Differences in the availability of diagnostics and treatment modalities for chronic hepatitis B across Europe

The prevalence and management of chronic hepatitis B virus (HBV) infection differ among European countries. The availability and reimbursement of diagnostics and drugs may also vary, determining distinct treatment outcomes. Herein, we analyse differences in medical facilities for the care of patients with chronic HBV infection across Europe. A survey was sent to the members of the ESCMID Study Group for Viral Hepatitis, all of whom are experts in chronic HBV infection management. The comprehensive survey asked questions regarding hepatitis B surface antigen (HBsAg) prevalence, the availability of diagnostics and drugs marketed, and distinct clinical practice behaviours in the management of chronic HBV infection. World Bank data were used to assess the economic status of the countries. With 16 expert physicians responding (69%), the HBsAg prevalence rates were <1% in France, Hungary, Italy, The Netherlands, Portugal, Spain, and the UK, intermediate (1-5%) in Turkey, Romania, and Serbia, and high (>5%) in Albania and Iran. Regarding the availability and reimbursement of HBV diagnostics (HBV DNA and liver stiffness measurement), HBV drugs (interferon, lamivudine, tenofovir, and entecavir), HBV prophylaxis, and duration of HBeAg-positive and HBeAg-negative HBV infection, the majority of high-income and middle-income countries had no restrictions; Albania, Iran and Serbia had several restrictions in diagnostics and HBV drugs. The countries in the high-income group were also the ones with no restrictions in medical facilities, whereas the upper-middle-income countries had some restrictions. The prevalence of chronic HBV infection is much higher in southern and eastern than in western European countries. Despite the availability of European guidelines, policies for diagnostics and treatment vary significantly across European countries.

Dynamics of the HIV-1 variability in adults from Bucharest, 1992-1998

Variability is a hallmark of HIV viruses both at the genetic and the phenotypic level. Viral sequencing and phylogenetic analysis of many isolates revealed specific distribution of HIV-1 subtypes according to the geographic location and route of transmission. In Romania, the currently available data coming from the study of pediatric HIV infection suggest the predominance of subtype F. However, there are few data concerning the distribution of HIV-1 subtypes among adults. We investigated the changes in the distribution of different HIV-1 subtypes among HIV-1 infected adult patients from Bucharest over a 6 years period (1992-1998) by means of V3 binding assays. The analysis of the relative incidence of different HIV-1 serotypes revealed the steady predominance of serotype F (50-75%) among the adults from Bucharest and a small but constant increase of the number of samples with serotype B- from 5% in 1994 to 14% in 1998. In contrast, the serotype E is either absent or weakly represented (4%) during the period of the study. All over the years there was a relatively high proportion (6-30%) of non-reactive samples. This could be an indication for the possible emergence of new or recombinant HIV-1 subtypes.

Complications of Varicella in Unvaccinated Children From Romania, 2002-2013: A Retrospective Study

The epidemiologic and clinical pattern of varicella-related hospitalizations recorded during 2002-2013 in Romania showed the highest hospitalization rate in the 0-1 year age group. Younger age and diagnosis after 2007 were independent predictors of varicella-related complications, recorded in half of the hospitalized cases.

Impact of Combined Antiretroviral Treatment (cART) on Latent Cytomegalovirus Infection

Cytomegalovirus infections and reactivations are more frequent in people living with HIV (PLWH) and have been associated with increased risk of HIV progression and immunosenescence. We explored the impact of combination antiretroviral therapy (cART) on latent CMV infection in 225 young adults parenterally infected with HIV during childhood. Anti-CMV IgG antibodies were present in 93.7% of participants, with lower levels correlating with longer cART exposure and better immunologic parameters. Patients with immunological treatment success (CD4 > 350 cells/mL) had significantly lower CMV IgG titers compared to those with suboptimal immune response to cART. In total, 78% of the tested patients had robust CMV-specific T-cell responses, measured by an IFN-γ release assay. A good immune response to treatment was significantly associated with CMV-specific cellular immunity: IFN-γ level was positively correlated with CD4 and CD8-T cell counts. No differences were observed between patients with suppressed/non-suppressed HIV viremia in terms of CMV humoral and cellular immune response. CMV DNA was detected in only 17% of participants, with lower levels among those with cART-induced immune recovery. The successful antiretroviral treatment with subsequent immunologic reconstitution may lead to restoration of CMV-specific immune responses and effective control of latent infection, limiting episodes of CMV reactivation in HIV-positive individuals.

[A seroprevalence study of the hepatitis C virus among multiply transfused patients]

A study was conducted on 61 polytransfused patients, 24 patients submitted to long lasting parenteral treatments, 116 blood donors and 132 controls. Immuno-enzymatic tests were used for detection of antibodies against hepatitis C virus (HCV). They were found in 56 (91.8%) out of the 61 polytransfused patients, in 5 (4.3%) of the donors, in 5 (20.8%) of the patients with multiple treatments and in 5 (3.7%) controls. The VHB markers were detected at variable rates in all investigated groups. The high rate of seropositivity indicates that hepatitis C is becoming an important public health problem in Romania.

