coli BL21 cells by IPTG induction, the expression product was purified by PEG6000, enzyme digestion and molecular sieve chromatography. The purified product, also named AR-NoV, was identified by SDS-PAGE, transmission electron microscopy (TEM) and RT-PCR. The value, homogeneity and stability of the AR-NoV were evaluated. SDS-PAGE analysis showed that with the molecular weight of tar-get protein expressed in BL21 was 10~15 ku, which was consistent with the predicted value. There were no impure proteins and residual nucleic acids in AR-NoV after purification. The AR-NoV presented as spherical VLPs with uniform particle size (about 25 nm) and integrated structure under TEM. The values of GI and GII targets in AR-NoV were (4.04±0.62)×107 copies/μL and (6.16±0.30)×107 copies/μL, respectively. The good homogeneity of AR-NoV was confirmed by single-factor ANOVA test (F<F0.05(25,52)). In addition, the stability result indicated that the AR-NoV could be stable at 37 ℃ for 引文格式:王鸣秋,杨俊,常雨桐,等.GI/GII型诺如病毒两联装甲RNA标准样品的研制[J].现代食品科技,2021,37(3):286-293W ANG Ming-qiu, Y ANG Jun, CHANG Y u-tong, et al. Preparation of coupled armored RNA reference material for Norovirus GI/GII [J]. Modern Food Science and Technology, 2021, 37(3): 286-293收稿日期:2020-09-04基金项目:湖北省重点研发计划项目(2020BCA091);中国检验检疫科学研究院基本科研业务费项目(2019JK017)作者简介:王鸣秋(1986-),女,高级工程师,研究方向:食品微生物检测通讯作者:刘丽娟(1971-),女,博士,研究员,研究方向:病原微生物检测与检疫研究15 days and 25 ℃ for 24 days at least. In conclusion, the armored RNA containing coupled Norovirus GI/GII prepared in this work was stable and uniform, with high copy number, which could help the whole process quality control of molecular detection for Norovirus.Key words: Norovirus; coupled armored RNA; MS2 bacteriophage; reference material; real-time RT-PCR诺如病毒(Norovirus,NoV)属于杯状病毒科(Caliciviridae),为单股正链无包膜RNA病毒,直径约为27~40 nm,全长7.5~7.7 kb。
T细胞条件性敲除Spi1基因小鼠的繁育及鉴定

Fabricationandperformanceevaluationofhigh modulusandhigh strengthsilkfibroinguidedboneregenerationmembraneLiaoXiaoyu1,FangHui1,YangFeiyu1,ZouDuohong1,2(1College&HospitalofStomatology,AnhuiMedicalUniversity,KeyLaboratoryofOralDiseasesResearchofAnhuiProvince,Hefei 230032;2ShanghaiNinthPeople'sHospital,ShanghaiJiaoTongUniversitySchoolofMedicine,ShanghaiJiaoTongUniversitySchoolofStomatology,ShanghaiKeyLaboratoryofStomatology,Shanghai 200011)Abstract Objective TodevelopahighmodulusandhighstrengthbiodegradablesilkfibroinGBRmembranetoaddresstheissueofmaintainingthespaceforboneregenerationintherepairofosseousdefects.Methods Afterpurifyingsilkfibroinprotein,membranematerialswerepreparedusingevaporation hotpressingmethod.Thephysi calandchemicalpropertiesandbiologicalperformanceofthemembraneswereevaluatedusingstretchingtests,invitrosimulations,andcellco culturingmethods.Results AsilkfibroinGBRmembranewassuccessfullyfabrica ted,resultinginasimulateddegradationrateof35 3%after12hinvitro.Thewet stateelasticmodulusreached45MPa,whilethetensilestrengthreached8 39MPa.Furthermore,thecellsurvivalratewasnearly100%after7days.Conclusion ThebiodegradableGBRmembraneproducedinthisstudypossesseshighmodulusandstrength,aswellasexcellentbiocompatibility,offeringapromiseasafoundationforaddressingthebonedefectre pairandbonespacemaintenance.Keywords bonedefectrepair;maintainingthespaceforboneregeneration;guidedboneregenerationmem brane;silkfibroin;evaporation heatpressingmethod;osteogenicdifferentiation;tensilestrength网络出版时间:2024-04-1213:52:17 网络出版地址:https://link.cnki.net/urlid/34.1065.R.20240410.1008.006T细胞条件性敲除Spi1基因小鼠的繁育及鉴定王卉卉,朱向玲,吴旭铭,张慧茹,周园园,王安琪,刘 崇,涂佳杰摘要 目的 繁育T细胞条件性敲除Spi1基因的小鼠并对其进行鉴定,为进一步探索Spi1编码蛋白PU 1的作用提供研究基础。
中国EV71疫苗的效力安全性和免疫原性研究SVA

T h e ne w engl a nd jour na l o f medicineEfficacy, Safety, and Immunogenicityof an Enterovirus 71 Vaccine in ChinaFengcai Zhu, M.D., Wenbo Xu, M.D., Jielai Xia, Ph.D., Zhenglun Liang, Ph.D., Yan Liu, M.P.H., Xuefeng Zhang, M.D., Xiaojuan Tan, Ph.D., Ling Wang, Ph.D., Qunying Mao, M.Sc., Junyu Wu, Ph.D., Yuemei Hu, M.D., Tianjiao Ji, M.P.H., Lifei Song, M.Sc., Qi Liang, M.P.H., Baomin Zhang, M.P.H., Qiang Gao, M.Sc., Jingxin Li, M.Sc., Shenyu Wang, M.Sc., Yuansheng Hu, M.P.H., Shanru Gu, M.D., Jianhua Zhang, M.D., Genhong Yao, M.D., Jianxiang Gu, M.D., Xushan Wang, M.D., Yuchun Zhou, M.D., Changbiao Chen, M.D., Minglei Zhang, M.D., Minquan Cao, M.D., Junzhi Wang, Ph.D., Hua Wang, M.D.,and Nan Wang, M.Sc.From the Jiangsu Provincial Center for Dis-ease Control and Prevention, Nanjing (F.Z., X.Z., Yuemei Hu, Q.L., J.L., S.W., H.W.); National Institutes for Viral Disease Con-trol and Prevention, Chinese Center for Disease Control and Prevention (W.X., X.T., T.J., B.Z.), National Institutes for Food and Drug Control (Z.L., Q.M., J. Wang), and Sinovac Biotech (Y.L., J. Wu, L.S., Q.G., Yuansheng Hu, N.W.), Beijing; the Fourth Military Medical University, Xi’an (J.X., L.W.); Sheyang County Center for Disease Control and Prevention, Yancheng City (S.G., J.G., C.C.); Ganyu County Center for Disease Control and Prevention, No. 98, Lianyungang City (J.Z., X.W., M.Z.); and Taixing County Center for Disease Control and Prevention, No. 224, Taizhou City (G.Y., Y.Z., M.C.) — all in China. Address reprint requests to Ms. N. Wang at Sino-vac B iotech, 39 Shangdi Western Rd., Haidian District, B eijing, China, or at wangnan@; to Dr. H. Wang at Jiangsu Provincial Center for Disease Control and Prevention, 172 Jiangsu Rd., Nanjing, Jiangsu Province, China, or at hua@; or to Dr. J. Wang at the Na-tional Institute for Food and Drug Control, No. 2, Tiantanxili, B eijing, China, or at wangjz@.Drs. F. Zhu, W. Xu, and J. Xia contributed equally to this article.N Engl J Med 2014;370:818-28.DOI: 10.1056/NEJMoa1304923Copyright © 2014 Massachusetts Medical Society.ABSTR ACTBackgroundEnterovirus 71 (EV71) is one of the major causative agents of outbreaks of hand, foot, and mouth disease or herpangina worldwide. This phase 3 trial was designed to evaluate the efficacy, safety, and immunogenicity of an EV71 vaccine.MethodsWe conducted a randomized, double-blind, placebo-controlled, multicenter trial in which 10,007 healthy infants and young children (6 to 35 months of age) were ran-domly assigned in a 1:1 ratio to receive two intramuscular doses of either EV71 vaccine or placebo, 28 days apart. The surveillance period was 12 months. The primary end point was the occurrence of EV71-associated hand, foot, and mouth disease or herpangina.ResultsDuring the 12-month surveillance period, EV71-associated disease was identified in 0.3% of vaccine recipients (13 of 5041 children) and 2.1% of placebo recipients (106 of 5028 children) in the intention-to-treat cohort. The vaccine efficacy against EV71-associated hand, foot, and mouth disease or herpangina was 94.8% (95% con-fidence interval [CI], 87.2 to 97.9; P<0.001) in this cohort. Vaccine efficacies against EV71-associated hospitalization (0 cases vs. 24 cases) and hand, foot, and mouth disease with neurologic complications (0 cases vs. 8 cases) were both 100% (95% CI, 83.7 to 100 and 42.6 to 100, respectively). Serious adverse events occurred in 111 of 5044 children in the vaccine group (2.2%) and 131 of 5033 children in the placebo group (2.6%). In the immunogenicity subgroup (1291 children), an anti-EV71 im-mune response was elicited by the two-dose vaccine series in 98.8% of participants at day 56. An anti-EV71 neutralizing antibody titer of 1:16 was associated with protection against EV71-associated hand, foot, and mouth disease or herpangina. ConclusionsThe EV71 vaccine provided protection against EV71-associated hand, foot, and mouth disease or herpangina in infants and young children. (Funded by Sinovac Biotech; number, NCT01507857.)Enterovirus 71 Vaccine in ChinaE nterovirus 71 (EV71), an enterovirusthat is not associated with poliomyelitis,was