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Contents lists available at ScienceDirect

Antiviral Research journal homepage: www.elsevier.com/locate/antiviral

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Review

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Animal models of viral hemorrhagic fever

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Darci R. Smith a,⇑, Michael R. Holbrook b, Brian B. Gowen c a

Southern Research Institute, Frederick, MD 21701, United States Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, MD, United States c Institute for Antiviral Research and Department of Animal, Dairy, and Veterinary Sciences, Utah State University, Logan, UT 84322, United States b

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a r t i c l e

i n f o

Article history: Received 11 June 2014 Revised 24 September 2014 Accepted 5 October 2014 Available online xxxx Keywords: Animal models Viral hemorrhagic fever Rodents Non-human primates Medical countermeasures

a b s t r a c t The term ‘‘viral hemorrhagic fever’’ (VHF) designates a syndrome of acute febrile illness, increased vascular permeability and coagulation defects which often progresses to bleeding and shock and may be fatal in a significant percentage of cases. The causative agents are some 20 different RNA viruses in the families Arenaviridae, Bunyaviridae, Filoviridae and Flaviviridae, which are maintained in a variety of animal species and are transferred to humans through direct or indirect contact or by an arthropod vector. Except for dengue, which is transmitted among humans by mosquitoes, the geographic distribution of each type of VHF is determined by the range of its animal reservoir. Treatments are available for Argentine HF and Lassa fever, but no approved countermeasures have been developed against other types of VHF. The development of effective interventions is hindered by the sporadic nature of most infections and their occurrence in geographic regions with limited medical resources. Laboratory animal models that faithfully reproduce human disease are therefore essential for the evaluation of potential vaccines and therapeutics. The goal of this review is to highlight the current status of animal models that can be used to study the pathogenesis of VHF and test new countermeasures. Ó 2014 Published by Elsevier B.V.

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Contents 1. 2.

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3.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Animal models of acute arenaviral infection and HF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1. Old World arenaviruses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.1. Lassa fever rodent models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.2. Lassa fever NHP models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.3. Lujo HF rodent models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2. New World arenaviruses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.1. New World arenavirus rodent infection models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.2. NHP models of Argentine and Bolivian HF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.3. Other rodent models of arenaviral HF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bunyavirus HF animal models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Rift Valley fever (RVF). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.1. RVF rodent models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1.2. RVF NHP models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Crimean-Congo HF (CCHF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1. CCHF rodent models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.2. CCHFV infection of NHPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3. Hantaviral HF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.1. Hantaviral HF rodent models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.3.2. Hantaviral HF NHP models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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⇑ Corresponding author at: Southern Research Institute, 431 Aviation Way, Frederick, MD 21701, United States. Tel.: +1 301 228 2191. E-mail address: [email protected] (D.R. Smith). http://dx.doi.org/10.1016/j.antiviral.2014.10.001 0166-3542/Ó 2014 Published by Elsevier B.V.

Please cite this article in press as: Smith, D.R., et al. Animal models of viral hemorrhagic fever. Antiviral Res. (2014), http://dx.doi.org/10.1016/ j.antiviral.2014.10.001

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6. 7.

Severe fever with thrombocytopenia syndrome (SFTS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.1. SFTS rodent models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4.2. SFTS NHP models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Filoviral HF animal models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1. Ebola HF (EHF) rodent models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.1. EHF NHP models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2. Marburg HF rodent models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.2.1. MHF NHP models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Flaviviral HF animal models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1. Mosquito-borne flaviviruses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.1. Dengue HF (DHF) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2. Yellow fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.1. YF rodent models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2. YF NHP model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3. Tick-borne flaviviruses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.1. Kyasanur forest disease/Alkhurma hemorrhagic fever . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4. Omsk hemorrhagic fever. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4.1. OHF rodent models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.4.2. OHF NHP models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Uncited references . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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1. Introduction

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Viral hemorrhagic fever (VHF) is a syndrome of acute febrile illness characterized by increased vascular permeability that may lead to shock and coagulation defects that may result in bleeding. The causative agents are some 20 different RNA viruses in the families Arenaviridae, Bunyaviridae, Filoviridae, and Flaviviridae. They range from the well-recognized filoviruses, Ebola (EBOV) and Marburg (MARV) and the flaviviruses yellow fever virus (YFV) and dengue virus (DENV), to more obscure pathogens such as Omsk hemorrhagic fever virus (OHFV) and Sabia virus. Newly emerging HF viruses include Alkhumra virus (AHFV) in Saudi Arabia (Qattan et al., 1996; Zaki, 1997) and severe fever with thrombocytopenia syndrome virus (SFTSV) in China (Yu et al., 2011). With the exception of DENV, which is transmitted among humans by mosquitoes, the HF viruses are maintained in a variety of animal species. Human infections result from direct or indirect contact with the reservoir host or the bite of an arthropod vector. The geographic distribution of each type of VHF therefore reflects the range of its maintenance host, with most being localized to Africa, Southeast Asia or South America. In Europe, VHF is limited to infections by hantaviruses and Crimean-Congo HF virus (CCHFV), while New World hantaviruses are the only cause of VHF in the United States. The various types of VHF differ in their average severity and overall case fatality rate, but all of them are characterized by increased permeability of the endothelial lining of blood vessels (‘‘vascular leak’’) and by coagulation defects that usually produce only minor hemorrhagic phenomena, but in some cases may lead to fatal bleeding (Schnittler and Feldmann, 2003). Major contributing factors to severe infection include viral subversion of the type I interferon response (Basler, 2005) and an uncontrolled proinflammatory cytokine/chemokine response (Bray, 2005). While all types of VHF share a common syndrome, specific pathogenic mechanisms vary by virus and host response. A recent review summarizes current understanding of the pathogenesis of VHF caused by filoviruses, flaviviruses and arenaviruses (Paessler and Walker, 2013). Therapies are available for Lassa fever and for Argentine HF, but there are no approved countermeasures against other types of VHF. The relative infrequency and sporadic occurrence of these zoonotic diseases coupled with ethical considerations constitute a major

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impediment to the conduct of human clinical trials, hindering the development of new intervention strategies. Animal models that faithfully reproduce most aspects of human disease are therefore essential for the evaluation of new candidate vaccines and therapeutics. The US Food and Drug Administration (FDA) has developed an ‘‘Animal Rule’’, which allows for the demonstration of drug or vaccine efficacy in laboratory animals instead of humans, when limited frequency and predictability or the severity of a disease makes clinical trials impossible. To satisfy FDA requirements, testing of potential vaccines and therapeutics should be performed using a well-characterized model, ideally employing an immunocompetent animal, a wild-type virus and a realistic challenge dose and route of exposure. Most importantly, the model should recapitulate the principal features of the human disease (FDA, 2009; Snoy, 2010). However, the development of animal models to mimic the full spectrum of HF disease presentation is complex and as discussed in the sections on specific virus families, it is not always possible to use immunocompetent animals, a wild-type virus and a realistic challenge dose and route of exposure. Nonhuman primates (NHPs) are the ‘‘gold standard’’ for evaluating medical countermeasures for several types of VHF, especially for advanced development efforts (Safronetz et al., 2013a). However, because of the cost-prohibitive nature, ethical concerns, and complicated logistical and safety aspects of NHP experiments, rodent models are frequently used for preclinical efficacy studies. The goal of the present article is to review NHP and rodent models currently available to study the pathogenesis of the various types of VHF and test new vaccines and therapies.

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2. Animal models of acute arenaviral infection and HF

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2.1. Old World arenaviruses

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Lassa virus (LASV) causes by far the greatest morbidity and mortality due to infection by arenaviruses that cause hemorrhagic fever (HF). Exposure to LASV and mortality associated with Lassa fever (LF) in hyperendemic areas of West Africa (Fig. 1) are estimated to be as high as 300,000 infections and 10,000 deaths annually, with 15–20% of hospitalized patients succumbing to the disease (McCormick, 1999; McCormick et al., 1987a). LASV is carried by chronically infected rodents (Mastomys species) and human

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Fig. 1. The geographic distribution of arenaviral hemorrhagic fevers.

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exposure most often occurs through inhalation of infectious virus particles aerosolized from rodent excreta or direct contact that may result in virus entry through abrasions in the skin (Yun and Walker, 2012). Nosocomial transmission via contact with contaminated medical devices or body fluids during patient care can occur, but is effectively mitigated by barrier nursing (Helmick et al., 1986). Following exposure and a 7–21 day incubation period, LF usually begins as a non-specific illness difficult to distinguish clinically from other febrile diseases (Frame et al., 1970; McCormick et al., 1987b). The clinical manifestations of LF and the disease pathogenesis have been recently reviewed in detail (Moraz and Kunz, 2011; Yun and Walker, 2012). Despite being the most studied of the arenaviral HFs, the events that lead to terminal shock are not well understood. The most consistent and dramatic pathologic findings are varying degrees of liver disease that are generally limited and insufficient to explain the cause of death. What appears to underlie the downfall of those afflicted is unchecked viral replication likely due to deficiencies in cell-mediated immunity, vascular dysfunction and leak, which may not be linked to the overproduction of proinflammatory cytokines, and thrombocytopenia (Fisher-Hoch et al., 1988; Flatz et al., 2010; Mahanty et al., 2001; Schmitz et al., 2002). Actual hemorrhagic manifestations are only observed in a minority of cases (Khan et al., 2008). Southeast of the LF-endemic region of Western Africa, a novel arenavirus, Lujo, was recently isolated from a nosocomial outbreak of HF originating in Lusake, Zambia (Paweska et al., 2009). Four caregivers in Johannesburg, South Africa, also contracted the disease with the index case and 3 of the 4 hospital-acquired cases ultimately resulting in death. The high mortality rate (80%) associated with the Lujo virus (LUJV) outbreak may reflect infection with a particularly pathogenic strain of the virus or exposure to greater infectious doses in the care of severely ill patients. This has also been the case for LF, with higher mortality rates of up to 65% observed with nosocomial outbreaks (Fisher-Hoch et al., 1995). Therefore, challenge dose and route are likely to be important factors in modeling LUJV HF and LF in animals for pathogenesis, antiviral or vaccine studies. 2.1.1. Lassa fever rodent models Consistent with the formidable disease burden associated with LASV infection, substantial work has been done to develop and

characterize small animal models to investigate therapeutic and vaccine intervention strategies and the study of pathogenesis (Table 1). Recent reports have described type I IFN receptor-deficient and MHC-1-deficient or humanized mice that support LASV replication and varying degrees of disease (Flatz et al., 2010; Rieger et al., 2013; Yun et al., 2012). More recently, LASV was shown to cause greater disease severity in STAT-1/ mice basing mortality on weight loss of greater than 20% and hypothermia (Yun et al., 2013). In general, however, adult mice of commonly used laboratory strains are refractory to challenge not involving direct inoculation into the brain (Lukashevich, 1985; Peters et al., 1987). Consequently, the guinea pig has been the principal small animal model in use for the evaluation of experimental therapies (Cashman et al., 2011; Huggins, 1989). A major limitation of the guinea pig model is the requirement for inbred strain 13 animals which are highly susceptible to LASV infection, as the standard Hartley outbred guinea pig strain is far less susceptible to challenge with wild-type virus (Jahrling et al., 1982). Very few strain 13 colonies exist and sufficient numbers of animals are difficult to obtain for the types of numbers required for drug or vaccine efficacy studies. Adaptation of LASV to the Hartley or other commercially available strains of guinea pigs would be advantageous for preclinical product evaluations.

