Search

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.

Corrigendum to " 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" [Trav. Med. Infect. Dis. 21, January-February 2018, 43-50].

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, 84% 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.

We assessed the immunogenicity of the paediatric dose of Epaxal(®) (0.25 mL) and the degrees of seroprotection achieved with the standard dose (0.5 mL) of Epaxal(®) or a dose of Havrix(®) Junior, in children in an open, randomised, controlled, multi-centre, parallel-group study conducted at 2 Chilean study centres. 360 healthy children and adolescents 12 months to

Few studies have examined the duration of protection following vaccination against hepatitis A virus (HAV) with currently licensed HAV vaccines. This study explored the long-term immunogenicity in individuals vaccinated with the virosomal hepatitis A virus, Epaxal®. Adult volunteers (N = 130) previously enrolled into four different studies between 1992 and 1994 and who had completed a 0/12-month immunization regimen (primary and booster dose) were asked to participate in this follow-up study. Yearly anti-HAV titers up to 6 years following booster vaccination, and then once 9–11 years after booster were measured using two assays, Enzygnost® and AxSYM® HAVAB 2.0. Based on the Enzygnost® assay, the seroprotection rate 9–11 years after booster was 100%, with a geometric mean concentration (GMC) of anti-HAV antibodies of 526 mIU/ml. Females had markedly higher GMCs than males (741 mIU/ml vs. 332 mIU/ml). Using an anti-HAV cut-off titer of ≥10 mIU/ml, a linear mixed mathematical model predicted a median duration of protection of 52.1 years. A duration of protection ≥35.7 years was predicted for 95% of subjects. A more stringent cut-off of ≥20 mIU/ml shortened the median predicted duration of protection to 45.0 years. In conclusion, a two-dose Epaxal® vaccination regimen confers in healthy adults a real-time protection of at least 9–11 years; this protection is predicted to last at least 30 years in over 95% of individuals. Further studies are necessary to assess the real duration of seroprotection and whether an additional booster is necessary later. J. Med. Virol. 82:1629–1634, 2010. 2010 Wiley-Liss, Inc.

Since hepatitis-B immune prophylaxis is possible, HIV infection could become the most important risk of infection facing medical personnel. Today, it must be assumed that HIV infection almost always leads to the fatal disease AIDS. The principal source of infection for medical personnel is patients' blood. The disease is usually transmitted parenterally, as a result of inoculation by a needle prick or similar injury. Blood contact with non-intact skin or mucosae can also lead to infection. In prospective studies, HIV infection was found in approximately 0.5% of cases following needle-prick injuries with anti-HIV-positive blood. The HIV infection risk for medical personnel thus ultimately depends on the frequency of needle prick-type injuries and the number of anti-HIV-positive patients. Assuming that there are 50,000-100,000 anti-HIV-positive persons in the Federal Republic of Germany (Federal Health Authority estimate) the occupational risk to the life of a surgeon sustaining 40 injuries per year could be over 1%. In densely-populated areas with above average contamination of patients a higher HIV infection risk must be expected. An increase in contamination in the next few years would also lead to an increased risk of 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.

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. 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. 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). Mulitvariate 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. 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.

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.

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.

In this open study, 20 toddlers and 80 schoolchildren received an intramuscular dose of Epaxal® and a booster dose 12 mo later to assess the efficacy and safety of this aluminium-free, virosomal hepatitis A vaccine. Four weeks after primary vaccination, 94% of toddlers and 99% of schoolchildren had seroconverted, and all toddlers and 94% of schoolchildren remained seroprotected for 12 mo. Conclusion: After vaccination with Epaxal® and booster, all subjects were seroprotected. Epaxal® was very well tolerated by both age groups.

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.

Background and objectivesNicaragua 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).MethodsThe 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.ResultsThe 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.ConclusionsThe 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.

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 Universitat Munchen. 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.

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 ≥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.

Summary 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.

Background: The objective of this cross-sectional, non-randomized, 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 and Methods: 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 significantly (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 transmittet 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.

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.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 (P0.001). 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.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.

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.

