Development of an RNAi therapeutic for alpha-1-antitrypsin liver disease

The autosomal codominant genetic disorder alpha-1 antitrypsin (AAT) deficiency (AATD) causes pulmonary and liver disease. Individuals homozygous for the mutant Z allele accumulate polymers of Z-AAT protein in hepatocytes, where AAT is primarily produced. This accumulation causes endoplasmic reticulum (ER) stress, oxidative stress, damage to mitochondria, and inflammation, leading to fibrosis, cirrhosis, and hepatocellular carcinoma. The magnitude of AAT reduction and duration of response from first-generation intravenously administered RNA interference (RNAi) therapeutic ARC-AAT and then with next-generation subcutaneously administered ARO-AAT were assessed by measuring AAT protein in serum of the PiZ transgenic mouse model and human volunteers. The impact of Z-AAT reduction by RNAi on liver disease phenotypes was evaluated in PiZ mice by measuring polymeric Z-AAT in the liver; expression of genes associated with fibrosis, autophagy, apoptosis, and redox regulation; inflammation; Z-AAT globule parameters; and tumor formation. Ultrastructure of the ER, mitochondria, and autophagosomes in hepatocytes was evaluated by electron microscopy. In mice, sustained RNAi treatment reduced hepatic Z-AAT polymer, restored ER and mitochondrial health, normalized expression of disease-associated genes, reduced inflammation, and prevented tumor formation. RNAi therapy holds promise for the treatment of patients with AATD-associated liver disease. ARO-AAT is currently in phase II/III clinical trials.

RNAi-based treatment of chronically infected patients and chimpanzees reveals that integrated hepatitis B virus DNA is a source of HBsAg

Chronic hepatitis B virus (HBV) infection is a major health concern worldwide, frequently leading to liver cirrhosis, liver failure, and hepatocellular carcinoma. Evidence suggests that high viral antigen load may play a role in chronicity. Production of viral proteins is thought to depend on transcription of viral covalently closed circular DNA (cccDNA). In a human clinical trial with an RNA interference (RNAi)-based therapeutic targeting HBV transcripts, ARC-520, HBV S antigen (HBsAg) was strongly reduced in treatment-naïve patients positive for HBV e antigen (HBeAg) but was reduced significantly less in patients who were HBeAg-negative or had received long-term therapy with nucleos(t)ide viral replication inhibitors (NUCs). HBeAg positivity is associated with greater disease risk that may be moderately reduced upon HBeAg loss. The molecular basis for this unexpected differential response was investigated in chimpanzees chronically infected with HBV. Several lines of evidence demonstrated that HBsAg was expressed not only from the episomal cccDNA minichromosome but also from transcripts arising from HBV DNA integrated into the host genome, which was the dominant source in HBeAg-negative chimpanzees. Many of the integrants detected in chimpanzees lacked target sites for the small interfering RNAs in ARC-520, explaining the reduced response in HBeAg-negative chimpanzees and, by extension, in HBeAg-negative patients. Our results uncover a heretofore underrecognized source of HBsAg that may represent a strategy adopted by HBV to maintain chronicity in the presence of host immunosurveillance. These results could alter trial design and endpoint expectations of new therapies for chronic HBV.

Phosphorylation-specific status of RNAi triggers in pharmacokinetic and biodistribution analyses

The RNA interference (RNAi)-based therapeutic ARC-520 for chronic hepatitis B virus (HBV) infection consists of a melittin-derived peptide conjugated to N-acetylgalactosamine for hepatocyte targeting and endosomal escape, and cholesterol-conjugated RNAi triggers, which together result in HBV gene silencing. To characterize the kinetics of RNAi trigger delivery and 5΄-phosphorylation of guide strands correlating with gene knockdown, we employed a peptide-nucleic acid (PNA) hybridization assay. A fluorescent sense strand PNA probe binding to RNAi duplex guide strands was coupled with anion exchange high performance liquid chromatography to quantitate guide strands and metabolites. Compared to PCR- or ELISA-based methods, this assay enables separate quantitation of non-phosphorylated full-length guide strands from 5΄-phosphorylated forms that may associate with RNA-induced silencing complexes (RISC). Biodistribution studies in mice indicated that ARC-520 guide strands predominantly accumulated in liver. 5΄-phosphorylation of guide strands was observed within 5 min after ARC-520 injection, and was detected for at least 4 weeks corresponding to the duration of HBV mRNA silencing. Guide strands detected in RISC by AGO2 immuno-isolation represented 16% of total 5΄-phosphorylated guide strands in liver, correlating with a 2.7 log10 reduction of HBsAg. The PNA method enables pharmacokinetic analysis of RNAi triggers, elucidates potential metabolic processing events and defines pharmacokinetic-pharmacodynamic relationships.

Safety, Tolerability, and Pharmacokinetics of ARC-520 Injection, an RNA Interference-Based Therapeutic for the Treatment of Chronic Hepatitis B Virus Infection, in Healthy Volunteers

ARC‐520 Injection, an RNA interference drug for the treatment of hepatitis B that targets cccDNA‐derived viral mRNA transcripts with high specificity, effectively reduces the production of viral proteins and HBV DNA. In this phase 1 randomized, double‐blind, placebo‐controlled study, 54 healthy volunteers (half male, half female) received a single, intravenous dose of 0.01–4.0 mg/kg ARC‐520 Injection (n = 36) or placebo (n = 18). Assessments included safety, tolerability, pharmacokinetics, and pharmacodynamics (cytokines and complement). Pharmacokinetics of the siRNA and peptide excipient components contained in ARC‐520 Injection showed a relatively short half‐life of 3–5 and 8–10 hours, respectively. Dose exposure linearity was demonstrated within the dose range. ARC‐520 Injection was well tolerated, with adverse‐event frequency the same as placebo and no serious adverse events. ARC‐520 Injection was initially found to induce histamine release through mast cell degranulation, resulting in 2 moderate hypersensitivity reactions. However, after initiation of pretreatment with oral antihistamine, no further hypersensitivity reactions occurred. Low‐level, transient complement induction and sporadic, mild, and transient elevations of several cytokines were observed but not associated with any symptoms. ARC‐520 Injection showed a favorable tolerability profile in this single‐dose study in healthy volunteers. Oral antihistamine pretreatment is recommended in the future to offset mast cell degranulation stimulation.

