Fulminant Adenoviral-Induced Hepatitis in Immunosuppressed Patients

Human adenovirus (HAdV) can often lead to fulminant hepatitis in immunocompromised patients, mostly after reactivation of HAdV. Different risk factors, e.g., transplantation and chemotherapy, increase the risk of developing a HAdV hepatitis. We retrospectively analyzed three patients who showed the characteristics of a HAdV hepatitis observed in disseminated disease. In addition to PCR, diagnosis could be proven by pathology, CT scan, and markedly elevated transaminases. All patients had a hemato-oncologic underlying disease. Two had received a stem-cell transplant, and one was under chemotherapy including rituximab. Despite therapy with cidofovir, all patients died. As the incidence of HAdV hepatitis is low, diagnosis may be easily overlooked. No treatment approaches have yet been established. HAdV hepatitis should be considered as a differential diagnosis, especially when risk factors are present. To avoid dissemination, treatment should be initiated as soon as possible.

An extra priming dose of hepatitis A vaccine to adult patients with rheumatoid arthritis and drug induced immunosuppression - A prospective, open-label, multi-center study

BACKGROUND

Previous studies have indicated that a pre-travel single dose of hepatitis A vaccine is not sufficient as protection against hepatitis A in immunocompromised travelers. We evaluated if an extra dose of hepatitis A vaccine given shortly prior to traveling ensures seroconversion.

METHOD

Patients with rheumatoid arthritis (n = 69, median age = 55 years) treated with Tumor Necrosis Factor inhibitor(TNFi) and/or Methotrexate (MTX) were immunized with two doses of hepatitis A vaccine, either as double dose or four weeks apart, followed by a booster dose at six months. Furthermore, 48 healthy individuals, median age = 60 years were immunized with two doses, six months apart. Anti-hepatitis A antibodies were measured at 0, 1, 2, 6, 7 and 12 months.

RESULTS

Two months after the initial vaccination, 88% of the RA patients had protective antibodies, compared to 85% of the healthy individuals. There was no significant difference between the two vaccine schedules. At twelve months, 99% of RA patients and 100% of healthy individuals had seroprotective antibodies.

CONCLUSION

An extra priming dos of hepatitis A vaccine prior to traveling offered an acceptable protection in individuals treated with TNFi and/or MTX. This constitutes an attractive pre-travel solution to this vulnerable group of patients.

Decreasing risk of hepatitis A infection in León, Nicaragua: evidence from cross-sectional and longitudinal seroepidemiology studies

BACKGROUND AND OBJECTIVES

Nicaragua is highly endemic for hepatitis A. We aimed to provide an estimate of the change in the age-specific risk of hepatitis A virus (HAV) infection based on serological data from cross-sectional and longitudinal samples collected in León, Nicaragua, in 1995/96 (n = 979) and 2003 (n = 494).

METHODS

The observed age-specific prevalence of anti-HAV antibodies was correlated to the age-specific risk of infection by calculating the probability of freedom from infection at a specific age.

RESULTS

The proportion of seropositive children aged 1.5 to 6 years was 42% in 2003 compared to 67% in 1995/96. Estimated annual risk of infection for a 3-year old child was 30% (95% CI: 27.0%, 33.1%) in 1995 and 15.5% (95% CI: 12.4%, 19.0%) in 2003. There was good agreement between estimates based on cross-sectional and longitudinal data. The age-specific geometric mean of the quantified anti-HAV antibody levels assessed in 2003 was highest at age 4 and decreased steadily up to age 40.

CONCLUSIONS

The substantially lower risk of HAV infection in 2003 than in 1995 for young children indicates a beginning transition from high to intermediate endemicity in León, Nicaragua. Consecutive age-stratified serosurveys are useful to assess changes in risk of infection following public health interventions. The decreasing age-specific GMC of anti-HAV antibodies during adulthood in a country with endemic HAV indirectly suggests that ongoing HAV exposure in the community has marginal boosting effect on antibody levels once protective immunity has been established by natural infection.

Successful memory response following a booster dose with a virosome-formulated hepatitis a vaccine delayed up to 11 years

Boosting adult travelers with the virosome-formulated, aluminum-free hepatitis A vaccine Epaxal up to 128 months after a single primary dose confers full protection against hepatitis A, even in travelers aged 50 years and above. Delaying the booster dose did not influence the immune memory response to Epaxal.