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2.1.2. Lassa fever NHP models Many of the clinical manifestations and pathologic features of LF are believed to occur in LASV-infected rhesus and cynomolgus macaques, which are considered to be the ‘‘gold standard’’ for modeling LF (Table 2). Important studies with ribavirin in the late 1970s demonstrated the efficacy of the compound in the rhesus macaque model (Jahrling et al., 1980), with ribavirin ultimately being evaluated and showing promise in the treatment of LF in humans (McCormick et al., 1986). More recently, LASV pathogenesis in cynomolgus macaques was investigated in detail and found to recapitulate many of the features of LF in humans (Hensley et al., 2011b). There now appears to be a preference for the use of the cynomolgus macaque model for LF research (Baize et al., 2009; Geisbert et al., 2005; Safronetz et al., 2013c). Other species of NHP have also been shown to be susceptible to lethal infection by LASV. Studies in the late 1980s and early 1990s reported on clinical and pathological findings in hamadryas

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Table 1 Rodent models of arenavirus infection and disease. Virus

Biocontainment

Disease modeled

Species

Selected references

Old World Lassa

BSL-4

Lassa fever Lassa virus disease Lassa virus replication

Lujo

BSL-3 BSL-2/BSL-2+ BSL-4

Acute arenaviral disease Arenaviral hemorrhagic disease Lujo hemorrhagic fever

Guinea piga STAT-1/ b mouse IFNAR/ c mouse HDDd mouse MHC-1/e mouse Guinea pig NZB mouse FVB mouse Guinea pigf

Walker et al. (1975), Jahrling et al. (1982) Yun et al. (2013) Rieger et al. (2013) Flatz et al. (2010) Flatz et al. (2010) Riviere et al. (1985) (Braccala PNAS paper) Schnell et al. (2012) Bird et al. (2012)

New World Flexal Guanarito

BSL-3 BSL-4

Arenaviral hemorrhagic disease Venezuelan hemorrhagic fever

Hamster Guinea pig

Junín

BSL-4g

Machupo

BSL-4

Argentine hemorrhagic fever Junín virus disease Bolivian hemorrhagic fever Machupo virus disease

Pichindé

BSL-2

Pirital Tacaribe

BSL-3 BSL-2

Guinea pig AG129h mouse Guinea pig STAT-1/b mouse AG129h mouse Guinea pigi Hamster Hamster AG129c mouse

Carlton et al. (2012) Tesh et al. (1994) Hall et al. (1996) Yun et al. (2008) Kolokoltsova et al. (2010) Webb et al. (1975) Bradfute et al. (2011) Patterson et al. (2014) Jahrling et al. (1981), Aronson et al. (1994) Buchmeier and Rawls (1977), Gowen et al. (2010a) Xiao et al. (2001b), Sbrana et al. (2006a) Gowen et al. (2010b), Sefing et al. (in press)

LCM

Acute arenaviral disease Arenaviral hemorrhagic disease Arenaviral hemorrhagic disease Acute arenaviral disease

Lymphocytic choriomeningitis, LCM. a Strain 13, not commercially available. b Signal transducer and activator of transcription 1-deficient. c Type I interferon receptor-deficient. d Expresses a human/mouse chimeric HLA-A2.1 in place of the murine MHC-I. e b2 microglobulin-deficient. f Aged strain 13. g BSL-3+ for vaccinated personnel. h Type I and II interferon receptor-deficient. i Virus adapted to produce lethal disease.

Table 2 Nonhuman primate models of arenaviral hemorrhagic fever. Virus

Biocontainment

Disease modeled

Species

Selected references

Old World Lassa

BSL-4

Lassa fever

LCM

BSL-3

Lassa fever

Rhesus macaque Cynomolgus macaque Marmoset Rhesus macaque

Stephen and Jahrling (1979), Jahrling et al. (19800) Jahrling et al. (1984), Baize et al. (2009), Hensley et al. (2011b) Carrion et al. (2007) Lukashevich et al. (2002)

New World Junín

BSL-4a

Argentine hemorrhagic fever

Machupo

BSL-4

Bolivian hemorrhagic fever

Rhesus macaque Marmoset Rhesus macaque Cynomolgus macaque African green monkey Marmoset

McKee et al. (1985b), Green et al. (1987) Weissenbacher et al. (1979), Gonzalez et al. (1983) Terrell et al. (1973), Kastello et al. (1976) Eddy et al. (1975) Wagner et al. (1977), McLeod et al. (1978) Webb et al. (1975)

Lymphocytic choriomeningitis, LCM. a BSL-3 + for vaccinated personnel. 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264

baboons and African green monkeys (Evseev et al., 1991; Peters et al., 1987), with the baboon model being used to evaluate ribavirin in studies conducted in Russia (Dvoretskaia et al., 1991, 1990). However, several decades have elapsed without further reports. More recently, LASV infection in marmosets was shown to resemble many features observed in human LF (Carrion et al., 2007). The reduced size (350–400 g range) and expense associated with using marmosets make them an attractive alternative to the more costprohibitive macaque experiments (Carrion and Patterson, 2012). However, because of the FDA ‘‘Animal Rule’’, the evaluation of promising countermeasures in the marmoset model would require additional studies in macaques widely considered to most accurately reproduce the human disease. Lymphocytic choriomeningitis virus (LCMV) also causes an acute lethal disease in rhesus macaques serving as a surrogate NHP model for LF requiring a lower biocontainment level (BSL-3)

(Table 1). The LCMV macaque model has been extensively studied to gain insights into the pathogenesis and pathophysiology of severe arenaviral infection (Zapata et al., 2011). However, because the FDA ‘‘Animal Rule’’ would ultimately require efficacy studies in two animal models of LF based on challenge with authentic LASV, it seems unlikely that the LCMV NHP model will prove useful for antiviral drug development, considering the high costs of macaques. Moreover, the use of LCMV is not widely accepted as a model virus for LASV. The susceptibility of a variety of NHP species to LUJV challenge is under investigation and it remains to be seen if the virus can produce lethal disease in macaques, marmosets or other primates, similar to LASV infection.

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2.1.3. Lujo HF rodent models To date, LUJV has only been shown to cause severe HF-like disease in adult (>1 year old) strain 13 guinea pigs (Bird et al., 2012).

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The infection progresses swiftly compared to LASV and reproduces key features of the few human cases, including diffuse pantropic infection, thrombocytopenia, and coagulation abnormalities (Paweska et al., 2009). Another characteristic marker of severe LUJV HF disease is elevation of liver transaminases, which were only moderately increased in the guinea pig model (Bird et al., 2012). Nevertheless, strain 13 guinea pigs appear to be suitable hosts to model LUJV infection based on limited data in humans. As with the LASV guinea pig model, limited availability of the inbred strain 13 animals presents challenges. Moreover, the requirement for adult animals further complicates matters as the larger guinea pigs are more difficult to obtain, are associated with greater costs for long-term housing and care, and require substantially greater quantities of test compounds which are usually in limited supply for initial antiviral drug development studies. A NHP model of LUJV infection has not been described.

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2.2. New World arenaviruses

280 281 282 283 284 285 286 287 288 289 290 291 292 293 294

297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342

Of the New World arenaviral HFs endemic in different regions of South America (Fig. 1), Junín virus (JUNV), the etiologic agent of Argentine HF (AHF), causes the greatest morbidity and mortality. AHF cases, although reduced in number, continue to be reported despite the vaccination of individuals with the greatest risk of exposure (Enria et al., 2008). Like LF, HF syndromes caused by New World arenaviruses are also rodent-borne diseases that initially progress gradually and largely indistinguishable from other febrile illnesses. The clinical presentation of the South American HFs is similar to LF; however, prominent thrombocytopenia, disseminated intravascular coagulation, and greater incidence of bleeding are observed in Argentine and Bolivian HF cases, the latter due to Machupo virus (MACV) infection (Geisbert and Jahrling, 2004). The other South American HF virus that has caused a significant number of VHF cases in Venezuela is Guanarito virus (GTOV), which causes a disease very similar to that described for Argentine and Bolivian HF (de Manzione et al., 1998; Salas et al., 1991). The case fatality rate (10–50%) in cases of Argentine, Bolivian, and Venezuelan HF requiring medical attention is significant. Sabiá (Brazil) and Chapare (Bolivia) arenaviruses have been linked to less than a Q3 handful of HF cases (Delgado et al., 2008; Lisieux, 1994), and therefore only limited information is available regarding these agents and their associated diseases. 2.2.1. New World arenavirus rodent infection models Several small animal models have been described for the New World HF arenaviruses (Table 1) to gain insights into their pathogenesis and evaluate antiviral therapies and vaccines, including Candid 1 currently approved for human use to prevent Argentine HF. Aside from studies involving intracerebral inoculation, there are no reports of JUNV challenge causing overt disease in immunocompetent mice, rats or hamsters. Susceptibility of AG129 mice lacking IFN-a/b and c receptors to JUNV (Romero strain) infection was recently reported providing a more cost-effective model for early stage proof-of-concept studies; however, the model is based on defined weight loss criteria of 15–20% as an endpoint (Kolokoltsova et al., 2010). Both strain 13 and commercially available Hartley guinea pigs are exquisitely sensitive to JUNV infection, and thus, infection in guinea pigs is considered to be the best rodent model for AHF. Intraperitoneal challenge with the Romero strain of the virus results in uniform lethality with a clinical presentation very similar to that described for human AHF including fever, tremors, convulsions, thrombocytopenia, elevated aspartate aminotransferase levels and mucosal hemorrhaging (Yun et al., 2008). This model has recently been implemented for antiviral and vaccine studies

