As hepatites são as causas mais comuns de cirrose hepática e carcinoma hepatocelular (HCC) no mundo, sendo as infecções por Vírus da Hepatite B (HBV) e Vírus da Hepatite C (HCV) consideradas aquelas de maior importância como problemas de saúde pública, devido ao grande número de indivíduos atingidos (cerca de 350 milhões com hepatite B crônica e 170 milhões com HCV). No Brasil, avaliações realizadas nas últimas décadas sugerem que a endemicidade da hepatite B na região amazônica não tem decaído, com o agravante da precariedade do acesso aos cuidados de saúde nessa região. Assim, este estudo tem por objetivo avaliar o tratamento dispensado aos pacientes com hepatites virais B e C no Amapá, que faz parte da Amazônia Legal, para que seja possível conhecer a situação da saúde publica dessa localidade. A coleta de dados foi realizada em um centro de referência que centraliza o atendimento aos pacientes portadores de hepatite B e C, por meio de instrumento de coleta de dados previamente validado e aprovado pelo Comitê de Ética em Pesquisa da Faculdade de Ciências Farmacêuticas de Ribeirão Preto, Universidade de São Paulo (CEPFCFRP/USP), entre 1º de julho de 2007 e 30 de junho de 2009, e o programa estatístico EPI INFO, versão 3.5.1, foi utilizado para o lançamento e análise dos dados coletados. Foram incluídos 123 pacientes suspeitos ou portadores de hepatites virais B e/ou C, com idade média de 48,3 anos e 85,4% dos indivíduos entre 30 e 69 anos de idade, sendo 55,3% do sexo masculino, 61,0% casados, 82,1% residentes em Macapá, e 39,0% encaminhados por detecção de suspeita através de exames de rotina/pré-operatório ou pelo HEMOAP. Somando-se monoinfecções e coinfecções, 66,4% e 33,6% eram de pacientes infectados por HCV e HBV, respectivamente, sendo que os crônicos eram 61,0%. O acompanhamento clínico/ambulatorial desses pacientes foi inferior a 6 meses em 52% dos casos, e 40,0% apresentavam algum grau de severidade da doença, mas em 28,6% e 65,1% desses pacientes houve ausência de exames de ultrassonografia abdominal e determinação de níveis de aminotransferases, respectivamente. O genótipo para HCV só foi determinado em 30,6% dos casos de HCV e houve falha de notificação no SINAN em 25,2% dos pacientes do estudo. Três (7,0%) portadores de HBV e 16 (18,8%) de HCV receberam tratamento farmacológico específico, entretanto, outros seis pacientes com HBV e 19 com HCV apresentavam um critério de inclusão no tratamento, mas não foram tratados por ausência de exames de monitoramento. Na avaliação dos protocolos clínicos brasileiros para tratamento de HBV e HCV em relação aos internacionais, os primeiros se mostraram adequados e atualizados, entretanto, as falhas em seu seguimento pelas unidades de saúde que integram a rede assistencial para pacientes com HBV e HCV resultaram em deficiências nos serviços oferecidos, possivelmente decorrentes de treinamentos e capacitações insuficientes, ausência serviços de maior complexidade, e também devido isolamento natural da região. Diante dessas evidências, verifica-se a necessidade de ações governamentais no combate às hepatites virais mais abrangentes e que alcancem essa região. / Hepatitis are the most common cause for cirrhosis and hepatocelullar carcinoma (HCC) in the worldwide, and infections by the Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are considered the most importance as public health problems, due to the large number of affected individuals (about 350 millions with chronic hepatitis B and 170 millions with HCV). In Brazil, evaluations made in the last decades suggest that the endemicity in Amazon area has not decreased, with the worsen situation of uncertain access to the health care in this location. Therefore, this research has the purpose to evaluate the treatment delivered to the patients infected by hepatitis virus B and C in Amapa, which belongs to the Legal Amazon, due to become possible to know the public health situation in this location. The data collection was placed in a reference center which concentrates the attendance to the hepatitis B and C carriers, using a data collection instrument previously validated and approved by the Ethics Committee in Research of the College of Pharmaceuticals Sciences of Ribeirão Preto, University of São Paulo (CEP-FCFRP/USP), between July 1st 2007 and June 30th 2009, in addition, the statistical software EPI INFO, version 3.5.1, was used to register and analyze the collected data. The 123 included individuals were suspected to have the infection or hepatitis B and/or C carriers, mean age of 48.3 years and 85.4% of these individuals were aged between 30 and 69 years old, 55.3% were men, 61.0% of them were married, 82.1% were resident in Macapa, and 39.0% of them were forwarded to the reference center due to detection of the infection by the routine exams / before surgery or by the HEMOAP, the blood bank. By the total of monoinfections and coinfections, 66.4% and 33.6% were patients infected by HCV and HBV, respectively, and the chronic patients were 61.0%. The clinical/ambulatorial follow-up of these patients were less than 6 months in 52.0% from the total, and 40.0% showed some severity grade due to the disease, however, 28.6% and 65.1 of these patients were lack of abdominal ultrasonography and aminotransferases determination exams, respectively. The genotype for HCV were determinate only in 30.6% of HCV infections and there were in SINAN notification failure in 25.2% of patients of study. Three (7.0%) HBV carriers and 16 (18.8%) HCV carriers receipt specific pharmacological treatment, nevertheless, others six HBV patients and 19 HCV patients had at least one criteria of inclusion in the treatment, but they were not treated because of monitoring exams absence. In the evaluation of Brazilian clinical protocol to HBV and HCV in regard to the international ones, those ones showed to be appropriates and updated, however, the failures in their following by the health units that integrate the assistance network to the HBV and HCV infected patients had outcomes in lack of offered services, probably due to insufficient training and qualification of the professionals, lack of more complex services, and also due to natural isolation of this area. Because of these evidences, it verifies the need of more including and reaching government actions to fight the viral hepatitis in this location.

This thesis examines cancer and mortality rates among people diagnosed with hepatitis B (HBV) and C (HCV) infection in New South Wales (NSW) from 1990 through 2002, by linking hepatitis notifications with the NSW Central Cancer Registry (CCR) and National Death Index. Of the 39101 HBV, 75834 HCV and 2604 HBV/HCV co-infection notifications included 1052, 1761 and 85 were linked to cancer notifications and 1233, 4008 and 186 were linked to death notifications respectively. Of 2072 hepatocellular carcinoma (HCC) notifications to the CCR 323, 267 and 85 were linked to HBV, HCV and HBV/HCV co-infection notifications. Incidence of HCC was 6.5, 4.0 and 5.9 per 1000 person years for HBV, HCV and HBV/HCV co-infected groups. Risk of HCC in those diagnosed with hepatitis was 20 to 30 times greater than the standard population. There was a marginally statistically significant increased risk of immunoproliferative malignancies associated with HCV infection (SIR=5.6 95% CI 1.8 ???17.5). Risk of death for those with hepatitis was significantly greater, 1.5 to 5 fold, than the general population with the greatest risk among those with HBV/HCV co-infection. The primary cause of HBV deaths was liver related, particularly HCC, whereas in the HCV groups drug related deaths were most frequent. Among people with HCV, risk of dying from drug related causes was significantly greater than from liver related causes (p=0.012), with the greatest increased risk in females age 15- 24 years (SMR 56.9, 95%CI 39.2???79.9). Median age at diagnosis of HCC varied markedly by country of birth and hepatitis group: HBV 66, 63 and 57years ; HCV 51, 68 and 71 years; unlinked 69, 70 and 64 years for Australian, European, and Asian-born groups, respectively (P<0.0001 for all groups). While the risk of cancer, particularly HCC, is elevated among people with HBV and HCV infection, the absolute risk remains low. Young people with HCV face a higher mortality risk from continued drug use than from liver damage related to their HCV infection. The influence of IDU in the epidemiology of HCC in New South Wales was possibly reflected in the varying distributions of age and country of birth.

