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Editor-in-Chief, HCV Advocate
Hepatitis B Virus: An Unresolved Problem
W. S. Mason
Fox Chase Cancer Center, Philadelphia PA 19111, USA
With the introduction of a hepatitis B virus (HBV) vaccine nearly 20 years ago, it was hoped that human HBV infection could be eliminated, or at least substantially reduced, within the foreseeable future. This is still just a hope.
Two objectives need to be fulfilled, universal vaccination, and development of effective therapies for chronic infection. Although not everyone will be protected using the current vaccine, most would be, and the carrier incidence should decline substantially, first among the young, as already demonstrated, and then among adults. However, the goal of complete elimination, with no potential for resurgence, seems far away without major advances in the treatment of chronic infections, particularly treatments that are rapid acting and cost effective. As demonstrated both clinically and in the laboratory, nucleoside analogs eliminate, or at least allow the host immune system to control an infection, akin to recovery from a transient infection, in only a minority of patients. In most cases, however, this is not the outcome, and drug resistant viruses emerge. New DNA synthesis inhibitors and combination treatment may limit the emergence of mutants, but antiviral treatment will not necessarily lead to complete virus elimination. Even better would be a means of inducing a host response that would by itself bring the infection under control. Aside from the fact that we don't know how to do this, an unresolved issue is whether covalently closed circular DNA (cccDNA) that sustains the infected state can be eliminated by the host via means other than cell death. Some cell culture studies have suggested that cccDNA has a half life of less than one week, but not all studies have shown this, and convincing evidence for this is yet to be provided by in vivo studies. In fact recent in vivo data suggests that cccDNA can survive cell division. If not, an immunotherapy that rapidly eliminated the infection might pose an unacceptable risk for a patient with compromised liver function. An alternative in this case might be suppression of virus load by inhibition of viral DNA synthesis, followed by stimulation of a host response that prevents rebound, similar to that occurring naturally in individuals that normally respond to treatment with virus elimination. Unfortunately, it is not yet clear how even this goal will be achieved and significant progress in eliminating HBV will be linked to progress in basic research for many years to come.
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Long Term Immunogenicity of the Hepatitis B Vaccine in 9 year-old School Children: A Five-Year Followup
B. Duvall, N.Boulianne, G.De Serres, P. De Wals, R. Masse, G. Trudeau, V.Gilca
The long-term duration of the protection conferred by the hepatitis B vaccine in children is a very important question since most exposures will occur many years after the primary immunization. We follow a cohort of 1109 nine year-old schoolchildren to measure the protection remaining 5, 10 and 15 years after the primary immunization. The results of the first phase of the study after a 5 year follow-up are presented.
The cohort was initiated in 1996. The participants had all reached the seroprotective titer of 10m IU/ml after the primary immunization with a GMT of 7307 mIU/ml. After 5 years, the remaining 978 subjects were randomly allocated to three groups. Anti-HBs were measured in the 303 subjects of the first group. A booster dose was then administered and the anti-HBs were tested one month later.
After 5 years, 5.3% had no detectable anti-HBs and 7.3% had a titer inferior to the protective level of 10 mIU/ml. The GMT was 252 mIU/ml. After the booster dose, only 1 subject (0.3%) had no detectable anti-HBs and 2 more had a titer inferior to 10 mID/mI. The GMT was 113 201 mIU/ml. All subjects who had a detectable titer and 62.5% of those who had a titer inferior to 10 mIU/ml reached a titer superior to 100 mIU/ml after boosting.
Among children who initially had reached the seroprotective level, more than 12% had no protective level of antibodies after 5 years. As expected, most of them had a good immune response to a booster dose even when they had no measurable antibodies. However, 1% of the children who were initially protected did not respond to the booster dose. It remains to be seen if this proportion will increase among the two other groups who will be tested after respectively 10 and 15 years.
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The Global Reduction in Hepatitis B Disease Burden from Vaccination
ST Goldstein, F Zhou, SC Hadler, EE Mase, BP Bell, HS Margolis
Division of Viral Hepatitis
National Immunization Program, Centers for Disease Control and Prevention, Atlanta, GA, USA
Few data are available regarding global hepatitis B virus (HBV)-related morbidity and mortality and potential reduction in disease burden from hepatitis B vaccination.
HBV-related cirrhosis and hepatocellular carcinoma (HCC) mortality curves, adjusted for background mortality, were used to calculate HBV-relate deaths among persons with chronic HBV infection. Disease burden in the year 2000 (current burden) was estimated by applying the mortality curves to the 2000 population structure. To estimate the lifetime disease burden in the year 2000 birth cohort (future burden), a decision analysis was used to calculate the age-specific risk of acquiring HBV infection, acute hepatitis B (illness and death), and progression to chronic infection. Hepatitis B vaccination impact was estimated from 3-dose vaccination coverage of infants, with and without a birth dose of vaccine.
The estimated year 2000 HBV-related disease burden included 620,075 deaths, 580,545 (93%) from chronic infection (cirrhosis and HCC) and 39,530 (7%) from acute hepatitis B. Over the lifetime of the year 2000 birth cohort, if not vaccinated, there would be an estimated 64.8 million HBV infections, 9.7 million chronic infections, and 1.4 million deaths (1,340,327 [95%] from chronic infection and 64,967 [5%] from acute hepatitis B). Infections acquired during the perinatal period, in early childhood (<5 years old), and =5 years of age would account for 21 %, 48%, and 31 % of deaths, respectively. Routine infant hepatitis B vaccination, with 90% 3-dose coverage and no birth dose, would prevent 68% of HBV-related deaths. The reduction in HBV-related deaths would increase to 84% if the 90% 3-dose vaccination coverage included a dose of vaccine administered at birth.
Globally, most HBV-related deaths result from the chronic sequelae of infection acquired in the perinatal and early childhood periods. Inclusion of hepatitis B vaccine in national infant immunization programs would prevent >80% of HBV-related deaths.
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Management of Fulminant Hepatitis Due to Hepatitis B
Hans L. Tillmann, Michael P. Manns
Medizinische Hochschule Hannover, Dept. Gastroenterology, Hepatology & Endocrinology, Carl Neuberg Str.l, 30623 Hannover, Germany
Fulminant hepatic failure may develop in about 1 % of patients suffering from acute hepatitis B. In addition, fulminant hepatitis can emerge in immunosuppressed patients due to reactivation. Without liver transplantation, death occurs in the majority of patients with fulminant hepatitic failure. No causative therapy is currently established for fulminant liver failure or its preceding severe acute hepatitis. The supportive therapy for fulminant hepatitis B does not differ from other forms of fulminant hepatitis.
For the therapy of chronic hepatitis B, two treatment options are currently licensed: interferon-alpha or lamivudine. Interferon is immune-stimulating and thus may be dangerous in fulminant hepatitis B, where overwhelming immune reaction is believed to be involved in the pathogenesis. In contrast, the oral nucleoside analogue "lamivudine" inhibits hepatitis B viral replication with an immediate decline of serum HBV -DNA.
In the absence of the option for emergency liver transplantation due chronic liver disease or an underlying malignancy, lamivudine has been used in number of patients suffering from fulminant hepatitis B due to reactivation of chronic hepatitis B. Seven single case reports describe the effective use of lamivudine to prevent deterioration of fulminant hepatitis. However, three case series including 10 or 24 patients still show a high rate of death. However, these case series also indicate that early start of lamivudine appears essential. There are no data on the use of lamivudine in patients with fulminant hepatitis B with an indication for liver transplantation, except one single case report with complex treatment regimen involving interferon, glucagons and insulin, methylprednisolon, cyclosporin, high-volume hemodiafiltration and lamivudine. However, prior to the development of fulminant hepatic failure, patients usually present with very severe acute hepatitis B, who are likely to develop liver failure. Using lamivudine in this setting appears to prevent deterioration in most patients. One report on three patients was published last month. We have used lamivudine in fourteen such patients, and only two patients required liver transplantation (p<0.001=. All patients cleared HBsAg.
Lamivudine appears safe in patients with severe acute or fulminant hepatitis B, and might have the potential to prevent liver failure when administered early enough. We would recommend to start lamivudine once prothombine time significantly deteriorates.
Biochemical Patterns of Anti-HBE Positive Chronic Hepatitis B: Clinical and Prognostic Implications
F. Oliveri, G. Rocca*, B. Coco, F. Bonino* and M.R. Brunetto
Gastroenterologia-Epatologia, AOU Pisana, Pisa *Ospedale Maggiore di Milano, IRCCS, Italy
The biochemical patterns of anti-HBe chronic hepatitis B were studied in 139 consecutive patients.
Before treatment monthly tests were performed for at least 12 months (m) and every 6 m for 21-145 m. Progression end points were cirrhosis at follow-up histology or end stage complications of cirrhosis in patients without or with baseline cirrhosis respectively. Three AL T patterns emerged: persistent elevation without peaks (pattern 1); peaks (> 300 U/l or < 2 SD) with (pattern 2) or without (pattern 3) normalization in between. The probability of disease progression (Kaplan-Meier) and Cox regression were used to estimate the independent effect of patterns, age, sex, risk factors, steatosis, HBeAg, HBV-DNA, IgM anti-HBc and treatment in all, hepatitis and cirrhosis phases.
The ALT patterns were not associated with age. The probability of progression differed in the 3 subgroups [P = 0.02 overall; P = 0.01 in hepatitis]. The best prognosis was associated with pattern 2 [P = 0.04 RR 0.52 overall; P = 0.01 RR 0.52 in hepatitis]. Pattern 3 was associated with the worst prognosis [P = 0.05 RR 1.83 overall; P = 0.007 RR 3.13 in hepatitis]. Progression of cirrhosis did not differ in the 3 subgroups. Age and IgM anti-HBc overall and sex, HBeAg and HBV-DNA in hepatitis were independently associated with progression.
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Treatment of Chronic HBC Infection via Oral Administration of HBV Specific Antigens: An Increase of IFNy Mediated Immunity and a Decrease of IL10 Mediated Pathology
E. Israelil, R. Safadil, O. Shiboletl, A. Blochl, O. Pappo2, A. Kleinl, R. Alperl, M. Rowel, N. Hemedl, B. Thalenfeld3, D. Engelhard3, E. Rabban3, and Y. Hanl
l Liver Unit, Department of Medicine
2Department of Pathology, Hadassah-Hebrew UniversityMedical Center, Jerusalem, Israel
3ENZO. Biochem, New York
Anti-viral immunity can be modulated via oral administration of viral proteins. Hepatitis B virus (HBV) associated hepatocellular injury is mediated by a defective host anti-viral immune response.