Isolated norovirus GII.7 strain within an extended GII.4 outbreak

Noroviruses are a major cause of viral gastroenteritis and have been detected with increasing prevalence in recent years. Currently, two main genogroups GI and GII with an increasing number of subtypes are differentiated. Because of a high genetic variability new variants emerge constantly allowing epidemiological tracing of viruses from year to year and location to location. A 282 bp sequence at the 5'end of the capsid gene was analyzed in isolates originating from the University hospital, Technische Universität München. Phylogenetic analysis was based on 20 GII positive samples from an outbreak in March/April 2006 and 8 samples from the following winter season 2006-2008. In the initial outbreak two distinct genotypes were identified. The GII.4 strain 2006a found in the majority of outbreaks in 2006 worldwide was isolated from all but two patients. These two individuals were infected with a GII.7 strain clustering mainly with isolates from Asia. Of note, they excreted noroviral RNA for 81 and 27 days, respectively. Longitudinal analysis of an extended 1381 bp sequence revealed positive selection in the P2 domain. The variant was very similar to GII.7 strains isolated in 1990 and 1994 suggesting slow evolution with evidence of recombination according to the SimPlot analysis. Strains found in the following years 2006-2008 clustered around the isolate GII.4 2006b, characterized in the spring of 2006 and reaching a high prevalence in 2006-2007. The results provide an insight into norovirus evolution at a University hospital over 3 years and describe intraindividual evolution within a patient infected chronically.

Virosomal hepatitis a vaccine: comparing intradermal and subcutaneous with intramuscular administration

BACKGROUND

Vaccination against hepatitis A virus (HAV) is unaffordable to many developing countries. Substantial reductions in cost occur when vaccines are administered intradermally at low doses. Aluminum-free HAV vaccines are considered more suitable for intradermal use than traditional vaccines which can cause long-lasting local reactions. Thus, we compared the immunogenicity and safety of an aluminum-free virosomal HAV vaccine (Epaxal) administered by different routes: intradermal (i.d.), subcutaneous (s.c.), and intramuscular (i.m.).

METHODS

Two open pilot studies were conducted as sub-studies of a large lot consistency trial. Healthy subjects aged 18 to 45 were enrolled. Study 1 compared two i.d. regimens of a lower dose of Epaxal [0.1 mL (4.8 IU), one or two injection sites] with i.m. administration of the standard dose [0.5 mL (24 IU)]. Study 2 compared the s.c. with the i.m. administration of the standard dose. At month 12, subjects in study 1 received a booster dose of 0.1 mL i.d. or 0.5 mL i.m.; subjects in study 2 received 0.5 mL via the respective route (s.c. or i.m.). Serum was tested for antibodies at baseline, 2 weeks (study 1), and 1 and 6 months after the primary vaccination as well as prior and 1 month after the booster dose. Incidences of solicited and unsolicited adverse events were recorded.

RESULTS

Seroprotection rates (anti-HAV geometric mean concentration of > or =20 mIU/mL) after 1 month ranged from 93.2% to 100% in all groups and remained high until month 12 (range 85.2&-90.2%). Complete (100%) seroprotection was achieved by all subjects in all groups after booster vaccination. All routes of administration were well tolerated. Local reactions were more common in subjects vaccinated i.d. and s.c. than i.m.

CONCLUSIONS

The aluminum-free virosomal HAV vaccine Epaxal is highly immunogenic and well tolerated when administered either via i.d., s.c., or i.m. Vaccination via the i.d. route may confer significant cost savings over the conventional i.m. route.

Cell type-specific cleavage of nucleocapsid protein by effector caspases during SARS coronavirus infection

