Hepatitis E Vaccines

Lessons from hepatitis E vaccine design

Acute hepatitis E is still a major public health issue, especially in developing countries, and hepatitis E virus (HEV) infection will likely only be preventable through prophylactic vaccines. In this review, we describe the lessons learnt from developing the first commercial hepatitis E vaccine (Hecolin), launched to market in China in 2012. The antigenicity and immunogenicity of VLP immunogens concomitant with the scalable Escherichia coli system and our large-scale clinical verification resulted in the success of our vaccine. The structures of the HEV capsid protein in complex with different antibodies provide important molecular insights into capsid assembly and antibody neutralization of the virus, providing a paradigm for B-cell epitope-based vaccine design.

Autochthonous hepatitis e virus infections: a new transfusion-associated risk?

Hepatitis E virus (HEV) has been recognized since 2004 as a transfusion-transmissible infectious agent, and recent epidemiological data suggest that it may pose a safety threat to the blood supply. It has recently become obvious that hepatitis E is endemic in industrialized countries, and that more infections are autochthonous than travel-associated. Epidemiological and phylogenetic analysis suggests that HEV infection has to be considered as a zoonosis and that viral transmission from animals (pigs, wild animals) occurs through food or direct contact. The seroprevalence and incidence of HEV in the general population and blood donors in European countries indicate an underestimated risk for transfusion transmissions. Recently reported cases of transfusion transmission of HEV infection, and detection of viremic, asymptomatic blood donors in nucleic acid amplification technique screening programs give an indication of the importance of this virus. Diagnostic assays for detection of anti-HEV antibodies, HEV antigens and RNA are discussed. Recent studies support the idea that active immunization can prevent hepatitis E, highlighting the need for vaccination programs. Here we review current knowledge of HEV and its epidemiology, blood transmission and prevention of this disease with emphasis on blood supply.

Spatial configuration of hepatitis E virus antigenic domain

Hepatitis E virus (HEV) is a human pathogen that causes acute hepatitis. When an HEV capsid protein containing a 52-amino-acid deletion at the C terminus and a 111-amino-acid deletion at the N terminus is expressed in insect cells, the recombinant HEV capsid protein can self-assemble into a T=1 virus-like particle (VLP) that retains the antigenicity of the native HEV virion. In this study, we used cryoelectron microscopy and image reconstruction to show that anti-HEV monoclonal antibodies bind to the protruding domain of the capsid protein at the lateral side of the spikes. Molecular docking of the HEV VLP crystal structure revealed that Fab224 covered three surface loops of the recombinant truncated second open reading frame (ORF2) protein (PORF2) at the top part of the spike. We also determined the structure of a chimeric HEV VLP and located the inserted B-cell tag, an epitope of 11 amino acids coupled to the C-terminal end of the recombinant ORF2 protein. The binding site of Fab224 appeared to be distinct from the location of the inserted B-cell tag, suggesting that the chimeric VLP could elicit immunity against both HEV and an inserted foreign epitope. Therefore, the T=1 HEV VLP is a novel delivery system for displaying foreign epitopes at the VLP surface in order to induce antibodies against both HEV and the inserted epitope.

Efficacy and safety of a recombinant hepatitis E vaccine in healthy adults: a large-scale, randomised, double-blind placebo-controlled, phase 3 trial

BACKGROUND

Seroprevalence data suggest that a third of the world's population has been infected with the hepatitis E virus. Our aim was to assess efficacy and safety of a recombinant hepatitis E vaccine, HEV 239 (Hecolin; Xiamen Innovax Biotech, Xiamen, China) in a randomised, double-blind, placebo-controlled, phase 3 trial.

METHODS

Healthy adults aged 16-65 years in, Jiangsu Province, China were randomly assigned in a 1:1 ratio to receive three doses of HEV 239 (30 microg of purified recombinant hepatitis E antigen adsorbed to 0.8 mg aluminium hydroxide suspended in 0.5 mL buffered saline) or placebo (hepatitis B vaccine) given intramuscularly at 0, 1, and 6 months. Randomisation was done by computer-generated permuted blocks and stratified by age and sex. Participants were followed up for 19 months. The primary endpoint was prevention of hepatitis E during 12 months from the 31st day after the third dose. Analysis was based on participants who received all three doses per protocol. Study participants, care givers, and investigators were all masked to group and vaccine assignments. This trial is registered with ClinicalTrials.gov, number NCT01014845.