To determine the effect of oral administration of HBV envelope proteins and/or liver extracted proteins to chronic HBV patients on viral load, liver injury, and the anti-viral T-cell response.
Fifty-five chronic HBV subjects were treated orally with HBsAg+preS1+preS2 (Group A, n=42), or liver extracted proteins with HBV proteins (Group B, n=13) three times a week for 20 or 30 weeks, and followed for an additional 20 weeks. Subjects were monitored for HBV-DNA levels, liver enzymes and liver histology. HBV-directed T-cell immunity was assessed by IFNy and IL1O ELISPOT, HBV-specific T-cellproliferation, cytotoxicity, and cytokine assays, and followed for peripheral NKT cell number.
Oral immune regulation induced a significant decrease in viral load in 46% and 35.7% of subjects in groups A and B, respectively. HBsAg/HBcAg biopsy scores improved in 58% and 50%, and histological improvement in liver necroinflammatory score was noted in 33% and 30.7% of subjects in groups A and B, respectively. Three out of eleven HBeAg-positive subjects in group A, and 0 out of 4 in group B, lost the HBeAg. A favorable response in the anti-HBV -specific T-cell response was noted, with a significant increase of IFNy-positive T-cell clones (62.9% and 35.7%, for groups A and B, respectively), along with a marked decrease in the IL10 -positive T-cell clones (48.1% and 50%, for groups A and B, respectively). A favorable augmentation of HBsAg-specific T-cell proliferation (78% and 50%, for groups A and B, respectively), and cytotoxicity (75% in group A), was noted. Serum IFNy levels increased in 50% and 30.7% in groups A and B, respectively. NKT lymphocytes increased significantly in peripheral blood of all treated subjects.
Immune regulation of the anti-HBV immune response via oral administration of HBV-envelope proteins alleviated the immune-mediated liver injury while augmenting the effective anti-viral immunity. Nonspecific liver epitopes did not increase the response rate in these subjects. This effect was accompanied by an increase in the anti HBV IFNy and a decrease in the anti HBV IL1O - T-cell clones.
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Efficacy of 5 Years of Lamivudine in Chinese Patients with Chronic Hepatitis B
GB Yaol, ZY Cui 2, BE Wang 3, JL Ya04, MD Zeng5, Y Huang6 and N Ji6
1 Shanghai Jin-An Qu Central Hospital, Shanghai, China
2 Beijing Ditan Hospital, Beijing, China
3 Beijing Friendship Hospital, Beijing, China
4 The 3rd Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
5 Shanghai Renji Hospital, Shanghai, China
6 GlaxoSmithKline, Beijing, China
To assess the efficacy of up to 5 years of lamivudine therapy in Chinese patients with chronic hepatitis B.
A total of 429 patients with chronic hepatitis B as deemed by positive HBsAg, HBeAg and HBV DNA were randomized 3:1 in a double-blind trial to receive either lamivudine or placebo respectively for 12 weeks. Thereafter all patients were offered a further 248 weeks of open label lamivudine treatment. After 3 years, patients who had achieved HBeAg seroconversion and were HBV DNA negative stopped therapy and subsequent data points for HBV DNA and ALT were excluded. Analyses were based on a modified intent-to-treat population.
227 patients completed 260 weeks of treatment. At baseline the median ALT value was 1.0xULN (range 0.2-17.3) and at week 260 was 0.9xULN (range 0.113.0). At the end of 5 years serum HBV DNA continued to be suppressed, with a median value of 99.1 Meq/ml (Chiron bDNA). For patients with baseline ALT >2xULN, HBeAg loss at end of weeks 52, 104, 156,208 and 260 was 19%,45%, 52%, 54% and 54% respectively, while HBeAg seroconversion (HBeAg negative, HBeAb positive) was 16%, 28%, 40%, 54% and 50% respectively. The higher the baseline ALT, the greater the HBeAg response. 73% of patients with elevated baseline AL T had normal AL T levels at week 260. This is despite 67% of patients having evidence of emergence of YMDD variant HBV by week 208 (sensitivity 500copies/ml). There was no increase in the frequency or intensity of adverse events with extended lamivudine treatment and the drug continued to be well tolerated.
=Lamivudine treatment for up to 5 years is associated with increased HBeAg loss and HBeAg seroconversion, particularly in patients with elevated baseline serum ALT.
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Adefovir Dipivoxil 10 MG (ADV) Results in Consistent Efficacy in Broad Range of Chronic Hepatitis B (CHB) Patients
I P. Marcellin, 2 S. Hadzyannis, 3 E. Schiff, 4 M. Peters, 5 Y. Benhamou, 6 G.M. Currie, 6 J. Fry, 6 M. Wulfsohn, 6 M. Sullivan, 6 C. Brosgart
I Hopital Beaujon-Clichy France
2 Henry Durant Hospital, Greece
3 University of Miami, FL, USA
4 University of California, CA, USA
5 Pitie-Salpetriere, Paris, France
6 Gilead Sciences, Inc., CA, USA
Adefovir is a nucleotide analogue with in vivo and in vitro activity against wild-type and lamivudine-resistant (LAM-R) hepatitis B virus (HBV).
To compare the efficacy of adefovir l0 mg over 48 weeks in a broad range of chronic hepatitis C (CHB) patients.
Serum HBV DNA (Roche AmplicorTM, lower limit of quantification 400 copies/mL) and ALT were evaluated in 692 patients with CHB receiving adefovir 10mg in 6 studies: HBeAg+ (n=171, study 437); HBeAg- (n=123, study 438); LAM-R, pre- (n=128) and post-liver transplantation (n=196, study 435); LAM-R, HBeAg+, compensated liver function, ADV (n=19) and LAM + ADV (n=20, study 461); LAM-R HIVIHBV coinfected (n=35, study 460i) and LAM-R patients with decompensated liver function (n=40, study 465).
All studies evaluated treatment from 48 to 52 weeks. In study 437, median change from baseline of serum HBV DNA was -3.5 10gl0 copies/mL and ALT normalised in 48% of patients; In study 438, median change of HBV DNA was -3.9 10gl0 copies/mL and ALT normalised in 72%. Median HBV DNA reductions was 4.3 and 4.1 logl0 copies/mL were observed in pre- and post-liver transplantation patients (study 435), respectively. ALT normalised in 49% and 75% of patients, respectively. In study 461, median HBV DNA reduced by 4.0 and 3.6 10gl0 copies/mL and ALT normalised in 47% and 53% of patients receivmg ADV and LAM+ADV, respectively. In HIV/HBV co-infected patients, mean serum HBV DNA reduced by 4.1 10gl0 copies/mL and AL T normalised in 35% of patients. In study 465, mean serum HBV DNA reduced by 5.4 10gl0 copies/mL and ALT normalised in 63% of patients
Adefovir 10mg once-daily resulted in consistent antiviral and biochemical response in patients with HBeAg positive and negative CHB, including LAM-R HBV, HIV coinfection, compensated and decompensated liver function and in the pre-and post-liver transplantation setting.
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Treatment with Peginterferon Alfa-2A (40KD) (Pegasys®) Results in Improved Response in ‘Difficult-To-Treat’ HBV
W.Q.E. Cooksley1, M-Y. Lai2, T. Piratvisuth3, Y-J. Wang4, V. Mahachai5, Y-C Cha06, T. Tanwandee7, A. Chutaputti8, W-Y. Chang9, F.E. ZahmlO, N. Pluckll
lRoyal Brisbane Hospital, Herston, Australia
2National Taiwan University, Taipei, Taiwan
> 3Songklanakarin Hospital, Songkla, Thailand 4Taipei Veterans General Hospital, Taipei, Taiwan
5Chulalongkorn Hospital, Bangkok, Thailand
6Tri-Service General Hospital, Taipei, Taiwan
7Siriraj Hospital, Bangkok, Thailand
8pramongkutklao Hospital, Bangkok, Thailand
9Kaohsiung University Hospital, Kaohsiung, Taiwan
lOF. Hoffmann-La Roche Ltd, Basel, Switzerland
11Roche Products Ltd, Welwyn Garden City, United Kingdom
High pre-treatment HBV DNA levels and low pretreatment AL T values are considered predictors of poor response to antiviral therapy in HBeAg-positive chronic hepatitis B (CHB). Evidence also suggests that HBeAg-positive CHB patients infected with HBV genotype C respond less well to treatment. Peginterferon alfa-2a (40KD) (PEGASYS®) has demonstrated superior efficacy over conventional interferon (IFN) in patients with 'difficult-to-treat' HCV. The efficacy of PEGASYS in patients with 'difficult-to-treat' CHB-genotype C, high pretreatment HBV DNA, low pre-treatment ALT-is unclear.
To assess the efficacy of PEGASYS in patients with 'difficult-to-treat' HBeAg-positive CHB (genotype C, high pre-treatment HBV DNA, low pre-treatment ALT).
194 adults with HBeAg-positive CHB were randomized to IFN a-2a 4.5 MIU tiw, or PEGASYS 90, 180, or 270 µg qw for 24 weeks, and followed up for 24 weeks.
In patients with the highest HBV DNA levels (=11 log10 copies/mL), combined response (HBeAg loss, HBV DNA <500,000 copies/mL, AL T normalization) was achieved by 13% of PEGASYS patients compared with 0% of IFN a-2a patients. Similarly, for patients with low pre-treatment AL T (0-<2 x ULN), 27% achieved a combined response when treated with PEGASYS compared with 11% when treated with IFN a-2a.
In patients with both high pre-treatment HBV DNA (=8 1ogl0 copies/mL) and low pre-treatment ALT, HBeAg clearance was achieved by 44% of PEGASYS patients, compared with 17% of IFN a-2a patients. Likewise, HBV DNA suppression (<500,000 copies/mL) was achieved by 25% of patients receiving PEGASYS compared with 17% receiving IFN a-2a.
In patients with HBV genotype C, combined response was achieved by 21 % of PEGASYS patients compared to 6% of IFN a-2a patients.
In patients with 'difficult-to-treat' CHB (HBV genotype C, high pre-treatment HBV DNA levels and/or low pre-treatment ALT values) PEGASYS demonstrated substantially greater efficacy than IFN a2a.
