This patent application claims the benefit and priority of the Chinese Patent Application No. 202311074921.8 filed with the China National Intellectual Property Administration on Aug. 24, 2023, and the Chinese Patent Application No. 202311481600.X filed with the China National Intellectual Property Administration on Nov. 9, 2023, the contents of which are incorporated by reference herein in its entirety as part of the present application.
A computer readable XML file entitled “GWP20240200991_sequence listing.xml”, which was created on Mar. 26, 2024 with a file size of about 20,625 bytes, contains the sequence listing for this application, has been filed with this application, and is hereby incorporated by reference in its entirety.
Microorganism Deposit
Exemplary microorganism of the disclosure Coxsackievirus CVA6-KM-J33 was deposited on Aug. 6, 2023 with the China Center for Type Culture Collection (CCTCC), as accession number CCTCC NO. V202384 under the Budapest Treaty. This deposit will be maintained at an authorized depository and replaced in the event of mutation, nonviability or destruction for a period of at least five years after the most recent request for release of a sample was received by the depository, for a period of at least thirty years after the date of the deposit, or during the enforceable life of the related patent, whichever period is longest. All restrictions imposed by the depositor on the availability to the public of the deposited material will be irrevocably removed upon the granting of the patent.
The present disclosure belongs to the technical field of biomedicine, and specifically relates to a Coxsackie virus A6 (CVA6) strain CVA6-KM-J33 and use thereof.
Hand-foot-mouth disease (HFMD) in children is a viral infectious disease that has been emerging in children in different regions around the world, especially in the Asia-Pacific region over the past 20 years. Since 2000, the incidence rate of HFMD has been concentrated in East Asia, and the cases of severe HFMD mainly manifesting neurological clinical symptoms account for about 1.5% to 2%. Some of the sick children have developed neurogenic pulmonary edema and even died due to damage to the cardiovascular system in a short period of time caused by damage to the nervous system. The HFMD thus poses a serious public health problem.
Research on the etiology of HFMD shows that this disease can be caused by a variety of human enteroviruses. Among them, in addition to enterovirus EV71, the main pathogens are Coxsackievirus A16 (CVA16) and Coxsackievirus A6 (CVA6). Sample surveys in most areas of China since 2013 have shown that the proportion of cases caused by CVA6 in the total incidence of children is about not less than 35% to 39% of the total number of cases [1-9]. Due to the application of EV71 and CVA6 vaccines, the proportion of patients caused by CVA6 has gradually increased in various regions. At the same time, clinical and epidemiological analysis of CVA6 infection cases also suggests that the proportion of severe cases has also increased among CVA6 infection patients. Therefore, it is extremely necessary to screen out a CVA6 strain with desirable neutralizing ability, genetic stability, and strong virulence.
CVA6 virus is an enterovirus and has similar structural characteristics to those of the EV71 and CVA16. As members of the genus Picornavirus, antigenic composition patterns of the above three viruses are also highly similar. All three viruses encode four structural proteins VP1, VP2, VP3, and VP4. Moreover, a capsid composed of three of these proteins works on the immune system to induce a complete immune response. Enteroviruses that cause HFMD mainly include four types: EV-A, EV-B, EV-C, and EV-D. The Coxsackievirus A6 (CVA6) strain belongs to an enterovirus group A that has a total of 16 subtypes, including 11 subtypes A and 5 subtypes B. According to different genotypes, the CVA6 is divided into five branches A to E. Currently, all CVA6 epidemic strains worldwide belong to type D, which are divided into subtypes D1, D2, and D3. The D3 subtype can be further subdivided into types D3a and D3b.
At present, the pathogenesis of HFMD is still unclear, and particularly the pathogenic mechanism of CVA6 has not been reported, making the screening of anti-CVA6 drugs and vaccines of great significance. In addition, since mice are generally less susceptible to clinically isolated strains, only a few clinically isolated viruses can infect mice. Accordingly, it is also of great significance to screen strains that can be used to construct animal models of CVA6 infection.
An objective of the present disclosure is to provide a CVA6 strain CVA6-KM-J33 and use thereof. The CVA6 strain CVA6-KM-J33 has desirable cross-neutralizing ability, genetic stability, and strong virulence.
The present disclosure provides a CVA6 strain CVA6-KM-J33 with a deposit number of CCTCC NO. V202384 in the China Center for Type Culture Collection (CCTCC).
