Chan Yoke Fun

Abstract: From 1989 to 2011 in Kuala Lumpur, Malaysia, multiple genotypes from both respiratory syncytial virus (RSV) subgroups were found co-circulating each year. RSV-A subgroup predominated in 12 out of 17 years with the remaining years predominated by RSV-B subgroup. Local RSV strains exhibited temporal clustering with RSV strains reported in previous epidemiological studies. Every few years, the existing predominant genotype was replaced by a new genotype. The RSV-A genotypes GA2, GA5 and GA7 were replaced by NA1 and NA2, while BA became the predominant RSV-B genotype. A unique local cluster, BA12, was seen in 2009, and the recently-described ON1 genotype with 72-nt duplication emerged in 2011. Our findings will have important implications for future vaccine intervention.

Abstract: Enterovirus 71 (EV-71) infections are usually associated with mild hand, foot, and mouth disease in young children but have been reported to cause severe neurological complications with high mortality rates. To date, four EV-71 receptors have been identified, but inhibition of these receptors by antagonists did not completely abolish EV-71 infection, implying that there is an as yet undiscovered receptor(s). Since EV-71 has a wide range of tissue tropisms, we hypothesize that EV-71 infections may be facilitated by using receptors that are widely expressed in all cell types, such as heparan sulfate. In this study, heparin, polysulfated dextran sulfate, and suramin were found to significantly prevent EV-71 infection. Heparin inhibited infection by all the EV-71 strains tested, including those with a single-passage history. Neutralization of the cell surface anionic charge by polycationic poly-D-lysine and blockage of heparan sulfate by an anti-heparan sulfate peptide also inhibited EV-71 infection. Interference with heparan sulfate biosynthesis either by sodium chlorate treatment or through transient knockdown of N-deacetylase/N-sulfotransferase-1 and exostosin-1 expression reduced EV-71 infection in RD cells. Enzymatic removal of cell surface heparan sulfate by heparinase I/II/III inhibited EV-71 infection. Furthermore, the level of EV-71 attachment to CHO cell lines that are variably deficient in cell surface glycosaminoglycans was significantly lower than that to wild-type CHO cells. Direct binding of EV-71 particles to heparin-Sepharose columns under physiological salt conditions was demonstrated. We conclude that EV-71 infection requires initial binding to heparan sulfate as an attachment receptor.

Abstract: Background: Chikungunya virus (CHIKV) and dengue virus (DENV) co-circulate in areas endemic with the Aedes mosquito vectors. Both viruses cause similar illnesses which may be difficult to distinguish clinically. CHIKV is also associated with persistent arthralgia. Objectives: To compare and describe factors which differentiate between DENV and CHIKV infections on presentation; and to describe predictors of persistent arthralgia in CHIKV patients. Study design: Patients aged > 14 years diagnosed with acute CHIKV and DENV infections in Kuala Lumpur, Malaysia were retrospectively identified. Clinical and laboratory data were obtained from medical records, and compared. CHIKV patients were telephoned 15-24 months later and interviewed about persistent symptoms. Logistic regression analysis was performed. Results: A total of 53 CHIKV and 113 DENV patients were included. CHIKV patients were older and more likely to be female. CHIKV was independently associated with arthralgia and rash, while DENV was associated with myalgia, raised aspartate transaminase, and leucopaenia. Forty CHIKV patients were followed up, with a median duration of self-reported arthralgia of 3 months (range, 0-24 months). Eighteen (45%) had persistent arthralgia beyond 4 months, for which age > 40 years was an independent predictor. At 1 year, 9 (22.5%) patients had arthralgia. Conclusion: In Kuala Lumpur, selected clinical and laboratory predictors help to distinguish between DENV and CHIKV infections. Persistent arthralgia was a frequent sequel of CHIKV infection in this cohort. (C) 2012 Elsevier B. V. All rights reserved.

