Human herpesvirus 8 (HHV8) transmission and related morbidity in organ recipients.

The aims of the study were to assess the risk of HHV8 transmission resulting from organ transplantation, and related morbidity in liver, heart and kidney transplant recipients. Donor and recipient serologies were screened between January 1, 2004 and January 1, 2005 using HHV8 indirect immunofluorescence latent assay (latent IFA) and indirect immunofluorescent lytic assay (lytic IFA). Recipients negative for latent IFA with a donor positive for at least one test were sequentially monitored for HHV8 viremia and underwent serological tests over a period of 2 years. The results showed that among 2354 donors, HHV8 seroprevalence was 9.9% (lytic IFA) and 4.4% (latent IFA). A total of 454 organ recipients (281 renal, 116 liver and 57 heart) were monitored over a 2-year period. Seroconversion was observed in 12 patients (cumulative incidence 28%) whose donor had positive latent IFA and in 36 patients (cumulative incidence 29%) whose donors were positive only for lytic IFA, without differences across types of transplants. Positive HHV8 viremia was detected in only 4 out of 89 liver transplant recipients during follow-up and not in recipients of other types of transplant. Two liver transplant recipients and one kidney transplant recipient developed KS. In conclusion, although HHV8 transmission is a frequent event after organ transplantation, HHV8-related morbidity is rather rare but can be life threatening. Donor screening is advisable for monitoring HHV8 seronegative liver transplant recipients.

Multicentric evaluation of new commercial enzyme immunoassays for the detection of immunoglobulin M and total antibodies against hepatitis A virus.

A multicentric clinical study was conducted on representative sera from 1,738 European and U.S. subjects for the evaluation of new anti-hepatitis A virus enzyme immunoassays from Bio-Rad Laboratories. Comparison with reference DiaSorin S.p.A. tests confirmed the good performance of Bio-Rad assays (99.85% and 99.47% overall agreement in detecting total antibodies and IgM, respectively).

[Genetic diversity of a rare hepatitis A virus genotype]. / Diversité génétique d'un génotype rare du virus de l'hépatite A.

PURPOSE OF THE STUDY: Very few is known on genotype II hepatitis A virus (HAV) since it is rarely isolated. From 2002 to 2007, the French observatory of HAV identified six sub-genotype IIA strains of which one from a patient having travelled to West Africa. To investigate the possible African origin of sub-genotype IIA, we determined its prevalence among French travellers in 2008 and characterised its genetic variability. PATIENTS AND METHODS: The 2008 mandatory notification records were screened for travel to Africa. Viral genotype was determined on the nucleotide sequencing of the VP1/2A junction region. The P1 region coding for capsid proteins was used to compare the genetic diversity of IIA isolates to those of other genotypes. RESULTS: In 2008, five out of 54 patients returning from West Africa were infected by IIA strains and an additional "autochthonous" case was identified. Two more African cases were identified in 2009. A total of 14 IIA isolates (eight African and six "autochthonous") were analysed. Nucleotide and amino-acid variability of IIA sequences was lower than that of the other genotypes. Phylogenetic analysis revealed the clustering of two "autochthonous" cases with African isolates whereas the other ones belonged to a different lineage. CONCLUSION: Most IIA strains isolated in France are imported by travellers returning from West Africa. However, the unexplained contamination mode of some "autochthonous" cases suggests another geographical origin to discover or a French reservoir to explore.

Extended measures for controlling an outbreak of VIM-1 producing imipenem-resistant Klebsiella pneumoniae in a liver transplant centre in France, 2003-2004.

