Polyphenon E: a new treatment for external anogenital warts

Background External genital warts (EGWs, condylomata acuminata) are a common, highly contagious disease caused by human papillomavirus (HPV), predominantly HPV 6 and HPV 11. Green tea catechins have been identified for their immunostimulatory, antiproliferative and antitumour properties. Two phase III trials evaluated treatment of EGWs with ointment containing a mixture of green tea catechins (Polyphenon E), U.S. adopted name: sinecatechins). Objectives To obtain additional data on the efficacy and safety of Polyphenon E ointment in the treatment of EGWs from two randomized, double-blind, vehicle-controlled trials. Methods Men and women aged > or = 18 years (n = 1005), with two to 30 EGWs (12-600 mm(2) total area) applied vehicle (G(Veh); n = 207), Polyphenon E ointment 10% (G(10%); n = 401) or Polyphenon E ointment 15% (G(15%); n = 397) three times daily until complete clearance of all EGWs (baseline + new EGWs) or for a maximum of 16 weeks. Results A total of 1004 patients were evaluable for safety and 986 for efficacy; 838 completed treatment after 16 weeks. Complete clearance of all EGWs was obtained in 53.6% (G(10%)) and 54.9% (G(15%)) of patients with Polyphenon E vs. vehicle (35.4%) (P < 0.001). Statistically significant differences in clearance rates appeared after 6 weeks of active treatment. Odds ratios vs. G(Veh) for G(10%) [2.10; 95% confidence interval (CI) 1.49-2.98] and G(15%) (2.22; 95% CI 1.57-3.14) indicated about a twofold higher chance of complete clearance under active treatment. Time to complete clearance was shorter with active treatment (hazard ratios 1.57 and 1.87, respectively, for G(10%) and G(15%) vs. G(Veh) groups; P < 0.001). Recurrence rates during follow-up were low and similar across groups: 5.8%, 6.8% and 6.5% (G(Veh), G(10%) and G(15%) groups, respectively). Adverse events were evenly distributed across groups ( approximately 30% of patients). Severe local signs were more frequent but moderate in the active treatment groups (1.5%, 9.2% and 13.5% for G(Veh), G(10%) and G(15%) groups, respectively). Conclusions Polyphenon E ointment is effective and well tolerated in the treatment of EGWs.

Antiviral therapy for herpes zoster: randomized, controlled clinical trial of valacyclovir and famciclovir therapy in immunocompetent patients 50 years and older

OBJECTIVE

To compare the efficacy and safety of valacyclovir hydrochloride and famciclovir for the treatment of herpes zoster.

DESIGN

A double-blind, randomized, controlled, multicenter clinical trial in which patients received 7 days of treatment and were followed up for 24 weeks.

SETTINGS

Patients reported directly to specialist centers or were referred from primary care centers.

PATIENTS

There were 597 otherwise healthy immunocompetent outpatients, aged 50 years and older, who presented within 72 hours of onset of zoster rash.

INTERVENTIONS

Treatment with valacyclovir hydrochloride (1 g 3 times daily) or famciclovir (500 mg 3 times daily) for 7 days.

MAIN OUTCOME MEASURES

Resolution of zoster-associated pain and postherpetic neuralgia, rash healing, and treatment safety.

RESULTS

Intent-to-treat analysis did not detect statistically significant differences for valacyclovir vs famciclovir on resolution of zoster-associated pain (hazard ratio, 1. 02; 95% confidence interval, 0.84-1.23; P =.84). Furthermore, no differences were evident between treatments on rash healing rates and on a range of analyses of postherpetic neuralgia. Safety profiles for valacyclovir and famciclovir were similar, with headache and nausea being the more common adverse events.

CONCLUSIONS

Valacyclovir treatment is comparable to famciclovir treatment in speeding the resolution of zoster-associated pain and postherpetic neuralgia. Current wholesale prices indicate that valacyclovir is the more cost-effective treatment for herpes zoster ($83.90 vs $140.70 per course).

Nongenital human papillomavirus infections

Although genital HPV types produce a broad spectrum of disease, the nongenital types are a bit more predictive. Particularly in the immunocompromised patient, it appears as though when they become symptomatic they cause warts. These warts can be a particular problem with immunocompromised patients where the malignant potential can also be expressed. Additional understanding of the relationship between the papilloma viruses and cutaneous oncology is very important. There needs to be an application of seroepidemiologic techniques to understand better the epidemiology and further research on more effective and less painful therapies.

Therapeutic response of basal cell carcinoma to the immune response modifier imiquimod 5% cream

BACKGROUND

Basal cell carcinoma (BCC) responds to interferon therapy. Imiquimod is a cytokine and interferon inducer.