Immunogenicity and tolerability of a new formalin-inactivated, alum-adjuvanted whole virus vaccine against hepatitis A (VAQTA, MSD, West Point, USA) were evaluated by immunizing 52 healthy, anti-HAV negative volunteers with a 1 ml dose. A booster dose was given 6 months later. In these young adult vaccinees [27 males and 25 females, 19–34 (mean 26) years of age] VAQTA proved to be well tolerated and highly immunogenic. Two weeks after administration of one vaccine dose, all but one of the recipients (98%) had anti-HAV concentrations above the presumed minimum protective level of 10 IU l −1 with a geometric mean concentration (GMC) of 165 IU l −1 . After 4 weeks, a 100% seroconversion rate could be demonstrated with a fourfold increase of the GMC to 728 IU l −1 . Six months after vaccination, all but one of the 50 volunteers coming back for booster (98%) showed anti-HAV levels within the protective range. The antibody concentrations had decreased in the majority of vaccinees to a GMC of 362 IU l −1 . The booster dose given at that time was shown to be very effective, leading to a pronounced rise of anti-HAV levels in all recipients with a 17-fold increase of the GMC to 6040 IU l −1 . Six months after the booster, all vaccinees were still seropositive with a GMC of 3444 IU l −1 . Higher antibody levels were found in females, the difference being significant 4 weeks and 6 months after vaccination and 4 weeks after booster. No serious local or systemic adverse reactions were observed.

Accumulation and persistence of hepatitis A virus (HAV) in the mussel Mytilus chilensis was evaluated. Under optimal filtration activity of mussels (temperature 12°C, salinity 3%, feeding twice a day with Dunaliella marina), HAV was concentrated 100-fold from the surrounding water. Similar concentrations of HAV were reached in the filtration apparatus and in the digestive system (hepatopancreas). HAV persisted for about 7 days in mussels. Elimination of HAV from mussels was slower than elimination of poliovirus. Without feeding of mussels (causing low filtration activity), there was no measurable uptake of HAV into mussels, and depuration of HAV from mussels was slower. The ability of mussels to concentrate HAV was used successfully to monitor fecally contaminated river water for the presence of HAV. © 1992 Wiley-Liss, Inc.

A placebo-controlled, double-blind study on the efficacy of a hepatitis A vaccine (SmithKline Beecham Biologicals) was started in a region of Chile in September 1990, using hepatitis B vaccine as control. A total of 260 healthy children, 6–15 years of age, negative for antibody to hepatitis A virus (anti-HAV), antibody to HAV immunoglobulin M (IgM), hepatitis B surface antigen, and antibody to hepatitis B surface and core antigens by ELISA tests within 7 days before vaccination, were randomly assigned to two study groups: 128 children received the vaccine with a yellow label (group 1), and 132 children the vaccine with an orange label (group 2) at months 0, 1 and 6. Blood for serology and transaminase determination was drawn at months 1, 2, 6, 7 and 12. Both vaccines were tolerated equally well and no serious side effects were seen. In group 1 (presumed hepatitis A vaccine group), anti-HAV was detected (20% inhibition was used as the cut-off level) in 122 of 128 children (95.5%) tested at month 1, in 126 of 127 (99.2%) at month 2, in 126 of 127 (99.2%) at month 6 and in 126 of 126 (100%) at month 7. One anti-HAV seroconversion seen at month 1 was associated with presence of anti-HAV IgM and therefore probably represents HAV infection. Geometric mean anti-HAV concentration of the other children was 128, 342, 214 and 2301 mIU/ml at months 1, 2, 6 and 7, respectively. In group 2 (presumed hepatitis B vaccine group), three anti-HAV seroconversions, all associated with transient appearance of anti-HAV IgM, were detected at months 1 and 2. The difference in HAV infection rate seen in the two vaccine groups is not significant at month 12 of the study.

