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Ding Y, Zhou Z, Li X, Zhao C, Jin X, Liu X, Wu Y, Mei X, Li J, Qiu J, Shen C. Screening and Identification of HBV Epitopes Restricted by Multiple Prevalent HLA-A Allotypes. Front Immunol 2022; 13:847105. [PMID: 35464415 PMCID: PMC9021956 DOI: 10.3389/fimmu.2022.847105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Accepted: 03/15/2022] [Indexed: 12/21/2022] Open
Abstract
Although host T cell immune responses to hepatitis B virus (HBV) have been demonstrated to have important influences on the outcome of HBV infection, the development of T cell epitope-based vaccine and T cell therapy and the clinical evaluation of specific T cell function are currently hampered markedly by the lack of validated HBV T cell epitopes covering broad patients. This study aimed to screen T cell epitopes spanning overall HBsAg, HBeAg, HBx and HBpol proteins and presenting by thirteen prevalent human leukocyte antigen (HLA)-A allotypes which gather a total gene frequency of around 95% in China and Northeast Asia populations. 187 epitopes were in silico predicted. Of which, 62 epitopes were then functionally validated as real-world HBV T cell epitopes by ex vivo IFN-γ ELISPOT assay and in vitro co-cultures using peripheral blood mononuclear cells (PBMCs) from HBV infected patients. Furthermore, the HLA-A cross-restrictions of each epitope were identified by peptide competitive binding assay using transfected HMy2.CIR cell lines, and by HLA-A/peptide docking as well as molecular dynamic simulation. Finally, a peptide library containing 105 validated epitopes which cross-binding by 13 prevalent HLA-A allotypes were used in ELISPOT assay to enumerate HBV-specific T cells for 116 patients with HBV infection. The spot forming units (SFUs) was significantly correlated with serum HBsAg level as confirmed by multivariate linear regression analysis. This study functionally validated 62 T cell epitopes from HBV main proteins and elucidated their HLA-A restrictions and provided an alternative ELISPOT assay using validated epitope peptides rather than conventional overlapping peptides for the clinical evaluation of HBV-specific T cell responses.
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Affiliation(s)
- Yan Ding
- Department of Microbiology and Immunology, Medical School, Southeast University, Nanjing, China
| | - Zining Zhou
- Department of Microbiology and Immunology, Medical School, Southeast University, Nanjing, China
| | - Xingyu Li
- Key Laboratory of Developmental Genes and Human Disease, Ministry of Education, School of Life Science and Technology, Southeast University, Nanjing, China
| | - Chen Zhao
- Department of Microbiology and Immunology, Medical School, Southeast University, Nanjing, China
| | - Xiaoxiao Jin
- Department of Microbiology and Immunology, Medical School, Southeast University, Nanjing, China
| | - Xiaotao Liu
- Department of Microbiology and Immunology, Medical School, Southeast University, Nanjing, China
| | - Yandan Wu
- Department of Microbiology and Immunology, Medical School, Southeast University, Nanjing, China
| | - Xueyin Mei
- Key Laboratory of Developmental Genes and Human Disease, Ministry of Education, School of Life Science and Technology, Southeast University, Nanjing, China
| | - Jian Li
- Key Laboratory of Developmental Genes and Human Disease, Ministry of Education, School of Life Science and Technology, Southeast University, Nanjing, China
| | - Jie Qiu
- Division of Hepatitis, Nanjing Second Hospital, Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing, China
| | - Chuanlai Shen
- Department of Microbiology and Immunology, Medical School, Southeast University, Nanjing, China
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Wang H, Liao F, Xie J, Gao W, Wang M, Huang J, Xu R, Liao Q, Shan Z, Zheng Y, Rong X, Li C, Fu Y. E2 Site Mutations in S Protein Strongly Affect Hepatitis B Surface Antigen Detection in the Occult Hepatitis B Virus. Front Microbiol 2021; 12:664833. [PMID: 34867835 PMCID: PMC8635997 DOI: 10.3389/fmicb.2021.664833] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 10/11/2021] [Indexed: 12/22/2022] Open
Abstract
The mechanism of occult hepatitis B infection (OBI) has not yet been fully clarified. Our previous research found that novel OBI-related mutation within S protein, E2G, could cause the hepatitis B surface antigen (HBsAg) secretion impairment, which resulted in intracellular accumulation in OBI of genotype B. Here, to further explore the role of E2 site mutations in the occurrence of OBI, we analyzed these site mutations among 119 OBI strains identified from blood donors. Meanwhile, 109 wild-type HBV strains (HBsAg positive/HBV DNA positive) were used as control group. Furthermore, to verify the E2 site mutations, two conservative 1.3-fold full-gene expression vectors of HBV genotype B and C (pHBV1.3B and pHBV1.3C) were constructed. Then, the E2 mutant plasmids on the basis of pHBV1.3B or pHBV1.3C were constructed and transfected into HepG2 cells, respectively. The extracellular and intracellular HBsAg were analyzed by electrochemical luminescence and cellular immunohistochemistry. The structural characteristics of S proteins with or without E2 mutations were analyzed using relevant bioinformatics software. E2 mutations (E2G/A/V/D) existed in 21.8% (26/119) of OBIs, while no E2 mutations were found in the control group. E2G/A/V/D mutations could strongly affect extracellular and intracellular level of HBsAg (p < 0.05). Notably, unlike E2G in genotype B that could cause HBsAg intracellular accumulation and secretion decrease (p < 0.05), E2G in genotype C could lead to a very significant HBsAg decrease both extracellularly (0.46% vs. pHBV1.3C) and intracellularly (11.2% vs. pHBV1.3C) (p < 0.05). Meanwhile, for E2G/A mutations, the relative intracellular HBsAg (110.7-338.3% vs. extracellular) and its fluorescence intensity (1.5-2.4-fold vs. with genotype-matched pHBV1.3B/C) were significantly higher (p < 0.05). Furthermore, N-terminal signal peptides, with a typical cleavage site for peptidase at positions 27 and 28, were exclusively detected in S proteins with secretion-defective mutants (E2G/A). Our findings suggest that: (1) E2G/A/V/D mutations were confirmed to significantly influence the detection of HBsAg, (2) the underlying mechanism of OBI caused by E2G mutation is quite different between genotype B and genotype C, and (3) E2G/A could produce a N-terminal truncated S protein, which might attribute to the HBsAg secretion impairment in the OBIs.