Preferably, a VP1 structural protein of the CVA6 strain CVA6-KM-J33 has the amino acid sequence set forth in SEQ ID NO:10.
The present disclosure further provides a propagation and passage method for the CVA6 strain CVA6-KM-J33, including conducting propagation and passage using a human diploid cell as a stromal cell.
Preferably, the human diploid cell includes a human embryonic lung diploid cell KMB17.
Preferably, the human embryonic lung diploid cell KMB17 is infected with the CVA6 strain CVA6-KM-J33 and then cultured at 37° C. under 5%+ CO2.
The present disclosure further provides a biological agent prepared using a genomic RNA of the CVA6 strain CVA6-KM-J33.
Preferably, the genomic RNA has the nucleotide sequence set forth in SEQ ID NO: 11.
The present disclosure further provides an antiserum against a CVA6 strain, where a preparation process of the antiserum includes injecting the CVA6 strain CVA6-KM-J33 into an animal and collecting serum of the animal to obtain the antiserum.
The present disclosure further provides a vaccine or a medicament for preventing and/or treating a CVA6 strain-caused disease, where an active ingredient of the vaccine or the drug includes the biological agent or the antiserum.
The present disclosure further provides the use of an inactivated strain of the CVA6 strain CVA6-KM-J33 as a drug delivery medium.
Beneficial effects: the present disclosure provides a CVA6 strain CVA6-KM-J33, which belongs to CVA6 virus. In the present disclosure, the strain CVA6-KM-J33 is isolated from Vero cells, amplified for 3 generations, and then inoculated on KMB17 cells for adaptive passage. The strain is susceptible to KMB17 cells and can achieve a relatively high titer. The strain has strong virulence, high pathogenicity and lethality to suckling mice, and desirable immunogenicity, and is a highly effective virus strain. This strain can be used for immunogenicity evaluation or protective evaluation of CVA6 vaccine to improve the accuracy and reproducibility of vaccine immunogenicity evaluation. This strain can also be used to prepare animal models of Coxsackievirus (CV) infection and exhibits desirable application prospects.
Deposit of Biological Material
The CVA6 strain CVA6-KM-J33 was deposited at the CCTCC on Aug. 6, 2023, in Wuhan University, Wuhan, China, with a deposit number of CCTCC NO. V202384.
The present disclosure provides a CVA6 strain CVA6-KM-J33 with a deposit number of CCTCC NO. V202384 in the CCTCC.
In the present disclosure, the strain CVA6-KM-J33 is isolated from Vero cells, amplified for 3 generations and then inoculated on KMB17 cells for adaptive passage. This strain is susceptible to KMB17 cells and can achieve a relatively high titer. This strain has strong virulence, high pathogenicity and lethality to suckling mice, and desirable immunogenicity, and is a highly effective virus strain.
In the present disclosure, a VP1 structural protein of the CVA6 strain CVA6-KM-J33 has the amino acid sequence shown in SEQ ID NO: 10, indicating that this strain belongs to a CVA6 virus.
The present disclosure further provides a propagation and passage method of the CVA6 strain CVA6-KM-J33, including conducting propagation and passage using a human diploid cell as a stromal cell.
In the present disclosure, the human diploid cell preferably includes a human embryonic lung diploid cell KMB17. The human embryonic lung diploid cell KMB17 is a human-derived cell line independently developed and established by the Institute of Medical Biology, Chinese Academy of Medical Sciences. Preferably, the human embryonic lung diploid cell KMB17 is infected with the CVA6 strain CVA6-KM-J33 and then cultured at 37° C. under 5% CO2. Under the culture conditions, cytopathic effect is observed in not less than 75% of the cells within 72 h to 96 h.
The present disclosure further provides a biological agent prepared using a genomic RNA of the CVA6 strain CVA6-KM-J33.
In the present disclosure, the biological agent preferably includes any one of the following items:
In the present disclosure, the animal model is preferably based on mice, such as Balb/c mice to establish the animal model. The genomic RNA has the nucleotide sequence preferably set forth in SEQ ID NO: 11.
The present disclosure further provides an antiserum against a CVA6 strain, where a preparation process of the antiserum includes injecting the CVA6 strain CVA6-KM-J33 into an animal and collecting a serum of the animal to obtain the antiserum.