We report the successful control of an outbreak caused by imipenem-resistant VIM-1-producing Klebsiella pneumoniae (IR-Kp) in France. This outbreak occurred in a care centre for abdominal surgery that includes a 15-bed liver intensive care unit and performs more than 130 liver transplantations per year. The index case was a patient with acute liver failure transferred from a hospital in Greece for urgent liver transplantation who was carrying IR-Kp at admission as revealed by routine culture of a rectal swab. Infection control measures were undertaken and included contact isolation and promotion of hand hygiene with alcohol-based hand rub solution. Nevertheless, secondary IR-Kp cases were identified during the six following months from 3 December 2003 to 2 June 2004. From 2 June to 21 October, extended infection control measures were set up, such as cohorting IR-Kp carriers, contact patients and new patients in distinct sections with dedicated staff, limiting ward admission, and strict control of patient transfer. They led to a rapid control of the outbreak. The global attack rate of the IR-Kp outbreak was 2.5%, 13% in liver transplant patients and 0.4% in the other patients in the care centre (p<0.005). Systematic screening for IR-Kp of all patients admitted to the care centre is still maintained to date and no secondary IR-Kp case has been detected since 2 June 2004.

[Hepatitis C virus genotyping: comparison of the Abbott RealTime HCV Genotype II assay and NS5B sequencing]. / Génotypage du virus de l'hépatite C : comparaison du test Abbott RealTime HCV Genotype II au séquençage de la région NS5B.

PURPOSE OF THE STUDY: Hepatitis C virus genotyping is needed for treatment decision and monitoring. The results of a genotyping assay based on real-time PCR and TaqMan chemistry were compared with the results of NS5B region sequencing. MATERIALS AND METHODS: One hundred and two sera (genotypes 1-6) were tested. Amplification and detection of viral RNA were performed with the Abbott RealTime HCV Genotype II assay targeting 5'non-coded region (5'NC) for the identification of genotypes 1 to 6 and NS5B, for 1a and 1b subtypes detection. Sequencing of 5'NC fragment was used to resolve discrepant results. RESULTS: No indeterminate results were obtained. Concordance with NS5B sequencing was 93% (95 on 102), 96% at the genotype level (98 on 102) and 93% for genotype 1 subtyping (40 on 43). Discordant genotyping results were a 2f subtype identified as 5, a 6a typed as 1, a 3a identified as a 1-3 co-infection and a 4r identified as a 1-4 co-infection. Discordant subtyping results were 2 1b subtypes only typed as 1 and a 1e identified as 1a. CONCLUSION: Abbott RealTime HCV Genotype II assay is a rapid, automated and simple to interpret method for HCV genotyping. It allows the detection of possible mixed infections which might have a negative impact on therapeutic response. However, the discrepant results found in this small series underline the need for assay optimization.

The impact of preexisting or acquired Kaposi sarcoma herpesvirus infection in kidney transplant recipients on morbidity and survival.

The impact of preexisting or acquired Kaposi sarcoma herpesvirus (KSHV) infection in kidney transplant recipients was evaluated in a prospective study. Serum collected from kidney donors and recipients before transplantation were tested for antibodies against KSHV latent nuclear antigen. Three groups of recipients were defined: group A (KSHV+), group B (KSHV-, KSHV+ donor) and group C (donor and recipient KSHV-). Blood was collected from recipients, every 3 months for 3 years, for KSHV viremia (groups A and B), quantitative (group A) and qualitative serology (group B). Data of group C recipients were extracted from a French database. The prevalence of KSHV antibodies was 1.1% in donors and 3.2% in recipients. There were respectively 161, 64 and 4744 recipients in groups A, B and C. In group A, 13% developed Kaposi's sarcoma (KS). Age >53.5 years (p = 0.025) and black skin (p = 0.0054) were associated with KS development. In group B, three recipients developed clinical manifestations related to KSHV infection. There was no difference in terms of survival and graft loss between the three groups. In conclusion, although kidney recipients should be aware of the additional risk of KSHV morbidity, KSHV+ recipients should not be systematically excluded from kidney transplantation.

An oyster-associated hepatitis A outbreak in France in 2007.

