Addressing barriers to the prevention, diagnosis and treatment of hepatitis B and C in the face of persisting fiscal constraints in Europe: report from a high level conference

In the WHO-EURO region, around 28 million people are currently living with chronic viral hepatitis, and 120,000 people die every year because of it. Lack of awareness and understanding combined with the social stigma and discrimination exacerbate barriers related to access to prevention, diagnosis and treatment services for those most in need. In addition, the persisting economic crisis has impacted on public health spending, thus posing challenges on the sustainable investment in promotion, primary and secondary prevention, diagnosis and treatment of viral hepatitis across European countries. The Hepatitis B and C Public Policy Association in cooperation with the Hellenic Center for Disease Prevention and Control together with 10 partner organizations discussed at the Athens High Level Meeting held in June 2014 recent policy developments, persisting and emerging challenges related to the prevention and management of viral hepatitis and the need for a de minimis framework of urgent priorities for action, reflected in a Call to Action (Appendix S1). The discussion confirmed that persisting barriers do not allow the full realisation of the public health potential of diagnosing and preventing hepatitis B and C, treating hepatitis B and curing hepatitis C. Such barriers are related to (a) lack of evidence-based knowledge of hepatitis B and C, (b) limited access to prevention, diagnosis and treatment services with poor patient pathways, (c) declining resources and (d) the presence of social stigma and discrimination. The discussion also confirmed the emerging importance of fiscal constraints on the ability of policymakers to adequately address viral hepatitis challenges, particularly through increasing coverage of newer therapies. In Europe, it is critical that public policy bodies urgently agree on a conceptual framework for addressing the existing and emerging barriers to managing viral hepatitis. Such a framework would ensure all health systems share a common understanding of definitions and indicators and look to integrate their responses to manage policy spillovers in the most cost-effective manner, while forging wide partnerships to sustainably and successfully address viral hepatitis.

On-treatment prediction of sustained response to peginterferon alfa-2a for HBeAg-negative chronic hepatitis B patients

BACKGROUND & AIMS

We assessed predictors of response in HBeAg-negative chronic hepatitis B patients treated with peginterferon alfa-2a in routine clinical practice.

METHODS

Ninety-five HBeAg-negative patients received peginterferonalfa-2a for 48 weeks and were followed-up for 48 weeks post-treatment. Serum HBsAg and HBV DNA levels were monitored during and after therapy with valid commercial assays. Sustained response (SR) was defined as HBV DNA <2000 IU/ml at study week 96.

RESULTS

Twenty-two patients (23%) achieved SR and nine (9.5%) lost HBsAg. HBsAg decline was more profound in patients with SR. HBsAg decline ≥10% from baseline to week 24 was significantly associated with SR [81% (17/21) vs 37% (21/57); Odds ratio: 7.286 (2.162-24.552), P = 0.001]. The PARC rule (no decrease in HBsAg and <2 log drop in HBV DNA at week 12) was evaluated in a subset of 47 patients. Among eight patients who fulfilled the PARC rule, none achieved SR. Of the 39 patients who did not fulfil the PARC rule, 24 (62%) had HBsAg decline of ≥10% at week 24 (12 achieved SR) and 15 (38%) had HBsAg decline of <10% (1 achieved SR; negative predictive value: 93%).

CONCLUSIONS

In HBeAg-negative chronic hepatitis B patients treated with peginterferon alfa-2a, HBsAg decline >10% at 24 weeks is significantly associated with SR. The combination of the PARC rule and week 24 decline in HBsAg can identify almost two-thirds of patients who are unlikely to achieve SR. Clinicaltrials.gov identifier: NCT01283074.

Hepatocellular carcinoma risk in HBeAg-negative chronic hepatitis B patients with or without cirrhosis treated with entecavir: HepNet.Greece cohort

Hepatocellular carcinoma (HCC) may still develop in chronic hepatitis B (CHB) patients treated with lamivudine. Whether HCC rates are comparable in patients treated with the current first-line antivirals remains uncertain. We estimated the incidence and evaluated predictors of HCC in a large nationwide prospective cohort (HepNet.Greece) of HBeAg-negative CHB patients treated with entecavir. HBeAg-negative CHB patients from the same cohort who were initially treated with lamivudine were used as controls. We included 321 patients treated with entecavir for a median of 40 months and 818 patients treated initially with lamivudine for a median of 60 months. In the entecavir group, HCC developed in 4 of 321 (1.2%) patients at a median of 1.5 (range: 1.0-4.5) years, while the cumulative HCC incidence was significantly higher in cirrhotics than noncirrhotics (1, 3, 5 years: 0%, 3%, 9% vs 1%, 1%, 1%; P = 0.024) and in older patients (P = 0.026). Entecavir compared with lamivudine group patients had lower HCC incidence (1, 3, 5 years: 0.3%, 1.2%, 2.8% vs 0.7%, 3.8%, 5.6%; P = 0.024). However, in multivariable Cox regression analysis, the HCC risk was independently associated with older age (P < 0.001), male gender (P = 0.011) and cirrhosis (P = 0.025), but not with the initial agent. In conclusion, our large nationwide study indicates that the HCC risk remains increased in entecavir-treated HBeAg-negative CHB patients with cirrhosis, particularly of older age, at least for the first 5 years. The HCC risk does not seem to be significantly reduced with entecavir compared with antiviral therapy starting with lamivudine.