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Unique Mechanism of Anti-HBV Activity of Clevudine (L-FMAU)
Y. Chong and Q. K Chu*
Department of Pharmaceutical and Biomedical Sciences, College of Pharmacy, The University of Georgia, Athens, GA 30602
Clevudine (L-FMAU) was discovered by our research group as a potent antiviral agent against hepatitis B virus (HBV), which demonstrated low cytotoxicity in a variety of cell lines including MT2, CEM, HI and HepG2 2.2.15 and bone marrow progenitor cells. LFMAU is currently undergoing phase II clinical trials in chronically infected HBV patients. However, even though clevudine is known to act specifically on viral DNA synthesis and its triphosphate can inhibit the HBV DNA synthesis in a dose-dependent manner, the precise understanding of the mechanism of action of clevudine at the polymerase level has not been realized. That is, L-FMAU is not incorporated to the growing HBV DNA chain, which is quite aberrant from all other polymerase inhibitors. It is known that nucleoside inhibitors, in general, interfere with the viral polymerase activities by both competitive inhibition and incorporation to the viral DNA strands.
In this study, the recently published homology model of HBV polymerase by Arnold et al. (Das, K.; Xiong, X.; Yang, H.; Westland, C. E.; Gibbs, C.; Sarafianos, S. G.; Arnold, E. J Viral. 2001, 75, 4771-4779) was complexed with L-FMAU-TP and simulated to obtain the structural as well as mechanistic information of LFMAU-TP binding to the active site of HBV polymerase in a molecular level. Our simulation suggests that the RT-like active site of HBV polymerase was not able to accommodate L-FMAU-TP because docking the L-FMAU-TP at the active site of HBV polymerase caused a steric hindrance of the 2'endo sugar moiety of L-FMAU with the 3'-end of the primer strand which has the 3' -endo conformation. Therefore, the conformational space of the active site of HBV polymerase was investigated by simulating the complex by molecular dynamics. The conformational adjustment initiated at Met519 propagated to the nearby Phe436 to give enough space for L-FMAU- TP to undergo the conformational change from 2' -endo to 3'-endo. As a result, the sugar moieties of L-FMAUIP and 3' -terminal nucleoside of the primer strand can acquire enough space between each other. On the other hand, the conformational change in L-FMAU-TP resulted in an interesting change in the polymerization geometry of the growing viral DNA chain. As the polymerization should take place by the SN2-type attack of the nucleophile (3' -OR group at the 3' -end of the primer strand) at the a-phosphorous atom of the nucleoside triphosphate, the distance and relative orientation between the two atoms are critical. In LFMAU- IP binding to the active site of HBV polymerase, as the sugar moiety of L-FMAU-TP separates from the 3' -end of the primer strand by the conformational change, its a-phosphate atom also moves out from the 3' -OR group of the primer end by more than 2 A (5.7 A, the optimum distance is around 3.5 A.). Therefore, the incorporation of L-FMAU-TP to the growing viral DNA chain can not take place easily because of this deformed polymerization geometry, which may explain the reason that L-FMAU is not incorporated to the HBV DNA.
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A Phase I/II Dose Escalating Trial of Clevudine in Patients Chronically Infected with Hepatitis B Virus
P. Marcellinl, H. Mommeja-Marin2, S. Sacks 3, GKK.. Lau4, D. Sereni5, J-P. Bronowicki6, B. Conway7, MR. Blum2, BC. Yo08, A. Sno2, J. Sorbel2, F. Rousseau2 and H-S. Lee9
1Hopital Beaujon, Clichy, France
2 Triangle Pharmaceuticals, Inc, Durham, NC
3 Viridiae, Vancouver, BC
4 Queen Mary Hospital, University of Hong Kong, Hong Kong SAR China
5 Hopital Saint Louis, Paris, France
6 Hopital Brabois, Nancy, France
7 University of British Columbia, BC
8 Sam sung Medical Center, Sang Kyun Kwan University, Korea, South Korea
9 Seoul National University Hospital, Seoul, South Korea
Clevudine (L-FMAU) is a pyrimidine nucleoside analogue that is a potent inhibitor of HBV replication in vitro and in the woodchuck model.
Multi-center, dose escalation study evaluating clevudine at 10, 50, 100 and 200mg QD for 28 days. Eligible patients had chronic HBV infection, HBV DNA levels =3xl06 copies/mL, were nucleoside-treatment naive and without HIV or HCV co-infection. Patients were followed-up off drug for 6 months to a year. HBV DNA levels (VL) were assayed using Digene Hybrid Capture II (limit of detection <4700 copies/mL). Genotyping was performed by di-deoxy-sequencing.
5, 10, 10 and 7 patients were enrolled in the 10, 50, 100 and 200mg cohorts, respectively, 81% were male, 81% Asian. Median pretreatment VL were 7.3, 8.0, 8.8 and 8.4 10glO copies/mL. Median ALT levels were 2 times the ULN. After 28 days, the median log10 change was 2.5, -2.7, -3.0 and -2.6 in the 10, 50, 100 and 200mg groups, respectively. Six months post dosing, a sustained biochemical and virologic response was observed with median log10 VL changes from Baseline of -1.2, -1.4, -2.7 and -1.6 in the 10, 50, 100 and 200mg cohorts, respectively. During the study 8(30%) patients lost HBeAg, 5(19%) seroconverted to HBeAb. Data available at 1 year show a 0.4(n=5) and 2.2(n=6) median loglO VL reduction in the 50 and 100mg cohorts, respectively. Clevudine was well tolerated, with no limiting Grade 3 or 4 toxicities. A transient increase in ALT was observed in the 100mg cohort but not in the 200mg group. None of the patients had treatment emergent mutations in the polymerase domain at Week 24.
These results demonstrate potent antiviral activity of clevudine in humans at all doses tested. After only one month therapy, the marked post-treatment effect translated into an interesting rate of HBeAg-loss and seroconversion.
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HBV, HCV and Aflatoxin-associate P53 Mutations in the Etiology of Hepatocellular Carcinoma from West Africa.
GD Kirk1,, OA Lesi2, M Mendl, H Whittle2, JJ Goedert1, CP Wild3, P Hainaut4 and R Montesano4
1 Viral Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, NIH 1 DHHS, Bethesda, MD;
2 Gambia Hepatitis Intervention Study, International Agency for Research on Cancer 1 Medical Research Council Laboratories, Banjul, The Gambia, West Africa
3 Molecular Epidemiology Unit, Academic Unit of Epidemiology and Health Services Research, University of Leeds, Leeds, UK
4 International Agency for Research on Cancer, Lyon, France
Hepatocellular Carcinoma (HCC) is the most common cancer in the Gambia. HBV is endemic with 15% chronic HBV carriers. HCV prevalence is low but dietary exposure to aflatoxin is ubiquitous. "Hotspot" mutations in the p53 gene at codon 249 in tumors as well as circulating plasma DNA have been associated with HCC in aflatoxin exposed areas.
Incident HCC cases (n=196) were diagnosed by ultrasound and AFP levels >100ng/ml. Cirrhotic patients (n=120) had ultrasound findings of cirrhosis without focal lesions. Outpatient controls (n=402) were recruited from the same study sites. HBV surface (HBsAg) and "e" antigenemia (HBeAg) were determined as markers of chronic carriage and active replication, respectively. HCV status was determined by 3rd generation ELISA with RIBA confirmation. 249ser p53 mutations in cell-free plasma DNA were detected by PCR amplification and restriction analysis followed by direct sequencing.
HBV carriage was present in 63% (124/196) of HCC cases, 56% (67/120) of cirrhotics and 16% (64/402) of controls and declined with age. HCV infection was found exclusively in older subjects; 19% (33/174) of HCC cases, 6.5% (7/108) of cirrhotics and 3% (11/382) of controls. 249ser p53 mutations were detected in 41% of HCC cases compared to 15% of cirrhotics and 5% of controls. The prevalence of 249ser p53 was higher among HBeAg positive (60%, 12/20) than negative (36%, 30/84) cases. HCC risk was significantly increased with chronic HBV infection (OR 23, 95%CI 11-48), HCV infection (24, 8-75) and plasma 249ser p53 mutations (17, 7-41).
HBV is the predominant causal factor for HCC in the Gambia but HCV is more important among older cases.
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Risk Factors and Consequences of YMDD Mutants Selected During Lamivudine Therapy in Liver Transplant Recipients:
HL Tillmannl, CT. Bock2, A. Fingerl, E. Jaeckel1, J. Rosenau1, KHW. Boker1, B. Nashan2, J. K1empnaue2, C. Trautweinl, MP. Manns1
1 Medizinische Hochschule Hannover, Gastroenterology, Heuatology Endocrinology Germany
2 Medizinische Hochschule Hannover, Visceral- & Transplant surgery, Germany
The course of hepatitis after selection of lamivudine resistant mutants has been reported to be benign in most cases of immunocompetent patients.
Aim: The aim of this study was to describe the risk factors for emergence of resistance to lamivudine and the clinical outcome in liver transplant recipients.
Patients & Methods:
Since autumn 1995, 21 patients were treated for more than 4 weeks with lamivudine because of hepatitis due to HBV infection after liver transplantation. HBV DNA load and sequence were determined factors associated with resistance were analysed by Kaplan-Meier and Cox regression analysis.
15/21 patients developed resistance to lamivudine after a mean treatment period of 58,5 weeks (±15,8) weeks. The remaining six patients without evidence for lamivudine resistance have currently been treated for 72 to 235 weeks (mean 149,0 ±66,5). Multiple regression analysis revealed three independent factors predicting the early emergence of resistance to lamivudine. Beside elevated HBV-DNA, ALT levels and HDV co-infection were independent predictors of resistance development.
4/15 liver recipients with virologic resistance to larnivudine had a dramatic course of hepatitis with sudden deterioration of liver function. The remaining patients had less dramatic disease requiring alternative therapeutic intervention in only 3 patients. 3/15 patients were hepatitis D virus (HDV) infected and did not show any improvement on lamivudine, but also no deterioration after emergence of resistance.
Hepatitis D coinfection, high ALT and HBV-DNA values are associated with an early development of resistance to lamivudine. The consequences of the occurrence of YMDD mutants range from sudden onset of liver disease to almost no disease.
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Effect of Tenofovir on Lamivudine Resistant HBV Mutants After Liver Transplantation
L. NervI, D. Lau2, C. Nery1 G. Neff1, S. Nishida1, D. Levil, J. Madariagal, T. Katol, E. Schiff, A. Tzakisl
I University of MiamilLiver & GI Transplant, Miami, Florida, USA
2University of Texas Medical Branch/Gastroenterology Galveston, Texas, USA
Resistant HBV strains develop in about 30% of liver transplant (LTx) recipients treated with lamivudine(LAM) within 2 years from time of transplantation. Adefovir(ADV) has been efficient against mutants, however its use may be limited by nephrotoxicity. We report our experience with Tenofovir (TNV), another nucleotide analogue reverse transcriptase inhibitor, in LTx recipients developing LAM resistance.