Abstract: Chikungunya virus (CHIKV) and related arboviruses have been responsible for large epidemic outbreaks with serious economic and social impact. The immune mechanisms, which control viral multiplication and dissemination, are not yet known. Here, we studied the antibody response against the CHIKV surface antigens in infected patients. With plasma samples obtained during the early convalescent phase, we showed that the naturally-acquired IgG response is dominated by IgG3 antibodies specific mostly for a single linear epitope E2EP3. E2EP3 is located at the N-terminus of the E2 glycoprotein and prominently exposed on the viral envelope. E2EP3-specific antibodies are neutralizing and their removal from the plasma reduced the CHIKV-specific antibody titer by up to 80%. Screening of E2EP3 across different patient cohorts and in non-human primates demonstrated the value of this epitope as a good serology detection marker for CHIKV infection already at an early stage. Mice vaccinated by E2EP3 peptides were protected against CHIKV with reduced viremia and joint inflammation, providing a pre-clinical basis for the design of effective vaccine against arthralgia-inducing CHIKV and other alphaviruses.

Abstract: Background: Viral respiratory tract infections (RTI) are relatively understudied in Southeast Asian tropical countries. In temperate countries, seasonal activity of respiratory viruses has been reported, particularly in association with temperature, while inconsistent correlation of respiratory viral activity with humidity and rain is found in tropical countries. A retrospective study was performed from 1982-2008 to investigate the viral etiology of children (<= 5 years old) admitted with RTI in a tertiary hospital in Kuala Lumpur, Malaysia. Methods: A total of 10269 respiratory samples from all children <= 5 years old received at the hospital’s diagnostic virology laboratory between 1982-2008 were included in the study. Immunofluorescence staining (for respiratory syncytial virus (RSV), influenza A and B, parainfluenza types 1-3, and adenovirus) and virus isolation were performed. The yearly hospitalization rates and annual patterns of laboratory-confirmed viral RTIs were determined. Univariate ANOVA was used to analyse the demographic parameters of cases. Multiple regression and Spearman’s rank correlation were used to analyse the correlation between RSV cases and meteorological parameters. Results: A total of 2708 cases were laboratory-confirmed using immunofluorescence assays and viral cultures, with the most commonly detected being RSV (1913, 70.6%), parainfluenza viruses (357, 13.2%), influenza viruses (297, 11.0%), and adenovirus (141, 5.2%). Children infected with RSV were significantly younger, and children infected with influenza viruses were significantly older. The four main viruses caused disease throughout the year, with a seasonal peak observed for RSV in September-December. Monthly RSV cases were directly correlated with rain days, and inversely correlated with relative humidity and temperature. Conclusion: Viral RTIs, particularly due to RSV, are commonly detected in respiratory samples from hospitalized children in Kuala Lumpur, Malaysia. As in temperate countries, RSV infection in tropical Malaysia also caused seasonal yearly epidemics, and this has implications for prophylaxis and vaccination programmes.

Abstract: Enterovirus 71 (EV-71) is the main causative agent of hand, foot and mouth disease (HFMD). In recent years, EV-71 infections were reported to cause high fatalities and severe neurological complications in Asia. Currently, no effective antiviral or vaccine is available to treat or prevent EV-71 infection. In this study, we have discovered a synthetic peptide which could be developed as a potential antiviral for inhibition of EV-71. Ninety five synthetic peptides (15-mers) overlapping the entire EV-71 capsid protein, VP1, were chemically synthesized and tested for antiviral properties against EV-71 in human Rhabdomyosarcoma (RD) cells. One peptide, SP40, was found to significantly reduce cytopathic effects of all representative EV-71 strains from genotypes A, B and C tested, with IC50 values ranging from 6-9.3 mu M in RD cells. The in vitro inhibitory effect of SP40 exhibited a dose dependent concentration corresponding to a decrease in infectious viral particles, total viral RNA and the levels of VP1 protein. The antiviral activity of SP40 peptide was not restricted to a specific cell line as inhibition of EV-71 was observed in RD, HeLa, HT-29 and Vero cells. Besides inhibition of EV-71, it also had antiviral activities against CV-A16 and poliovirus type 1 in cell culture. Mechanism of action studies suggested that the SP40 peptide was not virucidal but was able to block viral attachment to the RD cells. Substitutions of arginine and lysine residues with alanine in the SP40 peptide at positions R3A, R4A, K5A and R13A were found to significantly decrease antiviral activities, implying the importance of positively charged amino acids for the antiviral activities. The data demonstrated the potential and feasibility of SP40 as a broad spectrum antiviral agent against EV-71.

