Claire Crossan

Hepatitis E virus in Scottish blood donors

Published prevalence figures for hepatitis E virus (HEV) reveal significant regional differences. Several studies have reported virus transmission via blood transfusion. The aim of this study was to establish HEV seroprevalence and investigate a potential HEV RNA presence in Scottish blood donors.

Hepatitis E Virus Genotype 3 in Shellfish, United Kingdom

To the Editor: Bivalve mollusks (shellfish), such as mussels and oysters, are filter feeders; they concentrate microorganisms of human and animal origin (up to 100×) from the surrounding environment. Several recent reports have linked the incidence of human infection with hepatitis E virus (HEV) to consumption of undercooked pork, game products, and shellfish (1,2). Infectious HEV has been found in swine manure and wastewater (3); therefore, application of manure to land and subsequent runoff could contaminate coastal water, leading to contamination of shellfish and, subsequently, possible human infection. Because they are filter feeders, bivalve mollusks are biologically relevant sentinels and can indicate potential pathogens that are contaminating the environment. It is essential to ensure that this sustainable resource of coastal areas, where mussels and oysters are farmed or collected wild, is not subjected to environmental contamination that could lead to public health risks. Risk management for bivalve mollusks, aimed at control of fecal pollution, relies heavily on the use of Escherichia coli as an indicator of fecal (sewage) contamination and is enacted under European food regulations (Regulation 854/2004, www.cefas.co.uk/media/455777/extract_reg_no_854_2004.pdf). However, although these regulations probably reduce the number of infections, especially bacterial infections, they are not viewed as adequately controlling the risk for viral infections. Specific risks are posed by the robustness of viruses in the environment and the different behavior of viruses within bivalve mollusks compared with behavior within bacterial fecal indicators. HEV is deemed to be inactivated during processing procedures used to prepare mussels for consumption; however, HEV is only 50% inactivated at 56°C and 96% at 60°C for 1 hour, it is stable when exposed to trifluorotrichloroethane, and it is resistant to inactivation by acidic and alkaline conditions (4). Most shellfish are usually eaten raw, but viable virus can also pose a risk to public health in shellfish that are lightly steamed or preserved by smoking and/or in acetic acid. Indeed, a recent study by the Food Standards Agency, in which >800 oyster samples from 39 growing beds in the United Kingdom were collected and screened during 2009–2011, found norovirus at low levels in at least 76% of oysters (5). Other studies identified hepatitis A virus and norovirus in shellfish production areas and in ready-to-eat products in the United Kingdom (1,6). In fact, depuration experiments demonstrated no decrease in titers against hepatitis A virus over a 23-hour cleansing period (7). In addition, acute HEV infection attributed to consumption of shellfish was diagnosed for 33 passengers who recently returned from a cruise (2). However, data have been restricted to questionnaires implicating consumption of shellfish as a source of transmission; no follow-up analyses of the contaminated foodstuff have been conducted. Thus, possible transmission routes for HEV remain poorly studied in the United Kingdom (2). To determine whether HEV is present in mussels collected locally for human consumption, we examined 48 mussels from 5 tidal locations in Scotland. We collected closed mussels from the west coast of Scotland (11 at Lunderston Bay and 28 at Ardrossan) and the east coast of Scotland (9 at Stannergate, Dundee; Ferryden, Montrose; and the Ythan Estuary at Newburgh). The site at Ardrossan was near a slaughterhouse and a meat preparation purification plant that processes pigs. The plant was considered a potential source of contamination, and mussels were collected in a 10-m2 area around an outfall (drain/sewage pipe) directly in line with the processing plant. A total of 36 (92%) of the 39 mussels from the west coast were positive by PCR for HEV, and 5 (55%) of the 9 from the east coast were positive. The mean value of HEV RNA detected in the samples was 4.25 log10 IU/mL (range 3.73–5.2 log10 IU/mL), and the assay was validated by using the current candidate HEV World Health Organization standard (http://whqlibdoc.who.int/hq/2011/WHO_BS_2011.2175_eng.pdf). Phylogenetic analysis showed that most bivalve mollusk sequences clustered with HEV genotype 3 from humans and swine (Figure; Technical Appendix). Also, HEV sequences isolated specifically from a UK human source corresponded with sequences isolated from the bivalve mollusks. The presence of a swine-like HEV genotype 3 in freshwater bivalve mollusks has also been reported in Japan and South Korea (1,9). Figure Phylogenetic analysis of HEV open reading frame 2 sequences isolated from Mytilus spp. RNA was isolated from 50–100 mg of digestive gland or gill. Tissue was homogenized in 300 μL phosphate-buffered saline, and viral RNA was isolated by ... Worldwide, an estimated 40,000 persons die and another 40,000 experience long-term disability as a result of consuming raw or undercooked shellfish (10). This study, demonstrating the presence of HEV in mussels collected locally in Scotland for human consumption, raises concern as to whether these shellfish are a potential source of infection, as reported (2). The association between environmental contamination with HEV and possible transmission by eating shellfish warrants investigation. Technical Appendix: ClustalW alignment of sequences used to generate the phylogenetic tree in the Figure. Click here to view.(218K, pdf)