Patients & Methods:
8 patients developed LAM resistance 10-85 mos (median:26) post-LTx. tenofovir was added and continued for 2-12mos(median:4). Prior to tenofovir, they were excluded from receiving adefovir due to: age>60 y.o.(5), HIV co-infection(l), enlistment in another drug study(l) and potential non-compliance(l). Criteria for reinfection included abnormal liver chemistries and reappearance of HBsAg, HBeAg and/or HBVDNA. HBV genotype and YMDD variants were identified through DNA sequence analysis prior to and after TNV; sequential HBVDNA levels were measured by hybridization pts(2,4,6,7,8)or PCR(pts 1,3,5).
HBV DNA reduction was observed in all patients:
- patient# l log HBVDNA: pre- TNV = 6.98 vs post- TNV = 3.55 (treatment:2mos,p = 0.008);
- patient # 2 log HBVDNA: pre-TNV=2.21 vs post-TNV<-0.3 (treatment: 8mos,p=0.016);
- patient# 3 log HBVDNA: pre-TNV = 4.04 vs post-TNV=2.57 (treatment: llmos,p = 0.001);
- patient # 4 log HBVDNA: pre-TNV = 4.51 vs post-TNV<-O.3 (treatment: 3mos,p<0.001);
- patient # 5 log HBVDNA: pre-TNV>8.70 vs post-TNV = 7.11 (treatment: 2mos,p<0.001);
- patient # 6 log HBVDNA: pre-TNV>3.78 vs post-TNV = -0.16 (treatment: 2mos,p<0.001);
- patient # 7 log HBVDNA: pre-TNV = 3.53 vs post-TNV = 0.62 (treatment: 5mos,p = 0.004);
- patient # 8 log HBVDNA: preTNV=2.92 vs post-TNV<-O.3 (treatment: l2mos, p = 0.026)
Comparison between median pre- and post-TNV ALT levels showed a significant variation in patient#8 (preTNV= 951U/l vs post-TNV=301U/1, p= O.OOl)of ALT. None of the patients showed significant differences in median serum creatinine levels pre-and post-TNV. No adverse reaction was associated with the use of TNV.
This preliminary experience indicates that tenefovir markedly decreases replication of LAM-resistant HBV variants post-LTx. These results demonstrate another potential option for the treatment of HBV LAM resistance.
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Resistance Survellance of HBEAG Chronic Hepatitis B (CHB) for Two Years with Adefovir Dipivoxil (ADV)
S. Locaminil,H. Yang2, C. Westland2, W. Delaney IV2, D. Colledgel, A. BartholomeuszI, V. Thibault3, Y. Benhamou3 , P. Angus4, M. Wulfsohn2, C. Gibbs2, J. Fri, C. Brosgar2 and S. Xiong2
1. Victorian Infectious Diseases Reference Laboratory, N. Melbourne, Australia
2. Gilead Sciences, Foster City, CA USA
3. Hospital Pitie-Salpetriere, Paris, France
4. Austin and Repatriation Medical Center, Heidelberg, Australia
Lamivudine resistance occurs in 14-32% and 38-50% of CHB patients after 1 and 2 years. No resistance to adefovir was identified in patients treated for 48 weeks (n=629) and 96 weeks (n=45).
Monitor emergence of adefovir resistance following 96 weeks of adefovir in 79 HBeAg- patients.
HBV was sequenced for all patients with detectable HBV DNA (> 1000 copies/ml, Amplicor™ PCR) at baseline and week 96. In vitro drug susceptibility was determined by transfection of HepG2 cells with patient HBV clones or Huh7 cells with HBV lab strains.
A novel conserved site substitution in HBV polymerase (rtN236T) was identified in a patient who displayed increasing serum HBV DNA and was independently observed to emerge at week 96 in this patient plus a second patient during prospective blinded resistance surveillance in a separate lab. In vitro analyses of patient-derived HBV and lab strains carrying rtN236T showed 6- to 14-fold reduced susceptibility to adefovir but appeared susceptible to lamivudine. The two patients developing rtN236T had sub-optimal HBV DNA suppression at week 48 (~1. 7 10glO) and a slow increase to within 1 10g10 of baseline by week 96; 1 patient switched to lamivudine and HBV DNA suppression was observed.
A novel rtN236T mutation conferring reduced susceptibility to adefovir was identified in 2 HBeAgpatients taking adefovir for 96 weeks. This mutation remains susceptible to lamivudine. Adefovir has a favorable resistance profile with infrequent and delayed emergence of HBV with reduced susceptibility (0/629 patients at 48 weeks; 2/124[1.6%] patients at 96 weeks).
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The Global Burden of HBV and HCV Infections Attributable to Contaminated Health Care Injections
AM Hauri,1 YlF Hutin,1 GL Armstrong2
1World Health Organization, Geneva, Switzerland
2Centers for Disease Control, Atlanta, GA, USA
As part of the 2000 Global Burden of Disease (GBD) study, we quantified the death and disability secondary to injection-associated infections with hepatitis B virus (HBV) and hepatitis C virus (HCV).
We modeled the fraction of incident infections attributable to health care injections in the year 2000 on the basis of the annual number of injections, the proportion of injections administered with reused equipment, the probability of transmission following percutaneous exposure, the prevalence of active infection, the prevalence of immunity and the total incidence. Infections in 2000 were converted into disability-adjusted life years (DALYs) in 2000-2030 using natural history parameters, duration of disease, disability weights and background mortality. DALYs were age-weighted and 3% discounted according to GBD methods. Four GDB regions where unsafe injection practices are negligible were excluded from the analysis.
In the 10 regions analyzed, persons received an average of 3.4 injections per year, of which 39.3% were given with reused equipment. In 2000, contaminated injections may have caused 21 million HBV infections and two million HCV infections, accounting for 32% and 40% of new infections, respectively, for a total of 73,000 early deaths and a loss on 438 737 DALYs between 2000 and 2030.
Injection overuse and unsafe practices are common worldwide and account for a high burden of death and disability. There is a need for policies and plans for the safe and appropriate use of therapeutic injections in countries where poor practices occur.
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Risk of Hepatitis B Virus Infection in Health Care Workers who are Nonresponders to Hepatitis B Vaccine
A. De Schrvverl,2, G.Moens 1,3, J.DeWijngaertl, G.Leroux-Roels 2
1 Interdisciplinaire Dienst voor het Welzijn, IDEWE, Leuven, Belgium
2, 3 Ghent University and Hospital, Ghent, Belgium Department Occupational Medicine, KUL, Leuven, Belgium
Approximately 5% of healthy adult vaccine recipients do not mount a protective immune response (>10 IU/L) following 3 or 4 doses of hepatitis B vaccine. Health care workers (HCW) who are non-responders remain at increased of infection with HBV but are not systematically monitored for the occurrence of HBV infection.
Through the analysis of serological markers of HBV infection we have examined the occurrence of HBV infections in a group of HCW who were proven nonresponders to hepatitis B vaccine.
132 HCW, vaccine non-responders <10 IU/L measured 2 to 5 months after at least 4 doses of HB vaccine), aged between 20 and 60 years, were included in this survey. Serological HBV markers were determined using the AxsymTM platform (Abbott) and HBV -DNA was measured using HBV Amplicor Monitor™ (Roche).
21 of the 132 subjects were positive for at least one HBV marker. Subjects positive for HBsAg and/or anti-HBc were tested for the presence of HBVDNA. Presence of anti-HBc suggests that at least 5 subjects have been infected with HBV and in 4 this infection evolved towards chronicity.
Since 5 out of 132 (3.8%) non-responder vaccinees showed evidence of HBV infection and 4 became chronically infected, we dare to suggest that non responding HCW who remain exposed to HBV should:
- receive additional vaccine doses until they mount a protective response
- mean while be monitored closely for HBV infection (HBsAG and anti-HBc in addition to anti-HBs).
Vaccines with enhanced immunogenicity may help to achieve this goal. The results of a clinical evaluation of a candidate vaccine are presented as a separate abstract (Moens et al).
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Blood Borne Virus Transmission during Endoscopy – Viral Prevalence or Decontamination Breakdown
K. Vickery1, L. Bissetl, W. Selbl, R. West2, D. Catterson2 and Y.E. Cossartl
1University of Sydney, Sydney, Australia
2Royal Prince Alfred Hospital, Sydney, Australia
Decontamination of endoscopes is an intractable problem and the prevalence of infection and the risk of transmission during endoscopic procedures is unknown.
- To determine the prevalence of infection and viraemia in patients before and after endoscopy
- To monitor routine decontamination of endoscopes in the same hospital unit.
Consenting patients completed a risk factor questionnaire and blood was collected prior to and 6-12 months after their procedure. All blood samples were tested for HBsAg, anti-HBs, anti-HCV and anti-HIV, and positive samples were tested for viral nucleic acids by PCR. After completions of the decontamination cycle endoscope biopsy channels were flushed with 20ml sterile PBS which was then cultured aerobically and anaerobically. Washes from PCR positive patients were concentrated by ultracentrifugation and the pellet tested for viral nucleic acid.
2118 patients were enrolled, 99 (4.7%) were anti-HCV positive, 46 (2.2%) were positive for HBsAg and 17 (0.8%) were positive for anti-HIV. Three patients were positive for more than one virus.
Overall 7.7% were "biohazardous". But only 62(2.9%) were PCR positive. 18.4% anti-HCV and 28.3% HBsAg positive patients but none of the anti-HIV positive patients were previously unaware of their status. 204 of the 614 anti-HBs positives were positive for anti-HBc, indicating past infection.
No transmission has occurred in the 768 patients who have completed follow-up. 44/2367 (1.9%) of the patient ready endoscopes yielded bacteria. One of 41 washes from HCV viraemic patients was PCR positive.
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- There is a large pool of undiagnosed hepatitis B and C in the hospital population.
- Although small numbers of bacteria and viral nucleic acid may persist in endoscope channels after routine decontamination we found no evidence of patient infection as a result.
Detection and Quantification of HBV DNA in HBsAG Negative Patients Coinfected with HIV
MJ Mphahlele, ML Moropeng, MJ Ngobeni, and RJ Burnett
The Viral Hepatitis Research Laboratory, Department of Virology, Medical University of Southern Africa, Pretoria, South Africa
To investigate the effect of HIV co-infection on laboratory detection of HBV serological markers.
