Toxoplasmosis in Kosovo pregnant women.

This study presents the initial results of a collaborative project aimed at the evaluation of Toxoplasma seroprevalence in a population of Kosovar pregnant women. The serum samples of 334 pregnant women were tested to detect IgG, IgM, IgG avidity for toxoplasmosis. Data regarding age, occupation, area of origin and education were also obtained for the pregnant women examined; 97/334 (29.4%) resulted positive for IgG antibodies, four of whom (4.1%) were also positive for IgM, (1.2% of the total population examined). All four IgM-positive pregnant women also demonstrated low avidity tests. The rate of IgG seroprevalence found in our study was lower than that observed in various European countries, especially those of western Europe. Conversely, the percentage of recent infections was higher than expected. The higher rate of infections could be the result of a recent toxoplasmosis epidemic in Kosovo, most likely due to the altered hygienic conditions caused by the forced transfer of the ethnic-Albanian population from an area of low (Serbia) to high (Kosovo) toxoplasmosis prevalence.

Seroprevalence of HIV, HSV-2, and Treponema pallidum in the Kosovarian population.

The objective of this study was to evaluate the seroprevalence of infection with HIV, herpes simplex virus type 2 (HSV-2), and Treponema pallidum (TP) in a Kosovarian population. A cross-sectional study was performed in Peja, Kosovo, from January to March 2005, among 1285 persons recruited at the Peja Hospital. The seroprevalence of HIV, HSV-2, and TP was evaluated, and the viral correlates for each infection were analysed. No HIV-positive cases were found. The seroprevalence of HSV-2 was 20.2%. The factors significantly associated with HSV-2 infection at the multivariate analysis were: female gender (adjusted OR, 1.73; 95% CI 1.24-2.41) and being married (adjusted OR, 1.46; 95% CI 1.06-2.01). Three persons (0.2%) had a positive serology for TP. The only risk factor associated with TP infection was age = 50 y. Our results show a low seroprevalence of HIV infection and TP, and a high seroprevalence of HSV-2 in Kosovo. These findings suggest the need for appropriate surveillance systems, prevention programmes, and information aimed at controlling the spread of HIV and other sexually transmitted infections in this area. Moreover, the circulation of infections acquired through sexual contact may facilitate an increase in the sexually transmitted HIV epidemic in the near future.

Surveillance of toxoplasmosis in pregnant women in Albania.

This study presents the initial results derived from a collaborative project aimed at the surveillance of the toxoplasma infection in a population of 496 Albanian pregnant women. From October 2004 to March 2005, serum samples were tested to detect IgG, IgM and IgG avidity for toxoplasmosis. Of the 496 pregnant women examined, 241 (48.6% [range 44-53]; IC 95%). resulted positive for IgG, three of whom (1.3%) were also positive for IgM. As the preliminary results of our survey disclose the absence of an efficient pre-gravidic screening and counseling for the prevention of toxoplasmosis in Albania, we propose a health education program for all pregnant women, together with serological testing (screening) for those exposed to predictors of toxoplasmosis infection as an epidemiological support and financially sustainable alternative.

Clinical validation of combined serological biomarkers for improved hepatocellular carcinoma diagnosis in 961 patients.

BACKGROUND: Alpha-fetoprotein (AFP), the only serological marker currently available for the detection of hepatocellular carcinoma (HCC), is unsatisfactory because of its poor sensitivity, as are other recently proposed markers. Therefore new biomarkers are badly needed. Squamous cell carcinoma antigen (SCCA), a serine protease inhibitor physiologically present in the skin, has recently been reported to be present in HCC patients, as also the immunocomplexed (IC) forms of SCCA and AFP: SCCAIC and AFPIC, respectively. METHODS: To determine the diagnostic accuracy of new serum biomarkers for the diagnosis of HCC a rapid, simple ELISA test was applied in 961 patients. Sensitivity and specificity were determined for each marker and for all the markers combined in detecting smaller and larger HCC versus liver cirrhosis. RESULTS: In smaller HCC, receiver operating characteristics analysis yielded the following AUC: AFP 0.714 (CI 95% 0.679-0.748), AFPIC 0.691 (CI95% 0.655-0.748), SCCA 0.703 (CI95% 0.667-0.736), SCCAIC 0.694 (CI 95% 0.659-0.728). SCCA was inversely correlated with size. The combined use of AFPIC, SCCA and SCCAIC in patients displaying low levels of AFP (<20 IU/mL) identified 25.6% HCC (186/725). CONCLUSION: This study suggests that the use of a combination of all these markers in clinical practice provides a non invasive and simple test that could increase the accuracy of HCC diagnosis.

