Genetic variability of hepatitis A virus isolates in Rio de Janeiro: implications for the vaccination of school children

Hepatitis A virus: host interactions, molecular epidemiology and evolution

Infection with hepatitis A virus (HAV) is the commonest viral cause of liver disease and presents an important public health problem worldwide. Several unique HAV properties and molecular mechanisms of its interaction with host were recently discovered and should aid in clarifying the pathogenesis of hepatitis A. Genetic characterization of HAV strains have resulted in the identification of different genotypes and subtypes, which exhibit a characteristic worldwide distribution. Shifts in HAV endemicity occurring in different parts of the world, introduction of genetically diverse strains from geographically distant regions, genotype displacement observed in some countries and population expansion detected in the last decades of the 20th century using phylogenetic analysis are important factors contributing to the complex dynamics of HAV infections worldwide. Strong selection pressures, some of which, like usage of deoptimized codons, are unique to HAV, limit genetic variability of the virus. Analysis of subgenomic regions has been proven useful for outbreak investigations. However, sharing short sequences among epidemiologically unrelated strains indicates that specific identification of HAV strains for molecular surveillance can be achieved only using whole-genome sequences. Here, we present up-to-date information on the HAV molecular epidemiology and evolution, and highlight the most relevant features of the HAV-host interactions.

Exposure to multiple subgenotypes of hepatitis A virus during an outbreak using matched serum and saliva specimens

Matched serum and saliva samples were collected simultaneously from 124 subjects exposed during a hepatitis A virus (HAV) outbreak at a daycare center in Rio de Janeiro, Brazil. All samples were tested for IgM and total anti-HAV antibodies by enzyme immunoassay (EIA). HAV was detected by nested PCR in serum, saliva, and water samples employing primers for the VP1/2A region of the viral RNA; all positive products were then sequenced. The viral load of the matched samples was determined by real-time PCR using the TaqMan system. HAV-RNA was identified by nested PCR in 37.7% of the saliva samples, 29% of the serum samples, and one drinking water sample. The mean HAV viral load was similar in the serum and saliva specimens (10(3)  copies/ml). HAV genotypes IA and IB were detected in both specimen types, and the water sample isolate was classified as genotype IB, indicating the existence of more than one source of infection at the daycare center. In six infected patients, a different HAV subgenotype was found in their serum than in their saliva, and this unusual pattern of mixed HAV infection was investigated further by molecular cloning followed by nucleotide sequencing. All clones derived from the saliva samples belonged to subgenotype IB and shared 96.5-100% identity. However, clones derived from their corresponding serum sample belonged to subgenotype IA and shared 90.5-100% identity. This study showed the important role that non-invasive saliva samples can play in the molecular epidemiological analysis of a hepatitis A outbreak.

Molecular characterization of hepatitis A virus isolates from Goiânia, Gioás, Brazil

Hepatitis A virus (HAV) infection is a public health problem worldwide and the virus has been classified into six genotypes. In Brazil, the only genotype that has been found is genotype I, predominately from subgenotype IA. Here, the HAV genotypes were analyzed of 18 isolates circulating between 1996-2001 in Goiânia, state of Goiás, Brazil. Viral RNA was extracted from 18 serum samples and amplified (RT-PCR/nested-PCR), followed by the genomic sequencing of the VP1/2A junction region of the HAV genome. Sequences of 168 nucleotides were compared and analyzed using the BLAST N, Clustal X and PAUP v. 4.10b programs. All samples were classified as genotype I, with 10 belonging to subgenotype IA and eight to subgenotype IB. The subgenotype IA isolates showed greater diversity than the subgenotype IB isolates at the nucleotide level. Elevated identity values were found between isolates obtained in this study and those from other regions of the world, including Brazil, highlighting the high conservation among different isolates of this virus. However, changes in the HAV subgenotype circulation could also be observed during the evaluated period.

Should Brazilian patients with chronic hepatitis C virus infection be vaccinated against hepatitis A virus?

BACKGROUND AND AIM

Hepatitis A virus (HAV) superinfection is associated with a high risk of liver failure and death in patients with hepatitis C virus (HCV) infection. The aim of this study was to investigate the presence of serological and molecular HAV markers in a population of HCV-infected patients in order to determine a cost-effective strategy to vaccinate against HAV.

METHODS

The presence of total and immunoglobulin (Ig)M anti-HAV antibodies was investigated in 399 patients (median age, 50 years; range, 4-81) referred to the Public Health Central Laboratory of Pernambuco State who tested positive for anti-HCV antibodies and HCV RNA. HAV RNA was investigated by reverse transcription-nested polymerase chain reaction in these patients.