Long-term IgG response to porcine Neu5Gc-antigens without transmission of PERV in burn patients treated with porcine skin xenografts

Acellular materials of xenogenic origin are used worldwide as xenografts, and phase I trials of viable pig pancreatic islets are currently being performed. However, limited information is available on transmission of porcine endogenous retrovirus (PERV) after xenotransplantation and on the long-term immune response of recipients to xenoantigens. We analyzed the blood of burn patients who had received living pig-skin dressings for up to 8 wk for the presence of PERV as well as for the level and nature of their long term (maximum, 34 y) immune response against pig Ags. Although no evidence of PERV genomic material or anti-PERV Ab response was found, we observed a moderate increase in anti-αGal Abs and a high and sustained anti–non-αGal IgG response in those patients. Abs against the nonhuman sialic acid Neu5Gc constituted the anti–non-αGal response with the recognition pattern on a sialoglycan array differing from that of burn patients treated without pig skin. These data suggest that anti-Neu5Gc Abs represent a barrier for long-term acceptance of porcine xenografts. Because anti-Neu5Gc Abs can promote chronic inflammation, the long-term safety of living and acellular pig tissue implants in recipients warrants further evaluation.

Xenotransplantation of Galactosyl-Transferase Knockout, CD55, CD59, CD39, and Fucosyl-Transferase Transgenic Pig Kidneys Into Baboons

Galactosyl-transferase knockout (GT-KO) pigs represent the latest major progress to reduce immune reactions in xenotransplantation. However, their organs are still subject to rapid humoral rejection involving complement activation requiring the ongoing development of further genetic modifications in the pig. In a pig-to-baboon renal transplantation setting, we have used donor pigs that are not only GT-KO, but also transgenic for human CD55 (hCD55), hCD59, hCD39, and fucosyl-transferase (hHT). We studied kidney xenograft survival, physiological and immunologic parameters, xenogeneic rejection characteristics, as well as viral transmission aspects among two groups of baboons: control animals (n = 2), versus those (n = 4) treated with a cocktail of cyclophosphamide, tacrolimus, mycophenolate mofetil, steroids, and a recombinant human C1 inhibitor. Whereas control animals showed clear acute humoral rejection at around day 4, the treated animals showed moderately improved graft survival with rejection at around 2 weeks posttransplantation. Biopsies showed signs of acute vascular rejection (interstitial hemorrhage, glomerular thrombi, and acute tubular necrosis) as well as immunoglobulin (Ig)M and complement deposition in the glomerular and peritubular capillaries. The low level of preformed non-Gal-α1.3Gal IgM detected prior to transplantation increased at 6 days posttransplantation, whereas induced IgG appeared after day 6. No porcine endogenous retrovirus (PERV) transmission was detected in any transplanted baboon. Thus, surprisingly, organs from the GT-KO, hCD55, hCD59, hCD39, and hHT transgenic donors did not appear to convey significant protection against baboon anti-pig antibodies and complement activation, which obviously continue to be significant factors under a suboptimal immunosuppression regimen. The association, timing, and doses of immunosuppressive drugs remain critical. They will have to be optimized to achieve longer graft survivals.