Investigations on the role of the salmon louse, Lepeophtheirus salmonis (Caligidae), as a vector in the transmission of Aeromonas salmonicida subsp. salmonicida

A bacteria-parasite challenge model was used to study the role of sea lice, Lepeophtheirus salmonis (Copepoda), as a vector of Aeromonas salmonicida subsp. salmonicida. Three hypotheses were tested: (i) L. salmonis can acquire A. salmonicida subsp. salmonicida via water bath exposure; (ii) L. salmonis can acquire the bacteria via parasitizing infected Atlantic salmon, Salmo salar; and (iii) L. salmonis can transmit the bacteria to naïve Atlantic salmon via parasitism. Adult L. salmonis exposed to varying A. salmonicida subsp. salmonicida suspensions (10(1) -10(7)  cells mL(-1) ) for 1.0, 3.0 or 6.0 h acquired the bacteria externally (12.5-100%) and internally (10.0-100%), with higher prevalences associated with the highest concentrations and exposures. After exposure to 10(7)  cells mL(-1) , viable A. salmonicida subsp. salmonicida could be isolated from the external carapace of L. salmonis for 120 h. Lepeophtheirus salmonis also acquired the bacteria externally and internally from parasitizing infected fish. Bacterial transmission was observed only when L. salmonis had acquired the pathogen internally via feeding on 'donor fish' and then by parasitizing smaller (<50 g) 'naive' fish. Under specific experimental conditions, L. salmonis can transfer A. salmonicida subsp. salmonicida via parasitism; however, its role as a mechanical or biological vector was not defined.

Synthetic RNAi triggers and their use in chronic hepatitis B therapies with curative intent

Current therapies for chronic hepatitis B virus infection (CHB) - nucleos(t)ide analogue reverse transcriptase inhibitors and interferons - result in low rates of functional cure defined as sustained off-therapy seroclearance of hepatitis B surface antigen (HBsAg). One likely reason is the inability of these therapies to consistently and substantially reduce the levels of viral antigen production. Accumulated evidence suggests that high serum levels of HBsAg result in exhaustion of the host immune system, rendering it unable to mount the effective antiviral response required for HBsAg clearance. New mechanistic approaches are required to produce high rates of HBsAg seroclearance in order to greatly reduce off-treatment disease progression. Already shown to be a clinically viable means of reducing gene expression in a number of other diseases, therapies based on RNA interference (RNAi) can directly target hepatitis B virus transcripts with high specificity, profoundly reducing the production of viral proteins. The fact that the viral RNA transcripts contain overlapping sequences means that a single RNAi trigger can result in the degradation of all viral transcripts, including all messenger RNAs and pregenomic RNA. Advances in the design of RNAi triggers have increased resistance to degradation and reduced nonspecific innate immune stimulation. Additionally, new methods to effectively deliver the trigger to liver hepatocytes, and specifically to the cytoplasmic compartment, have resulted in increased efficacy and tolerability. An RNAi-based drug currently in clinical trials is ARC-520, a dynamic polyconjugate in which the RNAi trigger is conjugated to cholesterol, which is coinjected with a hepatocyte-targeted, membrane-active peptide. Phase 2a clinical trial results indicate that ARC-520 was well tolerated and resulted in significant, dose-dependent reduction in HBsAg for up to 57days in CHB patients. RNAi-based therapies may play an important role in future therapeutic regimes aimed at improving HBsAg seroclearance and eliminating the need for lifelong therapy. This paper forms part of a symposium in Antiviral Research on "An unfinished story: from the discovery of the Australia antigen to the development of new curative therapies for hepatitis B."

Chronic hepatitis B: Virology, natural history, current management and a glimpse at future opportunities

The host immune system plays an important role in chronic hepatitis B (CHB), both in viral clearance and hepatocellular damage. Advances in our understanding of the natural history of the disease have led to redefining the major phases of infection, with the "high replicative, low inflammatory" phase now replacing what was formerly termed the "immune tolerant" phase, and the "nonreplicative phase" replacing what was formerly termed the "inactive carrier" phase. As opposed to the earlier view that HBV establishes chronic infection by exploiting the immaturity of the neonate's immune system, new findings on trained immunity show that the host is already somewhat "matured" following birth, and is actually very capable of responding immunologically, potentially altering future hepatitis B treatment strategies. While existing therapies are effective in reducing viral load and necroinflammation, often restoring the patient to near-normal health, they do not lead to a cure except in very rare cases and, in many patients, viremia rebounds after cessation of treatment. Researchers are now challenged to devise therapies that will eliminate infection, with a particular focus on eliminating the persistence of viral cccDNA in the nuclei of hepatocytes. In the context of chronic hepatitis B, new definitions of 'cure' are emerging, such as 'functional' and 'virological' cure, defined by stable off-therapy suppression of viremia and antigenemia, and the normalization of serum ALT and other liver-related laboratory tests. Continued advances in the understanding of the complex biology of chronic hepatitis B have resulted in the development of new, experimental therapies targeting viral and host factors and pathways previously not accessible to therapy, approaches which may lead to virological cures in the near term and functional cures upon long term follow-up. This article forms part of a symposium in Antiviral Research on "An unfinished story: from the discovery of the Australia antigen to the development of new curative therapies for hepatitis B."

Protease-triggered siRNA delivery vehicles

The safe and efficacious delivery of membrane impermeable therapeutics requires cytoplasmic access without the toxicity of nonspecific cytoplasmic membrane lysis. We have developed a mechanism for control of cytoplasmic release which utilizes endogenous proteases as a trigger and results in functional delivery of small interfering RNA (siRNA). The delivery approach is based on reversible inhibition of membrane disruptive polymers with protease-sensitive substrates. Proteolytic hydrolysis upon endocytosis restores the membrane destabilizing activity of the polymers thereby allowing cytoplasmic access of the co-delivered siRNA. Protease-sensitive polymer masking reagents derived from polyethylene glycol (PEG), which inhibit membrane interactions, and N-acetylgalactosamine, which targets asialoglycoprotein receptors on hepatocytes, were synthesized and used to formulate masked polymer-siRNA delivery vehicles. The size, charge and stability of the vehicles enable functional delivery of siRNA after subcutaneous administration and, with modification of the targeting ligand, have the potential for extrahepatic targeting.