In the present disclosure, there is no special limitation on the type of the animal, and animals for conventional antiserum preparation in this field can be used.
The present disclosure further provides a vaccine or a drug for preventing and/or treating a CVA6 strain-caused disease, where an active ingredient of the vaccine or the drug includes the biological agent or the antiserum.
In the present disclosure, the CVA6 strain can produce immune effects through multiple immune routes, such as intradermal, intramuscular, and intradermal routes. After immunizing mice, the antibody titer can reach up to 1:1024, showing desirable immunogenicity, and can be used to prepare virus-free vaccines.
The present disclosure further provides the use of an inactivated strain of the CVA6 strain CVA6-KM-J33 as a drug delivery medium.
In the present disclosure, the CVA6 strain CVA6-KM-J33 has desirable infectivity and can be used as a drug delivery medium for drug delivery after inactivation.
To further illustrate the present disclosure, the CVA6 strain CVA6-KM-J33 and the use thereof provided by the present disclosure are described in detail below in combination with examples, but these examples should not be construed as limiting the claimed scope of the present disclosure.
1. Processing of clinical samples: anal swab samples were collected from children diagnosed with HFMD by the Yunnan Provincial Center for Disease Control and Prevention into 15 mL sterile centrifuge tubes, and 1 mL of 0.01 M PBS was added. The anal swab clinical specimen was fully oscillated with an oscillator, centrifuged at 4,000 rpm for 20 min, a supernatant was collected and an equal volume of chloroform was added, mixed repeatedly, centrifuged at 2,800 rpm for 15 min, and a supernatant was collected.
2. Virus isolation and culture: viruses were cultured and isolated on Vero cells, cultured statically at 37° C., 5% CO2, and observed continuously for 7 d. If cytopathic effect was observed in not less than 80% of the cells under the microscope, the virus fluid was collected. Passaging 3 times in this way could eliminate cell lesions caused by chloroform or other factors.
3. Virus harvesting and adaptive subculture in KMB17 cells: within 24 h to 48 h after KMB17 cell subculture, when the cell area approached 90%, the growth medium was discarded and the cells were washed once with PBS. After discarding the PBS, a serum-free maintenance solution was added to the cells, shaken gently, and then the maintenance solution was removed. An appropriate amount of the virus liquid was inoculated into the culture bottle, adsorbed at 37° C. for 1 h, an appropriate amount of the maintenance solution was added, and cultured at 37° C. When distinct cytopathic effect was observed in not less than 80% of the cells under a microscope, the culture bottle was frozen in a −30° C. refrigerator.
4. Virus identification: After 3 times of adaptive subculture, the virus liquid was obtained, and the harvested virus liquid was initially identified, including molecular biology identification (nucleic acid sequence determination and subtype analysis), research on cross-neutralization capabilities, and genome sequencing, so as to initially screen virus strains.
4.1. Molecular biology identification: RT-PCR was conducted to identify CVA6, CVA6-positive strains were subjected to VP1 nucleic acid sequence determination, and CVA6 genotyping was conducted based on the obtained VP1 nucleotide sequence.
1) The uploaded CV-A6 gene sequences in GenBank were selected as reference sequences (the reference sequences had gene accession numbers of MN845834.1 and MN845849.1, respectively), and the primers for the VP1 segment shown in Table 1 were designed using a Primer-BLAST primer design function in the National Center for Biotechnology Information (NCBI).
2) Viral nucleic acid was extracted using the AxyPrep body fluid viral DNA/RNA mini kit, and the VP1 fragment was amplified using the PrimeScript™ One Step RT-PCR Kit produced by Takara Bio (Dalian) Co., Ltd. The reaction conditions included: 50° C. for 30 min; 94° C. for 2 min; 35 cycles of 94° C. for 30 s, 50° C. for 30 s, and 72° C. for 1 min; and 72° C. for 10 min.
3) The target fragment was identified by 1% agarose gel electrophoresis and sent to Shanghai Sangon Biotech Co., Ltd. for sequencing. Germline evolution analysis was performed using MEGA5.0 software.
