Hepatitis E Virus. Sally A. Baylis, Division of Virology, Paul-Ehrlich-Institut, Langen, Germany

Transcription

1 Hepatitis E Virus Sally A. Baylis, Division of Virology, Paul-Ehrlich-Institut, Langen, Germany 20 th IPFA/PEI Workshop Lanzarote, 13 th -17 th May 2013

2 Background to HEV Blood and plasma issues Transmission of HEV by S/D plasma, concentrates Clearance of HEV WHO International Standard for HEV for NAT Update on introduction of HEV NAT for S/D plasma

3 Hepatitis E Virus (HEV) HEV is a major cause of acute hepatitis and a public health concern in many developing countries High mortality in certain patients fulminant hepatitis Individuals with underlying liver disease Pregnant women Primarily a water-borne disease poor sanitation New Delhi, India, winter , monsoon flooding of the Jamuna River - 30,000 cases of HEV It was a perfect storm. For about a week, raw sewage was running directly into the city s water supply with no treatment at all. Dr Robert Purcell, NIH

4 Examples of Large Reported Outbreaks of HEV Teshale et al., Clin Infect Dis 2010

5 HEV Outbreak in Kolhapur, India May/June 2012 Ichalkaranji in Kolhapur, India Most likely source of infection - consumption of contaminated water from the Panchganga river Since 15 May 2012: 4085 infected (jaundice) >2096 patients treated and discharged 1250 patients hospitalized ~300 patients still under medical care 78 pregnant women infected 12 deaths, 3 pregnant women (as of 21 st June 2012) Water Quality Monitoring Panchganga River River used for bathing, washing, religious practices

6 Hepeviridae Family of Viruses Hepeviridae family Humans, birds, pigs, wild boar, deer, rabbits, rats, ferrets, bats, fish Small non-enveloped viruses nm 7.2 kb RNA genome (5 cap and 3 poly A tail) ORF1 non-structural protein ORF2 virus capsid protein ORF3 protein involved in morphogenesis (overlaps ORF2) HEV strains infecting humans represent a single serotype

7 HEV Infection in Industrialized Countries HEV is an emerging (more recognized) infection in industrialised countries Infection may be due to travel to endemic areas More autochthonous cases of HEV are being recorded Tendency - older male patients Testing important in patients where other causes of hepatitis have been excluded (global issue) Liver toxicity of drugs some cases may be undiagnosed HEV Chronic infections increasingly recognised Solid organ transplant recipients (Kamar et al., 2008) Patients with haematological disease HIV patients with low CD4 counts

8 HEV Infection of Man Importance of Genotypes 4 main genotypes Genotypes 1 and 2 - humans, epidemics, poor sanitation Genotypes 3 and 4 - humans and range of animal species (pigs, wild boar, deer other animals) High sequence homology between locally circulating animal and human strains, zoonotic transmission (food-borne, animal contact ) The geographical distribution of HEV genotypes is complex Approximately 74% nucleotide identity between genotypes Genotype 3 is comprised of at least 10 sub-genotypes (subgenotypes can vary by as much as 15% nucleotide identity)

9 Hepeviridae Drexler et al., J Virol 2012

10 Geographic Distribution of HEV Genotypes Pelosi and Clarke, Emerg. Health Threats J, 2008

11 Clinical & Epidemiological Characteristics - HEV Genotypes Characteristic Genotypes 1 & 2 (Epidemic) Genotypes 3 & 4 (Autochthonous) Geographic distribution Developing countries only Both developing & developed countries Pattern of spread Epidemic and sporadic Sporadic Species specificity Human Swine, human (humans are accidental host) Major mode of spread Fecal-oral, waterborne Foodborne Rate of icteric illness High Low Age distribution (disease rates) Sex distribution Highest among adolescents & young adults Similar disease rates among men & women Highest among older adults Higher disease rates among men Mortality High among pregnant women High among older adults Extrahepatic features Few Neurological complications Chronic infection None Common in immunosuppressed Adapted from Hoofnagle et al., NEJM, 2012

12 HEV Transmission Transplantation Adapted from Kamar et al., Lancet 2012

13 HEV Infection Kamar et al., Lancet, 2012

14 Diagnosis of HEV Infection Serology detection of anti-hev Anti-IgM acute infection Anti-IgG acute infection and past infection Wide variability in sensitivity, specificity, and interassay agreement among anti-hev-igm immunoassays Drobeniuc et al., Clin Infect Dis Commercial assays for anti-igg show different sensitivities, WHO reference reagent Bendall et al., J Med Virol Underestimation of HEV seroprevalence - many published studies Detection of HEV RNA in blood and stool samples Limited mainly to in-house assays, not standardized