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Affiliation(s)
- Hao Wang
- Guangzhou Blood Center, Guangzhou, China
| | | | - Junmo Xie
- Guangzhou Blood Center, Guangzhou, China
| | - Wenbo Gao
- Guangzhou Blood Center, Guangzhou, China
| | - Min Wang
- Guangzhou Blood Center, Guangzhou, China
| | | | - Ru Xu
- Guangzhou Blood Center, Guangzhou, China
| | - Qiao Liao
- Guangzhou Blood Center, Guangzhou, China
| | | | | | - Xia Rong
- Guangzhou Blood Center, Guangzhou, China
| | - Chengyao Li
- Department of Transfusion Medicine, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, China
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3
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Gu S, Lv L, Lin X, Li X, Dai J, Zhang J, Kong R, Xie W, Li J. Using structural analysis to explore the role of hepatitis B virus mutations in immune escape from liver cancer in Chinese, European and American populations. J Biomol Struct Dyn 2020; 40:1586-1596. [PMID: 33030111 DOI: 10.1080/07391102.2020.1830852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hepatitis B virus (HBV) infection is an important problem threatening human health. After HBV virus invades human body, it may assemble a complete virus particle in the cytoplasm to trigger the immune reaction, especially the interaction between the HBV virus and the host that mediated by CD8+ T cell. We collected the sequences of HBV from the HBVdb database, then screened candidate mutation sites in Chinese, European and American populations based on conservation and physicochemical properties. After that we constructed the three-dimensional structure of Major histocompatibility complex class I (MHC I) -peptide complexes, performed molecular docking, run molecular dynamics to compare the binding free energy, stability, and affinity of MHC I-peptide complexes with the aim to estimate the effect of peptide mutation. The specific HBV virus subtypes of the Chinese, European and American population were studied and the candidate mutation sites were used to predict the mutant peptide antigen. Finally, based on physical and chemical properties and peptide antigen prediction scores, 21 HBV mutation sites were selected. Then combined with specific Human lymphocyte antigen (HLA) subtypes, 11 mutations were found to have a significant negative impact on affinity, stability and binding free energy. Overall, our work found important potential mutations, which provide an evaluation of HBV mutations and a clue of it in immunotherapy.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Shuanglin Gu
- Key Laboratory of DGHD, MOE, Institute of Life Sciences, Southeast University, Nanjing, China
| | - Li Lv
- Key Laboratory of DGHD, MOE, Institute of Life Sciences, Southeast University, Nanjing, China
| | - Xue Lin
- Department of Bioinformatics, School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
| | - Xingyu Li
- Key Laboratory of DGHD, MOE, Institute of Life Sciences, Southeast University, Nanjing, China
| | - Juncheng Dai
- Department of Bioinformatics, School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
| | - Jianqiong Zhang
- Key Laboratory of DGHD, MOE, Institute of Life Sciences, Southeast University, Nanjing, China
| | - Ren Kong
- Institute of Bioinformatics and Medical Engineering, School of Electrical and Information Engineering, Jiangsu University of Technology, Changzhou, China
| | - Wei Xie
- Key Laboratory of DGHD, MOE, Institute of Life Sciences, Southeast University, Nanjing, China
| | - Jian Li
- Key Laboratory of DGHD, MOE, Institute of Life Sciences, Southeast University, Nanjing, China
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Liu H, Shen L, Zhang S, Wang F, Zhang G, Yin Z, Qiu F, Liang X, Wang F, Bi S. Complete genome analysis of hepatitis B virus in Qinghai-Tibet plateau: the geographical distribution, genetic diversity, and co-existence of HBsAg and anti-HBs antibodies. Virol J 2020; 17:75. [PMID: 32532295 PMCID: PMC7291583 DOI: 10.1186/s12985-020-01350-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 06/03/2020] [Indexed: 12/17/2022] Open
Abstract
Background The genetic variation and origin of Hepatitis B Virus (HBV) in Qinghai-Tibet Plateau were poorly studied. The coexistence of HBsAg and anti-HBs has been described as a puzzle and has never been reported in the indigenous population or in recombinant HBV sequences. This study aimed to report geographical distribution, genetic variability and seroepidemiology of HBV in southwest China. Methods During 2014–2017, 1263 HBsAg positive serum were identified and 183 complete genome sequences were obtained. Serum samples were collected from community-based populations by a multistage random sampling method. Polymerase chain reaction (PCR) was used to amplify the HBV complete genome sequences. Then recombination, genetic variability, and serological analysis were performed. Results (1) Of the 1263 HBsAg positive serum samples, there were significant differences between the distribution of