New data from the Italian National Register of Congenital Coagulopathies, 2016 Annual Survey.

BACKGROUND: In Italy, the National Register of Congenital Coagulopathies (NRCC) collects epidemiological and therapeutic data from patients affected by haemophilia A (HA), haemophilia B (HB), von Willebrand's disease (vWD) and other rare coagulation disorders. Here we present data from the 2016 annual survey. MATERIALS AND METHODS: Data are provided by the Italian Haemophilia Centres, on a voluntary basis. Information flows from every Centre to a web-based platform of the Italian Association of Haemophilia Centres, shared with the Italian National Institute of Health, in accordance with current privacy laws. Patients are classified by diagnosis, disease severity, age, gender and treatment-related complications. RESULTS: In 2016, the total number of patients with congenital coagulopathies in the NRCC was 10,360: 39.8% of these patients had HA, 31.5% had vWD, 8.5% had HB, and 20.2% had less common factor deficiencies. The overall prevalence of HA and HB was 13.9/100,000 males and 3.0/100,000 males, respectively. The overall prevalence of vWD was 5.4/100,000 inhabitants. During 2016, 126 patients had current alloantibodies to factor VIII (FVIII) or factor IX (FIX) and were under treatment with bypassing agents and/or immune tolerance induction. Overall, 388 patients with a history of alloantibodies were recorded in the NRCC of whom 337 with severe HA and 12 with severe HB. Coagulation factor use, evaluated from treatment plans, was approximately 451,000,000 IU of FVIII for HA patients (7.5 IU/inhabitant), and approximately 53,000,000 IU of FIX for HB patients (0.9 IU/inhabitant). DISCUSSION: The prevalences of HA and HB fall within the ranges reported in more developed countries; the consumption of FVIII and FIX was in line with that of other European countries (France, United Kingdom) and Canada. The NRCC, with its bleeding disorder dataset, is a helpful tool for shaping public health policies, as well as planning clinical and epidemiological research projects.

Current trends of Hepatitis C virus genotypes and associated risk factors in hemophilia patients in Pakistan.

Hemophilia is a rare bleeding disorder that needs plasma or clotting factor concentrate transfusion. Therefore chances of blood-borne pathogens like HCV transmission increase due to high prevalence in healthy donors. This study was aimed to determine the prevalence of HCV genotypes and associated risk factors in hemophilia patients of Khyber Pakhtunkhwa, Pakistan. Blood samples and data were collected from 672 hemophiliacs after proper consent obtained from each patient. Samples were analyzed for anti-HCV, HCV RNA and HCV genotype/s detection. Of the total, 22.32% (150) were anti-HCV positive, of which HCV RNA was detected in 18.45% (124) individuals. HCV genotype 3a was found with significantly higher prevalence (p<0.05) (19.35%) as compared to 2a (16.13%) and 1a (12.90%). HCV-3b and HCV-4 were found each in 3.22% samples. Dual infection of genotypes was found in 22.58% of individuals and 22.58% HCV RNA positive sampels were not typed. A total of 572 (85.12%) subjects had hemophilia A and 100 (14.88%) had hemophilia B. In hemophiliacs A the most dominant genotype was 3a (19.27%) while in hemophilia B, genotype 1a was prevalent (26.67%). Whole blood and plasma transfusion were observed as the main risk factors of HCV. It is concluded that HCV genotype 3a and 2a are prevalent in hemophilia patients of Khyber Pakhtunkhwa Pakistan and the main risk factor observed was an unscreened whole blood transfusion.

Systemic elimination of de novo capsid protein synthesis from replication-competent AAV contamination in the liver.