OBJECTIVE

This randomized, double-blind pilot trial evaluated the safety and efficacy of imiquimod 5% cream versus vehicle in the treatment of BCC.

METHODS

In this population of 35 patients with BCC, 24 received imiquimod 5% cream and 11 received vehicle cream in 1 of 5 dosing regimens for up to 16 weeks. Six weeks after treatment, an excisional biopsy of the target site was performed.

RESULTS

BCC cleared (on the basis of histologic examination) in all 15 patients (100%) dosed twice daily, once daily, and 3 times weekly; in 3 of 5 (60%) patients dosed twice weekly; 2 of 4 (50%) dosed once weekly; and in 1 of 11 (9%) treated with vehicle. Adverse events were predominantly local reactions at the target tumor site, with the incidence and severity of local skin reactions declining in groups dosed less frequently.

CONCLUSION

Imiquimod 5% cream shows clinical efficacy in the treatment of BCC.

Genital warts and their treatment

Genital warts are manifestations of a common viral sexually transmitted disease (STD) that are often diagnosed and treated with a variety of clinical specialties. Unlike for other STDs, there is a general lack of a well-established treatment algorithm for the management of external genital warts. This, coupled with a wide variety of treatments and clinical settings, makes the development of a simple algorithm virtually impossible. In this review what is known and not known about current treatments and case management will be discussed.

External genital warts: report of the American Medical Association Consensus Conference. AMA Expert Panel on External Genital Warts

A consensus process was undertaken to describe and evaluate current information and practice regarding the diagnosis, treatment, and evaluation of patients with external genital warts (EGWs) and their sex partners. This process developed a number of key statements that were based on strong evidence in the literature or reasonable suppositions and opinions of experts. Key statements included the following. In most cases, EGWs can be diagnosed clinically by visual inspection. No one treatment is ideal for all patients or all warts. Women with EGWs and female sex partners of men with EGWs are at increased risk for human papillomavirus-related cervical disease and, like all women, should be screened for cervical cancer. The diagnosis of EGWs in children requires a sexual abuse evaluation. Clinicians who treat EGWs have a responsibility to counsel patients and to provide information about the infectivity, diagnosis, treatment, and natural history of EGWs and general information about sexual health and other sexually transmitted diseases.

Imiquimod, a patient-applied immune-response modifier for treatment of external genital warts

Genital human papillomavirus infection is one of the most common sexually transmitted diseases. Imiquimod is a new agent, an immune-response modifier, that has been demonstrated to have potent in vivo antiviral and antitumor effects in animal models. The present prospective, multicenter, double-blind, randomized, vehicle-controlled trial evaluated the efficacy and safety of daily patient-applied imiquimod for up to 16 weeks for the treatment of external genital warts. Wart recurrence was investigated during a 12-week treatment-free follow-up period. In the intent-to-treat analysis, baseline warts cleared from 49 of 94 (52%) patients treated with 5% imiquimod cream, 13 of 90 (14%) patients treated with 1% imiquimod cream, and 3 of 95 (4%) vehicle-treated patients; the differences between the groups treated with vehicle and imiquimod were significant (P < 0.0001). For subjects who completed the follow-up period, recurrence rates after a complete response were 19% (9 of 48 patients) in the 5% imiquimod cream group, 17% (2 of 12) in the 1% imiquimod cream group, and 0% (0 of 3) in the vehicle-treated group. There were no systemic reactions, although local skin reactions (generally of mild or moderate severity) were common, particularly in the 5% imiquimod cream group. Local reactions caused two patients to discontinue treatment. The most frequently reported local skin reactions were erythema, excoriation or flaking, and erosion. Patient-applied 5% imiquimod cream is effective for the treatment of external genital warts and has a favorable safety profile.

Treatment of genital warts with an immune-response modifier (imiquimod)

BACKGROUND

Genital warts are a common sexually transmitted disease caused by human papillomavirus. Imiquimod is a novel immune-response modifier capable of inducing a variety of cytokines, including interferon alfa, tumor necrosis factor-alpha, as well as interleukins 1, 6, and 8. In animal models imiquimod has demonstrated antiviral, antitumor, and adjuvant activity. In vitro, imiquimod has no antiviral or antitumor activity.

OBJECTIVE

Our purpose was to determine the safety and efficacy of topical imiquimod for the treatment of external genital warts.

