681
Seroprevalence of hepatitis
E in the
visitors to
Netherlands SIR,- The hepatitis E virus (HEV) causes epidemic and sporadic hepatitis without development of chronic liver disease,’ similar to the hepatitis A virus (HAV). Both HAV and HEV are transmitted by the faecal-oral route. In contrast to HAV, IgG antibodies directed against HEV may disappear within 1 year after infection.2 Cases of hepatitis E seem to occur mainly in countries with a warm climate. Possibly HEV causes sporadic or silent cases of hepatitis E in western Europe. We studied the prevalence of IgG HEV antibodies in low-risk blood donors and in patients’ samples sent to our laboratory for serological diagnosis of viral hepatitis, but with no serological evidence for recent infection with hepatitis A, B, or C virus, cytomegalovirus, or Epstein-Barr virus. For the detection of IgG HEV antibodies, an ELISA (Genelabs and Diagnostic Biotechnology), based on two recombinant HEV antigens was used. Repeat positive samples were confirmed in an immunoblot assay (Genelabs and Diagnostic Biotechnology) based on the same recombinant HEV antigens. In 269 samples, 8 (3-0%) were confirmed positive for IgG anti-HEV. In 275 donor samples, 5 (18%) were confirmed positive for IgG anti-HEV (not significant by X2 test). It is unlikely that all 13 anti-HEV positive subjects in our study acquired HEV infection abroad. If the reactivity we found was not caused by crossreactivity, HEV may be the cause of sporadic and silent cases of hepatitis E in the Netherlands. Viral Serology Department, Central Laboratories of the Netherlands Red Cross Blood Transfusion Service (CLB), 1066 CX Amsterdam, Netherlands, and Diagnostic Biotechnology (Pte) Ltd,
Singapore 1
2
H. L. ZAAIJER M. F. YIN P. N. LELIE
Balayan MS. HEV infection, historical perspectives, global epidemiology, and clinical features In Hollinger FB, ed Viral hepatitis and liver disease. Baltimore: Williams & Wilkins, 1991: 498-501. Goldsmith R, Yarbough PO, Reyes GR, et al. Enzyme-linked immunosorbent assay for diagnosis of acute sporadic hepatitis E in Egyptian children. Lancet 1992; 339: 328-31
Pneumococcal vaccination for travel to
Spain SIR,-Your July 11editorial highlights our recommendation’ that physicians should consider the use of pneumococcal vaccines for travellers to Spain, especially those with risk factors for pneumonia and invasive pneumococcal disease. Shapiro and co-workers’2 data show again the efficacy of the pneumococcal vaccine and suggest that the vaccine has been underused in the ten or so years since its introduction, even in patients for whom there are clear indications for its use. Dr Martinez and Dr Marcos (Aug 8, p 378) are concerned that fear of epidemic pneumococcal disease has been overstated. Pneumococcal disease is unlikely to arise in epidemics, but vaccination against pneumococcus may have other benefits. Pneumococcal vaccine reduces nasal carriage of the pneumococcus. Decreased acquisition of vaccine strains has been demonstrated in American military personnel3 and in South African miners (Austrian R, personal communication). Similar experience has been noted with other polysaccharide vaccines, including group A meningococcal vaccineand Haemophilus influenzae conjugate vaccine.s Health providers should continue to give pneumococcal vaccines to patients with individual risk factors for invasive disease. International travel provides opportunities for families to consult doctors about appropriate immunisations. Physicians may wish to use such opportunities not only to administer necessary immunisations, but also to give pneumococcal vaccine to eligible patients. In addition, doctors should be alert to the possibility of resistant strains of pneumococcus in patients who have travelled to areas where these strains are known to be prevalent. Maxwell Finland Laboratory for Infectious Diseases,
Boston City Hospital, Boston, MA 02118, USA
ED, Klein JO, Teele DW. Pneumococcal vaccine for Olympic athletes and Spain. New Engl J Med 1992; 326: 1572. 2 Shapiro ED, Berg AT, Austrian R, et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine N Engl JMed 1991; 325: 1453-60. 3. MacLeod CM, Hodges RG, Heidelberger M, Bernhard WG. Prevention of pneumococcal pneumonia by immunization with specific capsular polysaccharides. J Exp Med 1945; 82: 445-65. 4 Sivonen A Effect of Neisseria meningitidis group A polysaccharide vaccine on nasopharyngeal carrier rates J Infect 1981, 3: 266-72. 5 Takala AK, Eskola J, Leinonen M, et al. Reduction of oropharyngeal carriage of Haemophilus influenzae Type b (Hib) in children immunized with an Hib conjugate vaccine. J Infect Dis 1991; 164: 982-86. 1 Barnett