15 HEV Vaccine HEV recombinant vaccine HEV virus-like particles (E. coli) Zhu et al., Lancet 2010 Efficacy and safety of a recombinant hepatitis E vaccine in healthy adults: a large-scale, randomized, double-blind placebocontrolled, phase 3 trial Manufactured by Xiamen Innovax Biotech Co., China HEV 239 has recently been approved for use in China Other vaccine candidates are in development

16 HEV - Blood and Plasma Issues

17 Transfusion Transmission of HEV Several cases of documented cases of TT HEV Iran, Khuroo et al., J Gastroenterol Hepatol Retrospective IgM anti-hev and HEV RNA detected in a significantly higher number of multiple transfused patients (13 of 145) Post-transfusion HEV infection developed in three of 22 susceptible (IgG anti-hev negative) transfused patients UK, Boxall et al., Transfus. Med Donor, 40 yr old male, post-donation illness and jaundice Platelets (plasma removed) and red cells Red cell recipient (lymphoma) developed elevated alanine transaminase (ALT)/mild jaundice Genotype 3 virus identified in donor and recipient

18 Transfusion Transmission of HEV contd. France, Colson et al., EID, 2007 Donor, 24 yr old male, later seroconverted 7 yr old boy with a kidney tumour, received erythrocytes, platelets Elevated ALT (~800 IU/L), jaundice, hepatitis Genotype 3f virus identified in donor and recipient Series of cases in Japan: Matsubayashi et al., Transfusion 2004 Mitsui et al., J Med Virol (haemodialysis - gt 3) Tamura et al., Hepatol Res. 2007

19 Transfusion Transmission of HEV contd. Japan, Matsubayashi et al., Transfusion 2008 Platelet donor, 39 yr old male, subsequent donation showed ALT Lookback study showed previous donation was HEV RNA positive ~3 log copies/ml, gt 4 HEV contaminated platelets were transfused to a 64 yr old patient with non-hodgkin's lymphoma, developed acute hepatitis The donor and 13 relatives ate pork liver and intestines at a barbecue restaurant 23 days prior to donation Father of the donor died - fulminant hepatitis 6 other family members showed serum markers of HEV infection Demonstration that donor was infected by the zoonotic foodborne route

20 Transfusion Transmission of HEV contd. France, Haïm-Boukobza et al., J Hepatol 2012 Initial diagnosis was drug induced liver toxicity - cyclosporine treatment in the patient Patient didn t eat pork for religious reasons Patient received several transfusions; one donation was part of a platelet concentrate (4.2 log 10 IU/ml) Identical genotype 3f virus sequences detected in donor and recipient

21 HEV Infection in a German Plasma Donor Adlhoch et al., Vox Sang A regular plasma donor was diagnosed with acute hepatitis and elevated levels of ALT Negative for HAV, HBV, HCV, EBV, CMV and adenovirus Tested for anti-hev - IgM positive Robert Koch-Institut was notified and a look-back study was performed A genotype 3f virus was identified - donor worked in a slaughter house

22 The HEV Window Period Adlhoch et al., Vox Sang 2009

23 HEV and Plasma Products TTP Patients Canada, Andonov et al., ISBT July 2012 Retrospective study of thrombotic thrombocytopenic purpura patients (TTP) treated with large volumes of pooled plasma Solvent/detergent (S/D)-treated plasma (2500 donors) Cryosupernatant plasma (150 donors) 38 patients received litres of plasma 17 - S/D plasma 19 - cryosupernatant plasma 2 - FFP and Pentaspan or albumin Samples taken at 0, 1 and 6 months post-treatment

24 HEV and Plasma Products TTP Patients Contd. No clinical signs of viral hepatitis in any of the patients No serological evidence of HEV infection at 0 and 1 month post-treatment in any patients 4 out of 17 patients treated with S/D plasma seroconverted at 6 months for anti-hev IgG, 2 also anti-hev IgM +ve The 2 patients positive for anti-hev IgM and IgG were HEV RNA +ve at 1 month post-treatment - gt 3a Indirect evidence of HEV transmission by pooled plasma autochthonous HEV in Canada, 4 cases in last 5 years Annual incidence of HEV infection in German blood donors 0.34% (Juhl et al., Transfusion, Epub ahead of print)