Targeted in vivo delivery of siRNA and an endosome-releasing agent to hepatocytes

The discoveries of RNA interference (RNAi) and short interfering RNAs (siRNAs) have provided the opportunity to treat diseases in a fundamentally new way: by co-opting a natural process to inhibit gene expression at the mRNA level. Given that siRNAs must interact with the cells' natural RNAi machinery in order to exert their silencing effect, one of the most fundamental requirements for their use is efficient delivery to the desired cell type and, specifically, into the cytoplasm of those cells. Numerous research efforts involving the testing of a large number of delivery approaches using various carrier molecules and inventing several distinct formulation technologies during the past decade illustrate the difficulty and complexity of this task. We have developed synthetic polymer formulations for in vivo siRNA delivery named Dynamic PolyConjugates™ (DPCs) that are designed to mimic the features viruses possess for efficient delivery of their nucleic acids. These include small size, long half-life in circulation, capability of displaying distinct host cell tropism, efficient receptor binding and cell entry, disassembly in the endosome and subsequent release of the nucleic acid cargo to the cytoplasm. Here we present an example of this delivery platform composed of a hepatocyte-targeted endosome-releasing agent and a cholesterol-conjugated siRNA (chol-siRNA). This delivery platform forms the basis of ARC-520, an siRNA-based therapeutic for the treatment of chronic hepatitis B virus (HBV) infection. In this chapter, we provide a general overview of the steps in developing ARC-520 and detailed protocols for two critical stages of the discovery process: (1) verifying targeted in vivo delivery to hepatocytes and (2) evaluating in vivo drug efficacy using a mouse model of chronic HBV infection.

Modulation of cellular innate immunity by Lepeophtheirus salmonis secretory products

Lepeophtheirus salmonis produces pharmacologically active substances that have been shown to modify genetic expression of inflammatory mediators in SHK-1 cells and head kidney macrophages of salmon. Differences in genetic expression among genera of Oncorhynchus and Salmo reflect different susceptibilities to L. salmonis. This study was conducted to determine if the presence of L. salmonis secretory products (SEPs)(1) alters the cellular innate immune response (specifically macrophage function) among several salmonids. Phagocytic assays were performed using SHK-1 cells and macrophages isolated from pink (Oncorhynchus gorbuscha), chum (Oncorhynchus keta) and Atlantic (Salmo salar) salmon following incubation with SEPs and Aeromonas salmonicida. Respiratory burst assays were analyzed using pink, chum and Atlantic salmon macrophages after exposure to SEPs. For SHK-1 cells, incubation with SEPS led to dose-dependent increases in phagocytosis. Following incubation with SEPs, chum salmon macrophages had the highest phagocytic index (55.1%) followed by Atlantic (26.4%) and pink (15.8%) salmon. In contrast, respiratory burst response was greatest in pink salmon and minimal in the other two species. Our results suggest that the cellular innate immune response of salmon is modified in the presence of L. salmonis secretions and differences observed among species provide insight into species-specific consequences of sea lice infection.

Stochasticity in natural forage production affects use of urban areas by black bears: implications to management of human-bear conflicts

The rapid expansion of global urban development is increasing opportunities for wildlife to forage and become dependent on anthropogenic resources. Wildlife using urban areas are often perceived dichotomously as urban or not, with some individuals removed in the belief that dependency on anthropogenic resources is irreversible and can lead to increased human-wildlife conflict. For American black bears (Ursus americanus), little is known about the degree of bear urbanization and its ecological mechanisms to guide the management of human-bear conflicts. Using 6 years of GPS location and activity data from bears in Aspen, Colorado, USA, we evaluated the degree of bear urbanization and the factors that best explained its variations. We estimated space use, activity patterns, survival, and reproduction and modeled their relationship with ecological covariates related to bear characteristics and natural food availability. Space use and activity patterns were dependent on natural food availability (good or poor food years), where bears used higher human density areas and became more nocturnal in poor food years. Patterns were reversible, i.e., individuals using urban areas in poor food years used wildland areas in subsequent good food years. While reproductive output was similar across years, survival was lower in poor food years when bears used urban areas to a greater extent. Our findings suggest that bear use of urban areas is reversible and fluctuates with the availability of natural food resources, and that removal of urban individuals in times of food failures has the potential to negatively affect bear populations. Given that under current predictions urbanization is expected to increase by 11% across American black bear range, and that natural food failure years are expected to increase in frequency with global climate change, alternative methods of reducing urban human-bear conflict are required if the goal is to prevent urban areas from becoming population sinks.

Co-injection of a targeted, reversibly masked endosomolytic polymer dramatically improves the efficacy of cholesterol-conjugated small interfering RNAs in vivo

Effective in vivo delivery of small interfering (siRNA) has been a major obstacle in the development of RNA interference therapeutics. One of the first attempts to overcome this obstacle utilized intravenous injection of cholesterol-conjugated siRNA (chol-siRNA). Although studies in mice revealed target gene knockdown in the liver, delivery was relatively inefficient, requiring 3 daily injections of 50 mg/kg of chol-siRNA to obtain measurable reduction in gene expression. Here we present a new delivery approach that increases the efficacy of the chol-siRNA over 500-fold and allows over 90% reduction in target gene expression in mice and, for the first time, high levels of gene knockdown in non-human primates. This improved efficacy is achieved by the co-injection of a hepatocyte-targeted and reversibly masked endosomolytic polymer. We show that knockdown is absolutely dependent on the presence of hepatocyte-targeting ligand on the polymer, the cognate hepatocyte receptor, and the cholesterol moiety of the siRNA. Importantly, we provide evidence that this increase in efficacy is not dependent on interactions between the chol-siRNA with the polymer prior to injection or in the bloodstream. The simplicity of the formulation and efficacy of this mode of siRNA delivery should prove beneficial in the use of siRNA as a therapeutic.

Hepatocyte-targeted RNAi therapeutics for the treatment of chronic hepatitis B virus infection

RNA interference (RNAi)-based therapeutics have the potential to treat chronic hepatitis B virus (HBV) infection in a fundamentally different manner than current therapies. Using RNAi, it is possible to knock down expression of viral RNAs including the pregenomic RNA from which the replicative intermediates are derived, thus reducing viral load, and the viral proteins that result in disease and impact the immune system's ability to eliminate the virus. We previously described the use of polymer-based Dynamic PolyConjugate (DPC) for the targeted delivery of siRNAs to hepatocytes. Here, we first show in proof-of-concept studies that simple coinjection of a hepatocyte-targeted, N-acetylgalactosamine-conjugated melittin-like peptide (NAG-MLP) with a liver-tropic cholesterol-conjugated siRNA (chol-siRNA) targeting coagulation factor VII (F7) results in efficient F7 knockdown in mice and nonhuman primates without changes in clinical chemistry or induction of cytokines. Using transient and transgenic mouse models of HBV infection, we show that a single coinjection of NAG-MLP with potent chol-siRNAs targeting conserved HBV sequences resulted in multilog repression of viral RNA, proteins, and viral DNA with long duration of effect. These results suggest that coinjection of NAG-MLP and chol-siHBVs holds great promise as a new therapeutic for patients chronically infected with HBV.