The capsid protein synthesis in targeted tissues resulting from residual contaminating replication-competent adeno-associated virus particles (rcAAV) remains a concern for hazardous immune responses that shut down the factor IX expression in the hemophilia B clinical trial. To systematically reduce/eliminate the effects of potential contaminating rcAAV particles, we designed a novel adeno-associated virus (AAV) helper (pH22mir) with a microRNA binding cassette containing multiple copies of liver-specific (hsa-mir-122) and hematopoietic-specific (has-mir-142-3p) sequences to specifically control cap gene expression. In 293 cells, the rep and cap gene from pH22mir functioned similarly to that of conventional helper pH22. The vector yields and compositions from pH22mir and pH22 were indistinguishable. The performance of vector produced in this new system was comparable to that of similar vectors produced by conventional methods. In the human hepatic cell line, the capsid expression was reduced significantly from cap-mir cassette driven by a cytomegalovirus promoter. In the liver, 99.9% of capsid expression could be suppressed and no cap expression could be detected by western blot. In summary, we demonstrated a new concept in reducing de novo capsid synthesis in the targeted tissue. This strategy may not only help AAV vectors in controlling undesirable capsid gene expression, but can also be adopted for lentiviral or adenoviral vector production.

Molecular epidemiologic study of a human immunodeficiency virus 1 outbreak in haemophiliacs B infected through clotting factor 9 after 1990.

BACKGROUND AND OBJECTIVES: Twenty haemophiliacs were diagnosed as infected with human immunodeficiency virus 1 (HIV-1), 1 to 2 years after exposure to clotting factor 9 manufactured in Korea, beginning in early 1990. This study assessed the genetic relationships between viruses found in plasma donors and haemophiliacs. MATERIALS AND METHODS: Sequencing of the nef and pol genes of viruses from infected haemophiliacs, plasma donors whose plasma was used in domestic clotting factor manufacture, haemophiliacs infected outside Korea, and local controls were determined by nested polymerase chain reactions and direct DNA sequencing. Phylogenetic analysis was used to investigate the relationships among the sequences. RESULTS: Both plasma donors and the haemophiliacs were infected with a subclade of subtype B that is a founder effect lineage in Korea. CONCLUSION: Our data indicate that HIV-1 transmission to 20 haemophiliacs occurred through intravenous injection of Korean-made clotting factor. SUMMARY: A clotting factor made in Korea from blood from cash-paid donors infected at least 20 haemophiliacs with HIV-1 subtype B.

Prevalence of hepatitis C virus infection and HCV genotypes among hemophiliacs in the State of Bahia, Northeastern Brazil: analysis of serological and virological parameters

O objetivo deste estudo foi analisar parâmetros sorológicos e virológicos em hemofílicos no Estado da Bahia. O anti-VHC foi investigado por ELISA em uma coorte de 268 hemofílicos A/B sob acompanhamento em uma unidade de referência do Estado da Bahia. A viremia do VHC e genótipos foram determinados em um subgrupo de 66 hemofílicos soropositivos para o anti-VHC. A soroprevalência do anti-VHC entre os hemofílicos foi de 42,2% (IC 95% 36,5-48,1) e foi associada significativamente (p<0,05) a idade >10 anos, presenca de anticorpos antifator VIII/IX e outros marcadores sorológicos de infeccão. Nenhum dos hemofílicos com idade inferior a 5 anos foram anti-VHC positivos. A viremia foi detectada em 77,3% (51/66), sendo o genótipo 1 do VHC (74%) o mais prevalente, seguido pelos genótipos 3 (22%) e 2 (4%). Nossos resultados indicam que a prevalência do VHC é ainda alta entre os hemofílicos, muito embora a transmissão não tenha sido observada entre os menores de 5 anos.

Cost effectiveness of haemophilia treatment: a cross-national assessment.

The aim of this study was to assess the incremental cost effectiveness of on-demand versus prophylactic haemophilia therapy in Germany, Sweden, the United Kingdom and The Netherlands from the third-party payers' perspective. Using a decision tree model, the cost effectiveness of on-demand versus prophylactic therapy was analysed by extrapolating data from the European Haemophilia Economic Study to a 1-year analytic time horizon. Five hundred and six patients with severe haemophilia A and B, without inhibitors and at least 14 years of age, were enrolled in this study. Patients treated prophylactically had fewer bleeds than patients treated on-demand. With prophylactic treatment, the incremental cost per avoided bleeding ranged from 6,650 Euro dollars for patients 30 years of age or younger in Germany to 14,140 Euro dollars for patients over 30 years old in Sweden. If quality of life was taken into account, patients receiving prophylactic treatment had higher mean utilities than patients on on-demand therapy. The incremental effectiveness ratios in Germany were 1.2 million Euro dollars per quality-adjusted life year gained for patients 30 years or younger and HIV-positive and 2.2 million Euro dollars for patients 30 years or younger and HIV-negative. In the group aged over 30 years and HIV-positive the on-demand treatment strategy was dominant, whereas in the over 30 years/HIV-negative group the incremental cost-utility ratio was 4.7 million Euro dollars per quality-adjusted life year. Based on our decision analysis, the use of prophylactic treatment was overall more effective than on-demand therapy in young haemophiliacs, but at extremely high cost.