one of the major causative agents of outbreaks of hand, foot, and mouth disease or herpangina in Europe,1-3 Australia,4,5 and Japan6,7 between 1972 and 1988, and it has been impli-cated in a series of outbreaks across the Asia–Pacific region since the 1990s.8-11 The largest Asia–Pacific epidemic occurred in China in 2008, when approximately 490,000 infections and 126 deaths in infants and young children were report-ed.12 The vast majority of severe cases and fatal cases occurred in children younger than 3 years of age. EV71 infection can cause a wide spectrum of disease, including hand, foot, and mouth dis-ease, herpangina, aseptic meningitis, and non-specific illnesses such as febrile illness, viral ex-anthema, and airway infection.13-15 There are currently no approved vaccines against EV71, but by analogy with poliomyelitis, vaccination may offer the best option for disease control.The Vero cell–based EV71 inactivated vaccine with aluminum hydroxide has consistently been shown to induce immune responses to EV71 in infants and young children, 6 to 35 months of age, in phase 1 and 2 trials,16,17 and no safety concerns have been identified in these trials. Here, we report the results of a phase 3 trial.MethodsSTUDY DESIGN AND OVERSIGHTThis double-blind, randomized, placebo-con-trolled trial was designed by the Jiangsu Provin-cial Center for Disease Control and Prevention (JSCDC), Sinovac Biotech (the study sponsor and manufacturer of the vaccine), the Chinese Na-tional Institutes for Food and Drug Control, and the Chinese National Institute for Viral Disease Control and Prevention. Data were collected by investigators at the JSCDC. An independent data and safety monitoring board consisting of five members (for details, see Table S1 in the Supple-mentary Appendix, available with the full text of this article at ) monitored updated safety data, evaluated the risk to participants during the trial, and made the final determina-tion of the efficacy end points.This trial was performed at three centers (in Ganyu, Taixing, and Sheyang Counties) compris-ing 35 sites in Jiangsu Province, China. The trial protocol and the informed-consent form were approved by the ethics committee of the JSCDC. Before enrollment, written informed consent was obtained from a parent or guardian of each par-ticipant. The trial was conducted in accordance with the principles of the Declaration of Helsinki, the standards of Good Clinical Practice (as de-fined by the International Conference on Harmo-nization), and Chinese regulatory requirements. The first three authors and last three authors vouch for the accuracy and completeness of the reported data and the fidelity of the study to the protocol. All authors made the decision to sub-mit the manuscript for publication. The study sponsor had no role in data collection, analysis, or interpretation or in manuscript preparation.PARTICIPANTSHealthy infants and young children, 6 to 35 months of age, were recruited and enrolled in January 2012, before the anticipated seasonal peak of hand, foot, and mouth disease. Children with a history of hand, foot, and mouth disease or vac-cination with EV71 vaccine and those with acute febrile disease on the day of enrollment were ex-cluded (for additional exclusion criteria, see Table S2 in the Supplementary Appendix). The partici-pants were randomly assigned in a 1:1 ratio to receive EV71 vaccine or placebo, according to a randomization list (with a block size of 10) that was generated by an independent statistician. For further details of the study conduct, see the pro-tocol, available at .VACCINEThe Vero cell–based inactivated human EV71 vac-cine was developed with the use of EV71 strain H07 (subgenotype C4) as the seed virus.16 The EV71 vaccines contained 400 U of EV71 antigen with alum adjuvant, whereas the placebo con-tained aluminum hydroxide diluents with no EV71 antigen; both were packaged in syringes (0.5 ml per vial). Vaccine and placebo were supplied in coded, identical-appearing, single-dose vials and were administered intramuscularly in the deltoid region on days 0 and 28.SURVEILLANCE AND CASE DEFINITIONThe efficacy of EV71 vaccine was evaluated dur-ing a 12-month surveillance period from day 57 to month 14 (Fig. S1 in the Supplementary Appen-dix). The children’s parents or guardians were instructed to seek treatment for illness at desig-T h e ne w engl a nd jour na l o f medicinenated health care services (including 640 village clinics, 32 township hospitals, and 7 county hos-pitals). In addition, study staff visited partici-pants at least once a week to keep abreast of their health status and to determine whether their parents or guardians had sought medical care for them. Participants with any illness were eligible for screening, except conditions requiring sur-gery (e.g., hernias, fractures, or burns), congeni-tal diseases, tumors, and mental or behavioral disorders with a clear cause unrelated to EV71. Throat and anal swabs were collected from these children as soon as possible and then transferred to the on-site laboratories of the study centers for assessment. A real-time, fluorescence-based, quan-titative polymerase-chain-reaction (PCR) assay was used to detect EV71 RNA and discriminate it from other enteroviruses. After the first positive test for EV71 RNA, study staff performed clinical and epidemiologic evaluation at visits and col-lected a series of throat and anal swabs and stool samples from patients with suspected disease for laboratory assays at an interval of 3 days in the acute stage and 7 days in the recovery stage. Blood samples were collected at the acute stage. All specimens were sent to the central laboratory for case confirmation. Virologically confirmed EV71-associated disease was defined as cases with two consecutive positive results for EV71 RNA on real-time PCR assay or positive results for EV71 on viral isolation and analysis of the VP1 sequence in stool samples or throat and anal swabs.18,19EFFICACY END POINTSThe primary efficacy end point was the occurrence of EV71-associated hand, foot, and mouth disease or herpangina. Secondary efficacy end points were severe hand, foot, and mouth disease (with neuro-logic or other serious complications), EV71-asso-ciated hospitalization, and all EV71-associated diseases. For the detailed case definitions, see Table S4 in the Supplementary Appendix. Before unblinding, the data and safety moni-toring board reviewed all the epidemiologic data and laboratory-assay results for each patient with laboratory-confirmed EV71 infection, then made the final determination of cases of EV71-associated disease and classified the cases as hand, foot, and mouth disease, herpangina, or diseases other than hand, foot, and mouth dis-ease and herpangina.SAFETY ASSESSMENTThe parents or guardians of all participants who received the EV71 vaccine or placebo were asked to fill out diary cards that listed injection-site ad-verse reactions (e.g., pain, redness, and swelling) and systemic adverse reactions (e.g., fever, irrita-bility, and loss of appetite). Safety data were col-lected on solicited adverse events that occurred within 7 days after an injection and unsolicited adverse events (those reported spontaneously by a parent or guardian) that occurred within 28 days after an injection. Data on serious adverse events were collected throughout the trial. For grading of adverse events, see Table S3 in the Supplemen-tary Appendix. The relationship of the adverse event or serious adverse event with receipt of an injection was decided by investigators before un-blinding.IMMUNOGENICITYThe immunogenicity subgroup included partici-pants recruited from four sites at three centers. Blood