Rates of transformation of methyl parathion and diethyl phthalate by aufwuchs microorganisms

Using batch cultures, we determined transformation rates for low concentrations of two toxicants-an insecticide, methyl parathion (O,O-dimethyl O-p-nitrophenyl phosphorothioate), and a plasticizer, diethyl phthalate-by aufwuchs, aquatic microbial growth attached to submerged surfaces or suspended in streamers or mats. Aufwuchs samples were collected from field sites, an indoor channel, and a continuous-flow fermentor. Aufwuchs fungi, protozoa, and algae did not transform methyl parathion or diethyl phthalate, but bacteria rapidly transformed both chemicals. Second-order transformation rate coefficients, K(b), based on total plate counts of bacteria in aufwuchs, were determined for potential use in a mathematical model capable of predicting the transport and fate of chemicals in aquatic systems. K(b) for both methyl parathion and diethyl phthalate decreased as the concentration of total bacteria, [B], increased in aufwuchs. This effect resulted from the proportion of nontransformer to transformer bacteria increasing as [B] increased and from the rate of transformation per transformer cell decreasing as [B] increased. First-order transformation rate coefficients, K(1), were relatively stable per unit of surface area colonized by aufwuchs, because K(b) decreased as [B] increased (K(1) = K(b) x [B]).

Initial test of the benchmark chemical approach for predicting microbial transformation rates in aquatic environments

Using 2,4-dichlorophenoxyacetic acid methyl ester (2,4-DME) as a benchmark chemical, we determined relative pseudo-first-order rate coefficients for the butoxyethyl ester of 2,4-dichlorophenoxyacetic acid (2,4-DBE), methyl parathion, and methyl-3-chlorobenzoate in a diversity of microbial samples, including water, sediment, biofilm, and floating microbial mats collected from a laboratory mesocosm as well as from streams, lakes, and wetlands in Georgia and Florida. The decreasing order of reactivity for relative microbial transformation rates was 2,4-DBE > 2,4-DME > methyl-3-chlorobenzoate > methyl parathion. Half-lives of the chemicals varied about 60-fold depending on the chemical and microbial sample. Relative rate coefficients, however, typically varied only about threefold for field-collected samples. Relative rate coefficients determined with samples from a laboratory mesocosm were consistently low compared with the field sample data. Overall, the data indicated that microbial transformation rates of a chemical can be satisfactorily inferred for a wide variety of microbial habitats-such as water, biofilm, or a sediment-on the basis of its transformation rate relative to that of an appropriate benchmark chemical by using a single type of microbial sample.

Kinetics of mixed microbial assemblages enhance removal of highly dilute organic substrates

Our experiments with selected organic substrates reveal that the rate-limiting process governing microbial degradation rates changes with substrate concentration, S, in such a manner that substrate removal is enhanced at lower values of S. This enhancement is the result of the dominance of very efficient systems for substrate removal at low substrate concentrations. The variability of dominant kinetic parameters over a range of S causes the kinetics of complex assemblages to be profoundly dissimilar to those of systems possessing a single set of kinetic parameters; these findings necessitate taking a new approach to predicting substrate removal rates over wide ranges of S.

Translating Evidence into Practice: The Case of Dementia Guidelines in Specialized Geriatric Services

This paper describes a process of identifying best practice guidelines for non-pharmacological management for individuals with dementia and disseminating them to a group of frontline practitioners in specialized geriatric services. Our dissemination plan involved early participation of practitioners, development of a chart summarizing five guidelines showing commonalities, contrasts, and gaps in the guidelines, and their interpretation, colour-coded for the strength of the evidence on which they were based. Two sequential workshops were held in which recommendations for action were developed. Outcomes of the process included a resource manual, a network of practitioners, and action recommendations based upon survey data. An early follow-up evaluation showed increased adoption of guidelines.

Progress toward a nonviral gene therapy protocol for the treatment of anemia

Anemia frequently accompanies chronic diseases such as progressive renal failure, acquired immunodeficiency syndrome, and cancer. Patients are currently treated with erythropoietin (EPO) replacement therapy, using various recombinant human EPO protein formulations. Although this treatment is effective, gene therapy could be more economical and more convenient for the long-term management of the disease. The objective of this study was to develop a naked DNA-based gene therapy protocol that could fill this need. Hydrodynamic limb vein technology has been shown to be an effective and safe procedure for delivering naked plasmid DNA (pDNA) into the skeletal muscles of limbs. Using this method, we addressed the major challenge of an EPO-based gene therapy of anemia: maintaining stable, long-term expression at a level that sufficiently promotes erythropoiesis without leading to polycythemia. The results of our study, using a rat anemia model, provide proof of principle that repeated delivery of small pDNA doses has an additive effect and can gradually lead to the correction of anemia without triggering excessive hematopoiesis. This simple method provides an alternative approach for regulating EPO expression. EPO expression was also proportional to the injected pDNA dose in nonhuman primates. In addition, long-term (more than 450 days) expression was obtained after delivering rhesus EPO cDNA under the transcriptional control of the muscle-specific creatine kinase (MCK) promoter. In conclusion, these data suggest that the repeated delivery of small doses of EPO expressing pDNA into skeletal muscle is a promising, clinically viable approach to alleviate the symptoms of anemia.

Dynamic PolyConjugates for targeted in vivo delivery of siRNA to hepatocytes

Achieving efficient in vivo delivery of siRNA to the appropriate target cell would be a major advance in the use of RNAi in gene function studies and as a therapeutic modality. Hepatocytes, the key parenchymal cells of the liver, are a particularly attractive target cell type for siRNA delivery given their central role in several infectious and metabolic disorders. We have developed a vehicle for the delivery of siRNA to hepatocytes both in vitro and in vivo, which we have named siRNA Dynamic PolyConjugates. Key features of the Dynamic PolyConjugate technology include a membrane-active polymer, the ability to reversibly mask the activity of this polymer until it reaches the acidic environment of endosomes, and the ability to target this modified polymer and its siRNA cargo specifically to hepatocytes in vivo after simple, low-pressure i.v. injection. Using this delivery technology, we demonstrate effective knockdown of two endogenous genes in mouse liver: apolipoprotein B (apoB) and peroxisome proliferator-activated receptor alpha (ppara). Knockdown of apoB resulted in clear phenotypic changes that included a significant reduction in serum cholesterol and increased fat accumulation in the liver, consistent with the known functions of apoB. Knockdown of ppara also resulted in a phenotype consistent with its known function, although with less penetrance than observed in apoB knockdown mice. Analyses of serum liver enzyme and cytokine levels in treated mice indicated that the siRNA Dynamic PolyConjugate was nontoxic and well tolerated.