FINDINGS

11,165 of the trial participants were tested for hepatitis E virus IgG, of which 5285 (47%) were seropositive for hepatitis E virus. Participants were randomly assigned to vaccine (n=56,302) or placebo (n=56,302). 48,693 (86%) participants in the vaccine group and 48,663 participants (86%) in the placebo group received three vaccine doses and were included in the primary efficacy analysis. During the 12 months after 30 days from receipt of the third dose 15 per-protocol participants in the placebo group developed hepatitis E compared with none in the vaccine group. Vaccine efficacy after three doses was 100.0% (95% CI 72.1-100.0). Adverse effects attributable to the vaccine were few and mild. No vaccination-related serious adverse event was noted.

INTERPRETATION

HEV 239 is well tolerated and effective in the prevention of hepatitis E in the general population in China, including both men and women age 16-65 years.

FUNDING

Chinese National High-tech R&D Programme (863 programme), Chinese National Key Technologies R&D Programme, Chinese National Science Fund for Distinguished Young Scholars, Fujian Provincial Department of Sciences and Technology, Xiamen Science and Technology Bureau, and Fujian Provincial Science Fund for Distinguished Young Scholars.

Hepatitis E vaccine: current status and future prospects

HEV, a positive ssRNA and nonenveloped virus, is endemic in many developing countries and one of the most frequent causes of acute hepatitis after fecal–oral transmission. Pregnant women are at particular risk for a fatal course of disease, including maternal and fetal mortality. Recent reports indicate that HEV genotype 3, possibly related to zoonotic transmission, may cause chronic hepatitis in some immunosuppressed organ transplant patients. Various approaches have been conducted to develop HEV vaccines, but only one candidate, a recombinant HEV (rHEV) vaccine generated from Spodoptera frugiperda-9 cells by baculoviruses expressing the HEV capsid antigen, has reached clinical Phase I and II trials so far. These trials suggest that the rHEV vaccine is safe and can prevent clinically overt acute hepatitis E in high-risk populations. We herein review the different approaches in HEV-vaccine development and critically discuss the current status and future directions of the rHEV vaccine used in clinical trials.

Hepatitis E: a complex and global disease

Thirty years after its discovery, the hepatitis E virus (HEV) continues to represent a major public health problem in developing countries. In developed countries, it has emerged as a significant cause of non-travel-associated acute hepatitis. HEV infects a wide range of mammalian species and a key reservoir worldwide appears to be swine. Genomic sequence similarity between some human HEV genotypes and swine HEV strains has been identified and we know that humans can acquire HEV infection from animals. Although for the most part the clinical course of HEV infection is asymptomatic or mild, significant risk of serious disease exists in pregnant women and those with chronic liver disease. In addition, there are data on the threat of chronic infections in immunocompromised patients. Beyond management of exposure by public health measures, recent data support that active immunisation can prevent hepatitis E, highlighting the need for vaccination programmes. Here we review the current knowledge on HEV, its epidemiology, and the management and prevention of human disease.

Serological response to hepatitis E virus genotype 3 infection: IgG quantitation, avidity, and IgM response

Sequential sera were collected from 18 acute cases of UK-acquired hepatitis E. The virus strains in all cases were of genotype 3. The IgM and IgG response to acute infection were documented over time using EIA kits based on a peptide antigen, pE2, which is derived from a genotype 1 strain of hepatitis E virus (HEV). Ninety-five percentage of acute sera were IgM positive; after 6 months or more only 12% remained positive. The kit was adapted to quantify the IgG response (in WHO U/ml) and to determine antibody avidity. Following acute infection, anti-HEV IgG concentrations rose between 6.9- and 90-fold. IgG avidity was low (<25%) in most acute sera. After 6 months IgG avidity was greater than 50% in all cases. One patient with a poor IgM response and high avidity antibody in acute sera may have had a second HEV infection. Taken together, these results confirm that the pE2-based EIA kits are suitable for diagnosing acute HEV genotype 3 infection. With simple modifications the IgG kit can measure anti-HEV concentration and avidity, which can be used to confirm acute infection.