HIV is spreading rapidly in some developing countries. In only 2 years the estimated number of HIV infected prostitutes and intravenous drug users climbed from 100000 in Thailand. Professionals who follow the AIDS epidemic believe the spread of HIV among heterosexuals in India to be greater than that in Thailand. 20% of the prostitutes in 1 section of Bombay India have been infected with HIV. Further the HIV prevalence rate among adults in rural areas alone in Uganda and Tanzania stands at approximately 20%. Senegal used to be only endemic for HIV-2 but not HIV-1 is also present. 15% of adult males and almost 13% of adult females have already died from AIDS in Abidjan Cote dIvoire. Blood transfusions and contaminated needles have infected >1000 children in Romanian hospitals. Heterosexual transmission accounts for 60% of all worldwide HIV infections and may climb to 80% by 2000. WHO predicts that the number of HIV infected individuals worldwide will increase from 6-8 million (1990) to 15-20 million (2000). Even though there have been new modes of HIV transmission detected which are not epidemiologically important a small risk of infection still exists. For example 8 infants who acquired HIV infection in a hospital have infected their breast feeding mothers. 2 rugby players acquired HIV from a sports injury. Evidence shows that AZT prophylaxis does not always prevent HIV infection. HIV infection among homosexual men in some areas of the US is beginning to rise again despite educational campaigns after falling. Present preventive strategies have not been able to reduce HIV transmission. Research on animals indicate that development of a partially protective vaccine against HIV may be available by 2000.

To the Editor: The hepatitis E virus (HEV) is known to cause enterically transmitted epidemic and sporadic forms of hepatitis in tropical and subtropical countries. HEV has been reported occasionally in areas where the disease is not endemic1; however, such infections are predominantly associated with a history of travel to tropical or subtropical countries. Recently, HEV variants have been isolated in areas where the disease is not endemic, such as the United States (variant, HEV US-1).2 The impact of this finding on the incidence of hepatitis in Western Europe is unclear. We report a case of sporadic hepatitis E . . .

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.

Sera of 480 hospitalized hepatitis patients were tested for hepatitis B surface antigen (HBsAg), antibody to HBsAg (anti-HBs) and to hepatitis B core antigen (anti-HBc), antibody to hepatitis A virus (anti-HAV) and anti-HAV of IgM-class. Serological markers indicating hepatitis A infection were found in 107 (22.3%) and markers indicating hepatitis B in 297 patients (61.9%), while 63 patients (13.1%) were classified as hepatitis type "non-A, non-B". The latter group mainly comprised drug addicts (50.8%), cases of post-transfusion hepatitis (11.1%) and patients without obvious hepatitis exposure (28.6%). In spite of these epidemiological similarities to hepatitis B, the maximum levels of serum alanine aminotransferase and bilirubin were comparable to those in patients with hepatitis A and significantly lower than in hepatitis B infection. Chronic hepatitis developed in 7.1% of the "non-A, non-B" patients, a figure close to that reported for hepatitis B.

Hepatitis B e antigen (HBeAg) and its antibody (anti-HBe) were evaluated using a sensitive radioimmunoassay (RIA) in weekly serum samples obtained from nine chimpanzees experimentally infected with hepatitis B virus (HBV). In two chimpanzees with HBV infection with detectable hepatitis B surface antigen (HBsAG) for less than five weeks, and in one chimpanzee with documented HBV infection with no detectable HBsAg, HBeAg was not detected; in all three, anti-HBe became detectable early in the infection. In six chimpanzees in which HGsAg was detected for 16 weeks or longer, HBeAg was detected early in the infection; in five, anti-HBe became detectable and HBeAg undetectable prior to the clearance of HBsAg. The sixth remained HGsAg-positive and HBeAg-positive for more than two years and never developed anti-HBe. These results confirmed the sensitivity of this RIA and its value in predicting the course of HBV infections.

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.

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 virus surface antigen (HBsAg) could be studied until recently only by isolating it from the blood of carriers, thus making incorporation of radioactive precursors into this protein(s) impossible. The isolation of a cell line producing HBsAg [Alexander et al, 1978] has eliminated this obstacle. The cell line was therefore used for labeling HBsAg either with 35S-methionine or with 35S-cystine. HBsAg was purified by pelleting the component and by isopycnic centrifugation in CsCl gradients. HBsAg-positive fractions (as determined by solid-phase radioimmunoassay) were isolated from the gradients and analyzed in sodium dodecyl sulfate-containing polyacrylamide gels. It was found that although HBsAg contains substantial amounts of 35S-cystine, very little 35S-methionine was incorporated into this protein. In contrast, both labels were found in other structures having a buoyant density of about 1.3 gm/cm3 in CsCl. It was concluded that HBsAg is very low in methionine, and therefore this amino acid should not be used for labeling HBsAg in cells or in a cell-free system. Analysis of 35S-cystine-labeled HBsAg-positive material (buoyant density about 1.2 gm/cm3 in CsCl) revealed five proteins with molecular weights in the range of 48,000-82,000.