A target band with a size of 914 bp was observed in the positive sample using CVA6 VP1-specific primers, but no bands appeared in the amplification using EV71 and CA16 primers again, as shown in
4.3. Establishment of candidate strains for neutralizing antibody detection: validation of CVA6-KM-J33 was conducted. The results showed that this strain only had a specific neutralizing ability against the immune serum of CVA6, but had no cross-reactivity against the immune serum of other enteroviruses such as EVA71, CVA10, and CVA16, as shown in
1. Crude Purification for Virus Liquid of CVA6 Reference Strain
Vero cells were inoculated in a culture bottle. When the cell area was inoculated close to 90%, an appropriate amount of CVA6 reference strain GS2015-399 (from the Institute of Viral Disease Prevention and Control, Chinese Center for Disease Control and Prevention) was inoculated and placed in a 37° C. 5% CO2 incubator for adsorption for 1 h, added with an appropriate amount of serum-free maintenance solution, and cultured statically until cytopathic effect was observed in not less than 80%, and the virus liquid was harvested. The 15-399 virus harvest solution was centrifuged at 100,000×g for 4 h at 4° C., resuspended in 0.01 M PBS, extracted once with ½ volume of chloroform, centrifuged at 2,800 rpm for 20 min at room temperature, and a supernatant was collected to obtain crudely purified virus liquid.
2. Preparation of Standard Serum
During primary immunization, the 15-399 crude virus solution and a Freund's complete adjuvant were thoroughly mixed at a volume of 1:1, and injected subcutaneously at multiple points to immunize Japanese big-eared rabbits, 1 mL/rabbit. 28 d after the primary immunization, the crude virus liquid and an equal volume of Freund's incomplete adjuvant were fully mixed to allow booster immunization 4 times, while the control group was injected with an equal dose of PBS, and the growth of rabbit was continuously observed and recorded. Blood was collected from the car vein on the 28th day after the primary immunization and the 14th day after the booster immunization, and the neutralizing antibodies in the isolated serum had a titer of 1:2048 to 1:8192.
3. Negative Serum
The serum isolated from Japanese big-eared rabbits that had not been immunized with virus fluid and collected from the car vein was used as the negative serum used in the identification experiment.
1. A virus dilution of the initially screened virus strain in Example 1 was inoculated into a 6-well cell culture plate for purification.
1.1 Cell preparation: KMB17 cells were inoculated in a 6-well plate in advance and cultured. When the monolayer became dense, the original medium was discarded, the cell surface was washed, and residual bovine serum and dead cells were removed by washing.
1.2 Virus preparation: the virus liquid was diluted at appropriate times.
1.3 Virus adsorption: the virus was inoculated into a 6-well plate, 0.4 mL/well, while a cell control was set up, the two groups were placed in a 5% CO2 incubator at 37° C. to allow adsorption for 1 h to 2 h, where the cell plate was gently shaken several times every 15 min to 20 min to allow the virus to contact the entire cell surface during the adsorption.
1.4 Covering and culture: the virus liquid was discarded after the adsorption was completed, and the virus maintenance solution was added into the virus control and cell control wells at 3 ml/well. A mixture of agarose and virus maintenance solution was added into the remaining wells along the wall at 3 mL/well, allowed to stand at room temperature for not less than 30 min to cool and solidify into a covering layer. The culture plate with agarose was placed upside down in a 5% CO2 incubator and cultured at 37±1° C., and the plaque status (morphology, size, and number) and cytopathic effect in the virus control were observed every day.
1.5 Plaque picking: when obvious plaques were seen under the microscope, a marker pen was used to mark the bottom of the 6-well plate at the corresponding position of the plaque; in a class II biosafety cabinet in the clean room, a 200 μL pipette was used to draw 20 μL of the mixed liquid at the marked position with the pipette tip under the liquid surface, and a total of 10 plaques of suitable size was selected.
1.6 Plaque culture: a 200 μL pipette tip with a filter element was used to select 10 single plaques into a 1.5 mL EP tube containing 100 μL of virus maintenance solution, pipetted and mixed repeatedly, inoculated into a 96-well cell culture plate where the cells have grown to a monolayer, cultured at 37±1° C. in a 5% CO2 incubator, and CPE was observed every day. When the CPE of the cells reached 75%, a supernatant was collected and stored in a −20° C. refrigerator, and 3 virus clones that could cause the fastest pathogenesis of KMB17 cells were selected. At this time, the virus passage was P2. In this way, plaque purification was done 3 times continuously.
2. Identification and analysis: the virus clones selected for the third time were amplified, and infectivity titer testing was conducted on the virus clones selected each time and the virus amplification fluid from the third spot pick.