Antifibrogenic effect of IFN-alpha2b on hepatic stellate cell activation by human hepatocytes.

Liver fibrosis commonly occurs in patients with hepatitis C virus (HCV) infection as a consequence of the chronic liver damage, thus leading to the development of liver cirrhosis. When hepatic stellate cells (HSCs) become active, they play an essential role in liver fibrogenesis. In this study, interleukin-1beta (IL-1beta) and tumor necrosis factor-alpha (TNF-alpha), commonly elevated in chronic C hepatitis, stimulate the production of matrix metalloprotease-9 (MMP-9) by human hepatocytes at a transcriptional and translational level, but the addition of recombinant interferon-alpha2b (rIFN-alpha2b) hampers this effect. Furthermore, a human HSC line is activated in vitro by incubation with human MMP-9 in the presence of collagen I, and this effect is blocked by the MMP inhibitor BB94. A similar activation was observed when incubating HSCs with conditioned medium of hepatocytes previously stimulated with IL-1beta and TNF-alpha but not when using conditioned medium of hepatocytes costimulated with IL-1beta or TNF-alpha together with rIFN-alpha2b. In conclusion, our results show that hepatocytes stimulated by inflammatory cytokines participate in the activation of HSCs via MMP-9 production and that antiviral therapy modulates such activation.

Clinical role of serum and tissue matrix metalloprotease-9 expression in chronic HCV patients treated with pegylated IFN-alpha2b and ribavirin.

In chronic hepatitis C, the main goal of antiviral therapies is to block viral replication and to slow down the development of fibrosis. In this study, a decrease in matrix metalloprotease-9 (MMP-9) but not of MMP-2 and the tissue inhibitors of MMP (TIMP-1 and TMP-2) was observed in the plasma of chronic hepatitis C patients at the end of the follow-up period after ribavirin plus interferon-alpha2b (PEG-IFN-alpha2b) treatment in sustained virologic responders but not in nonresponders. Consistently, similar results are observed by immunofluorescence and real-time PCR in tissue specimens collected before and after therapy from the same patients in whom both Kupffer cells and hepatocytes express MMP-9. In conclusion, our results show that MMP-9 decreases in responder patients both in the serum and in the liver after therapy. Further studies are needed to investigate this new possible therapeutic activity of PEG-IFN-alpha2b.

MxA and PKR expression in chronic hepatitis C.

The effectiveness of therapy for chronic hepatitis C (CHC) patients has greatly improved in the last few years, and the gold standard is currently held to be pegylated interferon (IFN) in combination with ribavirin. Overall, however, the percentage of patients achieving a sustained virologic response (SVR) is only around 50%,and it is not possible to predict those patients who will benefit from therapy. The molecular mechanisms underlying lack of therapeutic response remain unknown. In this study, we investigated the tissue expression of MxA and RNA-dependent protein kinase (PKR), two antiviral proteins modulated by IFN, in biopsy samples from hepatitis C patients before the beginning of therapy. Our results show that expression of MxA, but not of PKR, is significantly lower in responders compared with nonresponders. No differences were observed regarding the hepatitis C virus (HCV) genotype and the viral load. These results suggest that expression of the MxA protein could play a role among the mechanisms underlying responsiveness to therapy.

Recommendations for the prevention, diagnosis, and treatment of chronic hepatitis B and C in special population groups (migrants, intravenous drug users and prison inmates).

The global spread of hepatitis B virus (HBV) and hepatitis C virus (HCV), their high chronicity rates and their progression to cirrhosis and hepatocellular carcinoma, are major public health problems. Research and intervention programmes for special population groups are needed in order to assess their infection risk and set up suitable prevention and control strategies. Aim of this paper is to give health care professionals information on HBV and HCV infections amongst migrants, drug users and prison inmates. The manuscript is an official Position Paper on behalf of the following Scientific Societies: Italian Association for the Study of the Liver (A.I.S.F.), Italian Society of Infectious and Tropical Diseases (S.I.M.I.T.), Italian Federation Department's Operators and Addiction Services (FederSerD), Italian Prison Medicine and Healthcare Society (S.I.M.S.Pe.). The considered population groups, having a high prevalence HBV and HCV infections, require specific interventions. In this context, the expression "special population" refers to specific vulnerable groups at risk of social exclusion, such as migrants, prison inmates, and intravenous drug users. When dealing with special population groups, social, environmental and clinical factors should be considered when selecting candidates for therapy as indicated by national and international guidelines.

Hepatitis B, C and Delta virus infections in Albanian patients with chronic liver disease: evaluation of possible changes during the last 10 years.