Prospective study of cross-infection from upper-GI endoscopy in a hepatitis C-prevalent population

BACKGROUND

A high prevalence of hepatitis C (HCV) in the Egyptian Nile Delta increases the demand for upper-GI endoscopy (UGIE) and the risk of cross-infection with this virus.

OBJECTIVE

To assess the potential for UGIE to transmit HCV when endoscopes are reprocessed according to current international standards.

DESIGN

A prospective cohort study to detect the incidence of HCV and hepatitis B cross-infections.

SETTING

The endoscopic unit of the National Liver Institute, a hospital for patients with chronic liver disease.

PATIENTS

A total of 859, including 149 of 249 patients (60%) at risk (HCV-antibody negative) retested 3 to 10 months after UGIE with endoscopes previously used on HCV carriers.

INTERVENTIONS

Nurses were trained to process endoscopes according to American Society for Gastrointestinal Endoscopy guidelines, and procedures were observed and recorded.

MAIN OUTCOME MEASUREMENTS

Seroconversions were determined by using enzyme immunoassays for anti-HCV; reverse transcriptase-polymerase chain reaction was used to detect HCV-ribonucleic acid (RNA).

RESULTS

Four patients, initially negative, tested positive for anti-HCV after UGIE. However, 2 of these had HCV-RNA in their baseline blood sample, and the other 2 did not have HCV-RNA in their follow-up sample.

LIMITATIONS

Very-high prevalence of anti-HCV in subjects reduced the proportion at risk of infection, and follow-up was difficult.

CONCLUSIONS

There were no cases of proven transmission of HCV when endoscopes were reprocessed by using currently accepted standards. This negative study is encouraging, because patients undergoing UGIE in the Nile Delta of Egypt where HCV-caused liver disease is so pervasive would be at maximum risk of HCV cross-infection from UGIE.

Systemic siRNA delivery via hydrodynamic intravascular injection

The main barrier to the use of RNAi in mammalian systems is the difficulty in delivering siRNA or shRNA to the appropriate tissues. Although progress has been made in this area, many of the technologies developed require specialized expertise and reagents that are beyond the reach of most investigators. In contrast, the hydrodynamic injection technique is simple to perform and enables highly efficient delivery of naked, unmodified siRNA to a number of tissues, especially the liver. This review describes the development of the technique and explores the possible mechanisms that enable uptake of siRNA to biological effect. Examples of the use of hydrodynamic injection in animal models of disease and for the study of gene function are presented and discussed.

Do the ABCS 135 short cognitive screen and its subtests discriminate between normal cognition, mild cognitive impairment and dementia?

BACKGROUND

Cognitive screening instruments are either too long for routine clinical use or not sensitive to distinguish mild cognitive impairment (MCI) from normal cognition (NC) or dementia.

OBJECTIVE

To evaluate the sensitivity and specificity of the AB Cognitive Screen (ABCS) and its subtests with a view to improving its ability to differentiate between dementia, MCI and NC. The influence of age and education on sensitivity and specificity is also examined.

DESIGN

Cross-sectional study.

METHODS

Participants with dementia and MCI were recruited from those presenting to four specialty geriatric clinics in southern Ontario. Participants with NC were recruited from the family and friends of patients. A comprehensive geriatric assessment was done including ABCS, SMMSE and 15 point Geriatric Depression Scale. Analysis of variance and receiver operating characteristic (ROC) curves compared test scores. SMMSE scores were also analysed for comparison purposes.

RESULTS

Three hundred and two participants had dementia, 166 had MCI and 174 had NC. ABCS total scores were significantly different between NC and MCI (mean difference 7.1, 1.8-12.5 CI, p = 0.000) while SMMSE scores were not (mean difference 0.5, -0.7-1.7, p < 0.628). Of individual ABCS subtests, verbal fluency and delayed recall were most sensitive to differences between NC and MCI. ROC curve analysis, which presents sensitivity and specificity, showed verbal fluency was better than delayed recall in distinguishing between NC and MCI, among participants 75 years of age or older.

CONCLUSION

The AB Cognitive Screen (ABCS) can be administered in 3-5 min. The SMMSE and ABCS total and subtests significantly distinguished between dementia and MCI or NC. Verbal fluency and delayed recall were best at distinguishing between MCI and NC. The analysis illustrates how each subtest contributes to the sensitivity of the ABCS and suggests ways that sensitivity might be improved.

Alternate forms of logical memory and verbal fluency tasks for repeated testing in early cognitive changes

BACKGROUND

Repeat cognitive testing is an essential diagnostic strategy to measure changes in cognition over time when following people with memory problems. Alternate forms may avert practice effects that can mimic improvements in cognition. We evaluated alternate forms of verbal fluency and logical memory (paragraph recall) tasks to evaluate their equivalence for clinical use.

METHODS

Participants with mild cognitive impairment (MCI) and dementia were recruited from five outpatient memory clinics and one nursing home. Participants with normal cognition (NC) were recruited from family members or friends. Verbal fluency categories of animals, cities & towns, fruits & vegetables and first names were used. Scores were recorded for 0-30 seconds, 31-60 seconds and errors. For the logical memory task, participants were read one of three different paragraphs and then were asked to recall the story. Immediate recall and delayed recall scores were recorded. The Standardized Mini-mental State Examination, the AB Cognitive Screen and the 15-point Geriatric Depression Scale were administered as part of the assessment. Analyses were performed using means, frequency distributions, t-tests, receiver-operating characteristic curves and effect sizes.

RESULTS

There were 46 NC participants, 45 with MCI and 55 with dementia. For verbal fluency, the mean number of animals, cities & towns, names or fruits & vegetables named in 60 seconds did not differ significantly within each cognitive group. First names was an easier category than the others: NC named 16.9-22.3 items, MCI named 11.6-14.4 items and dementia named 8.1-11.4 items. The mean number of items immediately recalled in logical memory was not significantly different for the three paragraphs. The verbal fluency task (in 60 seconds) and logical memory immediate recall were highly sensitive and specific to differences between NC and MCI (areas under the curves 0.87 and 0.76, respectively).