Hepatito B virusas (HBV) yra plačiai paplitęs žmogaus patogenas, bet iki šiol mažai ištirta jo šerdies baltymo (HBc), o ypač natūraliai aptinkamų mutantinių formų įtaka viruso dauginimuisi ir patogeniškumui. Šiame darbe mielių dviejų hibridų metodu atrinkti žmogaus kepenų baltymai, sąveikaujantys su laukinio tipo baltymu bei mutantais HBc1 ir HBc2. Su visomis tirtomis HBc atmainomis stipriausiai ir specifiškiausiai sąveikavo žmogaus baltymai GIPC1 ir GIPC2. Detaliau tiriant šias sąveikas nustatyta, kad HBc baltymo C-galas sąveikauja su GIPC1 ir GIPC2 baltymų PDZ domenais. HBc baltymo C-gale aptiktas PDZ domenų atpažįstamos sekos motyvas ir parodyta, kad šios sekos pokyčiai įtakoja HBc sąveiką su GIPC1 ir GIPC2. Vien su mutantais HBc1 ir HBc2 stipriausiai ir specifiškiausiai sąveikavo žmogaus baltymai FLJ20850 ir IKK (NEMO). Anksčiau netyrinėto nežinomos funkcijos žmogaus baltymo FLJ20850 raiška ir geno struktūra apibūdinta naudojantis bioinformatinėmis duomenų bazėmis. Detaliau tiriant mutantų sąveikas su FLJ20850 ir IKK buvo nustatytos baltymų sritys, apsprendžiančios tarpusavio sąveiką. IKK baltymas reguliuoja transkripcijos veiksnio NF-κB aktyvumą, todėl buvo tiriama ir mutanto HBc1 įtaka NF-κB aktyvumui žmogaus ląstelėse. Aptiktos baltymų sąveikos gali padėti geriau suprasti HBV dauginimosi ciklą bei patogeniškumą ir tapti naujų antivirusinių vaistų taikiniais. / Hepatitis B virus (HBV) is a major human pathogen, but up to now little is known about its core protein (HBc) interactions with host proteins. The role of mutated HBc proteins in enhanced pathogenicity of mutant viruses is also unclear. In this work, the yeast two-hybrid system was employed to find human proteins interacting with HBV core mutants HBc1 and HBc2, as well as with the wild-type core protein. All HBc variants strongly and specifically interacted with human proteins GIPC1 and GIPC2. Common protein interaction domain PDZ in both GIPC1 and GIPC2 was identified as the region interacting with the C-end of HBc. A putative PDZ-interacting motif was identified at the C-end of the HBc protein, and variation of this sequence influenced determined interactions. Human proteins FLJ20850 and IKKγ (NEMO) strongly and specifically interacted with mutants HBc1 and HBc2 only. Gene structure and expression FLJ20850 protein, which was never before described in scientific literature, were analyzed bioinformatically. Detailed analysis of interacting protein pairs revealed regions, responsible for discovered interactions. IKKγ is known as an important regulator of transcription factor NF-kB, therefore HBc1 influence on NF-kB activity in human cells was evaluated experimentally. Determined protein interactions potentially add to understanding of HBV replication and pathogenicity and could serve as targets for developing of new antivirals.

Hepatitis B virus (HBV) is a major human pathogen, but up to now little is known about its core protein (HBc) interactions with host proteins. The role of mutated HBc proteins in enhanced pathogenicity of mutant viruses is also unclear. In this work, the yeast two-hybrid system was employed to find human proteins interacting with HBV core mutants HBc1 and HBc2, as well as with the wild-type core protein. All HBc variants strongly and specifically interacted with human proteins GIPC1 and GIPC2. Common protein interaction domain PDZ in both GIPC1 and GIPC2 was identified as the region interacting with the C-end of HBc. A putative PDZ-interacting motif was identified at the C-end of the HBc protein, and variation of this sequence influenced determined interactions. Human proteins FLJ20850 and IKKγ (NEMO) strongly and specifically interacted with mutants HBc1 and HBc2 only. Gene structure and expression FLJ20850 protein, which was never before described in scientific literature, were analyzed bioinformatically. Detailed analysis of interacting protein pairs revealed regions, responsible for discovered interactions. IKKγ is known as an important regulator of transcription factor NF-kB, therefore HBc1 influence on NF-kB activity in human cells was evaluated experimentally. Determined protein interactions