This comprised of 295 stored (-20°C) sera (128 HIV negative and 167 HIV-positive), which were previously tested for both HBV and HIV serological markers, as part of routine diagnosis, with results being available for HBsAg, anti-HBc, anti-HBs, HBeAg, anti-HBe, and anti-HIV 1/2. All of the specimens were positive for at least one of the HBV markers.
For detection of HBV DNA, viral DNA was extracted with High Pure Viral Nucleic Acid kit (Roche Diagnostics). This was followed by a nested in-house PCR assay, employing independent sets of primers to the S-gene and C-gene. Quantification of HBV DNA was determined with the COBAS AMPLICOR HBV MONITOR™ assay (Roche Diagnostics). <
Of 167 HIV co-infected patients, 140 (83.8%) were HBsAg negative, and of these, 22.1% (31/140) had detectable HBV DNA by the in-house PCR assay. In contrast, 83 of 128 (64.8%) of the HIV negative group were HBsAg negative, and only 2.4% (2/83) of these were HBV DNA positive. The odds ratio was 11.52, which was found to be statistically significant (chi-square: p = 0.00006), indicating that in patients positive for at least one HBV marker but negative for HBsAg, HIV co-infected patients are more likely to be viraernic than HIV negative patients. Quantification of HBV DNA from HBsAg negative/HIV co-infected patients demonstrated variable ranges of HBV viral loads, ranging from <200 copies/ml to >2 x 105 copies/ml. Finally, HBV DNA was detected in 3 specimens with anti-HBs as the sole marker of infection in the HIV co-infected group, but in none of the HIV -negative patients.
The results strongly suggest that HIV co-infection may be a risk factor for occult HBV infection. This poses a challenge to effective laboratory diagnosis and management of hepatitis B in HIV co-infected patients.
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Severe Hepatitis Due to Lamivudine Resistance in an HIV/HBV Coinfected Patient: PCR/RFLP Analysis
I.Gouskos1, LEamest-Sylveira1, S.Lewin2, J.Torresi1, F.Wightman2,
1 Department of Medicine, University of Melbourne, Vic, Australia
2 Department of Microbiology and Immunology, University of Melbourne, Vic, Australia
The pathogenesis of lamivudine (LMV) resistant hepatic flares in the context of human immunodeficiency virus (HIV) and hepatitis B virus (HBV) coinfection has not been extensively studied. Despite consensus that LMV resistant mutants are replication defective and not usually associated with flares of hepatitis, there are increasing numbers of reports of fulminant hepatitis on a background of immunosuppression or cirrhosis and HIV coinfection. Such reports illustrate the need for monitoring of coinfected patients for the emergence of LMV resistant mutants
Herein we describe a severe flare of hepatitis due to LMV resistant HBV in an HIV/HBV coinfected patient. The serum ALT peaked at 1100 IU/ml and the billirubin rose to 40 U/L. The HBV DNA rose to 834 pg/ml (pre-treatment level 975 pg/ml). The HIV viral load was <200 copies/ml and the CD4 count was 550 x 109 cells/mm3. A sensitive PCR based RFLP assay has been developed in our lab and was used to detect emergence of specific LMV resistance profiles in serum samples. LMV was discontinued and the patient was commenced on tenofovir resulting in stabilization and subsequent normalization of serum ALT.
Cloning and sequencing of the entire polymerase gene at the time of the flare revealed the presence of mutations that may have influenced the replication fitness of the LMV resistant mutant and in addition, confirmed the RFLP assay findings. Sequence alignment with 20 published sequences demonstrated that one amino acid in the fingers subdomain was common to sequences reported from three cases of fulminant hepatitis. It has been previously reported that mutations in the fingers subdomain restore replication phenotypes to LMV resistant. This mutant is currently under further investigation to determine its replication phenotype.
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Hepatitis B Virus (HBV) Carriage in a Rural Population of Burkina Faso: Familial Aggregation and Male Predominance
D. Jeannell,2, C. Fretz3, Y. Traore4, T. Suzuki2,5 C. Julierl, J.J. Fournel1, P. Van De perre4, F. Fumoux6, V Berae
I Institut Pasteur, France
2 ICRF-Cancer Epidemiology Unit, UK 3ETS-APHP, France
4 Centre Muraz, Burkina Faso
5 Niigata University, Japan
6 INSERM U399, France
- to study HBV chronic carriage in a rural population in order to characterize infection dynamic according to age and sex
- to test familial aggregation.
In two villages of Bobo Dioulasso area, HBsAg screening was performed in all individuals aged over 2 (1974 tested, participation rate: 77%). Positive individuals were followed up 9 to 15 months later, with clinical examination, HBV serologies and liver function tests. Family members were tested for HBV and HCV infections.
HBsAg prevalence was 11.2 % [9.2%-13.5%] in males and 7.2% [5.8-8.9] in females (p<.01). Infection occurred early in life: in age group 2-4 years, HBsAg prevalence was 13.3% in males and 6.7% in females. Sex difference decreased with age. Most HBsAg positive individuals were still positive at follow-up (92.5%), showing chronic infection. Viral clearance tended to be more frequent after 30 years old. In chronic carriers aged 2614 years, 75.6% were HbeAg positive, compared to 30.8 % in carriers aged 15 or more (p<.0001). Annual incidence among negative family members was at least 2.7 %. Familial aggregation of HBsAg was significant (Smith&Pike close pairs test).
The risk of HBV carriage for the youngest child of a family increased significantly with the number of other child carriers in the family, but not with adult carriage. A first analysis of family trees showed an increased risk in siblings of an index carrier (49%) compared to the overall population, giving a recurrence risk ?=5.4 . The risk was lower for half-siblings (23%, ? =5.4).
Our results indicates that familial aggregation may not be fully explained by increased exposure to a chronic carrier; suggesting the implication of genetic factors of susceptibility. However, little is known about HBV horizontal transmission routes among African children and what causes gender difference in chronic carriage.
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Changing Epidemiology of Hepatitis B in St Petersburg, Russia
P. Beutelsl, Z. Shkedy2, S. Mukomolov3, M. Aerts2, E. Shargorodskaya3, V. Plotnikova3, G. Molenberghs2, P. Van Dammel
1 Centre for the Evaluation of Vaccination, WHO collaborating centre for the prevention and control of viral hepatitis, Epidemiology and Community Medicine, University of Antwerp, Antwerp, Belgium
2 Biostatistics, Centre for Statistics, Limburgs Universitair Centrum,Diepenbeek, Belgium
3 Pasteur Institute, St Petersburg, Russia
The incidence of hepatitis B infections in St Petersburg, Russia, was estimated from mandatory reported cases. The two-sided t-test for independent samples and the LOESS smoother were used to compare the age at infection for symptomatic, asymptomatic and chronic infections, by gender. The force of infection was estimated from seroprevalence data (907 sera taken in 1999) using a newly developed non-parametric method based on local polynomials, as well as an earlier described method based on isotonic regression and kernel smoothers. With the local polynomial method, pointwise confidence intervals (95%) were constructed by bootstrapping.
On average, men contracted hepatitis B infection at a significantly younger age than women, particularly given rising incidence (in 1999, 21.8 versus 22.7 years, respectively), also for symptomatic and asymptomatic infections separately. The overall male to female ratio was 1.92. In 1999 the overall incidence almost doubled compared to the preceding years and tripled among the age groups with highest incidence (15-29 year olds: 85% of cases in 1999). The incidence increase was associated with a lower average age at infection (24.1 years in 1994 versus 22.1 years in 1999). Female carriers were on average infected at a younger age than male carriers, and the average age for this group has increased for both genders between 1998 and 1999. The age and gender-specific force of infection estimates generally confirmed the incidence estimates and emphasized the usefulness of local polynomials to do this.
In summary, hepatitis B transmission in St Petersburg occurs mainly in young adults. The dramatic increase of infections in 1999 was likely due to injecting drug use. Without intervention, HBV is expected to continue to spread rapidly with a greater proportion of female infections due to sexual transmission.
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Molecular Epidemiology of HBV in Southern Africa Eludicated using a Novel and Efficient Full Genome Amplification
S.M. Bowyer, CT. Tiemessen and B.D. Schoub, National Institute for Communicable Diseases, University of the Witwatersrand, Johannesburg, South Africa.
Regional studies undertaken in southern Africa reveal hyper-endemic foci and regional differences in the prevalence of both HBsAg and other markers of hepatitis B (HBV) infection. It has also been shown that southern African adult, black carriers, have predominantly nonreplicative infection.
Median serum HBV-DNA levels in inactive carriers were recently shown to range from 400 to 29000 copies per millilitre which is close to the lower limit of sensitivity of even nested PCR. We have used rolling circle amplification to obtain efficient full genome HBV amplification even in asymptomatic chronic carriers presently on lamivudine therapy. This method has enabled us to complete a thorough molecular epidemiological study of the genotypes of HBV in both South Africa and Namibia. As reported previously, South Africa has predominantly genotype A with a small proportion of genotype D. The local genotype A specimens cluster in a separate clade within genotype A having subgroup (> 4 % difference) difference from the rest of genotype A.
In Namibia genotype E is the predominant type with smaller percentages of both genotype A and D. The genotype A specimens also cluster with other African genotype A specimens sequenced to date. This method has enabled us to characterise Namibian strains which frequently give "larger than expected" PCR fragment lengths as well as ambiguous results in an HBV genotype-specific EIA (enzyme immunoassay). Rolling circle amplification should be useful to detect very low levels of HBV DNA in self-resolving acute HBV disease and anti-viral treatment monitoring. Since the method uses random primers, it will also prevent false negatives in surveillance studies by vaccine escape, therapeutic and other mutants.
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Economic Implication of Hepatitis B Vaccination at Sexually Transmitted Disease Clinics in the United States
K. Billahl, I. Buffmgtonl, C. Weinbauml, E. Mastl, P. Murray, R. Gunnl,2, H. Margolis1,
1 Centers for Disease Control and Prevention, Atlanta, GA, USA
2 San Diego County Health and Human Services Agency, San Diego, CA, USA
Sexually transmitted disease (SID) clinics are effective venues for vaccinating adults at increased risk of hepatitis B virus (HBV) infection in the US. The cost of a national program to vaccinate the estimated 2 million clients who attend STD clinics annually was estimated using program specific data from a demonstration project at a large STD clinic in San Diego, California. A decision model that included program interventions and the outcomes of HBV infection was used to estimate discounted direct medical costs with and without vaccination. Cost of antiviral treatment and liver transplants were not included. Age specific estimates of HBV infection prevalence among STD clinic clients were used in a catalytic model to determine the lifetime risk of HBV infection, and vaccination service costs were estimated from a time-motion study of provider-STD client interactions.