samples were collected before the first in-jection and at day 56, month 8, and month 14 for immunogenicity evaluation. All serum samples were assessed for EV71 neutralizing antibody by means of a modified cytopathogenic effect assay.16 A titer of 1:8 or higher indicated seropositivity.STATISTICAL ANALYSISWe calculated that a sample of 5000 participants per group was required for 80% statistical power to show that the lower bound of the 95% confi-dence interval for vaccine efficacy exceeded that observed with placebo at a significance level of 0.05, assuming a vaccine efficacy rate of 80% and an incidence density of 8 cases of EV71-associated hand, foot, and mouth disease or herpangina per 1000 person-years among unvaccinated children. The vaccine efficacy rate was calculated as fol-lows: [1 − (incidence density of the vaccine group ÷ incidence density of the placebo group)] × 100. We collected 3-ml blood samples on day 56 from all participants who received at least one dose of EV71 vaccine or placebo for detection of neutralizing antibodies. All participants who re-ceived at least one dose and entered the surveil-lance period were included in the intention-to-treat cohort for the primary efficacy analysis. Efficacy was also calculated in the per-protocol efficacy cohort, which included participants whoEnterovirus 71 Vaccine in Chinareceived two doses and completed the 12-month surveillance period. The safety analysis was per-formed on data from the total cohort of par-ticipants who received at least one dose of EV71 vaccine or placebo, and the immunogenicity analysis was performed on data from the per-protocol immunogenicity cohort.To evaluate the correlation between EV71 neu-tralizing antibody levels and disease protection, an exploratory analysis was performed in a per-protocol subcohort consisting of the participants with EV71-associated hand, foot, and mouth dis-ease or herpangina and matched case-free partici-pants, in a ratio of 1:5. In the analysis, sensitivity was defined as the proportion of participants with antibody titers below the cutoff value on day 56, for those with EV71-associated hand, foot, and mouth disease or herpangina, and specificity was defined as the proportion of par-ticipants with titers greater than or equal to the cutoff value on day 56, for the matched case-free participants. The possible serologic marker forT h e ne w engl a nd jour na l o f medicineprotection was the lowest titer with the maxi-mum sum of the specificity and sensitivity cor-responding to each cutoff value.A chi-square test or Fisher’s exact test was used to compare categorical data, and Student’s t-test was used to compare log-transformed neu-tralizing antibody values. Vaccine efficacy and case-free survival were estimated with the use of a Cox proportional-hazards model and the Kaplan–Meier method, respectively. Hypothesis testing was two-sided with an alpha value of 0.05. Analy-ses were conducted by statisticians at the Fourth Military Medical University with the use of SAS software, version 9.2 (SAS Institute).R esultsSTUDY POPULATIONIn January 2012, a total of 10,077 children were enrolled and received at least one dose of EV71 vaccine or placebo, and 9430 of these children (4719 in the vaccine group and 4711 in the placebo group) received the second dose (93.6% of all participants). On day 57, a total of 5041 partici-pants in the vaccine group and 5028 in the placebo group entered the surveillance period. A total of 9165 participants (90.9%) completed the 12-month surveillance period in accordance with the proto-col. Information on study enrollment, random-ization, and surveillance is shown in Figure 1. The vaccine and placebo groups were well bal-anced in terms of sex and mean age, height, and weight (Table 1, and Table S7 in the Supplemen-tary Appendix).VACCINE EFFICACYA total of 119 participants (13 [0.3%] in the vac-cine group and 106 [2.1%] in the placebo group) had EV71-associated disease during the sur-veillance period. Of these participants, 99 had confirmed hand, foot, and mouth disease or her p angina (83.2%), 15 presented with res p i-ratory symptoms (12.6%), 3 presented with gastro i ntestinal symptoms (2.5%), and 2 ap-peared to have only a febrile syndrome (1.7%).The efficacy of the vaccine against EV71-asso-ciated hand, foot, and mouth disease or herpan-gina was 94.8% (95% confidence interval [CI], 87.2 to 97.9) during the 12-month surveillance period in the intention-to-treat cohort (Table 2). The vaccine was effective in preventing EV71-associated hospitalization (0 cases in the vaccine group vs. 24 cases in the placebo group, P<0.001) and severe hand, foot, and mouth disease (0 cases in the vaccine group vs. 8 cases [all with neu-rologic complications] in the placebo group, P = 0.004), resulting in vaccine efficacies of 100% (95% CI, 83.7 to 100 and 42.6 to 100, respec-tively). The overall efficacy of the EV71 vaccine against EV71-associated disease was 88.0% (95% CI, 78.6 to 93.2) during the 12-month period.The efficacy was slightly higher during the first* Plus–minus values are means ±SD. There were no significant differences be-tween the groups in any of the characteristics listed here (P>0.05).† Although 1291 children recruited from four sites at three centers were includ-ed in the immunogenicity subgroup, only 1150 of them were eligible for the per-protocol analysis of immunogenicity.Enterovirus 71 Vaccine in China6 months, a difference that was not significant. Similar efficacies were also observed in the per-protocol analysis (Table S8 and Fig. S3 in the Supplementary Appendix). Among patients with EV71 infection, the average EV71 shedding period did not differ significantly between the vaccine and placebo groups (5.0 days and 7.9 days, respec-tively) (Fig. S5 in the Supplementary Appendix). We also estimated vaccine efficacy against EV71-associated hand, foot, and mouth disease or herpangina in an analysis with stratification according to age and study center (Tables S10 and S11, respectively, in the Supplementary Ap-pendix). According to the Cox proportional-hazards model, children 12 to 23 months of age and those at the study centers in Sheyang and Taixing Counties had an increased risk of EV71-associated hand, foot, and mouth disease or her-pangina (Table S13 in the Supplementary Appen-dix). In the 12-month surveillance period, a total of 1950 cases of hand, foot, and mouth disease or herpangina were observed. Of those, 627 cases (32.2%) were caused by coxsackievirus A16. The vaccine showed no protection against hand, foot, and mouth disease or herpangina caused by cox-sackievirus A16 (protective efficacy, 6.6% [95% CI, −9.2 to 20.1]) and limited protection against all hand, foot, and mouth disease or herpangina (protective efficacy, 19.8% [95% CI, 11.0 to 27.7]) (Table S9 in the Supplementary Appendix).ADVERSE REACTIONSDuring the entire study period, 242 serious ad-verse events were reported (111 in the vaccine group and 131 in the placebo group), with a sim-ilar rate of occurrence in the two groups (Table 3,* CI denotes confidence interval, EV71 enterovirus 71, and HFMD hand, foot, and mouth disease.† In the vaccine group, there were 2651.3 person-years of follow-up at 6 months and 4973.2 person-years at 1 year.‡ In the placebo group, there were 2607.1 person-years of follow-up at 6 months and 4873.0 person-years at 1 year.§ P<0.001.¶ All cases of EV71-associated hospitalization were in patients with HFMD.