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Lineage-Specific Real-Time Reverse Transcription PCR for Yellow Fever Virus Outbreak Surveillance, Brazil.

Yellow fever virus (YFV) is a mosquitoborne member of the genus Flavivirus within the family Flaviviridae (online Technical Appendix Figure 1, panel A, https://wwwnc.cdc.gov/EID/article/23/11/17-1131-Techapp1.pdf) that is endemic to Africa and South America (1). Within YFV, 2 American and at least 3 African genotypes can be differentiated (2). The American YFV genotypes evolved from ancestral African viruses several hundred years ago and now are found only in South America (3).

In December 2016, Brazil reported the country's largest yellow fever (YF) outbreak in decades. Through May 31, 2017, a total of 3,240 suspected cases were reported, including 435 deaths (4). The geographically widespread outbreak was caused by the American genotype 1 (online Technical Appendix Figure 1, panel B) (5). In response to the outbreak, authorities launched large-scale vaccination campaigns aimed at distributing >20 million doses of YFV vaccine (6). Two different live-attenuated vaccines are being deployed. Most contain the vaccine strain 17DD, produced in Brazil (7). International authorities are deploying another 3.5 million doses of the standard vaccine strain, 17D (6). Both vaccine strains originate from the same parental strain, Asibi, and represent the West African genotype 2 (online Technical Appendix Figure 1, panel B).

While YFV vaccines are considered safe, rare vaccine-associated adverse events (YF-VAAE) can occur (8). Viscerotropic YF-VAAE symptoms can overlap those of YF disease (9). In YFV-endemic regions, it is essential to distinguish between YF-VAAE and wild-type YFV infection (10). Routine diagnostic procedures can take several days, usually requiring 2 separate steps, detection and strain characterization by nucleotide sequencing. Here, we present 2 highly sensitive real-time reverse transcription PCRs (RT-PCRs) designed to detect and discriminate between YFV vaccine and American wild-type (hereafter referred to as wild-type) strains within 1 hour.

The Study

We followed 2 rationales for real-time RT-PCR design. First, a small number of oligonucleotides per assay can be beneficial in resource-limited settings. Therefore, we designed 5 different single-target assays using primers capable of simultaneously amplifying vaccine and wild-type YFV strains. However, these criteria restricted the ability to design optimal oligonucleotides. Therefore, we designed 2 additional dual-target assays that target 2 separate genomic regions in which vaccine and wild-type strains differ sufficiently from one another (Figure 1, panel A). Vaccine and wild-type strains were generally discriminated by lineage-specific hydrolysis probes within a single tube reaction, incapable of detecting the heterologous lineage due to high numbers of nucleotide mismatches under oligonucleotide binding sites (Figure 1, panel B) (12).

We selected the 2 most sensitive single- and dual-target assays on the basis of preliminary experiments using full viral RNA of wild-type and vaccine strains (Table; online Technical Appendix Figure 2). For assay validation and quantification, we designed 2 in vitro transcripts (IVTs) based on the vaccine strain 17DD and an outbreak strain from Brazil (5), as described previously (12).

The 95% lower limit of detection of the single- and dual-target assays ranged from 4.0 to 8.8 RNA copies/reaction for vaccine and wild-type YFV strains (online Technical Appendix Figure 3). Discrimination between vaccine and wild-type strains was reliable even at high concentrations of IVTs and full viral RNA in the range of 106 copies/reaction. Assay specificity was assessed using a set of 39 high-titer flavi-virus cell culture isolates (online Technical Appendix Figure 1, panel A), all of which tested negative in the novel assays.

Hypothetically, near-simultaneous infection with wild-type YFV and vaccination may occur in the outbreak setting in Brazil. In the case of co-occurrence of vaccine and wild-type YFV within a single sample, 1 target may occur in relatively higher concentrations than, and thus outcompete amplification of, the other target, resulting in an incomplete test result. We observed no target competition with the dual-target assay even in the presence of high concentrations of the heterologous RNA (Figure 2, panel A). In contrast, the single-target assay showed decreased sensitivity at [less than or equal to] 1,000 copies/reaction upon the presence of 100-500-fold higher concentrations of the heterologous target.