Genotype 4 HCV infection is difficult to cure with pegylated interferon and ribavirin. Results from a Greek Nationwide Cohort Study

BACKGROUND AND AIM

Patients with genotype 4 (G4) chronic hepatitis C (CHC) are considered a difficult to treat population, although current data on G4 treatment responsiveness and duration are controversial. Greece represents a country with an intermediate prevalence of G4 infections, offering an opportunity to compare treatment outcomes by genotype and to identify potential prognostic factors for sustained virologic response (SVR).

METHODS

All CHC patients from the HepNet.Greece, an ongoing nationwide cohort study on viral hepatitis, with known hepatitis C virus (HCV) genotype who received treatment with Peg-IFNa and ribavirin were analyzed.

RESULTS

From 4443 patients, 951 (61.7% males, 78.4% Greeks, median age 40.6 years, 10% cirrhosis) fulfilled the inclusion criteria. G4 was found in 125 (13.1%) patients. Genotype distribution was not significantly different between Greeks and immigrants. Patients with G4 had similar odds of SVR compared to G1 but significantly lower compared to G2/G3. Age, treatment discontinuation, presence of cirrhosis and previous history of HCV-treatment were associated with lower probabilities of SVR. Ethnicity did not affect SVR for all genotypes while response to treatment was similar between Greek and Egyptian patients groups (35.7% vs 40.9%, p=0.660%) with G4 infection. The relation between SVR and genotype did not substantially change after adjustment for age, gender, cirrhosis, treatment interruption and history of HCV-treatment.

CONCLUSIONS

The findings of this large cohort of CHC patients with a well balanced genotype distribution further supports the idea of considering G4 as a difficult to treat genotype. Further investigation is needed to identify genotype specific prognostic factors.

Virologic response and resistance to lamivudine in patients with chronic hepatitis B: a ten-year retrospective analysis

BACKGROUND

Emergence of resistance was recognized shortly after the introduction of lamivudine. This 10 year retrospective study investigates resistance to lamivudine and the modifications of antiviral strategies required.

PATIENTS AND METHODS

Two hundred and nine patients were treated with lamivudine. Sixty seven out of 209 patients were excluded from the present study. HBVDNA was tested using the PCR assay and genotypic resistance was performed using the direct PCR sequencing.

RESULTS

In the 125 patients initially treated with lamivudine monotherapy: Α) 48 (38.4%) patients with a mean time of 63.6±26.2 months under lamivudine treatment have normal ALT levels with negative (19%) or low (<1X102) HBVDNA levels, 10% developed cirrhosis, 1 HCC and 6% cleared HBsAg. Β) Resistance was developed in 61.60% patients within 45±23.84 months of lamivudine treatment. These patients were: 1) either switched to adefovir (9), entecavir (2) or tenofovir (2) or adefovir was added to lamivudine (21) for a short time and then they were switched to adefovir alone. Six out of 34 patients developed cirrhosis and 4 HCC while on treatment. 2) or adefovir was added-on to lamivudine (43). In 39 out of 43 treatment is ongoing while on virological response. No one developed cirrhosis or HCC. C) Seventeen patients received de novo combination therapy with lamivudine and adefovir and 2 out of 17 (11.7%) showed resistance to adefovir after 24 months of therapy.

CONCLUSIONS

Our results showed that a) approximately 38.4% of patients maintain viral suppression more than 5 years of lamivudine treatment and b) rescue therapy with add-on adefovir to ongoing lamivudine, seems to be a better treatment strategy associated with long term benefit regarding disease complications.

Hepatitis B reactivation in a patient with rheumatoid arthritis with antibodies to hepatitis B surface antigen treated with rituximab

Hepatitis B virus (HBV) can still be found within the hepatocytes after its clearance and the control of viral replication depends on the immune response. However during immunosuppression, seroconversion of HBsAg has been described followed by disease reactivation. Hepatitis B virus reactivation represents an emerging cause of liver disease in patients undergoing treatment with biologic agents and in particular, by the use of rituximab (anti-CD20) and alemtuzumab (anti-CD52) that cause profound and long-lasting immunosuppression. We describe a case of a 64-year old female patient with rheumatoid arthritis and resolved HBV infection, who experienced a severe hepatitis B reactivation after the administration of rituximab.

Virological suppression does not prevent the development of hepatocellular carcinoma in HBeAg-negative chronic hepatitis B patients with cirrhosis receiving oral antiviral(s) starting with lamivudine monotherapy: results of the nationwide HEPNET. Greece cohort study

OBJECTIVE

To evaluate the risk and predictors of hepatocellular carcinoma (HCC) in HBeAg-negative chronic hepatitis B patients of the large HEPNET.Greece cohort study who received long-term oral antivirals starting with lamivudine monotherapy.