RESULTS

Three hundred and eighty-four (96%) patients were positive for anti-HAV total and negative for IgM anti-HAV antibodies (immune patients). Three patients had IgM (and total) anti-HAV antibodies, showing an acute infection, and two of them had HAV RNA detected in serum samples. HAV RNA was also found in another patient in the absence of detectable anti-HAV antibodies. By nucleotide sequencing, it was demonstrated that the HAV isolates infecting these patients belonged to subgenotype 1B.

CONCLUSION

This study provides valuable new data on anti-HAV prevalence among HCV carriers in Brazil. In the present study, we found a high proportion of patients with anti-HAV positivity, indicating that anti-HAV testing of HCV-infected patients is a cost-effective strategy and should be carried out before vaccination against HAV in these patients, particularly in regions such as our geographical area with high total anti-HAV prevalence.

Changing epidemiology of hepatitis A in Brazil: reassessing immunization policy

Recent studies have shown that the prevalence of antibody to hepatitis A virus (HAV) is decreasing in several Latin American countries. Brazil is a very large and heterogeneous country, showing striking regional differences. With regard to sanitary facilities, 81.7% of the districts in the south-eastern region have sewage systems, compared with only 5.8% in the northern region. Results of sero-epidemiological studies and reported hepatitis A outbreaks indicate a change in the epidemiological pattern of hepatitis A in the country. Individuals, especially those under the age of 10, are mostly unprotected from HAV infection, regardless of their socioeconomic status. During 2000-2005, approximately 14 000-21 000 cases of hepatitis A were reported annually in Brazil, a rate of 7.5-11 cases per 100 000 population. Nationwide, hepatitis A mortality rates declined progressively from 1980 to 2002. As fatal cases constitute a small, but predictable, portion of all acute hepatitis A cases, which are in turn part of the total number of HAV infections, these data suggest that there has been a decline in HAV circulation in all Brazilian regions over the last two decades. Taken together these facts point out that the epidemiological pattern of hepatitis A is changing in Brazil. Besides improvements in sanitary conditions in the poorest Brazilian regions, the introduction of hepatitis A vaccination of young children could be a strategy for controlling HAV infection in the country.

The need for an evidence-based decision-making process with regard to control of hepatitis A

Universal hepatitis A (HA) vaccination was implemented by the Argentinean Ministry of Health in June 2005 with a single dose at age 12 months. The decision was made taking into account the following factors. (1) Disease burden: The incidence rate for the disease increased from 2003 to 2004; the northern and western regions of the country were the most affected. Sero-prevalence data for children 1-15 years old was 54% for the whole country, with differences per region and age. From May 1982 to September 2002, 210 patients were recruited with acute hepatic failure; HA was the aetiology in 61% of them. (2) Cost-effectiveness: Compared with no vaccination, the one-dose schedule would save US$15.3 millions, with regional variations. (3) Vaccine features: Immunization with one-dose schedule HA vaccine confers good immunogenicity and effectiveness. (4) Programmatic feasibility: The National Immunizations Program has appropriate distribution system for vaccines, with adequate cold chain. (5) Social acceptance and political compromise: The population largely accepts HA vaccination and the national authorities should be committed to providing it regularly. The main global issue is that hepatitis A virus infection remains the most commonly reported vaccine-preventable disease in many parts of the world despite the availability of vaccines.

Molecular detection of hepatitis A virus in urban sewage in Rio de Janeiro, Brazil

AIMS

A one-year survey was conducted to examine hepatitis A virus (HAV) prevalence, distribution of genotypes and their relationship to bacterial indicators in raw and treated sewage samples.

METHODS AND RESULTS

Fifty sewage samples (raw = 25 and treated = 25) were collected twice monthly from one sewage treatment plant in Rio de Janeiro. Virus concentration was performed by adsorption to an electronegative membrane followed by ultrafiltration. Viral RNA was detected by nested reverse transcriptase-polymerase chain reaction (RT-PCR) and real-time PCR and positive products were directly sequenced. Total and faecal coliform concentrations were also determined. By nested RT-PCR, HAV RNA was detected in 16/50 (32%) and eight (16%) of them were found in treated sewage samples. By real-time PCR, HAV RNA was detected in 46/50 (92%) samples and 24 were from treated sewage. Phylogenetic analyses classified nine isolates (56%) as subgenotype IA and seven (44%) as IB.

CONCLUSIONS

Real-time PCR was more sensitive than nested RT-PCR; the presence of subgenotypes IA and IB was described and bacterial indicators cannot be used to predict HAV presence in sewage.

SIGNIFICANCE AND IMPACT OF THE STUDY

These results demonstrated that HAV still remains in the environment after sewage treatment and could play an important role in maintaining the endemicity of HAV infection.