Commonly used clinical specimens for YFV diagnostics may contain substances that can interfere with PCR (13). To assess our assays' performance in different clinical matrices, we used human plasma and urine previously tested negative for YFV and spiked them with [10.sup.1]-[10.sup.6] copies/mL of either vaccine or wild-type YFV. Three replicates of each spiked specimen were purified individually and tested by using our PCRs and a YFV reference assay (13). We detected samples containing [greater than or equal to] 1,000 copies/mL in all replicates irrespective of the clinical matrix (Figure 2, panel B). Detection of samples containing [less than or equal to] 100 copies/ mL was unreliable in all 3 assays. As exemplified before for Zika virus, final RNA copy numbers in eluates used for RT-PCR will depend on the RNA extraction protocol, illustrating that even assays with analytical sensitivity in the single-copy range may not correctly detect weakly positive clinical specimens (12).

Clinical specimens may differ from spiked materials, and assay performance needs to be assessed in an outbreak context. Therefore, we compared the new assays to the reference assay (13) in a Brazilian flavivirus reference laboratory, using different clinical specimens obtained from 11 YF cases previously confirmed by nucleotide sequencing as wild-type YFV infections. The sensitivity of the dual-target assay was identical to that of the reference assay, whereas the single-target assay was slightly less sensitive (Figure 2, panel C). Identification of wild-type YFV was reliable in all cases, consistent with specific detection of lineages even in highly positive clinical specimens.

Conclusions

The new PCRs we describe enable YFV detection with diagnostic sensitivity. The dual-target assay was superior to the single-target assay in sensitivity and robustness to target competition. However, the single-target assay may be advantageous in resource-limited settings and may be more convenient for multiplex usage in combination with assays targeting co-circulating arboviruses, such as chikungunya, Zika, and dengue viruses. Beyond rapid test results, the real-time RT-PCR-based protocols provide considerably higher sensitivity than protocols aiming at generating longer PCR amplicons necessary for strain discrimination by nucleotide sequencing, enabling conclusive results even when virus concentrations in specimens are low or when these materials are available only in limited quantity. Of note, PCR-based YFV detection is most reliable 5-7 days after symptom onset, during the viremic phase. Reliable YFV surveillance should thus include serologic methods. However, serologic tests used for virologic diagnostics cannot discriminate between vaccination and wild-type YFV infection.

Of note, our novel assays are limited to vaccine and American YFV wild-type strains. West African wild-type stains would be detected by our YFV vaccine assays due to the close genetic relatedness between these strains, but our assays are not suitable to detect the genetically diverse Eastern and Central African wild-type strains. If needed, one could extend our assays by an additional primer/probe combination targeting the Eastern and Central African genotypes.

Recently, the first attenuated live dengue virus vaccine was approved in several countries, including Brazil (14). Inactivated Japanese encephalitis virus vaccines are currently replaced by attenuated live vaccines in Asia (15), and an attenuated live West Nile virus vaccine has completed a phase II clinical trial (16). Largescale deployment of these vaccines will raise the need to discriminate between potential vaccination-associated events and wild-type virus infection in symptomatic patients. Our work with YFV may provide a diagnostic blueprint for establishing and validating suitable methods for differentiating between vaccine and wild-type viruses for these other viruses as well.

Acknowledgments

We thank Monika Eschbach-Bludau, Janett Wieseler, and Tobias Bleicker. Positive controls for reaction control and quantification are available at the EVAg portal (https://www.european-virusarchive.com).

This work was partially supported by the European Union's Horizon 2020 research and innovation program (ZIKAlliance, grant agreement no. 734548; EVAg, grant agreement no. 653316; Zikaplan, grant agreement no. 734584); the German Centre for Infection Research through the ZIKApath project; the Faperj (Fundacao de Amparo a Pesquisa do estado do Rio de Janeiro, grant no. E-18/2015TXB); and the Secretaria de Vigilancia em Saude/Coordenacao Geral de Laboratorios de Saude Publica/ Ministerio da Saude do Brasil.

Mr. Fischer is a PhD student at the Institute of Virology of the University of Bonn Medical Centre and the German Centre for Infection Research. His main research interests are diagnostics of emerging arboviruses.