‖ P<0.01.T h e ne w engl a nd jour na l o f medicineand Table S15 in the Supplementary Appendix). Eleven serious adverse events that occurred with-in 28 days after an injection were considered to be related to receipt of an injection: 5 in the vac-cine group (4 cases of infection or infestation and 1 case of a gastrointestinal disorder) and 6 in the placebo group (4 cases of infection or infes-tations, 1 case of a gastrointestinal disorder, and 1 case of a general disorder with injection-site reaction) (Table S16 in the Supplementary Ap-pendix). During the study period, 5 deaths due to drowning (1 in the vaccine group and 4 in the placebo group) and 1 death due to a traffic acci-dent (in the vaccine group) were recorded (Table S17 in the Supplementary Appendix). The frequen-cies of both solicited and unsolicited adverse events were similar in the two study groups (Ta-ble 3, and Tables S18, S19, and S20 in the Supple-mentary Appendix). The most common systemic adverse reactions were fever, diarrhea, and loss of appetite, and the most common injection-site ad-verse reactions were redness, induration, and pain.A total of 150 participants in the vaccine group(3.0%) and 158 participants in the placebo group (3.1%) had grade 3 adverse events within 7 days after an injection.IMMUNOGENICITYThe baseline EV71 neutralizing antibody titers inthe 1291 participants in the immunogenicity sub-Enterovirus 71 Vaccine in Chinagroup were low and similar in the two study groups (Table 4). A significant neutralizing anti-body response was elicited by two-dose vaccina-tion: 98.8% of participants in the vaccine group were seropositive on day 56, with a geometric mean titer of 165.8 (95% CI, 145.9 to 188.5). Dur-ing the 1-year observation period, 11 participants in the immunogenicity subgroup had confirmed EV71-associated hand, foot, and mouth disease or herpangina. All 11 participants were in the placebo group and did not have EV71 infection at baseline.With respect to the duration of EV71 neutral-izing antibody titers, a moderate decrease be-* Participants could have more than one adverse event.† Data on serious adverse events were collected throughout the trial. For serious adverse events classified according to the Medical Dictionary for Regulatory Activities, see Table S15 in the Supplementary Appendix.‡ Five participants died from drowning, and one participant died from a traffic accident.§ Details of the serious adverse events considered to be related to receipt of an injection are available in Table S16 in the Supplementary Appendix.¶ Solicited adverse reactions were those listed on diary cards that were filled out by the parents or guardians of the partici-pants. For all solicited reactions, those that occurred in more than 1% of participants in either group and that were considered to be related to receipt of an injection are listed here. For the criteria used to grade solicited adverse reactions, see Table S3 in the Supplementary Appendix.‖ These data include unsolicited adverse reactions (those spontaneously reported by a parent or guardian).T h e ne w engl a nd jour na l o f medicinetween day 56 and month 8 was observed, fol-lowed by a leveling off between month 8 and month 14 (Fig. S4 and Table S21 in the Supple-mentary Appendix), even after exclusion of the confirmed cases of EV71-associated disease and the subclinical cases of EV71 infection during the surveillance period (Tables S22 and S23 in the Supplementary Appendix).In the evaluation of the correlation between EV71 neutralizing antibody levels and disease protection, little variation was observed in the sum of specificity and sensitivity values for neu-tralizing antibody titers of 1:8 to 1:32. A titer of 1:16 had the maximum summed sensitivity and specificity values (Table S24 in the SupplementaryAppendix), and this titer may be considered as a* Seroconversion was defined by a titer of less than 1:8 before any injections of EV71 vaccine or placebo with a titer of 1:8 or more after any injections or by an increase in the antibody titer by a factor of four or more. P<0.001 for all com-parisons between the study groups at day 56 and months 8 and 14.Enterovirus 71 Vaccine in Chinapossible serologic marker for protection against EV71-associated hand, foot, and mouth disease or herpangina in vaccinated children.DiscussionThe EV71 vaccine showed efficacy against EV71-associated hand, foot, and mouth disease or her-pangina and EV71-associated hospitalization or severe cases of hand, foot, and mouth disease (i.e., those with neurologic complications). The vaccine did not have efficacy against EV71-asso-ciated diseases other than hand, foot, and mouth disease and herpangina, an observation that may reflect the small number of cases and insuffi-cient power. One limitation of this trial is that no assessment of etiologic factors other than EV71 was performed in participants with EV71-associ-ated disease, and we could therefore not exclude the possibility of coinfection with other patho-gens. In addition, 15.0 to 18.0% of participants in the immunogenicity subgroup were seroposi-tive at baseline, a finding that suggests that some participants may have already had immunity against EV71 before receiving EV71 vaccine or placebo. B ecause blood samples were collected before the first injection only in the immunoge-nicity subgroup, we could not identify all partici-pants in the study cohort who were seropositive at baseline. Assuming, however, that the numbers of participants with seropositivity at baseline were small and were evenly distributed between the study groups through randomization, the assess-ment of vaccine efficacy was not likely to have been substantially biased by baseline seropositivity. As expected, data in this trial indicated that the EV71 vaccine offered no protection against hand, foot, and mouth disease or herpangina caused by coxsackievirus A16 or other enterovi-rus serotypes, a finding that is consistent with the results of a preclinical study.20 EV71 account-ed for only a small proportion of the cases of hand, foot, and mouth disease or herpangina identified in this trial (99 of 1950 cases), a find-ing that suggests that EV71 was not the predom-inant virus associated with hand, foot, and mouth disease and herpangina in the study area in 2012, when coxsackievirus A16 was also circulating. Therefore, immunization with EV71 vaccine did not significantly decrease the overall incidence of hand, foot, and mouth disease or herpangina.The EV71 neutralizing antibody titer was mon-itored over a period of 12 months after day 56; it declined by half during the first 6 months and then remained stable during the next 6 months.A similar trend was reported in a previous study.17 In this trial, evaluation of the efficacy of the vaccine and the duration of immunogenicity involved a paradoxical situation: vaccine efficacy could be better observed in a population with high EV71 prevalence, but the duration of im-munogenicity elicited by the vaccine could be affected by natural infections during EV71 epi-demics. Therefore, data from this trial may lead to an overestimation of the duration of neutral-izing antibodies.In this trial, an EV71 neutralizing antibody titer of 1:16 was found to correlate with the es-timated vaccine efficacy among children. The fact that more than 90% of vaccine recipients had a geometric mean titer of 1:16 or higher up to month 14 after vaccination is consistent with probable protection against EV71-associated hand, foot, and mouth disease or herpangina for 1 year. Longer-term surveillance of the study participants is being performed to evaluate the longevity of serologic responses and vaccine protection and the need for booster injections.The incidence of solicited injection-site or systemic adverse reactions that may have been related to vaccination was consistent with that reported in phase 1 and 2 trials.16,17 The safety profile of the vaccine is also similar to that of other inactivated EV71 vaccine candidates.21,22 The current EV71 vaccine candidates in clinical research were developed on the basis of a single subgenotype strain (B3, B4, or C4) of EV71.23,24 Although some immunogenicity studies in ani-mals indicated that EV71 inactivated vaccine could elicit antibody responses that cross-neu-tralized with different EV71 subgenotypes,20,25,26 this has not been tested yet in clinical trials.In conclusion, this study showed that the EV71 vaccine consistently elicited immunogenicity and provided protection against mild-to-severe dis-ease caused by EV71 for at least 1 year in in-fants and young children. A neutralizing anti-body titer of 1:16 was associated with protection against EV71.Supported by Sinovac Biotech.Disclosure forms provided by the authors are available with the full text of this article at .。
