Global Burden of Norovirus and Prospects for Vaccine Development Primary author Ben Lopman Centers for Disease Control and Prevention Contributors and Reviewers Robert Atmar, Baylor College of Medicine Ralph Baric, University of North Carolina Mary Estes, Baylor College of Medicine Kim Green, NIH; National Institute of Allergy and Infectious Diseases Roger Glass, NIH; Fogarty International Center Aron Hall, Centers for Disease Control and Prevention Miren Iturriza-Gómara, University of Liverpool Cherry Kang, Christian Medical College Bruce Lee, Johns Hopkins University Umesh Parashar, Centers for Disease Control and Prevention Mark Riddle, Naval Medical Research Center Jan Vinjé, Centers for Disease Control and Prevention The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, or the US Department of Health and Human Services. This work was funded in part by a grant from the Bill & Melinda Gates Foundation to the CDC Foundation. GLOBAL BURDEN OF NOROVIRUS AND PROSPECTS FOR VACCINE DEVELOPMENT | 1 Table of Contents 1. Executive summary ....................................................................3 2. Burden of disease and epidemiology 7 a. Burden 7 i. Global burden and trends of diarrheal disease in children and adults 7 ii. The role of norovirus 8 b. Epidemiology 9 i. Early childhood infections 9 ii. Risk factors, modes and settings of transmission 10 iii. Chronic health consequences associated with norovirus infection? 11 c. Challenges in attributing disease to norovirus 12 3. Norovirus biology, diagnostics and their interpretation for field studies and clinical trials..15 a. Norovirus virology 15 i. Genetic diversity, evolution and related challenges for diagnosis 15 ii. Evolutionary and public health importance of GII.4 viruses 16 b. Norovirus diagnostics and genotyping tools 17 c. Detection of norovirus in healthy controls: implications for: 19 i. Disease attribution 19 ii. Clinical trial design 20 d. Progress in cell culture systems for human norovirus 21 4. Acquired immunity and innate susceptibility to norovirus ...............................23 a. Patterns of acquired immunity and potential correlates of protection 23 b. Genetic susceptibility 23 c. Interaction of host immune response and viral evolution 25 d. Candidate correlates of protection 26 e. Evidence for early acquisition of immunity 26 f. Innate immunity 28 5. Norovirus vaccines ....................................................................29 a. Developmental challenges and questions 29 i. Can a vaccine be developed that will elicit broad protection against multiple genotypes? 29 ii. Will a norovirus vaccine have to be regularly updated in order to match viral evolution? 29 iii. How will prior norovirus infection history affect vaccine immunogenicity and effectiveness? 30 iv. Will the same vaccine formulation and schedule be effective in all groups? 30 v. How will the genetic susceptibility affect vaccine outcomes? 30 b. Candidate vaccines 31 i. Transgenic plant-based norovirus vaccine 31 ii. Norovirus P particle and combination vaccines 31 iii. Trivalent norovirus /rotavirus combination vaccine 32 iv. Takeda Pharmaceutical/Ligocyte VLP vaccine 32 6. The road to a norovirus vaccine ........................................................36 a. specific age and risk groups 36 i. Age-based vaccination 36 ii. Risk group-based vaccination 36 b. The potential population-level effects of a norovirus vaccine 38 c. Economic impact of norovirus and potential cost-effectiveness of vaccination 38 d. Economics and financing of a norovirus vaccine 38 e. Bridging the developed and developing world markets 39 7. References...........................................................................41 2 | GLOBAL BURDEN OF NOROVIRUS AND PROSPECTS FOR VACCINE DEVELOPMENT GLOBAL BURDEN OF NOROVIRUS AND PROSPECTS FOR VACCINE DEVELOPMENT | 3 1. Executive summary The burden of norovirus - is there a need for a norovirus vaccine? Much progress had been made in the fight against diarrheal diseases. Global deaths have declined dramatically, from 2.6 million annually in 1990 to 1.3 million in 2013. Gains for children under the age of 5 years have been at least as impressive, with rates of decline in deaths at around 5% per year in absolute numbers. Largely, these gains have come about through improvements in water, sanitation and hygiene and use of oral rehydration solution, facilitated by economic development. Recently, rotavirus vaccination has offered a biomedical tool for further reducing child diarrheal deaths. Despite this progress, diarrheal disease remains the fourth most common cause of mortality and second most common cause of morbid­ ity worldwide in children under the age of 5 years. Norovirus