Syncytium forming capacity of HIV 1 strains in inhibited by pretreatment of CD4 expressing cells with 3'-azido-3'-deoxythymidine but not by alpha interferon

3'azido-3'deoxythymidine (AZT) inhibits the ability of uninfected CD4 expressing cells to participate in syncytium formation, when cocultured with cells chronically infected with human immunodeficiency virus type 1 (HIV 1). The inhibition of giant cells formation is similar, irrespective of the AZT-sensitive or resistant phenotype of the HIV1 strains. The effect on syncytium formation occurs when the uninfected target cells are pretreated with AZT, the therapeutic index varying between 290 (CEMss, H9 and > 2000 (HeLa CD4 beta gal). The syncytium reducing effect of AZT is an additional antiviral property, distinct from the inhibition of HIV replication. The HIV 1 phenotype (AZT sensitive or resistant) determines differences both in the morphology of syncytia and in the kinetics of syncytium formation. Pretreatment of the target cells with alpha interferon (125-2000 UI/ml) either alone or in combination with AZT, has no effect on the ability of these cells to participate in syncytium formation, probably owing to the basal IFN synthesis in the system.

The effectiveness of cytological rescreening in the reduction of false negative/positive Pap reports

BACKGROUND

Cytological investigation of the cervix has proven to be a valuable tool in the early detection of cervical cancer; however, the high incidence of false negative or false positive smear reports is an important drawback.

OBJECTIVES

To investigate retrospectively the value of partial rescreening methods as tools for improving the sensitivity and specificity of Pap test routine screening.

METHODS

Out of a total of 4664 cervical samples examined by Pap test, 20% were randomly selected and rescreened with a more detailed examining protocol by the same cytologist; in addition, targeted rescreening of all samples with severe lesions was carried out.

RESULTS

During initial testing, 478 smears (10.24%) showed cytological abnormalities, classified as ASC-US (5.79%); L-SIL (3.32%) and H-SIL (1.14%). At random rescreening, a significant decrease in the number of negative smears (83.05% vs. 85.9%, p = 0.036) was recorded, together with an increase (7.68% vs. 5.79%, p = 0.043) in the number of smears classified as ASC-US. No significant differences were recorded for L-SIL or H-SIL samples. Retrospective targeted rescreening of all 208 samples initially diagnosed as L-SIL and H-SIL revealed 42 false positive results and 12 false negative ones. Errors were linked to suboptimal smear preparation: scant cellularity, material in clumps, paucity of abnormal cells, pale dyskarosis, small microbiopsy- like aggregates.

CONCLUSION

Partial random rescreening or targeted rescreening enables a better interpretation of suboptimal prepared smears. Targeted rescreening allows a correct detection of even low percentages of atypical cells. Other confounding factors, such as the laboratory workload and the regional prevalence of the disease, can exert an important effect on the correct classification of cytological lesions.

Relevance of the reactivity of HIV 1 positive sera with synthetic peptides for understanding antigenic differences between circulating strains

Several problems have arisen concerning the detection methodology of sources and chains of HIV transmission based on molecular and antigenic relatedness of HIV isolates. Great progress in mapping virus genome or provirus, especially in identifying the changes in the env gene provides interesting data for molecular epidemiology. We address the same problem by the investigation of the reactivity of sera from HIV 1 seropositive children with two panels of synthetic peptides mimicking immunoreactive fragment of HIV1 glycoproteins in solid phase EIA. The samples proceed from two distinct settings: an orphanage in which nosocomial transmission was highly suspected and from different hospitals caring for HIV infected children. The synthetic peptides have sequences which reproduce two target regions: one in the principal neutralization domain of gp 120 (V3 loop) and the other at the COOH end of gp 41. Our results indicate that minimal differences in aminoacids flanking central conserved GPGRA region in V3 loop of gp 120 evidence strain specific antibodies while the COOH end of gp 41 reveals antibodies which link HIV 1 strains in a broad fashion. Sera from HIV infected children collected in different settings recognize the same synthetic peptides panel with distinct frequencies suggesting circulation of different antigenic strains.

