Assessment of needs for plasma for fractionation in Europe.

In the early 1990s, a series of outbreaks of hepatitis C (HCV) infections clustering among recipients of certain lots of plasma-derived medicinal products (PDMP) alarmed regulatory authorities, manufacturers and the public alike. Also, a few episodes of Hepatitis A (HAV) infections occurred in haemophiliacs receiving solvent-detergent-treated factor VIII concentrates. Thus, several measures were brought into effect to reestablish the safety of the incriminated products and to further increase the margin of safety of PDMP in general. Therefore, intramuscular immunoglobulins had to be free of HCV RNA as shown by nucleic acid amplification technology (NAT) in the final products. Furthermore, the manufacturing process of PDMP had to be validated for both viral inactivation and elimination. Finally, HCV-NAT was to be standardised and implemented as a validated test of plasma pool samples. In 1994, a joint meeting of EPFA, EAPPI and Regulatory Authorities was held in Brussels to outline the state of the art and to delineate the actions to be taken. Five years later, in 1999, the incidence rates of HIV, HBV and HCV in unpaid blood donors have been minimized, especially in European countries. With probabilities for window period donations as low as 0.6 in 1 million for both HIV and HCV and 2.1 in 1 million for HBV in Switzerland, labile blood products have reached extreme, but not absolute safety. The introduction of HCV-NAT roughly doubles this safety resulting in a 1 in 3 million probability of a window donation.Concomittantly, extensive viral validation studies document effective inactivation and removal of viruses in PDMP. The demonstrated margins of safety, expressed as logarithmical reduction factors (LRF), range from 4 to over 20 log(10), depending on product, virus, and inactivation procedure used. Further progress to even safer PDMP shall be acomplished by consolidating the GMP processes, abandoning of obsolete requirements and harmonising national regulations within Europe. Before introducing new measures for additional agents such as HAV or Parvovirus B 19, gains and risks and even potential new threats have to be carefully assessed. Alternative efforts for the safeguard of patients, e.g. vaccination for HAV, need to be balanced against the risks of changing established and validated manufacturing procedures of PDMP with long-lasting safety records.

High frequency of non-B subtypes in newly diagnosed HIV-1 infections in Switzerland.

HIV-1 subtypes were determined in newly diagnosed residents of Switzerland. Blood was anonymously collected from patients with a first confirmed positive HIV-1 test result. Viral DNA from the env V3-V5 region was amplified by nested polymerase chain reaction (PCR) and screened for subtype B by heteroduplex mobility assay. All amplicons not identified as B were sequenced. From November 1996 to February 1998, 206 samples were analyzed. Main transmission risks were unprotected heterosexual (55.7%) or homosexual (27.1%) sexual contact or intravenous drug use (12.9%). Subtype B dominated in patients of Swiss, other European, American, or Asian citizenship; particularly high frequencies were found in homosexuals (97%) and drug users (94%). Non-B subtypes including A, C, D, E, F, G, H, a possible B/F recombinant, and a sequence related to J were present in 28.2% (95% confidence interval [CI], 22.9%-35.0%). Non-B were frequent in African citizens (95%), heterosexually infected individuals (44%), and women (43%). Heterosexually infected Swiss males harbored non-B strains in 18% and females in 33%. The results document a change in the epidemiology of newly diagnosed HIV-1 infections in Switzerland: predominance of heterosexual transmission and a high frequency of non-B subtypes.

Safety and activity of saquinavir in HIV infection.

We evaluated saquinavir, an orally active, selective inhibitor of HIV proteinase, in a randomised, double-blind, dose-ranging study in 49 zidovudine-naive HIV-positive patients with few or no symptoms and CD4 cell counts of 500 or less. The study was designed to assess the antiviral activity and tolerability of saquinavir. Patients were randomised to receive 25, 75, 200, or 600 mg of saquinavir three times daily for 16 weeks. No serious adverse events occurred. CD4 cell counts showed a trend indicative of a dose response in favour of the 600 mg dosage, the maximum increase being seen around week 4. In none of the 8 patients with positive plasma viraemia at baseline did cultures become negative after treatment; peripheral blood mononuclear cell and plasma-viral load by culture and DNA and RNA PCR all showed a trend towards reduction at higher doses of saquinovir. Saquinavir was well tolerated in this group of previously untreated patients with few or no symptoms; this study shows that an HIV-proteinase inhibitor is active in HIV-infected patients.

