Infectivity markers in HBsAg chronic carriers and intrafamilial spread of hepatitis B virus infection

Sera from 28 HBsAg chronic carriers were tested for the presence of HBeAg, anti-HBe and Dane particle-associated DNA-polymerase activity, in order to evaluate the relationship between the presence of these markers and the spread of HBV infection in their family contacts. A highly significant prevalence of HBV infection was observed in the relatives of HBsAg carriers who were positive for either HBeAg or DNA-polymerase activity or both. These observations support the inference of a striking correlation between the presence of these markers and the infectivity of HBsAg carriers. Therefore, serological determination of HBeAg and DNA-polymerase activity may be considered in the epidemiological control of HBV infection

Hepatitis B virus markers, alpha-fetoprotein and survival in fulminant viral hepatitis

The serological markers of hepatitis B virus and serum alpha-fetoprotein (AFP) levels have been studied in 28 consecutive cases of fulminant hepatitis, correlating the data with survival. On admission, 20 patients were found to be positive for HBsAg and eight for anti-HBs. All anti-HBs-positive cases showed high titers of anti-HBc, and six patients were positive for specific anti-HBc-IgM. DNA polymerase activity was detected in serum of 11 HBsAg-positive (55%) and four anti-HBs-positive (50%) patients. HBeAg was detected in six (21.4%) subjects (five HBsAg-positive and one anti-HBs-positive), whereas anti-HBe was present in nine (32.1%) subjects (six HBsAg-positive and three anti-HBs-positive). AFP levels greater than 60 ng/ml were found in sera of 14 patients (50%). No significant difference was evidenced in the survival rate between HBsAg-positive and anti-HBs-positive and between HBeAg-positive and HBe Ag-negative patients. However, a statistically significant difference (P less than 0.05) in the survival rate was found in patients positive and negative for DNA polymerase activity and in those with AFP levels higher and lower than 60 ng/ml (P less than 0.005). Pathogenetic and prognostic significance of these findings are discussed.

[Markers of viral replication (HBeAg and DNA polymerase activity) in chronic uremia, HBsAg positive, hemodialysis patients]

The contagiousness of hepatitis B virus (HBV) carriers with end-stage renal disease undergoing chronic hemodialysis has been ascribed to an immunologic tolerance for HBV antigens, especially hepatitis B core antigen, supporting persistently high levels of virus replication. In this context hepatitis B e antigen and core-associated DNA polymerase (DNA P) activity have proved to be distinct markers of HBV replication. In order to evaluate the potential infectivity of these subjects, thirty-five HBsAg positive hemodialysis patients were studied for the presence of HBeAg/anti-HBe system correlating the results with serum DNA P activity. Twenty out of 35 patients were HBeAg positive (57%) and 21 DNA P positive (60%). A highly significant correlation (P less than 0,001) was recorded between detection of HBeAg and presence of serum DNA P activity. These findings confirm that the majority of hemodialysis patients carrying HBsAg show high levels of virus replication so that the determination of HBeAg and DNA P activity other than HBsAg is required for the identification of patients highly infectious.

[Surface antigen (HBsAg) and core antibody (anti-HBc) in chronic uremia during periodic hemodialysis treatment of hepatitis B patients. Correlation with viral replication markers (HBeAg and DNA polymerase activity)]

Sera of thirty-five hepatitis B surface antigen (HBsAg) positive hemodialysis patients and fifty-three asymptomatic HBsAg chronic carrier were studied to assess the relationship between markers of virus activity (hepatitis B e antigen and core-associated DNA polymerase activity) and titers of HBsAg and of antibody to hepatitis B core antigen (anti-HBc). All sera were tested by solid-phase radioimmunoassay methods. HBeAg was detected in 20 (51%) hemodialysis patients and in 14 (26%) asymptomatic carriers, whereas DNA P activity was present in sera of 21 (60%) and 17 (32%) respectively. The highest titers of HBsAg and anti-HBc expressed as P/N ratio between positive and negative controls, were detected in the majority of hemodialysis patients, whereas asymptomatic carriers showed low titers of these markers. These data suggest that in HBsAg positive hemodialysis patients a more active viral replication occurs and further underline the difference between these patients and other categories of HBsAg carriers in terms of infectivity.