New interferons in the treatment of chronic hepatitis C

The current standard therapy for chronic HCV infection is a combination of pegylated-interferon (PEG-IFN) and weight-based ribavirin, administered for 24-48 weeks, according to the viral genotype. Although the weekly administration of pegylated interferons provides superior antiviral efficacy over standard interferon alpha, the rate of sustained virological response rarely overpasses 50% in patients infected with HCV genotypes 1 and 4. Consequently, multiple clinical trials with congeners of interferon (consensus interferon, interferon lambda, albinterferon, and controlled-release interferons) are ongoing. Their main advantages consist in maintenance of viral suppression across a longer dosing interval, avoidance of interdose trough and reduced dosing frequencies (twice or even once per month compared to once per week for the actual PEG-IFNs). Along with these superior pharmacokinetic properties, new interferons are expected to have improved side-effect profiles and better tolerability compared with the currently available formulations, providing an option for otherwise difficult to treat, challenging populations. New interferon formulation can be incorporated into future combination with direct acting antivirals, in order to maintain viral suppression over longer periods and minimize the development of viral resistance.

An outbreak of aseptic meningitis due to ECHO 30 virus in Romania during the 1999 summer

Between April-September 1999 an unusually high number of acute aseptic meningitis was reported in six North Eastern counties of Romania. At the end of 1999 summer the epidemic area extended in South Romania including the Capital City Bucharest. The total number of cases surpassed 5500. The majority of confirmed cases were young children under 15 years of age. More than 1800 cases were registered in the same interval in the neighboring Republic of Moldavia. We report the isolation of ECHO 30 virus from 12 CSF samples of 52 tested on RD and human diploid cells. A small case control study identified high seroneutralization titers confirming a recent ECHO 30 infection in 74% of patient's samples and in 54% of samples from control children tested. The time spent outdoors and poor hygiene practices were prominent risk factors for transmission.

HIV-1 circulating subtypes in Romania

The Romanian HIV epidemic is characterized by the prevalence of a single particular HIV1 subtype, called F, a minor form, previously reported only in South America and Central Africa. Initially reported in the early '90s by serotyping studies in the large cohort of parenterally infected children, this subtype remained dominant during the following two decades, despite the continuous growth in the number of heterosexually-acquired infections in adults. A steady prevalence of F subtype was further demonstrated by genotyping and molecular epidemiology studies. This article reviews the hypothesis on the origin and the unusual steady persistence of this HIV strain and discusses the recent changes in the molecular epidemiology of the epidemic, associated to the emergence of new infection routes. Phylogenetic and phylogeography studies conducted through the epidemic seem to indicate that HIV F subtype originated in the 1950s in the Democratic Republic of Congo and was separately spread by immigration waves to Brazil, Angola and Romania. Data released at the end of 2012 report F1 subtype as the dominant HIV-1 clade in Romania in all categories of patients: recently infected or late presenters, antiretroviral- naive or heavily treated, but signal the emergence of other subtypes (B--the most frequent non-F subtype among the newly diagnosed individuals, followed by subtypes C, A and several circulating recombinant forms). In this context, it is of outmost importance to follow the spreading of new emerging subtypes in the predictable setting of new infection waves in the Romanian HIV epidemic.

MICRORNA BIOGENESIS AND ITS ROLE IN HIV-1 INFECTION

MicroRNA (miRNA) are small- 19-24 nucleotides, non-coding RNA molecules that regulate translational and post-translational processes through mRNA degradation and protein translation repression, or sometimes through heterochromatin formation or activation of protein translation. Lately, miRNA are investigated as predictive biomarkers for the evolution and prognosis of viral diseases, as well as therapeutic targets. Although the role of non-coding RNA molecules during HIV infection is not yet fully elucidated, several studies have reported strong correlations between cellular and viral miRNA expression and the immunologic and virological status of infected patients. Some studies have proven the existence of host cellular miRNA able to influence all important steps in HIV replicative cycle and to interfere with the establishment of latent infection in CD4+ cells. Although the function and existence of viral encoded miRNA remains controversial, new studies have shown their potential in modulating the host cell response or the efficiency of viral replication. This review aims to summarize the current level of knowledge in the interaction between miRNA and HIV-1 and to describe new therapeutic strategies entailing miRNAs as new and potent players in controlling viral infectivity, replication and latency.

Insights into the Risk Factors and Outcomes of Post-COVID-19 Syndrome-Results from a Retrospective, Cross-Sectional Study in Romania

Post-Coronavirus Disease 2019 (post-COVID-19) syndrome represents a cluster of persistent symptoms following Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection that can severely affect quality of life. The pathogenic mechanisms and epidemiology in different regions are still under evaluation. To assess the outcomes of post-COVID-19 syndrome, we performed a questionnaire-based, cross-sectional study in previously infected individuals. Out of 549 respondents, (male:female ratio: 0.32), 29.5% had persistent symptoms at 3 months, 23.5% had persistent symptoms at 6 months, and 18.3% had persistent symptoms at 12 months after the initial infection. The most common symptoms included fatigue (8.7%), sleep disturbances (7.1%), and cognitive impairment (6.4%). The risk of developing post-COVID-19 syndrome increased for those with more symptoms in the acute phase (OR 4.24, p < 0.001) and those experiencing reinfections (OR 2.405, p < 0.001), while SARS-CoV-2 vaccination halved the risk (OR = 0.489, p = 0.004). Individuals with post-COVID-19 syndrome had a 5.7-fold higher risk of being diagnosed with a new chronic condition, with 44% reporting cardiovascular disease, and a 6.8-fold higher likelihood of needing medical care or leave. Affected individuals reported significant impairments in mobility, pain/discomfort, and anxiety/depression, with 20.7% needing to adjust their work schedules. Overall, patients with post-COVID-19 syndrome require ongoing monitoring and rehabilitation, and further socio-economic impact studies are needed.