Hepatitis E virus in patients with decompensated chronic liver disease: a prospective UK/French study

In developed countries, hepatitis E is a porcine zoonosis caused by hepatitis E virus (HEV) genotype 3. In developing countries, hepatitis E is mainly caused by genotype 1, and causes increased mortality in patients with pre‐existing chronic liver disease (CLD).

Review article: hepatitis E—a concise review of virology, epidemiology, clinical presentation and therapy

Hepatitis E virus (HEV) is a leading cause of acute icteric hepatitis and acute liver failure in the developing world. During the last decade, there has been increasing recognition of autochthonous (locally acquired) HEV infection in developed countries. Chronic HEV infection is now recognised, and in transplant recipients this may lead to cirrhosis and organ failure.

Activation of metabotropic glutamate receptor 7 in spinal cord inhibits pain and hyperalgesia in a novel formalin model in sheep.

This study set out to characterize the contribution of group III metabotropic glutamate receptor 7 activation to nociceptive behaviour and mechanical hypersensitivity in a novel formalin test in sheep. The mGlu receptor 7 allosteric agonist, N,N′-dibenzhydrylethane-1,2-diamine dihydrochloride (AMN082; 2–20 mM), the nonselective group III mGlu receptor agonist L-(+)-2-amino-4-phosphonobutyric acid (0.2–20 mM) and drug vehicle were injected intrathecally into naive subjects (n=7 per group), or 5 min preformalin (3%; 0.2 ml)/saline injection (intradermal), into the lower forelimb of adult female sheep (n=5–7 per group). Forelimb withdrawal thresholds to noxious mechanical stimulation and pain behaviours (time spent nonweight bearing or flinching) were assessed for up to 180 min. Formalin induced a characteristic biphasic pain–behaviour response and mechanical hyperalgesia between 1–5 and 30–120 min postinjection. Treatment with AMN082, but not L-(+)-2-amino-4-phosphonobutyric acid significantly inhibited both early and late phase formalin-induced hyperalgesia and pain behaviours. AMN082 also induced a rapid but short lasting analgesia in naive subjects. These data suggest that enhancing endogenous metabotropic glutamate receptor 7 activity in spinal cord, using the novel allosteric modulator, AMN082, blocks pain and hyperalgesia, and may be of therapeutic benefit for the treatment of inflammatory pain.

Hepatitis E seroprevalence in recipients of renal transplants or haemodialysis in southwest England: A case–control study†

Locally acquired HEV infection is increasingly recognized in developed countries. Anti‐HEV IgG seroprevalence has been shown to be high in haemodialysis patients in a number of previous studies, employing assays of uncertain sensitivity. The aim of this study was to investigate anti‐HEV IgG seroprevalence in recipients of haemodialysis and renal transplants compared to a control group using a validated, highly sensitive assay. Eighty‐eight patients with functioning renal transplants and 76 receiving chronic haemodialysis were tested for HEV RNA and anti‐HEV IgG and IgM. Six hundred seventy controls were tested for anti‐HEV IgG. Anti‐HEV IgG was positive in 28/76 (36.8%) of haemodialysis and 16/88 (18.2%) of transplant patients. HEV RNA was not found in any patient. 126/670 (18.8%) of control subjects were anti‐HEV IgG positive. After adjusting for age and sex, there was a significantly higher anti‐HEV IgG seroprevalence amongst haemodialysis patients compared to controls (OR = 1.97, 95% CI = 1.16–3.31, P = 0.01) or transplant recipients (OR = 2.63, 95% CI = 1.18–6.07, P = 0.02). Patients with a functioning transplant showed no difference in anti‐HEV IgG seroprevalence compared to controls. The duration of haemodialysis or receipt of blood products were not significant risk factors for HEV IgG positivity. Patients receiving haemodialysis have a higher seroprevalence of anti‐HEV IgG than both age‐ and sex‐matched controls and a cohort of renal transplant patients. None of the haemodialysis patients had evidence of chronic infection. The reason haemodialysis patients have a high seroprevalence remains uncertain and merits further study. J. Med. Virol. 85:266–271, 2013.