Prevention of hepatitis C infection in haemodialysis units. A prospective study.

A prospective study was begun in our haemodialysis unit after four previously negative patients were found to be anti-HCV positive. A dedicated area and dedicated dialysis equipment (but not a separate room) were assigned to anti-HCV-positive patients and testing for HCV antibodies was performed every 3 months. A total of 131 patients were treated during the study period of 18 months. Of these, 50 patients were dialysed during the entire 18 months, and 21 were available to be tested six or more months after having left the centre. During the first 6 weeks after implementing the precautions two more anti-HCV-positive patients were detected. However, during the rest of the study period no further newly infected patients were found. It is concluded that the spread of HCV infection in a haemodialysis environment can be prevented by limited isolation procedures.

Amplification of DNA from whole blood.

A method is described for the amplification by PCR of human chromosomal DNA sequences from whole blood samples. Various amounts of blood samples, with either EDTA, citrate, or heparin used as the anticoagulant, have been used to determine optimal PCR conditions for each type of sample. Up to 80% (vol/vol) of whole blood sample is tolerated in PCR with Taq polymerase. Amplification from whole blood requires the optimization of salt (K+ and Mg++) according to sample volume and type of anticoagulant used. Pretreatment of fresh blood samples to lyse the leukocytes is required for EDTA-treated blood samples and is beneficent in PCR with heparin- and citrate-treated blood samples to obtain maximal amplicon amounts. A satisfactory method of pretreating samples is freeze/thawing. In addition, EDTA-treated blood samples require a heat treatment before PCR for maximal amplicon synthesis. It appears that purification of the DNA is not necessary for any of the whole blood samples analyzed by PCR. Results of amplification reactions from unpurified hepatitis B virus (HBV) sequences of whole sera samples are shown also.

Biochemistry and molecular biology of MCA.

The mucin-like carcinoma-associated antigen (MCA) is a mucin with a molecular weight of 350-500 kD. It circulates in the serum and its serum content can be determined with the Cobas Core MCA EIA test. Patients with breast cancer show elevated MCA serum levels. The molecule has a polypeptide backbone consisting of three parts: the C-terminus the N-terminus and the transmembrane sequences. The protein is heavily glucosylated with carbohydrate side chains that contain fucose, galactose and N-acetyl galactosamine. The antibody b-12 recognizes a repetitive epitope on the peptide portion of the MCA molecule. The epithelial mucin, which is coded by a unique gene, was cloned using PCR technology. Peptides corresponding to the N- and C-terminus were expressed in E. coli. Analysis of the purified peptides revealed molecular weights of 12 and 18 kD.

[Seroprevalence of hepatitis C virus in hemophiliacs in Switzerland]. / Hepatitis-C-Virus-Serostatus der Hämophilen in der Schweiz.

The sera of patients with hemophilia and von Willebrand factor deficiency, collected during clinical trials with virus-inactivated coagulation factor preparations, were retrospectively screened for the presence of antibodies against hepatitis C virus (HCV). Using the anti-HCV c100-3 assay, 10 out of 35 study patients had no HCV antibodies when entering the studies. The samples originally negative for anti-HCV were retested with a second-generation assay: all negative samples except two were positive on retesting. We conclude that the HCV seroprevalence in Swiss hemophiliacs must be of the order of > 90%. These results confirm that the first-generation assay for HCV antibodies is not sensitive enough; to obtain more accurate information on the seroprevalence of hemophiliacs, second-generation tests should be used.

Human serum induced opsonization of immunoglobulin G-coated polystyrene microspheres with complement components C3 and C4 as measured by flow cytometry.