seromarkers in Tibet and Qinghai. (2) Of 183 complete genome sequences, there were 130 HBV/CD1 (71.0%), 49 HBV/CD2 (26.8%) and four HBV/C2 isolates (2.2%). Serotype ayw2 (96.1%) was the main serological subtype. (3) Several nucleotide mutations were dramatically different in CD1 and CD2 sequences. Clinical prognosis-related genetic variations such as nucleotide mutation T1762/A1764 (27.93%), A2189C (12.85%), G1613A (8.94%), T1753C (8.38%), T53C (4.47%) T3098C (1.68%) and PreS deletion (2.23%) were detected in CD recombinants. (4) From the inner land of China to the northeast boundary of India, different geographical distributions between CD1 and CD2 were identified. (5) Twenty-seven (2.14%) HBsAg/HBsAb coexistence serum samples were identified. S protein amino acid mutation and PreS deletion were with significant differences between HBsAg/HBsAb coexistence group and control group. Conclusions HBV/CD may have a mixed China and South Asia origin. Based on genetic variations, the clinical prognosis of CD recombinant seems more temperate than genotype C strains in China. The HBsAg/HBsAb coexistence is a result of both PreS deletion and aa variation in S protein. Several unique mutations were frequently detected in HBV/CD isolates, which could potentially influence the clinical prognosis.
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Affiliation(s)
- He Liu
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Changbai Rd 155#, Changping District, Beijing, China.,Department of Infectious Disease, Tianjin Center for Disease Control and Prevention, Tianjin, People's Republic of China
| | - Liping Shen
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Changbai Rd 155#, Changping District, Beijing, China
| | - Shuang Zhang
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Changbai Rd 155#, Changping District, Beijing, China
| | - Feng Wang
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Changbai Rd 155#, Changping District, Beijing, China
| | - Guomin Zhang
- National Immunization Program, Chinese Center for Disease Control and Prevention, Beijing, People's Republic of China
| | - Zundong Yin
- National Immunization Program, Chinese Center for Disease Control and Prevention, Beijing, People's Republic of China
| | - Feng Qiu
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Changbai Rd 155#, Changping District, Beijing, China
| | - Xiaofeng Liang
- Chinese Center for Disease Control and Prevention, Beijing, People's Republic of China
| | - Fuzhen Wang
- National Immunization Program, Chinese Center for Disease Control and Prevention, Beijing, People's Republic of China
| | - Shengli Bi
- NHC Key Laboratory of Medical Virology and Viral Diseases, National Institute for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Changbai Rd 155#, Changping District, Beijing, China.
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5
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Zang H, Xu Z, Liu Y, Li X, Rong Y, Jiang L, You S, Hu J, Zhao J, Xu D, Xin S. Clinical and virological implications of A1846T and C1913A/G mutations of hepatitis B virus genome in severe liver diseases. Scand J Gastroenterol 2018; 53:319-328. [PMID: 29322851 DOI: 10.1080/00365521.2018.1424934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Mutations occurring within different genes of hepatitis B virus (HBV) genome may have different clinical implications. This study aimed to observe the clinical and virological implications of the A1846T and C1913A/G mutations of HBV genome in the development and treatment outcome of severe liver diseases, which has not been previously determined. MATERIALS AND METHODS A total of 438 cases of patients with liver diseases were retrospectively reviewed, including 146 with mild chronic hepatitis B infection (CHB-M), 146 with severe chronic hepatitis B infection (CHB-S), and 146 with acute-on-chronic liver failure (ACLF). Partial or full-length HBV genome was directly sequenced. Replicons containing A1846T, C1913A or other mutant sequences, or the wild-type counterparts were constructed respectively, and then transfected into HepG2 cells for phenotype analysis. RESULTS There was significant difference in the detection rates of A1846T (30.82%, 40.41% and 55.48%, respectively) and C1913A/G (15.52%, 28.77%, and 35.62%, respectively) among patients with CHB-M, those with CHB-S, and those with ACLF (p < .01). A1846T was significantly associated with the mortality of ACLF patients within six months after the disease onset (OR 1.704, p = .041). In vitro experiment revealed that A1846T mutant resulted in 3.20-fold and 1.85-fold increase of replication capacity and promoter activity, respectively compared with wild type counterpart (p < .001), while C1913A led to a significant decrease of core protein expression (p < .05). CONCLUSION Occurrence of A1846T and C1913A is positively associated with clinical presentations of severe liver disease. A1846T mutation is significantly associated with poor prognosis of ACLF.
