Abstract Background Amino acid (AA) substitutions in the fusion (F) protein of respiratory syncytial virus (RSV) and their effects on antibody susceptibility remain unclear. We analyzed AA substitutions in the main neutralizing epitopes of the F protein. Methods We analyzed F protein genes of 236 RSV strains isolated from children hospitalized with RSV infection in Fukushima, Japan (June 2008–February 2023). AA substitutions in antigenic sites II, V, and Ø were detected, and their effects on antibody susceptibility and viral replication were evaluated. Results Site II: The K272M (RSV-A) and the K272E (RSV-B) substitutions in strains from palivizumab-treated children reduced antibody susceptibility. Site V: In RSV-A, >50% of strains isolated since 2022 harbored the V178I substitution; however, this did not change antibody susceptibility. In RSV-B, L172Q/S173L mutant strains became predominant around 2016, leading to reduced antibody susceptibility. Site Ø: No AA substitutions were detected in RSV-A. In RSV-B, the I206M/Q209R mutant strain became predominant around 2018, leading to improved antibody susceptibility and replicative ability. However, none of the substitutions reduced antibody susceptibility. Conclusions The RSV F protein in Fukushima has naturally undergone AA substitutions with corresponding changes in antibody susceptibility, including unique regional patterns. Monitoring substitutions and antibody susceptibility is essential.
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