25 HEV and Plasma Products - Haemophiliacs Japan, Toyoda et al., Intervirology, 2008 Evaluation of haemophiliacs, haemodialysis patients vs. blood donors 16.3% of haemophiliacs were anti-hev positive vs. blood donors (3.7%) Parental transmission of HEV likely in recipients of nonvirally inactivated concentrates

26 Inactivation/Removal of HEV HEV small non-enveloped virus Yunoki et al., Vox Sang Investigation of: Liquid heat treatment - 25% albumin, 60 C Dry heat treatment - 60 C, 80 C Virus filtration Viruses used for spiking studies swine faeces (gt 3 or 4) A549 cells (lung carcinoma) used for virus titration or detection of HEV RNA genome by qrt-pcr

27 HEV Reduction Factors (log 10 ) - Liquid-Heat Treatment Heat treatment Liquid heating, 60 C, 30 min Liquid heating, 60 C, 5h, 25% albumin 3JP± swjb-n2 3US swjb-m5 3SP swjb-e10 4JP swjb-h1 e 2.7 e 3.7 e 3.7 e e 2.2 Virus titres determined by infectivity assays Residual virus was detected after heat treatment in the presence of albumin Yunoki et al., Vox Sang. 2008

28 HEV Reduction Factors (log 10 ) - Dry-Heat Treatment Heat treatment Dry-heat, 80 C, 24h, fibrinogen Dry-heat, 60 C, 72h, fibrinogen 3US swjb-m5 3SP swjb-e10 e 4.0 e Virus titres determined by infectivity assays Residual moisture was < 0.3% Matrix may affect sensitivity to inactivation method Yunoki et al., Vox Sang. 2008

29 HEV Reduction Factors (log 10 ) - Virus Filtration Filter 3JP± swjb-n2 3US swjb-m5 3SP swjb-e10 3SP cultured HEV 4JP swjb-h1 35N 1.3 e e N e 3.8 e 3.6 e 3.2 e 2.8 e N e 3.8 e 3.6 e 3.2 e 2.8 e 2.6 Virus spiked into PBS 0.2 µm filtration/75 nm filtration Dead end filtration using Planova 35N, 20N and 15N virus filters Virus titres determined by qrt-pcr Yunoki et al., Vox Sang. 2008

30 HEV Partitioning During Ethanol Fractionation Intermediates spiked HEV derived from swine faeces or human plasma Evaluation using real-time PCR Partitioning of HEV (different spike preparations) during ethanol fractionation is variable -? lipid, Ab effects M. Yunoki, Pers. Comm. 2013

31 Transfusion Transmission of HEV - Japan Year HEV Markers in Donor Plasma HEV RNA HEV IgG HEV IgM Hepatitis E severity in recipient Anti-HEV may not always effectively neutralize virus M. Yunoki, Pers. Comm Possible to propagate infectious HEV in culture using viraemic serum containing anti-hev Takahashi et al., J Clin Microbiol 2010 Vaccine studies protective levels of anti-rhev immunoglobulin of at least 20 WR U/ml (~ 2.5 WHO units/ml) Shrestha et al., NEJM 2008

32 HEV RNA Positive Japanese Donations Area Dates HEV Positive Ratio Hokkaido (Japanese Red Cross) 01/ / / 2,207,772 (1 / 8,692) Tokyo (Japanese Red Cross) 05/ / / 44,332 (1 / 14,777) Japan excl. Hokkaido (Benesis source plasma) 07/ / / 378,718 (1 / 15,800) Genotypes 3 and 4 indentified in donors M. Yunoki, Pers. Comm. 2013

33 Analysis of HEV RNA in Indian and Chinese Blood Donors Country Rate Reference India 3: 200 Arankalle & Chobe, 1999 J Viral Hepat China Detection of gt 1 & gt 4 in anti-hev IgM positive donations Guo et al., 2010 J Clin Microbiol

34 Analysis of HEV RNA in Europe and the US Country Rate Reference England 1: 7,040 Ijaz et al. Vox Sang 2012 extrapolated* Germany 1: 4,415 Sweden 1: 8,278 Baylis et al., Vox Sang 2012 ** USA <1: 50,456 * Blood donors ** S/D plasma donors Similar data in Germany - Vollmer et al., J Clin Micro, Hourfar et al., ISBT abstract, Corman et al., Vox Sang, 2013

35 HEV RNA Positive German & Swedish Donations Viraemic titers usually ~2 to >5 log 10 IU/ml However, viraemic titers may exceed 7 log 10 IU/ml Only 3 of 12 viraemic donations were ALT positive All viruses genotype 3 (3a, 3c, 3e, 3f etc.)