Without a national vaccination program, an estimated 237,000 new HBV infections would occur over the lifetime of the 2 million STD clinic clients, and would cost $198 million in discounted direct medical costs for acute and chronic hepatitis. Based on estimated completion rates in a national vaccination program, 1,480,000 clients would receive one dose, 784,400 two doses, and 447,108 three doses of vaccine. This level of vaccine coverage would prevent 102,389 HBV infections from the expected number of new infections without vaccination, a 43% reduction. The vaccination program would cost an estimated $69 million, and HBV infections not averted by the program would cost an estimated $112 million, resulting in a net savings of $17 million.
This cost model demonstrates that hepatitis B vaccination implemented at STD clinics throughout the US would result in a net savings in medical costs from the reduction in new infections. The extent of this savings should be considered conservative since it does not include antiviral treatment, liver-transplant, and work-loss.
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Response to Recombinant Hepatitis B Vaccine in HIV-Infected Patients Using Two Different Dose Regimens
M.Q.Fonseca1, N.P. Cavalheirol, A.A. Baronel, S.C.F. Musa2, M.H. Lopesl
1 University of Sao Paulo, Sao Paulo, Brazil,
2 Instituto de Infectologia Emilio Ribas, Sao Paulo, Brazil
Studies have shown the negative effects of human immunodeficiency virus (HIV) infection on the response to hepatitis B virus (HBV) vaccination. Vaccine response is reduced in HIV sero-positive individuals. The Brazilian Ministry of Health recommends a guideline for vaccination and revaccination for HIV infected patients with a double dose as used in other immunocompromised patients.
To evaluate the anti-HBs response to recombinant HBV vaccine in HIV adult infected individuals, comparing two different dose regimens: the standard dose (20 ug antigen) 1M in three doses administered at months 0, 1, and 6 and double dose ( 40 ug antigen) 1M at months 0,1, and 6.
Patients and Methods:
Anti-HIV positive patients with negative serum markers to HVB were enrolled, after informed consent, and were randomized to receive one of the two dose regimens (Engerix-B, Smith-Kline-Beecham). Testing for anti-HBs was done by enzyme immunoassay (Microelisa system, Hepanostika Anti-HBs New).The absolute number ofCD4 T lymphocytes was detennined by a fluorescence-activated cell analyzer, using monoclonal antibodies (FACSCount System).
The overall antibody response rate from 167 patients who received the 3 HBV vaccine doses was 47.3%. From 84 patients who received the double dose and 83 patients who received the standard dose, the antibody response rate was 52% and 42% respectively (p=0,1). Patients with CD4 T lymphocytes count =350/mm3 showed better antibody response than patients with CD4 T lymphocytes count < 350/mm3 (p<0,01).
The seroconversion rate to anti-HBs in this study was very low and similar to that observed in previous trials. No significant statistical difference were observed using the two different dose regimens. The results suggested an association between the CD4 T lymphocyte counts and response to the vaccine.
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Effectiveness of Universal Infant Hepatitis B Vaccination Program in Hawaii
J. F Perzl, J.L. Elm2, J.I. Huggler2, LA. Farringtonl, A.E. Fiorel, and P.V. Efflen2
1 Centers for Disease Control and Prevention, Atlanta, GA,USA
2 Hawaii Department of Health, Honolulu, HI, USA
Infections acquired during birth, infancy or childhood account for much of the disease burden associated with chronic hepatitis B virus (HBV) infection. In a 1989 serologic survey among Oahu, Hawaii, school children in grades 1-3, markers of HBV infection were present in 4.5%, including a 1.6% overall prevalence of chronic infection. Following the 1991 Advisory Committee on Immunization Practices recommendation, Hawaii implemented routine infant hepatitis B vaccination in 1992, and required it for school entry in 1997. We conducted a follow-up survey to evaluate the impact of this program.
This serologic survey was performed in Oahu during the 2001-2002 school year among children in grades 2 and 3 (typically born between 1992-1994). Consenting parents/guardians were interviewed to ascertain demographic information including place of birth. HBV infection status was determined by analyzing serologic patterns of hepatitis B surface antigen and antibodies to hepatitis B surface antigen and core antigen (total and IgM). School records of participating children were audited to determine the number and timing of hepatitis B vaccine doses.
Completed hepatitis B vaccination series were documented for 85% of participants by age 24 months and for 99% prior to school entry. Records indicated receipt of a birth dose for 42% of children. Serologic markers of HBV infection were found in six (0.24%) of 2,471 participants, including one (0.04%) student with chronic infection and five (0.2%) students with resolved infections. The chronically-infected child was born outside the United States to an infected mother and received the first dose of hepatitis B vaccine at age 75 days.
HBV infection prevalence among grade school children in Oahu has declined more than 90% following the introduction of universal infant hepatitis B immunization. These results should encourage continued support and expanded adoption of such immunization programs.
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International Phase IIB Trial of LdT, and LdT Plus Lamivudine, In Patients with Chronic Hepatitis B
C-L. Lail, N. Leung2, E-K. Te03, M. Tong4, F. Wong5, H-W. Hann6, S. Han7, T. poynard8, M. Myers9, G. Cha09, D. Lloyd9, and N. Brown9
1University of Hong Kong
2Prince of Wales Hospital, Hong Kong
3Changi General Hospital, Singapore
4Huntingdon Memorial Hospital, Pasadena, CA
5Toronto General Hospital, Toronto, Canada
6Jefferson Medical College, Philadelphia, P A
7UCLA School of Medicine, Los Angeles, CA
8Groupe Hospitalier Pitie-Salpetriere, Paris, France
91denix Pharmaceuticals, Cambridge, MA
Reductions in HBV viremia to levels below 3-4 loglO copies/mL in the first 6 months of antiviral treatment have been associated with better HBeAg response rates and low resistance. Phase I/II data suggest that LdT treatment may allow more patients to achieve this degree of HBV suppression.
A Phase IIB international trial was undertaken to compare 5 treatment regimens: LdT (600 mg/day), LdT (400 mg/day), lamivudine alone (100 mg/day), LdT (600 mg/day) + lamivudine, and LdT (400 mg/day) + lamivudine, for 1 year, in patients with HBeAg positive chronic hepatitis B. An interim data analysis has been completed at Week 24, by protocol.
The 104 patients are predominantly male (81%), Asian (87%) or Caucasian (10%), mean age 37 years (range 18-68). Treatment groups are well-matched for baseline parameters.
Median reductions in serum HBV DNA (logl0 copies/mL, Amplicor PCR assay) at Week 24 were: LdT 400mg, -6.08; LdT 600mg, -6.11; LdT 400mg + lamivudine, -6.21; LdT 600mg + lamivudine, -6.15; and lamivudine, -4.67. There was significantly greater viral suppression with the combined LdT monotherapy arms and the two combination arms, compared to standard lamivudine monotherapy (p = 0.05 and 1- = 0.01, respectively), but not for the combination arms vs LdT monotherapy arms.
More patients receiving LdT -containing regimens had viremia reduced below the PCR assay limit of detection: LdT monotherapy, 32%; LdT + lamivudine combination, 31%; Lam monotherapy, 16%. Serum ALT normalization ranged 67-79% among the 5 treatment regimens.
Study treatments have been well-tolerated, with no serious adverse events (AEs) attributed to study drug and no discontinuations for AEs.
Significantly greater early viral suppression was observed for LdT monotherapy and LdT combined with lamivudine, compared to lamivudine monotherapy. No safety issues have been identified to date. These results support expanded investigation of LdT in Phase III registration trials.
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Incidence of Acute Hepatitis B in the United States, 1990-2001
L. Finelli, 1. Miller, A. Wasley, B.P. Bell
Centers for Disease Control and Prevention, National Center for Infectious Diseases, Division of Viral Hepatitis
Rates of acute hepatitis B peaked at 11.5 per 100,000 population in the mid 1980s. In 1991, the Advisory Committee on Immunization Practices recommended a comprehensive strategy, which included universal infant immunization, post-exposure prophylaxis of infants born to infected mothers, and vaccination of high-risk adolescents and adults; the recommendation was expanded in 1995 to vaccinate all adolescents. Hepatitis B trends were evaluated to assess the impact of vaccination.
Summary data for symptomatic acute hepatitis B cases reported to state health departments during 1990-2001 were sent weekly to the Centers for Disease Control and Prevention, including demographic and risk characteristics. Hepatitis B rates were calculated per 100,000 population by using denominators from census data.
In 2001, 7,844 cases of acute hepatitis B were reported (rate 2.8/100,000 population) compared to 21,102 in 1990 (rate 8.1/100,000 population) representing a 66% decline. The greatest decline was among children aged 0-11 years (90%) followed by adolescents 12-19 years (85%); only 3.5% of cases were reported among children < 19 years in 2001. Declines were also observed in other age groups, and in men and women. However, from 1999-2001, incidence among men >20 years rose 11 %. An increasing proportion of transmission resulted from high risk behaviors: in 1990, 7% of male cases self-identified as homosexual, and 15% reported multiple sex partners, compared to 14% and 32%, respectively, in 2001.
Implementation of universal infant hepatitis B immunization has been followed by significant declines in incidence nationwide. These declines have been largest among the cohort of vaccinated children. Despite recommendation for vaccination of persons with high risk behaviors, transmission is increasingly concentrated in those persons. These data highlight need for continued monitoring of the epidemiology of hepatitis B, and for developing effective strategies to vaccinate adults at high risk.
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Immunogenicity of Twinrix™ In Older Adults: A Critical Analysis
M. Stoffel, M. Lievens, I. Dieussaert, I. Martin, and F. Andre
GlaxoSmithKline Biologicals, Rixensart, Belgium
Hepatitis A and B infections are prevalent worldwide and continue to be a significant cause of morbidity and mortality. A vaccine providing dual protection against hepatitis A and B is available (TwinrixTM, GlaxoSmithKline Biologicals, Rixensart, Belgium) in 72 countries worldwide. This vaccine, administered in three doses, is safe, well tolerated and highly immunogenic. However, limited data is available about responses that follow immunization of elderly individuals with Twinrix, a topic becoming increasingly relevant as the number of aged people travelling to endemic destination increases.
This review presents a critical analysis of antibody responses stratified by age following vaccination with Twinrix in 264 seronegative adults above 40 years old enrolled in five prospective clinical trials.