METHODS

This prospective double-blind, placebo-controlled, parallel design clinical trial was performed in three outpatient centers, a public health clinic, a university-based clinic, and a private practice. One hundred eight patients with external genital warts (predominantly white men) were entered into the trial. Fifty-one patients were randomly selected to receive 5% imiquimod cream; 57 patients were randomly chosen to receive placebo cream. Study medication was applied three times weekly for up to 8 weeks. Patients whose warts cleared completely were observed for up to 10 weeks to determine recurrence rates.

RESULTS

In the intent-to-treat analysis, the warts of 37% (19 of 51) of the imiquimod-treated patients and 0% (0 of 57) of the placebo group cleared completely (p < 0.001). In addition, many patients experienced a partial response. A reduction in baseline wart area of 80% or more was observed in 62% of imiquimod-treated patients (28 of 45) and 4% of the placebo group (2 of 50) (p < 0.001); a 50% reduction or more in wart area was noted in 76% of imiquimod-treated patients (34 of 45) and 8% of placebo recipients (4 of 50) (p < 0.001). Of imiquimod-treated patients whose warts cleared completely and who finished the 10-week follow-up period, 19% (3 of 16) experienced recurrences of warts. Imiquimod-treated patients experienced a significantly greater number of local inflammatory reactions than the placebo group. Symptoms and signs associated with the local inflammatory reactions included itching (54.2%), erythema (33.3%), burning (31.3%), irritation (16.7%), tenderness (12.5%), ulceration (10.4%), erosion (10.4%), and pain (8.3%). There were no differences in systemic reactions or laboratory abnormalities between treatment groups.

CONCLUSION

Topical 5% imiquimod cream appears to have a significant therapeutic effect in the treatment of external genital warts.

Human papillomavirus and human disease

Human papillomaviruses (HPVs) are associated with a spectrum of different diseases in humans, including common warts and genital warts. Of more serious concern is the connection between certain HPV types and some malignancies, particularly cervical and anal cancer. DNA from HPV-16 and HPV-18, two types frequently found in cervical cancer tissue, can immortalize cells in laboratory cultures, unlike DNA from HPV types associated with benign genital lesions. Although it is unclear how high-risk HPV types cause cancer, studies indicate that malignant transformation involves the viral E6 and E7 gene products, which may exert their effect by interfering with the cellular proteins that regulate cell growth. The vast majority of those infected do not develop malignancies, indicating that HPV infection alone is not enough to cause cancer. Cofactors such as cigarette smoking, may be required before neoplasia can occur. The potential seriousness of HPV infections is suggested by the observations that the number of genital HPV infections diagnosed is increasing and that cervical cancer is the second leading cause of cancer deaths in women throughout the world.

Therapeutic approaches to genital warts

Although many treatments are available for genital warts caused by human papillomavirus (HPV), none are uniformly successful in the treatment of this disease. Most current treatment options work by destroying affected tissue, either by a cytotoxic or a physically ablative mode of action. Interferons have antiviral, antiproliferative, and immunomodulatory activities, but these have not translated into a high level of cure rates against warts. With all current treatments, recurrent warts are common. Therapies currently being investigated include a 5-fluorouracil/epinephrine collagen gel that achieves high concentrations of 5-fluorouracil at the site of injection. Other new treatment modalities focus on activating the host's immune system or improving the delivery of therapeutic compounds to the affected site. Imiquimod, a novel immune-response modifier, induces interferon and a number of other endogenous cytokines. A cream formulation containing 5% imiquimod resulted in good total clearance rates and generally tolerable side effects in controlled clinical trials of patients with external genital warts. Perhaps the most effective means for managing HPV disease would be a vaccine that prevents the occurrence of genital warts. Although it is unlikely that such a vaccine will be introduced in the near future, preliminary studies indicate that it may be possible to develop suitable prophylactic and therapeutic vaccines.

Human papilloma virus infection of the vulva

The relationship between human papilloma virus (HPV) and cervical cancer is in the process of being defined. This potential opportunity to understand a human oncogenic virus has drawn significant attention to HPV. While cervical cancer is a potentially fatal outcome of HPV infection, genital warts are the most common manifestation of genital HPV infection. In addition to knowledge of etiology, natural history, and therapeutic options, patients and providers need to consider emotional impact to successfully manage the care of patients with this common infection. This article summarizes current knowledge of recent advances of HPV infection of the vulva.