[Serologic diagnosis of acute hepatitis A. Refinement and evaluation of 3 methods of determining specific anti-HAV IgM]

A solid phase radioimmunoassay (RIA) procedure was developed and three methods for detection of IgM specific antibody to hepatitis A virus (anti-HAV IgM) were compared: triple antibody method, 2-MercaptoEthanol (2-ME) for IgM cleavage and Staphylococcal A Protein (StAP) for IgG absorption. Specificity and sensitivity of the tests were checked for evaluating acute and convalescent sera from 40 patients with serologically (seroconversion) diagnosed hepatitis A and 64 sera from patients with various acute viral diseases or with high titre of rheumatoid factor (RF). Specimens to be assayed for anti-HAV IgM were pretreated with 2-ME or StAP and tested by RIa using 125I labelled anti-HAV IgG. Triple antibody method showed to be more sensitive than other two methods giving false positive result in only one serum containing high levels of monoclonal RF. No significant difference in sensitivity and specificity was found between 2-ME and StAP procedure, but these methods were able to detect anti-HAV IgM for only two weeks after the onset of the disease, whereas triple antibody method gave positive results for at last seven weeks.

[Non-A, non-B post-transfusion hepatitis. Serological survey of 85 patients with acute hepatitis following blood transfusion]

In a serological survey of 85 adult patients hospitalized for an episode of transfusion-associated hepatitis, 45 were reactive for hepatitis B surface antigen and therefore diagnosed as having hepatitis B. Forty HBsAg non reactive patients were examined for development of antibody to hepatitis A and B antigens, cytomegalovirus and Epstein-Barr virus. Three patients showed serologic evidence of hepatitis B and one for hepatitis A. None of the remaining 36 subjects developed serologic evidence of acute infection with the viruses tested during the study period, so that they were classified as having so-called NANB hepatitis. As reported in other studies, analysis of the incubation period showed that two subgroups of NANB hepatitis may be identified with short and long incubation period, so that it appears likely that at least two agents are implicated in NANB hepatitis. Our data confirm that also in our area a large proportion of transfusion-associated hepatitis is related to NANB agent(s) requiring additional measures for its prevention.

Discontinuing therapy in childhood acute lymphocytic leukemia. A multicentric survey in Italy

The results of discontinuing therapy in children with acute lymphocytic leukemia observed at four associated institutions are presented. Of the 247 patients who achieved complete remission, 122 (49.3%) reached the point of discontinuing therapy after 2-4 years of continuous remission. The median period off therapy was 13 months with a range of 1-69 months. Of the 122 children removed from therapy, 27 (22.1%) relapsed, mainly in the bone marrow; relapses occurred 1-32 months after cessation of therapy (median ten months) with only two relapses occurring later than two years. By actuarial analysis, 57% of the patients are projected in continuous remission after five years from cessation of therapy. Neither selected features at diagnosis nor single modalities of treatment were found to predict whether relapse would occur after discontinuing therapy. Long-term remission and possibly cure can be expected in over one-third of newly diagnosed children with ALL after 2-4 years of antileukemic treatment.

[Radiotherapy of anal carcinomas. Case reviews]

Radiotherapy is commonly assigned an important role in the treatment of anal neoplasia. Interstitial treatment with 192Ir and high-energy transcutaneous therapy will lead to survival and cure percentages comparable with those obtainable surgically, if correctly employed in accordance with precise indications, in stage T1 and T2 tumours. External high-energy management, with or without surgery, may also be effective in stage T3 cases. The seriousness and frequency of radionecrosis have hitherto helped to create a lack of trust in radiation management. Modern irradiation techniques, however, have reduced these complications to low percentages, and their resolution by destructive surgery is rarely required.

HBeAg/anti-HBe system and cell-mediated immunity in patients with HBsAg-positive chronic active hepatitis

Determinations of HBeAg, anti-HBe and cell-mediated immune response were carried out in 29 patients with HBsAg-positive chronic active hepatitis. Out of 29 patients with chronic active hepatitis B, 18 were found to be HBeAg positive, 7 anti-HBe positive, and 4 without detectable HBeAg/anti-HBe by radioimmunoassay. The presence of HBeAg in serum (n = 18) was associated with impaired lymphocyte response in 15 patients (83.3%, p less than 0.05). Out of these 15 patients 6 developed cirrhosis within a period of 6 months to 2 years. By contrast, this occurred in only 1 out of 8 HBeAg-negative patients (6 were anti-HBe positive) with normal lymphocyte function. Although HBeAg and depressed cellular immune response in chronic active hepatitis is not necessarily associated with a bad clinical and histological outcome of the disease, these data suggest that, in a number of cases, host cell-mediated immune response seems to be correlated with the presence of HBeAg and the outcome of chronic active hepatitis and, in this respect, HBeAg could assume the significance of a prognostic marker in hepatitis B virus infection.