The propagation of hepatitis A virus (HAV) in the cell line PLC/PRF/5 made possible the radiolabelling in vivo of mature, infectious hepatitis A virions and the determination of their physicochemical properties. In contrast to poliovirus type 2 (160S, 1.340 g/ml), HAV had a sedimentation coefficient of 156 +/- 2S and a buoyant density of 1.332 g/ml in CsCl. The genome of HAV consisted of linear single-stranded RNA which sedimented at 32.5S under non-denaturing conditions. Compared to the size and sedimentation behaviour of poliovirus RNA (2.6 X 10(6) mol. wt., 35S) this corresponds to a mol. wt. of 2.3 X 10(6). Electrophoresis under fully denaturing conditions, however, revealed a mol. wt. of 2.8 X 10(6) and indicates the existence of relatively extended regions with secondary structure. The purified virus genome, containing a poly(A) sequence, served as a messenger for the synthesis of virus antigen in PLC/PRF/5 cells. Finally, in accordance with previous observations, the capsid of the virion was found to be constructed of three major polypeptides (VP1, 31 X 10(3); VP2, 26 X 10(3); VP3, 21 X 10(3) mol. wt.) and of two less readily demonstrable components probably corresponding to VP4 (8 X 10(3) to 10 X 10(3) mol. wt.) and the precursor polypeptide VP0 (40 X 10(3) mol. wt.).

199 children with acute hepatitis hospitalized between 1968 and 1978 were tested for serological markers of hepatitis A and B infection. In 24 out of 28 HBsAg-positive patients, hepatitis B infection was diagnosed because of the disappearance of the antigen during convalescence. The histories of the 171 HBsAg-negative children suggested acute hepatitis A infection in 69% of the patients. This diagnosis could be confirmed in 110 of the 116 tested cases (95%) by a more than fourfold increase in the anti-HAV titer or by detection of anti-HAV of the IgM class. In the 55 HBsAg-negative patients without epidemiological clues as to the type of hepatitis, 40 children exhibited anti-HAV which could be related to acute A infection in 21 out of 22 tested cases. At least 11 patients had to be classified as having nonn A--non B infection. The results indicate that a combination of evaluation of the patient's history and selected serological tests will permit a fast preliminary diagnosis. This is important in the clinical management of patients and protection of contacts with immunoglobulin.

A prospective study of post-transfusion hepatitis was conducted in 97 adult patients undergoing open heart surgery. Twelve patients developed presumed non-A, non-B hepatitis (five of these were hospitalized and three were jaundiced), and all 12 had received clotting factors from pooled plasma (fibrinogen, factor VIII, factor IX complex) from different manufacturers. Of the remaining 85 patients none received these high risk plasma derivatives and none developed hepatitis. Multiple peak ALT elevation seems to be an indication of development of chronic non-A, non-B hepatitis. In addition to the 12 cases of presumed non-A, non-B hepatitis, nine cases of serological changes related to hepatitis B virus were observed as follows: six early booster reactions of anti-HBs, but not anti-HBc, in anti-HBs and anti-HBc positive persons; one late immunization-like response for anti-HBs and two serological hepatitis B infections without transaminase elevation. Five of the nine cases were also associated with the administration of pooled clotting factors.