DESIGN

Retrospective analysis of HCC incidence in HBeAg-negative chronic hepatitis B patients from a retrospective-prospective cohort who were treated with nucleos(t)ide analogue(s) starting with lamivudine monotherapy for ≥12 months.

SETTING

A nationwide network of liver centres.

PATIENTS

818 patients were included: 517 with chronic hepatitis B only; 160 with compensated cirrhosis; 56 with decompensated cirrhosis; 85 with unclassified disease severity.

INTERVENTIONS

All patients were treated with nucleos(t)ide analogue(s) starting with lamivudine monotherapy.

MAIN OUTCOME MEASURES

Development of HCC.

RESULTS

During a median follow-up of 4.7 years, HCC developed in 49 (6.0%) patients. The 5-year cumulative incidence of HCC was higher in patients with cirrhosis than in those with chronic hepatitis B only (11.5% vs 3.2%, respectively; p<0.001). HCC developed in 0.7%, 6.7% and 11.7% of patients <50, 50-60 and >60 years old, respectively (p<0.001). Virological on-therapy remission did not significantly affect the incidence of HCC in all patients or those with cirrhosis, but it showed a trend for lower HCC incidence in patients with chronic hepatitis B only (p=0.076). In multivariate analysis, age, gender and cirrhosis were independently associated with HCC risk regardless of virological remission.

CONCLUSIONS

Long-term therapy with nucleos(t)ide analogue(s) starting with lamivudine monotherapy does not eliminate HCC risk in HBeAg-negative chronic hepatitis B. The risk of HCC is particularly high in patients with cirrhosis, who should remain under HCC surveillance even during effective therapy. Older age and male gender remain independent risk factors for HCC, while virological on-therapy remission does not seem to significantly reduce the overall incidence of HCC.

Efficacy and safety of entecavir versus adefovir in chronic hepatitis B patients with hepatic decompensation: a randomized, open-label study

A randomized, open-label comparative study of entecavir versus adefovir therapy was performed in subjects with chronic hepatitis B who had hepatic decompensation (Child-Turcotte-Pugh score ≥7). Adult subjects were randomized and treated (n = 191) with entecavir 1.0 mg or adefovir 10 mg daily for up to 96 weeks from the date of last subject randomization. Subjects were positive or negative for hepatitis B e antigen and experienced or naive for treatment with nucleos(t)ide analogues. The primary efficacy endpoint was the mean reduction in serum hepatitis B virus (HBV) DNA, as determined by polymerase chain reaction, at week 24, adjusted for baseline HBV DNA and lamivudine resistance status by linear regression analysis. Entecavir demonstrated superiority to adefovir for this endpoint (treatment difference 1.74 log(10) copies/mL [95% confidence interval -2.30, -1.18]; P < 0.0001). The entecavir group showed a greater change from baseline in HBV DNA at all time points through week 48 and a higher proportion of subjects who achieved HBV DNA < 300 copies/mL at weeks 24 (entecavir 49%; adefovir 16%; P < 0.0001) and 48 (entecavir 57%; adefovir 20%; P < 0.0001). Approximately two-thirds of subjects in both groups showed improvement/stabilization in Child-Turcotte-Pugh status. Model for End-Stage Liver Disease score change at week 48 was -2.6 for entecavir and -1.7 for adefovir. Adverse event rates were comparable between groups. Cumulative hepatocellular carcinoma rates were 12% for entecavir and 20% for adefovir. Cumulative death rates were 23% for entecavir and 33% for adefovir. Week 24 mortality rates were 12% for both groups. conclusion: Entecavir demonstrated superior virologic efficacy to adefovir in a population of patients with chronic hepatitis B who had hepatic decompensation. Biochemical and clinical benefits were also demonstrated. Entecavir was well tolerated, and early mortality rates were consistent with rates observed in similar populations treated with lamivudine.

A randomized trial of peginterferon alpha-2a with or without ribavirin for HBeAg-negative chronic hepatitis B

OBJECTIVES

Hepatitis B e antigen (HBeAg)-negative chronic hepatitis B patients are at high risk of treatment relapse after any antiviral therapy. Combining peginterferon alpha-2a with ribavirin might improve sustained response rates.

METHODS

Overall, 138 HBeAg-negative chronic hepatitis B patients were randomized to receive monotherapy (peginterferon alpha-2a 180 microg weekly plus placebo) or combination therapy (peginterferon alpha-2a weekly plus ribavirin 1,000 or 1,200 mg daily, depending on body weight) for 48 weeks. Post-treatment follow-up lasted 24 weeks. Analyses were based on the modified intention-to-treat population after exclusion of five patients.

RESULTS

At the end of follow-up, 14 (20%) of 69 patients assigned to monotherapy and 10 (16%) of 64 assigned to combination therapy had a combined response (hepatitis B virus (HBV) DNA <10,000 copies/ml (<1,714 IU/ml) and a normal alanine aminotransferase level, P=0.49). At the end of treatment, more patients had a combined response (25 (36%) vs. 26 (41%) in the monotherapy and combination therapy group, respectively, P=0.60), but subsequently relapsed during follow-up. Serum HBV DNA and hepatitis B surface antigen (HBsAg) levels decreased during treatment (mean change at week 48 compared with baseline -3.9 vs. -2.6 log copies/ml, P<0.001 and -0.56 vs. -0.34 log IU/ml, P=0.23, respectively). HBV DNA levels relapsed after treatment discontinuation; HBsAg remained at end-of-treatment levels. In general, combination therapy was well tolerated, although it was associated with a higher risk of anemia and neutropenia.