2.1 Although each clone strain selected was from the same strain of virus, there were differences in infectivity titers between clone strains, and the difference range was within 1 lgCCID50/mL. In addition, the infectivity titers between clones increased with the rounds of plaque purification, and the infectivity titers of clones after the third plaque purification could reach a maximum of 6.25 lgCCID50/mL.
2.2 The nucleic acid electrophoresis bands of the 9 spot-picked samples were single and bright, with a size of about 914 bp, which was consistent with expectations (
The growth curve of strain CVA6-KM-J33 was observed on KMB17 cells, the virus liquid was harvested at 11 time points (0 h, 12 h, 24 h, 36 h, 48 h, 72 h, 96 h, 5 d, 6 d, 7 d, 8 d), and the infectious titer was measured detection. Virus titration: the infectivity titer of CVA6 was detected using the microcytopathy method and the virus growth characteristics were observed, and the results were calculated using Karber's formula:
6) the virus infectivity titer (lgCCID50/mL) was calculated according to the Karber's method, and the average was taken after 3 replicated tests.
Experimental results: as shown in
1-day-old SPF grade Balb/c suckling mice, 6 mice/group, were injected with different doses of CVA6-KM-J33 virus liquid via the intracerebral route while suckling mice in the control group were injected with equal doses of PBS. After 18 days of continuous observation, the growth, onset, and death of the suckling mice were recorded to evaluate the severity of the disease caused by the strain CVA6-KM-J33 at different doses. 3 infected suckling mice were sacrificed on days 3, 5, and 9 after infection, and their organs and tissues were collected for viral load detection. Histopathological examination (H&E staining) was conducted on the brain, lung, and heart tissues of suckling mice.
1. In this example, 1-day-old suckling mice were injected into the brain via the intracerebral route. The dosage groups were 104 CCID50/mouse, 105 CCID50/mouse, and 106 CCID50/mouse, while the control group suckling mice were given equal doses of PBS, with 6 mice in each group. Suckling mice began to become ill 3 days to 6 days after injection, and the latest onset time was the 6th day after injection. Compared with the control group, mice in different dose groups experienced varying degrees of morbidity and death. The symptoms of disease are shown in Table 2.
Clinical scores and mortality results are shown in
2. Detection of Viral Load in Organs of Suckling Mice Infected with Strain CVA6-KM-J33
In order to study the load and distribution of strain CVA6-KM-J33 in different organs of suckling mice in different stages at different doses, the viral load was measured 3, 5, and 9 days after intracerebral challenge.
2.1 Preparation of titer standard: CVA6 (CVA6-KM-J33) of known titer (7.0 lgCCID50/mL) was selected.
2.2 Extraction of total tissue RNA: 3 infected suckling mice in different dose groups of the intracerebral route were sacrificed on days 3, 5, and 9 after infection, their heart, liver, spleen, lung, kidney, brain, spinal cord, trigeminal nerve, and skeletal muscle where ground thoroughly, 0.01 g of tissue grinds were placed in 1.5 mL sterile centrifuge tubes, added with 0.01 M PBS to 1 mL, centrifuged at 9,000 rpm 4° C. for 10 min, and the supernatant after centrifugation was collected to extract viral nucleic acid by Trizol method to detect the viral load in each tissue.
2.3 qPCR system and reaction conditions: Following the instructions of the One-Step RT qPCR Kit (TAKARA/RR064), 4 μL of template was selected to allow one-step RT qPCR on a fluorescence quantitative PCR instrument (Biorad, CFX-96), where a total reaction system was 25 μL. The viral load (CCID50/10 mg) in the sample was absolutely quantified based on the standard curve. The qPCR probe and primer sequences, reaction procedures, and systems are shown below.
Primer Sequence
The reaction system included: 12.5 μL of 2× OnestepRT-PCRbuffer III, 0.5 μL of ExTaqHS, 0.5 μL of PrimeScriptRTEnzymeMixII, 5.5 μL of RNase Free ddH2O, 0.5 μL each of Primer F/R, 1 μL of Probe, and 4 μL of template.
Reaction parameters: 425 min; 9,510 s; 955 s, 6,030 s, 39 cycles.
