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Journal of Clinical Microbiology, December 2006, p. 4577-4583, Vol. 44, No. 12
0095-1137/06/$08.00+0 doi:10.1128/JCM.01295-06
Prevalence and Sequence Variants of IS481 in Bordetella bronchiseptica: Implications for IS481-Based Detection of Bordetella pertussis
,
Karen B. Register1* and
Gary N. Sanden2
Respiratory Diseases of Livestock Research Unit, USDA/Agricultural Research Service/National Animal Disease Center, P.O. Box 70, Ames, Iowa 50010,1
U.S. Public Health Service Commissioned Corps, Centers for Disease Control and Prevention, National Center for Infectious Diseases, Division of Bacterial and Mycotic Disease, Meningitis and Special Pathogens Branch, Epidemiologic Investigations Laboratory, Atlanta, Georgia 303332
Received 23 June 2006/
Returned for modification 10 August 2006/
Accepted 11 October 2006

ABSTRACT
We report the prevalence in
Bordetella bronchiseptica of IS
481,
a frequent target for diagnosis of
Bordetella pertussis, as
approximately 5%. However, PCR amplicons of the predicted size
were detectable in 78% of IS
481-negative strains. Our results
suggest that PCR targeting IS
481 may not be sufficiently specific
for reliable identification of
B. pertussis.

TEXT
Bordetella pertussis is the etiologic agent of whooping cough,
an acute respiratory disease occurring exclusively in humans.
Widespread vaccination provides a high level of protection in
children, but unvaccinated populations and cohorts in whom vaccination-induced
immunity has waned remain at risk. Recently, a reemergence of
the disease within highly vaccinated populations has occurred,
and transmission from adult reservoirs to unimmunized or partially
immunized children is of increasing concern in many areas of
the world (
36). A sensitive and specific method for identification
of
B. pertussis is crucial for monitoring prevalence, accurately
defining epidemiology, and optimizing intervention and prevention
strategies, including management of outbreaks. Culture remains
the diagnostic standard but suffers from poor sensitivity, slow
turnaround time, and practical difficulties. Additionally, it
is necessary to distinguish between
B. pertussis and
Bordetella parapertussis, which may cause a milder pertussis-like syndrome
in humans. PCR assays that differentiate between these bacteria,
either alone or combined with traditional culture, are increasingly
being implemented in diagnostic laboratories.
A frequently used target for PCR detection of B. pertussis is the repetitive element IS481 (29, 30), which is absent in B. parapertussis (8, 48) but found in approximately 50 to a few hundred copies in B. pertussis (16, 27, 34, 35, 42). While IS481 is generally regarded as specific for B. pertussis, few studies definitively examine the prevalence of IS481 in the closely related agent Bordetella bronchiseptica. Despite recent evidence that B. pertussis may have evolved from a human-associated lineage of B. bronchiseptica (8), the latter agent is primarily associated with disease in mammals other than humans and, therefore, has been considered to have little clinical significance. However, human illness and carriage associated with B. bronchiseptica is on the rise, particularly in infants or immunocompromised hosts with exposure to carrier animals (1, 4, 5, 6, 11, 14, 15, 17, 26, 31, 32, 38, 44, 52, 54, 55). While rare, disease in immunocompetent adults may also occur (5, 22, 26, 54).