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ARTICLEEnterovirus RNA in longitudinal blood samples and risk of islet autoimmunity in children with a high genetic riskof type1diabetes:the MIDIA studyOndrej Cinek&Lars C.Stene&Lenka Kramna&German Tapia&Sami Oikarinen&Elisabet Witsø&Trond Rasmussen&Peter A.Torjesen&Heikki Hyöty&Kjersti S.RønningenReceived:26February2014/Accepted:18June2014#Springer-Verlag Berlin Heidelberg2014AbstractAims/hypothesis Only a few longitudinal molecular studies of enterovirus and islet autoimmunity have been reported,and positive results seem to be limited to Finland.We aimed to investigate an association between enterovirus RNA in blood and islet autoimmunity in the MIDIA study from Norway,a country which largely shares environmental and economic features with Finland.Methods We analysed serial blood samples collected at ages 3,6,and9months and then annually from45children who developed confirmed positivity for at least two autoantibodies (against insulin,GAD65and IA-2)and92matched con-trols,all from a cohort of children with a single high-risk HLA-DQ-DR genotype.Enterovirus was tested in RNA extracted from frozen blood cell pellets,using real-time RT-PCR with stringent performance control.Results Out of807blood samples,72(8.9%)were positive for enterovirus.There was no association between enterovirus RNA and islet autoimmunity in samples obtained strictly before(7.6%cases,10.0%controls,OR0.75[95%CI0.36, 1.57]),or strictly after the first detection of islet autoantibodies (10.5%case,5.8%controls,OR2.00[95%CI0.64,6.27]). However,there was a tendency towards a higher frequency of enterovirus detection in the first islet autoantibody-positive sample(15.8%)compared with the corresponding time point in matched controls(3.2%,OR8.7[95%CI0.97,77]). Neither of these results was changed by adjusting for potential confounders,restricting to various time intervals or employing various definitions of enterovirus positivity.Conclusions/interpretation Positivity for enterovirus RNA in blood did not predict the later induction of islet autoanti-bodies,but enterovirus tended to be detected more often at the islet autoantibody seroconversion stage.Keywords Autoimmunity.Enterovirus.Infancy. Longitudinal Study.RNA.RT-PCR.Virus-associated aetiologyAbbreviationDAISY Diabetes Autoimmunity Study in the YoungIntroductionEnterovirus infection has long been suspected to trigger or accelerate islet autoimmunity,which precedes type1diabetes Electronic supplementary material The online version of this article(doi:10.1007/s00125-014-3327-4)contains peer-reviewed but uneditedsupplementary material,which is available to authorised users.O.Cinek(*):L.KramnaDepartment of Paediatrics,2nd Faculty of Medicine,CharlesUniversity in Prague and University Hospital Motol,V Uvalu84,15006Prague5,Czech Republice-mail:Ondrej.Cinek@Lfmotol.cuni.czL.C.Stene:G.Tapia:E.Witsø:T.RasmussenDivision of Epidemiology,Norwegian Institute of Public Health,Oslo,NorwayS.Oikarinen:H.HyötyDepartment of Virology,University of Tampere,Tampere,FinlandP.A.TorjesenHormone Laboratory,Oslo University Hospital,Oslo,NorwayH.HyötyFimlab Laboratories,Pirkanmaa Hospital District,Tampere,FinlandK.S.RønningenDepartment of Pediatric Research,Oslo University Hospital,Oslo,NorwayDiabetologiaDOI10.1007/s00125-014-3327-4[1,2].Although several serological patient–control studies observed an association between enterovirus antibodies and type1diabetes,their validity has been disputed[3],mostly because of insufficient matching or unreliable antibody as-says.The advent of molecular testing opened new avenues of research into enteroviruses as potential causative agents for type1diabetes.Infections detected in the blood and its components seem to be more strongly associated with an autoimmune response compared with gut infections detected in faeces[1,4].Published prospective studies on islet autoimmunity that utilise molecular detection of enterovirus from the blood are surprisingly scarce.A recent review[5]and our literature search identified six publications utilising molecular detection from blood in case–control sets nested within prospective cohorts.Indications of an association between enterovirus infection and islet autoimmunity in these prospective studies came from Finland[6–9],whereas another prospective mo-lecular study,Diabetes Autoimmunity Study in the Young (DAISY),from the USA[10]did not support such an associ-ation.Moreover,significant heterogeneity exists in the defini-tions of islet autoimmunity,in sampling frequency and in enterovirus detection methods.The present study used the Norwegian MIDIA(Norwegian acronym for‘Environmental Triggers of Type1Diabetes’) birth cohort.Norway shares many characteristics with its neighbour Finland:among these are a very high incidence of type1diabetes,latitude,shape of the territory,climatic con-ditions,a heterogeneous population density and socioeconom-ic conditions that include a high gross domestic product.To reduce differences in detection methods,this study used an assay very similar to the one used in the Finnish studies.In contrast to other studies,the participating children carried a single high-risk genotype,and whole blood rather than serum was used for enterovirus testing.Our aim was to investigate a putative association between the presence of enterovirus in the blood and islet auto-immunity in the Norwegian MIDIA study.MethodsEnterovirus frequency(i.e.members of Enterovirus A,B,C and D species)was compared between cases(participants with islet autoimmunity)and matched controls nested within a birth cohort of Norwegian children with the highest-risk HLA genotype.Study cohort After genetic screening of46,939newborns from the general Norwegian population during2001–2007, the MIDIA study identified1,047newborns with the HLA class II genotype conferring the highest risk of type1diabetes, DRB1*04:01-DQA1*03-DQB1*03:02/DRB1*03-DQA1*05-DQB1*02.Of these participants,911were recruited for follow-up.Three families later withdrew and their data were deleted.Of the remaining908children,blood samples and questionnaires were collected at ages3,6,9and12months, and annually thereafter,and plasma samples were tested for the presence of islet autoantibodies,indicating islet autoimmunity.Written parental consent was obtained.The study was approved by the Regional Committee for Medical Research Ethics(Office for Human Research Protections IRB name ‘Regional Med Resch Ethics Comm South IRB#2—South-East A’,IRB00001871)and the Norwegian Data Protection Authority.Nested case–control dataset By October2011,48out of908 children in the observed cohort[11,12]had developed islet autoimmunity(as defined below)and were included as cases. For each case,we randomly selected two controls from the cohort,matched for age(with a maximum tolerance of 1month wherever possible;this difference is