One month after completion of a 0, 1, 6 -month vaccination schedule of Twinrix, anti-hepatitis A virus (anti-HAV) seroconversion was 99.6% and anti-hepatitis B surface antigen (anti-HBs) a seroprotection rate was 93.8%. In addition, anti-HAV and anti-HBs GMTs remained high and superior to the levels usually considered as protective, regardless of the age and medical condition of the subjects. These results strongly support the fact that Twinrix is an effective vaccine against hepatitis A and hepatitis B infection in older adults.
In addition, the immune response induced by Twinrix in subjects older than 40 years was compared to the immune response induced by HavrixTM and EngerixBTM (GlaxoSmithKline Biologicals), administered concomitantly. The immune response induced by the combination vaccine was at least as good as the one induced by the corresponding monovalent vaccines.
In conclusion, our data clearly demonstrated that Twinrix TM is effective against hepatitis A and hepatitis B infections in older adults and offers at least equivalent protection to the corresponding monovalent vaccines while adding greater convenience and logistical superiority over monovalent vaccines.
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Livfit (LF) Efficacy on Hepatitis B Virus (HBV) DNA Levels: Randomized Double Blind Placebo Control Clinical Study
RID Mehrotral, N. Sin_h1, C.K. Katiyar2, AK. Jain3, S.A Dahanukar4, N.N. Rage P.Abraharn5 and D.B.A Narayana2,
1Liver Unit, King George's Medical College, Lucknow 226003
2Dabur Research Foundation, Sahibabad 201010
3Department of Gastroenterology, Institute of Medical Science, BHU, Varanasi 221005
4Ayurveda Research Center, Department of Pharmacology and Therapeutics
5Department of Gastroenterology, Seth G.S. Medical College & K.E.M. Hospital,Mumbai 400012, India
Livfit (LF)-United States America Patent 6,136,316; 2000, is a polyherbal standardized composition possessing liver specific antioxidant, free radical scavenger, hepatoprotective activity, besides having therapeutic effects in HBV infection. Livfit contains an aqueous extract of Rheum emodi, Tephrosea purpurea, Tinospora cordifolia, Phyllanthus amarus, Andrographis paniculata, Picrorrhiza kurroa, Ec1ipta alba, Cichorium intybus, Boerhaavia diffusa, Terminalia chebula and Fumaria officinalis.
Evaluate Livfit for its effects on HBV DNA in acute HBV and chronic Hepatitis B (CHB) viral infections.
12 acute HBV patients presenting within 2 weeks of their illness, and 12 naive CHB (HBsAg, anti HBe, HBV DNA positive, mildly elevated ALT > 6 month, anti HBcIgM, HCV-RNA, anti HIV negative) were included. Two double blind placebo controlled studies were done as per Helsinki world medical association guidelines (1975). Patients were randomized to receive either LF or placebo two tablets thrice a day. Treatment periods were 12 wk. in A VH and 48 wk. for CHB. Digene ultra-sensitive hybrid capture assay (detection range 0.017 to 200 pg/ml) was used for HBV DNA quantitation.
Acute HBV patients: at baseline HBV DNA levels (p>0.05) in Livfit treated (6) were 52.735 pg/ml and 39.243 pg/ml in placebo controls (6). At 12 wk. significant HBV DNA clearance (p<0.01) was observed in Livfit treated (0.101 pg/ml) as compared to placebo controls (0.479 pg/ml).
CHB patients: At baseline there was insignificant difference (p>0.05) in HBV DNA in 6 Livfit treated (4.473 pg/ml) and 6 placebo controls (9.245 pg/ml). At 24 wk. HBV DNA fell in Livfit treated patients (3.892 pg./ml), while no change occurred in placebo controls (9.675 pg/ml). Reduction in HBV DNA in Livfit treated (0.313 pg./ml) was significant (p<0.05) as compared to placebo controls (9.125 pg/ml) at 48 wk. therapy
Livfit inhibits HBV replication and its addendum will potentate the recommended HBV therapies response rate.
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Rebound Hepatitis Following Withdrawal of Immunosuppresive Therapy in Patients with Chronic Hepatitis Viral Infections
J. Rempel, P Wong, M Zhang, S. Wong, W. Wong, A. Meyers, J. Uhanova, G. Minuk University Of Manitoba, Winnipeg, MB, Canada
Rebound hepatitis is an unexplained, potentially lifethreatening complication of withdrawal from immunosuppressive therapy in patients with chronic hepatitis B (HBV).
To document the incidence of rebound hepatitis and determine whether the condition is associated with immunologic rebound or the appearance of HBV mutants.
In 1993-4, a total of 40 adult, chronic HBeAg positive, carriers participated in a trial of prednisone (6®1O mg/d x 6 weeks), rest period (x 2 weeks) and acyclovir (600 mg/d x 6 weeks) versus placebo/rest/placebo (PL/PL, n=20). Patients were seen q 2.4 weeks during treatment and monthly thereafter x 6 months. Rebound hepatitis was defined as a =2X increase in mean baseline AL T levels. Serum cytokines (IL-6, IL-10, TNF-a and IFN-y) were documented by ELISA and HBV mutants [surface (nt 587), core (nt 1900-2300), pre-core (nt 1896) and basal core promoter (nt 1762/1764)] by real-time PCR and melting curve analyses.
Rebound hepatitis occurred in 6/20 (30%) PR/AC versus 2/20 (10%) PL/PL recipients (p=0.24). Serum cytokine levels were similar in those with and without rebound hepatitis. HBV mutants were absent prior to and during treatment but developed during follow-up in three patients. All three patients were PR/AC recipients and in each case, the mutation involved the basal core promoter. In two of the patients, the mutation appeared at the time of rebound hepatitis (10 weeks post prednisone) while in the third, rebound hepatitis did not occur.
Rebound hepatitis occurs in approximately one-third of HBV-infected individuals being withdrawn from immunosuppressive therapy. Only a minority of cases can be explained by the appearance of HBV mutants and there is no serologic evidence of immunologic rebound. These findings suggest that either immune hyper-responsiveness is confined to the liver or additional HBV mutations are responsible for the majority of cases of rebound hepatitis in humans.
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Monitoring Enforcing, and Promoting Skin Penetration Guidelines in New South Wales
A. Oberdorferl, J. Wiggersl,2
l School of Medical Practice and Population Health, University of Newcastle, Newcastle, NSW, Australia
2 Hunter Centre for Health Advancement, Hunter Area Health Service, NSW, Australia
The objective of the study was to determine the skin penetration inspection practices of local councils and public health units in New South Wales.
The general manager or director of all local councils and public health units were invited to participate in a telephone survey.
One hundred seventy two local councils (99%) and all public health units (16) completed the survey. Approximately 85%, 76.5% and 83.8% of councils with tattooing, beauty therapy and hairdressing premises in their area reported their council conducted inspections of such premises. All public health units reported conducting inspections of tattooing and hairdressing premises and 93.7% reported conducting inspections of beauty therapy premises. Two third of councils carried out skin penetration inspections annually, whereas public health units mainly carried out skin penetration inspections in response to complaints. Most councils reported charging on inspection fee from $50 to $350. Fifty five percent of councils and 60%-82% of public health units reported providing information concerning cleaning, disinfection and sterilisation during inspections.
No single pattern concerning inspections of tattooing, beauty therapy, and hairdressing premises is evident in New South Wales, Australia. Standardised monitoring and enforcing of State legislation concerning infection control from these services needs to be considered.
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Knowledge of and Attitudes towards the Prevention of Blood Borne Diseases Among Tattooists, Body Piercers, Beauty Therapist and Hairdressers Following the Dissemination of Practice Guidelines
A. Oberdorferl, L Wiggers 1.2, R. Considine1, J. Bowman3, J. Cockburn 1
1 School of Medical Practice and Population Health, University of Newcastle, Newcastle, NSW, Australia
2 Hunter Centre for Health Advancement, Hunter Area Health Service, NSW, Australia
3 School of Behavioural Sciences, University of Newcastle, Newcastle, NSW, Australia
To assess knowledge and attitudes regarding skin penetration practices among tattooists, body piercers, beauty therapists and hairdressers following the distribution of disease prevention guidelines.
A randomly selected sample of owners/managers of tattooing, beauty therapy, and hairdressing premises in New South Wales, Australia participated in a telephone survey.
Eight hundred and seventy four premises owners/managers participated (77.2%). Of these, only 53 % reported having received the guidelines. Less than 39% correctly identified recommended disinfection procedures whereas most (>86%) correctly identified recommended sterilisation procedures. However, between 42% to 67 % of respondents were not aware of what constituted inappropriate sterilisation procedures. Almost all (> 95%) agreed that guidelines were necessary and expressed support for regular inspections by council officers. Up to one third reported that a busy shop and the cost of compliance were barriers to adoption of guidelines. Two thirds agreed that council officers lacked sufficient knowledge and skills in undertaking inspections of premises.
Despite the introduction of guidelines, there is a continuing need to improve knowledge and skills regarding the prevention of blood-borne disease among tattooists, body piercers, beauty therapists, and hairdressers. Further research is required to identify improved methods of achieving this.
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Three-Year Analysis of HBV Infection in HIV-Infected Antenatal Women from National HIV surveys in South Africa
Burnett RJ 1, François G 2, Hoosen AA 3, Leroux-Roels G 4, Meheus A 2, and Mphahlele MJ 1
Departments of Virology 1 and Microbiology 3, Medical University of Southern Africa, Pretoria, South Africa, 2 Department of Epidemiology and Social Medicine, University of Antwerpen, Antwerpen, Belgium, and 4 Center for Vaccinology, Ghent University, Ghent, Belgium
South Africa monitors the HIV/AIDS pandemic by conducting annual national HIV surveys of women attending antenatal clinics of the Public Health Service. We studied the burden of HBV in HIV-positive and HIV -negative (selected for control group, matched for age and area) antenatal women.
This comprised of 864 stored (-20°e) sera from anonymous, pregnant women from the l0th, 11th, and 12th National HIV Surveys in Limpopo, South Africa, conducted in October 1999, October 2000, and October 2001. Specimens were stratified for HIV status, with 432 HIV positive samples selected for the test group, and 432 HIV negative samples for the control group.
All specimens were tested for HBsAg and anti-HBc, using the IMx HBsAg and CORE kits, respectively (ABBOTT Laboratories). Unfortunately, most specimens were insufficient for performing tests for anti-HBs and HBeAg, as originally intended. For the same reason, a nested PCR assay for HBV DNA was performed only on 374 sera from the year 2000.