CONCLUSIONS

Alternate forms allow serial testing without learning bias. Verbal fluency and logical memory tasks are sensitive to early cognitive changes.

Interactions of pathogens and irritant chemicals in land-applied sewage sludges (biosolids)

Fertilization of land with processed sewage sludges, which often contain low levels of pathogens, endotoxins, and trace amounts of industrial and household chemicals, has become common practice in Western Europe, the United States, and Canada. Local governments, however, are increasingly restricting or banning the practice in response to residents reporting adverse health effects. These self-reported illnesses have not been studied and methods for assessing exposures of residential communities to contaminants from processed sewage sludges need to be developed.

METHODS

To describe and document adverse effects reported by residents, 48 individuals at ten sites in the United States and Canada were questioned about their environmental exposures and symptoms. Information was obtained on five additional cases where an outbreak of staphylococcal infections occurred near a land application site in Robesonia, Pennsylvania. Medical records were reviewed in cases involving hospitalization or other medical treatment. Since most complaints were associated with airborne contaminants, an air dispersion model was used as a means for potentially ruling out exposure to sludge as the cause of adverse effects.

RESULTS

Affected residents lived within approximately 1 km of land-application sites and generally complained of irritation (e.g., skin rashes and burning of the eyes, throat, and lungs) after exposure to winds blowing from treated fields. A prevalence of Staphylococcus aureus infections of the skin and respiratory tract was found. Approximately one in four of 54 individuals were infected, including two mortalities (septicemia, pneumonia). This result was consistent with the prevalence of S. aureus infections accompanying diaper rashes in which the organism, which is occasionally found in the lower human colon, tends to invade irritated or inflamed tissue.

CONCLUSIONS

When assessing public health risks from applying sewage sludges in residential areas, potential interactions of chemical contaminants with low levels of pathogens should be considered. An increased risk of infection may occur when allergic and non-allergic reactions to endotoxins and other chemical components irritate skin and mucous membranes and thereby compromise normal barriers to infection.

PPARalpha siRNA-treated expression profiles uncover the causal sufficiency network for compound-induced liver hypertrophy

Uncovering pathways underlying drug-induced toxicity is a fundamental objective in the field of toxicogenomics. Developing mechanism-based toxicity biomarkers requires the identification of such novel pathways and the order of their sufficiency in causing a phenotypic response. Genome-wide RNA interference (RNAi) phenotypic screening has emerged as an effective tool in unveiling the genes essential for specific cellular functions and biological activities. However, eliciting the relative contribution of and sufficiency relationships among the genes identified remains challenging. In the rodent, the most widely used animal model in preclinical studies, it is unrealistic to exhaustively examine all potential interactions by RNAi screening. Application of existing computational approaches to infer regulatory networks with biological outcomes in the rodent is limited by the requirements for a large number of targeted permutations. Therefore, we developed a two-step relay method that requires only one targeted perturbation for genome-wide de novo pathway discovery. Using expression profiles in response to small interfering RNAs (siRNAs) against the gene for peroxisome proliferator-activated receptor alpha (Ppara), our method unveiled the potential causal sufficiency order network for liver hypertrophy in the rodent. The validity of the inferred 16 causal transcripts or 15 known genes for PPARalpha-induced liver hypertrophy is supported by their ability to predict non-PPARalpha-induced liver hypertrophy with 84% sensitivity and 76% specificity. Simulation shows that the probability of achieving such predictive accuracy without the inferred causal relationship is exceedingly small (p < 0.005). Five of the most sufficient causal genes have been previously disrupted in mouse models; the resulting phenotypic changes in the liver support the inferred causal roles in liver hypertrophy. Our results demonstrate the feasibility of defining pathways mediating drug-induced toxicity from siRNA-treated expression profiles. When combined with phenotypic evaluation, our approach should help to unleash the full potential of siRNAs in systematically unveiling the molecular mechanism of biological events.

Mechanism of plasmid delivery by hydrodynamic tail vein injection. I. Hepatocyte uptake of various molecules

BACKGROUND

The hydrodynamic tail vein (HTV) injection of naked plasmid DNA is a simple yet effective in vivo gene delivery method into hepatocytes. It is increasingly being used as a research tool to elucidate mechanisms of gene expression and the role of genes and their cognate proteins in the pathogenesis of disease in animal models. A greater understanding of its mechanism will aid these efforts and has relevance to macromolecular and nucleic acid delivery in general.

METHODS

In an attempt to explore how naked DNA enters hepatocytes the fate of a variety of molecules and particles was followed over a 24-h time frame using fluorescence microscopy. The uptake of some of these compounds was correlated with marker gene expression from a co-injected plasmid DNA. In addition, the uptake of the injected compounds was correlated with the histologic appearance of hepatocytes.

RESULTS

Out of the large number of nucleic acids, peptides, proteins, inert polymers and small molecules that we tested, most were efficiently delivered into hepatocytes independently of their size and charge. Even T7 phage and highly charged DNA/protein complexes of 60-100 nm in size were able to enter the cytoplasm. In animals co-injected with an enhanced yellow fluorescent protein (EYFP) expression vector and fluorescently labeled immunoglobulin (IgG), hepatocytes flooded with large amounts of IgG appeared permanently damaged and did not express EYFP-Nuc. Hepatocytes expressing EYFP had only slight IgG uptake. In contrast, when an EYFP expression vector was co-injected with a fluorescently labeled 200-bp linear DNA fragment, both were mostly (in 91% of the observed cells) co-localized to the same hepatocytes 24 h later.

CONCLUSIONS

The appearance of permanently damaged cells with increased uptake of some molecules such as endogenous IgG raised the possibility that a molecule could be present in a hepatocyte but its transport would not be indicative of the transport process that can lead to foreign gene expression. The HTV procedure enables the uptake of a variety of molecules (as previous studies also found), but the uptake process for some of these molecules may be associated with a more disruptive process to the hepatocytes that is not compatible with successful gene delivery.

Transcriptional and phenotypic comparisons of Ppara knockout and siRNA knockdown mice

RNA interference (RNAi) has great potential as a tool for studying gene function in mammals. However, the specificity and magnitude of the in vivo response to RNAi remains to be fully characterized. A molecular and phenotypic comparison of a genetic knockout mouse and the corresponding knockdown version would help clarify the utility of the RNAi approach. Here, we used hydrodynamic delivery of small interfering RNA (siRNA) to knockdown peroxisome proliferator activated receptor alpha (Ppara), a gene that is central to the regulation of fatty acid metabolism. We found that Ppara knockdown in the liver results in a transcript profile and metabolic phenotype that is comparable to those of Ppara^−/− mice. Combining the profiles from mice treated with the PPARα agonist fenofibrate, we confirmed the specificity of the RNAi response and identified candidate genes proximal to PPARα regulation. Ppara knockdown animals developed hypoglycemia and hypertriglyceridemia, phenotypes observed in Ppara^−/− mice. In contrast to Ppara^−/− mice, fasting was not required to uncover these phenotypes. Together, these data validate the utility of the RNAi approach and suggest that siRNA can be used as a complement to classical knockout technology in gene function studies.