Prevalence of hepatitis C virus infection and HCV genotypes among hemophiliacs in the State of Bahia, Northeastern Brazil: analysis of serological and virological parameters.

The objective of the present study was to analyze HCV serological and virological parameters from hemophiliacs in the State of Bahia. Anti-HCV was investigated by ELISA in a cohort of 268 hemophiliacs A/B who were followed-up in a reference unit for hemotherapy in the State of Bahia. HCV viremia and genotypes were also determined from a subset of 66 anti-HCV seropositive hemophiliacs. Seroprevalence among hemophiliacs was 42.2% (95% CI 36.5-48.1) and was significantly higher (p<0.05) according to age > or =10 years, presence of factor VIII/IX inhibitory antibodies and other infection markers. None of the hemophiliacs less than 5 years of age were anti-HCV seropositive. Viremia was detectable in 77.3% (51/66). HCV genotype 1 (74%) was the most prevalent followed by genotype 3 (22%) and genotype 2 (4%). Our results indicate that HCV prevalence is still high among hemophiliacs, although HCV transmission was not observed in young hemophiliacs.

MonoFIX-VF, a new mono-component factor IX concentrate: a single-centre continuous-infusion study.

MonoFIX-VF, a monocomponent factor IX concentrate, has replaced the use of Prothrombinex-HT as the treatment of choice for patients with factor IX deficiency in Australia. The haemostatic effect of MonoFIX-VF, administered by continuous infusion, was assessed in four subjects being treated for 10 bleeding episodes including five surgical procedures. MonoFIX-VF was found to be a safe and effective treatment for patients with haemophilia B.

Factors predictive of death among HIV-uninfected persons with haemophilia and other congenital coagulation disorders.

Historically, the leading cause of death among persons with haemophilia and other congenital coagulation disorders was uncontrolled bleeding. Mortality was associated with severe deficiency of coagulation factors VIII or IX and especially with high-titre antifactor neutralizing antibodies (inhibitors). The catastrophic contamination of plasma donor pools with human immunodeficiency virus (HIV) resulted in acquired immunodeficiency syndrome replacing haemorrhage as the leading cause of death among persons with haemophilia. Rather little has been written, however, about mortality among those not infected with HIV. The objective of this study was to identify conditions associated with all-cause mortality among HIV-uninfected patients who were followed for a mean of 8.8 years in the Multicentre Hemophilia Cohort Study. Among the 364 children (mean age 8 years), there were four deaths; two related to cancer, one to trauma, and the fourth to haemorrhage, end-stage liver disease and sepsis. Among the 387 HIV-uninfected adults (mean age 35 years) there were 29 deaths, with haemorrhage the leading cause of death, followed by hepatic, stroke and cancer deaths. Prognostic factors for all-cause mortality among the adults included haemophilia Type A with neutralizing antibodies [age-adjusted relative rate (RR) 3.1, 95% confidence interval (CI) 1.4-6.9] and serologic evidence of both hepatitis B and C virus (RR 4.1, 95% CI 0.97-17.6). Although hepatitis C viral load was slightly lower in patients with hepatitis B virus surface antigenaemia, it was unrelated to vital status. We conclude that causes of death and prognostic factors for current HIV-uninfected haemophilia patients are similar to those noted before the HIV epidemic. Better understanding, prevention and control of neutralizing antibodies and hepatitis infections may substantially improve longevity for people with haemophilia.

Reproductive choices for couples with haemophilia.