Analysis of a few isolates by Southern blotting suggested that IS481 may not be found in B. bronchiseptica (19, 27, 34), but one study provided evidence for a single copy in an isolate of unstated origin (16). van der Zee et al. (50) reported a prevalence of approximately 1% based on a diverse group of 144 strains. Unfortunately, the data upon which this conclusion is based were not presented, and specific methods used to identify IS481 are not detailed either in the original report or in the supporting references provided (49, 51). A more recent investigation evaluating 91 B. bronchiseptica isolates from a variety of host species identified only 2 (both equine) positive by PCR for an amplicon derived from the central region of IS481 (8). From a clinical perspective, it is important to know whether amplicons can be generated from B. bronchiseptica strains using IS481-specific primers designed to detect B. pertussis, potentially leading to an erroneous diagnosis. A review of the literature encompassing PCR methods used to identify B. pertussis reveals that "diagnostic" amplicons were obtained from B. bronchiseptica isolates in at least five investigations using primers specific for the 5' end of the repetitive element (7, 13, 16, 20, 21) but by none using primers that target the 3' end (3, 9, 10, 45). No diagnostic PCRs targeting the central region of IS481 have been proposed. Only about 20 B. bronchiseptica isolates were evaluated overall in these studies (the exact number being unclear from the details provided), and only a few were obtained from humans. The goal of the present study was to establish the prevalence of IS481 based on a larger number of B. bronchiseptica isolates, including those of human origin, and to assess the potential for misidentification of IS481-containing strains of B. bronchiseptica as B. pertussis when using IS481-specific PCR primers.
PCR primers IS481-1 and IS481-2 (Fig. 1) were used to screen for IS481 in B. bronchiseptica. This primer set is used by the Pertussis Program Laboratory of the Centers for Disease Control and Prevention for IS481-based identification of B. pertussis and encompasses a 252-bp region of the insertion sequence frequently selected as a target in B. pertussis diagnostic PCRs (3, 9, 10, 45, 53). Reaction mixtures included 0.4 µM each primer, 1 U AmpliTaq polymerase (Applied Biosystems, Foster City, CA), 2.5 µl 10x buffer II (100 mM Tris-HCl, pH 8.3, 500 mM KCl), 2.5 mM MgCl2, 200 µM deoxynucleotide triphosphates, and either 100 ng of purified DNA (n = 17), 0.5 µl of a cell lysate (n = 9) (41), or in separate reactions, both (n = 123), in a final volume of 25 µl. PCR was carried out in an Applied Biosystems (Foster City, CA) 9700 thermal cycler. Cycling conditions were as follows: 3 min at 95°C; 35 cycles, with 1 cycle consisting of 95°C for 15 s, 58°C for 30 s, and 72°C for 30 s; and a final extension step of 72°C for 10 min. A total of 149 B. bronchiseptica isolates were evaluated (see Table S1 in the supplemental material). These were obtained primarily from humans and companion or farm animal species; some have previously been examined for IS481 by other methods (8, 50). B. pertussis (Tohama) was used as a positive control. The integrity of templates and reagents was established by parallel testing with a 16S rRNA-specific PCR (41). Five microliters of each PCR mixture was analyzed by agarose gel electrophoresis.
Unexpectedly, an amplicon of the predicted size was detected
from 118
B. bronchiseptica isolates, including 22 of 24 isolates
of human origin, following PCR with primer pair IS
481-1/IS
481-2.
Strain RB50, included as one of the negative controls since
it does not contain IS
481 (
35), gave false-positive results.
One or two additional bands were present in reactions from 12
isolates. No amplification products were visualized from negative
controls containing water in place of template, included with
every set of PCRs. Representative results are shown in Fig.
2A and B. Increasing the annealing temperature to 60°C (primer
melting temperature is 62 to 63°C) reduced the intensities
of some weakly fluorescent amplicons but did not completely
eliminate them. Significant differences in band intensity apparent
in reaction mixtures with a standardized amount of purified
DNA (Fig.
2A) suggest that some isolates may contain one or
more copies of IS
481, although it seems likely that weaker amplicons
of the expected size represent false-positive results.