Hepatitis A virus in environmental water samples from the Amazon Basin

Hepatitis A virus (HAV) is a significant waterborne human pathogen. Of the global supply of potable water, Brazil retains 13%, of which 75% resides in the Amazon Basin. Although hepatitis A morbidity has declined progressively in Brazil as a whole, it remains high in the Amazon region. We used nested and real-time reverse-transcription polymerase chain reaction (RT-PCR) to detect and quantify the viral load in water samples from the Amazon Basin. Most samples tested positive (92%), with viral loads varying from 60 to 5500 copies /L, depending on sanitary conditions and the degree of flooding. Nested RT-PCR of the VP1-2A region detected HAV RNA in 23% of the samples. In low viral load samples, HAV was detected only with real-time RT-PCR, suggesting that this technique is useful for monitoring HAV contamination. The presence of HAV in water samples constitutes a serious public health problem.

Genetic variability and molecular evolution of hepatitis A virus

Hepatitis A virus (HAV), the causative agent of type A viral hepatitis, was first identified about three decades ago. Recent findings have shown that HAV possess several characteristics that make it unique among the family Picornaviridae, particularly in terms of its mechanisms of polyprotein processing and virion morphogenesis. HAV circulates in vivo as distributions of closely genetically related variants referred to as quasispecies. HAV exploits all known mechanisms of genetic variation to ensure its survival, including mutation and recombination. Only one serotype and six different genetic groups (three humans and three simian) have been described. HAV mutation rate is significantly lower as compared to other members of the family Picornaviridae. The mode of evolution appears, at least in part, to contribute to the presence of only one known serotype.

Evaluation of methods used to concentrate and detect hepatitis A virus in water samples

Two adsorption-elution concentration methods, both involving negatively charged membranes, were evaluated in order to monitor hepatitis A virus (HAV) contamination in tap, river, mineral and coastal water samples: elution with urea-arginine phosphate buffer/reconcentration with magnesium chloride (method 1); and sodium hydroxide elution/reconcentration with a commercial concentrator (method 2). Nested (qualitative) reverse transcriptase PCR (RT-PCR) and real-time (quantitative) RT-PCR were used to detect and quantify HAV RNA in concentrated water samples. For concentrating HAV, method 1 was found to be the most suitable for tap water and method 2 most suitable for mineral water. HAV inoculated experimentally was detected in river water samples by both methods and in coastal water samples by neither method. The detection limits were 6 x 10(9) g equiv./ml for qualitative PCR and 60 g equiv./ml for quantitative PCR. In a field application study, HAV was detected in 20% of river and tap water samples but not in coastal or mineral water samples. River water samples contained subgenotype IA, and tap water samples contained subgenotype IB. It is concluded that, although influencing qualitative PCR, the concentration method does not affect quantitative PCR, which could therefore be used for all types of water samples. Both techniques are recommended for detecting HAV in environmental water samples.

Molecular epidemiology of hepatitis A virus in Brazilian Amazon

BACKGROUND

Hepatitis A virus (HAV) is highly endemic in the Amazon. However, few data are available regarding HAV genotypes circulating in this region of the world. The aim of the present study was to characterize genetically HAV isolates circulating in the Brazilian part of the Amazon.

METHODS

Blood samples were collected from 134 IgM anti-HAV positive patients (sporadic cases). Viral RNA was extracted and the virion protein (VP)1/2A junction region of the HAV genome was successfully amplified by reverse transcription-polymerase chain reaction for 81 samples (60.4%). Nucleotide sequences (210 bp) of the 81 isolates were determined.

RESULTS

All HAV samples were from genotype I, with 78 (96.3%) belonging to subgenotype IA and three (3.7%) to subgenotype IB. By phylogenetic analysis, it was shown that 72/78 of the subgenotype IA isolates formed a cluster separated from the other South American HAV isolates previously characterized.

CONCLUSION

The present study provides valuable new data on the genetic relatedness of HAV from the Amazon. Subgenotype IB circulates in the Brazilian Amazon but the predominant genotype is 1A, similar to what occurs in most South American countries.

Co-circulation of genotypes IA and IB of hepatitis A virus in Northeast Brazil

The Northeast region is the location of most cases of acute hepatitis A virus (HAV) in Brazil. In the present study, the genotypes of HAV strains from Pernambuco State, one of most populous states in the Northeast region, were characterized. Blood samples positive for anti-HAV IgM from 145 individuals (mean age = 29.1 years), collected during 2002 and 2003, were submitted to nested RT-PCR for amplification of the 5'non-translated region (5'NTR) and VP1/2A regions of the HAV genome. The VP1/2A and 5'NTR regions were amplified in 39 and 21% of the samples, respectively. Nucleotide sequencing was carried out in 46% of VP1/2A and in 53% of 5'NTR isolates. The identity in nucleotide sequence of the VP1/2A region ranged from 93.6 to 100.0%. Phylogenetic analysis of the VP1/2A sequences showed that 65% belong to sub-genotype IA and 35% to sub-genotype IB. Co-circulation of both sub-genotypes was observed in the two years studied. Distinct clusters of highly related sequences were observed in both sub-genotypes, suggesting endemic circulation of HAV strains in this area. In the 5'NTR isolates, 92.7-99.2% identity was observed and two isolates presented one deletion at position 413. Phylogenetic analysis showed that genotype IA strains cluster in the tree in the same way as genotype IB strains, but one IIIA isolate from Spain clusters with genotype IB strains. These results do not allow us to state that 5'NTR could be used to genotype HAV sequences. This is the first report of co-circulation of sub-genotypes IA and IB in this region, providing additional information about the molecular epidemiology of HAV strains in Brazil.

