Norovirus Variant GII.4/Sydney/2012, Bangladesh

To the Editor: Noroviruses (NoVs) are the most common cause of foodborne and waterborne outbreaks of gastroenteritis in persons from all age groups in industrialized and developing countries (1). Although NoV outbreaks occur throughout the year, activity increases in the winter months, especially in the countries with a temperate climate. As expected, during the last few months of 2012, outbreaks of NoV gastroenteritis markedly increased in Europe and the United States (2–4). These increases corresponded with the emergence of a variant of genotype GII.4, Sydney/2012, which was first reported from Australia in March 2012 and, subsequently, in the United States, Belgium, Denmark, Scotland, and Japan (2,5–7). 
 
We identified the NoV GII.4 variant Sydney/2012 through hospital surveillance on diarrhea etiology in Bangladesh in December 2011 and then throughout 2012. These strains came from 3 hospitals in Dhaka, Matlab, and Mirzapur, where ≈150,000 patients with diarrhea are treated annually. We randomly selected 795 fecal specimens from patients of all ages who sought treatment for diarrhea in these hospitals during 2010–2012 and detected NoV RNA in 90 (33.6%), 72 (27.9%), and 92 (34.2%) samples in 2010, 2011, and 2012, respectively, by performing real-time PCR (8). For characterization, we amplified and sequenced 108 samples on the basis of the capsid genes (9). 
 
Ages of diarrhea patients with NoV infection ranged from 1 month to 91 years (median 15 months; mean 11.9 years). Most (66%) NoV-positive patients were 18 years of age). NoVs were detected throughout the year, and no clear seasonal peaks were observed. 
 
Overall, GII was the most predominant genogroup (66.1%), followed by GI (18.1%) and GIV (3.9%). Mixed infections were detected in 11.8% of samples. We observed a high diversity in the GII genogroup and identified at least 11 different genotypes within the group, in which GII.4 constituted 30.1% of all GII strains. Until December 2011, the GII.4 variant NewOrleans/2009 was the most predominant strain (Figure). However, the new GII.4 variant, Sydney/2012, replaced the old variant and appeared as the dominant strain in 2012. We constructed a phylogenetic tree on the basis of 1,026 bases around the junction region of pol and cap genes, and it revealed that the newly identified variant has evolved from previous NoV GII.4 variants Apeldoorn/2007 and NewOrleans/2009 (data not shown). 
 
 
 
Figure 
 
Distribution of 108 norovirus (NoV) genotypes in Bangladesh, 2010–2012. Bar chart shows the percentage of NoV genotypes. Mixed genotypes comprise NoV GI and GII. GI comprises GI.1, GI.3, GI.4, GI.5, and GI.9. GII.others comprises GII.2, GII.3, ... 
 
 
 
NoVs, old and new, remain a substantial threat to human health, with a new variant emerging every 2–3 years. The Sydney/2012 strain appears to have replaced the previously predominant strain, but its clinical effects and epidemiology are largely unknown and warrant further investigation.


Norovirus Variant GII.4/Sydney/2012, Bangladesh
To the Editor: Noroviruses (NoVs) are the most common cause of foodborne and waterborne outbreaks of gastroenteritis in persons from all age groups in industrialized and developing countries (1). Although NoV outbreaks occur throughout the year, activity increases in the winter months, especially in the countries with a temperate climate. As expected, during the last few months of 2012, outbreaks of NoV gastroenteritis markedly increased in Europe and the United States (2)(3)(4). These increases corresponded with the emergence of a variant of genotype GII.4, Sydney/2012, which was first reported from Australia in March 2012 and, subsequently, in the United States, Belgium, Denmark, Scotland, and Japan (2,5-7).
We identified the NoV GII.4 variant Sydney/2012 through hospital surveillance on diarrhea etiology in Bangladesh in December 2011 and then throughout 2012. These strains came from 3 hospitals in Dhaka, Matlab, and Mirzapur, where ≈150,000 patients with diarrhea are treated annually. We randomly selected 795 fecal specimens from patients of all ages who sought treatment for diarrhea in these hospitals during 2010-2012 and detected NoV RNA in 90 (33.6%), 72 (27.9%), and 92 (34.2%) samples in 2010, 2011, and 2012, respectively, by performing real-time PCR (8). For characterization, we amplified and sequenced 108 samples on the basis of the capsid genes (9).
Ages of diarrhea patients with NoV infection ranged from 1 month to 91 years (median 15 months; mean 11.9 years). Most (66%) NoV-positive patients were <5 years of age. Infection rates were lowest in patients <3 months (2.1%) and 5-18 years (2.5%) of age. A high number of NoV infections were recorded in adults (28.8% in patients >18 years of age). NoVs were detected throughout the year, and no clear seasonal peaks were observed.
Overall, GII was the most predominant genogroup (66.1%), followed by GI (18.1%) and GIV (3.9%). Mixed infections were detected in 11.8% of samples. We observed a high diversity in the GII genogroup and identified at least 11 different genotypes within the group, in which GII.4 constituted 30.1% of all GII strains. Until December 2011, the GII.4 variant NewOrleans/2009 was the most predominant strain (Figure). However, the new GII.4 variant, Sydney/2012, replaced the old variant and appeared as the dominant strain in 2012. We constructed a phylogenetic tree on the basis of 1,026 bases around the junction region of pol and cap genes, and it revealed that the newly identified variant has evolved from previous NoV GII. 4 variants Apeldoorn/2007 and NewOrleans/2009 (data not shown).
NoVs, old and new, remain a substantial threat to human health, with a new variant emerging every 2-3 years. The Sydney/2012 strain appears to have replaced the previously predominant strain, but its clinical effects and epidemiology are largely unknown and warrant further investigation. To the Editor: Noroviruses (NoVs) are the major cause of acute gastroenteritis in children and adults; they are responsible for sporadic cases and outbreaks of gastroenteritis in various epidemiologic settings. NoVs can be classified genetically into at least 5 genogroups, GI to GV (1). Although >30 genotypes within genogroups GI, GII, and GIV can infect humans (2), a single genotype, GII.4, has been associated with most NoV-related outbreaks and sporadic cases of gastroenteritis worldwide (3).
GII.4 NoV strains continuously undergo genetic/antigenic diversification and periodically generate novel strains through accumulation of punctate mutations or recombination. New GII.4 variants emerge every 2-3 years (4). Increased incidence of NoV-related illness and/or outbreaks in various countries in late 2012 has been related to the emergence of a novel GII.4 variant, Sydney 2012. This variant was first identified in March 2012 in Australia (5).