Following the notification of nine hepatitis A cases clustered in the Cotes d Armor district in northwestern France, epidemiological, environmental and microbiological investigations were set up in order to identify the source and vehicle of contamination and implement control measures. In total, 111 cases were identified in the outbreak, all of whom lived or had stayed as tourists in the Cotes d Armor district. Of the cases, 87% had eaten raw shellfish, and 81% specifically oysters. Traceback investigations carried out on raw shellfish consumed by the cases showed that the raw shellfish originated from a single shellfish farm. The shellfish were probably contaminated either in the submersible tanks or in a depuration land-based tank where they were stored. The source of contamination was not identified but shellfish could have been tainted by sewage overflows or by wastewater releases from a polluted storm sewer close to the shellfish farm or from on-site sanitation facilities. To prevent future hepatitis A outbreaks due to shellfish consumption from this area, hazards specific to each farm should be analysed. Timely information on sewage overflows should also be part of communities efforts regarding sewage collection and treatment.

Cluster of cases of hepatitis A with a travel history to Egypt, September-November 2008, France.

Since September 2008, 26 cases of hepatitis A with a history of travel to Egypt have been reported in France. Investigations indicate that a common source of contamination linked to Nile river cruises is the most likely explanation of the increase in the number of cases reported in France as well as in several other European Union countries.

[Laboratory based hepatitis A surveillance in New Caledonia: from an endemic to an epidemic pattern (1986-2007)]. / Surveillance biologique de l'hépatite A en Nouvelle-Calédonie: de l'endémie à l'épidémie (1986-2007).

UNLABELLED: This study aimed at describing the evolution of the epidemiological pattern of hepatitis A in New Caledonia since 1986 and the recent epidemic which occurred in 2005-2006, regarding particularly its demographic and virological aspects and the public health response implemented. The annual or monthly activity records for Hepatitis A sero-diagnostic performed at the Pasteur Institute of New Caledonia were processed in a retrospective analysis (9723 samples tested for the detection of IgM to hepatitis A). Over the 2004-2006 period, a phylogenetic study of representative strains from New Caledonia and other Pacific islands was carried out by the French National Reference Laboratory for hepatitis A (Paul-Brousse hospital, Villejuif, France). RESULTS: The continuous improvement of hygiene that occurred in New Caledonia during the last two decades led to a dramatic drop in the frequency of hepatitis A among patients tested, ranging from an average value of 79 cases (14%) for the 1986-1999 period to 0 case from 2002. However, in 2005, a strong increasing number of confirmed cases was notified, mainly among young people (78% were under the age of 20). In 2006, this epidemic reached the island of Futuna where it involved more than 1% of the total population (56 cases). The phylogenetic study has confirmed the clonality of the virus circulating during this epidemic, not related to other regional strains (Fiji, Vanuatu, New Zealand) nor with a New Caledonian strain from the previous endemic period. This transition situation, with persistence of a high epidemic risk, should encourage the health authorities to implement adapted response strategies, based in particular on systematic case declaration and targeted immunisation programmes.

A food-borne outbreak of hepatitis A virus (HAV) infection in a secondary school in Upper Normandy, France, in November 2006.

In November 2006, six symptomatic cases of hepatitis A in pupils of a secondary school in Upper Normandy, France, were reported to the district health service. This paper describes the outbreak investigation undertaken with the aim to identify the vehicle and source of infection, implement control measures and estimate the size of the outbreak. A primary case at the secondary school was defined as a pupil or a member of the staff with IgM anti-HAV detected in the serum and with onset of symptoms between 12 and 21 November 2006; a secondary case was defined as a contact to a primary case and who developed symptoms and had IgM anti-HAV two to seven weeks later. We performed a case control study of primary cases, controls being pupils visiting the same school (cases/controls 1:4) and inspected the canteen facilities. All 13 canteen employees were examined for anti-HAV IgM antibodies. A phylogenetic analysis of HAV of cases was performed. We identified 10 primary and 5 secondary cases. Among primary cases 90% reported eating liver pate at the canteen compared to 62% among controls (OR 5.5, 95% CI 0.62-256.9). One liver pate sample contained markers of faecal contamination. HAV genotypes were of one identical type. All 13 canteen employees were negative for IgM anti-HAV while four had anti-HAV total antibodies. We found deficiencies regarding food preparing procedures and insufficient hand washing facilities. The vehicle of the outbreak was believed to be the liver pate but the source of HAV could not be identified. Insufficient facilities in the canteen hindered staff from maintaining a high hygiene standard and were subsequently improved.