5

(Gowen et al., 2013; Salazar et al., 2012; Seregin et al., 2010). The prospect of vaccinated personnel conducting research with pathogenic JUNV strains in Biosafety Level (BSL)-3+ facilities may increase accessibility to this virus, that otherwise requires BSL-4 containment (CDC, 2009). MACV and GTOV are also important HF viruses causing sporadic outbreaks in endemic areas of Bolivia and Venezuela, respectively. In addition to a guinea pig (strain 13) model described more than 30 years ago (Webb et al., 1975), MACV has recently been shown to cause lethal infection in STAT-1- and IFN-ab/c receptor-deficient mice (Bradfute et al., 2011; Patterson et al., 2014) (Table 1). The applicability of the STAT/ model as a tool to evaluate antiviral therapies was demonstrated using ribavirin, for which partial efficacy was observed and is consistent with limited clinical data in humans (Kilgore et al., 1997). Contiguous with the theme of guinea pig susceptibility to the pathogenic clade B New World arenaviruses, GTOV causes lethal disease resembling Venezuelan HF in both Hartley and strain 13 animals. No other rodent models have been described for GTOV, but based on findings with related JUNV and MACV, studies in IFN receptor- or signaling-deficient mice are warranted.

343

2.2.2. NHP models of Argentine and Bolivian HF The rhesus macaque and marmoset models of AHF were originally described in the late 1970s and 1980s (Green et al., 1987; McKee et al., 1987; Weissenbacher et al., 1979); however, several decades have passed since the last published reports (Table 2). Efforts to characterize low-passage clinical isolates of JUNV are in the planning stages to identify a strain of virus that best models the HF syndrome in cynomolgus macaques. This is particularly important, as previous work has demonstrated strain-dependent differences in the type of disease (hemorrhagic vs. neurologic) produced in rhesus macaques (Green et al., 1987; McKee et al., 1987). Modeling neurotropic infections is also of interest since this form of disease is observed in humans, but due to the time required to develop the neurologic disease, studies would be required to extend beyond several months, which increases costs and presents logistical issues. As with LF, the common marmoset JUNV model produces a lethal HF that responds to ribavirin therapy (Gonzalez et al., 1983; Weissenbacher et al., 1986), consistent with limited human clinical data (Enria and Maiztegui, 1994). Several models of Bolivian HF in NHPs have been described (Table 2). Following infection with MACV, rhesus and cynomolgus macaques, African green monkeys and marmosets all develop severe disease that resembles Bolivian HF in humans. Because of their phylogenetic similarity (Briese et al., 2009), findings in existing NHP models of JUNV and MACV infection may extend to GTOV and the less studied Sabiá and Chapare viruses in terms of preclinical drug development.

364

2.3. Other rodent models of arenaviral HF

391

Because the arenaviruses that cause HF require maximum containment facilities, early stage preclinical drug development can be difficult due to limited access and the high expense of efficacy studies in BSL-4. Consequently, a number of useful rodent models have been developed to conduct efficacy testing in BSL-2 and BSL-3 conditions (Table 1). Certain strains of the prototypical Old World arenavirus, LCMV, can cause acute lethal diseases in Hartley outbred guinea pigs (WE strain, BSL-3) (Riviere et al., 1985) and FVB or NZB mice (Clone 13 strain, BSL-2/BSL-2+) (Baccala et al., 2014; Schnell et al., 2012), serving as surrogate models for LF and other types of arenaviral HF. The FVB mouse model demonstrates dramatic hemorrhagic disease manifestations including petechia and tissue hemorrhage more commonly seen with New World arenaviral HF, as opposed to LF (Schnell et al., 2012). Vascular leak, a car-

392

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dinal feature of VHF, and thrombocytopenia are observed with LCMV infection in NZB mice (Baccala et al., 2014). Several New World arenaviruses, including Pichindé virus (PICV) and Tacaribe virus (TCRV), can be worked with in BSL-2 containment, and have been useful surrogate viruses for antiviral efficacy studies (Gowen and Bray, 2011). PICV infection in both hamsters and guinea pigs with wild-type or adapted viruses, respectively, produces uniformly lethal disease with very low challenge doses. The hamster model has many similarities with AHF, in that diffuse systemic infection triggers proinflammatory cytokines, coagulation abnormalities, and vascular leak just prior to death (Gowen et al., 2010a). Hemorrhagic manifestations in the form of petechia are evident in nearly all PICV-infected hamsters as they become moribund, and bleeding from nasal and oral mucosa is commonly observed. In contrast, guinea pigs do not show clear signs of hemorrhage and vascular leak, but they develop thrombocytopenia and delayed clotting times (Mendenhall et al., 2011). The other arenavirus amenable to BSL-2 containment is TCRV (Gowen et al., 2010b), which can productively infect AG129 mice, culminating in a profound cytokine response, measurable vascular leak, and death (Sefing et al., in press). Thus, both the hamster PICV and TCRV mouse models could be used to evaluate compounds that can mitigate the deleterious vascular leak that likely leads to terminal shock. Two other clade A arenavirus models have been described. Pirital virus (PIRV) produces a lethal infection in hamsters similar to PICV and has been employed for antiviral efficacy testing (Vela et al., 2010). Flexal virus (FLEV) is less pathogenic in hamsters, but can still result in up to 80% lethality (Carlton et al., 2012). Because these models require BSL-3 containment and appear to be less pathogenic in hamsters than PICV, based on the requirement for higher challenge doses, they are considered to be less attractive surrogate models for arenavirus preclinical drug development.

438

3. Bunyavirus HF animal models

439

3.1. Rift Valley fever (RVF)

440

Rift Valley fever virus (genus Phlebovirus) has caused severe epidemics and epizootics throughout Africa and the Arabian peninsula

441

(Fig. 2) (Bird et al., 2009; Meegan and Bailey, 1989). Severe outbreaks have involved tens of thousands of human and livestock cases. Human infections result from the bite of infected mosquitoes or contact with tissues, blood, or fluids from infected animals. After an incubation period of 2–6 days, an abrupt onset of fever, chills, and general malaise ensues. Human disease is usually mild, and recovery occurs without major consequences. About 1–2% of infected individuals develop severe illness, characterized by acute liver disease, delayed-onset encephalitis, retinitis, blindness, or a hemorrhagic syndrome, with a case fatality ratio of 10–20% in hospitalized individuals (Laughlin et al., 1979; Madani et al., 2003; McIntosh et al., 1980).

442

3.1.1. RVF rodent models Several rodent models are available for the evaluation of RVFV infection (Table 3), which has been reviewed in greater detail (Ross et al., 2012). Mice, rats, hamsters, and gerbils have been described as rodent models (Anderson et al., 1991; Anderson et al., 1987, 1988; Gray et al., 2012; Kende et al., 1985; Niklasson et al., 1984; Peters et al., 1986; Peters and Slone, 1982; Smith et al., 2010). Mice are highly susceptible to infection with RVFV by multiple exposure routes. However, different genetic strains of mice have exhibited differences in their susceptibility to RVFV. Infection of BALB/c mice with RVFV strain ZH501 SC or by aerosol resulted in high-titer viremia and demonstrated viral tropism for a variety of tissue and individual cell types on the basis of histopathology, immunohistochemistry, and electron microscopy (Reed et al., 2013, 2012; Smith et al., 2010). For mice exposed by aerosol and SC, a major consequence of infection was overwhelming infection of hepatocytes that subsequently underwent apoptosis. Most BALB/c mice succumbed to RVFV between days 3 and 6 PI which was attributed primarily to severe hepatitis as indicated by the overwhelming infection of hepatocytes and increase in high levels of hepatic enzymes in the blood. The remaining mice were able to effectively clear virus from the liver and blood, but exhibited neuroinvasion and developed lethal panencephalitis. However, the development of neuropathology occurred much earlier and was more severe in mice exposed by aerosol compared to SC exposed mice (Reed et al., 2013).

454

Fig. 2. The geographic distribution of bunyaviral hemorrhagic fevers.

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D.R. Smith et al. / Antiviral Research xxx (2014) xxx–xxx Table 3 Principal rodent models for the study of bunyaviral hemorrhagic fevers. Virus

Biocontainment

Genus

Disease modeled

Species

Selected references

Rift Valley

BSL-3+

Phlebovirus

Rift Valley fever

Mouse

Gray et al. (2012), Kende et al. (1985), Peters et al. (1986), Reed et al. (2013), Smith et al. (2010) Anderson et al. (1987, 1991), Bales et al. (2012), Peters and Slone (1982) Niklasson et al. (1984), Peters et al. (1986) Anderson et al. (1988) Anderson et al. (1990), Fisher et al. (2003), Gowen et al. (2006, 2007), Perrone et al. (2007) Tignor and Hanham (1993) Bente et al. (2010), Bereczky et al. (2010), Zivcec et al. (2013) Dowall et al. (2012)

Rat

*

480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508 509 510 511

Punto Toro

BSL-2

Phlebovirus

Rift Valley fever

Crimean-Congo hemorrhagic fever

BSL-4

Nairovirus

Crimean-Congo hemorrhagic fever

Hazara

BSL-2

Nairovirus

Hantaan

BSL-3

Hantavirus

Crimean-Congo hemorrhagic fever Hemorrhagic fever with renal syndrome

Puumala

BSL-3

Hantavirus

Seoul

BSL-3

Hantavirus

Dobrava

BSL-3

Hantavirus

Andes

BSL-4

Hantavirus *

Maporal

BSL-4

Sin Nombre

BSL-4

Hantavirus

Severe fever with thrombocytopenia syndrome

BSL-3

Phlebovirus

Hantavirus

Hemorrhagic fever with renal syndrome Hemorrhagic fever with renal syndrome Hemorrhagic fever with renal syndrome Hantavirus pulmonary syndrome Hantavirus pulmonary syndrome Hantavirus pulmonary syndrome Severe fever with thrombocytopenia syndrome

Hamster Gerbil Hamster Mouse (newborn) Mouse (immunodeficient) Mouse (immunodeficient) Mouse (suckling) Hamster

Hamster

Huggins et al. (1986), McKee et al. (1985a) Hooper et al. (2001), Kamrud et al. (1999), Schmaljohn et al. (1990) Hooper et al. (2001), Kamrud et al. (1999), Sanada et al. (2011), Schmaljohn et al. (1990) Hooper et al. (1999, 2001), Kamrud et al. (1999)

Hamster

Hooper et al. (2001)

Hamster Hamster

Campen et al. (2006), Hooper et al. (2001), WahlJensen et al. (2007) Milazzo et al. (2002)

Hamster

Brocato et al. (2014), Safronetz et al. (2013b)

Mouse (Immunocompetent) Mouse (suckling) Mouse (immunodeficient)

Jin et al. (2012)

Hamster

Chen et al. (2012) Liu et al. (2014)

Previously worked with in BSL-3, but due to biosafety concerns the current recommendation is BSL-4.