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Affiliation(s)
- Hong Zang
- a Institute of Infectious Diseases and Liver Failure Medical Center , Beijing 302 Hospital , Beijing , P.R. China
| | - Zhihui Xu
- b Research Center for Clinical and Translational Medicine , Beijing 302 Hospital , Beijing , P.R. China
| | - Yan Liu
- b Research Center for Clinical and Translational Medicine , Beijing 302 Hospital , Beijing , P.R. China
| | - Xiaodong Li
- b Research Center for Clinical and Translational Medicine , Beijing 302 Hospital , Beijing , P.R. China
| | - Yihui Rong
- c Treatment and Research Center for Liver Cancer , Beijing 302 Hospital , Beijing , P.R. China
| | - Ling Jiang
- b Research Center for Clinical and Translational Medicine , Beijing 302 Hospital , Beijing , P.R. China
| | - Shaoli You
- a Institute of Infectious Diseases and Liver Failure Medical Center , Beijing 302 Hospital , Beijing , P.R. China
| | - Jinhua Hu
- a Institute of Infectious Diseases and Liver Failure Medical Center , Beijing 302 Hospital , Beijing , P.R. China
| | - Jun Zhao
- a Institute of Infectious Diseases and Liver Failure Medical Center , Beijing 302 Hospital , Beijing , P.R. China
| | - Dongping Xu
- a Institute of Infectious Diseases and Liver Failure Medical Center , Beijing 302 Hospital , Beijing , P.R. China
| | - Shaojie Xin
- a Institute of Infectious Diseases and Liver Failure Medical Center , Beijing 302 Hospital , Beijing , P.R. China
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6
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Zhang K, Liu Y, Chen R, Li Q, Xu Z, Si L, Cheng Y, Yang Y, Chen J, Xu D, Lin S. Antigenicity reduction contributes mostly to poor detectability of HBsAg by hepatitis B virus (HBV) S-gene mutants isolated from individuals with occult HBV infection. J Med Virol 2017; 90:263-270. [PMID: 28876463 DOI: 10.1002/jmv.24936] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Accepted: 08/24/2017] [Indexed: 12/11/2022]
Abstract
Mutations in hepatitis B virus (HBV) S gene are one of factors contributing to occult HBV infection (OBI). The study aimed to uncover the impact of OBI-related S-gene mutations on the detectability of hepatitis B surface antigen (HBsAg). Nine representative mutations within the major hydrophilic region of the S region were investigated. These included six (M1-M6) from an OBI patient with HBV-related hepatocellular carcinoma, and three (M7-M9) from three OBI blood donors. Recombinant plasmids on the basis of pTriEx-mod-1.1 HBV and pcDNA3.1(-)/myc-His A vectors were constructed for each and transfected into HepG2 or Huh7 cells, respectively. Electrochemical luminescence, ELISA, Western blotting, and confocal immunofluorescence were used to examine HBsAg expression and antigenicity. In comparison to wild-type strain, supernatant and intracellular HBsAg levels of the nine mutants were reduced by 56.39-99.09% and 42.76-99.77% upon Roche quantitative Elecsys assay, respectively. Confocal immunofluorescence showed that relative intensity ratios of HBsAg-myc-His fusion protein detected by anti-HBs and anti-His-tag were lower by 11.87-76.27% for the nine mutants compared to the wild-type strain. Specifically, M1-M5 mutants that we firstly found recently were 33.14%, 76.27%, 57.93%, 53.37%, and 40.88% lower, respectively. Consistent results were obtained using double-antibody sandwich ELISA assays (anti-myc + anti-HBs vs anti-myc + anti-His). Antigenicity reduction played a major role for the poor detectability of HBsAg caused by the OBI-related mutations, although decreased HBsAg expression of some mutants and anti-HBs in samples might play coordinated roles. Taken together, antigenicity reduction contributes mostly to poor detectability of HBsAg caused by these OBI-related mutations.