: Summary. The impact of having a child with an inherited bleeding disorder such as haemophilia can have a far-reaching effect on the individual as well as other close family members. This situation is further complicated in the case of human immunodeficiency (HIV) serodiscordant couples, where the haemophilic man is affected with HIV through infected blood products whilst his partner is seronegative and wanting to have children. It is essential that information on the effects of haemophilia, its inheritance, the possibilities of antenatal diagnosis, the consideration of selective abortion and the new reproductive opportunities available to these couples are made accessible so that an informed decision about proceeding with having a family can be made. Couples may wish to have a family through nonreproductive methods such as fostering or adoption. Alternatively, they may wish to remain childless. In this paper, the terms 'having children' and 'having a family' will refer to conception through biological reproduction. Pre-implantation genetic diagnosis (PGD) offers families at risk of having a child with certain inherited genetic disorders the opportunity to give birth to an unaffected child. It may be considered as an option for couples who would not wish to have prenatal diagnosis leading to possible termination of a pregnancy. Assisted conception techniques, such as 'sperm washing' or the use of 'donor sperm', offer serodiscordant couples affected by HIV a risk-reduced or risk-free opportunity, respectively, to have a child without infecting the mother, who could in turn infect the fetus by vertical transmission. This article, in addition to outlining the inheritance of haemophilia and the more common prenatal screening and diagnostic tests, discusses in more detail the latest reproductive opportunities available for families affected by haemophilia and considering having a family.

Treatment with interferon plus ribavirin in anti-HIV negative patients with congenital coagulation disorders and chronic hepatitis C.

BACKGROUND: Hepatitis C virus (HCV) infected hemophiliacs respond at low rate to interferon (IFN) monotherapy. AIMS: To assess efficacy of IFN and RBV in HIV negative hemophiliacs with chronic hepatitis C and identify early predictive factors of response. METHODS: Twenty naive patients were treated with interferon and RBV for twelve months. Response was assessed by both serial ALT and HCV RNA levels. RESULTS: Normalization of ALT with clearance of HCV RNA occurred in seven (35%) patients. Age and age at infection were the only features associated with a higher likelihood of response. In all responders the viral load had decreased by at least one log within two months of starting treatment. CONCLUSIONS: Combination of interferon and ribavirin is well tolerated by hemophiliacs who achieve similar sustained response rates to non-hemophiliacs. Quantitative assessment of viral load at two months of treatment is a useful method to identify non-responders at an early stage.

Liver biopsy in Irish hepatitis C-infected patients with inherited bleeding disorders.

The majority of patients receiving plasma-derived clotting factor concentrates between 1970s and the mid-1980s are now hepatitis C positive. The progression of hepatitis C is extremely variable and there is frequently a poor correlation among liver biochemistry, viral load and the stage of liver disease. Liver biopsy remains the only definitive way of staging fibrosis and grading necroinflammatory activity. Concerns have been expressed about the safety of the procedure; however, with modern regimes for the correction of coagulopathy in patients with inherited bleeding disorders, normal haemostasis may be maintained during the peribiopsy period. We performed 21 liver biopsies between 1984 and 1997 on patients with factor VIII (FVIII) or IX (FIX) deficiency and von Willebrand's Disease (VWD). Four had concomitant human immunodeficiency virus (HIV) infection, five were thrombocytopenic and one had a prolonged prothrombin time (PT). Haemostasis was achieved using an intermittent bolus of factor concentrate or continuous infusion regimens. One patient with VWD received Desmopressin (DDAVP). There were no bleeding episodes associated with biopsy. We suggest that liver biopsy is a safe procedure in patients with inherited bleeding disorders when the coagulopathy is fully corrected. It is the only definitive method of staging the extent of fibrosis associated with hepatitis C infection, and it is this that defines prognosis.

Drug-induced and traumatic nail problems in the haemophilias.

Many persons with haemophilia suffer from HIV and receive highly active antiretroviral therapy. Three patients received indinavir and required surgery due to ingrown toenails. Two patients suffered from a traumatic subungual haematoma. The treatment protocol is described whereby the pressure exerted onto the germinal layer and the nail bed is relieved in order to alleviate pain and nail matrix damage.

Prevalence of human parvovirus B19 and TT virus in a group of young haemophiliacs in South Africa.