OBJECTIVE AND METHODS: The prevalence of viral hepatitis markers and of alcohol intake was evaluated in 106 and 99 Albanian patients with the diagnosis of viral and/or alcoholic chronic liver disease who were consecutively admitted to the University Hospital Center of Tirana, during 1995 and 2005, respectively. RESULTS: A slight decrease in HBsAg (78 vs. 70%) and HBeAg (18 vs. 12%) prevalences were observed in patients admitted to the hospital during 2005 compared with those admitted during 1995, respectively. In both periods of time, hepatitis B virus (HBV) DNA (genotype D) tested positive in all HBsAg-positive patients and in 36% of HBsAg-negative patients. Anti-hepatitis C virus (HCV) prevalence (mainly observed after 30 years of age) was 14 versus 11%; anti-hepatitis Delta virus (HDV) prevalence (more frequently present in young age group patients) was 9 versus 7% during 1995 and 2005, respectively. Among patients who reported alcohol intake, alcoholic liver disease (HBsAg and anti-HCV negative) was diagnosed in 35 and in 57% of patients admitted during 1995 and 2005, respectively (P = 0.05). CONCLUSION: In Albanian patients with chronic liver disease, we have found that: (i) HBV remained the most important aetiologic factor of chronic liver disease; HDV and HCV prevalences were still low, (ii) in HBsAg-positive patients, HBeAg-negative chronic hepatitis prevailed, (iii) in HBsAg-negative patients, HBV DNA prevalence was high, (iv) during the last decade, an increased prevalence of alcohol intake in the aetiology of chronic liver disease was observed.

Prevalence and risk factors for viral hepatitis in the Kosovarian population: implications for health policy.

The prevalence of hepatitis infection among the Kosovarian population is largely unknown. The aim of the study was to evaluate the prevalence and risk factors of hepatitis A, B, C, and D (HAV, HBV, HCV, HDV) infection among the general population and in a group of health care workers in the Kosovo region. Overall, 1,287 participants were recruited, 460 males (36%) and 827 females (64%). Health care workers accounted for 253 individuals (20%), 301 were blood donor candidates (23%), 334 were pregnant women (26%), and 399 (31%) were subjects who had been examined in two clinics for routine laboratory testing. The prevalence of total anti-HAV was 88.6% (95% CI: 86.69-90.25). Prevalence of anti-HAV among children up to 10 years was 40.5% (95% CI: 29.6-53.15), reaching 70% (95% CI: 62.25-77.10) in the 11-20 age group. Age, living in rural areas and unemployment were factors associated with higher risk of HAV infection. HBsAg was detected in 2.4% (95% CI: 1.57-3.38%) of the study sample, with a significant age trend (P-value:0.0110). Positivity for total anti-HBc was detected in 18.4% (95% CI = 16.27-20.59) of the subjects. Ninety-three subjects (7.2%) were positive for anti-HBs alone. An association between age, HSV-2 positivity, working nurses and HBV infection has been observed. One patient was HDV positive. The prevalence for HCV was 0.5% (95% CI: 0.22-1.12%). HAV infection seems to be high-intermediate, while HBV shows an intermediate endemicity. It is necessary to highlight the importance of an immunization strategy against HAV and HBV in reducing the incidence of the infection. The prevalence for HCV was very low.

Safety, tolerability, and immunogenicity of a two-dose regimen of high-titer varicella vaccine in subjects > or =13 years of age.

A new manufacturing process, known as process upgrade varicella vaccine (PUVV) was developed for a refrigerated formulation of varicella vaccine and for an investigational zoster vaccine. Safety and tolerability of a two-dose regimen of high-titered (approximately 50,000 PFU) PUVV were compared to a lower-titer formulation (approximately 5400 PFU) of VARIVAX; in 1366 healthy subjects > or =13 years old. Only one vaccine-related clinical serious adverse experience (pruritus; no hospitalization) was reported, in the VARIVAX group. Injection-site adverse experiences following any dose were higher in the PUVV group, 70.0%, than in the VARIVAX group, 56.2%, but generally were mild. Immunogenicity were similar in both groups in seronegative subjects. PUVV was generally well tolerated, and elicited an immune response similar to that induced by the marketed formulation of VARIVAX.