Infection of C57BL/6 mice with RVFV strain ZH501 SC results in a similar disease course compared to BALB/c mice except they all succumb by day 4 PI from acute-onset hepatitis with little evidence of pathology in the brain indicating meningoencephalitis (Gray et al., 2012). An analysis of the immune response to RVFV in C57BL/6 mice indicates that the pathogenicity is driven by an unregulated host pro-inflammatory response which results in a significant loss of liver function and the development of neurologic disease (Gray et al., 2012). Another study in C57BL/6 mice infected with RVFV strain ZH548 found that the route of virus inoculation and the presences of Aedes mosquito saliva can potentially affect pathogenicity (Le Coupanec et al., 2013). In contrast to inbred laboratory mouse strains, the wild-derived Mus m. musculus MBT/Pas mice succumbed from RVFV infection several days earlier and developed higher viremias, which was demonstrated to result from the absence of a complete innate immune response (do Valle et al., 2010). Infection of various inbred rat strains with RVFV strain ZH501 also results in different disease manifestations. Wistar-Furth (WF) rats were found to develop severe hepatic disease when inoculated SC whereas August-Copenhagen-Irish (ACI) rats developed encephalitis (Anderson et al., 1987; Bird et al., 2007; Bucci et al., 1981; Peters and Anderson, 1981; Peters and Slone, 1982). In contrast, when Lewis rats were infected SC, little or no mortality was observed, even though the rats became viremic (Anderson et al., 1987; Peters and Slone, 1982). A recent study by Bales et al. assessed the susceptibility of these different inbred rat strains to aerosolized virus and determined that Wistar-Furth and ACI rats developed a similar disease course and outcome when exposed SC and by aerosol. In contrast, they report that Lewis rats developed fatal encephalitis after aerosol infection, but only mild disease following SC exposure (Bales et al., 2012). The breeding

history and supplier of the various rat strains has been shown to affect the resistance or susceptibility to RVFV infection (Ritter et al., 2000), which further complicates the noted differences in disease outcome of inbred rat strains. Other rodent models utilized less frequently in RVFV research include hamsters (Niklasson et al., 1984; Peters et al., 1986) and gerbils (Anderson et al., 1988). Syrian hamsters are more susceptible than BALB/c or C57BL/6 mice and succumb from acute-onset hepatitis within days following SC or IP exposure. The hamster model has relied mainly on experimental infection with the related bunyavirus Punta Toro virus where hepatitis, but not encephalitis is the dominant pathologic feature (Anderson et al., 1990; Fisher et al., 2003). Gerbils infected with RVFV reportedly develop uniformly fatal encephalitis in the absence of significant extraneural lesions (Anderson et al., 1988).

512

3.1.2. RVF NHP models In contrast to most rodent models, infection of NHPs with RVFV does not produce a uniformly fatal disease (Table 4); reviewed more extensively by (Ross et al., 2012). Rhesus macaques historically have been used to evaluate potential vaccines and therapeutics (Peters and Linthicum, 1994). For this model, the rhesus monkeys were usually infected IV, and can be divided into three groups based on the disease course observed with larger cohorts of animals (usually 15–20 monkeys):

527

 fatally infected monkeys that developed severe clinical disease and succumbed (18%);  clinically ill monkeys that survived (41%); and  monkeys that developed very mild or no apparent clinical illness and survived (41%).

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Table 4 Principal NHP models for the study of bunyaviral hemorrhagic fevers. Virus

Biocontainment

Genus

Disease modeled

Species

Selected references

Rift Valley

BSL-3+

Phlebovirus

Rift Valley fever

Rhesus macaque

Hemorrhagic fever with renal syndrome Hantavirus pulmonary syndrome Hantavirus pulmonary syndrome

Marmoset African green monkey Cynomolgus macaque Cynomolgus macaque Rhesus macaque

Hartman et al. (2014), Morrill et al. (1989), Peters et al. (1986, 1988) Hartman et al. (2014), Smith et al. (2012) Hartman et al. (2014) Groen et al. (1995), Klingstrom et al. (2002) McElroy et al. (2002) Safronetz et al. (2014)

Puumala Andes Sin Nombre

BSL-3 BSL-4 BSL-4

Hantavirus Hantavirus Hantavirus

541

570

All of the monkeys develop viremia and have an increase in liver enzymes. Severe disease was accompanied by extensive liver necrosis, evidence of disseminated intravascular coagulation (DIC), and microangiopathic hemolytic anemia (Cosgriff et al., 1989; Morrill et al., 1990; Peters et al., 1988, 1989). More recently, a new model for RVF was described using the common marmoset, which overcomes some of the major limitations of other NHP models. Marmosets were more susceptible to RVFV than rhesus macaques and experienced higher rates of morbidity, mortality, and viremia and marked aberrations in hematological and chemistry values. Depending on the route of exposure, these animals exhibited acute-onset hepatitis, delayedonset encephalitis, and hemorrhagic disease, which are dominant features of severe human RVF (Smith et al., 2012). A recent study described the susceptibility of rhesus macaques, cynomolgus macaques, African green monkeys, and marmosets exposed to RVFV by aerosol (Hartman et al., 2014). Cynomolgus and rhesus macaques developed mild fevers, but no other clinical signs were observed and all the monkeys survived. In contrast, African green monkeys and marmosets were highly susceptible to aerosol infection, and the majority developed fatal encephalitis (Hartman et al., 2014). Collectively, these results indicate the utility of rodent and NHP models of RVF to evaluate potential medical countermeasures because of their ability to mimic different features of severe human disease. However, genetic determinants appear to play an important role in disease outcome as well as the route of virus exposure, which should be taken into account when evaluating vaccines and therapeutics.

571

3.2. Crimean-Congo HF (CCHF)

572

CCHF virus (CCHFV; genus Nairovirus) is thought to be primarily maintained in ticks of the Hyalomma genus of the Ixodidae family with a wide distribution spanning western, central, and southern Africa, the Balkans, the Middle East, southern Russia, and western Asia (Fig. 2) (Ergonul, 2006; Vorou et al., 2007; Whitehouse, 2004). Humans can become infected through tick bites, by contact with a patient during the acute phase of infection, or through exposure to the blood or tissues of viremic livestock (Hoogstraal, 1979; Watts et al., 1988). Human infection with CCHFV is characterized by 4 distinct phases designated the incubation, prehemorrhagic, hemorrhagic, and convalescence. The incubation phase generally lasts 1– 7 days, but can extend longer. The prehemorrhagic phase can last 3–7 days and is characterized by fever, fatigue, cephalagia, dizziness, photophobia, myalgia and in some cases nausea, vomiting, and diarrhea. Severe CCHF progresses to the hemorrhagic phase, which can last 2–3 days and is characterized by petechiae, ecchymosis, epistaxis and hemorrhage. During the hemorrhagic phase the case-fatality rate is approximately 30% (although this can vary by geographical locations) where the main causes of death include severe liver necrosis, shock, and subsequent multiorgan failure (Burt et al., 1997). Predictors of fatal outcome include high viral loads, increased liver enzymes, thrombocytopenia, increased clotting times and

542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569

573 574 575 576 577 578 579 580 581 582 583 584 585 586 587 588 589 590 591 592 593 594

cytokines/chemokines (Cevik et al., 2008; Duh et al., 2007; Onguru et al., 2010; Papa et al., 2006, 2007; Saksida et al., 2010; Weber and Mirazimi, 2008; Wolfel et al., 2007; Yesilyurt et al., 2011; Yilmaz et al., 2010). The convalescent phase begins 10– 20 days after onset of symptoms and may be characterized by tachycardia, polyneuritis, breathing impairment, loss of hearing, memory, or vision. The pathogenesis of CCHF remains poorly understood because of limited human pathology data, the need for BSL-4 containment facilities to handle CCHFV, and the lack of an immunocompetent animal model that recapitulates human disease.

595

3.2.1. CCHF rodent models No immunocompetent mammals other than humans are known to develop disease (Table 3). Adult mice, rats, guinea pigs, hamsters, rabbits, sheep, calves, donkeys, NHPs, and other adult animals develop low to undetectable viremia and clear the infection with no signs of illness (Fagbami et al., 1975; Shepherd et al., 1989; Smirnova, 1979). A suckling mouse model has been described in which high viral titers were demonstrated in the blood and liver, with Kupffer cells staining for viral antigen (Tignor and Hanham, 1993). However, virus could not be isolated from the spleen and overall the model does not portray human CCHF. Recently, adult mice with gene knockouts of the signal transducer and activator of transcription 1 (STAT1/) or the interferon a/b receptor (IFNAR/) have been described as lethal CCHF models (Bente et al., 2010; Bereczky et al., 2010). Infection of STAT-1 KO mice was characterized by fever, leukopenia, thrombocytopenia, elevated liver enzymes and proinflammatory cytokine levels, and death within 3 to 5 days. Extensive viral replication in the liver and spleen was associated with necrosis in the liver and lymphocyte depletion in the spleen. However, interstitial pneumonia and intestinal hemorrhage, which are found in lethal human infections, was not apparent (Bente et al., 2010). Infection of IFNAR/ mice resulted in high viral replication in the liver and spleen and death within 2–4 days (Bereczky et al., 2010). A recent study evaluated the sensitivity of IFNAR/ mice and age-matched wild-type mice to multiple exposure routes to CCHFV and analyzed the pathologic, virologic, hematologic, biochemical, and immunologic parameters associated with infection (Zivcec et al., 2013). Wild-type mice cleared CCHFV without developing any sign of disease whereas IFNAR/ mice were susceptible to multiple exposure routes and developed an acute fulminant disease characterized by high viral loads leading to pathology in the liver and lymphoid tissues. Viral replication was detected in antigen-presenting and immune cells, which secreted high levels of chemoattractant and proinflammatory molecules. Severe thrombocytopenia and coagulopathy was also observed in these mice (Zivcec et al., 2013). Therefore, this model mimics the manifestations of severe human CCHF disease (see Table 5). A potential surrogate model for testing antivirals has been described utilizing the closely related Hazara virus, which can be handled at BSL-2. Infection of type I IFN receptor KO mice leads to a lethal disseminated infection with histopathological changes

606

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596 597 598 599 600 601 602 603 604 605

607 608 609 610 611 612 613 614 615 616 617 618 619

620 621 622 623 624 625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648

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a

Biocontainment

Disease modeled

Species

Ebola

BSL-4

Ebola hemorrhagic fever

Marburg

BSL-4

Marburg hemorrhagic fever

Selected references

a

Mouse Immunodeficient mice Guinea piga Hamster Mousea Immunodeficient mice Guinea piga Hamster

Bray et al. (1999), Gibb et al. (2001) Bray (2001), Raymond et al. (2011) Connolly et al. (1999), Ryabchikova et al. (1999) Lofts et al. (2007), Warfield et al. (2009) Warfield et al. (2007) Hevey et al. (1998), Lofts et al. (2007)

Virus adapted to produce lethal disease.