Hepatocyte Targeting of Nucleic Acid Complexes and Liposomes by a T7 Phage p17 Peptide

A critical step for liver-directed gene therapy is the selective targeting of nucleic acids to hepatocytes. We have previously discovered that the proximal half of the T7 phage tail fiber protein (p17) targeted intact T7 phage and recombinant proteins to hepatocytes in vivo. In the present study, we have localized the targeting activities to a 33 amino acid sequence within the p17 coiled-coil rod domain. Given that the tail fiber domain from which the peptide was derived may form alpha and triple helical structures, biophysical studies (CD spectra and analytical ultracentrifugation) were conducted to determine the secondary and tertiary structures of the peptide. This peptide is able to target proteins, polymers, and siRNA and also particles such as DNA polyplexes and liposomes to hepatocytes. A variety of coupling strategies and chemistries were employed, thus demonstrating that this peptide is a versatile system for delivering cargo. The ability of this hepatocyte-targeting peptide to target DNA-containing particles suggests that it should be useful in the development of both nonviral and viral vectors. However, biological function of delivered cargo has not been demonstrated. This was primarily due to failure of delivered cargo to escape the endosomes. Further studies are in progress to provide functional activity of delivered nucleic acids by enabling their endosomal escape.

Non-viral approaches for gene transfer

Gene therapy has great potential to treat or prevent a variety of both genetic and acquired conditions that include neuromuscular disorders, cardiovascular disease, cancer, and infectious diseases. For recessive genetic disorders such as Duchenne muscular dystrophy, delivery of the normal dystrophin gene to muscle should prevent the myofibers from dying. Despite the great promise and sound principles of gene therapy, its application to humans have been hampered by the inability to safely and effectively deliver genes to the target tissues. Among the several gene transfer methods under development, the use of non-viral delivery methods and specifically naked DNA is particularly attractive in that many of the concerns over the use of viral-mediated methods, such as immunogenicity of viral packaging proteins and cost of viral vector production can be avoided. Recently we used limb veins for efficient, repeatable, and safe delivery of nucleic acids to skeletal myofibers throughout the limb muscles of mammals in vivo. Promising results have been obtained in both rodents and larger animals including non-human primates. Studies in the mdx mouse model indicate that the approach should be of use for patients with Duchenne muscular dystrophy. Based upon these encouraging results, a human clinical trial to deliver the human dystrophin gene to patients with DMD is being planned. The initial objective is to preserve hand and forearm function to increase the quality of life.

Long-term RNA interference from optimized siRNA expression constructs in adult mice

DNA constructs for small interfering RNA (siRNA) expression in mammalian cells have the potential for longer-term target gene knockdown than synthetic siRNAs. We compared in adult mice the efficacy and longevity of target gene knockdown from siRNA expression cassettes contained in plasmids, PCR-generated linear constructs or PCR constructs containing "dumbbell" ends using the hydrodynamic delivery method. Plasmid siRNA expression constructs were more effective than PCR constructs for target gene knockdown. The efficacy of the PCR constructs was improved by addition of short extensions beyond the transcription termination signal and greatly improved by addition of dumbbell ends. Constructs containing the H1 promoter were significantly less effective in mice than those containing the U6 promoter, whereas both promoters functioned equally well in cultured cells. Target gene knockdown perdured for at least 20 weeks in mice after delivery of either PCR or plasmid siRNA expression cassettes. These results will help guide RNAi vector design.

Delivery of siRNA and siRNA expression constructs to adult mammals by hydrodynamic intravascular injection

Extensive use of RNA interference in mammals has been hindered by the inability to effectively deliver small interfering RNAs (siRNAs) or DNA-based constructs designed to express siRNAs. In this chapter, we describe the high-pressure or hydrodynamic intravascular injection technique used to deliver these nucleic acids to mice and nonhuman primates. Emphasis is placed on the use of this technique for delivery to the liver.

A facile nonviral method for delivering genes and siRNAs to skeletal muscle of mammalian limbs

Delivery is increasingly being recognized as the critical hurdle holding back the tremendous promise of nucleic acid-based therapies that include gene therapy and more recently siRNA-based therapeutics. While numerous candidate genes (and siRNA sequences) with therapeutic potential have been identified, their utility has not yet been realized because of inefficient and/or unsafe delivery technologies. We now describe an intravascular, nonviral methodology that enables efficient and repeatable delivery of nucleic acids to muscle cells (myofibers) throughout the limb muscles of mammals. The procedure involves the injection of naked plasmid DNA or siRNA into a distal vein of a limb that is transiently isolated by a tourniquet or blood pressure cuff. Nucleic acid delivery to myofibers is facilitated by its rapid injection in sufficient volume to enable extravasation of the nucleic acid solution into muscle tissue. High levels of transgene expression in skeletal muscle were achieved in both small and large animals with minimal toxicity. Evidence of siRNA delivery to limb muscle was also obtained. The simplicity, effectiveness, and safety of the procedure make this methodology well suited to limb muscle gene therapy applications.

Screening for mild cognitive impairment: comparing the SMMSE and the ABCS

OBJECTIVE

To compare the sensitivity and specificity of the AB Cognitive Screen (ABCS) with the Standardized Mini-Mental State Examination (SMMSE) to differentiate normal cognition from mild cognitive impairment (MCI), especially when educational level and age are taken into account.

METHOD

This cross-sectional study took place at geriatric outpatient memory clinics. Participants were community-dwelling adults, aged 55 years or over, referred from primary care settings (a minority of participants were referred from specialists) for assessment of memory loss and age-matched control subjects with no complaint of memory loss. Each participant had the ABCS and the SMMSE administered in random order on the same day.