Valacyclovir: a review of its antiviral activity, pharmacokinetic properties, and clinical efficacy

Oral administration of the prodrug valacyclovir results in enhanced bioavailability and significantly greater plasma concentrations of acyclovir than can be achieved with oral doses of acyclovir itself. The results of clinical trials with valacyclovir have demonstrated significant benefits in the resolution of pain associated with herpes zoster infection. Efficacy parameters were similar for valacyclovir and acyclovir in the treatment of herpes simplex; however the results were achieved with lower and less-frequent doses of valacyclovir. The cost of a course of therapy with valacyclovir is expected to be similar to that of other antivirals. The potential clinical benefits of valacyclovir will likely be apparent in the case of acyclovir-resistant herpesvirus infections, where high-dose intravenous treatment with acyclovir has been necessary. Most of these resistant viruses have been encountered in immunocompromised patients, and the resistance has been attributed to inadequate exposure to the drug. Because optimal levels of acyclovir are achieved with a simpler dosing regimen of valacyclovir, compliance may be improved in many patients, thus reducing the incidence of resistant virus.

Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults

Acyclovir treatment of acute herpes zoster speeds rash healing and decreases pain and ocular complications. The limited oral bioavailability of acyclovir necessitates frequent dosing. Valaciclovir, the l-valyl ester of acyclovir, is rapidly and almost completely converted to acyclovir in vivo and gives three- to fivefold increases in acyclovir bioavailability. In a randomized, double-blind, multicenter study, the safety and efficacy of oral valaciclovir given at a dosage of 1,000 mg three times daily for 7 or 14 days and oral acyclovir given at a dosage of 800 mg five times daily for 7 days were compared in immunocompetent adults aged > or = 50 years with herpes zoster. Patients were evaluated for 6 months. The intent-to-treat analysis (1,141 patients) showed that valaciclovir for 7 or 14 days significantly accelerated the resolution of herpes zoster-associated pain (P = 0.001 and P = 0.03, respectively) compared with acyclovir; median pain durations were 38 and 44 days, respectively, versus 51 days for acyclovir. Treatment with valaciclovir also significantly reduced the duration of postherpetic neuralgia and decreased the proportion of patients with pain persisting for 6 months (19.3 versus 25.7%). However, there were no differences between treatments in pain intensity or quality-of-life measures. Cutaneous manifestations resolved at similar rates in all groups. Adverse events were similar in nature and prevalence among groups, and no clinically important changes occurred in hematology or clinical chemistry parameters. Thus, in the management of immunocompetent patients > or = 50 years of age with localized herpes zoster, valaciclovir given at 1,000 mg three times daily for 7 days accelerates the resolution of pain and offers simpler dosing, while it maintains the favorable safety profile of acyclovir.

Rational use of acyclovir in the treatment of mucocutaneous herpes simplex virus and varicella zoster virus infections

The herpes family of viruses establishes latent infection in neurons and produces a spectrum of acute and recurrent clinical disease. Therapies to terminate the neurolatency or to enhance host responses are not yet available. Current therapy consists of antiviral drugs, which interfere with viral replication, can favorably alter the signs and symptoms of symptomatic disease, and act as prophylaxis against recurrent disease. Because the severity of acute and recurrent herpes group infection varies greatly between individuals, proper selection of patients to be treated with antiviral therapy is important. In general in immunocompetent patients, antiviral therapy has the greatest potential benefit for patients early in the course of primary or initial disease, or for patients with frequent and/or severe recurrent disease. Patients late in acute disease or with infrequent and/or mild recurrent disease are very unlikely to benefit from antiviral therapy. With immunocompromised patients, antiviral therapy is of the greatest potential value. By careful selection of patients, the clinician can maximize the benefits of antiviral therapy for patients with cutaneous herpes group viral infections.

Epidemiology of human papillomavirus infections

Human papillomavirus infection represents the most common mucocutaneous viral infection, and 3% to 5% of all patients have clinically evident warts. Human papillomavirus infections of the genital tract are one of the most common sexually transmitted viral infections in the United States. Data from STD clinics and private physicians' offices reveal that genital warts, one manifestation of genital HPV infection, have been diagnosed more frequently in recent years. With the use of a variety of diagnostic techniques, asymptomatic HPV infection has been identified in men and women and is probably much more common than is clinically apparent infection.

Topical podofilox for the treatment of condylomata acuminata in women

The purpose of this study was to determine the efficacy and safety of 0.5% podofilox solution (Condylox) for the treatment of genital warts in women. Thirty-seven women with anogenital warts applied the solution to the surface of these warts twice daily for 3 days, followed by 4 drug-free days. A minimum of two and a maximum of four treatment cycles were given. The subjects were evaluated weekly for the first 4 weeks and again at 6 and 10 weeks. At the end of 10 weeks, the mean number of warts per patient was reduced from 6.27 to 1.1, and half of the patients were completely cleared of warts. Only eight of 37 subjects (21.6%) developed new warts during the study period. Approximately 15% of patients reported "severe" local reactions to the treatment after the first treatment cycle, but this was reduced to only 5% by the last treatment cycle. During the same period, the patients reporting no side effects increased from 44 to 86%. The only woman who discontinued the study did so because of dizziness and epigastric discomfort, probably unrelated to drug use. Thus, 0.5% podofilox solution appears to be an effective treatment for condylomata acuminata, with acceptable side effects that are local and temporary.