The poor contribution of chimpanzee experiments to biomedical progress

Biomedical research on captive chimpanzees incurs substantial nonhuman animal welfare, ethical, and financial costs that advocates claim resultin substantial advancements in biomedical knowledge. However, demonstrating minimal contribution toward the advancement of biomedical knowledge generally, subsequent papers did not cite 49.5% (47/95), of 95 experiments randomly selected from a population of 749 published worldwide between 1995 and 2004. Only 14.7% (14/95) were cited by 27 papers that abstracts indicated described well-developed methods for combating human diseases. However, detailed examination of these medical papers revealed that in vitrostudies, human clinical and epidemiological studies, molecular assays and methods, and genomic studies contributed most to their development. No chimpanzee study made an essential contribution, or, in most cases, a significant contribution of any kind, to the development of the medical method described. The approval of these experiments indicates a failure of the ethics committee system. The demonstrable lack of benefit of most chimpanzee experimentation and its profound animal welfare and bioethical costs indicate that a ban is warranted in those remaining countries - notably the United States - that continue to conduct it.

Safety and efficacy of a recombinant hepatitis E vaccine

BACKGROUND

Hepatitis E virus (HEV) is an important cause of viral hepatitis. We evaluated the safety and efficacy of an HEV recombinant protein (rHEV) vaccine in a phase 2, randomized, double-blind, placebo-controlled trial.

METHODS

In Nepal, we studied 2000 healthy adults susceptible to HEV infection who were randomly assigned to receive three doses of either the rHEV vaccine or placebo at months 0, 1, and 6. Active (including hospital) surveillance was used to identify acute hepatitis and adverse events. The primary end point was the development of hepatitis E after three vaccine doses.

RESULTS

A total of 1794 subjects (898 in the vaccine group and 896 in the placebo group) received three vaccine doses; the total vaccinated cohort was followed for a median of 804 days. After three vaccine doses, hepatitis E developed in 69 subjects, of whom 66 were in the placebo group. The vaccine efficacy was 95.5% (95% confidence interval [CI], 85.6 to 98.6). In an intention-to-treat analysis that included all 87 subjects in whom hepatitis E developed after the first vaccine dose, 9 subjects were in the vaccine group, with a vaccine efficacy of 88.5% (95% CI, 77.1 to 94.2). Among subjects in a subgroup randomly selected for analysis of injection-site findings and general symptoms (reactogenicity subgroup) during the 8-day period after the administration of any dose, the proportion of subjects with adverse events was similar in the two study groups, except that injection-site pain was increased in the vaccine group (P=0.03).

CONCLUSIONS

In a high-risk population, the rHEV vaccine was effective in the prevention of hepatitis E. (ClinicalTrials.gov number, NCT00287469 [ClinicalTrials.gov].).

A simple, rapid, and sensitive integrated protein microarray for simultaneous detection of multiple antigens and antibodies of five human hepatitis viruses (HBV, HCV, HDV, HEV, and HGV)

Protein microarrays for parallel detection of multiple viral antigens and antibodies have not yet been described in the field of human hepatitis virus infections. Here, we describe a simple, rapid and sensitive integrated protein microarray with three different reaction models. The integrated protein microarray could simultaneously determine in human sera two viral antigens (HBsAg, HBeAg) and seven viral antibodies (HBsAb, HBcAb, HBeAb, HCVAb, HDVAb, HEVAb, HGVAb) of human hepatitis viruses within 20 min. The results of the protein microarray were assessed directly by the naked eye but can also be analyzed by a quantitative detector. The detection limit of this protein microarray was 0.1 ng/ml for HBsAg. Overall, >85% concordance was observed between the integrated protein microarrays and an enzyme-linked immunosorbent assay for above hepatitis viral antigen and antibody detections in human sera. This integrated protein microarray can be easily optimized for clinical use and epidemiological screening for multiple hepatitis virus infections.