Abstract: Three genomic regions, VP4 capsid, VP1 capsid and 3D RNA polymerase of human enterovirus 71 (EV-71) and coxsackievirus A16 (CV-A16) were sequenced to understand the evolution of these viruses in Malaysia. A total of 42 EV-71 and 36 CV-A16 isolates from 1997-2008 were sequenced. Despite the presence of many EV-71 subgenotypes worldwide, only subgenotypes B3, B4, B5, C1 and C2 were present in Malaysia. Importation of other subgenotypes such as C3, C4/D and C5 from other countries was infrequent. For CV-A16, the earlier subgenotype B1 was replaced by subgenotypes B2a and the recent B2c. Subgenotype B2a was present throughout the study while B2c only emerged in 2005. No genetic signatures could be attributed to viral virulence suggesting that host factors have a major role in determining the outcome of infection. Only three EV-71 B3 isolates showed non-consistent phylogeny in the 3D RNA polymerase region which indicated occurrence of recombination in EV-71. High genetic diversity was observed in the Malaysian EV-71 but Malaysian CV-A16 showed low genetic diversity in the three genomic regions sequenced. EV-71 showed strong purifying selection, but that occurred to a lesser extent in CV-A16.

Abstract: Background: Mosquito-borne Chikungunya virus (CHIKV) has recently re-emerged globally. The epidemic East/Central/South African (ECSA) strains have spread for the first time to Asia, which previously only had endemic Asian strains. In Malaysia, the ECSA strain caused an extensive nationwide outbreak in 2008, while the Asian strains only caused limited outbreaks prior to this. To gain insight into these observed epidemiological differences, we compared genotypic and phenotypic characteristics of CHIKV of Asian and ECSA genotypes isolated in Malaysia. Methods and Findings: CHIKV of Asian and ECSA genotypes were isolated from patients during outbreaks in Bagan Panchor in 2006, and Johor in 2008. Sequencing of the CHIKV strains revealed 96.8% amino acid similarity, including an unusual 7 residue deletion in the nsP3 protein of the Asian strain. CHIKV replication in cells and Aedes mosquitoes was measured by virus titration. There were no differences in mammalian cell lines. The ECSA strain reached significantly higher titres in Ae. albopictus cells (C6/36). Both CHIKV strains infected Ae. albopictus mosquitoes at a higher rate than Ae. aegypti, but when compared to each other, the ECSA strain had much higher midgut infection and replication, and salivary gland dissemination, while the Asian strain infected Ae. aegypti at higher rates. Conclusions: The greater ability of the ECSA strain to replicate in Ae. albopictus may explain why it spread far more quickly and extensively in humans in Malaysia than the Asian strain ever did, particularly in rural areas where Ae. albopictus predominates. Intergenotypic genetic differences were found at E1, E2, and nsP3 sites previously reported to be determinants of host adaptability in alphaviruses. Transmission of CHIKV in humans is influenced by virus strain and vector species, which has implications for regions with more than one circulating CHIKV genotype and Aedes species.