Isolation of
atypical HIV-1-related retrovirus from AIDS patient
Laurence and colleagues (Aug 1, p 273) report five of AIDS without evidence of HIV-1 or HIV-2 infection. Highly divergent variants of HIV-1 raise the question of their detection and of their causative role in AIDS. These variants are associated with unusual serological HIV reactivity and have been described mainly in Africa.l,2 We report the isolation of an atypical HIV-1-related retrovirus from a French AIDS patient who had an aytpical western blot profile. A 39-year-old French woman was admitted to Hopital Robert Debre in January, 1990, because of cervical cancer, genital condylomas, and pancytopenia. HIV-1 ELISA was positive; HIV-1western blot showed clear bands at p24, p31, and p55, and a very faint band at gp 160. Serological HIV-2 tests were negative and no p24 antigenaemia was detected. The patient did not mention any risk factor for HIV transmission and her husband was HIV-1 and HIV-2 seronegative. In July, 1991, the patient had anorexia, fatigue, and severe weight loss with very decreased CD4 cell count (20/µl). In October, Pneumocystis carinii pneumonia was diagnosed. AIDS was diagnosed and zidovudine was started in November, although serological HIV profiles were unchanged and no HIV had ever been detected by either culture or PCR in peripheral blood
SIR,-Dr
cases
lymphocytes (PBL). On December 17, with zidovudine at 300 mg daily, a novel PBL cocultivation was started at the Hopital Pitié-Salpêtrière. After 6 days, a positive signal was detected in cell culture supernatant with an immunocapture p24 antigen assay (polyclonal antibody capture, Abbott) and was associated with increasing reverse transcriptase (RT) activity. p24 reactivity, which exceeded 2000 pg/ml, was specifically inhibited by the antigen neutralisation test provided by the manufacturer. p24 reactivity was also confirmed by a monoclonal antibody capture assay (Abbott) that did not react with prototype HIV-2 antigens. Further attempts at viral cocultivation
Electron micrographs of thin sections of infected
lymphocytes.
ELIZABETH D. BARNETT
A = mature virion with dense cone-shaped core, B = budding particles, and C = elongated virus particles Bar=100 nm, A, B, and C at same
JEROME O. KLEIN
magnification
Seroprevalence of hepatitis
E in the
visitors to
Netherlands SIR,- The hepatitis E virus (HEV) causes epidemic and sporadic hepatitis without development of chronic liver disease,’ similar to the hepatitis A virus (HAV). Both HAV and HEV are transmitted by the faecal-oral route. In contrast to HAV, IgG antibodies directed against HEV may disappear within 1 year after infection.2 Cases of hepatitis E seem to occur mainly in countries with a warm climate. Possibly HEV causes sporadic or silent cases of hepatitis E in western Europe. We studied the prevalence of IgG HEV antibodies in low-risk blood donors and in patients’ samples sent to our laboratory for serological diagnosis of viral hepatitis, but with no serological evidence for recent infection with hepatitis A, B, or C virus, cytomegalovirus, or Epstein-Barr virus. For the detection of IgG HEV antibodies, an ELISA (Genelabs and Diagnostic Biotechnology), based on two recombinant HEV antigens was used. Repeat positive samples were confirmed in an immunoblot assay (Genelabs and Diagnostic Biotechnology) based on the same recombinant HEV antigens. In 269 samples, 8 (3-0%) were confirmed positive for IgG anti-HEV. In 275 donor samples, 5 (18%) were confirmed positive for IgG anti-HEV (not significant by X2 test). It is unlikely that all 13 anti-HEV positive subjects in our study acquired HEV infection abroad. If the reactivity we found was not caused by crossreactivity, HEV may be the cause of sporadic and silent cases of hepatitis E in the Netherlands. Viral Serology Department, Central Laboratories of the Netherlands Red Cross Blood Transfusion Service (CLB), 1066 CX Amsterdam, Netherlands, and Diagnostic Biotechnology (Pte) Ltd,
Singapore 1
2
H. L. ZAAIJER M. F. YIN P. N. LELIE
Balayan MS. HEV infection, historical perspectives, global epidemiology, and clinical features In Hollinger FB, ed Viral hepatitis and liver disease. Baltimore: Williams & Wilkins, 1991: 498-501. Goldsmith R, Yarbough PO, Reyes GR, et al. Enzyme-linked immunosorbent assay for diagnosis of acute sporadic hepatitis E in Egyptian children. Lancet 1992; 339: 328-31
Pneumococcal vaccination for travel to