The strongly fluorescent amplicons of

250 bp generated with
purified DNA from three
B. bronchiseptica isolates, representing
three different species of origin, were each purified with spin
columns (QIAGEN, Valencia, CA) and sequenced directly (minimum
of three reactions, at least one from each strand) as described
previously (
39). Sequence alignment showed 98.8 to 100% identity
with the sequence originally reported for this region of
B. pertussis IS
481 (
27; K. B. Register, unpublished data). The
specificities of the IS
481-1/IS
481-2 PCR products from the 118
positive isolates were evaluated by Southern blotting, as described
previously (
40), using as a probe one of the sequenced
B. bronchiseptica amplicons labeled with digoxigenin. Following exposures of 30
min or less, an intense signal was evident only from the

250
bp product of seven isolates (Table
1; see Table S1 in the supplemental
material), all of which displayed strongly fluorescent amplicons
of this size in ethidium bromide-stained gels. Representative
results are shown in Fig.
2C.
View this table:
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|
TABLE 1. Prevalence and host species distribution of IS481 in the B. bronchiseptica isolates included in this study
|
The 7 confirmed IS
481-positive isolates, as well as 48 PCR-positive
isolates whose amplicons failed to hybridize with the IS
481 probe, were further evaluated by Southern blotting with genomic
DNA. Following digestion of 3 µg of purified DNA with
PstI, for which no recognition sites are present in
B. pertussis IS
481 (
27,
28), fragments were separated on 0.6% agarose gels,
and blots were prepared and hybridized with the
B. bronchiseptica IS
481 probe as described above. Signals were detected only from
the seven isolates already identified as containing IS
481, and
at least some appeared to contain more than a single copy (K.
B. Register, unpublished data). Additional Southern blot analysis
using alternative restriction enzymes clearly demonstrated all
seven isolates possess multiple copies of IS
481. Results obtained
with NarI, which has the most frequently occurring recognition
sequence of the enzymes tested, are shown in Fig.
3.
These data suggest that moderately to weakly fluorescent IS
481-1/IS
481-2
amplicons, although of the predicted size, are not derived from
IS
481. Amplicons obtained from six IS
481-negative
B. bronchiseptica isolates, including RB50, were sequenced in an attempt to determine
their origin. All sequences shared 100% identity with one another
as well as with the 5' and flanking region of an RB50 open reading
frame predicted to encode an extracellular solute-binding protein
(locus tag BB5004), identified from a BLASTN search of the genome
database (
http://www.sanger.ac.uk/Projects/B_bronchiseptica).
Alignment of the IS
481 primers with this segment of the RB50
genome revealed likely primer-binding locations which would
result in a product of 252 bp (Fig.
4), consistent with our
observations. No other regions of significant identity with
the IS
481-1/IS
481-2 amplicon were noted within the sequence
of the extracellular solute-binding protein gene spanned by
the primers.
Because of this unexpected finding, additional analysis was
carried out to assess the potential for unintended primer binding
to DNA from other genera that might contaminate clinical samples
or be inadvertently introduced from the environment. A BLAST
search of the GenBank RefSeq database revealed regions of 100%
identity with the 13 to 15 consecutive 3'-terminal bases of
IS
481-1 in sequences derived from
Aspergillus oryzae,
Candida albicans, and
Streptomyces avermitilis and of IS
481-2 in sequences
from
Saccharomyces cerevisiae,
Homo sapiens, and multiple strains
of both
Streptococcus pyogenes and
Escherichia coli. However,
when the database was queried with a single sequence comprised
of the concatenated primers and an N
22 spacer, no alignments
with the potential to result in amplification of a product were
identified. These results suggest that while there may be sequences
in human DNA and some bacterial and fungal species capable of
weakly binding IS
481-1 or IS
481-2, a PCR amplicon is not likely
to be generated.