KSHV after an organ transplant: should we screen?

The incidence of Kaposi sarcoma (KS) related to Kaposi sarcoma-associated herpesvirus (KSHV/HHV-8) after organ transplantation is 500-1000 times greater than in the general population, and its occurrence is associated with immunosuppressive therapy. The reported incidence of posttransplant KS ranges from 0.5% to 5%, depending on the patient's country of origin and the type of organ received, mainly after renal transplantation. Posttransplant KS is caused by two possible mechanisms: KSHV reactivation in patients who were infected before the graft and KSHV contamination from the infected organ's donor to the recipient. KSHV reactivation appears to play a greater role in the risk of KS than incident infections. However, some studies, with findings based not only on serological data but also on molecular tracing of the viral infection, have shown that organ-related transmission of KSHV could be more common than previously thought and associated in some cases with severe KSHV-related disease. Precise estimates of KSHV seroprevalence in the organ donor and recipient populations in different countries are lacking. However, studies have reported seroprevalences among donors and recipients that are similar to those among the general population of the country considered. Many studies have suggested the potential utility of screening of KSHV antibodies among organ donors and recipients. However, to date the results of these studies have argued in favor of KSHV screening, even in low-KSHV infection prevalence countries, not to exclude the graft but to have the KSHV status information in order to have the opportunity to monitor, clinically and biologically, patients at risk for KSHV-related disease development. The detection of KSHV antibodies could be done in the days after the transplantation and the results transmitted to the physicians retrospectively. In conclusion, the question of screening donors and recipients for KSHV, even in low-KSHV infection prevalence countries, is still debated, and prospective studies are needed to evaluate the benefit of pre- and posttransplantation strategies.

[Hepatitis A virus epidemiology in 2007]. / Épidémiologie de l'hépatite A : qu'en est-il en 2007 ?

Improvements in hygienic and sanitary conditions, especially in developing countries, have lead to a progressive shift in the epidemiologic pattern of hepatitis A. This infection, most commonly transmitted via feco-oral route, is now observed in adult patients reflecting the reduced circulation of the hepatitis A virus in many countries. Paradoxically, the risk of more severe disease forms and outbreaks is increased. Vaccination against hepatitis A appears as an effective way to reduce hepatitis A incidence, HAV could be eradicated if routine vaccination of children is implemented in all countries. However, this vaccination is not presently recommended for areas with high overall and age-specific incidence.

[Rapid seroreversion following spontaneous recovery of acute hepatitis C in an HIV infected patient]. / Séroréversion rapide après résolution spontanée de l'hépatite C aiguë chez un patient VIH positif.

We present a case of acute hepatitis C in an HIV infected patient. According to the findings of third-generation serological assays, 18 months after spontaneous recovery, anti-HCV specific antibodies were completely disappeared, leaving no trace of HCV infection.

[HBs antigen mutants: prevalence, clinical and diagnostic implications]. / Les mutants de l'antigène HBs: prévalence, impact diagnostique et clinique.