The epidemic outbreak of severe acute respiratory syndrome (SARS) in 2003 was caused by a novel coronavirus (CoV), designated SARS-CoV. The RNA genome of SARS-CoV is complexed by the nucleocapsid protein (N) to form a helical nucleocapsid. Besides this primary function, N seems to be involved in apoptotic scenarios. We show that upon infection of Vero E6 cells with SARS-CoV, which elicits a pronounced cytopathic effect and a high viral titer, N is cleaved by caspases. In contrast, in SARS-CoV-infected Caco-2 cells, which show a moderate cytopathic effect and a low viral titer, this processing of N was not observed. To further verify these observations, we transiently expressed N in different cell lines. Caco-2 and N2a cells served as models for persistent SARS-CoV infection, whereas Vero E6 and A549 cells did as prototype cell lines lytically infected by SARS-CoV. The experiments revealed that N induces the intrinsic apoptotic pathway, resulting in processing of N at residues 400 and 403 by caspase-6 and/or caspase-3. Of note, caspase activation is highly cell type specific in SARS-CoV-infected as well as transiently transfected cells. In Caco-2 and N2a cells, almost no N-processing was detectable. In Vero E6 and A549 cells, a high proportion of N was cleaved by caspases. Moreover, we examined the subcellular localization of SARS-CoV N in these cell lines. In transfected Vero E6 and A549 cells, SARS-CoV N was localized both in the cytoplasm and nucleus, whereas in Caco-2 and N2a cells, nearly no nuclear localization was observed. In addition, our studies indicate that the nuclear localization of N is essential for its caspase-6-mediated cleavage. These data suggest a correlation among the replication cycle of SARS-CoV, subcellular localization of N, induction of apoptosis, and the subsequent activation of caspases leading to cleavage of N.

Prevalence and clinical role of GBV-C infection after cardiac surgery in childhood: a study on 414 patients

OBJECTIVES

GB-virus C (GBV-C) and hepatitis C virus (HCV) share similar modes of transmission. We, therefore, examined the prevalence and clinical role of GBV-C and HCV in patients after cardiac surgery in childhood.

METHODS

We analysed blood samples of 414 patients and compared them to 487 controls. Evidence of liver disease and risk factors for infection was analysed.

RESULTS

Overall prevalence of GBV-C infection was 22.5% in the patients, compared to 6.2% in the controls (HCV infection 11.3 vs. 0.7%). GBV-C RNA was detected in 8.2% of the patients vs. 3.7% in the controls (HCV RNA in 6 and 0%, respectively). Eleven patients had detectable RNA of GBV-C and HCV. 63.4% of patients infected with GBV-C and 46.8% of patients infected with HCV cleared the virus from circulation. GBV-C infection was not associated with hepatitis. Liver disease was not more frequent in patients co-infected with HCV and GBV-C.

CONCLUSIONS

before 1991 have a substantial risk for HCV and GBV-C infection. However, GBV-C infection seems not to be associated with a liver disease. Co-infection with GBV-C and HCV has no influence on long-term clinical outcome or viral clearance of HCV infection.

Prevalence and Risk Factors of Hepatitis C Infection after Cardiac Surgery in Childhood before and after Blood Donor Screening

BACKGROUND

Since 1974, the risk of acquiring non-A non-B hepatitis by blood transfusion is well known. In 1999, children having had polytransfusions (group 1) after cardiac surgery prior to the establishment of routine blood donor screening could be identified as a risk group for hepatitis C (HCV) infection.

PATIENTS AND METHODS

In 1991, Germany began screening blood donors for hepatitis C. To describe the risk after the implementation of blood donor screening, we studied 211 children (group 2) having had open heart surgery after 1991 and compared prevalence for anti-HCV antibodies and known risk factors to group 1.

RESULTS

None of the 211 patients with cardiac surgery after 1991 had detectable anti-HCV antibodies, compared to 67 of the 458 patients (14.6%) of group 1 (p < 0.001). The mean number of operations in both groups was virtually the same (mean 1.7 +/- 0.9 in group 1, mean 1.6 +/- 0.9 in group 2, p = 0.075), whereas the total number of blood products per patient differed significantly (group 1 mean 8 +/- 17.6, group 2 mean 3.5 +/- 2.8; p < 0.001). Multivariate analysis of risk factors demonstrates affiliation to group 1, transfusion of fresh blood, warm whole blood, heparinized blood (p < 0.001) and plasma (p = 0.004) as significant.

CONCLUSION

After the implementation of blood donor screening, the risk for HCV infection after cardiac surgery in childhood dropped significantly from 14.6% to < 0.5%. These data show the necessity of HCV screening for patients at risk (operations before 1991) and do not favor a general screening for all patients.