Since some B. bronchiseptica strains possess at least a portion of IS481, misidentification of such strains as B. pertussis could occur when IS481-based PCR assays are used as the basis for a diagnosis of whooping cough. To more precisely evaluate the potential for misidentification with particular primer sets, we determined the DNA sequence of the B. bronchiseptica insertion element. Primers specific for the 5' and 3' ends of B. pertussis Tohama IS481 (IS481-5 and IS481-12 [Fig. 1]) were used to generate amplicons comprising the entire insertion element from the seven IS481-containing B. bronchiseptica isolates. Amplicons were purified and directly sequenced as described above. Sequence alignment revealed two variants of IS481, neither of which is identical to any of the three variants reported for B. pertussis (Fig. 1). It should be noted that, since all positive isolates have multiple copies of IS481 and the DNA sequences were obtained from purified PCR products, it is not possible to rule out the existence of additional, less frequently occurring variants. B. bronchiseptica IS481 variant 1 was found only in isolate MBORD731 and shares the greatest degree of identity with B. pertussis variants (one to three base substitutions depending on the variant used for comparison). The IS481 sequences from the six remaining B. bronchiseptica isolates are identical to one another (B. bronchiseptica IS481 variant 2) and have 25 to 27 base substitutions compared to the B. pertussis variants. No base substitutions are shared between B. pertussis IS481 variants and those of B. bronchiseptica. Interestingly, one substitution in B. bronchiseptica IS481 variant 2 eliminates a purported start codon for ORF3 (28), suggesting the insertion sequence may not be functional in most IS481-containing B. bronchiseptica isolates and perhaps explaining both its low prevalence and copy number. The single B. bronchiseptica isolate with an intact ORF3 start codon contains many more copies of IS481 than the other positive isolates. Alternatively, if IS481 had been acquired relatively recently, insufficient time may have elapsed for generating additional copies.
On the basis of a comparison of the B. bronchiseptica IS481 sequences with those of IS481 primers used for conventional PCR identification of B. pertussis (2, 3, 9, 10, 12, 13, 16, 18, 20, 21, 23, 25, 37, 45, 46, 47, 53), it seems likely that misidentification of IS481-containing strains of B. bronchiseptica would occur. Many of the suggested primers are 100% identical to the B. bronchiseptica sequence reported here, while others have a few base substitutions which may still permit amplification. A subset of the most commonly used primer pairs, including IS481-5/IS481-6 (18, 23, 46, 47), IS481-7/IS481-8 (21), IS481-5/IS481-8 (25), IS481-5/IS481-10 (13, 16), IS481-9/IS481-12 (9), IS481-11/IS481-14 (53), and IS481-13/IS481-16 (45; see Fig. 1 for primer sequences and locations), was tested with genomic DNA from the seven B. bronchiseptica isolates containing IS481. Selection of an appropriate melting temperature during cycling was problematic, since the temperature used by different investigators for the same primer pair sometimes varied greatly (e.g., a range of 55°C to 66°C for IS481-5/IS481-6) and many primer pairs are poorly matched (some differing by 10°C or more). In keeping with the conditions reported most frequently, primer pairs were tested at both 55°C and 58°C. PCR components and other cycling parameters were as described above. Amplicons were obtained from all isolates at both melting temperatures with all primer pairs tested, including those having one or more mismatched bases in comparison with B. bronchiseptica IS481 sequence. Representative results are shown in Fig. 5. Although no false-positive results were noted with strain RB50, faint bands
100 to 150 bp larger and/or smaller than the IS481-specific amplicons were evident for a few of the B. bronchiseptica isolates using two of the three primer pairs directed against the 3' portion of the insertion element (K. B. Register, unpublished data).
Our data indicate an IS
481 prevalence of roughly 5% in the group
of
B. bronchiseptica isolates examined (Table
1); others have
reported a prevalence of roughly 1 to 2% (
8,
50). The isolates
evaluated by Diavatopoulos et al. (
8) include 35 also evaluated
here. Our results are concordant with the exception of strain
MBORD669, previously reported to be IS
481 negative but found
here to be positive. Comparison of the sequence of MBORD669
IS
481 with the primers used by Diavatopoulos et al. reveals
the sequences are identical except for a single, internal base
mismatch in the reverse primer, which seems unlikely to explain
the discrepancy. Accidental cross-contamination of cultures
in our laboratory also seems unlikely since the PvuII ribotype
of MBORD669 is unique among our IS
481-positive isolates (
40;
K. B. Register, unpublished data). A comparative evaluation
of MBORD669 DNA obtained from each laboratory could perhaps
assist in resolving the discrepancy. The remaining study (
50),
in which the method used to identify IS
481 was not detailed,
included 76 strains examined here. Our results are in agreement
with theirs, except for five isolates reported here as positive
for IS
481 which were previously reported as IS
481 negative.