The serological diagnosis hepatitis B (HBV) infections relies mainly on the detection of the small surface antigen (HBsAg). Immuno-enzymatic assays use antibodies directed against epitopes of the major hydrophilic region, in particular against a determinant. Genetic variants have been detected in vaccinated children, liver transplanted patients receiving anti-HBs immunoprophylaxis and chronic carriers with an occult infection (negative HBsAg). Substitutions in this region can induce conformational changes abolishing some diagnostic antibodies binding leading to false negative results. To estimate the prevalence of such substitutions, we studied 55 sequences of the gene S obtained between 2002 and 2004, carried out mainly in the search of changes of resistance to the lamivudine. The polymorphism of the major hydrophilic region (positions 102 to 169) was studied using Mutation Master software. Each sequence was compared with a consensus sequence of the same genotype. Genotype distribution is as follows: D, 40%; With, 20%; C, 16%; B, 11%; E, 9%; F, 2% and G, 2%. Changes I195 M and W196L, reflecting lamivudine resistance are present among 18 patients (33%). Substitutions of the major absorbent area are found among 31 patients (56%), of which a third associated with resistance mutations. The most frequent substitutions involved the following amino-acids: F/Y134 (7/31), M133 (6/31), D144 (6/31) and G145 (6/31). These two latter are known to be associated anti-HBs immunoglobulins or vaccine escape. BLOSUM scores are indicative of substitutions inducing important changes of physicochemical properties in 16 patients (29%). Such substitutions could thus potentially alter the binding of antibodies used in diagnostic assays. In conclusion, changes of the major hydrophilic loop of HBs antigen are not rare and could have an important implications for transfusion safety and diagnostic reliability.

[Hepatitis delta virus RNA detection by one-step RT-PCR]. / Détection de l'ARN du virus de l'hépatite delta par une RT-PCR rapide en une étape.

We have developed a method of detection HDV RNA where the reverse transcription and amplification are carried out in the same tube, thus reducing the handling time and the contamination risk. RNA extracted from serum or plasma on a microcolumn technique (kit QIAamp viral RNA, QIAgen) is submitted to reverse transcription and amplification by using the One-Step RT-PCR kit (QIAgen). Primers and probe were placed in the conserved ribozymic regions of the HDV genome. The sensitivity of the technique was estimated to 420 copies per reaction by using serial dilutions of a tittered sample. Its specificity was shown by the negativity of 24 samples from anti-HDV negative subjects, either healthy or coinfected by HBV, HCV or HGV. A low tittered sample was reproductively detected in different series. This One-step RT-PCR technique is specific, reproducible and allows the fast detection of active HDV RNA replication. Its adaptation to the routine diagnosis in a laboratory of medical virology is possible and will allow its evaluation on a greater number samples.

[Liver transplantation: is it possible in HIV/HCV co-infected patients?]. / La transplantation hépatique est-elle possible chez les patients co-infectés par le VIH et le VHC?

The prognosis of HIV infection has been modified by antiretroviral therapy. However, the morbidity and the mortality of HCV co-infection increase and may be a major problem of health service. Up to now co-infected patients are excluded of transplantation due to complexity, the ethical aspects, the immunodeficiency and the co-infection. This study tries to estimate the feasibility in this population. Between December 1999 and March 2002, seven patients were transplanted. The average of CD4 was 332/ml; the viral load was <50 copies/ml. Before transplantation, no patient had experienced opportunist infection and all patients received antiretroviral therapy adapted to their history. The average follow-up is of 14 months: one patient died 3 months after transplantation, the other one presented a candida in oesophagus, the average of CD4 was 280/ml, and viral load was <50 copies/ml in five patients. A relapse of HVC was observed in all patients. Interferon/rivabirine therapy was proposed for four patients. Every patient received tacrolimus and corticoids. HAART were modified four times for toxicity and one time for virological failure. We observed two cases of transient renal insufficiency, two cases of diabetes, two cases of pancreatitis, and abnormalities of the respiratory mitochondrial chain in four patients. Finally, liver transplantation in HIV-HCV co-infected patients seems to be feasible when strict criteria of selection are taken into account. This still experimental strategy requires a multidisciplinary partnership.

Performance of TRUGENE hepatitis C virus 5' noncoding genotyping kit, a new CLIP sequencing-based assay for hepatitis C virus genotype determination.