Radioimmunoassay in the detection of the hepatitis B e antigen/antibody system in asymptomatic carriers of hepatitis B surface antigen. Correlation with serum Dane particle associated DNA polymerase activity

A radioimmunoassay for hepatitis e antigen (HBeAg) and antibody to e (anti-HBe) was developed and sera of 71 asymptomatic chronic carriers of hepatitis B surface antigen (HBsAg), in 44 of whom liver biopsy was obtained, were tested. In addition, testing for Dane particle associated DNA polymerase activity was performed in all sera. HBeAg was detected in 14 subjects (19.7%) and anti-HBe in 46 (64.8%). The highest proportion of HBeAg positivity (40%) was found among carriers with histological evidence of chronic hepatitis, whereas anti-HBe was present in 80% of carriers with normal liver histology, in 58% of carriers with non-specific reactive hepatitis and in 60% of carriers with chronic liver lesions. DNA polymerase activity was present in 92.8% of sera positive for HBeAg, in 13% of sera positive for anti-HBe, and in 9% of sera negative for both markers. Our results demonstrate that not all HBsAg carriers reactive to HBeAg show evidence of chronic hepatitis nor, conversely, that anti-HBe is invariably associated with the healthy carrier state of HBsAg. Finally, circulating Dane particles, as revealed by the presence of serum specific DNA polymerase activity, may also be present in anti-HBe positive sera other than those of some HBsAg carriers lacking both HBeAg and anti-HBe.

[Distribution of anti-HAV in a population sample from Puglia]

To investigate the prevalence and distribution of antibody to hepatitis A virus (anti-HAV), we tested by solid phase radioimmunoassay method 461 sera of selected people of Bari, according to age. In addiction, sera from cord blood of 11 newborns and their mothers at delivery were also investigated for anti-HAV. Taken together 64.4 per cent of subjects tested were found to be anti-HAV positive. The rate of antibody detection was strongly correlated with age. The prevalence were 4.5 per cent from 6 months to 3 years but gradually increased throughout childhood (from 35.6 to 80 per cent). Anti-HAV was detected in all cord blood samples from newborns whose mothers carried anti-HAV. These data suggest that circulation of hepatitis A virus in our area is very high, so that serological evidence of infection become evident in the majority of individuals during infancy.

[Antinuclear antibody (anti-HBc) and liver pathology in acute and chronic virus B hepatitis]

HBsAg and anti-HBc, the antibody to core antigen of hepatitis B virion, were titrated by solid phase radioimmunoassay in 40 sera of HBsAg carriers with acute and chronic hepatitis and in 20 healthy subjects carrying anti-HBc alone or associated with anti-HBs. No correlation was found between HBsAg and anti-HBc titers in the single category of patients. In contrast, geometric mean titer of anti-HBc (ranging from 2(14) to 2(15)) of patients with chronic active hepatitis was significantly higher ( p = < 0.01) than that of patients with acute or chronic persistent hepatitis and healthy HBsAg carriers (ranging from 2(9) to 2(14)). Anti-HBc titer of 20 subjects without detectable HBsAg was less than 2(7). These data suggest that in subjects with persistent B virus infection, anti-HBc response is correlated with synthesis of viral genome rather than of surface antigens, so that a much higher titer of anti-HBc was detected only in patients with a more active liver disease.