Current status of podophyllotoxin for the treatment of genital warts

An evolutionary process that began 50 years ago with a crude plant resin (podophyllum) has currently developed to the point where a fine chemical podophyllotoxin can be safely and effectively applied by patients for the treatment of external genital warts. In this brief review, the fundamental chemistry, pharmacology, and toxicology of podophyllotoxin will be reviewed, along with the sequence of clinical studies that resulted in the development of patient applied podophyllotoxin.

Patient-applied podofilox for treatment of genital warts

In a double-blind trial, 0.5% podofilox (podophyllotoxin) or placebo was applied by patients to their own genital warts in up to four treatment cycles. At some time during the study, 25 of the 56 podofilox treated patients and none of the 53 placebo group were completely wart-free. At the end of the treatment, 73.6% of the original warts in podofilox treated patients were gone compared with only 8.3% of those in the placebo group (mean percentage of total original wart area was reduced by 82.3% compared with 4.2%). 82% of the treated warts in the podofilox group and 13% in the placebo group had resolved at 6 weeks. Recurrence was observed in 34% of the previously resolved warts. Consistent with this rate of recurrence, new warts developed in a third of the subjects in each group at sites remote from the treatment site. There were no systemic adverse reactions, although transient inflammation, erosion, pain, and burning were common.

Neutrophilic eccrine hidradenitis associated with Hodgkin's disease and chemotherapy. A case report

A 44-year-old man with Hodgkin's disease developed fever and erythematous macules and plaques associated with doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy. Biopsy results demonstrated a neutrophilic infiltrate around sweat glands and degeneration of eccrine glands. These findings are characteristic of neutrophilic eccrine hidradenitis, which, to our knowledge, has previously been reported only in patients with acute myelogenous leukemia who were receiving cytarabine chemotherapy. Neutrophilic eccrine hidradenitis may represent a reaction pattern to chemotherapeutic agents and may not be specific for a particular disease or drug.

Serum immunoconglutinin titers during acute and chronic hepatitis B virus infection

Sera from 99 chronic hepatitis B surface antigen carriers, 12 individuals with acute type B hepatitis, 26 hepatitis B surface antibody-seropositive subjects, and 50 hepatitis B surface antigen, hepatitis B surface antibody-seronegative subjects were evaluated for the presence of serum imunoconglutinis (IKs). The mean serum IK titers of hepatitis B surface antibody-seropositive and hepatitis B virus-seronegative subjects wre 5.3 and 4.9, respectively. The IK titers of subjects with acute and chronic hepatitis B virus infections were 215.4 and 19.1, respectively. These groups also manifested IK titers greater than or equal to > 16 significantly (P < 0.005) more often than controls did. Among chronic hepatitis B surface antigen carriers, high IK titers were associated with low levels of hepatitis B surface antigen. IK titers of individuals chronically infected with hepatitis B virus and having the rheumatoid factor were similar to those of individuals without the rheumatoid factor. Elevated IK titers represent a physiological autoimmune response and may indicate the presence of immune complexes in acute and chronic hepatitis B virus infection.

Hemagglutinin and neuraminidase specific cell-mediated immune responses to influenza A virus following immunization in guinea pigs

Groups of guinea pigs were immunized with different inactivated recombinant influenza A viruses including H3ChN2Ch, Heq1N2Ch, H3ChNeq1 or uninfected allantoic fluid. Employing hemagglutination and neuraminidase inhibition tests, an in-vitro lymphocyte transformation (LTF) assay, and rosetting techniques for the separation of lymphocytes, influenza hemagglutinin (HA) and neuraminidase (NA) specific antibody and cell-mediated immune (CMI) responses were evaluated. Inactivated H3ChN2Ch, H3ChNeq1, HavN2Ch, and Heq1Neq1 recombinant influenza viruses were used as test antigens. Following immunization the CMI and antibody responses to influenza were characterized by the induction of specific LTF and antibody activity to homotypic HA or NA antigens but not to heterotypic HA or NA antigens. The temporal kinetics of the antibody response to influenza antigens was characterized by a prompt onset being initially detected at 1-2 weeks and reaching peak titers 3-4 weeks after immunization. Influenza specific LTF responses were first detected one week after immunization and declined to minimal responses at eight weeks. T-lymphocytes but not B-lymphocytes were capable of in-vitro recognition of the HA and NA antigens. After recognition the subsequent in-vitro lymphoproliferation was shown to involve both T and B lymphocytes.