Of 432 HIV positive specimens, 32 (7.4%) were HBsAg positive and 175 (40.5%) were anti-HBc positive. Of the 432 HIV-negative women, 36 (8.3%) were HBsAg positive and 140 (32.4%) were anti-HBc positive. The overall exposure, based on these two markers, was 187 (43.3%) for the HIV- positive women, and 151(35%) for the HIV-negative women. The odds ratio was 1.42, which is statistically significant (chi-square: p = 0.012). When the results for each year were analysed separately, the difference for each year did not attain statistical significance and no upward trend in the burden of HBV over the 3 years was observed. Of the 187 HIV -positive sera from the year 2000, 6 (3.2%) were positive for HBV DNA (2 were negative for HBsAg, whilst 1 was negative for both HBsAg and anti-HBc). Of the 187 HIV-negative sera, 8 (4.3%) were positive for HBV DNA, and this increased the total HBV exposure slightly in the HIV positive group, but was not statistically significant (chisquare: p = 0.09).
Since HIV shares transmission routes with HBV, and both are major public health problems in South Africa, our results do not suggest a massive increase in exposure to HBV infection (or active HBV infection) in HIV infected antenatal women of the province of Limpopo.
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Prevalence of HBeAg and HBeAg Clearance in HBsAg Positive Patients
D. Christodoulou 1 S. Filis l, K. Katsanos l, T. Passas 1, E. Zervou 2, EV. Tsianos l
IDepartment of Internal Medicine, Hepato-Gastroenterology Unit, Medical School of Ioannina-Greece and,
2Blood Bank at the University Hospital of Ioannina
The aim of the study was the description of prevalence of HBeAg and its clearance during follow up in HBsAg positive patients in North-West Greece.
We conducted a retrospective study of the history files of 535 patients with positive HBsAg, which have been kept at our Outpatient Hepatology Clinic since 1989 (11 years period). Our University Hospital is a referral Center for viral hepatitis in North-West Greece. The study was conducted from January 2000 to April 2000. We investigated the virological profile of HBsAg positive patients, and we focused on prevalence and possible special characteristics of HBeAg positive patients.
Among these 535 patients with positive HBsAg (353 males/ 182 females) we identified 27 patients with positive HBeAg. From these 27 patients 15 were males and 12 females with a mean age of 33.8±5.3 and 23.6±4.8 respectively. During following up these patients, six of them (3 males / 3 females, mean age: 34.0±5.8/ 21.2±4.7 cleared HBeAg. The mean time of HBeAg clearance since first diagnosis was 1.33 years; one year for 5 patients and about three years for only one patient.
Patient's origin was mainly from urban areas and the contamination route remains unknown for the majority of those patients. Interferon-a (4.5-5 MU three times per week) was administered in 13 of 27 patients and three of them cleared HBeAg.
It is remarkable that in a family with four HBsAg positive patients, two were HBeAg positive and two negative.
The prevalence of positive HBeAg in HBsAg positive patients is 5.5% in our region and its seems more common in younger ages. The mean clearance time of HBeAg is 1.33 years and it may be reduced by interferon-a therapy. It still remains to be determined whether the HBeAg clearance is connected with a specific genotype and phenotype of the virus.
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The Global Burden of HBV and HCV Infection Attributable to Unsafe Blood Transfusions
E. Rapiti,1 IN Dhingra 1, YJF Hutin, 1 and S Lloyd 1
1World Health Organization, Geneva, Switzerland
Unsafe blood transfusions are a cause of continuing concern in developing countries. We estimated the proportion of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections that may be attributable to unsafe blood transfusions worldwide.
We modeled the fraction of incident infections attributable to blood transfusions in 2000 on the basis of the annual number of blood transfusions, the proportion of untested units, the residual risk associated with screened blood, the probability of transmission following infected transfusions, the prevalence of active infection, the prevalence of immunity and the total incidence. Screening practices and estimations of the number of blood units were based upon WHO's Global Database on Blood Safety. To account for a potential underestimation of the annual number of blood transfused and for a potential over-reporting of screening practices, we doubled the number of transfusions and assumed that in developing countries, only 50% of blood units were screened in a "worst case scenario" analysis.
In 2000, approximately 90 million blood transfusions were received worldwide (0.02 per person and per year). Of these, 11% and 23% had not been screened for HBV and HCV, respectively.
Overall, infected blood transfusions may have caused 78,224 HBV infections and 525,368 HCV infections, accounting for 0.12% and 10% of all new infections respectively. Under the "worst case scenario", infected blood transfusions would have caused 869,761 HBV infections and 1,261,365 HCV infections, accounting for 1.3% and 24% of new infections, respectively.
Unsafe blood transfusion remains a source of HBV and HCV infections worldwide. To prevent these infections, national blood transfusion services should be established to ensure blood safety through (1) recruitment of voluntary, non-remunerated donors, (2) universal testing and (3) appropriate clinical use of blood.
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Alternate HBV Transmission Routes Prompt Improved infectivity Testing
Lund University, Lund, Sweden
Infectivity testing of patients infected with hepatitis B virus (HBV) has varied over the years. The HBeAg/anti-HBe system has largely been replaced by HBV DNA testing by PCR. In a clinical setting, however, these tests are only performed on serum and as HBV DNA PCR is costly, are used sparingly. Most recommendations regarding infection control of HBV are limited to blood and sexual transmission.
A recent case of acute HBV in a preschool teacher prompted us to investigate the role of other body fluids in the transmission of HBV and the importance of ALT levels in the assessment of the infectivity of HBsAgpositive patients.
After excluding other sources of infection, the only remaining risk factor for the teacher was a toddler she had had sparse contact with and whose diapers she had changed on a few occasions. Sequencing of the HBV strains of the teacher and the child showed identical sequences over the pre-S, S and X genes, including a characteristic mutation in the pre-S gene. HBV DNA was found in the urine of the child, with a 100-fold lower concentration than in serum. This supports our earlier findings, where 50% of unselected HBV -carriers had HBV DNA detectable in urine.
We proceeded to investigate the significance of ALT levels in the assessment of infectivity in HBV -positive patients. We found that 68% (n=l04) of patients with normal AL T levels were HBV DNA positive in serum. AL T levels are therefore not reliable tools for assessing the infectivity of HBV -positive patients and cannot replace HBV DNA testing.
These findings lead us to suggest that the presence of HBV in body fluids other than blood should be taken into account when issuing infection control guidelines and that HBV DNA testing of blood and, when necessary, other body fluids be used to assess infectivity.
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Genomic Mutations of Circulating Hepatitis B Virus Found in Non-B, Non-C Hepatocellular Carcinoma
N. Nakamoto1 S. Tada1, K. Kitamura1 S. Kurita1, Y. Saito1, H. Ebinuma2, H. Saito1, H. Ishii1
1Keio University, School of Medicine, Department of Internal Medicine, Tokyo, Japan
2Tokyo Electric Power Company Hospital, Department of Internal Medicine, Tokyo, Japan
Most hepatocellular carcinoma (HCC) in Japan is caused by chronic infection with hepatitis B virus (HBV) or hepatitis C virus (HCV). HBV DNA has been detected in the serum and liver tissue of some proportion of those patients who are HBs antigen-negative and HCV antibody-negative; i.e., non-B, non C (NBNC) patients with HCC. We investigated HBV DNA in the sera from NBNC HCC cases and examined genomic mutations of HBV to make clear the reason for seronegativity.
Patients and Methods:
In these 30 patients, 18 (60.0%) had a history of excessive alcoholic intake and 23 (76.7%) was complicated with liver cirrhosis. With regard to serology markers, seven was anti-HBs positive, and nine was anti-HBc positive. The sera from the 30 NBNC HCC patients were examined by polymerase chain reaction (PCR) followed by southern blotting for existence of HBV DNA. The precore/core, polymerase, and preS/S regions of the HBV genome in the sera from five seronegative cases were analyzed by direct sequence.
HBV DNA was detected in 18 of 30 patients (60.0%). Demographic factors such as age, gender, anti-HBs positivity, anti-HBc positivity, complication with cirrhosis, and excessive alcohol intake did not affect circulating HBV positivity. Genomic mutations with amino acid (aa) substitutions were detected in the polymerase, precore, and S (in the antigen determinant part) regions from each one of the five seronegative cases, and common aa substitutions were found in the core region (aa 130 from P to T) from four of the five cases.
PCR-based HBV screening is necessary in patients suffering from liver diseases of unknown etiology, although etiological importance of HBV and benefit of viral elimination have not been established. Very low levels of HBV replication and its genomic mutations detected in this study may be involved in the lack of HBsAg in NBNC HCC cases.
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Short Schedule Hepatitis B Vaccination of Injecting Drug Users in and Outside European Prisons
P.B Christensen l,2, N.Fisker3, O, Anagnostou 2,4, E.Liebert5, J.Georgsen3
1Dept. Infectious Diseases, Odense University Hospital, Denmark
2European Network against HIV and Hepatitis in Prison
3Dept. Clinical Immunology, Odense University Hospital, Denmark
42nd Substitution Treatment Programme, OKANA, Athens, Greece
5Ministry of Justice, Tallinn, Estonia
Prisoners and injecting drug users (IDUs) continue to have very high prevalence of hepatitis B infection (HBV). Vaccination against HBV has been recommended for these groups for decades, but still most studies report less that half of the population vaccinated. One of the reasons is that IDUs have a low compliance with the 6 months schedule of vaccination; a second reason is that IDUs have a weaker serological respond to the vaccine. This study compares the compliance and serological response of a 3 weeks vaccination schedule with that of the standard 6 months regime.
We performed a randomized study in European prisons comparing vaccination at 0, 1 and 3 weeks with vaccination at 0, 1 and 6 months (20µg Engerix B s.c.). Outcome were compliance and anti-HBs >10 lU/L (seroproctection). In a drug treatment program we compared 0, I and 2 month with a 0, 1, and 6 month schedule among 230 IDUs and assessed the relation between seroprotection and infection with hepatitis C.
After randomization of 72 patients there was a significant difference in compliance: 20% in the 6month arm and 58% in the 3 weeks arm (p =0.017) had 3 doses. The study was changed to evaluate the seroprotection rate of the 3-week schedule. Of 566 prisoners included 80% completed 3 doses. Seven month follow-up will be presented at the conference. In the 2 vs. 6 months programme compliance was 89% versus 74%, and seroprotection 50% versus 76% at month seven. Vaccine failure was associated with presence of hepatitis C (seroprotection among HVC+ 69%, among HCV- 100%, p=0.047).
Among IDUs and prisoners a short hepatitis B vaccination schedule has a significantly higher compliance and should be preferred in this population. Low seroprotection rate was correlated to concurrent HCV infection.
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