In 1968, studies of infectious hepatitis in volunteers were reported. Immunologic procedures for serologic study of the hepatitis A virus were not available at that time, and only the clinical and biochemical parameters of the disease were reported. Serial serum specimens from the participants in the study were retained; these specimens had been taken before inoculation and up to more than 100 days after inoculation. When a radioimmune assay for antibody to hepatitis A virus was developed, the series of sera was analyzed retrospectively. Forty-four male volunteers were involved in a series of three studies. Twenty (46%) of the volunteers were found to be initially immune to hepatitis A virus. Eighteen susceptible volunteers (with no preexisting antibody) were challenged with infectious virus. Eight of these volunteers developed clinical hepatitis and seroconverted; one seroconverted without evidence of clinical disease; and nine neither seroconverted nor had evidence of clinical disease. The radioimmune assay provided a method for diagnosis of immune status and of the acute disease caused by hepatitis A virus. In 1968, Boggs et al. [1] and Melnick and Boggs [2] reported a series of studies in which serum obtained from patients in the early stages of infectious hepatitis was administered to volunteers. The incubation period of the infectious hepatitis

An epidemic outbreak of non-A, non-B hepatitis occurred in 1977/78 involving 30 donors at a plasmapheresis center. A chimpanzee inoculated with serum of one donor developed non-A, non-B hepatitis with characteristic tubular alterations in the endoplasmatic reticulum. Infections were detected over a period of several months, with two well defined peaks in December 1977 and between the end of January and the beginning of February 1978. Epidemiological data suggested a spread within the center. The most probable mode of transmission was contamination with serum from plastic bags used for reinfusing erythrocytes. The estimated mean incubation time was 41 days (range 27 to 59 days).

The age distribution, seasonal distribution, and source of infection of acute hepatitis A in Germany was studied by examining 6847 sera from patients with clinical diagnoses of acute liver disease (increased serum bilirubin and/or transaminase levels) for markers of hepatitis A and B viruses. Antibodies of the IgM class to hepatitis A virus (anti-HAV IgM) were identified by a solid phase radioimmunoassay which was adjusted to detect anti-HAV IgM for about 90 days after infection. During one calendar year (September 1978 to August 1979) 14.3% of sera from hepatitis patients was positive for anti-HAV IgM. The distribution peak varied in populations of different origins; in German patients it was at 21–25 years of age whereas non-German adults were rarely infected, presumably because they were immune from earlier infections contracted in their native countries where hepatitis A is endemic. In younger patients (one to ten years) most cases occurred in children of foreign workers from Mediterranean countries; in contrast, German children had a low incidence up to 15 years of age. A peak of hepatitis A cases was observed in the autumn. Questioning of 471 patients with hepatitis A revealed that 61.8% had visited foreign countries where hepatitis A is still endemic shortly before onset of their illness. It is therefore concluded that in Germany hepatitis A is largely an infection of young adults, most of whom contract the disease during summer holiday periods abroad.

The persistence of antibody to hepatitis A antigen (anti-HAV) of the immunoglobulin M (IgM) class was evaluated in 88 sera of 51 acute hepatitis A patients. IgM was separated from IgG by a 2-h reorienting sucrose gradient ultracentrifugation, and the titer of anti-HAV was determined in the IgG- and IgM-containing fractions by solid-hase radioimmunoassay. IgM anti-HAV was the predominating antibody at onset of jaundice and persisted in these patients for at least 60 days, but not longer than 115 days. The demonstration of IgM anti-HAV is therefore a valuable tool for the diagnosis of recent hepatitis A infection.

The parameters for the use of reorienting gradients in vertical rotors for rapid separation of immunoglobulin M from immunoglobulin G on a preparative scale for the rapid diagnosis of infectious diseases are described.

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.

Sera from 44 patients with a well-documented diagnosis of chronic active hepatitis (CAH) were analysed for antibodies to hepatitis A virus (anti-HAV), hepatitis B surface antigen (HBsAg) and anti-HBs, e-antigen (HBeAg) and anti-HBe, as well as antibodies to hepatitis B core antigen (anti-HBc). Twenty-two patients had serologic evidence of hepatitis A infection. The frequency of anti-HAV was low in patients under 50 years of age (21%) but high among older patients (72%). There was, however, no significant difference between patients and age-matched controls regarding the prevalence of anti-HAV in serum. Markers for hepatitis B virus were found in 10 patients or 23% as compared with about 10% in Swedish blood donors. The results indicate that hepatitis A virus is of little importance in the pathogenesis of CAH and confirm the association between hepatitis B virus and development of chronic active hepatitis.