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Affiliation(s)
- Kai Zhang
- Department of Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Yan Liu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Rongjuan Chen
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Qi Li
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Zhihui Xu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Lanlan Si
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Yongqian Cheng
- International Center for Diagnosis and Treatment of Liver Diseases, Beijing 302 Hospital, Beijing, China
| | - Yue Yang
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Jianhong Chen
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Dongping Xu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Shumei Lin
- Department of Infectious Diseases, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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7
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Wu DX, Fu XY, Gong GZ, Sun KW, Gong HY, Wang L, Wu J, Tan DM. Novel HBV mutations and their value in predicting efficacy of conventional interferon. Hepatobiliary Pancreat Dis Int 2017; 16:189-196. [PMID: 28381384 DOI: 10.1016/s1499-3872(16)60184-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Accumulating studies assessing the impacts of hot spot mutations on conventional interferon (IFN) efficacy come to discrepant conclusions; studies regarding the mutations in S and RT regions are also unclear. The present study aimed to evaluate the impacts of HBV mutations on the efficacy of conventional IFN. METHODS A total of 126 patients who received conventional IFN treatment for 48 weeks were enrolled. Biochemical and serological parameters were routinely tested. The sequences of HBV from 78 serum samples were amplified by nested-PCR; mutations were identified with sequence scanner V1.0 after ABI 3730xl direct sequencing, HBV genotypes were determined according to RT gene sequences utilizing NCBI Genotyping Tool which was based on phylogenetic analysis. RESULTS The baseline DNA levels of virological response (VR) group were significantly lower than those of no VR group [7.13+/-0.76 vs 7.69+/-0.56 lg (copies/mL), P=0.001]. The baseline ALT levels were significantly higher in the HBeAg clearance group (204.72+/-88.65 vs 162.80+/-85.81 IU/L, P<0.05) and HBeAg seroconversion group (204.89+/-95.68 vs 166.75+/-84.43 IU/L, P<0.05). Females and lower BMI levels (20.01+/-2.33 vs 21.65+/-3.66 kg/m2, P<0.05) were prone to acquired biochemical response (BR). PC-W28STOP (ntG1896A) was significantly higher in the combined response (CR) group than that in the no CR group (91.7% vs 39.7%, P=0.001). Multivariate logistic regression analysis showed that baseline DNA, PC-P159T (ntC2288A), BCP-N118T (ntA1726C) and BCP-L134L (ntA1775C/G/T) influenced VR independently. PC-G182C (ntG2357T), PC-S64A/T (ntT2003G/A) and BMI were independent influence factors for HBeAg clearance, HBeAg seroconversion and BR, respectively. The new predicting model concluded that baseline DNA and new mutations for VR were established successfully, and ROC analysis showed that AUC was 0.842 (P<0.001) with a sensitivity of 0.652 and a specificity of 0.933. CONCLUSIONS PC-P159T (ntC2288A), BCP-N118T (ntA1726C), BCP-L134L (ntA1775C/G/T), PC-G182C (ntG2357T) and PC-S64A/T (ntT2003G/A) were novel identified mutations that impacted IFN therapeutic efficacy. These novel mutations could serve as important predictors before conventional IFN treatment.
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Affiliation(s)
- Da-Xian Wu
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Key Laboratory of Viral Hepatitis of Hunan Province, Changsha, China.
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8
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Liao H, Liu Y, Chen J, Ding W, Li X, Xu Z, Yang Y, Chen R, Si L, Xu X, Guo J, Xu D. Characterization of hepatitis B virus (HBV) preS/S gene mutations in blood donors with occult HBV infection in the Baoji area of North China. Transfusion 2017; 57:857-866. [PMID: 28236303 DOI: 10.1111/trf.14046] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 12/21/2016] [Accepted: 12/22/2016] [Indexed: 02/07/2023]
Affiliation(s)
- Hao Liao
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital; Beijing China
| | - Yan Liu
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital; Beijing China
| | - Jianhong Chen
- Department of Infectious Diseases; Peking University First Hospital; Beijing China
| | | | - Xiaodong Li
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital; Beijing China
| | - Zhihui Xu
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital; Beijing China
| | - Yuan Yang
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital; Beijing China
| | - Rongjuan Chen
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital; Beijing China
| | - Lanlan Si
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital; Beijing China
| | - Xiaoyuan Xu
- Department of Infectious Diseases; Peking University First Hospital; Beijing China
| | | | - Dongping Xu
- Research Center for Clinical and Translational Medicine/Institute of Infectious Diseases, Beijing 302 Hospital; Beijing China
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9
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Haghighat A, Moafi M, Sharifian J, Salehi H, Taleban R, Kalbasi N, Salehi M, Salehi MM, Salehi M. Effect of Tetanus-diphtheria Vaccine on Immune Response to Hepatitis B Vaccine in Low-responder Individuals. Int J Prev Med 2016; 7:94. [PMID: 27563430 PMCID: PMC4977968 DOI: 10.4103/2008-7802.186586] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 06/11/2016] [Indexed: 12/04/2022] Open
Abstract
Background: Conventional hepatitis B virus (HBV) vaccination fails to achieve efficient protection in about 5–10% of the world population. Hence, different strategies have been adopted to ameliorate HBV antibody titers. This study aimed to evaluate the concurrent application of tetanus-diphtheria (Td) and HBV vaccination on hepatitis B surface (HBs) antibody titer in low-responder healthy individuals. Methods: This was a randomized clinical trial, which was implemented among 140 of medical staff working as health-care workers assumed as low-responders. The subjects were randomly allocated to either control or interventional groups. The control and interventional groups received HBV recombinant vaccine while the latter group was also vaccinated through Td. Enzyme-linked immunosorbent assay was applied to measure HBs antibody (HBsAb) titers just before and 6 months after the last vaccination. All data were entered into SPSS software. Independent t-test, paired t-test, and Chi-square or Fisher's exact test were applied for data comparison. Results: Antibody titers of the subjects in the intervention and control groups soared from 49.08 ± 20.08 IU/L to 917.78 ± 204.80 IU/L and from 46.95 ± 18.55 to 586.81 ± 351.77 IU/L, respectively (both P < 0.001); nevertheless, by comparison with control group, variation of antibody titer in the interventional group was significantly higher (P < 0.001). Conclusions: Concurrent application of Td and HBV vaccine could effectively enhance protective levels of HBsAb titers in low-responder individuals.