is ubiquitous, associated with 18% (95% CI: 17-20%) of diarrheal disease globally, with similar proportions of disease in high- middle- and low- income settings. Norovirus is estimated to cause approxi­ mately 200,000 deaths annually worldwide, with 70,000 or more among children in developing countries. The entire age range is affected, with children experiencing the highest incidence. Severe outcomes, including hospitalization and deaths, are common among children and the elderly. In both high- and middle-income countries with mature rotavirus vaccination programs, norovirus is being unmasked as the most common cause of pediatric gastroenteritis requiring medical care. Disease occurs across the age range in all settings, but incidence is highest in young children, with higher rates and an earlier age-distribution in lower income settings. Depending on setting, a person will experi­ ence an average of three to eight norovirus illness episodes in their lifetime, of which at least one will occur by 5 years of age. Noroviruses are transmitted by multiple routes but person-to-person spread predomi­ nates. Noroviruses remain a leading cause of sporadic disease and outbreaks of AGE even in industrialized settings, highlighting that improved hygiene and sanitation alone may not be fully effective in controlling norovirus. Considering the substantial disease burden and the difficulty in controlling norovirus, vaccines may be an attractive, and, perhaps, the only way to effectively control norovirus in the wider community. There are two overarching questions, answers to which will ultimately determine the fate of a norovirus vaccine: Does the burden of norovirus represent a compelling need for a vaccination program? Can technical challenges be overcome to develop an effective norovirus vaccine for the populations that stand to benefit most? Challenges for quantifying disease burden The current evidence is that disease burden of norovirus is high, second only to rotavirus as a cause of severe acute gastroenteritis and diarrhea-associated mortality worldwide. However there remains consid­ erable uncertainty and some scientific controversy in defining the disease burden. A number of factors complicate attributing a fraction of acute gastroenteritis to norovirus. First, data are lacking, especially from developing countries. Second, little routine testing is performed in ongoing sur­ veillance platforms, because robust laboratory diagnostics have only recently been more widely available. Real-time quantitative RT-PCR (RT-qPCR) is the most sensitive and specific diagnostic assay for noroviruses, however, use of these assays is mainly restricted to public health and research laboratories in middle and high income settings. With the use of sensitive RT-qPCR assays, norovirus can also be detected in stool of healthy individuals, complicating the interpretation of diagnostic results. Attributing a fraction of the overall diarrheal disease 4 | GLOBAL BURDEN OF NOROVIRUS AND PROSPECTS FOR VACCINE DEVELOPMENT burden to norovirus has been particularly challenging because reinfection is common and the virus can be shed for several weeks, detected at low concentration, and current diagnostics cannot readily discriminate between disease-causing and asymptomatic infection. In a number of studies, particularly in low income countries, norovirus has been nearly as prevalent, and sometimes more so, in controls than in cases. This includes the recent Global Enterics Multi-Center Study (GEMS), the largest systematic assessment for understanding the etiology of childhood diarrhea in devel­ oping countries. GEMS and other case-control studies use the odds ratio of a microbe being present in cases versus healthy controls, to calculate an attributable or etiologic fraction. However, when a pathogen causes asymptomatic infection, the association between pathogen detection and disease weakens. But that does not mean that the pathogen is not causing disease when detected among cases. Many noro­ virus infections result in subclinical disease, virus shedding can last for weeks, and poor nutritional status could result in low level immunosuppression leading to chronic infection. So, we think it is inaccurate to conclude that norovirus is not an important pathogen because it is detected frequently in AGE cases and healthy controls. An alternative explanation is that high levels of asymptomatic infection are a result of frequent exposure, some of which will result in asymptomatic infection because of acquired immunity. Therefore, high prevalence of norovirus detection in healthy controls may be characteristic of ‘hyper-ende­ micity’ where burden is higher, not lower. Challenges for norovirus