Early infection and asymptomatic spread of hepatitis A virus in a public child care center in Rio de Janeiro, Brazil: should attending children under two years of age be vaccinated?

A cross-sectional study was conducted in order to identify hepatitis A virus (HAV) serological markers in 418 individuals (mean age, 16.4 years; range, 1 month-80 years) at a public child care center in Rio de Janeiro, Brazil, as well as to analyze risk factors and determine circulating genotypes. Serum samples were tested using an enzyme immunoassay. Reverse transcription polymerase chain reaction (RT-PCR) was used to detect and characterize HAV RNA, and sequencing was performed. Anti-HAV antibodies and IgM anti-HAV antibodies were detected, respectively, in 89.5% (374/418) and 10.5% (44/418) of the individuals tested. Acute HAV infection in children was independently correlated with crawling (p < 0.05). In 56.8% (25/44) of the IgM anti-HAV-positive individuals and in 33.3% (5/15) of the IgM anti-HAV-negative individuals presenting clinical symptoms, HAV RNA was detected. Phylogenetic analysis revealed co-circulation of subgenotypes IA and IB in 93.3% (28/30) of the amplified samples. In present study, we verify that 79% (30/38) of children IgM anti-HAV-positive were asymptomatic. In child care centers, this asymptomatic spread is a more serious problem, promoting the infection of young children, who rarely show signs of infection. Therefore, vaccinating children below the age of two might prevent the asymptomatic spread of hepatitis A.

Prevalence of hepatitis A virus infection in Goiânia, Goiás, Brazil, by molecular and serological procedures, 1995-2002

In this study, a total of 865 serum samples were collected between 1995 and 2002 from individuals living in Goiânia, Central Brazil, and clinically suspected of hepatitis. After exclusion of 162 samples which were positive for hepatitis B virus or hepatitis C virus, 703 samples were tested for anti-hepatitis A virus (anti-HAV) IgM antibodies by enzyme immunoassay. In addition, 588 of these samples and 22 fecal samples were analyzed by reverse transcription-nested PCR for HAV RNA detection, with positivity indices of 13.1% (77/588) and 54.5% (12/22), respectively. A similar index of viral RNA detection in anti-HAV-IgM positive or negative samples was observed in serum samples. HAV infection is a public health problem worldwide and this study underscores the extent of HAV circulation in our region.

Diagnosis of hepatitis a virus infection: a molecular approach

Current serologic tests provide the foundation for diagnosis of hepatitis A and hepatitis A virus (HAV) infection. Recent advances in methods to identify and characterize nucleic acid markers of viral infections have provided the foundation for the field of molecular epidemiology and increased our knowledge of the molecular biology and epidemiology of HAV. Although HAV is primarily shed in feces, there is a strong viremic phase during infection which has allowed easy access to virus isolates and the use of molecular markers to determine their genetic relatedness. Molecular epidemiologic studies have provided new information on the types and extent of HAV infection and transmission in the United States. In addition, these new diagnostic methods have provided tools for the rapid detection of food-borne HAV transmission and identification of the potential source of the food contamination.

Epidemiological pattern and mortality rates for hepatitis A in Brazil, 1980-2002: a review

The prevalence of hepatitis A virus (HAV) infection is high in developing countries, in which low standards of sanitation promote the transmission of the virus. In Latin America, which is considered an area of high HAV endemicity, most HAV-positive individuals are infected in early childhood However recent studies have shown that prevalence rates are decreasing. Herein, we review the data on HAV prevalence and outbreaks available in scientific databases. We also use official government data in order to evaluate mortality rates in Brazil over the last two decades. Studies conducted in the northernmost regions of Brazil have indicated that, although improved hygiene has led to a reduction in childhood exposure to HAV, the greatest exposure still occurs early in life. In the Southeastern region, the persistence of circulating HAV has generated outbreaks among individuals of low socioeconomic status, despite adequate sanitation. Nationwide, hepatitis A mortality rates declined progressively from 1980 to 2002. During that period, mortality rates in the Northern region consistently exceeded the mean national rate and those for other regions. Excluding the North, the rates in all regions were comparable. Nevertheless, the trend toward decline observed in the South was paralleled by a similar trend in the North.