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Affiliation(s)
- Abbas Haghighat
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Moafi
- Acquired Immunodeficiency Research Centre, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Jalil Sharifian
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran
| | - Hassan Salehi
- Department of Infectious Diseases, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Roya Taleban
- Department of Community Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nader Kalbasi
- Department of Oral Pathology, School of Dentistry, Islamic Azad University (Khorasgan Branch), Isfahan, Iran
| | - Marzieh Salehi
- Department of Infectious Diseases, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Mahdi Salehi
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Salehi
- Department of Oral and Maxillofacial Surgery, School of Dentistry, Isfahan University of Medical Sciences, Isfahan, Iran
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10
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Liao H, Li X, Liu Y, Xu Z, Huang P, Nian X, Liu X, Xu D. Intergenotype recombinant analysis of full-length hepatitis B virus genomes from 516 Chinese patients with different illness categories. J Med Virol 2016; 89:139-145. [PMID: 27328656 DOI: 10.1002/jmv.24609] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2016] [Indexed: 01/05/2023]
Abstract
This study aimed to reveal characteristics and clinical relevance of HBV intergenotypic recombinants. Serum samples of 516 patients from Northern China were collected, including 131 with acute hepatitis B (AHB), 239 with chronic hepatitis B (CHB), and 146 with acute-on-chronic liver failure (ACLF). Full-length HBV genomes were sequenced and HBV genotypes were analyzed. Genotypes C, B, D, and intergenotypic recombinants were detected in 71.12% (367/516), 19.96% (103/516), 0.78% (4/516), and 8.14% (42/516) of the patients. The latter comprised 21 with AHB, 10 with CHB, and 11 with ACLF; and the occupations of intergenotypic recombinants in AHB, CHB, and ACLF groups were 16.03%, 4.18%, and 7.53% (P < 0.01), respectively. HBV B/C and C/D hybrids accounted for 85.71% (36/42) and 14.29% (6/42) of the intergenotypic recombinants. In AHB and CHB groups, serum HBV DNA levels were significantly lower in patients with intergenotypic recombinants than those without intergenotypic recombinants. Difference in basal core promoter A1762T/G1764A mutations and precore G1896A mutation incidences was not significant between B/C recombinant and genotypes B or C virus, although the significance was there between genotypes B and C viruses. Clonal sequence analysis showed that intergenotypic recombinant viral strains existed in single or in concomitance with other genotype virus. Phenotypic analysis showed that viral replication capacity was similar between recombinant and non-recombinant strains in tested samples. Taken together, the occurrence of intergenotypic recombinant HBV is relatively low in HBV-infected patients in Northern China, and intergenotypic recombinant HBV infection is likely favorable to induce an acute course of disease. J. Med. Virol. 89:139-145, 2017. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Hao Liao
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Xiaodong Li
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Yan Liu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Zhihui Xu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Pengyu Huang
- Institute of Biochemistry and Molecular Biology, Guangdong Medical College, Guangdong, China
| | - Xueyuan Nian
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China
| | - Xinguang Liu
- Institute of Biochemistry and Molecular Biology, Guangdong Medical College, Guangdong, China. .,Guangdong Provincial Key Laboratory of Medical Molecular Diagnostics, Guangdong, China.
| | - Dongping Xu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing, China. .,Institute of Biochemistry and Molecular Biology, Guangdong Medical College, Guangdong, China.