Abstract: Background: Respiratory syncytial virus (RSV) is the most common respiratory virus detected in children. RSV disease ranges from mild flu-like symptoms to bronchiolitis and severe pneumonia, and predisposes to the development of asthma. Preterm birth and pre-existing respiratory tract disorders increase risk of developing severe RSV infection. There is conflicting evidence about whether severe RSV disease is correlated to RSV genotype. Molecular epidemiological data from tropical Asia is relatively lacking. This study aims to identify the potential risk factors of severe RSV infection by analysis of clinical data and RSV genotypes in Malaysia. Methods: The medical records of 138 RSV cases were analysed for demographic and clinical data, including age, gender, ethnicity, prematurity, co-morbidity, and source of infection. Severe RSV infection was defined in patients who died, or required ventilation, intensive care, or inotropes. The hypervariable region of the G gene was sequenced for 91 RSV samples from 1989-2009, for genotype identification and phylogenetic analysis. Demographic factors, clinical factors and genotype were entered into logistic regression analysis as predictors of severe RSV disease. A p-value of <0.05 was considered significant. Results: The mean age of the study population was 1.4 years, with a majority (62.3%) aged <1 year. Multivariate analysis showed three independent predictors of severe RSV: male gender (odds ratio 4.25; 95% confidence intervals 1.14–15.85), underlying co-morbidity or prematurity (OR 7.11; CI 2.11–23.94), and nosocomial infection (OR 4.71; CI 1.27–17.41). Genotype was not associated with severity. Of the 91 RSV samples sequenced, 66 (72.5%) were in subgroup A and 25 (27.5%) were in subgroup B. The most commonly detected genotypes were GA2 (52.8%, n=48), GB13 (20.9%, n=19), and GA5 (13.2%, n=12). Nucleotide and amino acid similarity between subgroups were 49.9% and 27.0%. RSV A was detected every year, but RSV B only circulated for 2-3 years before being undetected for 1-2 years. Conclusion: Male gender, underlying co-morbidity or prematurity, and nosocomial infection increases the risk of developing severe RSV infection. RSV A was seen every year, while RSV B circulated in 4-5 year cycles

Abstract: In the last decade, Malaysia has experienced several hand, foot and mouth disease (HFMD) epidemics, complicated by fatalities due to severe neurological involvement. Enterovirus 71 (EV-71) has been implicated as the major causative agent for these epidemics. EV-71 infection is a global public health problem with pandemic potential. In many parts of Asia-Pacific, the virus has emerged as one of the most deadly virus infections amongst young children. The virus is highly transmissible through faecal-oral route and respiratory droplets. A recent rise in neurological complications and deaths suggests that the viruses currently circulating may be more virulent. The major risk factor associated with more severe EV-71 infection is young age and poor cellular immunity. Rapid laboratory diagnosis and molecular surveillance is important to closely monitor the emergence of new EV-71 subgenotypes. Since vaccine and anti-virals for EV-71 are not available, control and prevention strategies remain the only ways to combat the infection.

Abstract: In 2006, an outbreak of Chikungunya virus (CHIKV) of the Asian genotype affected over 200 people in Bagan Panchor village in Malaysia. One year later, a post-outbreak survey was performed to determine attack rate, asymptomatic rate, and post-infection sequelae. Findings were compared with recent CHIKV outbreaks of the Central/East African genotype. A total of 180 residents were interviewed for acute symptoms and post-infection physical quality of life and depressive symptoms. Sera from 72 residents were tested for CHIKV neutralizing antibodies. The estimated attack rate was 55.6%, and 17.5% of infected residents were asymptomatic. Arthralgia was reported up to 3 months after infection, but there were no reports of long-term functional dependence or depression. Symptomatic and seropositive residents were significantly more likely to live in the area with the most dense housing and commercial activities. CHIKV had a high attack rate and considerable clinical impact during the Bagan Panchor outbreak.

Abstract: Objectives: The clinical impact of seasonal influenza is understudied in tropical countries. The aim of this study was to describe the clinical features and seasonal pattern of influenza in children hospitalized in Malaysia, and to identify predictors of severe disease. Methods: Children hospitalized with community-acquired, laboratory-confirmed influenza at a teaching hospital in Kuala Lumpur, Malaysia during 2002-2007 were identified retrospectively. Clinical data were collected, and predictors of severe disease were identified by multivariate logistic regression. All influenza cases from 1982 to 2007 were also analyzed for seasonal patterns. Results: A total of 132 children were included in the study, 48 (36.4%) of whom had underlying medical conditions. The mean age was 2.5 years and 116 (87.9%) were < 5 years old. The most common presenting features were fever or history of fever, cough, rhinitis, vomiting, and pharyngitis. Severe influenza was seen in 16 patients (12.1%; nine previously healthy), including 12 (9.1%; eight previously healthy) requiring intensive care. There were three (2.3%) deaths. Severe disease was associated with age < 12 months, female sex, and absence of rhinitis on admission. Influenza was seen year-round, with peaks in November-January and May-July. Conclusions: Seasonal influenza has a considerable impact on children hospitalized in Malaysia, in both the healthy and those with underlying medical conditions. (C) 2010 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Abstract: Chikungunya virus (CHIKV) is a mosquito-borne alphavirus which causes fever, rash, and arthralgia. In the past, life-threatening complications were very rarely reported. However, during the recent worldwide outbreaks, there have been several reports of unusually severe complications and deaths. Malaysia is experiencing a nationwide outbreak of CHIKV, with over 10 000 patients affected since April 2008. We report the first case of culture-confirmed CHIKV-associated death in Malaysia, in a patient with fever, rash, acute exacerbation of pre-existing heart failure, rhabdomyolysis, and multiple organ failure. CHIKV infections may cause atypical, severe or fatal presentations.