Table 6 Principal NHP models for the study of filoviral hemorrhagic fever. Virus

Biocontainment

Disease modeled

Species

Selected references

Ebola

BSL-4

Ebola hemorrhagic fever

Rhesus macaque

Bowen et al. (1978), Bukreyev et al. (2007), Feldmann et al. (2007), FisherHoch et al. (1983, 1985), Geisbert et al. (2003a), Oswald et al. (2007), Warfield et al. (2006) Geisbert et al. (2002, 2003b,d), Jahrling et al. (1996a,b), Jones et al. (2005), Reed et al. (2004), Sullivan et al. (2000) Daddario-DiCaprio et al. (2006b) Daddario-DiCaprio et al. (2006a), Hensley et al. (2011a), Hevey et al. (1998), Jones et al. (2005) Carrion et al. (2011)

Cynomolgus macaque Marburg

BSL-4

Marburg hemorrhagic fever

Rhesus macaque Cynomolgus macaque Marmoset

Table 7 Principal rodent models for the study of flaviviral hemorrhagic fever. Arthropod vector

Virus

Disease modeled

Species

Selected references

Mosquito-borne

Dengue

Neurological

Mouse

Dengue hemorrhagic fever

Mouse Mouse

Yellow fever

Yellow fever

Alkhurma hemorrhagic fever Kyasanur forest disease Omsk hemorrhagic fever

Alkhurma hemorrhagic fever Kyasanur forest disease Omsk hemorrhagic fever

Mouse Hamster No available model Mouse Mouse

An et al. (2004), Blaney et al. (2002), Lin et al. (1998), Shresta et al. (2004) Bente et al. (2005) Grant et al. (2011) Shresta et al. (2006), Tan et al. (2010), Zellweger et al. (2010) Meier et al. (2009) McArthur et al. (2003), Tesh et al. (2001)

Tick-borne

649 650 651 652 653 654 655 656 657

similar to what is described above (Dowall et al., 2012). Therefore, this model could potentially be used for initial evaluations of medical countermeasures; however, this virus has not been reported to cause human disease and may not accurately predict drug or vaccine efficacy for humans. There are obvious limitations for using mouse models with defective IFN responses, but currently these models represent the most appropriate animal disease model of CCHF which can be used for pathogenesis studies and evaluating medical countermeasures.

665

3.2.2. CCHFV infection of NHPs Efforts to develop a NHP model of CCHF that mimics human disease have been unsuccessful thus far. However, studies of CCHFV infection of African green monkeys, baboons, and patas monkeys have been reported (Butenko et al., 1968; Fagbami et al., 1975; Smirnova, 1979). The development of a NHP model that recapitulates human disease would significantly benefit development efforts for medical countermeasures to CCHF.

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3.3. Hantaviral HF

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The hantaviruses (family Bunyaviridae, genus Hantavirus) are a large group of viruses that are primarily maintained in specific rodent hosts that dictate their geographic range. At least 23 unique species of hantaviruses are currently recognized by the ICTV and at least half are of medical importance to humans (ICTV, 2013). Han-

658 659 660 661 662 663 664

668 669 670 671

Bhatt et al. (1966), Work and Trapido (1957) Holbrook et al. (2005), Tigabu et al, (2009)

taviruses can cause severe disease in humans that is associated with two clinical syndromes: hemorrhagic fever with renal syndrome (HFRS) and hantavirus pulmonary syndrome (HPS) with fatality rates as high as 15% and in excess of 40%, respectively (Jonsson et al., 2010). HFRS occurs primarily in Eurasia (Fig. 2) and is generally caused by the Old World hantaviruses Hantaan (HTNV), Seoul (SEOV), Dobrava (DOBV), and Puumala (PUUV) viruses. HPS is confined to the Americas and is most frequently caused by infection with the New World hantaviruses Andes (ANDV) and Sin Nombre (SNV) viruses (Wahl-Jensen et al., 2007) (see Table 6). HFRS mainly affects the kidneys and HPS affects the lungs, while both syndromes are associated with vascular leakage. Although hemorrhage is not seen in HPS, respiratory failure resulting from vas2ular leakage is a prominent feature of the disease (Peters et al., 1999), and therefore, a brief description of animal models of HPS warrants inclusion in this review. Transmission of hantaviruses to humans occurs primarily by inhalation or ingestion of contaminated rodent excreta. Direct transmission through rodent bites and human-to-human transmission have also been documented to occur (Martinez et al., 2005; Padula et al., 1998; St Jeor, 2004; Torres-Perez et al., 2010). Currently, there are no FDA approved medical countermeasures for HFRS and HPS. Therefore, efforts to develop vaccines and antivirals to treat or prevent these diseases are an important area of research (see Table 7).

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Table 8 Principal NHP models for the study of flaviviral hemorrhagic fevers. Arthropod vector

Virus

Disease modeled

Species

Selected references

Mosquito-borne

Dengue Yellow fever Alkhurma hemorrhagic fever Kyasanur forest disease

Dengue hemorrhagic fever Yellow fever Alkhurma hemorrhagic fever Kyasanur forest disease

Rhesus macaque Rhesus macaque No available model Bonnet macaque

Onlamoon et al. (2010) Monath et al. (1981)

Tick-borne

698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739

740 741 742 743 744 745 746 747 748 749 750 751 752 753

3.3.1. Hantaviral HF rodent models Currently, there is no rodent model that faithfully reproduces human HFRS disease (Table 3). Several small animal models have been described for Old World hantaviruses using mainly suckling mice or natural rodent hosts (reviewed in (Safronetz et al., 2012)). Infection of suckling, juvenile and adult mice with certain strains of HTNV and by certain routes of infection results in lethal disease. However, the primary disease manifestations are neurological or pulmonary, which differs from HFRS in humans (Ebihara et al., 2000; Kurata et al., 1983; McKee et al., 1985a; Seto et al., 2012; Tamura et al., 1989; Wichmann et al., 2002). Despite this limitation, these lethal models have provided a means to evaluate potential antivirals for HFRS (Huggins et al., 1986; Murphy et al., 2001). Syrian hamster models have been described for HTNV, PUUV, SEOV and DOBV, which have been useful for evaluating vaccine candidates (Hooper et al., 1999, 2001; Kamrud et al., 1999; Safronetz et al., 2012; Sanada et al., 2011; Schmaljohn et al., 1990). Development of animal models for HPS (Table 2) is more limited due to the need for high containment facilities for experimental infections with the New World hantaviruses (reviewed in (Safronetz et al., 2012)). Syrian hamsters appear to provide the best small animal HPS model to date. Infection of hamsters with ANDV results in a uniformly fatal disease in which the animals develop pulmonary dysfunction similar to what is described for the human disease (Hooper et al., 2001; Safronetz et al., 2011). When hamsters are infected with Maporal virus (MPRLV) it is reportedly less lethal (Milazzo et al., 2002). Hamsters are susceptible to infection with other New World hantaviruses (SNV and Choclo virus), but show no signs of illness (Eyzaguirre et al., 2008; Hooper et al., 2001; Wahl-Jensen et al., 2007). Safronetz et al. repeatedly passaged SNV in hamsters in an effort to create a lethal disease model. This model demonstrated increased dissemination of the virus, but no signs of disease were observed and no animals succumbed from infection (Safronetz et al., 2013b). Brocato et al. recently described a lethal SNV disease model in immunosuppressed Syrian hamsters (Brocato et al., 2014). Infection with SNV resulted in a mean time to death of 13 days, and the animals displayed clinical signs associated with HPS, including pulmonary edema (Brocato et al., 2014). This newly described lethal model will assist efforts to evaluate candidate Q4 medical countermeasures (see Table 8). 3.3.2. Hantaviral HF NHP models Infection of NHPs with Old World hantaviruses does not provide a good model for HFRS (Yanagihara et al., 1988). Although a nonlethal cynomolgus macaque PUUV infection model has been described, it does not reproduce human disease (Groen et al., 1995). Infection of cynomolgus macaques with PUUV leads to a mild disease suggestive of acute nephropathy, which currently provides the most realistic NHP model (Klingstrom et al., 2002; Sironen et al., 2008). Cynomolgus macaques are susceptible to infection with ANDV, but no signs of illness were observed (McElroy et al., 2002). Recently, a novel NHP model of HPS in rhesus macaques was described (Safronetz et al., 2014). Following infection with SNV propagated in deer mice, the animals developed HPS characterized

Kenyon et al. (1992), Webb and Chaterjea (1962), Webb and Rao (1961)

by thrombocytopenia, leukocytosis, and rapid onset of respiratory distress caused by severe interstitial pneumonia. This newly described NHP model will contribute to a greater understanding of the pathogenesis of HPS and the evaluation of medical countermeasures to treat hantaviral diseases.