[Serodiagnosis of acute hepatitis A]

Hepatitis A antibody (anti-HAV) was detected by specific radioimmunoassay (RIA) method in sera from 10 patients with acute icteric hepatitis. Anti-HAV was detectable in many subjects very early before the onset of jaundice, but the diagnosis of type A hepatitis in all patients was confirmed by the demonstration of seroconversion during convalescence. Since the initial antibody detected by RIA is predominantly IgM, while IgG specific anti-HAV appears later reaching peak levels within 1 to 2 months, we treated serum specimens of these patients with 2-mercaptoethanol (2ME) in order to differentiate acute-from convalescent-phase hepatitis A sera. Inactivation of IgM fraction with 2ME produced a significant reduction of anti-HAV titer only in acute-phase sera, so that this procedure may be used for early diagnosis of acute type A hepatitis.

[Prognostic value of alpha-foetoprotein in fulminant hepatitis (author's transl)]

Serum concentrations of alpha-foetoprotein (AFP) were measured sequentially by radioimmunoassay in 32 patients with fulminant hepatitis and coma, 22 of whom died. Levels were significantly elevated in 100% of patients who survived and in 7 out of 22 patients (38.5%) who died (P = less than 0.005). In the survivors the rise of AFP levels was found early after the development of coma and subsequently in all serum samples obtained during acute phase of illness. In 2 of 7 fatal cases who had raised AFP levels and the more protracted illness, AFP levels fall after 6 days. The high levels of serum AFP observed in severe forms of hepatitis may represent active hepatocyte regeneration after extensive hepatic necrosis. Although the correlation between survival and serum concentration of AFP is not absolute, our finding indicate that the rise in serum of this protein in patients with massive hepatic necrosis may be considered a favorable prognostic sign.

Persistence of e antigen as prognostic marker in acute hepatitis B

Serial determinations of HBeAg and anti-HBe were made in sera of 155 selected patients with acute hepatitis B who were followed up for one to four years. In the early phase of hepatitis, HBeAg was present in 43 cases (27.7%) and anti-HBe in 12 cases (7.7%). Evaluation of the outcome of hepatitis showed that development of chronic hepatitis occurred in 11 out of 43 HBeAg positive patients, in 10 out of 100 HBeAg negative patients (P = less than 0.05) and in 2 out of 12 patients carrying anti-HBe. Nine out of 11 HBeAg positive chronic subjects showed persistent HBe antigenemia over two months, while the remaining 32 patients, who recovered completely, lost HBeAg within two to three weeks from the onset of the disease. These data suggest that the prognostic value of HBeAg in acute hepatitis patients may be taken into account when HBeAg persists in the serum and that anti-HBe does not invariably protect from the development of chronic hepatitis.

[Factors of contagiousness in the epidemiology of hepatitis type B (author's transl)]

Since morbidity of viral hepatitis B is increasing, the causes of diffusion of this infection have been studied. There are several routes of transmission and undoubtedly apparent non-parenteral routes have a great importance. In a study performed on 32 families of HBsAg carriers, familial aggregation of infection has been acquired through close personal contact. Transmission of infection from mother to infant may occur transplacentally for vertical transmission, or, after the birth, for horizontal transmission, so that a high percentage of children is infected. Percutaneous transmission of hepatitis B in families affected by scabies is evident. The presence of infectivity markers is of major importance for transmission of virus: these are HBeAg and specific DNA-polymerase activity of serum. Well, when the carrier exhibits the markers, the contacts are involved in the infection in a high percentage. From this point of view the carriers with chronic liver disease are more dangerous than the asymptomatic ones. The problem of carrier exists: nevertheless it is possible to carry out a better prophylaxis, if we take into account the presence of the infectivity markers.

[Role of chronic HBsAg carriers in intrafamilial diffusion of hepatitis B virus infection]

To assess the hepatitis B virus infection risk to household contacts exposed to HBsAg-positive chronic carriers, 169 family members of 20 healthy carriers of HBsAg and of 12 with chronic hepatitis were followed up prospectively for two to five years. All family members are investigated for the presence of serum HBsAg/antiHBs system and for the presence of liver disease. Our results indicate that the family contacts of HBsAg carriers with evidence of chronic liver disease are at greater risk of exposure to HBV than the contacts of healthy carriers and that acquisition of HBsAg is more common among males than among females. Evidence of exposure to HBsAg is very frequent in young age with a striking rise between 10 and 20 years. On the contrary acquisition of anti-HBsAg is more common after 40 years of age. These data suggest that persistent circulation of HBV in a family of chronic HBsAg carrier increases the risk of infection in household contacts and that HBV is eliminated in a more infective form from the carriers with chronic liver disease.