Efficacy of virosome hepatitis A vaccine in young children in Nicaragua: randomized placebo-controlled trial

Immunization of young children could control hepatitis A virus (HAV) infection, but the efficacy of hepatitis A vaccines in early childhood is unknown. In a randomized, double-blind trial of a single dose of a virosome-formulated, aluminum-free inactivated HAV vaccine in Nicaragua, 274 children (age range, 1.5-6 years) received vaccine or placebo injections; 239 children seronegative for hepatitis A were included in the primary efficacy analysis. HAV infection documented by immunoglobulin M antibodies was the primary end point. Among children seronegative for hepatitis A, infection was diagnosed in 4 children in the vaccine group and 22 children in the placebo group (protective efficacy, 84.6%; 95% confidence interval, 54.7%-96.1%). All infections in children in the vaccine group occurred within 6 weeks. After 6 weeks, protective efficacy was 100% (79.8%-100%). In children in the placebo group, the incidence of HAV infection was 17.6 and that of icteric illness was 1.6 cases/100 person-years. Adverse effects were rare in both children in the vaccine group and children in the placebo group. A single dose of a hepatitis A virosome vaccine is safe and protects young children against HAV infection.

Prevalence of GB virus C/hepatitis G virus RNA and anti-E2 glycoprotein antibodies in homosexual men with HIV coinfection

BACKGROUND

The objective of this cross-sectional, nonrandomized, prospective study was to generate data on the prevalence of GB virus C (GBV-C)/hepatitis G virus (HGV) in a cohort of HIV-infected homosexuals from Munich.

PATIENTS

A total of 71 HIV-infected homosexual men were analyzed for prevalence of GBV-C RNA and antibodies to the E2 envelope glycoprotein (E2Ab). 475 healthy volunteer blood donors in southern Bavaria served as a control group.

RESULTS

The prevalence of GBV-C RNA was 27% (control group: 2.3%) and the prevalence of E2Ab was 35% (control group: 6%). The total prevalence for present and past infection was 62%. The differences between the HIV-infected patients and the control group were significant (p < 0.0001). GBV-C RNA and E2Ab were not detected simultaneously in any serum sample. The E2Ab positive patients were older than the GBV-C RNA positives (mean 46 years versus 39 years, p = 0.0350). The GBV-C RNA and E2Ab negative patients were older than the GBV-C RNA positives (mean 47 years versus 39 years, p = 0.0236). The E2Ab positive patients had suffered sexually transmitted diseases more frequently than the patients negative for markers of GBV-C infection (p = 0.0308). E2Ab positive patients also had higher mean levels of alanine aminotransferase compared to patients without evidence of GBV-C infection (p = 0.0164). 59.4% of all individuals were anti-HBc IgG positive.

CONCLUSION

The data can be interpreted as indirect evidence for sexual transmission of GBV-C.

Prevalence and clinical outcome of hepatitis C infection in children who underwent cardiac surgery before the implementation of blood-donor screening

BACKGROUND AND METHODS

There are few data on the prevalence and clinical outcome of hepatitis C infection in children. We studied 458 children who underwent cardiac surgery in Munich, Germany, before 1991, when blood-donor screening for hepatitis C was introduced in Germany. Their mean age at first operation was 2.8 years; none of the children had received blood transfusions before or 'after cardiac surgery, and none of their mothers had antibodies to the hepatitis C virus (anti-HCV). We compared these patients with 458 control subjects matched for age and sex.

RESULTS

Sixty-seven (14.6 percent) of the 458 patients who had undergone cardiac surgery had anti-HCV, as compared with 3 (0.7 percent) of the control subjects (P<0.001). At a mean interval of 19.8 years after the first operation, 37 (55 percent) of the 67 patients who were positive for anti-HCV had detectable HCV RNA in their blood. The infection had cleared in the other 30 patients, as evidenced by negative results on three polymerase-chain-reaction analyses performed at six-month intervals. Only 1 of the 37 patients who were positive for HCV RNA had elevated levels of liver enzymes; that patient had severe right-sided congestive heart failure. Of the 17 patients who underwent liver biopsies, only 3 had histologic signs of progressive liver damage. These three patients had additional risk factors: two had congestive heart failure, and the third had also been infected with hepatitis B virus.

CONCLUSIONS

Children who had undergone cardiac surgery in Germany before the implementation of blood-donor screening for hepatitis C had a substantial risk of acquiring the infection. However, after about 20 years, the virus had spontaneously cleared in many patients. The clinical course in those still infected seems more benign than would be expected in people infected as adults.