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3.4. Severe fever with thrombocytopenia syndrome (SFTS)

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SFTS virus (SFTSV) is a newly identified Phlebovirus in the family Bunyaviridae that has caused severe disease in humans in China (Yu et al., 2011). Signs and symptoms of SFTS include high fever, gastrointestinal symptoms, thrombocytopenia, leukocytopenia, and multiorgan dysfunction. Neural symptoms, hemorrhages, DIC, and multiorgan failure have been reported in severe human cases (Gai et al., 2012). However, little is known about the pathology of SFTSV infection because autopsies have not been performed on hfatal cases. The host range of SFTSV has yet to be determined, but Haemophysalis longicornis ticks have been described as potential vectors (Yu et al., 2011, 2012) and a high seroprevalence reported in goats (Zhao et al., 2012). A recent study suggests that SFTSV has a wide host range and natural infections occur in several domesticated animal hosts in endemic areas (Niu et al., 2013). SFTSV antibodies and RNA were detected in sheep, cattle, dogs, pigs, and chickens. While RNA was frequently detected in these animals, infectious virus was only isolated from a single sheep, cow and dog during the study (Niu et al., 2013).

760

3.4.1. SFTS rodent models Adult immunocompetent rodents do not appear to be highly susceptible to SFTSV (Chen et al., 2012; Jin et al., 2012; Liu et al., 2014). C57BL/6 and BALB/c mice, Wistar rats, and Syrian hamsters infected by multiple routes did not develop disease or succumb to infection (Chen et al., 2012; Jin et al., 2012). However, a reduction in white blood cells and platelets was observed in C57BL/6 mice suggesting that this model resembles human SFTS disease (Jin et al., 2012). In contrast to adult rodents, newborn Kunming mice and rats were highly susceptible to intracranial infection with SFTSV (Chen et al., 2012). In an effort to create a more realistic lethal model to test medical countermeasures, Liu et al. recently described a mouse model utilizing IFNAR/ mice, which were highly susceptible to subcutaneous infection. All mice succumbed within 3–4 days postinfection. Virus was detected in all tissues except for the lungs; the major target cells appeared to be reticular cells in the lymphoid tissues of the intestine and spleen (Liu et al., 2014). Future work should aim at further characterizing this mouse model to better understand the pathogenesis of this emerging disease.

779

3.4.2. SFTS NHP models No NHP models of SFTS have been described.

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4. Filoviral HF animal models

801

Ebola hemorrhagic fever (EHF) and Marburg hemorrhagic fever (MHF) are caused by viruses of the genera Ebolavirus (EBOV) and Marburgvirus (MARV), respectively, of the family Filoviridae

802

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755 756 757 758

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Fig. 3. The geographic distribution of filoviral hemorrhagic fevers.

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(Sanchez et al., 2007). These zoonotic viruses are highly pathogenic and have been associated with devastating outbreaks causing case fatality ranging from 25–90% (Feldmann and Geisbert, 2011). Currently, the largest outbreak of EBOV ever recorded is ongoing in West Africa and the number of confirmed cases and deaths continue to rise (Nunes-Alves, 2014). Fruit bats are most likely the reservoir of EBOV and MARV, and the geographical distribution of both viruses appear to be limited to sub-Saharan Africa (Fig. 3) (Leroy et al., 2005; Pourrut et al., 2007; Towner et al., 2007, 2009). However, Reston ebolavirus (REBOV) was identified in the Philippines by positive serology in pig farmers, but was not associated with causing human disease (Barrette et al., 2009; Taniguchi et al., 2011). Outbreaks of EHF and MHF are usually the result of person-to-person transmission that occurs through direct contact with bodily fluids or contaminated clothes or bedding of an infected person (Baron et al., 1983; Bausch et al., 2007; Dowell et al., 1999; Francesconi et al., 2003; Roels et al., 1999). The incubation period for EBOV and MARV infection in humans range from 3–13 days with death occurring during the second week of illness with a median survival of 9 days after the onset of symptoms (Kortepeter et al., 2011). Signs and symptoms include fever, chills, headache, malaise, and myalgia generally occurring within 4 days following infection (1978; Bente et al., 2009; Q5 Bwaka et al., 1999). Respiratory and gastrointestinal symptoms have been reported, along with vascular abnormalities to include conjunctival infection, hypotension, and edema (Centers for Disease Control, 2001, 2005; Formenty et al., 1999). Hemorrhagic manifestations include petechiae on the torso and arms, ecchymoses, bleeding from venipuncture sites and mucous membranes, gingival bleeding, epistaxis, and visceral hemorrhaging (Bente et al., 2009). Currently, there are no FDA-approved vaccines or therapeutics to prevent or treat EBOV or MARV infections and only supportive care or experimental therapeutics are available. Efforts to develop effective vaccines and therapeutics using animal infection models (Table 3) are therefore an active area of research.

841

4.1. Ebola HF (EHF) rodent models

842

Mice and guinea pigs are generally used as rodent models of EHF, but they do not succumb to infection with wild-type virus

843

unless it has been adapted to virulence for these species, or immunodeficient animals are used (Bray et al., 1999; Connolly et al., 1999). Mouse models of EHF have been extensively reviewed (Bradfute et al., 2012). Mice are generally used as the initial models for evaluating potential vaccines and therapeutics and do mimic some of the predominant EHF disease features. Mice develop viremia and high viral titers in multiple tissues to include the spleen and liver. Liver damage results in high levels of liver enzymes being detected in the serum. An early inflammatory cytokine response is apparent along with lymphopenia, thrombocytopenia, and neutropenia (Bradfute et al., 2012). One limitation of the mouse model is that the animals do not develop DIC, fibrin deposits, or petechiae, but some coagulation abnormalities are apparent. Guinea pigs offer an additional model for preliminary evaluation of vaccines and therapeutics for EHF. Connolly et al. developed a lethal guinea pig adapted strain that produced disease manifestations similar to those reported in experimentally infected NHPs and human cases (Connolly et al., 1999). Fever and coagulation defects, including a drop in platelet counts and an increase in coagulation time, are apparent, but fibrin deposition and coagulopathy (DIC) are not as marked as that observed in NHPs (Connolly et al., 1999; Reed and Mohamadzadeh, 2007). Similar to mice, a maculopapular rash does not develop in these animals. Another important limitation of the guinea pig model is that bystander lymphocyte apoptosis, which is prevalent in primates and mice, has not been determined in this model. Because of the differences observed in the EHF rodent models, several therapeutics that are effective in mice and guinea pigs fail to protect NHPs challenged with wildQ6 type EBOV (Wahl-Jensen et al., 2012) (see Fig. 4). Recent work has focused on utilizing the Syrian hamster as an alternative to NHPs (Ebihara et al., 2013). Syrian hamsters challenged intraperitoneally or subcutaneously with wild-type EBOV do not develop prominent disease, whereas intraperitoneal infection with mouse-adapted EBOV causes severe coagulopathy, lymphocyte apoptosis, cytokine dysregulation, target organ necrosis and/or apoptosis (lymph node, spleen, liver), and a lethal outcome, suggesting that the Syrian hamster model more faithfully reproduces the features of the human and NHP disease. Therefore, this newly developed model may provide a beneficial alternative for testing medical countermeasures for EHF. The prominent disease features in mice, guinea pigs, hamsters and

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Fig. 4. The geographic distribution of flaviviral hemorrhagic fevers. 885 886

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NHPs were directly compared in a recent review (Wahl-Jensen et al., 2012). 4.1.1. EHF NHP models NHPs are the ‘‘gold standard’’ for evaluating vaccines and therapeutics for EHF (Shurtleff et al., 2011). Several species are susceptible to infection with EBOV (Fisher-Hoch et al., 1983; Perry et al., 2012; Ryabchikova et al., 1999), but rhesus and cynomolgus macaques have been used most frequently in research, as they reliably mimic human disease (Kortepeter et al., 2011). EBOV-infected NHPs develop a fever, macular rash, petechiae, leukocytosis, lymphopenia, thrombocytopenia, DIC, and a cytokine-associated systemic inflammatory response (Ebihara et al., 2011; Kortepeter et al., 2011). Macrophages and dendritic cells are primary targets of EBOV infection which leads to a rapid systemic viral dissemination, immunosuppression through antagonism of the type I interferon response and induction of lymphocyte apoptosis, infection of hepatocytes and other parenchymal cells, coagulation defects, and increased vascular permeability resulting in terminal shock (Baize et al., 1999; Bowen et al., 1978; Feldmann et al., 1996; Fisher-Hoch et al., 1985; Geisbert et al., 2003b,c,d). EBOV infection of NHPs has been intensively investigated, and the pathogenesis has recently been reviewed in detail (Paessler and Walker, 2013). A recent review (Shurtleff et al., 2012) points out that rhesus macaques have been used preferentially over cynomolgus macaques for evaluating small molecule therapeutics, because of the longer time-frame for rhesus monkeys to develop symptoms and succumb to disease (8 days for rhesus macaques and 6 days for cynomolgus macaques) (Geisbert et al., 2010; Warren et al., 2010; Bente et al., 2009). However, there has been no guidance from the FDA that rhesus macaques are the definitive species for evaluation of candidate therapeutics.

916

4.2. Marburg HF rodent models

917

Similar to EHF, rodent models of infection with wild-type MARV are not available unless the virus has first been adapted to virulence for that species (Table 3) (Lofts et al., 2007; Warfield et al., 2009). Some strains were adapted to severe, combined immunodeficient (SCID) mice by serial passaging to develop lethal models (Warfield et al., 2007). Lethal infection models were also developed

918 919 920 921 922

for guinea pigs (Lofts et al., 2007; Simpson et al., 1968) and hamsters (Simpson, 1969; Zlotnik, 1969) by serial passaging for adaptation to virulence for that species. The hamster is the only rodent model demonstrating neuropathogenicity (Zlotnik, 1969). Similar to EHF, a major limitation of MHF rodent models is that coagulation abnormalities, typical rash development, and hemorrhagic manifestations (particularly in mice) are not as pronounced as in NHPs (Bente et al., 2009; Brauburger et al., 2012; Warfield et al., 2009).