Spain SIR,-Your July 11editorial highlights our recommendation’ that physicians should consider the use of pneumococcal vaccines for travellers to Spain, especially those with risk factors for pneumonia and invasive pneumococcal disease. Shapiro and co-workers’2 data show again the efficacy of the pneumococcal vaccine and suggest that the vaccine has been underused in the ten or so years since its introduction, even in patients for whom there are clear indications for its use. Dr Martinez and Dr Marcos (Aug 8, p 378) are concerned that fear of epidemic pneumococcal disease has been overstated. Pneumococcal disease is unlikely to arise in epidemics, but vaccination against pneumococcus may have other benefits. Pneumococcal vaccine reduces nasal carriage of the pneumococcus. Decreased acquisition of vaccine strains has been demonstrated in American military personnel3 and in South African miners (Austrian R, personal communication). Similar experience has been noted with other polysaccharide vaccines, including group A meningococcal vaccineand Haemophilus influenzae conjugate vaccine.s Health providers should continue to give pneumococcal vaccines to patients with individual risk factors for invasive disease. International travel provides opportunities for families to consult doctors about appropriate immunisations. Physicians may wish to use such opportunities not only to administer necessary immunisations, but also to give pneumococcal vaccine to eligible patients. In addition, doctors should be alert to the possibility of resistant strains of pneumococcus in patients who have travelled to areas where these strains are known to be prevalent. Maxwell Finland Laboratory for Infectious Diseases,
Boston City Hospital, Boston, MA 02118, USA
ED, Klein JO, Teele DW. Pneumococcal vaccine for Olympic athletes and Spain. New Engl J Med 1992; 326: 1572. 2 Shapiro ED, Berg AT, Austrian R, et al. The protective efficacy of polyvalent pneumococcal polysaccharide vaccine N Engl JMed 1991; 325: 1453-60. 3. MacLeod CM, Hodges RG, Heidelberger M, Bernhard WG. Prevention of pneumococcal pneumonia by immunization with specific capsular polysaccharides. J Exp Med 1945; 82: 445-65. 4 Sivonen A Effect of Neisseria meningitidis group A polysaccharide vaccine on nasopharyngeal carrier rates J Infect 1981, 3: 266-72. 5 Takala AK, Eskola J, Leinonen M, et al. Reduction of oropharyngeal carriage of Haemophilus influenzae Type b (Hib) in children immunized with an Hib conjugate vaccine. J Infect Dis 1991; 164: 982-86. 1 Barnett
Isolation of
atypical HIV-1-related retrovirus from AIDS patient
Laurence and colleagues (Aug 1, p 273) report five of AIDS without evidence of HIV-1 or HIV-2 infection. Highly divergent variants of HIV-1 raise the question of their detection and of their causative role in AIDS. These variants are associated with unusual serological HIV reactivity and have been described mainly in Africa.l,2 We report the isolation of an atypical HIV-1-related retrovirus from a French AIDS patient who had an aytpical western blot profile. A 39-year-old French woman was admitted to Hopital Robert Debre in January, 1990, because of cervical cancer, genital condylomas, and pancytopenia. HIV-1 ELISA was positive; HIV-1western blot showed clear bands at p24, p31, and p55, and a very faint band at gp 160. Serological HIV-2 tests were negative and no p24 antigenaemia was detected. The patient did not mention any risk factor for HIV transmission and her husband was HIV-1 and HIV-2 seronegative. In July, 1991, the patient had anorexia, fatigue, and severe weight loss with very decreased CD4 cell count (20/µl). In October, Pneumocystis carinii pneumonia was diagnosed. AIDS was diagnosed and zidovudine was started in November, although serological HIV profiles were unchanged and no HIV had ever been detected by either culture or PCR in peripheral blood
SIR,-Dr
cases
lymphocytes (PBL). On December 17, with zidovudine at 300 mg daily, a novel PBL cocultivation was started at the Hopital Pitié-Salpêtrière. After 6 days, a positive signal was detected in cell culture supernatant with an immunocapture p24 antigen assay (polyclonal antibody capture, Abbott) and was associated with increasing reverse transcriptase (RT) activity. p24 reactivity, which exceeded 2000 pg/ml, was specifically inhibited by the antigen neutralisation test provided by the manufacturer. p24 reactivity was also confirmed by a monoclonal antibody capture assay (Abbott) that did not react with prototype HIV-2 antigens. Further attempts at viral cocultivation
Electron micrographs of thin sections of infected
lymphocytes.
ELIZABETH D. BARNETT
A = mature virion with dense cone-shaped core, B = budding particles, and C = elongated virus particles Bar=100 nm, A, B, and C at same
JEROME O. KLEIN
magnification