Evaluation of a neuraminidase-specific influenza A virus vaccine in children: antibody responses and effects on two successive outbreaks of natural infection

Three groups of children were immunized with an inactivated Port Chalmers (H3ChN2Ch) influenza vaccine (group A), a neuraminidase-specific (Heq1N2Ch) influenza vaccine (group B), or a placebo. Immunization induced seroconversion for H3Ch and N2Ch-specific antibody in group A and for N2Ch antibody in group B. The protective efficacies observed against naturally acquired illness with the Port Chalmers strain of influneza A virus were 68.7% and 37.4% in groups A and B, respectively, in comparison to the placebo group, and those against illness produced by the subsequent outbreak of the Victoria strain were 80.0% and 72.7%. These data support the role of neuraminidase-specific immunization in protection against influenza. Although the degree of protection after vaccination with the Heq1N2Ch vaccine was less than that provided by the biphasic H3ChN2Ch vaccine against the Port Chalmers strain, it appeared to be similar in the two vaccine study groups against the Victoria strain.

Cell-mediated immune responses to the hemagglutinin and neuraminidase antigens of influenza A virus after immunization in humans

Humoral and cell-mediated immunity (CMI) were evaluated in groups of school children after immunization with inactivated influenza virus vaccines. A conventional biphasic strain (H3ChN2Ch) of Port Chalmers influenza virus (X-41), a recombinant influenza virus specific for the neuraminidase antigen (Heq1N2Ch) of Port Chambers influenza A virus (X-42), and a placebo were employed for immunization. The techniques of hemagglutination inhibition and neuraminidase inhibition were used to determine serum antibody titers. The CMI responses were evaluated by the in vitro lymphocyte transformation assay employing HavN2Ch, Heq1Neq1, H3ChNeq1, and H3ChN2Ch influenza A virus strains as stimulants. Specific HAI antibody and CMI responses to H3Ch were observed in X-41 but not in X-42 vaccinees. Specific anti-neuraminidase antibodies and CMI responses to N2Ch were manifested by both X-41 and X-42 vaccinees. Immunization with the placebo resulted in no influenza-specific immune responses. The CMI response was first detectable 10 days after immunization and then declined. These observations demonstrate the induction of CMI responses to the HA and NA influenza surface antigens after immunization. These responses may be important in antiviral immunity and the recovery from influenza infection.

Immunological aspects of cryoprecipitates from the sera of chronic HBsAg carriers

The sera of chronic hepatitis B surface antigen (HBsAg) carriers and seropositive controls were examined for the presence of immune complexes by cryoprecipitation. Cryoprecipitates (CP) were tested for HBsAg, antibody to HBsAg (anti-HBs), major classes of immunoglobulins, components of the complement system, rheumatoid factor and the ability to activate the alternative pathway of the complement system. For this analysis the methods employed included: radioimmunoassay, reverse passive haemagglutination, immunofluorescence, sucrose density gradient ultracentrifugation, agar-gel diffusion, immunoelectrophoresis, counterimmunoelectrophoresis, latex agglutination, and a haemolytic method for the detection of the activation of the alternative pathway of the complement system. HBsAg was frequently observed in the CP from chronic HBsAg carriers. No anti-HBs activity was detected in the serum of chronic HBsAg carriers. However, the CP from a number of chronic HBsAg carriers contained immunoglobulins and components of the complement system in the absence of rheumatoid factor, anti-HBs activity and were able to activate the alternative pathway of the complement system. On immunoelectrophoresis, a component of the CP reacting with anti-IgG, ANTI-IgA and anti-HBs antisera and demonstrating an altered (faster) electrophoretic mobility was observed. The nature of the CP strongly suggests the presence of circulating immune complexes in asymptomatic chronic HBaAg carriers. These immune complexes may be important in the eventual expression and outcome of clinical disease in apparently healthy carriers of HBsAg.