Hepatitis E in Damascus, Syria

A hospital-based study of acute hepatitis was conducted in Damascus, Syria, from 1995 to 1998. One hundred ninety-three sera from defined acute hepatitis cases were screened by ELISA for IgM anti-HAV, HBsAg, IgM anti-HBc and anti-HCV. Serum samples negative for all markers indicating recent infection by hepatitis A, B, or C were tested for HEV markers. Overall, 47 cases (24.4%) had no detectable hepatitis markers (non-A-E). HAV infection was detected in 71.2% of all viral hepatitis cases. Acute hepatitis B and C constituted 24 and 1.4% of the cases, respectively. Only five cases of acute hepatitis E were noted. Of 47 patients who had non-A-E hepatitis, fifteen (31.9%) tested positive for IgG anti HEV. This study provides indirect evidence that HEV is very likely to be endemic in Damascus, Syria. It reports for the first time the occurrence of hepatitis E in the country, a health problem that should be investigated further.

[Prevalence of antibodies against hepatitis A in school children]

BACKGROUND

As sanitary conditions of a population improve, hepatitis A virus infection occurs at higher ages, thus decreasing the prevalence of antibodies against the virus. In the eighties, the prevalence of antibodies among children was 97% and depended on the socioeconomic level.

AIM

To assess the prevalence of antibodies against hepatitis A virus in school age children living in Valdivia.

SUBJECTS AND METHODS

Two thousand three hundred thirty three school age children were studied. Total antibodies against hepatitis A virus were detected using an ELISA kit from Abbott. Children were stratified in age groups and school were classified as private, subsidized, municipal or foster homes.

RESULTS

Antibodies were positive in 65% of children (59% in children aged 6 to 8 years old, 66% in children aged 9 to 11 years and 69% in children aged 12 to 15 years. In private schools, the prevalence was 26%, in subsidized schools the figure was 54%, in municipal schools 73% and in foster homes 91%.

CONCLUSIONS

The general prevalence of antibodies against hepatitis A virus is higher in low socioeconomic level children. There is a global decrease in the prevalence of these antibodies in the last years.

Quality control study on the performance of GB virus C/hepatitis G virus PCR

BACKGROUND/AIMS

A novel virus, GBV-C/HGV, with a genome RNA organization similar to that of the Flaviviridae family was identified in sera of patients with hepatitis. The presence of GBV-C/HGV RNA can only be determined by the amplification of genomic regions using the reverse transcriptase-polymerase chain reaction (RT-PCR).

METHODS

To assess the quality of the RT-PCR, 14 laboratories investigated a coded serum panel that comprised three GBV-C/HGV RNA-positive sera from three different patients, dilutions of these sera, and three GBV-C/HGV RNA-negative serum samples, two of which were collected from patients with hepatitis C but without GBV-C/HGV infection. In-house RT-PCR as well as commercially available GBV-C/HGV test kits were used in this study.

RESULTS

Only four laboratories (29%) reported the expected results, and four laboratories (29%) false-positive results; nine laboratories (64%) reported at least one false-negative result. Eleven laboratories (79%) detected the undiluted samples. The majority of false results were obtained with the dilutions of GBV-C/HGV RNA-positive samples. Negative results in the 10(-4) dilution were not considered to be false-negative, since during pre-screening GBV-C/HGV RNA had been detected in this dilution in only 50% of assays by the three laboratories involved in organizing the evaluation. Results obtained by commercial kits and by in-house assays were indiscriminate in quality of performance in this study.

CONCLUSION

To facilitate further quality assessment studies on the performance of GBV-C/HGV RNA detection, an international GBV-C/HGV RNA standard should be made available. Further efforts are required to optimize GBV-C/HGV RT-PCR.

[Cross reactions of patients with acute dengue fever to tick-borne encephalitis]

Sera from 20 patients with acute dengue fever were tested on their cross reactivities to other flaviviruses, especially against tick-borne encephalitis (TBE). One of the test systems used, indirect immunofluorescence (IIFT), was shown to exhibit strong cross reactivity. The reactivity pattern of sera from patients with pre-existing vaccine-induced antibodies against TBE or yellow fever was found similar to dengue secondary antibody response. In plaque reduction neutralization tests (PRNT) no cross reactions between different flaviviruses were found. The results show that PRNT is the most specific test system for differentiation of flavivirus antibodies.