Hepatitis E virus in patients with acute severe liver injury

AIM To examine the incidence of hepatitis E (HepE) in individuals with acute liver injury severe enough to warrant treatment at a transplant unit. METHODS Hepatitis E virus (HEV) is an emerging pathogen in developed countries causing severe illness, particularly in immunocompromised patients or those with underlying chronic liver disease. HepE infection is often under diagnosed, as clinicians can be reluctant to test patients who have not travelled to regions traditionally considered hyperendemic for HepE. There are few data regarding the significance of HEV in patients with very severe acute liver injury in developed countries. Eighty patients with acute severe liver injury attending the Scottish Liver Transplant unit were tested for HEV and anti-HEV IgG and IgM. Severe acute liver injury was defined as a sudden deterioration in liver function confirmed by abnormal liver function tests and coagulopathy or presence of hepatic encephalopathy. Eighty percent of these patients were diagnosed with paracetomol overdose. No patients had a history of chronic or decompensated chronic liver disease at time of sampling. IgG positive samples were quantified against the World Health Organization anti-HEV IgG standard. Samples were screened for HEV viral RNA by quantitative reverse transcription polymerase chain reaction. RESULTS Four cases of hepatitis E were identified. Three of the four cases were only diagnosed on retrospective testing and were initially erroneously ascribed to drug-induced liver injury and decompensated chronic liver disease, with the cause of the decompensation uncertain. One case was caused by HEV genotype 1 in a traveller returning from Asia, the other three were autochthonous and diagnosed on retrospective testing. In two of these cases (where RNA was detected) HEV was found to be genotype 3, the most prevalent genotype in developed countries. Three patients survived, two of whom had been misdiagnosed as having drug induced liver injury. The fourth patient died from sepsis and liver failure precipitated as a result of hepatitis E infection and previously undiagnosed cirrhosis. Histopathology data to date is limited to mainly that seen for endemic HepE. All patients, with the exception of patient 1, demonstrated characteristics of HepE infection, as seen in previously described locally acquired cases. CONCLUSION In patients with acute severe liver injury, HEV testing should be part of the initial diagnostic investigation algorithm irrespective of suspected initial diagnosis, age or travel history.

Suggestions for the diagnosis and elimination of hepatitis E virus in pigs used for xenotransplantation

The hepatitis E virus (HEV) is considered a zoonotic pathogen. In xenotransplantation, given the high prevalence of HEV infection in pigs, the risk of zoonotic transmission from a porcine source is considered high. Currently no clear data are available on how to diagnose and eliminate HEV in herds used for medical purposes and the importance of viral infection at the stage of harvest. In this study, several groups of animals currently used for medical purposes were found RNA positive in both serum and faeces for HEV genotype 3. In addition, viraemia was found in animals up to 3.6 yr of age, which is much longer than originally expected. Herd transmission rates appeared to be significantly lower in animals kept under minimal barrier conditions, compared with those observed for commercial animals, and as expected, segregation of animals at an early age prevented spread of infection. This study makes suggestions to ensure appropriate detection and eradication of HEV from a donor herd to be used for xenotransplantation purposes.