Cell-mediated immune response to liver tissue antigen and hepatitis B surface antigen after infection with hepatitis B virus in humans

The in vitro correlates of cell-mediated immunity to liver tissue antigens and hepatitis B surface antigen (HBsAg) were studied in groups of subjects with acute and chronic hepatitis B virus (HBV) infection and in a population of HBV-seronegative controls. The technique of in vitro lymphocyte transformation (LTF) was employed in these studies. No LTF response to liver-specific antigen and HBsAg was observed in the control population. LTF activity in response to HBsAg was present in 11 of the 14 subjects with acute type B viral hepatitis during the early phase of the disease, and eight of these subjects also had LTF reactivity to liver antigen. During the convalescent phase the LTF reactivity to these antigens usually disappeared. More than 70% of patients with chronic carriage of HBsAg who had elevated levels of liver enzymes showed LTF responses to HBsAg, and a significant number of these subjects also exhibited LTF response to liver-specific antigen. On the other hand, chronic HBsAg carriers who persistently showed normal liver enzyme values (asymptomatic carriers) failed to show significant responses to liver antigen or HBsAg. It is suggested that the persistence of cellular reactivity to liver antigens may lead to the establishment of chronic liver disease.

Hepatitis B surface antigen-specific cell-mediated immune responses in human chronic hepatitis B surface antigen carriers

The presence of hepatitis B surface antigen (HBsAg) and antibody (anti-HBs), hepatitis B e antigen (HBeAg) and antibody (anti-HBe), the nature of T-cell function, and specific cell-mediated immunity to HBsAg were determined and evaluated serially in groups of subjects with chronic HBsAg carrier states and in seronegative controls. The techniques of in vitro lymphocyte transformation, spontaneous rosette formation, radioimmunoassay, reverse passive hemagglutination, passive hemagglutination, rheophoresis, and liver function tests were employed for these studies. For the lymphocyte transformation assay, multiple concentrations of phytohemagglutinin and purified HBsAg were used as stimulants. Cell-mediated immunity to HBsAg was detectable in 50% of the chronic HBsAg carriers (responders) at one or more concentrations of HBsAg. The remaining carriers (nonresponders) and controls failed to manifest HBsAg-specific lymphocyte transformation activity. The profile of the responders was characterized by elevated serum glutamic pyruvic transaminase levels, the presence of anti-HBe, high HBsAg titers, and the conspicuous absence of HBeAg in the serum. The nonresponders were characterized by normal serum glutamic pyruvic transaminase levels, the presence of HBeAg and anti-HBe, and lower HBsAg titers. These observations demonstrate the presence of specific cell-mediated immunity to HBsAg in chronic HBsAg carriers who manifest biochemical evidence of liver disease.

Strain-specific local and systemic cell-mediated immune responses to cytomegalovirus in humans

Employing the techniques of complement fixation, immunofluorescence, and in vitro lymphocyte transformation assay, the antibody and cell-mediated immunity to cytomegalovirus (CMV) were studied in the serum, peripheral blood lymphocytes, tonsillar lymphocytes, and cord blood lymphocytes. The study population consisted of 32 children undergoing tonsillectomy and adenoidectomy. In the lymphocyte transformation assay, three strains of CMV (AD-169, ADH-1-41, and Davis), herpes simplex type 1, and phytohemagglutinin were employed as antigens. Sixty-five percent of the subjects were found to have CMV-specific antibody activity. The lymphocyte transformation response to phytohemagglutinin was similar in all subjects. No CMV-specific lymphocyte transformation activity was detected in cultures of cord blood lymphocytes. Significant cell-mediated immunity was observed in the tonsillar lymphocytes of 30% (3/10) of the seronegative individuals and in the peripheral blood lymphocytes obtained from one such subject. Over 75% (16/21) of the seropositive subjects demonstrated cell-mediated immunity against one or more strains of CMV in the peripheral blood lymphocytes and tonsillar lymphocytes. In the lymphocyte transformation assay, no cross-reactivity was apparent between CMV and herpes simplex type 1. These studies demonstrate the presence of strain-specific systemic and mucosal cell-mediated immune response to CMV in humans. The frequency and distribution of lymphocyte transformation responses to the three CMV strains suggest antigenic heterogeneity of CMV.

Hepatitis B e antigen and antibody activity in hepatitis B virus infection

Groups of institutionalized subjects, volunteer blood donors with serologic evidence of asymptomatic hepatitis B virus infection, and patients with acute type B viral hepatitis were studied for the presence of hepatitis B e antigen and antibody in a sequential manner over a period of two to three years. HBeAg was detected in 9.5% of institutionalized residents and volunteer blood donors and in 24% of patients with acute type B viral hepatitis. HBeAg positive subjects frequently had persistently elevated pyruvic glutamic transaminase levels in the serum. Anti HBe activity was observed in 26 to 32% of subjects positive for hepatitis B surface antigen. Long-term follow-up indicated that HBsAg positive subjects with anti HBe did not eventually become seronegative for HBsAg.