Human IgG-coated polystyrene microspheres (IgG-ms) were incubated with human serum followed by biotinylated monoclonal anti-C3d or anti-C4d antibody, and phycoerythrin-streptavidin. The intensity of fluorescence was measured by flow cytometry and corresponds to the amount of deposited C3 and C4. Binding of C3 and C4 was dependent on the activation of the classical pathway of complement and on the amount of IgG adsorbed to the particles. No deposition was observed on control particles coated with bovine serum albumin or ovalbumin. Incubation of constant amounts of IgG-ms with increasing amounts of normal human serum (NHS) resulted in a dose-dependent increase in C3 deposition. The same result was found for C4 deposition at moderate NHS dilutions, but less C4 was detectable using a higher input of NHS. Half-maximum C3 and C4 deposition was observed at a mean serum dilution of 1/114 and 1/520, respectively (n = 26). No correlation was found between C4 or C3 deposition and either total C4 and C3 serum concentrations as measured by nephelometry or complement-mediated lysis of antibody-coated sheep red blood cells. Reduced or absent C4 or C3 deposition was found in the sera of patients with low amounts or deficiencies of components involved early in classical complement pathway activation whereas essentially normal C4 or C3 deposition was obtained with the sera of patients with deficiencies in components of the membrane attack complex. With this simple and specific functional assay using stable reagents an altered function of early components of the classical pathway of complement may be quickly and reliably detected in routine diagnostic laboratories. Moreover, such opsonized and well characterized particles may be useful in assays of phagocytic cell function.

[No HCV seroconversion in hemophilia following substitution with virus-inactivated coagulation factor VIII and IX concentrates]. / Keine HCV-Serokonversion bei Hämophilen nach Substitution mit Viren-inaktivierten Gerinnungsfaktor VIII- und IX-Konzentraten.

Since 1986 the factor VIII and IX concentrates of the Central Laboratory, Swiss Red Cross Blood Transfusion Service have been virus inactivated with tri-(n-butyl) phosphate and Tween 80. Clinical studies had shown that both preparations were well tolerated and hemostatically effective; no HIV infection was transmitted. However, safety from transmission of non-A/non-B hepatitis could not be shown since the study included no previously untreated patients. In the meantime, a laboratory test has become available which allows retrospective testing for anti-hepatitis C antibodies in frozen sera of the study patients. 5 of the 26 patients, observed during a 2-year follow-up study, had no HCV antibodies before entering the long-term trial. During this trial, each of these 5 patients substituted an average quantity of 40,200 coagulation factor units (7500-69,000) from 45 production lots. None of these 5 patients developed anti-HCV antibodies, nor did any of them show clinical signs of infection with hepatitis. This suggests that virus inactivation using solvent/detergent treatment reduces the risk of transmission of HCV.

Human immunodeficiency virus DNA amplification and serology in blood donors.

The significance of indeterminate screening antibody test for human immunodeficiency virus (HIV) serology is still difficult to evaluate, especially in low-risk populations. One hundred twenty-seven blood donors with an initially reactive screening test for HIV antibodies were enrolled in this study. The sera of 95 of these blood donors were reactive on repetition of the test, and none had detectable circulating p24 antigen. Western blot (WB) analysis of the repeatedly reactive sera was as follows: 9 positive, 31 indeterminate, and 55 negative. One of the blood donors with indeterminate WB later presented a seroconversion. On subsequent control 3 to 12 months later, the sera from donors with indeterminate or negative WB did not present any parameters that may indicate a seroconversion. DNA was purified from citrated blood collected from the 127 blood donors at the time of the initial antibody screening. Five micrograms of each DNA sample corresponding to 7 x 10(5) nucleated white blood cells was amplified by polymerase chain reaction (PCR) in the presence of oligonucleotides (primers) corresponding to a highly conserved segment of the pol gene. The detection of amplified DNA was achieved by dot blot and Southern blot using appropriate 32P-labeled oligonucleotides. Ten DNA samples were positive, 9 corresponded to blood donors with a positive HIV serology, and 1 to the blood donor who later presented a seroconversion. These results confirm the sensitivity of the PCR for the diagnosis of HIV infection; they also suggest that repetition of the serology at 3- to 12-month intervals is a valuable procedure for the control of HIV infection status in blood donors.