CONCLUSIONS

Treatment with peginterferon alpha-2a resulted in a limited sustained response rate in HBeAg-negative chronic hepatitis B patients. Addition of ribavirin did not improve response to therapy.

Cytokine mRNA expression in hepatitis C virus infection: TH1 predominance in patients with chronic hepatitis C and TH1-TH2 cytokine profile in subjects with self-limited disease

Many determinants of the immune response have been implied in the pathogenesis of chronic hepatitis C. TH1 and TH2 cytokines play a prominent role in viral infections and a dysregulation of these cytokines could account for viral persistence and evolution of chronic disease. To explore a possible TH1 and TH2 cytokine dysregulation resulting in the inability to terminate hepatitis C virus (HCV) infection, we studied TH1 [interferon (IFN)-gamma, interleukin (IL)-2] and TH2 (IL-4, IL-10) mRNA expression of peripheral blood mononuclear cells (PBMC) in response to NS3 HCV antigen stimulation, in 31 untreated patients with chronic hepatitis C and 29 subjects with self-limited disease. After a 48 h culture of PBMC, total RNA isolation was performed and complementary DNA was prepared by reverse transcription. mRNA levels were quantified by real-time polymerase chain reaction using a standard curve formed after cloning each cytokine gene and a reference gene using recombinant DNA technology in a specific plasmid vector. In the patients group, mRNA expression of IFN-gamma, IL-2 and IL-4 but not IL-10 was detected, IFN-gamma being the predominant cytokine expressed. All four cytokines were expressed in subjects with self limited disease, however levels of IFN-gamma were lower and a significant higher expression of IL-10 compared to patients was found. There was a significant correlation between IFN-gamma mRNA expression levels and stage of fibrosis. Our findings show that in chronic hepatitis C, TH1 cytokines predominate and correlate to liver immunopathology. Furthermore, subjects with self-limited disease, maintain the ability to respond to HCV antigens for a long time after disease resolution.

Adamantiades-Behcet disease (ABD) in northern Greece patients: experience from a single center

OBJECTIVE-METHODS: Adamantiades-Behcet disease (ABD) is a multi-systemic vasculitis of unknown origin, with a characteristic geographic distribution, that affects vessels of all kinds and sizes and is characterized by recurrent mucosal, skin and ocular lesions. In the present study, a series of 36 patients from Northern Greece is analyzed retrospectively in regard to the epidemiological, clinical and immunological parameters.

RESULTS

All patients had recurrent oral ulcerations (36/36, 100%), while 23/36 (63.9%) experienced genital ulcerations and 22/36 (61.1%) developed ocular disease. Skin manifestations were observed in 23/36 patients (63.9%) and pathergy test was found positive in 14/36 patients (38.9%). Other manifestations included central nervous system involvement, recurrent genitourinary inflammations, arthralgias and superficial thrombophlebitis. Laboratory findings were not specific, partly reflecting the severity of inflammation. Ocular disease was more often observed in HLA-B51 (+) patients (20/31, 64.5%) than in HLA-B51 (-) patients. Standard of care (SOC) treatment consisted of cyclosporine A, azathioprine, methylprednisolone and aspirin, whereas refractory disease was treated with intravenous pulses of methylprednisolone and cyclophosphamide. Occasionally, anti-TNF agents (infliximab) were applied to treat refractory ocular disease.

CONCLUSION

The findings of the present study come in agreement with those reported for other Mediterranean series. HLA-B51 seems to predispose to more severe disease, while early therapeutic intervention is beneficial for these patients.

Long term follow-up of a large cohort of inactive HBsAg (+)/ HBeAg (-)/ anti-HBe (+) carriers in Greece

AIM

To investigate the long-term outcome and the risk of progression to chronic hepatitis B in inactive hepatitis B surface antigen carriers.

MATERIAL AND METHODS

A total of 307 HBsAg (+)/HBeAg (-)/antiHBe (+) subjects with initially normal alanine aminotransferase (ALT) levels and undetectable/ low serum HBVDNA with hybridization assay and later with PCR (10(5) copies/ml), were followed-up every 6 months for a period of 3 to 21 years (7.45 +/- 3.75 years).

RESULTS

234 out of the 307 HBsAg (+) patients (76.2%) had persistently normal ALT and undetectable / low (10(5) copies/ml) HBVDNA during follow-up. In 73 patients (23.8%), a reactivation of the disease with elevated ALT and positive HBVDNA (> (10(5)copies/ml) was recorded during the follow up. Thirty-five out of 73 patients underwent liver biopsy, while 22 of them received treatment. Twenty-four patients (7.8%) lost HBsAg after a mean of 7.4 +/- 3.6 years. Regarding the complications of chronic hepatitis B, only one patient developed compensated cirrhosis and no one developed HCC.