RESULTS

Participants included 124 patients diagnosed with MCI and 111 with normal cognitive function. The ABCS showed a statistically significant difference between normal cognition and MCI (ABCS score 111.7 and 104.6 points, respectively, P < 0.001) for the whole group. This difference was significant with the ABCS, regardless of participants' age or education. There was a significant difference between normal cognition and MCI for SMMSE scores (SMMSE score 27.8 and 27.2 points, respectively, P = 0.040), but the differences were not significant when age and education were taken into account. Age and education were shown to affect the scores of both instruments except for the ABCS scores of MCI subjects, which were not significantly affected by education (P = 0.059).

CONCLUSIONS

The ABCS is more sensitive than the SMMSE in differentiating normal cognition from MCI. The ABCS appears to be less influenced by education. It has improved clinical utility with a wider range of scoring gradations, reduced ceiling effects, and shorter scoring and administration times.

A high-level disinfection standard for land applying sewage sludges (biosolids)

Complaints associated with land-applied sewage sludges primarily involve irritation of the skin, mucous membranes, and the respiratory tract accompanied by opportunistic infections. Volatile emissions and organic dusts appear to be the main source of irritation. Occasionally, chronic gastrointestinal problems are reported by affected residents who have private wells. To prevent acute health effects, we recommend that the current system of classifying sludges based on indicator pathogen levels (Class A and Class B) be replaced with a single high-level disinfection standard and that methods used to treat sludges be improved to reduce levels of irritant chemicals, especially endotoxins. A national opinion survey of individuals impacted by or concerned about the safety of land-application practices indicated that most did not consider the practice inherently unsafe but that they lacked confidence in research supported by federal and state agencies.

The beta2-adrenergic receptor specifically sequesters Gs but signals through both Gs and Gi/o in rat sympathetic neurons

Beta(2)-adrenergic receptors (beta(2)-AR) and CB1 cannabinoid receptors share the property of being constitutively active. The CB1 cannabinoid receptor can also sequester G(i/o) proteins; however, it is not known whether the beta(2)-AR can also sequester G proteins. Beta(2)-ARs were heterologously expressed in rat superior cervical ganglion neurons by microinjection of cDNA and studied using the patch-clamp technique. The beta-AR agonist isoproterenol increased the Ca(2+) current 25.9+/-1.6% in neurons microinjected with 100 ng/microl beta(2)-AR cDNA but was without effect on control neurons. Pretreatment with cholera toxin (CTX) abolished the effect of isoproterenol, indicating coupling via G(s) proteins. In neurons microinjected with 200 ng/microl beta(2)-AR cDNA, isoproterenol had the opposite effect of inhibiting the Ca(2+) current 36.5+/-2.0%. Inhibition of the Ca(2+) current was sensitive to pertussis toxin, indicating beta(2)-AR coupling to G(i/o) proteins. Pretreatment with CTX resulted in a greater 54+/-3.8% inhibition of the Ca(2+) current, indicating that G(s) coupling masks the full effect of G(i/o) coupling. Expression of beta(2)-ARs abolished signaling by G(s)-coupled receptors for vasoactive intestinal polypeptide (VIP). VIP inhibited the Ca(2+) current 49.5+/-0.5% in control neurons but had no effect in neurons expressing beta(2)-ARs. In contrast, expression of beta(2)-ARs had no effect on signaling by the G(i/o)-coupled alpha(2)-adrenergic receptor. This study demonstrates that the beta(2)-AR couples to both G(s) and G(i/o) proteins but specifically sequesters G(s) proteins, preventing their interaction with another G(s)-coupled receptor. beta(2)-adrenergic receptors thus have the potential to prevent other G(s)-coupled receptors from transducing their biological signals.

Endosomolysis by masking of a membrane-active agent (EMMA) for cytoplasmic release of macromolecules

Endosomolysis, a critical barrier to efficient delivery of macromolecules such as nucleic acids, has been breached using a novel approach: endosomolysis by masking of a membrane-active agent (EMMA). To demonstrate the concept of EMMA, a cationic membrane-active peptide, melittin, was reversibly inhibited using a maleic anhydride derivative. At neutral pH, the lysines of melittin are covalently acylated with the anhydride, thereby inhibiting melittin's membrane disruption activity. Under acidic conditions such as those present within endosomes, the amide bond of the maleamate is cleaved, thus unmasking melittin. The active melittin can then disrupt the endosomal membrane resulting in release of biologically active molecules into the cytoplasm. This approach avoids cellular toxicity by restricting melittin's activity until it reaches the endosomal compartment. The utility of this approach was demonstrated by delivery phosphorodiamidate morpholino oligonucleotides (PMOs).

Efficient delivery of siRNA for inhibition of gene expression in postnatal mice

It has recently been shown that RNA interference can be induced in cultured mammalian cells by delivery of short interfering RNAs (siRNAs). Here we describe a method for efficient in vivo delivery of siRNAs to organs of postnatal mice and demonstrate effective and specific inhibition of transgene expression in a variety of organs.

Interactions of pathogens and irritant chemicals in land-applied sewage sludges (biosolids)

BACKGROUND

Fertilisation of land with processed sewage sludges, which often contain low levels of pathogens, endotoxins, and trace amounts of industrial and household chemicals, has become common practice in Western Europe, the US, and Canada. Local governments, however, are increasingly restricting or banning the practice in response to residents reporting adverse health effects. These self-reported illnesses have not been studied and methods for assessing exposures of residential communities to contaminants from processed sewage sludges need to be developed.

METHODS

To describe and document adverse effects reported by residents, 48 individuals at ten sites in the US and Canada were questioned about their environmental exposures and symptoms. Information was obtained on five additional cases where an outbreak of staphylococcal infections occurred near a land application site in Robesonia, PA. Medical records were reviewed in cases involving hospitalisation or other medical treatment. Since most complaints were associated with airborne contaminants, an air dispersion model was used as a means for potentially ruling out exposure to sludge as the cause of adverse effects.

RESULTS

Affected residents lived within approximately 1 km of land application sites and generally complained of irritation (e.g., skin rashes and burning of the eyes, throat, and lungs) after exposure to winds blowing from treated fields. A prevalence of Staphylococcus aureus infections of the skin and respiratory tract was found. Approximately 1 in 4 of 54 individuals were infected, including 2 mortalities (septicaemia, pneumonia). This result was consistent with the prevalence of S. aureus infections accompanying diaper rashes in which the organism, which is commonly found in the lower human colon, tends to invade irritated or inflamed tissue.

CONCLUSIONS

When assessing public health risks from applying sewage sludges in residential areas, potential interactions of chemical contaminants with low levels of pathogens should be considered. An increased risk of infection may occur when allergic and non-allergic reactions to endotoxins and other chemical components irritate skin and mucus membranes and thereby compromise normal barriers to infection.