Diagnosis of tick-borne encephalitis: evaluation of sera with borderline titers with the TBE-ELISA

Tick-borne encephalitis (TBE) is a member of the Flaviviridae family. Strong cross-reactions can occur between members of this family, so that it may be difficult to diagnose specific flavivirus infections, especially when tests with frequent cross-reactions e.g. ELISA tests are used. We tested 238 sera with borderline titers for TBE using the indirect immunofluorescence or neutralization test for other flaviviruses (yellow fever, dengue, West Nile) to detect cross-reactions due to other flavivirus infections or flavivirus vaccination. Only one serum reacted against all the flaviviruses tested, indicating cross-reactivity due to infection with any of the flaviviruses. Two other sera exhibited low antibody titers against yellow fever, which could be confirmed by the neutralization test, indicating recent yellow fever vaccination. None of the other sera reacted at all against any of the flaviviruses tested in the tests used, which indicates false positive reactions with the TBE-ELISA. Sera with borderline titers in the TBE-ELISA in particular should be retested using other test systems (preferably neutralization) and for other flaviviruses (yellow fever, dengue, West Nile) to detect cross-reactions and to confirm positive results.

Improvement of virus safety of a S/D-treated factor VIII concentrate by additional dry heat treatment at 100 degrees C

In order to increase the virus safety of a solvent/detergent-treated Factor VIII concentrate in regard to non-lipid coated viruses and to respond to the continuous discussion about reports on hepatitis A transmission by Factor VIII preparations, we have investigated the effect of a terminal dry heat treatment (30 min 100 degrees C) on HAV and various other viruses. By this treatment Hepatitis A virus was inactivated below detectable level after a few minutes (> 5.3 log10). Other RNA viruses such as the Human Immunodeficiency Virus (> 6.6 log10), bovine viral diarrhoea virus (> 6.6 log10) and vesicular stomatitis virus (> 5.8 log10) were also inactivated below detectable level. Pseudo rabies virus and reovirus Type 3 are inactivated by 5.7 and > 6.0 log10, respectively. SV40 and bovine parvo virus showed significant resistance to dry heat treatment. We conclude that the involvement of two strong virus inactivation steps, acting by different mechanisms, improves the virus safety of Factor VIII concentrates without destroying the Factor VIII activity. Moreover, the terminal 100 degrees C heat treatment for 30 min represents an effective measure to inactivate non-lipid enveloped viruses, in particular hepatitis A, which is resistant to solvent/detergent treatment.

Activation of a heterogeneous hepatitis B (HB) core and e antigen-specific CD4+ T-cell population during seroconversion to anti-HBe and anti-HBs in hepatitis B virus infection

Overcoming hepatitis B virus infection essentially depends on the appropriate immune response of the infected host. Among the hepatitis B virus antigens, the core (HBcAg) and e (HBeAg) proteins appear highly immunogenic and induce important lymphocyte effector functions. In order to investigate the importance of HBcAg/HBeAg-specific T lymphocytes in patients with acute and chronic hepatitis B and to identify immunodominant epitopes within the HBcAg/HBeAg, CD4+ T-cell responses to hepatitis B virus-encoded HBcAg and HBcAg/HBeAg-derived peptides were studied in 49 patients with acute and 39 patients with chronic hepatitis B. The results show a frequent antigen-specific CD4+ T-cell activation during acute hepatitis B infection, a rare HBcAg/HBeAg-specific CD4+ T-cell response among HBeAg+ chronic carriers, and no response in patients with anti-HBe+ chronic hepatitis. An increasing CD4+ T-cell response to HBcAg/HBeAg coincides with loss of HBeAg and hepatitis B virus surface antigen (HBsAg). Functional analysis of peptide-specific CD4+ T-cell clones revealed a heterogeneous population with respect to lymphokine production. Epitope mapping within the HBcAg/HBeAg peptide defined amino acids (aa) 1 to 25 and aa 61 to 85, irrespective of the HLA haplotype, as the predominant CD4+ T-cell recognition sites. Other important sequences could be identified in the amino-terminal part of the protein, aa 21 to 45, aa 41 to 65, and aa 81 to 105. The immunodominant epitopes are expressed in both proteins, HBcAg and HBeAg. Our findings lead to the conclusion that activation of CD4+ T lymphocytes by HBcAg/HBeAg is a prerequisite for viral elimination, and further studies have to focus on the question of how to enhance or induce this type of T-cell response in chronic carriers. The immunodominant viral sequences identified may have relevance to synthetic vaccine design and to the use of peptide T-cell sites as immunotherapeutic agents in chronic infection.