CONCLUSIONS

Our results show that in almost 24% of inactive chronic hepatitis B carriers reactivation of the disease may occur even after many years. However the risk of liver-related complications is very low in these subjects.

CD80/CD28 co-stimulation in human brucellosis

Despite treatment, 10-30% of brucellosis patients develop chronic disease, characterized by atypical clinical picture and/or relapses. A defective T helper 1 (Th1) response and a low [corrected] percentage of CD4(+)/CD25(+) cells have been described in chronic brucellosis patients. CD80/CD28 co-stimulation is critical for an efficient Th1 response and has not been studied previously in human brucellosis. In order to investigate the role of CD80/CD28 co-stimulation, 13 acute brucellosis patients (AB), 22 chronic brucellosis patients (CB, 12/22 relapsing type-CB1 and 10/22 atypical type-CB2), 11 'cured' subjects and 15 healthy volunteers (controls) were studied. The percentage of CD4(+)/CD28(+) T lymphocytes and CD14(+)/CD80(+) monocytes were analysed by flow cytometry both ex vivo and after phytohaemagglutinin (PHA)-stimulation with or without heat-killed Brucella abortus (HkBA). Ex vivo analysis showed no differences between all groups studied. PHA stimulation up-regulated the percentage of CD80(+) monocytes in AB compared to 'cured' subjects and controls (P < 0.001), although the proportion of CD4(+)/CD28(+) cells did not alter. A higher percentage of CD80(+) monocytes was observed in the CB1 subgroup, compared to AB, 'cured' subjects and controls (P = 0.042, < 0.001 and < 0.001, respectively). CB2 was characterized by a lower percentage of CD80(+) monocytes in comparison to CB1 (P = 0.020). HkBA in PHA cultures down-regulated the percentage of CD80(+) monocytes compared to PHA alone in all groups, especially in AB and CB patients (P < 0.001 and P = 0.007, respectively). In conclusion, the diminished percentage of CD4(+)/CD25(+) T cells in CB is not associated with inadequate CD80/CD28 co-stimulation. We speculate that differential frequency of CD80(+) monocytes after PHA stimulation could serve as a qualitative parameter of disease status, related to the different clinical forms of chronic brucellosis.

Brucellar spondylodiscitis: noncontiguous multifocal involvement of the cervical, thoracic, and lumbar spine

Brucellosis is a zoonosis of worldwide distribution presenting with a wide clinical spectrum. Brucellosis can involve any organ or system. The axial skeleton is the most common site of involvement with a frequency ranging from 2% to 53%. Multiple-level spinal involvements are rare. This report describes the first case of noncontiguous synchronous multifocal involvement of all cervical, thoracic, and lumbar regions in a patient with brucellar spondylodiscitis.

Diminished percentage of CD4+ T-lymphocytes expressing interleukine-2 receptor alpha in chronic brucellosis

OBJECTIVES AND METHODS

Despite the treatment, a considerable proportion of brucellosis patients develop chronic disease, characterized by atypical clinical picture and/or relapses. Th1 cytokines are critical for the clearance of Brucella infection and diminished production of IL-2 in response to PHA, has been described in chronic brucellosis. In order to investigate the role of IL-2R alpha (CD25) in disease outcome, we evaluated the ex vivo and PHA-induced percentage of peripheral CD4+ T-lymphocytes expressing CD25 in 13 acute brucellosis patients (AB), 22 chronic brucellosis patients (CB), 11 "clinically cured" subjects and 15 healthy volunteers (controls). Simultaneously, CD3+, CD4+ and CD8+ T-lymphocytes subsets were measured.

RESULTS

The ex vivo percentage of CD4+/CD25+ T-cells was significantly higher in AB patients compared to "clinically cured" subjects (p=0.005) and controls (p=0.006). By contrast, CD4+/CD25+ T-cells were significantly lower in CB patients (p=0.001). T-lymphocytes subsets did not significantly differ between the groups. After PHA stimulation, CD4+/CD25+ T-cells remained significantly lower in CB and specifically in the relapsing form of chronic disease compared to AB (p=0.044, 0.023). Additionally, CD8+ T-lymphocytes were found to be significantly increased in CB and mainly in the relapsing subgroup of CB patients compared to AB (p=0.044, 0.011).

CONCLUSION

Diminished percentage of peripheral CD4+ T-lymphocytes expressing IL-2R alpha is associated with chronic relapsing brucellosis.