Abstract: Human enterovirus 71 (EV-71) is one of the major etiologic causes of hand, foot, and mouth disease (HFMD) among young children worldwide, with fatal instances of neurological complications becoming increasingly common. Global VP1 capsid sequences (n = 628) sampled over 4 decades were collected and subjected to comprehensive evolutionary analysis using a suite of phylogenetic and population genetic methods. We estimated that the common ancestor of human EV-71 likely emerged around 1941 (95% confidence interval [CI], 1929 to 1952), subsequently diverging into three genogroups: B, C, and the now extinct genogroup A. Genealogical analysis revealed that diverse lineages of genogroup B and C (subgenogroups B1 to B5 and C1 to C5) have each circulated cryptically in the human population for up to 5 years before causing large HFMD outbreaks, indicating the quiescent persistence of EV-71 in human populations. Estimated phylogenies showed a complex pattern of spatial structure within well-sampled subgenogroups, suggesting endemicity with occasional lineage migration among locations, such that past HFMD epidemics are unlikely to be linked to continuous transmission of a single strain of virus. In addition, rises in genetic diversity are correlated with the onset of epidemics, driven in part by the emergence of novel EV-71 subgenogroups. Using subgenogroup C1 as a model, we observe temporal strain replacement through time, and we investigate the evidence for positive selection at VP1 immunogenic sites. We discuss the consequences of the evolutionary dynamics of EV-71 for vaccine design and compare its phylodynamic behavior with that of influenza virus.

Abstract: Human enterovirus 71 (EV-71) is genotyped for molecular epidemiological investigation mainly using the two structural genes, VP1 and VP4. Based on these, EV-71 is divided into three genotypes, A, B and C, and within the genotypes B and C, there are further subgenotypes, B1-B5 and C1-C5 Classification using these genes is useful but gives incomplete phylogenetic information In the present study, the phylogenetic relationships amongst all the known EV-71 and human enterovirus A (HEV-A) isolates with complete genome sequences were examined A different tree topology involving EV-71 isolates of subgenotypes. C4 and B5 was obtained in comparison to that drawn using VP1 The nucleotide sequence divergence of the C4 Isolates was 18.11% (17-20%) when compared to other isolates of subgenotype C However, this positions the C4 isolates within the cut-off divergence value of 17-22% used to designate the virus genotypes. Hence, it is proposed here that C4 should be designated as a new genotype D. In addition, the subgenotype B5 isolates had an average nucleotide divergence of only 6.14% (4-8%) when compared to other subgenotype B4 isolates This places the B5 isolates within the subgenotype B4 It is proposed here that the B5 isolates to be redesignated as B4 With the newly proposed genotype D and inclusion of subgenotype B5 within B4, the average nucleotide divergence between genotypes was 18 99% (17-22%) Inter- and intra-subgenotype average divergences were 12 02% (10-14%) and 3 92% (1-10%), respectively A phylogenetic tree built using the full genome sequences is robust as it takes into consideration changes in the sequences of both the structural and non-structural genes. Similar nucleotide similarities, however, were obtained if only VP1 and 3D RNA polymerase genes were used. Furthermore, addition of 3D RNA polymerase sequences will also show recombination events Hence, in the absence of full genome sequences, it is proposed here that a combination of VP1 and 3D RNA polymerase gene sequences be used for initial genotyping of EV-71 isolates (C) 2009 Elsevier B V. All rights reserved