Immunosuppressive serum factors in viral hepatitis. III. Prognostic relevance of rosette inhibitory factor and serum inhibition factor in acute and chronic hepatitis

Two immunosuppressive serum factors, serum inhibition factor (SIF) and rosette inhibitory factor (RIF), were studied in sera from patients with acute and chronic viral hepatitis. In a study of 30 patients with acute viral hepatitis, an association was found between RIF, SIF, and biochemical and virological parameters in 27 patients (90%), 25 of whom recovered completely; two had a protracted course. In three patients, the clinical course was not reflected by the immunosuppressive factors. In 26 patients with chronic persistent hepatitis, 3 had RIF and 7 had SIF of low activity. In patients with HBsAg-positive and -negative chronic active hepatitis, 32 of 47 had RIF and 24 had SIF. SIF activity was significantly increased in HBsAg positive as compared to -negative cases. There was no correlation between RIF and SIF activity at any stage of viral hepatitis. Although SIF was demonstrated in patients with various infectious and other inflammatory diseases, RIF was infrequently detected in nonviral liver disorders, and was not present in any of the nonhepatic diseases tested. It was confirmed that RIF is associated with the beta-lipoprotein fraction. RIF was easily separated from SIF by density gradient ultracentrifugation. The evaluation of SIF and RIF may be helpful in determining the outcome of acute viral hepatitis. In chronic hepatitis, RIF was a better indicator of disease activity than was SIF. These clinical data support previous findings that SIF may be related to the immune response whereas RIF is associated with liver cell damage.

Sporadic non-A, non-B hepatitis: frequency and epidemiology in an urban U.S. population

Patients with acute viral hepatitis were identified at five hospitals in Baltimore, Maryland between February 1979-August 1980. Of the 295 patients with serologically diagnosed hepatitis, 42% had non-A, non-B hepatitis; 48% had hepatitis B; and 10% had hepatitis A. Compared with matched control patients with no liver disease, patients with non-A, non-B hepatitis more often had received a blood transfusion (11% vs. O, P less than 0.001), used parenteral drugs (42% vs. 4%, P less than 0.001), were employed as health workers in direct patient care or hospital laboratory work (6% vs. 3%, P less than 0.05), had personal contact with others who had hepatitis (16% vs. 1%, P less than 0.001), or had ingested raw shellfish (34% vs. 20%, P less than 0.01). A history of previous clinical hepatitis and serologic markers indicating previous hepatitis B infection were found in patients with non-A, non-B hepatitis more often than in the control patients. Chronic non-A, non-B hepatitis was found in 34 (42.5%) of 80 patients with non-A, non-B hepatitis.

[Destroying of antigenicity and influencing the immunochemical reactivity of hepatitis B virus antigens (HBsAg, HBcAg and HBeAg) through disinfectants--a proposed method for testing (author's transl)]

So far, hepatitis B virus cannot be grown in tissue cultures. Consequently, the inactivating effect of disinfectants upon the infectivity of hepatitis B virus could only be insufficiently investigated. Investigations using the only suitable test animal, the chimpanzee, are associated with substantial efforts and high cost and are also limited in their extent. A relatively simple and probably reliable method as test model for disinfectants used in hepatitis B prophylaxis is outlined: the destruction of the antigenicity and the decrease in the immunochemical reactivity of hepatitis B virus antigens (HBsAg, HBcAg and HBeAg). Effects of one alcoholic antiseptic and two peracetic acid containing disinfectants are investigated.

Clearance of hepatitis B e-antigen in chronic hepatitis B infection

HBeAg and anti-HBe were determined by radioimmunoassay (Abbott HBe) in serial serum samples from 22 patients who had been HBsAg-positive for more than 1 year. Seventeen patients (77%) were HBeAg-positive at onset of illness. Eight of these patients were persistently HBeAg-positive during 2.5-8.5 years' follow-up study (mean, 5.4 years). Chronic persistent hepatitis (CPH) developed in one of these patients and chronic active hepatitis (CAH) in seven patients. Nine persistently HBsAg-positive patients were transiently HBeAg-positive. Seven of these patients developed CPH, and they all lost HBeAg within 2 years of onset of illness. One patient, who was HBeAg-positive for 4 years, developed CAH with cirrhosis after loss of HBeAg. In five patients, HBeAg could not be detected. They were anti-HBe-positive at onset of illness; four developed CAH and/or cirrhosis, and one developed CPH. Progression from CPH or nonspecific reactive hepatitis to CAH was observed in two persistently HBeAg-positive patients. Prolonged detection of HBeAg in CPH is a reason for repeated liver biopsy to reevaluate the diagnosis. The behaviour of the e-antigen system in CAH seems to be more complex than in CPH, perhaps indicating a different pathogenetic mechanism of chronicity in CAH.