Prevalence of hepatitis C virus infection in a cohort of pregnant women in northern Greece and transmission of HCV from mother to child

The prevalence of hepatitis C virus (HCV) infection and the mother-to-child transmission of HCV were studied in 2408 pregnant women. Positive antiHCV were detected in 47 women (1.95%), 21 of whom (44.7%) were HCVRNA(+), but only seven had abnormal aminotransferases. Three/21 HCVRNA(+) women had an abortion. We lost contact with other 10 women. Thirty-four babies were tested for antiHCV, HCVRNA and levels of aminotransferases at birth and at the age of 6 and 12 months. AntiHCV were detectable in all babies at birth and these maternally acquired antibodies disappeared by the age of 12 months in all but two of who were infected with HCV. HCVRNA was detected at birth in one (6.25%) baby born out of 16 HCVRNA(+) mothers and this baby also had abnormal aminotransferases. However, HCVRNA was undetectable and aminotransferases returned to normal levels by the age of 6 months. In another baby born also from an HCVRNA(+) mother, the HCVRNA was detected for the first time at the age of 12 months. The HCV genotype from both babies was the same as their mother's. These results show that (a) the high prevalence in the group of pregnant women studied can possibly be attributed to the fact that 311/2408 (12.91%) of them came from the former eastern countries, where disposable syringes were not used but lately or were ex-drug addicts and (b) there is a low risk of perinatal mother-to-child transmission of HCV and this risk is related to the presence of HCVRNA in the carrier mother.

Interferon-alpha 2b treatment of chronic hepatitis C in haemodialysis patients

Nineteen haemodialysis (HD) patients with chronic hepatitis C were treated with interferon-alpha 2b (IFN-alpha) at a dose of 3 or 1 MU thrice weekly for 6 months and were followed-up for another 14 months without treatment. Six patients discontinued treatment because they either presented severe side-effects to IFN-alpha or had complications of their primary disease. Levels of AST and ALT were within normal limits on the 2nd month of treatment and remained so throughout the treatment and the follow-up period in all patients except one who showed an elevation of transaminase levels 2 months after the end of treatment. Serum HCVRNA became negative in 10/13 patients at the end of treatment and was negative in all patients on the 6th month and in 12/13 patients on the 14th month during the follow-up period. Levels of 2'5' oligosynthetase were increased significantly on the 2nd and 4th month of treatment and returned to pretreatment values the 2nd month after treatment. These findings demonstrate that haemodialysis patients with chronic hepatitis C respond well to interferon treatment and that a long-term response is achieved in a high proportion of patients.

Interleukin 2-dependent immunoregulatory function in hemodialysis patients with chronic hepatitis C

To investigate the state of activation of T lymphocytes in hemodialysis patients with chronic hepatitis C, serum levels of soluble interleukin-2 receptors (sIL-2R), interleukin-2 (IL-2) and expression of interleukin-2 receptors (IL-2R) on peripheral T lymphocytes were measured in 30 hemodialysis patients with chronic hepatitis C, 14 hemodialysis patients without hepatitis, 30 patients with chronic hepatitis C and 41 normal subjects. A significant increase in sIL-2R levels was noted in all patients with chronic hepatitis compared to normal controls. This increase was even more significant in hemodialysis patients, while a less significant increase was also found in hemodialysis patients without hepatitis C viral infection. Expression of IL-2R on T lymphocytes was increased only in hemodialysis patients with chronic hepatitis. All patients had low levels of serum IL-2. These findings show that a T-cell activation involving the IL-2 system is present in chronic hepatitis C and that this activation is more prominent in hemodialysis patients, probably due to additional extrahepatic factors.

The effect of interferon on activated peripheral blood T lymphocytes in patients with chronic active hepatitis B

The effect of interferon-alpha 2b treatment on activated T lymphocytes -T cells expressing interleukin-2 receptors-(IL-2R) was studied in 18 patients with chronic active hepatitis B. Blood samples were taken before, on the 2nd, 4th and 6th month of treatment. Patients were divided in 3 groups according to their response to therapy (complete, partial, no response). At the end of treatment, IL-2R+ cells were decreased in the group of patients with complete response, unchanged in patients with partial response and increased in patients with no response. These results confirm the immunomodulatory effect of interferon and reflect the effect of treatment in the management of the disease.

Immunotherapy in chronic brucellosis. Effect of levamisole and interferon; mechanisms of action and clinical value

Thirty two anergic patients with chronic brucellosis treated with a) interferon-alpha 2b(group 1), b) levamisole (group 2) and c) conventional therapy(group 3) were studied. The effect of treatment on T lymphocyte blast formation in the presence of PHA, specific cell mediated immunity against brucella antigens, titers of brucella antibodies and clinical symptoms were evaluated .T lymphocyte blast formation was shown to range in normal levels in all patients before treatment compared to 10 normal controls suggesting against a generalized impairment of cell mediated immunity. Titers of brucella antibodies were significantly decreased in group 1, almost significantly in group 2 and were significantly increased in group 3 at the end of treatment. A significant improvement of symptoms as well as production of leukocyte migration inhibition against brucella antigens were noted in both groups 1 and 2, in contrast to group 3. This response to treatment was however greater in group 1. These findings demonstrate that immunotherapy resulted in both clinical and immunological improvement and that interferon seems to be a more promising therapeutic approach of chronic brucellosis.