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Abstract: Background: Chikungunya virus (CHIKV) of the Central/East African genotype has caused large outbreaks worldwide in recent years. In Malaysia, limited CHIKV outbreaks of the endemic Asian and imported Central/East African genotypes were reported in 1998 and 2006. Since April 2008, an unprecedented nationwide outbreak has affected Malaysia. Objective: To study the molecular epidemiology of the current Malaysian CHIKV outbreak, and to evaluate cross-neutralisation activity of serum from infected patients against isolates of Asian and Central/East African genotypes. Study design: Serum samples were collected from 83 patients presenting in 2008, and tested with PCR for the El gene, virus isolation, and for IgM. Phylogenetic analysis was performed on partial El gene sequences of 837 bp length. Convalescent serum from the current outbreak and Bagan Panchor outbreak (Asian genotype, 2006) were tested for cross-neutralising activity against representative strains from each outbreak. Results: CHIKV was confirmed in 34 patients (41.0%). The current outbreak strain has the A226V mutation in the El structural protein, and grouped with Central/East African isolates from recent global outbreaks. Serum cross-neutralisation activity against both Central/East African and Asian genotypes was observed at titres from 40 to 1280. Conclusions: The CHIKV strain causing the largest Malaysian outbreak is of the Central/East African genotype. The presence of the A226V mutation, which enhances transmissibility of CHIKV by Aedes albopictus, may explain the extensive spread especially in rural areas. Serum cross-neutralisation of different genotypes may aid potential vaccines and limit the effect of future outbreaks. (C) 2009 Elsevier B.V. All rights reserved.

Abstract: Varicella-zoster virus (VZV) infections are a particular problem in healthcare settings. A survey of chickenpox was carried out amongst healthcare workers (HCWs) following potential ward exposures. A prior history of chickenpox was given by 61/98 (62.2%). Of 64 HCWs tested for VZV IgG, 10 (15.6%) were seronegative, indicating susceptibility. The sensitivity, specificity, positive predictive value, and negative predictive value of a history of prior chickenpox were 57.4%, 90%, 96.4%, and 31.0%, respectively. VZV screening of HCWs without a history of chickenpox, and vaccination of susceptible HCWs should be undertaken in this hospital.

Abstract: Background: Dengue viruses are thought to be maintained in a sylvatic cycle with the endemic or epidemic viruses arising from ancentral sylvatic strains. In general it is thought that sylvatic dengue viruses are not particularly virulent for humans and may only cause mild disease. In January 2008 we isolated a sylvatic dengue 2 virus from a patient presenting to a fever surveillance clinic. This patient subsequently developed DHF and we present here a description of the case, and early attempts at characterizing the infecting sylvatic virus.

Abstract: The 1st 9 clinical isolates of multisensitive community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) from Malaysia carry SCCmec type IN and predominantly cause skin and soft-tissue infections. Seven were classified as nosocomially acquired. There was considerable clonal diversity, with both pandemic and novel multilocus sequence types detected. CA-MRSA rates appear to be increasing in our hospital, warranting close surveillance. (C) 2008 Elsevier Inc. All rights reserved.

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Abstract: Background: Human enterovirus 71 (EV-71) is a common causative agent of hand, foot and mouth disease (HFMD). In recent years, the virus has caused several outbreaks with high numbers of deaths and severe neurological complications. Several new EV-71 subgenotypes were identified from these outbreaks. The mechanisms that contributed to the emergence of these subgenotypes are unknown. Results: Six EV-71 isolates from an outbreak in Malaysia, in 1997, were sequenced completely. These isolates were identified as EV-71 subgenotypes, B3, B4 and C2. A phylogenetic tree that correlated well with the present enterovirus classification scheme was established using these full genome sequences and all other available full genome sequences of EV-71 and human enterovirus A (HEV-A). Using the 5’ UTR, P2 and P3 genomic regions, however, isolates of EV-71 subgenotypes B3 and C4 segregated away from other EV-71 subgenotypes into a cluster together with coxsackievirus A16 (CV-A16/G10) and EV-71 subgenotype C2 clustered with CV-A8. Results from the similarity plot analyses supported the clustering of these isolates with other HEV- A. In contrast, at the same genomic regions, a CV-A16 isolate, Tainan5079, clustered with EV-71. This suggests that amongst EV- 71 and CV-A16, only the structural genes were conserved. The 3’ end of the virus genome varied and consisted of sequences highly similar to various HEV-A viruses. Numerous recombination crossover breakpoints were identified within the non-structural genes of some of these newer EV-71 subgenotypes. Conclusion: Phylogenetic evidence obtained from analyses of the full genome sequence supports the possible occurrence of inter-typic recombination involving EV-71 and various HEV-A, including CV-A16, the most common causal agent of HFMD. It is suggested that these recombination events played important roles in the emergence of the various EV-71 subgenotypes.