36 HEV in Plasma Pools for Fractionation Source of Pools No. Positive / No. Analysed Europe 3/34 Europe/North America 0/3 North America 1/4 Middle East 0/11 Asia 4/23 Overall 8/75 RNA concentration: d 1000 copies/ml Low antibody levels in fractionation pools (except Asia) Genotype 4 HEV Asia; genotype 3 Europe and USA

37 HEV Strains Developed into Reference Materials for NAT-Based Assays Genotype Virus strain HEV RNA Anti-HEV ALT (IU/L) Reference (copies/ml) IgM/IgG preparation WHO 3a HRC-HE x /- 36 International Standard Japanese 3b JRC-HE3 2.5 x /- 398 National Standard

38 Example - Qualitative Analysis of HRC-HE104 (Genotype 3a) Nominal concentration (log 10 copies/ml) Lab no / a b / / / a b + + +/ a b a b /- - Total number of tests Percentage positive /88 75/67 38/25 13/8

39 Histograms of Participants Results Quantitative assays (white - copies/ml); qualitative assays (blue - NAT-detectable /ml).

40 Potencies Expressed Relative to Sample 1 Potency relative to candidate IS = difference in estimated log 10 units/ml + assigned value of candidate IS (5.39 log 10 IU/ml) Quantitative assays (white); qualitative assays (blue).

41 Establishment of the 1 st WHO IS for HEV RNA 1 st WHO International Standard (IS) for Hepatitis E Virus RNA was established in October 2011 Japanese NIID simultaneously establishing a national standard The IS contains a blood donor-derived genotype 3a HEV strain, diluted in plasma, and lyophilized The IS has a unitage of 250,000 International Units/ml The IS is available from the PEI (code # 6329/10) WHO/BS/

42 HEV Reference Panels The WHO Expert Committee on Biological Standardization endorsed the proposal to prepare an HEV RNA genotype panel at the annual meeting in October 2011 (WHO/BS/ ) The panel is intended to contain representative of all genotypes and important sub-genotypes Candidate samples for the preparation of the panel include materials evaluated in the original collaborative study, strains detected in blood/plasma donors & clinical isolates Future, re-evaluate the WHO anti-hev IRR

43 Analysis based upon partial RdRp sequence b

44 Proposal to Amend the Ph. Eur. Monograph 1646 The proposal is to amend monograph Human plasma (pooled and treated for virus inactivation) Not plasma for fractionation Plasma for fractionation undergo further processing including steps for virus inactivation/removal No inactivation/removal step for non-enveloped viruses, such as HEV, during the production of S/D plasma HEV detected in respective European plasma donations Amendment would see the introduction of HEV NAT

45 Proposed Text The Hepatitis E virus RNA: The plasma pool is tested using a validated nucleic acid amplification technique (2.6.21). A positive control with 2.5 log 10 IU of hepatitis E virus RNA per mililitre and, to test for inhibitors, an internal control prepared by addition of a suitable marker to a sample of the plasma pool are included in the test. The test is invalid if the positive control indicates the presence of inhibitors. The pool complies with the test if it is found non-reactive for hepatitis E virus RNA.

46 Proposal to Amend the Ph. Eur. Monograph 1646 The proposal was discussed at the group 6B (Human Blood and Blood Products) meeting at EDQM - March 2012 Jan-Mar 2013 Pharmeuropa public consultation Mar-May 2013 Pharmeuropa National Authority comments Pharmeuropa 25.1.: until 31/05/2013 Oct 2013 Discussion of comments by Group 6B Nov 2013 Proposal to Ph. Eur. Commission 1 Jul 2014 Publication 1 Jan 2015 Implementation Biological Standardisation Programme project (BSP127) Biological Reference Preparation HEV RNA for NAT

47 JRCS Keiji Matsubayashi Hidekatsu Sakata JBPO Mikihiro Yunoki NIID, Japan Saeko Mizusawa Yoshiaki Okada Thomas Gärtner Anton Andonov WHO Acknowledgments PEI Ana Padilla and Collaborative Study Participants Johannes Blümel Kay-Martin Hanschmann Roswitha Kleiber Sigrid Nick Micha Nübling Gudrun Winskowsky Institute of Virology, Bonn UK Felix Drexler Victor Corman Harry Dalton Linda Scobie/Claire Crossan