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11
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Li X, Qin Y, Liu Y, Li F, Liao H, Lu S, Qiao Y, Xu D, Li J. PreS deletion profiles of hepatitis B virus (HBV) are associated with clinical presentations of chronic HBV infection. J Clin Virol 2016; 82:27-32. [PMID: 27415434 DOI: 10.1016/j.jcv.2016.06.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 06/20/2016] [Accepted: 06/28/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The association of hepatitis B virus (HBV) preS1 and preS2 deletions with progressive liver diseases are not fully understood. OBJECTIVE The study aimed to investigate characteristics of HBV preS deletion in HBV-infected patients with different illness categories. STUDY DESIGN Total of 539 HBV-infected patients were enrolled in the study, including 146 with chronic hepatitis B (CHB), 111 with HBV-related liver cirrhosis (LC), 146 with HBV-related acute-on-chronic liver failure (ACLF), and 136 with HBV-related hepatocellular carcinoma (HCC). PreS deletion was determined by sequencing. Replicons containing representative preS1 and preS2 deletion mutants and wild-type were respectively constructed and transfected into HepG2 cells for phenotypic analysis. RESULTS The detection rates of overall preS deletion were 15.8%, 26.1%, 24.0%, and 34.6% in CHB, LC, ACLF, and HCC patients, respectively. PreS1 deletion was most frequently detected in LC patients while preS2 deletion was most frequently detected in HCC patients, both frequencies were significantly higher than that in CHB patients (17.1% vs. 4.8%, P<0.01; 19.1% vs. 4.8%, P<0.01). The deletion patterns across preS gene were different among the 4 illness categories. Compared with wild-type strain, the preS1 deletion mutant had defected preS1 expression, significantly decreased viral mRNA level and SP II promoter activity; while preS2 deletion mutant had defected preS2 expression, and significantly decreased viral mRNA level. CONCLUSIONS HBV preS deletion was associated with advancement of liver diseases not only presented in preS deletion incidence, but also in the deletion pattern. Patients with preS2 deletion might have a higher risk to develop HCC.
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Affiliation(s)
- Xiaodong Li
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Yaqun Qin
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Yan Liu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Fan Li
- The Second Liver Cirrhosis Medical Center, Beijing 302 Hospital, Beijing 100039, China
| | - Hao Liao
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Shanshan Lu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Yan Qiao
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Dongping Xu
- Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China.
| | - Jin Li
- Medical Department, Beijing 302 Hospital, Beijing 100039, China.
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12
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Su M, Xiang K, Li Y, Li Y, Deng J, Xu X, Yan L, Zhuang H, Li T. Higher detection rates of amino acid substitutions in HBV reverse transcriptase/surface protein overlapping sequence is correlated with lower serum HBV DNA and HBsAg levels in HBeAg-positive chronic hepatitis B patients with subgenotype B2. INFECTION GENETICS AND EVOLUTION 2016; 40:275-281. [DOI: 10.1016/j.meegid.2016.03.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/07/2016] [Accepted: 03/18/2016] [Indexed: 01/05/2023]
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Chen J, Liu Y, Zhao J, Xu Z, Chen R, Si L, Lu S, Li X, Wang S, Zhang K, Li J, Han J, Xu D. Characterization of Novel Hepatitis B Virus PreS/S-Gene Mutations in a Patient with Occult Hepatitis B Virus Infection. PLoS One 2016; 11:e0155654. [PMID: 27182775 PMCID: PMC4868315 DOI: 10.1371/journal.pone.0155654] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 05/02/2016] [Indexed: 12/19/2022] Open
Abstract
Objective The impact of hepatitis B virus (HBV) preS/S-gene mutations on occult HBV infection (OBI) is not fully understood. This study characterized multiple novel HBV preS/S-gene mutants obtained from an OBI patient. Methods PreS/S-gene mutants were analyzed by clonal sequencing. Viral replication and expression were analyzed by transfecting HBV genomic recombinants into HepG2 cells. Results Twenty-one preS/S-gene mutants were cloned from four sequential serum samples, including 13 mutants that were not previously documented: (1) sI/T126V+sG145R; (2) preS1 nt 3014−3198 deletion; (3) preS1 nt 3046−3177 deletion; (4) preS1 nt 3046−3177 deletion+s115−116 “INGTST” insertion; (5) preS1 nt 3046−3177 deletion+s115−116 “INGTST” insertion+sG145R; (6) preS1 nt 3115−3123 deletion+sQ129N; (7) preS1 nt 3115−3123 deletion+s126−127 “RPCMNCTI” insertion; (8) s115−116 “INGTST” insertion; (9) s115−116 “INGTST” insertion+sG145R; (10) s126−127 “RPCMNCTI” insertion; (11) preS1 nt 2848−2862 deletion+preS2 initiation codon M→I; (12) s122−123 “KSTGLCK” insertion+sQ129N; and (13) preS2 initiation codon M→I+s131−133TSM→NST. The proportion of preS1 nt 3046−3177 deletion and preS2 initiation codon M→I+s131−133TSM→NST mutants increased in the viral pool with prolonged disease. The 13 novel OBI-related mutants showed a 51.2−99.9% decrease in HBsAg levels compared with that of the wild type. Additional N-glycosylation-associated mutations, sQ129N and s131−133TSM→NST, but not s126−127 “RPCMNCTI,” greatly attenuated anti-HBs binding to HBsAg. Compared with the wild type, replication and surface antigen promoter II activity of the preS1 nt 3046−3177 deletion mutant decreased by 43.3% and 97.0%, respectively. Conclusion PreS/S-gene mutations may play coordinated roles in the presentation of OBI and might be associated with disease progression. This has implications for HBV diagnosis and vaccine improvement.