narrow enough to account for the known enterovirus seasonality because sampling schedules of case and control participants were identical up to the first occurrence of islet autoantibodies) and county of residence(including the closest neighbouring county,if necessary).Children were ineligible as controls if they had one or more autoantibodies(as described below). Controls were followed at least until the time point of con-firmed islet autoimmunity in the corresponding case.To en-sure comparability,blood samples from cases that did not have a matching control sample were removed from the analysis.For three case and four control participants,there was not enough material for enterovirus testing,and they were therefore excluded from the analysis.The final case–control dataset included45cases and92controls:their characteristics are listed in Table1and generation of the case–control dataset is shown in Fig.1.Sample handling,islet autoantibody assays and case definition Capillary blood samples were collected into tubes containing EDTA and sent to the Norwegian Institute of Public Health by mail.Upon arrival,samples were centri-fuged:plasma was separated and tested for islet autoanti-bodies,while cell pellets containing residual plasma were stored at−80°C until further processing.All frozen samples were thawed once only.Autoantibodies to insulin,65kDa glutamic acid de-carboxylase(GAD-65)and tyrosine phosphatase-like protein IA-2were measured in duplicate by RIA in the hor-mone laboratory at Aker University Hospital,as previously described[12].We defined islet autoimmunity as detection of either(1)two or more islet autoantibodies in two or more consecutive samples,or(2)at least one islet autoantibody twice or two antibodies once followed by progression toDiabetologiatype 1diabetes during the current follow-up,or (3)at least one islet autoantibody in at least three consecutive samples,including the most recent sample.Nucleic acid extraction Frozen cell pellets containing red and white blood cells with a small amount of residual plasma were thawed at 4–8°C,and RNA was co-purified with DNA using the TRIzol Plus RNA Purification System (Invitrogen,Carls-bad,CA,USA)according to the manufacturer ’s protocol with minor modifications.Specifically,0.1ml of the blood cell pellet was added to 1ml Trizol containing 3.7μg carrier RNA (Qiagen,Hilden,Germany)and 0.5μl 1%(vol/vol in PCR-grade water)Armored RNA West Nile Virus (Asuragen Diagnostics,Austin,TX,USA)as an exogenous internal control.The extraction was then performed as indicated in the manufacturer ’s protocol until binding to PureLink columns and washing:these steps were not performed by centrifugation,but instead used a Qiagen vacuum manifold and vacuum pump set to −20to −30kPa,with columns connected to the manifold through Qiagen V acConnectors.Before the final elution steps,columns were centrifuged for 2min at 12,000g to dry the membranes.Elution was performed into 120μl A VE buffer (Qiagen)and used for downstream applications after an over-night incubation at 4°C.Quantitative RT-PCR of enterovirus RNA Samples were test-ed for enterovirus,an exogenous internal control and human RNA content.Enterovirus RNA was assayed using the QuantiTect Probe RT-PCR Kit (Qiagen),using 900nM primers and 300nM probes (as reported in a previous Finnish study [13]).The combination of primers and probes reacts with an equal sensitivity to human Enterovirus A —D species (i.e.members of species Enterovirus A ,Enterovirus B ,En-terovirus C and Enterovirus D of the genus Enterovirus ,family Picornaviridae ,order Picornavirales ,according to the latest nomenclature of the International Committee on Taxonomy of Viruses,/,accessed 9May 2014).The assay does not cross-react with Rhinovirus A –C species.The analysis was carried out using ABI7300or ABI7700real-time thermocyclers and Sequence Detection Software (Applied Biosystems,Foster City,CA,USA).PCR conditions were 30min reverse transcription at 50°C,followed by 15min initial denaturation at 95°C,and 50cycles of 15s denaturation at 94°C and 1min combined annealing –synthesis at 60°C.Absolute quantification was performed using an eight-point standard curve spanning the range from 375,000to 1copy per microlitre Armored RNA West Nile Virus (quantitated spec-trophotometrically by the manufacturer).Samples were run in triplicate.The assay was sufficiently sensitive to consistently detect a single copy per microlitre source RNA;of note,very low virus quantities showed strong stochastic effects,with varying number of positive replicates.To ensure robustTable 1Characteristics of case and control participants in the present study CharacteristicParticipants Case (n =45)Control (n =92)Age at onset of islet autoimmunity (months)a 24.5(6.2–75)NA Female sex 28(62.2%)50(54.4%)Number of other children in the household b012(26.7%)30(32.6%)115(33.3%)45(48.9%)≥218(40.0%)17(18.5%)First-degree relatives with type 1diabetes c None 35(77.8%)87(94.5%)YesSiblings only 30Father only 32Mother only23Multiple family members 20Progression to type 1diabetes Yes20(44.4%)n.a.Age (years)at diabetes onset4.2(0.7–7.4)Blood samples in the matched analysis Total d258417Before the development of islet autoimmunity a,e144251Islet autoantibody seroconversion sample f3862After seroconversion g 76104Data are median (range),n (%)and n NA,not availableaAge at the time when the first islet autoantibody-positive sample was collectedbIncluding full siblings,half-siblings and step-siblings.The number of chil-dren was counted when the index child was 3months old.Case participants tend to have more children in the family compared with controls (p =0.018)cOnly full siblings were counted.Of the two cases with multiple affected first-degree relatives,the father,mother and one sibling were affected in one case,and two siblings and the father (but not the mother)were affected in the other case.First-degree relatives with diabetes were observed more often in the families of cases than controls,p =0.009dOf the 807samples tested for enterovirus and passing the quality control,675were included in the matched analysis.The remaining 132were removed because their matching sample was missingeThese include the samples before the first islet autoantibody-positive sample,and the corresponding samples from controls.Several initial blood samples taken in 2003and 2004were not available for enterovirus testing because of the lack of a cell pellet sample as the RNA source.Three cases and four controls were affected;thus,in total,45cases and 92controls were analysedfThe first islet autoantibody-positive sample and its matched control sample;several case samples could not be matched with a sufficiently similar control samplegFor association analysis with islet autoimmunity,samples without prop-erly age-matched controls (primarily after islet autoantibody seroconver-sion,owing to study design in which these participants were followed with more frequent blood samples)were removed from analysis,and not all cases and controls contributed samples to all three periods (before,during and after seroconversion)Diabetologiadetection,we defined samples as positive for enterovirus only if at least two out of three triplicate wells were positive. Negative controls were included in every extraction(at least one per every batch of15samples,at a random location within the batch)and independently in the PCR.Neither of these negative controls tested positive.In parallel with enterovirus and using an identical protocol, we also tested an exogenous internal control(a small amount of West Nile Virus fragment added to the first extraction step), and the B2M gene transcript,a commonly used control that is abundant in