The effect of loratadine on activated cells of the nasal mucosa in patients with allergic rhinitis

The effect of loratadine on the numbers of activated cells--cells expressing interleukin-2 receptors(IL-2R), HLA-DR antigens and proliferating cell nuclear antigen (PCNA)--in the nasal mucosa was studied in 48 patients with allergic rhinitis. Patients were treated with either loratadine (10 mg) or placebo for 1 month. At the end of treatment, a significant decrease in the symptom scores was noted in both groups of patients. However, the clinical score was significantly lower in the loratadine group compared to the placebo group. At the end of treatment, the numbers of IL-2R+, HLA-DR+ and PCNA+ cells were significantly decreased only in the group on loratadine. An almost significant correlation was also observed between the numbers of IL-2R+ cells and symptoms in the loratadine group. Our results show that loratadine exerts its beneficial effect possibly by inhibiting both the action of histamine and immune activation.

alpha-Interferon therapy in patients with chronic active hepatitis B: immunological profile

The effect of interferon-alpha 2b (IFN) on viral markers, liver function and immunological parameters (CD3, CD4, CD8, B, NK, II-2 receptor and HLA-DR positive cells in blood and T cell proliferation) was studied in 9 patients with HBsAg(+), HBeAg(-) chronic active hepatitis (CAH). Three patients were HBV-DNA(+) and 6 also had complications of cirrhosis of the liver (LC). IFN was given at a dose of 2.5 mil IU x 3 weekly for 6 months. One patient with LC developed hepatic coma and died 2 months later. Severe leukopenia limited duration of treatment to 2 and 4 months in another 2 patients. By the end of treatment, the 8 patients were in good clinical status, SGOT, SGPT levels and prothrombin time were decreased, HBV-DNA became negative in 2 out of 3 patients and proportions of CD3, CD4, B, NK and activated cells were significantly decreased. When compared to controls, NK and activated cells were significantly increased in patients before and were gradually decreased by the end of treatment. In contrast, T transformed cells were significantly decreased before and ranged in normal levels by the end of treatment. These findings suggest that immunomodulatory activity possibly contributes to the beneficial effect of IFN therapy.

Immunohistological phenotyping of the stomach infiltrating lymphocytes in chronic gastritis

Subsets of lymphocytes infiltrating the gastric mucosa were phenotyped by their surface antigens in biopsies of 30 patients with chronic gastritis (12 with superficial, 9 with atrophic gastritis and 9 with gastric atrophy) and 10 controls. Using direct and indirect immunofluorescent staining, monoclonal antibodies OKT3, OKT4, OKT8, OKB7, antiLeu11b and anti-IL-2 receptor were employed to detect T cell subsets, B cells, NK cells and activated cells. Most of the infiltrating lymphocytes were T cells expressing the CD4 phenotype. B cell proportions were found to increase in relation to the severity of the gastric lesion. IL-2 receptor positive cells were significantly increased in superficial gastritis. These findings indicate an involvement of T cells in the pathogenesis of chronic gastritis. Furthermore, the predominance of CD4 positive cells together with the increase of B cells parallel to the severity of the gastric lesion possibly support the concept of a T-B cooperation leading to tissue damage.

Possible mechanisms underlying peripheral lymphocyte activation in chronic liver disease and asymptomatic HBsAg carriers

Proportions of T lymphocyte subsets (OKT3, OKT4, OKT8) and expression of interleukin-2 (IL-2), transferrin (TFR) receptors and HLA-DR antigens were studied in the peripheral blood of 21 healthy HBsAg carriers, 10 patients with chronic active hepatitis B (CAH), 10 patients with alcoholic liver cirrhosis (ALC) and 10 subjects with negative markers of previous hepatitis B virus (HBV) infection. T lymphocyte subsets ranged within normal levels in CAH and carriers, whereas a significant decrease of OKT4 was noted in ALC possibly involved in the pathogenesis of this disorder. Significantly elevated numbers of activated cells (cells expressing IL-2, TFR receptors and HLA-DR antigens) were observed in all three groups. A significant increase in OKT8 cells within the TFR population was noted in CAH and ALC, whereas proportions of T subsets in the TFR population were normal in carriers. These findings possibly suggest a common pathogenetic mechanism in the activation of lymphocytes in CAH and ALC leading to liver damage and an immune response against HBV in healthy carriers.

Activated lymphocytes in the peripheral blood of asymptomatic HBsAg carriers

Proportions of T lymphocyte subsets and activated cells bearing receptors for transferrin, Il-2 and HLA-DR antigens were studied in 15 asymptomatic HBsAg carriers and 10 subjects with negative markers of hepatitis B virus infection. T lymphocyte subsets ranged within normal values in HBsAg carriers whereas a significant increase in activated cells was noted (P less than 0.001). These data suggest that abberations of T cell subsets are not responsible for the failure of HBV clearance. Furthermore, the increased levels of activated lymphocytes support the view that other factors, possibly in the serum, are modulating the immune response to HBV thus playing an important role in the pathogenesis of the carrier state.