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Affiliation(s)
- Jianhong Chen
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Yan Liu
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Jun Zhao
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Zhihui Xu
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Rongjuan Chen
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Lanlan Si
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Shanshan Lu
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Xiaodong Li
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Shuai Wang
- Department of liver disease, General Hospital of Beijing Military Region, Beijing 100700, China
| | - Kai Zhang
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Jin Li
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
| | - Juqiang Han
- Department of liver disease, General Hospital of Beijing Military Region, Beijing 100700, China
- * E-mail: (DX); (JH)
| | - Dongping Xu
- Institute of Infectious Diseases/Research Center for Clinical and Translational Medicine, Beijing 302 Hospital, Beijing 100039, China
- * E-mail: (DX); (JH)
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Hu F, Bi S, Yan H, Shi Y, Sheng J. Associations between hepatitis B virus basal core promoter/pre-core region mutations and the risk of acute-on-chronic liver failure: a meta-analysis. Virol J 2015; 12:87. [PMID: 26063382 PMCID: PMC4485863 DOI: 10.1186/s12985-015-0313-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 05/25/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Several studies have suggested a relationship between hepatitis B virus (HBV) basal core promoter/pre-core mutations and HBV-induced acute-on-chronic liver failure (ACLF). Therefore, we evaluated this potential relationship using a meta-analysis. METHODS Chinese or English studies from 1966 to January 31, 2014 were included in the analysis. A random or fixed-effects model was used to merge the odds ratios (ORs). RESULTS We identified 31 case-control studies containing a total population of 1995 ACLF and 3822 chronic hepatitis B (CHB) patients. Several mutations were significantly correlated with ACLF: T1753V (1.889, 95 % confidence interval (CI) [1.357-2.631]), A1762T (2.696 [2.265-3.207]), G1764A (3.005 [2.077-4.347]), A1762T/G1764A (2.379 [1.519-3.727]), C1766T (1.849 [1.403-2.437]), T1768A (2.440 [1.405-3.494]), A1846T (3.163 [2.157-4.639]), G1896A (2.181 [1.800-2.642]), G1899A (3.569 [2.906-4.385]) and G1896A/A1762T/G1764A (1.575 [1.172-2.116]). Additionally, HBeAg-negative status was also statistically significant for the progression to ACLF (OR = 2.813, 95 % CI = 2.240-3.533, p < 0.001). However, there was no association between ACLF development and HBV genotype. CONCLUSIONS The HBV basal core promoter/pre-core mutations T1753V, A1762T, G1764A, C1766T, T1768A, A1846T, G1896A and G1899A, and an HBeAg-negative status correlate with an increased risk of HBV-ACLF.
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Affiliation(s)
- Feishu Hu
- State Key Lab of Diagnostic and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital of Medical School, Zhejiang University, Hangzhou, 310000, China.
| | - Sheng Bi
- State Key Lab of Diagnostic and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital of Medical School, Zhejiang University, Hangzhou, 310000, China.
| | - Huadong Yan
- Department of Hepatology, Ningbo No. 2 Hospital, Ningbo, 315010, China.
| | - Yu Shi
- State Key Lab of Diagnostic and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital of Medical School, Zhejiang University, Hangzhou, 310000, China.
| | - Jifang Sheng
- State Key Lab of Diagnostic and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital of Medical School, Zhejiang University, Hangzhou, 310000, China.
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15
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Yan YP, Su HX, Ji ZH, Shao ZJ, Pu ZS. Epidemiology of Hepatitis B Virus Infection in China: Current Status and Challenges. J Clin Transl Hepatol 2014; 2:15-22. [PMID: 26356070 PMCID: PMC4521251 DOI: 10.14218/jcth.2013.00030] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/07/2014] [Accepted: 02/10/2014] [Indexed: 12/13/2022] Open
Abstract
The prevalence of hepatitis B is high in China. Based on the National Disease Supervision Information Management System of China, the mean reported incidence of hepatitis B was 84.3 per 100,000 in China between 2005 and 2010. There are differences in population distribution based on region and ethnic group. Here, risk factors, virological characteristics, and prophylaxis of hepatitis B in China are reviewed. Although the prevalence of HBV infection is gradually declining, there are many challenges in HBV infection control, including higher prevalence in floating population, poor compliance of antiviral therapy, and high disease burden.
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Affiliation(s)
- Yong-Ping Yan
- Department of Epidemiology, and the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hai-Xia Su
- Department of Epidemiology, and the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhao-Hua Ji
- Department of Epidemiology, and the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhong-Jun Shao
- Department of Epidemiology, and the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Zhong-Shu Pu
- Department of Epidemiology, and the Ministry of Education Key Lab of Hazard Assessment and Control in Special Operational Environment, Fourth Military Medical University, Xi'an, Shaanxi, China
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