References

(1.) Gardner CL, Ryman KD. Yellow fever: a reemerging threat. Clin Lab Med. 2010;30:237-60. http://dx.doi.org/10.1016/j.cll.2010.01.001

(2.) Beasley DW, McAuley AJ, Bente DA. Yellow fever virus: genetic and phenotypic diversity and implications for detection, prevention and therapy. Antiviral Res. 2015;115:48-70. http://dx.doi.org/10.1016j.antviral.2014.12.010

(3.) Bryant JE, Holmes EC, Barrett AD. Out of Africa: a molecular perspective on the introduction of yellow fever virus into the Americas. PLoS Pathog. 2007;3:e75. http://dx.doi.org/10.1371/ journal.ppat.0030075<jrn>

(4.) Ministerio da Saude Brazil. Informe especial febre amarela no Brasil No. 01/2017: Ministerio da Saude 2017 [cited 2017 Sep 1]. http://portalarquivos.saude.gov.br/images/pdf/2017/marco/18/ Informe-especial-COES-FA.pdf

(5.) Bonaldo MC, Gomez MM, Dos SantosAA, Abreu FVS, Ferreira-de-Brito A, Miranda RM, et al. Genome analysis of yellow fever virus of the ongoing outbreak in Brazil reveals polymorphisms. Mem Inst Oswaldo Cruz. 2017;112:447-51. http://dx.doi.org/10.1590/0074-02760170134

(6.) World Health Organization. WHO dispatched 3.5 million doses of yellow fever vaccine for outbreak response in Brazil. 2017 30 March 2017 [cited 2017 Aug 30]. http://www.who.int/csr/disease/ yellowfev/vaccination-in-Brazil/en/

(7.) de Melo AB, da Silva MP, Magalhaes MC, Gonzales Gil LH, Freese de Carvalho EM, Braga-Neto UM, et al. Description of a prospective 17DD yellow fever vaccine cohort in Recife, Brazil. Am J Trop Med Hyg. 2011;85:739-47. http://dx.doi.org/10.4269/ ajtmh.2011.10-0496

(8.) Thomas RE. Yellow fever vaccine-associated viscerotropic disease: current perspectives. Drug Des Devel Ther. 2016;10:3345-53. http://dx.doi.org/10.2147/DDDT.S99600

(9.) Monath TP, Vasconcelos PF. Yellow fever. J Clin Virol. 2015;64:160-73. http://dx.doi.org/10.1016/j.jcv.2014.08.030

(10.) Boyd AT, Dombaxe D, Moreira R, Oliveira MS, Manuel E, Colorado CN, et al. Notes from the field: investigation of patients testing positive for yellow fever viral RNA after vaccination during a mass yellow fever vaccination campaign--Angola, 2016. MMWR Morb Mortal Wkly Rep. 2017;66:282-3. http://dx.doi.org/10.15585/mmwr.mm6610a5

(11.) Simmonds P SSE: a nucleotide and amino acid sequence analysis platform. BMC Res Notes. 2012;5:50-9. http://dx.doi.org/10.1186/1756-0500-5-50

(12.) Corman VM, Rasche A, Baronti C, Aldabbagh S, Cadar D, Reusken CB, et al. Assay optimization for molecular detection of Zika virus. Bull World Health Organ. 2016;94:880-92. http://dx.doi.org/10.2471/BLT.16.175950

(13.) Domingo C, Patel P, Yillah J, Weidmann M, Mendez JA, Nakoune ER, et al. Advanced yellow fever virus genome detection in point-of-care facilities and reference laboratories. J Clin Microbiol. 2012;50:4054-60. http://dx.doi.org/10.1128/ JCM.01799-12

(14.) World Health Organization. Dengue vaccine: WHO position paper--July 2016. Wkly Epidemiol Rec. 2016;91:349-64.

(15.) Hegde NR, Gore MM. Japanese encephalitis vaccines: Immunogenicity, protective efficacy, effectiveness, and impact on the burden of disease. Hum Vaccin Immunother. 2017;13:1320-1337. http://dx.doi.org/10.1080/21645515.2017.1285472

(16.) Dayan GH, Bevilacqua J, Coleman D, Buldo A, Risi G. Phase II, dose ranging study of the safety and immunogenicity of single dose West Nile vaccine in healthy adults [greater than or equal to] 50 years of age. Vaccine. 2012;30:6656-64. http://dx.doi.org/10.1016/j.vaccine.2012.08.063

Addresses for correspondence: Ana Maria Bispo de Filippis, Laboratorio de Flavivirus, Instituto Oswaldo Cruz, Pavilhao Helio e Peggy Pereira, Avenida Brasil, 4365, Manguinhos-Rio de Janeiro, Brazil; email: abispo@ioc.fiocruz.br; Jan Felix Drexler, Helmut-Ruska-Haus, Institute of Virology, Campus Charite Mitte, Chariteplatz 1, 10117 Berlin, Germany; email: felix.drexler@charite.de