Influenza Vaccination of Romanian Medical Students and Resident Physicians-A Matter of Accessibility

In Romania, influenza vaccination of healthcare professionals is recommended, but not mandatory. This study aims to investigate the attitudes and behaviors of medical students and resident physicians-the youngest healthcare professionals-towards influenza immunization, focusing on the barriers and facilitators, as well as on the impact of the COVID-19 pandemic. An anonymous online survey was conducted during the 2021/2022 influenza season, with responses from332 medical students and resident physicians. The majority (73.5%) were not vaccinated against influenza (68% of the students, 52.3% of the residents), although they were vaccinated against COVID-19 (94% students, 94.8% resident physicians) and believed that the pandemic positively influenced their attitude towards influenza vaccination. Vaccine accessibility (p < 0.001) and the necessity to pay for vaccination (p < 0.001) were identified as barriers in both groups, while lack of recommendation from a medical professional/teacher was significant only for students (p < 0.001). Forgetfulness and lack of prioritizations were the most cited reasons for not being vaccinated. These barriers could be diminished through proactive recommendation and simplification of the vaccination process, with accessible vaccination centers and implementation of vaccine reimbursement policies. Improved vaccination rates in young medical professionals are of the utmost importance both in their professional settings and as a model for the general population.

SARS-CoV-2 Humoral and Cellular Immune Responses in People Living with HIV

Immunosuppressed individuals, such as people living with HIV (PLWH), remain vulnerable to severe COVID-19. We analyzed the persistence of specific SARS-CoV-2 humoral and cellular immune responses in a retrospective, cross-sectional study in PLWH on antiretroviral therapy. Among 104 participants, 70.2% had anti-S IgG antibodies, and 55.8% had significant neutralizing activity against the Omicron variant in a surrogate virus neutralization test. Only 38.5% were vaccinated (8.76 ± 4.1 months prior), all displaying anti-S IgG, 75% with neutralizing antibodies and anti-S IgA. Overall, 29.8% of PLWH had no SARS-CoV-2 serologic markers; they displayed significantly lower CD4 counts and higher HIV viral load. Severe immunosuppression (present in 12.5% of participants) was linked to lower levels of detectable anti-S IgG (p = 0.0003), anti-S IgA (p < 0.0001) and lack of neutralizing activity against the Omicron variant (p < 0.0001). T-cell responses were present in 86.7% of tested participants, even in those lacking serological markers. In PLWH without severe immunosuppression, neutralizing antibodies and T-cell responses persisted for up to 9 months post-infection or vaccination. Advanced immunosuppression led to diminished humoral immune responses but retained specific cellular immunity.

Molecular epidemiology of hepatitis C virus strains from Romania

BACKGROUND AND AIMS

A high seroprevalence of Hepatitis C Virus (HCV) infection has been reported in Romania, with limited data on the viral subtypes' distribution. In order to detect any changes in the genetic composition of the epidemic, a survey on the recent profile of circulating HCV genotypes was conducted.

METHODS

241 hepatitis C infected patients with active viral replication diagnosed between September 2004 - October 2008 were included in a retrospective study. Genotyping using commercial Line Probe Assay (Innogenetics) was confirmed by sequencing of Core PCR products followed by phylogenetic analysis.

RESULTS

HCV subtype 1b was found in 92.6% of the samples, subtype 1a in 5.4 % of the samples, subtype 4a in 1.2%, and subtype 3a in 0.8% of the samples. Chronic hepatitis C infections with subtype 1b were found in women aged 40-60 years old with a history of blood transfusions received during surgical/obstetrical interventions. No geographical clustering was evident for HCV 1b sequences. The new emerging non-1b genotypes were detected mainly in younger patients with a history of intravenous drug use. The genetic distances among the HCV 1a strains are very homogeneous and small, with a high sequence identity with other European strains, suggesting the recent entrance of this subtype in Romania from singular or limited sources of infection.

CONCLUSION

The introduction of new HCV genotypes in Romania stimulates a continuous epidemiological surveillance, suggesting shifts in the transmission pathways and risk factors, with the possible emergence of recombinant strains in patients with multiple infections.