In the absence of additional experimental details, the reason
for this discrepancy is unclear. It could be postulated that
our results are confounded by the presence of IS
1002, an insertion
sequence closely related to IS
481 found in multiple
Bordetella species including, rarely,
B. bronchiseptica (
8,
49). However,
the degree of sequence identity between IS
1002 (
49) and our
IS
481 probe is insufficient to withstand the stringency of the
conditions used for hybridizations. Detection of many identically
sized restriction fragments with the IS
481 probe in all strains
positive by Southern blotting (Fig.
3A; K. B. Register, unpublished
data) also argues against cross-hybridization of the probe with
IS
1002.
The prevalence and sequences of IS481 in B. bronchiseptica reported here suggest that the specificity of this target for identification of B. pertussis is less than presently perceived. Although the insertion sequence was not detected in any of the 26 human isolates tested, its occurrence in strains obtained from farm and companion animals suggests that transmission of IS481-containing B. bronchiseptica strains to humans remains a possibility. Also of concern is the finding that secondary amplicons not derived from IS481 but of the predicted size, as well as some with slightly different mobilities, were often apparent when using some primers derived from the 3' region of B. pertussis IS481. Utilization of amplicon-specific probes in real-time PCR formats may alleviate this problem, but careful evaluation of IS481-based diagnostic assays for B. pertussis is essential, including an analysis of proven IS481-positive and -negative strains of B. bronchiseptica. It is unclear whether B. bronchiseptica isolates reported as PCR positive in assays targeting the 5' region of IS481 are, in fact, IS481 positive (7, 13, 16, 20, 21). The details available suggest that at least some amplicons may have been derived from secondary primer-binding sites (16, 21) as observed for most isolates in this study with primers IS481-1/IS481-2.
Our observations, together with reports identifying numerous IS481-positive Bordetella holmesii strains (21, 24, 42, 45, 46, 47), raise significant concerns as to the likelihood of a false diagnosis of B. pertussis if IS481 PCR is the only test carried out, as observed in a recent quality assessment proficiency panel (33). All laboratories utilizing IS481 PCR mistakenly identified both B. bronchiseptica and B. holmesii as B. pertussis. The suggestion that IS481 PCR assays are sufficiently specific for diagnosis of B. pertussis (43) may be premature. Consequently, promising alternative and/or confirmatory PCR targets should continue to be evaluated, and clinical sensitivity and specificity of IS481-based PCR for pertussis need to be more rigorously defined.
Nucleotide sequence accession numbers.
The GenBank accession numbers for the DNA sequences determined in this study are EF043395 to EF043401.

ACKNOWLEDGMENTS
We gratefully acknowledge the technical assistance of Michael
Mullins. We are indebted to David Alt and the National Animal
Disease Center Genomics Unit for DNA sequence data and to B.
Rath, G. Foster, R. Welsh, and H.-J. Riising for providing
B. bronchiseptica isolates.

FOOTNOTES
* Corresponding author. Mailing address: Respiratory Diseases of Livestock Research Unit, USDA/ARS/National Animal Disease Center, P.O. Box 70, 2300 Dayton Road, Ames, IA 50010. Phone: (515) 663-7700. Fax: (515) 663-7458. E-mail:
kregiste{at}nadc.ars.usda.gov.

Published ahead of print on 25 October 2006. 
Supplemental material for this article may be found at http://jcm.asm.org/. 

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Journal of Clinical Microbiology, December 2006, p. 4577-4583, Vol. 44, No. 12
0095-1137/06/$08.00+0 doi:10.1128/JCM.01295-06
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