Carlo Fischer, [1] Maria C. Torres, [1] Pranav Patel, Andres Moreira-Soto, Ernest A. Gould, Remi N. Charrel, Xavier de Lamballerie, Rita Maria Ribeiro Nogueira, Patricia C. Sequeira, Cintia D.S. Rodrigues, Beate M. Kummerer, Christian Drosten, Olfert Landt, Ana Maria Bispo de Filippis, Jan Felix Drexler

Author affiliations: University of Bonn Medical Centre, Bonn, Germany (C. Fischer, A. Moreira-Soto, B.M. Kummerer); German Centre for Infection Research (DZIF) (C. Fischer, C. Drosten, J.F. Drexler); Instituto Oswaldo Cruz, Rio de Janeiro, Brazil (M.C. Torres, R.M.R. Nogueira, P.C. Sequeira, C.D.S. Rodrigues, A.M.B. de Filippis); TIB MOLBIOL Syntheselabor GmbH, Berlin, Germany (P. Patel, O. Landt); Charite--Universitatsmedizin Berlin, corporate member of Freie Universitat Berlin, Humboldt-Universitat zu Berlin, and Berlin Institute of Health, Institute of Virology, Germany (A. Moreira-Soto, C. Drosten, J.F. Drexler); Aix-Marseille University, Marseille, France (E.A. Gould, R.N. Charrel, X. de Lamballerie); Institut Hospitalo Universitaire Mediterranee-Infection, Marseille (R.N. Charrel, X. de Lamballerie)

DOI: https://doi.org/10.3201/eid2311.171131

[1] These authors contributed equally to this article.

Caption: Figure 1. Design of new real-time RT-PCRs for differentiation between vaccine and wild-type YFV. A) YFV genomic representation (GenBank accession no. DQ100292) with real-time RT-PCR target sites, indicated by arrowheads, and identity plot of all complete YFV sequences available in GenBank as of May 24, 2017. Plots were done in SSE version 1.2 (11) using a sliding window of 200 and a step size of 40 nt. Target sites of the eventually selected assays are indicated by filled arrowheads; all other designed assays excluded after preliminary testing by open arrowheads. Of the real-time RT-PCR assays developed in this study, 1 assay targets only 1 genomic region, whereas the other assay targets 2 different genomic regions of vaccine and wild-type YFV strains. Both PCRs are duplex assays in which vaccine and wild-type YFV RNA are detected by lineage-specific probes. We called the assay targeting only 1 genomic region a single-target assay and the assay targeting 2 separate genomic regions a dual-target assay, even though the term dual-target commonly refers to detection of 2 different genes of a single pathogen, which is not the case in this study. B) Alignment of real-time RT-PCR oligonucleotide binding sites with YFV 17DD and American wild-type strains. The 100% consensus sequences were generated in Geneious (Biomatters Ltd., Auckland, New Zealand) and mapped to respective PCR primers and probes. Potential nucleotide mismatches are indicated by asterisks. D = A/G/T, M = A/C, R = A/G, W = A/T, Y = C/T. Black indicates a mismatch with all American wild-type strains, gray a mismatch with some American wild-type strains, based on the complete genetic information of American YFV strains and YFV vaccine strains available in GenBank as of March 24, 2017. C, capsid; E, envelope; Fwd, Forward; NS, nonstructural protein; prM, precursor membrane; Rev, reverse; RT-PCR, reverse transcription PCR; UTR, untranslated region; YFV, yellow fever virus.

Caption: Figure 2. Validation of new real-time RT-PCRs for differentiation between vaccine and wild-type YFV. A) Effects of target competition on YFV real-time RT-PCRs. Mean cycle threshold (Ct) values are plotted against IVT concentrations. Triplicates were tested for each datum point. B) Validation of the assays with clinical matrices. Spiked viruses were vaccine strain 17D and the American genotype 2 wild-type strain BOL88/1999. RNA purification was performed using the MagNA Pure 96 Viral NA Small Volume Kit (Roche, Basel, Switzerland) according to the manufacturer's instructions. C) Clinical validation. Clinical specimens (serum, liver, whole blood, and plasma) from 11 YFV-infected patients were tested. RNA was extracted using the MagMAX Pathogen RNA/DNA Kit (Thermo Fisher, Sao Paulo, Brazil) and serial dilutions of the RNA were tested using the new assays and a YFV reference assay (12). Viral loads were determined for clinical specimens using a commercially available quantitative real-time RT-PCR (Bio Gene Research Yellow Fever PCR kit; Bioclin, Minas Gerais, Brazil), following the manufacturer's instructions. Standard curves and sample copies per millileter were calculated using an in-house IVT standard. IVT, in vitro transcript; RT-PCR, reverse transcription PCR; YFV, yellow fever virus.
Table. Oligonucleotides for new yellow fever virus real-time RT-PCRs *