The performance of the recently developed, standardized direct sequencing assay for hepatitis C virus (HCV) genotyping [TRUGENE HCV 5'-NC (noncoding)] was assessed in comparison with the reverse hybridization-based assay INNO-LIPA HCV II. Both assays allow HCV genotyping starting from amplification products generated by the diagnostic Roche AMPLICOR HCV test. HCV amplicons from 205 patients were used for this study: 34 were tested prospectively by both methods, while 171 had been stored at -20 degrees C for up to 2 years after LiPA genotyping. The TRUGENE procedure failed to determine a genotype in six low-titered samples (3.5 +/- 0.3 log UI/mL vs. 5.2 +/- 0.5 UI/mL for typable samples). Type and subtype could be determined by sequencing for 199 samples (97%). Among them, five were considered as coinfections by the LiPA method. Three LiPA patterns suggesting type 1 and 4 coinfection were not supported by sequence analysis while one 1a/2b and one 1a/3a coinfection was backed up by direct sequencing. For the remaining 194 samples, type assignment was concordant in 100% of the cases. LiPA subtyping was available for 162 samples (83.5%). Sub-typing results concurred in 128 cases (79%). NS5B sequencing of discrepant samples underscored the limitation of the 5'-noncoding region (NCR) in correct subtype assignment. In conclusion, the TRUGENE HCV 5'-NC genotyping kit appeared to be a specific and reliable method that can be used in the current indication of HCV genotyping.

Antibodies to hepatitis B surface antigen prevent viral reactivation in recipients of liver grafts from anti-HBC positive donors.

BACKGROUND AND AIMS: Liver donors with serological evidence of resolved hepatitis B virus (HBV) infection (HBV surface antigen (HBsAg) negative, anti-HBV core (HBc) positive) can transmit HBV infection to recipients. In the context of organ shortage, we investigated the efficacy of hepatitis B immunoglobulin (HBIG) to prevent HBV infection, and assessed the infectious risk by polymerase chain reaction (PCR) testing for HBV DNA on serum and liver tissue of anti-HBc positive donors. PATIENTS: Between 1997 and 2000, 22 of 315 patients were transplanted with liver allografts from anti-HBc positive donors. Long term HBIG therapy was administered to 16 recipients. Four naive and two vaccinated patients received no prophylaxis. RESULTS: Hepatitis B developed in the four HBV naive recipients without prophylaxis and in none of the vaccinated subjects. Among the 16 recipients receiving HBIG, one patient with residual anti-HBs titres below 50 UI/ml became HBsAg positive. The remaining 15 remained HBsAg negative and HBV DNA negative by PCR testing throughout a 20 month (range 4-39) follow up period. HBV DNA was detected by PCR in 1/22 donor serum, and in 11/21 liver grafts with normal histology. A mean of 12 months post-transplantation (range 1-23) HBV DNA was no longer detectable in graft biopsies from patients remaining HBsAg negative. CONCLUSION: Anti-HBs antibodies may control HBV replication in liver grafts from anti-HBc positive donors, without additional antiviral drugs. These grafts are thus suitable either to effectively vaccinated recipients or to those who are given HBIG to prevent HBV recurrence.

Genetic clustering of hepatitis C virus strains and severity of recurrent hepatitis after liver transplantation.

The influence of viral factors on the severity of hepatitis C virus (HCV)-related liver disease is controversial. We studied 68 liver transplant patients with recurrent hepatitis C, of whom 53 were infected by genotype 1 strains. Relationships between core sequences, serum HCV RNA levels, and fibrosis scores for each patient were analyzed in pairwise fashion 5 years after transplantation. We used Mantel's test, a matrix correlation method, to evaluate the correspondence between measured genetic distances and observed phenotypic differences. No clear relationship was found when all 68 patients were analyzed. In contrast, when the 53 patients infected by genotype 1 strains were analyzed, a strong positive relationship was found between genetic distance and differences in 5-year fibrosis scores (P = 0.001) and differences in virus load (P = 0.009). In other words, the smaller the genetic distance between two patients' viral core sequences, the smaller the difference between the two patients' fibrosis scores and viral replication levels. No relationship was found between genetic distance and differences in age, sex, or immunosuppression. In multivariate analysis, the degree of fibrosis was negatively related to the virus load (r = -0.68; P = 0.003). In the particular setting of liver transplantation, and among strains with closely related phylogenetic backgrounds (genotype 1), this study points to a correlation between the HCV genetic sequence and the variability of disease expression.