[Hepatitis B vaccine trial in healthy adults - an immunogenicity study (author's transl)]

The clinical and immunological response in healthy adults to active and passive - active immunization with a vaccine prepared from purified HBsAg (Merck Sharp and Dohme) in combination with a hepatitis B immune serum globulin (HBIG) were determined and compared with each other. The subjects were randomly assigned to one of three groups: group I received 3 doses of vaccine (20 micrograms per dose) at 0, 1 and 6 months, group II received in addition with the first dose of vaccine 3 ml of HBIG and group III received HBIG together with the first and the second doses of vaccine. No serious side effects were seen during the observation period. Antibody response was comparable in all three groups after 6 months, showing that the passive antibodies did not interfere with active antibody formation. Our results also prove the safety and efficacy of the hepatitis B vaccine and establish the feasibility of passive-active immunization.

Acute hepatitis non-A, non-B following administration of factor VIII concentrates

A retrospective survey on clinical hepatitis in patients with bleeding disorders was performed. Nine episodes of hepatitis non-A, non-B occurred in 8 out of 20 patients (40%) with mild hemophilia A or von Willebrand's disease, who had been treated with commercial factor VIII concentrates. Only two episodes of hepatitis B occurred during the study period. The non-A, non-B attack rate after the first treatment was 40% with factor VIII concentrate obtained from large plasma pools (= 2,000 donors) including professional plasma donors as compared to 8% after treatment with factor VIII concentrate obtained from smaller (100-250 donors) plasma pools from Scandinavian donors.

Cloning of hepatitis A virus genome

Hepatitis A virus (HAV) was highly purified from faeces. The genomic RNA was transcribed to cDNA and this DNA was then cloned into plasmid pBR 322 at the Pst I site, and clones were selected in presence of tetracycline. Most clones contained inserts which hybridized to HAV-specific RNA isolated from HAV-infected cell cultures derived from a human hepatocellular carcinoma. Two clones expressed low amounts of viral antigens.

[Non-A, non-B viral hepatitis: occurrence, epidemiology and prognosis]

Out of 117 cases with acute viral hepatitis, 37 (32%) were classified as hepatitis A, 50 (43%) as hepatitis B and 30 (25%) as hepatitis non-A-non-B (NANB). In 21 of the 30 patients with hepatitis NANB, a possible mode of parenteral transmission could be found. The mean incubation period was 53 days. Only 3 patients had had blood transfusions. 14 (52%) of the 27 patients with sporadic hepatitis (without transfusions) had a mild course of the acute illness without, or with only mild, jaundice and transaminase values below 500 IU. The remaining 13 patients had a more severe form of acute hepatitis (bilirubin above 5 mg/dl, GPT above 500 IU), and in 11 of these 13 cases confluent necrosis was demonstrable on liver biopsy. 10 (37%) of the sporadic cases, of whom 8 had a mild form of acute hepatitis, and the 3 cases of posttransfusion hepatitis, were followed by a chronic course.

[Hepatitis A antibody: placental transmission and disappearance in the first year of life (author's transl)]

Sera of 114 mothers and their newborn (cord blood) were tested for the presence of antibodies to hepatitis A virus (Anti-HAV) by a competitive solid phase radioimmunoassay. Antibodies were detectable in 80 pairs of sera but not in another 31 pairs. 3 newborns proved to be anti-HAV positive, while their mothers had not detectable antibodies. 72 infants could be followed up for about one year. The disappearance of antibodies occurred between the first and 14th month of life. 50% of the tested infants were still(Anti-HAV positive at the age of 7-8 months.

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.

Serum immunoglobulin levels in hepatitis non-A, non-B: a comparison with hepatitis A and B

The serum levels of IgA, IgG and IgM were determined by the single radial immunodiffusion method in 86 patients with acute viral hepatitis serologically differentiated by radioimmunoassays. The levels of IgA and IgG were similar in patients with hepatitis A, B and non-A, non-B, while differences in IgM levels were observed between the three groups. The hepatitis non-A, non-B group had significantly lower levels of IgM than both the hepatitis A and hepatitis B group, a finding which may be diagnostically useful if hepatitis A serology fails.