Clinical and immunologic evaluation of neuraminidase-specific influenza A virus vaccine in humans

Groups of schoolchildren were immunized with an inactivated recombinant influenza virus vaccine specific for the neuraminidase antigen of Port Chalmers influenza A virus (Heq1N2Ch), a conventional biphasic Port Chalmers strain of influenza virus vaccine (H3ChN2Ch), or a placebo. Immunization with either virus vaccine was found to be safe and had no major adverse effects. Immunization with the Heq1N2Ch vaccine resulted in no specific hemagglutination-inhibiting antibody response to H3Ch antigen, although a specific neuraminidase antibody response to N2Ch antigen was observed in greater than 90% of the vaccinees. A subsequent natural outbreak of influenza virus resulted in serologically proven infection with H3Ch virus in 26% of vaccinees receiving H3ChN2Ch virus vaccine, 47% of those receiving Heq1N2Ch virus vaccine, and 44% of those receiving a placebo. However, the protective efficacy against illness was 74.3% for the H3ChN2Ch vaccine and only 51.4% for the Heq1N2Ch vaccine. Regardless of the type of vaccine employed, vaccinees with serologic evidence of infection and clinical illness were found to have very low titers of hemagglutination-inhibiting and neuraminidase antibody. However, vaccinees with serologically proved infection but without clinical illness were found to have titers of antibody to neuraminidase before infection that were four- to eightfold higher than titers in vaccinees who were infected and who had clinical illness.

Distribution and characteristics of hepatitis B surface antigen in body fluids of institutionalized children and adults

Specimens of blood, feces, urine, and nasopharyngeal washings collected at regular intervals from subjects in an institutionalized population were tested for the presence of hepatitis B surface (HBS Ag) and antibody by passive hemagglutination, radioimmunoassay, and immune electron microscopy. HBS Ag, confirmed by radioimmunoassay and immune electron microscopy, was frequently detected in nasal washings, urine, and feces of chronic carriers of HBS Ag and occasionally in subjects with recent seroconversion for HBS Ag. In addition, some subjects who had recently become positive for antibody to HBS Ag in serum had HBS Ag transiently present in urine and occasionally in the feces, without demonstrable antigenemia.

Hepatitis B infection in health care personnel of an institution for mentally handicapped children and adults

The health care personnel (HCP) of an institution for the mentally handicapped were serially tested for the presence of hepatitis B surface antigen (HBSAg) and antibody over a period of 1.5 years. HBSAg was present in 1.8% and anti-HBS in 20.8% of HCP. The prevalence of seropositive HCP appeared to be related to the age and the prevalence of seropositive residents cared for by the HCP. The occurrence of seropositivity was higher in the HCP who cared for children under 15 years of age, who demonstrated a high prevalence of HBSAg or anti-HBS. Although the prevalence of HBSAg-positive subjects was 4- to 8-fold lower in HCP than in residents, the degree of seroconversion in susceptible seronegative HCP and residents was strikingly similar. These observations suggest that HCP working in a closed institutional setting are at considerable risk of contacting hepatitis B infection.

Development and Characteristics of In-Vitro Correlates of Cellular Immunity to Rubella Virus in the Systemic and Mucosal Sites in Guinea Pigs

The development of rubella-specific cell-mediated immunity (CMI) in splenic and bronchial lymphoid cells and antibody activity in serum and bronchial washings was studied in guinea pigs after subcutaneous or intranasal inoculation with live attenuated HPV-77 DE/5, RA27/3 rubella vaccines or live Brown strain of rubella virus. The techniques of hemagglutination inhibition, in vitro lymphocyte transformation, and assay of migration inhibitory factor with rubella virus as the antigen were employed to determine antibody and CMI in the systemic and secretory sites. Subcutaneous immunization resulted in regular appearance of serum antibody response. However, no antibody was detected in bronchial washings. Intranasal administration of the virus preparation resulted in little or no antibody response in the serum or respiratory tract. The CMI response after subcutaneous administration of rubella virus was characterized by the specific induction of lymphocyte transformation and migration inhibitory factor activity in the spleen cells without any detectable response in the bronchial lymphoid cells. Intranasal immunization resulted in the appearance of migration inhibitory factor activity in the bronchial cells with little or no response in the spleen cells. The CMI responses were initially detected 2 weeks after immunization. Peak responses were often found at 4 weeks, and no specific migration inhibitory factor or lymphocyte transformation activity was detected after 6 weeks. The results of this study suggest the development of local cellular immune response in the respiratory tract after local application of rubella virus.