Laboratory workshop on the characterization of anti-platelet antibodies in immune thrombocytopenic purpura.

The aim of this laboratory workshop was to evaluate the state of knowledge concerning the demonstration of membrane glycoprotein specific anti-platelet antibodies. The main interest lay in investigating whether specific antibody detection offers possibilities to distinguish the chronic from the acute form of ITP. In five laboratories four different methods were applied to demonstrate such antibodies. These methods are briefly described and compared. In all, except two, of the 45 ITP samples anti-platelet antibodies could be detected by at least one participating laboratory, in 85% of the samples antibodies were found by two or more laboratories. For seven out of eight control samples no positive results were reported. The comparison of glycoprotein specific anti-platelet antibodies shows partly considerable differences which may be due to the different methods as well as the different antibodies used (monoclonal antibody against membrane glycoprotein and antihuman globulin sera). This laboratory workshop leads to the conclusion that by exchange of reagents and patient samples the different methods may be compared and evaluated. The results obtained allowed no further characterization of ITP. All participants agreed on the usefulness of further similar laboratory workshops.

Immunoglobulin G subclass distribution in three human intravenous immunoglobulin preparations.

In immunodeficiency patients the lack of immunoglobulins (Ig) can be total or partial with a specific IgG subclass imbalance masked by normal values for total IgG. In the latter case therapy with intravenous IgG preparations (IVIG) is generally beneficial, provided the IVIG preparations used originate from large pools of normal blood donors and exhibit a normal IgG subclass distribution. We have analyzed the subclass distribution of three IVIG products: Sandoglobulin (SAGL), GamimuneN (GI), Gammagard (GG), 6-10 lots each, in four different laboratories. The competitive enzyme immunoassays and radial immunodiffusion methods used different monoclonal and polyclonal antibodies specific for IgG1, IgG2, IgG3, and IgG4, respectively. Despite minor interlaboratory differences, the results show that the slightly lower IgG1 content of SAGL versus GI and GG was quantitatively compensated by a higher proportion of IgG2, that no differences existed in IgG3 levels, but that one preparation (SAGL) contained 2-3% of IgG4 compared to 0.5-1.5% in GI and below 0.5% in GG. This difference was significant, the two latter preparations being at or below the lower limit of what are considered to be normal values found in human adults. Such differences may have important clinical consequences.

[A hepatitis non-A, non-B-associated substance in the feces--identification and cloning of a partially double-stranded circular DNA]. / Hepatitis-Non-A-Non-B-assoziierte Substanz im Stuhl--Nachweis und Klonierung einer partiell doppelsträngigen zirkulären DNA.

By means of a radioimmunoassay a substance excreted in feces could be detected in patients with hepatitis non-A,non-B (HNANB). Feces extracts of patients with sporadic and posttransfusion HNANB as well as of healthy persons were precipitated with PEG, digested with RNase and DNase and separated on CsCl. In HNANB-patients a RIA-positive material with a density of 1.3 g/ml CsCl could be detected which contained a partially double-stranded circular DNA. Cloning of this DNA in lambda-phase resulted in DNA of about 5 Kb, which hybridized with feces DNA under stringent conditions. The 5 Kb-DNA were mapped with different restriction enzymes. A 1.5 Kb EcoRi-fragment cross-hybridizes with HBV-DNA. No hybridization and sequence homologies were found with human, viral and procaryotic DNA as well as with plasmid and phage DNA (data base EMBL, Heidelberg). It is assumed that the DNA excreted in feces of HNANB-patients represents a viral genome not detected so far.

[Hepatitis non-A, non-B-associated substance in stool from patients with posttransfusion and sporadic hepatitis]. / Hepatitis-Non-A-Non-B-assoziierte Substanz im Stuhl bei Patienten mit posttransfusioneller und sporadischer Hepatitis.