                           Primer/         Sequence, 5' [right arrow]
Oligonucleotide name   probe ([dagger])       3' ([double dagger])

Single-target assay
  YFVsingle-fwd             Primer           GTGGAGRAGCAGRGCRGATGAG
  YFVsingle-rv              Primer            AAHGGRTGWGTYCCTCTCTGR
  YFVsingleP-vac         Probe (FAM)      TTCTGTTGTCGTGCAGGATCCAAAGAATG
  YFVsingleP-wt          Probe (YAK)      TAGAYATYTCAGTGGTGGTYCAAGACY C

Dual-target assay
  YFVdual-fwd-vac           Primer            GGGACTAGCGTGATCATTGA
  YFVdual-rv-vac            Primer           GAATAACTTTCCCGCTATCCGT
  YFVdualP-vac           Probe (FAM)          TCCCCGTCCATCACAGTTGCC
  YFVdual-fwd-wt            Primer           CAATGCCATYCTTGAGGAGAAT
  YFVdual-rv-wt             Primer             CGGATGTGTCCCTCTCTG
  YFVdualP-wt            Probe (YAK)       TCTTGRACCACCACTGAGATGTCTACC

                         Target
                         genomic
                       domain, no.
Oligonucleotide name      bases      Orientation

Single-target assay
  YFVsingle-fwd        2,653-2,674        +
  YFVsingle-rv         2,743-2,763        -
  YFVsingleP-vac       2,710-2,738        +
  YFVsingleP-wt        2,703-2,730        +

Dual-target assay
  YFVdual-fwd-vac      3,296-3,315        +
  YFVdual-rv-vac       3,356-3,377        -
  YFVdualP-vac         3,317-3,337        -
  YFVdual-fwd-wt       2,677-2,698        +
  YFVdual-rv-wt        2,744-2,761        -
  YFVdualP-wt          2,701-2,727        -

* 25 [micro]L real-time RT-PCR reactions were performed using the
Superscript III one-step RT-PCR system with Platinum Taq polymerase
(Thermo Fisher Scientific, Darmstadt, Germany). Target genomic domain
positions according to GenBank reference genome NC_002031. Reactions
were set up with 5 [micro]L of RNA; 12.5 [micro]L of 2 x reaction
buffer; 0.4 [micro]L of a 50 mM magnesium sulfate solution
(Superscript III one-step RT-PCR system with Platinum Taq polymerase
kit, Thermo Fisher Scientific); 1 [micro]g of nonacetylated bovine
serum albumin; and 1 [micro]L enzyme. Single-target assay reactions
contained 400 nM forward primer, 600 nM reverse primer, and 280 nM of
each probe. Dual-target assay reactions contained 400 nM of each
primer and 220 nM of each probe. RT-PCR.

([dagger]) Probes are labeled with either fluorescein amidite (FAM)
or Yakima Yellow (YAK) at the 5'/end and a Black Hole Quencher (TIB
MOLBIOL Syntheselabor GmbH, Berlin, Germany) at the 3'/end. Primer
concentrations were optimized using the YFV vaccine strain IVT and
the wild/type YFV IVT. Amplification involved 50[degrees]C for 15
min, followed by 95[degrees]C for 3 min and 45 cycles of 95[degrees]C
for 15 s and 58[degrees]C for 30 s with fluorescence read at the
58[degrees] annealing/extension step on a LightCycler 480
thermocycler (Roche, Basel, Switzerland).

([double dagger]) H = A/C/T, M = A/C, R = A/G, W = A/T, Y = C/T.
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Title Annotation:DISPATCHES
Author:Fischer, Carlo; Torres, Maria C.; Patel, Pranav; Moreira-Soto, Andres; Gould, Ernest A.; Charrel, Re
Publication:Emerging Infectious Diseases
Geographic Code:3BRAZ
Date:Nov 1, 2017
Words:3042
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