A well recognized hazard of transfusion with blood or blood products is the acquisition of a viral infection. Parvovirus B19 and transfusion transmitted virus (TTV) are two of several non-enveloped viruses that may on rare occasions be present in coagulation factor concentrates. The prevalence of these viruses in the South African Haemophilia population has not previously been studied. Thirty-nine Haemophiliac children were investigated for evidence of parvovirus and TTV infection. 26 boys with Haemophilia A had been treated with cryoprecipitate or intermediate purity factor VIII, and 13 boys with Haemophilia B had received prothrombin complex concentrates. All the plasma products were prepared from South African donors and were virally inactivated by heat or solvent/detergent since 1992. A control group of 32 children who had not been transfused were also studied. IgG antibodies to B19 were present in 29 of the 39 patients (74%), 18/26 (69%) with Haemophilia A and 12 of the 13 (85%) with Haemophilia B. None of the patients was IgM antibody positive but two children were PCR positive for B19 DNA. Of the control children, 47% had IgG antibodies to B19, but none were IgM antibody or B19 DNA positive. TTV viral DNA was found in 10.2% of patients and in 9% of the control group. The results indicate that our locally produced plasma products are not a significant source of TTV transmitted infection but may contribute to infection by B19 parvovirus.

Guidelines on replacement therapy for haemophilia and inherited coagulation disorders in Italy.

In the last years, the availability in Italy of technologically advanced products for replacement therapy has produced significant changes in the management of haemophilia and of hereditary bleeding disorders in general. With the aim of a uniform approach to treatment, the Italian Association of Haemophilia Centres express in these guidelines a consensus on therapeutic strategies designed to ensure the highest degree of safety and efficacy for the treatment of inherited coagulopathies. The guidelines provide specific recommendations for the choice of the product according to updated scientific evidence, and advice on optimal dosages for the treatment of rare bleeding disorders. The system for haemophilia care and funding in Italy is briefly described.

Health status and satisfaction of asymptomatic HIV-positive haemophiliacs in Kyushu, Japan.

The purpose of this study was to elucidate the effects of human immunodeficiency virus (HIV) on haemophiliacs with physical functional disabilities induced by haemophilia in Kyushu, Japan. The subjects were 38 adult haemophiliacs who were selected from 129 patients registered with the North Kyushu Haemophilia Centre. They were divided into 21 asymptomatic HIV-positive and 17 HIV-negative adult haemophiliacs. Coagulation factor levels, modified DePalma classification, Arthritis Impact Measurement Scale 2 (AIMS 2), and a satisfaction in daily life (SDL) questionnaire were used to investigate the clinical severity of their haemophilia and arthropathy, physical functional disabilities, and satisfaction. Although there were no significant differences in the objective assessments of health status between the HIV-positive and -negative haemophiliacs, the HIV-positive haemophiliacs were significantly more dissatisfied with their social activities and mood, according to AIMS 2, and with social intercourse, job, self-development, and social security and pension according to SDL assessment. These dissatisfactions were due to the effects of HIV, in addition to the physical functional disabilities that were caused by haemophilia. Dissatisfaction with social security and pension may be a specific feature in HIV-positive haemophiliacs in Japan resulting from the origin of HIV infection.

Prevalence and persistence of a novel DNA TT virus (TTV) infection in Japanese haemophiliacs.

To clarify the clinical implication of a newly discovered 'TT virus (TTV)', we assayed TTV DNA in sera from 50 haemophiliacs by a seminested-PCR. TTV DNA was detected in 75% (35/50), which was a much higher prevalence than for HBV (HBc-Ab), HCV RNA, or HGV RNA. In particular, TTV DNA was found in 44.4% (4/8) of patients who had been treated only with virally inactivated factor VIII concentrates. Elevated ALT levels were observed in patients with HCV RNA and TTV DNA; however, the elevation in TTV DNA was obtained from patients co-infected with HCV RNA (62.9%, 22/35). There was no significant difference in ALT levels between TTV DNA-positive and DNA-negative in patients without HCV RNA. 85.3% (35/41) of TTV DNA-positive sera in 1990 were again positive for TTV DNA in 1995. These findings suggest that many haemophiliacs have been infected with TTV. Although TTV infection was not associated with serum ALT elevation, persistent TTV infection may contribute to cryptogenic hepatic failure in haemophiliacs.