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4.2.1. MHF NHP models Similar to EHF, NHPs represent the ‘‘gold standard’’ for evaluating vaccines and therapeutics for MHF (Brauburger et al., 2012; Shurtleff et al., 2011). Paessler and Walker recently reviewed the pathogenesis of MHF in detail (Paessler and Walker, 2013). Uniform lethality is observed in cynomolgus and rhesus macaques and African green monkeys (Alves et al., 2010; Fritz et al., 2008; Geisbert et al., 2007; Gonchar et al., 1991; Hensley et al., 2011a; Johnson et al., 1996; Lub et al., 1995; Simpson, 1969; Simpson et al., 1968). Following infection, the animals develop a febrile illness with a high fever, anorexia, weight loss and become lethargic. Death is observed 6–13 days post-infection and thrombocytopenia, lymphopenia, blood coagulation abnormalities and hemorrhages are observed. Other NHP models for MHF include squirrel monkeys (Simpson, 1969) and marmosets (Carrion et al., 2011). Both mimic the features of human MARV infections, except that in marmosets the typical maculopapular rash that is observed in old world NHP species and humans is not observed (Carrion et al., 2011). However, virus was isolated from the brains of infected marmosets, which also showed micro-hemorrhages (Carrion et al., 2011). This suggests that marmosets may provide a good model recapitulating the CNS involvement first described in the initial outbreak in Germany (Brauburger et al., 2012). The development of CNS pathology in other MHF models is unclear, because no brain pathology has been observed in mice (Warfield et al., 2007) or cynomolgus macaques (Alves et al., 2010).

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5. Flaviviral HF animal models

958

Research on flaviviruses associated with development of HF has been severely limited by the lack of animal models that accurately

959

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recapitulate human disease. While there have been a number of advances in recent years, in most cases researchers have been required to either adapt a virus to the model system, utilize immunodeficient animals, or both. The use of modified systems raise significant concerns with the value of the research completed, particularly with immunodeficient animals, as it is not clear that measured viral pathogenesis and host immune responses can be translated back to the human condition. The use of rodent models is unreliable as mice do not realistically predict human disease. However, until the past few years there have been no small animal models for some types of flaviviral HF.

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5.1. Mosquito-borne flaviviruses

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5.1.1. Dengue HF (DHF) Human infection by dengue virus (DENV) can result in disease ranging from a febrile illness to severe hemorrhagic disease and death. DENV exists as four antigenically similar but distinct serotypes (DENV1–4), which allows for productive infection with viruses from each of the four serotypes due to a lack of cross-protective antibodies. Many primary DENV infections are asymptomatic or develop into dengue fever (DF) when they occur during childhood. However, in some cases, typically in the event of secondary dengue infections with a virus from a different serotype, infection can lead to severe dengue hemorrhagic fever (DHF) or dengue shock syndrome (DSS) (Kurane, 2007; Whitehorn and Simmons, 2011). Most cases of acute DF have some evidence of vascular leakage, but this is typically limited to a macular or maculopapular rash (i.e. petechiae) that resolves (Kurane, 2007; Whitehorn and Simmons, 2011). In severe cases, increased evidence of plasma leakage and hemorrhage occurs with the loss of vascular volume leading to development of shock and, potentially, death (Kurane, 2007; Whitehorn and Simmons, 2011). The specific mechanisms related to severe vascular leakage in DHF or DSS cases are not well understood, however there appears to be a significant immunological role in the development of vascular leakage and severe disease (Halstead, 2012, 2013; Whitehorn and Simmons, 2011). Currently, DENV research is severely hampered by limited availability of animal models that recapitulate human disease. The majority of the effort focused on understanding the mechanisms of viral pathogenesis following DENV infection uses either human samples or cell culture systems.

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5.1.1.1. DHF rodent models. Historically, mice have been used in DENV research for the sole purpose of cultivating virus or evaluating the neuroinvasive properties of different strains. Peripheral challenge of most immunocompetent adult mouse strains with DENV does not result in overt disease. The development of a mouse model for DENV has been an area of significant progress over the past decade and has been reviewed in two recent papers (Plummer and Shresta, 2014; Zompi and Harris, 2012) . The first models for DENV infection utilized SCID mice xenografted with human HuH-7, HepG2 and K562 tumor cells. While the ability of an adult mouse to support productive DENV infection was exciting, these animals have limited utility in evaluating pathogenesis, as DENV infects primarily the engrafted cells before migrating to the brain (An et al., 2004; Blaney et al., 2002; Lin et al., 1998). Subsequent to development of the xenografted SCID mouse model, Shresta et al. utilized intravenous infection of A/J mice with DENV2 and found that neurologic disease occurred in about half of the animals (Shresta et al., 2004; Zompi and Harris, 2012). In each of these mouse models, the development of neurological infection is not representative of human disease and diminishes the enthusiasm for either of these models. A model using NOD-SCID mice xenografted with human CD34+ cells was introduced in 2005 (Bente et al., 2005). When these mice

13

were infected with DENV-2 virus, they developed a disease similar to DHF with evidence of thrombocytopenia, rash and fever (Bente et al., 2005). Unlike SCID mice, in which DENV specifically targets the xenografted cells, in the NOD-SCID mice DENV was found to infect cells in the bone marrow, spleen and liver. More recently, NOD-SCID IL2rc(null) (NSG) mice have been used to demonstrate that engrafted animals can develop B and T cell responses that could make the model useful for testing DEN vaccines (Jaiswal et al., 2012, 2009). Unfortunately, except for the xenografted human tissues, little else in the response to virus infection would fundamentally replicate a human response. In addition, while the NOD-SCID and NSG humanized mouse models appear to reflect human disease, the technical component of reliably generating humanized mice can be challenging and time-consuming. The NOD-SCID mouse model was followed closely by a type I/II interferon receptor (IFNAR)-deficient AG129 mouse model (Shresta et al., 2006; Zellweger et al., 2010). This model initially relied in part on the use of a mouse-adapted DENV2 strain, but it does develop severe disease, including vascular leak, similar to humans with DHF. More recently, the AG129 model has employed a virus that has not been adapted to mice (Grant et al., 2011; Tan et al., 2010). The AG129 mouse model has subsequently been used for a number of studies, including some evaluating potential therapeutic and vaccine interventions for DENV infection (Brewoo et al., 2012; Stein et al., 2011; Watanabe et al., 2012). The AG129 mouse model possibly represents the best small animal model for DENV infection at the current time. The small number of small animal models that accurately recapitulates human disease for evaluating DENV infection has limited progress toward understanding mechanisms of viral pathogenesis. However, as more models become available, perhaps our understanding of this disease will improve.

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5.1.1.2. DHF NHP models. While NHPs, including rhesus macaques, cynomolgus macaques and African green monkeys, are used routinely in dengue vaccine research, they do not generally represent a model of severe human disease. In primate vaccine studies, vaccine protection is evaluated by induction of neutralizing antibodies and/or viremia following challenge of vaccinated animals (Li et al., 2013; Osorio et al., 2011). NHPs are generally not considered a useful model for the evaluation of human disease, as healthy animals do not typically develop clear signs of disease or succumb to infection. However, recently Onlamoon et al. have used a very high dose (107 pfu) intravenous virus challenge to induce a disease similar to dengue fever as seen in humans (Onlamoon et al., 2010). In this model, animals developed thrombocytopenia, neutropenia, decreased hemoglobin, elevated D-dimers, petechiae and signs of severe coagulopathy. Unsurprisingly, the viral load in the plasma of these animals was high through 6 days postinfection, but subsequently waned in reverse correlation with an increase in DENVspecific antibody titers. While the development of this new model provides as excellent opportunity to more carefully evaluate pathogenesis, the large intravenous bolus of virus required to induce disease may limit the value of the model in vaccine and therapeutic trials, as one would need to carefully evaluate the impact of the large dose of virus/viral antigen on the efficacy of a vaccine or therapeutic.

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5.2. Yellow fever

1080

Yellow fever (YF) is caused by infection with the YF virus (YFV), which is endemic in tropical regions of South America and Africa, where it is thought to infect around 200,000 people per year with some 30,000 deaths (Markoff, 2013). The largest recent documented outbreak of YF occurred in the fall of 2012 in the Darfur

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region of Sudan, where approximately 1000 cases and 250 deaths were documented (Markoff, 2013). Infection of humans with YFV can cause disease ranging from a nondescript febrile illness to severe hemorrhagic fever and death. The mechanisms determining severity of disease are unknown, but may be related to specific host susceptibility and immune response (Monath, 2012). YF can present with rapid onset of a high fever and headache which resolves in about 80% of people. The remaining 20% may suffer from a bi-phasic disease, in which the first period of infection is characterized by viremia, high fever, myalgia, bradycardia, nausea and vomiting (Gardner and Ryman, 2010). The period of infection is followed by a 1–2 day period of remission and then the period of intoxication wherein fever, vomiting, nausea, jaundice, hemorrhage and renal failure can occur. The case fatality rate is about 20% with death occurring 6–8 days post-onset (Gardner and Ryman, 2010). Despite the isolation of YFV in 1927, very little is known about the pathogenicity of infection. In part, the lack of knowledge regarding YF is the result of a very effective live-attenuated vaccine (17D) that was first tested in humans in 1936 and provides potentially life-long immunity following a single inoculation (Monath, 2012). The 17D vaccine has significantly limited the spread of YFV, restricted the expansion of outbreaks and contributed to the prevention of YF in urban environments. Despite the success of the 17D vaccine, there are occurrences of vaccine-associated disease without a clearly defined etiology (Monath, 2012). A scientific challenge that has limited our understanding of YFV, and the host factors that may be associated with development of vaccine associated disease, has been the lack of viable small animal models that reliably recapitulate human disease. 5.2.1. YF rodent models The weanling mouse has long been used as a model to demonstrate YFV neurovirulence and neuroinvasiveness, as well as to cultivate virus. Until recently, the adult mouse has not proved to be a useful model for YFV infection, but in 2009 Meier et al. described the use of A129 and STAT129 mice as models wherein infection with wild-type YFV (Asibi and Angola73 strains) was lethal in adult animals following footpad challenge (Meier et al., 2009). Infection of these mouse strains with the vaccine strain 17D-204 did not result in disease, demonstrating selective pathogenicity, similar to what is seen in humans and NHPs. The identification of the A129/STAT129 model has provided an excellent new approach for evaluating therapeutic interventions for the treatment of YFV infection. The value of these models for elucidating mechanisms of YFV pathogenicity in humans remains to be determined, as both mouse strains are deficient in their IFN response which could lead to inappropriate interpretation of data and correlation with human disease. However, the evident restriction of 17D-204 infection in these models also clearly demonstrates a critical role for the IFN response following YFV infection. In the early 2000s a hamster model was developed by two groups as a legitimate model for evaluating YFV pathogenicity (McArthur et al., 2003; Sbrana et al., 2006b; Tesh et al., 2001; Xiao et al., 2001a). In both cases, the model required adaptation of a wild-type YFV strain by serial passage. The first described model was developed using the South American Jimenez strain (isolated from a fatal human case in Panama, 1974) and the second used the Asibi strain, which was isolated in Ghana (non-fatal human case, 1927). The Jimenez model was more completely described, but both adapted strains appear to cause similar disease in hamsters and both recapitulate human disease with reasonable fidelity. Infected hamsters developed hallmarks of YFV infection in humans, including microvesicular steatosis, apoptosis and hepatic necrosis (Tesh et al., 2001). Of note however, is that Councilman bodies, a hallmark of YFV infection in the liver of humans, were

not described in either model. The spleen exhibited lymphoid hyperplasia and evidence of necrosis. Additional analysis identified increased liver enzymes in the serum, increased coagulation times, thrombocytopenia, lymphopenia and vascular leak (Gowen et al., 2010a; McArthur et al., 2003; Sbrana et al., 2006b; Tesh et al., 2001; Xiao et al., 2001a). Immunohistochemical evaluation of viral dissemination identified viral antigen in the liver and spleen, but not in the kidneys (Xiao et al., 2001a). Since the initial description of the hamster model, it has been used for a number of studies evaluating therapeutic interventions for disease (Julander, 2013; Julander et al., 2009, 2010, 2011a,b).