In vitro effect of interferon alpha-2b on T lymphocyte transformation and leukocyte migration inhibition in patients with chronic brucellosis

The in vitro effect of IFN-a on lymphocyte transformation and specific immune response against Brucella antigens was studied in 33 patients with chronic brucellosis and 10 normal controls. The following immunologic in vitro tests were applied: PHA activated lymphocyte transformation test using Bromodeoxyuridine and a monoclonal antibody in the presence and absence of 50 and 100 IU IFN Alpha-2b and leukocyte migration inhibition test against Brucella antigens in the presence and absence of 100 and 500 IU of IFN Alpha-2b. Patients were further divided to 2 subgroups according to a positive or negative migration inhibition test. Our results showed that T lymphocyte transformation was similar in patients and controls and that the addition of 50 IU IFN resulted in a significant increase of transforming cells whereas in the concentration of 100 IU IFN only anergic patients and controls responded positively. IFN also resulted in a significant leukocyte migration inhibition only in anergic patients and controls. These findings suggest that the chronic infection is not due to a generalized cellular immunodeficiency state and that IFN Alpha-2b might be a promising therapeutic approach in anergic patients.

Reevaluation of the effect of levamisole in chronic brucellosis: in vitro and in vivo effect on monocyte phagocytosis

The in vitro effect of levamisole on peripheral blood monocyte (P.B.M.) phagocytosis was studied in 32 patients with chronic brucellosis and 20 normal subjects. It was shown that levamisole enhances P.B.M. phagocytic capacity, not reaching however normal levels. A subgroup of 11 patients were treated with levamisole for 6 months and the drug effect on cellular and humoral immunity and monocyte phagocytosis was also studied. By the end of the 6 month treatment-study period, the following results were obtained: 1. six patients were symptom free while five had significantly improved. 2. T lymphocyte number and monocyte phagocytosis reached normal values. 3. Significant specific cellular immunity against both brucella antigens was noted. 4. B. lymphocytes showed no significant changes. 5. Antiglobulin titers varied. These findings suggest that the good therapeutical effect of levamisole in patients with chronic brucellosis could probably be a attributed to the enhancement of both T-cell function and monocyte phagocytosis.

Lymphocyte subpopulations in gastric disease; effect of histamine and cimetidine on immunoregulatory T cell subsets

The numbers of T lymphocytes, helper and suppressor T lymphocytes, were measured in peripheral blood of 10 patients, 13 patients with gastric cancer and 20 normal controls. T lymphocyte subpopulations were enumerated by the use of monoclonal antibodies OKT3 (pan-T lymphocytes), OKT4 (helper/inducer lymphocytes) and OKT8 (cytotoxic/suppressor lymphocytes) in an indirect immunofluorescence technique. Furthermore, the possible pharmacological modulation of 10(-4) histamine and 10(-4), 10(-6) M cimetidine of T lymphocyte subsets was investigated. Lymphocyte subpopulations were found to range in normal values in patients with ulcer and chronic gastritis. A marked decrease of OKT3 and OKT8 positive lymphocytes was noted in patients with gastric cancer, whereas OKT4 lymphocytes from the three groups of patients to histamine and cimetidine resulted in no significant changes of lymphocyte subsets.

A study of cell-mediated immunity to gastric antigens in patients with atrophic type A and B gastritis

The leucocyte migration in the presence of gastric antigens was studied in 10 patients with type A gastritis, 38 patients with type B gastritis (28 with atrophic and 10 with superficial gastritis) and 10 healthy controls. A positive leucocyte migration was found in a significant proportion of patients with both types of gastritis, whereas no difference between the two types was observed. These results indicate that cellular immunity is implicated in the aetiology of both types of gastritis, is of greater importance than auto-antibody production and is associated with the severity of the atrophic lesion.

Peripheral blood monocyte phagocytosis in patients with chronic brucellosis

Peripheral blood monocyte phagocytosis of SRBC was studied in 32 patients with chronic brucellosis and 20 normal controls. It was found that phagocytosis was significantly decreased in patients with chronic brucellosis. Our findings suggest that disfunction of this cell-system in chronic brucellosis could be responsible for the chronicity of the disease.

Levamisole in the treatment of chronic brucellosis

Ten patients with chronic brucellosis were treated with levamisole, 150mg daily for 3 consecutive days every week for 6 months. Patients were followed up for another 6 months after the end of treatment. By the end of the treatment period, patients improved clinically, their E rosettes showed a significant increase and specific leukocyte inhibition migration factor (LIF) was produced. By the end of the follow up period, all patients except one became symptom free, antiglobulin titers were very low or negative, E rosettes showed a further increase ranging to normal levels and specific LIF activity was not detected to most of the patients. Our results suggest that levamisole might prove to be beneficial in the treatment of chronic brucellosis.

Antimicrobial proteins in sterilised human milk

Human milk contains factors such as IgA and lactoferrin that increase the newborn infant's resistance to infection. Preterm infants are fed pooled milk, which is normally sterilised by heating. After standard heat sterilisation IgA and lactoferrin were undetectable in milk samples. Pasteurisation also sterilised milk samples even after heavy artificial contamination and did not damage the proteins. Gamma-irradiation sterilised equally effectively but caused some denaturation of IgA and lactoferrin. Since most of the milk samples were sterile or had only light contamination with skin bacteria, there seems to be no need for routine sterilisation. If sterilisation is necessary, the method used should be chosen to minimise damage to milk proteins.