Promoter and intron-1 region polymorphisms in the IFNG gene in patients with hepatitis E

Allelic and genotype variations in the promoter region and the dinucleotide (CA)(n) repeat region in intron 1 of the interferon-g (IFNG) gene were analysed by direct sequencing and simple sequence length polymorphism (SSLP), respectively, in patients with acute hepatitis, and the prevalence was compared with that in healthy controls. Our results showed a significant association of heterozygous genotypes (CA)12/(CA)14 and (CA)12/(CA)16 in intron 1 of the IFNG gene in all categories of patients with acute hepatitis, classified on the basis of presence or absence of hepatitis E virus (HEV), in comparison with healthy controls. A novel polymorphism, -288 A-->T [from the translational start site, as per Human Genome Organization (HUGO) nomenclature], in the promoter region of the IFNG gene leading to a loss of the consensus domain for the interferon-stimulated response element (ISRE), as predicted by in silico analysis, was observed in 12.5% of patients with acute HEV infection. However, no significant difference in allele or genotype frequency was observed for the -288 promoter polymorphism, although the heterozygous -288 A/T genotype showed a moderate risk in patients with acute HEV infection alone (P = 0.29, odds ratio = 1.964, confidence interval = 0.46-8.45). The data suggest that the genotype at intron 1 of IFNG might affect susceptibility to acute hepatitis in HEV infection, which warrants further elucidation in a larger sample and also functional studies.

Comparison of a new immunochromatographic test to enzyme-linked immunosorbent assay for rapid detection of immunoglobulin m antibodies to hepatitis e virus in human sera

An immunochromatographic test for rapid detection of IgM antibodies in patients with acute hepatitis E infection was developed utilizing the well-characterized recombinant protein EP2.1 and monoclonal antibody 4B2. The new rapid test based on a novel reverse-flow technology was able to generate a positive result within 2 to 3 min. Our study showed that this test was able to detect anti-HEV IgM antibodies in 96.7% of the patient samples tested (n = 151) while maintaining an excellent specificity of 98.6% with samples from various patient or healthy control groups (total n = 208). Furthermore, this rapid test gave a good specificity of 90.9% when tested with rheumatoid factor (RF)-positive sera (RF value of < or =850 IU/ml; n = 11) although a higher concentration of RF in samples might cause cross-reactivity. The new test has a good agreement of 97.2% with a kappa value of 0.943 when compared with a reference enzyme-linked immunosorbent assay. The positive predictive value and the negative predictive value for the rapid test thus reached 98.0 and 97.6%, respectively. This is the first rapid, point-of-care test for hepatitis E and will be especially useful for the diagnosis of acute hepatitis E virus infection in field and emergency settings and in resource-poor countries.

Hepatitis E viruses in humans and animals

Hepatitis E virus (HEV) is an emerging pathogen belonging to a newly recognized family of RNA viruses (Hepeviridae). HEV is an important enterically transmitted human pathogen with a worldwide distribution. It can cause sporadic cases as well as large epidemics of acute hepatitis. Epidemics are primarily waterborne in areas where water supplies are contaminated with HEV of human origin. There is increasing evidence, however, that many animal species are infected with an antigenically similar virus. A recently isolated swine virus is the best candidate for causing a zoonotic form of hepatitis E. The virus is serologically cross-reactive with human HEV and genetically very similar, and the human and swine strains seem to be cross-infective. Very recent evidence has also shown that swine HEV, and possibly a deer strain of HEV, can be transmitted to humans by consumption of contaminated meat. In this review, we discuss the prevalence, pathogenicity, diagnosis and control of human HEV, swine HEV, the related avian HEV and HEV in other hosts and potential reservoirs.

Hépatite virale E autochtone dans le sud-est de la France

INTRODUCTION

Hepatitis E virus is endemic in developing countries where it is especially lethal among pregnant women. As the circulation of goods and people grows between these countries and the industrialized nations, this virus is emerging as a cause of imported acute hepatitis in the latter, where authentic autochthonous cases also exist.

OBSERVATIONS

We report two cases observed in Marseille, in men aged 27 and 81 years; no mode of contamination was detected, and both outcomes were positive.

DISCUSSION

This virus is circulating in non-endemic areas (as shown by its seroprevalence, which ranges from 0.4 to 2.6%, its identification in urban sewage, and the autochthonous cases reported). This dissemination, combined with its high mortality rate, even outside pregnancy (up to 12%), show the need for systematic consideration of and an early search for the often-fleeting presence of the virus and of IgM and IgG type serum antibodies in plasma and (when necessary) feces in cases of acute hepatitis, because of their often transient nature. Prophylaxis is based on improving water hygiene and is thus more difficult in industrialized countries where the level of hygiene is already high, especially when no risk factors can be identified in the autochthonous cases. Recombinant vaccines are under development.