The experimental results are shown in
3. Histopathological Examination of Suckling Mice after Immunization with CVA6 Strain CVA6-KM-J33
Histopathological examination of CVA6-KM-J33-immunized suckling mice: the pathology of the brain and lung tissues of suckling mice was observed, and organs were fixated in 10% neutral formalin for 48 h and then embedded in paraffin to make paraffin sections for H&E staining.
CVA6-KM-J33 intracerebral route: 1-day-old SPF grade Balb/c suckling mice infected at a dose of 106 CCID50/mouse were sacrificed, and brain and muscle (forelimbs and hindlimbs) tissues of the diseased suckling mice and the healthy suckling mice of the control group were collected on the 9th day after infection for histopathology. The H&E staining results are shown in
In order to explore the immune dose of CVA6-KM-J33 and the impact of different immune routes on the immune effect of CVA6-KM-J33, 3 immune routes of muscle, abdominal cavity, and intradermal were set up, and vaccination doses were: 9 different combinations of 104 CCID50/mouse, 105 CCID50/mouse, and 106 CCID50/mouse were used to immunize 6-week-old Balb/c mice.
The serum antibody titer test results showed that the neutralizing antibody seroconversion rates of mice in the 9 experimental groups on the 7th day after primary immunization were all lower than 50% (1:8 was regarded as a threshold for vaccine efficacy evaluation). As the days after infection increased, the serum neutralizing antibody seroconversion rates of mice in the medium-dose group and the high-dose group increased; on the 28th day after the primary immunization, the positive conversion rates of the intramuscular low-dose group, intraperitoneal low-dose group, intradermal low-dose group, and intramuscular medium-dose group were less than 100%, while the positive conversion rates of the other experimental groups all reached 100%. A booster immunization was carried out on the 28th day. On the 7th day after the booster immunization, except for the intramuscular low-dose group, intraperitoneal low-dose group, and intradermal low-dose group, the antibody-positive conversion rate of each experimental group increased to 100% (
Statistical analysis of the data showed that there was no statistically significant difference in the data of the muscle, intraperitoneal, and intradermal route immune groups in different dose groups (t=0.216, p=0.892), such that the data of the 9 experimental groups could be combined and analyzed. From the perspective of immunization time points, except for the low-dose group, the antibody levels of mice on the 7th day after booster immunization were significantly higher than those on the 28th day after the primary immunization (
Although the above example has described the present disclosure in detail, it is only a part of, not all of, the examples of the present disclosure. Other examples may also be obtained by persons based on the example without creative efforts, and all of these examples shall fall within the protection scope of the present disclosure.
Number | Date | Country | Kind |
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202311074921.8 | Aug 2023 | CN | national |
202311481600.X | Nov 2023 | CN | national |
Number | Date | Country |
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114807060 | Jul 2022 | CN |
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Feng et al., “A novel recombinant lineage's contribution to the outbreak of coxsackievirus A6-associated hand, foot and mouth disease in Shanghai, China, 2012-2013,” Scientific Reports, 5:11700, Jun. 30, 2015. |
He et al., “An emerging and expanding clade accounts for the persistent outbreak of Coxsackievirus A6-associated hand, foot, and mouth disease in China since 2013,” Virology, 518:328-334, 2018. |
Hu et al., “Six amino acids of VP1 switch along with pandemic of CV-A6-associated HFMD in Guangxi, southern China, 2010-2017,” J. of Infection, 78:323-337, 2019. |
Qiao et al., “Identification of recombinant coxsackievirus A6 variants in hand, foot and mouth disease in Nanjing, China, 2013,” J. of Medi. Microbiol., 67:1120-1129, 2018. |
Su et al., “Genome Sequence of a Human Coxsackievirus A6 Strain Isolated from a Severe Hand, Foot, and Mouth Disease Case in Qingdao, China, in 2017,” Amer. Soc. for Microbiol., 9(17):e01449-19, 2020. |
Tan et al., “Molecular epidemiology of coxsackievirus A6 associated with outbreaks of hand, foot, and mouth disease in Tianjin, China, in 2013,” Arch Virol., 160(4): 1097-1104, 2015. |
Xu et al., “Pathogenic characteristics of hand, foot and mouth disease in Shaanxi Province, China, 2010-2016,” Scientific Reports, 10:989, 2020. |
Zhang et al., “Continued Prevalence of Coxsackievirus A6 in Heilongjiang Province, China, from 2015 to 2018,” Chinese Journal of Virology, 36(2):201-206, 2020. |