A hepatitis non-A,non-B-associated substance (HNANB-AS) excreted in feces has been detected by means of a sandwich radioimmunoassay using reconvalescent serum and IgG from patients with posttransfusion HNANB. 4380 stool filtrates from 1599 patients were screened with this assay. In patients with posttransfusion or sporadic acute and chronic HNANB the substance was detected with a mean frequency of 34%, in acute posttransfusion HNANB, where samples were screened at the beginning of the clinical symptoms, 71.4% of stool specimens were positive for HNANB-AS. A high frequency of positive results was found in patients undergoing dialysis (31.3%), hemophiliacs (16.6%) and patients with cryptogenic cirrhosis (16%). Positive specimens were seen in hepatitis A (7.1%), acute and chronic HBV-infection (9.6%), various liver diseases (7.8%), outpatients of a physician (3.1%) and clinical or laboratory staff (6%). In these groups, too, anamnestic data speaking in favour for a possible HNANB frequently were obtained. The discovery of a partially double-stranded circular DNA of 5.0 Kb in HNANB-AS which sequence differs from human, bacterial and known viral DNA, argues the presence of a viral particle in stools of patients with sporadic and parenteral HNANB.

[Hepatitis non-A, non-B-associated DNA--demonstration of DNA in proven infectious anti-D-immunoglobulin]. / Hepatitis-Non-A-Non-B-assoziierte DNA--Nachweis der DNA in gesichert infektiösem anti-D-Immunglobulin.

An anti-D-immunoglobulin preparation implicated in a hepatitis non-A,non-B transmission was analyzed for the presence of a DNA, which was originally isolated, cloned and sequenced from feces of a patient with posttransfusion HNANB. The investigation was performed by a DNA polymerase chain reaction using synthetic oligoprimers. Commercially available immunoglobulin preparations served as controls. The demonstration of identical DNA sequences in the infectious material speaks in favour of this up to now unknown circular and partially double-stranded DNA to be a virus genome involved in hepatitis non-A,non-B.

Complexity of the early genetic response to growth factors in mouse fibroblasts.

Genes whose expression is growth factor regulated are likely to be important components in the mechanisms controlling cell proliferation and differentiation. With the aim of identifying some of those genes, a lambda cDNA library was prepared with poly(A)+ RNA from quiescent NIH 3T3 cells stimulated with serum for 4 h in the presence of cycloheximide. Differential screening of approximately 200,000 recombinant phage plaques revealed 2,540 clones that cross hybridized preferentially with [32P]cDNA derived from RNA of stimulated cells rather than with cDNA derived from nonstimulated cells. Cross hybridization of these clones identified 82 independent sequences, including c-fos and c-myc. Seventy-one clones were further studied. Analysis of the changes in transcription and mRNA levels after serum stimulation demonstrated that the kinetics and extent of the induction vary dramatically between the different genes. Cycloheximide in all cases superinduced the mRNA levels by two mechanisms, inhibiting the shutoff of transcription and prolonging the half-lives of the mRNAs. Our results showed that induction of proliferation is accompanied by the onset of a complex genetic program.

Involvement of common and cell type-specific pathways in c-fos gene control: stable induction of cAMP in macrophages.

The c-fos proto-oncogene is rapidly and transiently induced by PDGF in fibroblast and by CSF-1 in macrophages. In both cells, the breakdown of phospholipids with the ensuing activation of protein kinase C (PKC) and intracellular release of Ca2+ seems to play a role in the induction of c-fos. The transient induction of c-fos mRNA and protein by PDGF is both increased and prolonged by inhibitors of calmodulin, apparently by inhibiting the degradation of c-fos mRNA. While no response to cyclic nucleotides is observed in fibroblasts, cAMP is a strong inducer of c-fos in macrophages. In contrast to the transient induction by PKC/Ca2+, cAMP induces stable transcription of the c-fos gene for many hours, suggesting the existence of different mechanisms regulating c-fos transcription in the same cell.