human blood[14].Threshold cycles were inspected to identify those strongly deviating from the mean (signifying a lack of cells or possible failure of extraction). Samples that exceeded two SDs of the threshold cycle from the average were marked as suspect of a low RNA content, and this fact was taken into account in downstream analyses. Forty-one samples(4.8%)had low RNA content;however, three of these were still enterovirus positive.A second set of nucleic acid extractions could not be performed because all blood sample material was used up in the first extraction. Therefore,we excluded these41suspect samples in the pri-mary analysis;in the sensitivity analysis,we re-ran all statis-tical analyses including these41samples,and results were essentially unchanged.Statistical analysis The association between enterovirus in-fections and islet autoimmunity was estimated using mixed effects logistic regression models with enterovirus positivity in a blood sample as the dependent variable,and case or control status(and other covariates)as independent variables. To account for the matched design and repeated measure-ments of enterovirus within individuals,random intercepts were specified for each matched set and for each individual within the matched set using the xtmelogit command with default settings in Stata,version12(StataCorp,College Sta-tion,TX,USA).The primary analysis used data from samples collected strictly before islet autoantibody seroconversion.Additional analyses included samples from the seroconver-sion period and after seroconversion.Case samples without a properly age-matched control(primarily after islet autoanti-body seroconversion,owing to the study design where these participants were followed with more frequent blood sam-ples),were removed from the analysis.We performed two sensitivity analyses:(1)we assessed the influence of also defining as enterovirus positive those sam-ples that tested positive in a single replicate,i.e.we extended the positivity definition to samples likely to be affected by the stochastic character of low copy number templates;(2)we performed a further sensitivity analysis including samples presumed to contain low levels of RNA,as indicated by assessment of control templates.ResultsEnterovirus in blood and islet autoimmunity A total of807 samples were tested,of which72(8.9%)were positive for enterovirus.Positivity for enterovirus was not associated withFig.1Generation of thecase–control set used in thepresent studyDiabetologiathe subsequent development of islet autoimmunity in samples taken prior to islet autoantibody seroconversion(Table2;OR 0.75[95%CI0.36,1.57]).There was a tendency towards an association with enterovirus detection in samples taken in the islet autoantibody seroconversion interval of case participants (6/38,15.8%),and the corresponding time point in controls (2/62,3.2%,OR8.7[95%CI0.97,77]).No significant association was observed after islet autoantibody seroconver-sion.The results are summarised in Table2,where unadjusted measures of association are presented along with results from models adjusted for potential confounders and modifiers(sex, first-degree relative with diabetes[yes or no]and number of other children in the household[coded as0,1and2or more]). The results were essentially unchanged upon adjustment.A graphical representation of enterovirus testing and islet autoimmunity data is provided in electronic supplementary material(ESM)Fig.1.The cumulative probability of a first enterovirus infection in blood was26%(95%CI19,34)by the second birthday and 38%(95%CI30,48)by3years of age(ESM Fig.2),with no significant difference between case and control participants in the timing of the first infection(data not shown).The estimated virus quantity in blood was generally low: only three samples had more than100copies per microlitre RNA extract,13had10–99copies per microlitre,and all remaining positive signals contained fewer than10copies per microlitre,where an accurate quantification is difficult.As our definition of enterovirus positivity required two or more positive replicates,we included a sensitivity analysis containing all low-quantity samples that were positive in only one of the three replicates(samples indicated by half-filled circles in ESM Fig.1;the total number of positive samples included in this relaxed definition of positivity was127/807, 15.7%).This analysis did not alter either of the above conclu-sions(data not shown).Enterovirus detection over the whole observation period The median number of samples tested for enterovirus per child was six(range1–14),and55participants(40.1%)had at least one positive sample during follow-up.Forty participants(29.2%) had one enterovirus RNA-positive blood sample during follow-up,13(9.5%)participants had two positive samples and two(1.5%)participants had three positive samples. Among the15participants for whom two or three enterovirus RNA-positive samples were observed during follow-up,five had consecutive samples positive for enterovirus RNA, whereas10had a second enterovirus RNA-positive sample after an intervening negative sample.If we assume that pos-itive consecutive samples formed part of a single infectious episode and the intermittent remaining positive samples rep-resented separate infection episodes,then there was a total of 67infectious episodes,of which5(7.5%)were‘prolonged’(group7,case;group11,case and the first control;group19, case;group36,case;ESM Fig.1).There was no detectableTable2Frequency of human enterovirus in blood,and islet autoimmunitySamples Participants OR(95%CI)aCase Control Unadjusted Adjusted bCollected before islet autoantibody seroconversion cEV−133226 1.0(reference) 1.0(reference)EV+11(7.6%)25(10.0%)0.75(0.36,1.57),p=0.440.60(0.27,1.32),p=0.20 Collected during seroconversion dEV−3260 1.0(reference) 1.0(reference)EV+6(15.8%)2(3.2%)8.7(0.97,77),p=0.0539.08(0.95,86),p=0.055 Collected after seroconversion eEV−6898 1.0(reference) 1.0(reference)EV+8(10.5%)6(5.8%) 2.00(0.64,6.27),p=0.23 2.76(0.87,8.77),p=0.086Data are n,n(%)and OR(95%CI)EV−,enterovirus negative samples;EV+,enterovirus positive samplesa Estimated from a mixed effects logistic regression model,with enterovirus positivity as the dependent variable and random intercepts for matched set and(within each matched set)individualsb Adjusted for sex,first-degree relative with type1diabetes(yes or no)and number of other children in the household(0,1or≥2).The final adjusted model does not include other tested covariates such as age,time of blood sampling and introduction of cow’s milk before3months of age since they did not influence the observed OR and did not improve the modelc Strictly excluding the sample first showing islet autoantibody positivityd Seroconversion time point defined as the first islet autoantibody-positive sample from case participants and corresponding matched controls.Note that for these samples we cannot know the temporal sequence of events,i.e.whether enterovirus RNA or islet autoantibody seroconversion occurred first e Seroconversion time point defined as first islet autoantibody-positive case sample and the control sample from the corresponding period Diabetologiaassociation between prolonged infections and seroconversion of islet autoantibodies.Modifiers of enterovirus positivity The highest frequency of enterovirus positivity was seen in samples obtained at2years of age(ESM Fig.3a),and the frequency decreased thereafter. There was an appreciable seasonal pattern,with a peak in late summer(p=0.019in the Walter and Elwood test[15];ESM Fig.3b).Enterovirus detection rates did not differ among calendar years.The frequency of enterovirus positivity was similar in children exposed to