Clinical role of tissue and serum levels of SCCA antigen in hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the fifth most frequent cancer in the world and a common occurrence in patients with liver cirrhosis in western and North American countries. Ultrasound screening is a powerful technique for HCC diagnosis, whereas the only available serologic test, alpha-fetoprotein, has poor reliability. It has been reported that the squamous cell carcinoma antigen (SCCA) is overexpressed in HCC tissue. In our study, the expression of SCCA was investigated in tumoral and peritumoral tissues and in the serum of 52 HCC patients, as well as in the serum of 48 cirrhotic patients. The results show that SCCA expression is much stronger in the tumoral than in the peritumoral tissue of HCC. Moreover, it is also evident in metastatic nodules present in the peritumoral tissue. SCCA serum levels were significantly higher in HCC samples than in cirrhotic samples. However, no correlation was found between SCCA expression and the HCC histologic degree, nor did SCCA expression correlate with tumor size, presence of metastasis or clinical outcome. In conclusion, in HCC patients, the SCCA antigen could represent a useful marker for the detection of micro-metastasis in the tissues and for large-scale screening of serum in patients at risk.

SCCA antigen combined with alpha-fetoprotein as serologic markers of HCC.

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world. Because of its increased incidence in the last decade and the estimated further increase in the next 2 decades, HCC is arousing great interest. In Europe and North America, it commonly develops on cirrhotic livers, and surveillance programs have therefore been suggested to identify early HCC, at a stage when it remains suitable for surgical therapy and has a better clinical outcome. The only serologic marker used in clinical practice is alpha-fetoprotein (alpha-FP), but its sensitivity is poor. In our study, 120 patients with HCC and 90 patients with liver cirrhosis were investigated. We report for the first time to our knowledge that as a marker of HCC, the squamous cell carcinoma (SCCA) antigen has high sensitivity (84.2%) but low specificity (48.9%). However, the combination of alpha-FP and SCCA yielded a correct serologic diagnosis in 90.83% of the HCC patients. A small percentage of patients remain undetected, likely because of the low specificity of SCCA. In conclusion, the combined use of alpha-FP and SCCA antigen represents a more powerful tool for the serologic detection of HCC.

Evaluation of the immunogenicity and reactogenicity of a DTPa-HBV-IPV Combination vaccine co-administered with a Hib conjugate vaccine either as a single injection of a hexavalent combination or as two separate injections at 3, 5 and 11 months of age.

A combined DTPa-HBV-IPV/Hib vaccine containing diphtheria (D), tetanus (T), acellular pertussis (Pa), hepatitis B (HBV) and types 1, 2 and 3 inactivated polioviruses (IPV) extemporaneously mixed with a conjugated Haemophilus influenzae type b (Hib) vaccine (Group 1) was compared to the DTPa-HBV-IPV and Hib vaccines (Group 2) administered separately at 3, 5 and 11 months of age (n = 440). A microneutralization assay was used to detect antibodies against the 3 polio virus types (cut-off 1:8 dil), RIA for anti-HBs antibodies (cut-off 10 mIU/ml) and ELISA for antibodies against all other vaccine antigens (cut-off: 0.1 IU/ml for anti-tetanus and anti-diphtheria antibodies; 5 El.U/ml for antibodies against each of the 3 acellular pertussis antigens and 0.15 microg/ml for anti-PRP antibodies). Similar immune responses were observed in both groups 1 month after dose 2 as well as after dose 3. Six months after dose 2 however, the proportion of subjects maintaining an anti-tetanus antibody concentration > or = 0.1 IU/ml was lower in Group 2 and a slight group difference in favour of Group 1 was also observed for anti-PRP, anti-diphtheria and anti-polio type 1 antibody persistence prior to the third dose. The overall incidence of local and general solicited symptoms was similar in both groups. One subject discontinued study vaccination following an SAE considered to be related to vaccination. The DTPa-HBV-IPV/Hib combined vaccine is immunogenic and well tolerated when administered according to a 3, 5 and 11 month vaccination schedule and can therefore be considered as a feasible alternative to the separate administration of the pentavalent DTPa-HBV-IPV and the monovalent Hib vaccines.

Anamnestic response to administration of purified non-adsorbed hepatitis B surface antigen in healthy responders to hepatitis B vaccine with long-term non-protective antibody titres.

A clinical trial with four groups receiving either 0.6, 3.5, 10 or 20 micro g of purified non-adsorbed hepatitis B surface antigen (HBsAg) was performed to study the kinetics as well as the capacity of the immune memory to respond following exposure to HBsAg in responders to a complete course of hepatitis B vaccine, in whom anti-HBs titres had declined below the seroprotective level. The study population included 64 healthy individuals. All response parameters seropositivity, seroprotection rates, booster response rates and geometric mean titres (GMTs), consistently showed that the immune response was highly satisfactory and dose-dependent. A remarkable immune response was obtained even with a trace amount of HBsAg. This study further supports recent indication that booster hepatitis B vaccine doses may be unnecessary in healthy adult responders to a full course of hepatitis B vaccination.