Abstract: The efficacy of Virkon S, a commercial disinfectant as a virucidal spray against human enterovirus 71 (HEV71), the causative agent of the fatal form of hand, foot and mouth disease was examined. At least one log10 reduction of HEV71 titer was achieved when one spray of Virkon (1% or 2%) with ten minutes of contact time was applied. The infectivity was completely lost when four sprays of 1% or 2% Virkon were applied, suggesting that at least four sprays of 1% Virkon to the surface bound HEV71 was necessary to completely inactivate the virus. These findings suggest that Virkon S at the proper concentration is suitable to be used as an effective and easy to use disinfectant against HEV71.

Abstract: Background: At least three different EV-71 subgenotypes were identified from an outbreak in Malaysia in 1998. The subgenotypes C2 and B4 were associated with the severe and fatal infections, whereas the B3 virus was associated with mild to subclinical infections. The B3 virus genome sequences had = 85% similarity at the 3’ end to CV-A16. This offers opportunities to examine if there are characteristic similarities and differences in virulence between CV-A16, EV-71 B3 and EV-71 B4 and to determine if the presence of the CV-A16-liked genes in EV-71 B3 would also confer the virus with a CV-A16-liked neurovirulence in mice model infection. Results: Analysis of human enterovirus 71 (EV-71) subgenotype B3 genome sequences revealed that the 3D RNA polymerase and domain Z of the 3’-untranslating region RNA secondary structure had high similarity to CV-A16. Intracerebral inoculation of one-day old mice with the virus resulted in 16% of the mice showing swollen hind limbs and significantly lower weight gain in comparison to EV-71 B4-infected mice. None of the mice presented with hind leg paralysis typical in all the CV-A16 infected mice. CV-A16 genome sequences were amplified from the CV-A16-infected mice brain but no amplification was obtained from all the EV-71-inoculated mice suggesting that no replication had taken place in the suckling mice brain. Conclusion: The findings presented here suggest that EV-71 B3 viruses had CV-A16-liked nonstructural gene features at the 3’-end of the genome. Their presence could have affected virulence by affecting the mice general health but was insufficient to confer the EV-71 B3 virus a CV-A16-liked neurovirulence in mice model infection.

Abstract: Two human enterovirus 71 (HEV71) isolates were identified from hand, foot and mouth disease patients with genome sequences that had high similarity to HEV71 (greater than or equal to93%) at 5’UTR, P1, and P2 and coxsackievirus A16 (CV-A16, greater than or equal to85%) at P3 and 3’UTR. Intertypic recombination is likely to have occurred between HEV71 and CV-A16 or an as-yet to be described CV-A16-like virus.

Abstract: Phylogenetic analyses of the envelope (E) gene sequence of five recently isolated dengue virus type 4 (DENV-4) suggested the emergence of a distinct geographical and temporal DENV-4 subgenotype IIA in Malaysia. Four of the isolates had direct ancestral lineage with DENV-4 Indonesia 197 3 and showed evidence of intra-serotypic recombination with the other recently isolated DENV-4, MYO1-22713. The E gene of isolate MYO1-22713 had strong evidence of an earlier recombination involving DENV-4 genotype II Indonesia 1976 and genotype I Malaysia 1969. These results suggest that intra-serotypic recombination amongst DENV-4 from independent ancestral lineages may have contributed to the emergence of DENV-4 subgenotype IIA in Malaysia.