cow’s milk products before vs after 3months of age(OR0.68[95%CI0.36,1.24])and did not vary with sex(OR1.05[95%CI0.64,1.72]for males)nor with having first-degree relatives with diabetes(OR1.21 [95%CI0.61,2.39]).In contrast,enterovirus positivity was marginally increased when one or more other children were present in the household compared with none(OR 1.82[95%CI1.01,3.28]).We explored whether islet autoimmunity was associated with enterovirus RNA positivity in subgroups defined by the aforementioned factors(sex,children exposed before vs after 3months of age to cow’s milk products,first-degree relatives with diabetes,presence of other children in the household and calendar season of birth)using a stratified analysis and testing for interactions.None of these tests indicated any subgroup effects.DiscussionOur results do not support the hypothesis that enterovirus RNA in longitudinally collected blood samples predicts the subsequent development of islet autoimmunity,despite a high overall enterovirus frequency and inclusion of the highest number of cases among the prospective molecular studies published so far.Interestingly,in samples showing the first occurrence of islet autoantibodies we observed an almost significant increase in enterovirus RNA frequency.It is currently impos-sible to determine the sequence of events,i.e.whether entero-virus positivity occurred before islet autoimmunity or vice versa.If our enterovirus-positive samples reflected only acute viraemia(which is usually short),then only infections towards the end of the sample interval would be detected;thus,our data would support reverse causation(increased susceptibility to enterovirus in the blood as a result of islet autoimmunity). However,all but16positive samples contained only minute quantities of the virus,which is inconsistent with viraemic peaks.Our source of RNA(i.e.packed blood cells)may bear a certain‘memory’of past viral infections because peripheral white blood cells are permissive to enterovirus infection[16]and may be a better source of enterovirus RNA than plasma or serum[17,18].Thus,we speculate that the enterovirus posi-tivity we observed may reflect infection occurring over longer periods of time,leaving the direction of the causality unresolved.Study strengths Using a strict definition of positivity,we obtained a high enterovirus frequency of8.9%in blood sam-ples.This frequency is similar to that found in the DAISY study[10](although in that study a visit was deemed positive if serum,saliva or stool samples were positive)and is twofold higher than that of the Finnish DIPP(Diabetes Prediction and Prevention)study(4%and3%sera positivity in case and control participants)[7].Our high enterovirus frequency may thus also support the notion of the non-inferiority or superiority of whole blood compared with other sources of nucleic acid,as previously observed in testing for other viruses[19,20].Our study stems from the most homogeneous prospective cohort yet published,which reduces the possible variation in enterovirus frequency resulting from HLA genotypes[21].A strict matching protocol was employed,demonstrated by the clustering of infections across the matching groups(ESM Fig.1).Furthermore,factors modifying enterovirus positivity were either taken into consideration in the matched study design(age,place,season)or adjusted for in the analysis. Comparison with other studies The prospective studies pub-lished so far on enterovirus and islet autoimmunity show variations in several aspects,including sampling intervals and definitions of positivity[1].We specifically aimed to minimise methodological differences with prospective molec-ular studies from neighbouring Finland[6–9].In the Finnish studies,a significantly higher enterovirus RNA frequency was noted in sera taken in the6-month period before the first detection of islet autoantibodies,thus reflecting an excess of acute viraemic infections during that period [7,8],whereas no such association was observed in the present study.The differences in enterovirus frequency may partly explain this discrepancy.There is an unusually low enterovirus prevalence in Finland,which is several fold lower than in other populations[7,22–24].Assuming that a putative diabetogenic strain or serotype is hiding among a hundred or more other,innocuous strains,its effect may be easily overshadowed if these background strains are overly preva-lent.This may also be the case for the present Norwegian study,which shows the highest frequency so far of enterovirus RNA in the blood of prediabetic children.Study limitations One limitation shared by this study,as well as all other studies using pan-enterovirus RT-PCR analysis of blood or serum[7,8,10],is the lack of sequence information. Although detection using the5′-untranslated region is veryDiabetologiasensitive,the amplicon contains no information on serotype specificity.Amplification of the VP1(serotype-specific)re-gion is unfeasible in low positivity samples such as ours because degenerate PCR analysis requires relatively high template concentrations.Second,if a hit-and-run infection mechanism is involved in the pathogenesis of islet autoimmu-nity,then all currently available molecular studies—including ours—have an insufficient blood sampling frequency and would therefore detect only a small fraction of the total infections.In summary,we were not able to see a statistically signif-icant association between enterovirus RNA positivity in blood and the subsequent development of islet autoantibodies in children with a high genetic risk of type1diabetes.Although induction of islet autoantibodies tended to be associated with enterovirus detection in blood,we cannot conclude a causal relationship between the two events.Acknowledgements We thank the public healthcare nurses for their recruitment efforts for the MIDIA study and the follow-up of high-risk children,and the staff at the Biobank Department at the Norwegian Institute of Public Health.In particular,we would like to express our gratitude to all of the parents for their efforts in handling their children’s type1diabetes risk,for allowing samples to be taken from their children and for completing questionnaires.Funding This study and the MIDIA project were funded by the Norwegian Organization for Health and Rehabilitation(2008/0182),the Ministry of Health of the Czech Republic(IGA MZ11465–5),the Research Council of Norway(grants135893/330,155300/320,156477/730, 205086/F20and166515/V50),the Norwegian Diabetes Association,the Academy of Finland(grant to HH)and the Project for the Conceptual Development of Research Organisation00064203(University Hospital Motol,Prague,Czech Republic).OC’s sabbatical at HH’s laboratory in 2012was supported by an ISPAD Research Fellowship.Duality of interest HH is a minor shareholder(<5%)of Vactech Ltd., which develops picornavirus vaccines.All other authors declare that there is no duality of interest associated with their contribution to this manuscript.Contribution statement KSR and LCS conceived and designed the study.OC,LK,SO and HH collected data(performed or supervised the enterovirus testing),PAT collected data(tested islet autoantibodies),and TR managed the databases.LCS,GT,EW,TR and OC analysed and interpreted data.All authors drafted the manuscript and/or revised it for important intellectual content,and have approved the final version.LCS is the guarantor of this work and,as such,had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.References1.Stene LC,Rewers M(2012)Immunology in the clinic review series;focus on type1diabetes and viruses:the enterovirus link to type1 diabetes:critical review 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