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5.2.2. YF NHP model NHPs have been used as models for YF since the discovery of the virus, when rhesus macaques were used for virus isolation and histopathological studies (Hudson, 1928a,b,c; Klotz and Belt, 1930a; Klotz and Belt, 1930b,c; Stokes et al., 1928). Since that time, NHPs have largely been used for vaccine efficacy studies (Marchevsky et al., 2003; Mudd et al., 2010; Neves et al., 2009) or for demonstrating a lack of vaccine virulence during manufacture (Minor, 2011) and are considered the ‘‘gold standard’’ of YF animal models. Despite ecological evidence that howler monkeys are highly susceptible to YFV infection (Holzmann et al., 2010), rhesus macaques are the only species in which pathogenesis has been evaluated extensively in a research setting. Rhesus macaques generally develop a monophasic disease that resembles the toxic (terminal) phase of human disease (Monath et al., 1981). Infected animals develop fever, lethargy, diminished urine output, hypotension and coma, with death occurring approximately 5 days post-infection (Monath et al., 1981). Infected animals also become viremic beginning around 2 days postinfection, peaking at 4–5 days postinfection (Monath et al., 1981). Loss of liver function is evident close to death, as liver enzymes become elevated and coagulation times become extended. Histological evidence of liver disease is evident as necrosis of hepatocytes and Kupffer cells, and evidence of Councilman bodies and Torres bodies, similar to what is seen in humans (Monath et al., 1981).

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5.3. Tick-borne flaviviruses

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5.3.1. Kyasanur forest disease/Alkhurma hemorrhagic fever Kyasanur forest disease (KFD) and isolation of the causative agent, KFDV, were first described in the late 1950s (Work and Trapido, 1957). KFDV is found in a fairly localized region of southwestern India, where human cases occur annually and large outbreaks are identified with some regularity (Holbrook, 2012; Kasabi et al., 2013). KFDV is transmitted by ticks and has genetic and serological qualities that group the virus within the tick-borne encephalitis serocomplex of flaviviruses. There is serological evidence suggesting that KFDV might be more widespread than has been thought, but confirmed cases outside of the endemic region have not been documented. In the mid-1990s a virus serologically related to KFDV was isolated in the Jeddah region of Saudi Arabia, following the occurrence of several cases of hemorrhagic fever (Zaki, 1997). It was subsequently named Alkhurma hemorrhagic fever (AHF) virus (AHFV) and was shown to be closely related to KFDV genetically (Dodd et al., 2011). AHFV has been found in other areas of southwestern Saudi Arabia, and indirect evidence from exported cases suggests it may also be present in southern Egypt (Carletti et al., 2010). Human disease following infection with either KFDV or AHFV is similar, in that hemorrhagic symptoms can be apparent. Neither virus is typically associated with development of neurological disease although such disease can occur (Holbrook, 2012). The case fatality rate for KFD is estimated at 3–5% while AHF is up to 25%, a number that may be somewhat inflated due to incomplete surveillance.

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5.3.1.1. AHF and KFD rodent models. A rodent model for AHF has not yet been described, although it is expected that rodents infected with AHFV would have a disease process similar to those infected with KFDV. In the case of KFDV, suckling mice were used for the initial isolation of the virus and for development of reagents for diagnostic assays (Bhatt et al., 1966; Work and Trapido, 1957). Sub-adult mice have subsequently been used to test vaccine efficacy as these animals will become infected and succumb to the infection. However, these animals develop a neurological disease, rather than a hemorrhagic or visceral disease, which would more accurately reflect human disease.

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5.3.1.2. AHF and KFD NHP models. Shortly after the initial isolation of KFDV, rhesus macaques were used in challenge studies to determine if they were a possible model for human disease. Infected macaques became viremic and developed neutralizing antibodies, but did not demonstrate overt signs of illness (Work, 1958). Subsequent studies in red-faced bonnet macaques (Macaca radiata) found that these animals were quite susceptible to viral infection. Bonnet macaques that have been found dead in the forest within the endemic region of KFDV often herald the onset of human disease. Bonnet macaques infected with KFDV develop signs of disease similar to what is seen in humans including anemia, bradycardia, hypotension, leukopenia and lymphopenia (Kenyon et al., 1992; Webb and Chaterjea, 1962; Webb and Rao, 1961). Postmortem evaluation of the liver and kidneys has identified histological lesions similar to those in humans. M. radiata infected with KFDV may develop neurological disease, with evidence of encephalitis on postmortem examination in one study. While M. radiata may be an excellent model for evaluating KFDV (and possibly AHFV) pathogenesis, a 1978 ban on exportation of these animals from India has limited their availability for scientific research (Johnsen et al., 2012).

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5.4. Omsk hemorrhagic fever

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Omsk hemorrhagic fever (OHF) virus (OHFV) is found in a localized area of south-central Russia near the Siberian cities of Omsk and Novosibirsk. The isolation of OHFV in 1947 was the result of an investigation into an outbreak of severe disease, characterized by overt hemorrhage from the gastrointestinal tract and mucosa (Chumakov, 1948). OHFV infection of humans causes an acute febrile illness that can progress to severe disease (Ruzek et al., 2010). While OHFV is considered a very dangerous virus and is classified as a BSL-4 pathogen, there have been just over 1200 human cases identified with a relative disappearance of the virus over the past few decades (Ruzek et al., 2010). The principal hosts for OHFV are thought to be small mammals, particularly the water vole (Arvicola amphibius), although ticks may also be involved in maintenance of the virus. Muskrats also harbor OHFV and are thought to be the source of many human cases of OHF, when hunters slaughter the animals for their pelts (Kharitonova and Leonov, 1985; Ruzek et al., 2010).

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5.4.1. OHF rodent models A number of rodent species have been shown to be susceptible to OHFV infection and develop disease ranging from asymptomatic infection to the fatal neurological disease seen in muskrats (Ruzek et al., 2010). The only established laboratory rodent model is the mouse, which develops a viscerotropic disease with few signs of neurological involvement after peripheral infection (Holbrook et al., 2005). OHFV can be found in the brains of infected mice, and it is possible that overt neurological disease would become apparent if the animals survived longer post challenge. Juvenile hamsters, guinea pigs and weaning or juvenile mice infected by intracerebral challenge will develop neurological disease and suc-

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cumb to infection. There are no published reports of other rodent models.

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5.4.2. OHF NHP models A lethal NHP model has not been established for OHFV or other members of the tick-borne encephalitis serocomplex viruses other than KFDV. Recently, Pripuzova et al. completed infection studies in African green monkeys (Cercopithecus aethiops) and crab-eating macaques (Macaca fascicularis) which found that these animals did not develop overt signs of disease following subcutaneous challenge (Pripuzova et al., 2013). Infection of C. aethiops with OHFV resulted in a hemolytic syndrome represented by anemia, thrombocytopenic purpura and lymphocytopenia. These animals also had evidence of liver disease (increased ALT levels). The limited availability of animal models for KFD and OHF has significantly inhibited progress toward understanding their pathophysiology. Hopefully, over the next few years progress will be made toward identification of models for studying these diseases.

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6. Summary

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A better understanding of disease pathogenesis and development of effective medical countermeasures for the treatment of VHF is dependent on the accurate modeling of the infection in laboratory animals. Rodent models are essential for providing valuable preclinical information about candidate vaccines and therapeutics prior to advancing into the more costly and restrictive NHP models. Murine models are commonly used for VHF research, but often do not meet the FDA Animal Rule requirements because they do not reproduce important aspects of human disease or the virus must first be adapted to this species. Hamsters and guinea pigs have proven valuable for studying some HFVs, but research involving these species is hampered by the lack of available reagents. Because of these limitations, NHP animal models are generally the ‘‘gold standard’’ for evaluating potential medical countermeasures for several HFVs (Safronetz et al., 2013a) particularly in the advanced development stage leading towards licensure. Most importantly, the animal model used to assess the efficacy of candidate vaccines and therapeutics for HFVs must accurately portray human disease. Future efforts and guidance from the FDA should identify which animal models will successfully meet the Animal Rule requirements.

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7. Uncited references

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Ergonul et al. (2006), Kaya et al. (2011), Sbrana et al. (2006a), Tigabu et al. (2009), Warfield et al. (2006, 2009), Warren et al. Q7 (2010), World Health Organization (1978).

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Acknowledgements

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The authors would like to thank Jiro Wada for his illustration work. MRH is an employee of Battelle Memorial Institute under its prime contract with NIAID No. HHSN272200200016I. The information presented here is the responsibility of the authors and does not necessarily represent views or policies of the US Department of Health and Human Services or Battelle Memorial Institute.

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Please cite this article in press as: Smith, D.R., et al. Animal models of viral hemorrhagic fever. Antiviral Res. (2014), http://dx.doi.org/10.1016/ j.antiviral.2014.10.001

Animal models of viral hemorrhagic fever.

The term "viral hemorrhagic fever" (VHF) designates a syndrome of acute febrile illness, increased vascular permeability and coagulation defects which...
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