Abstract: Molecular characterization and prenatal diagnosis for beta-thalassemia can be carried out using the Amplification Refractory Mutation System (ARMS). The ARMS is a rapid and direct molecular technique in which beta-thalassemia mutations are visualized immediately after DNA amplification by gel electrophoresis. In the University of Malaya Medical Center, molecular characterization and prenatal diagnosis for beta-thalassemia is carried out using ARMS for about 96% of the Chinese and 84.6% of the Malay patients. The remaining 4% and 15.4% of the uncharacterized mutations in the Chinese and Malay patients respectively are detected using DNA sequencing. DNA sequencing is an accurate technique but it is more time-consuming and expensive compared with the ARMS. The ARMS for the rare Chinese beta-mutations at position -29 (A-->G) and the ATG-->AGG base substitution at the initiator codon for translation in the beta-gene was developed. In the Malays, ARMS was optimized for the beta-mutations at codon 8/9 (+G), Cap (+1) (A-->C) and the AATAAA-->AATAGA base substitution in the polyadenylation region of the beta-gene. The ARMS protocols were developed by optimization of the parameters for DNA amplification to ensure sensitivity, specificity and reproducibility. ARMS primers (sequences and concentration), magnesium chloride concentration, Taq DNA polymerase and PCR cycling parameters were optimized for the specific amplification of each rare beta-thalassemia mutation. The newly-developed ARMS for the 5 rare beta-thalassemia mutations in the Chinese and Malays in Malaysia will allow for more rapid and cost-effective molecular characterization and prenatal diagnosis for beta-thalassemia in Malaysia.

Abstract: The outbreak of enterovirus 71 infection in Taiwan, reported by Ho et al. (Sept. 23 issue), 1 occurred almost a year after the outbreak in Malaysia. Though both outbreaks occurred in Asia and both involved large numbers of deaths, it was not known whether the two outbreaks were related. We studied the nucleotide sequence and secondary RNA structure of some of the isolates, using the sequence of the 5’ untranslated region (UTR). Enterovirus 71 isolates from patients in Singapore (seven isolates), Taiwan (two isolates), and Japan (one isolate) were examined and compared with those previously reported in Malaysia 2,3 or with sequences deposited in GenBank. A phylogenetic tree that we constructed using the aligned 5’ UTR sequences revealed at least two major clusters of enterovirus 71 isolates. Cluster 1 included the isolate from Japan and six of the seven isolates from Singapore, together with isolates found predominantly in Malaysia during the 1997 outbreak. The isolates in this cluster had at least 89 percent sequence homology with enterovirus 71 MS isolates. The isolates in cluster 1 formed two subclusters. The isolate from Japan and five of the six isolates from Singapore were clustered with isolates from the Malaysian peninsula, forming one subcluster, and the remaining isolates, which included others from the Malaysian peninsula, Sarawak, and Singapore, formed the other subcluster. Three other isolates examined, one from Singapore and two from Taiwan, were in cluster 2, which consisted mostly of isolates from the 1998 outbreak in Taiwan. Cluster 2 also had two subclusters, with all the isolates from Taiwan, including the two sequenced in this study, in one subcluster and the remaining isolates from the Malaysian peninsula and Singapore in the other. The isolates in these two subclusters had at least 97 percent homology with each other and approximately 85 percent homology with the coxsackievirus A9 5’ UTR sequence rather than with the enterovirus 71 MS group, which contained the other enterovirus 71 strains found predominantly in Malaysia and Singapore. A comparison of the 5’ UTR secondary RNA structure, which has been associated with the degree of virulence, in the cluster 2 isolates revealed no significant differences in the structure of the three domains within the 5’ UTR sequence. These findings suggest that the 5’ UTR features of the enterovirus 71 strains from the Taiwanese outbreak were almost identical to those of the coxsackievirus A9âￜￜlike strains isolated previously in the Malaysian peninsula. 3 Because of these similarities and the high frequency of travel between Malaysia and Taiwan, it is tempting to speculate that the predominant enterovirus 71 strains in the Taiwanese outbreak may have been accidental imports.