potentially add to understanding of HBV replication and pathogenicity and could serve as targets for developing of new antivirals. / Hepatito B virusas (HBV) yra plačiai paplitęs žmogaus patogenas, bet iki šiol mažai ištirta jo šerdies baltymo (HBc), o ypač natūraliai aptinkamų mutantinių formų įtaka viruso dauginimuisi ir patogeniškumui. Šiame darbe mielių dviejų hibridų metodu atrinkti žmogaus kepenų baltymai, sąveikaujantys su laukinio tipo baltymu bei mutantais HBc1 ir HBc2. Su visomis tirtomis HBc atmainomis stipriausiai ir specifiškiausiai sąveikavo žmogaus baltymai GIPC1 ir GIPC2. Detaliau tiriant šias sąveikas nustatyta, kad HBc baltymo C-galas sąveikauja su GIPC1 ir GIPC2 baltymų PDZ domenais. HBc baltymo C-gale aptiktas PDZ domenų atpažįstamos sekos motyvas ir parodyta, kad šios sekos pokyčiai įtakoja HBc sąveiką su GIPC1 ir GIPC2. Vien su mutantais HBc1 ir HBc2 stipriausiai ir specifiškiausiai sąveikavo žmogaus baltymai FLJ20850 ir IKK (NEMO). Anksčiau netyrinėto nežinomos funkcijos žmogaus baltymo FLJ20850 raiška ir geno struktūra apibūdinta naudojantis bioinformatinėmis duomenų bazėmis. Detaliau tiriant mutantų sąveikas su FLJ20850 ir IKK buvo nustatytos baltymų sritys, apsprendžiančios tarpusavio sąveiką. IKK baltymas reguliuoja transkripcijos veiksnio NF-κB aktyvumą, todėl buvo tiriama ir mutanto HBc1 įtaka NF-κB aktyvumui žmogaus ląstelėse. Aptiktos baltymų sąveikos gali padėti geriau suprasti HBV dauginimosi ciklą bei patogeniškumą ir tapti naujų antivirusinių vaistų taikiniais.

Glomerulonephritis as an extra hepatic manifestation of chronic HBV infection has now been well documented [1,2,3,4,5]. HBV-associated nephropathy has been described in areas of both high and low endemicity [6]. In Africa HBV-associated nephropathy has been reported from the southern, central and northern regions [7,8,9,10,11]. In the southern African continent the prevalence of HBV-associated nephropathy appears to be higher than the rest of the continent [12]. In KwaZulu/Natal, South Africa, the prevalence of hepatitis B surface antigenaemia (HbsAg) in urban, rural and institutionalised children was reported to be 6.3%, 18.5% and 35.4% and the HBV exposure rates, as shown by the presence of any marker of HBV infection, 19.5%, 65.1% and 70.1% respectively amongst black children [13]. Prior experience of nephrotic syndrome (NS) and its association with HBV in black children, already published in a series of reports, showed HBV-associated nephropathy to be the commonest form of nephrotic syndrome among black patients in KwaZulu/Natal; membranous nephropathy (MN) being the commonest histological type reported [7,14]. The only other large series of HBV-associated nephropathy in southern Africa was from Cape Town of a large cohort of children, mainly of mixed ancestory (coloured), with a small number of black children [8]. There have been no other large studies of this condition amongst black children in Africa. We therefore undertook a series of studies to delineate the spectrum of this disease in black children with regard to the following: clinical presentation, laboratory findings, natural history, biosocial background, genetics (using HLA Class I and II antigens) as well as the impact of treatment and prevention by immunisation. We commenced these studies by reviewing our 20-year experience of 636 children with NS in Durban, South Africa for the period 1976- - 1995. Three hundred and six (48.2%) were blacks, 307 (48.2%) Indians and 23 (3.6%) were a mixed group (coloured); 91 (14.3%) could not be categorised and were excluded from the analysis. In black children, membranous nephropathy accounted for 43% of all cases of NS; 86.2% of these 306 children were associated with hepatitis B virus antigens [15]. This contrasts with the 2% - 5% prevalence of idiopathic membranous nephropathy reported in western countries [16]. We then proceeded to document the clinical features of this disease in black children. One hundred and thirty-three children with NS positive for HBV carriage were studied. In 70 patients the histological type was membranous; 46 of these 70 patients were followed up for a mean of 3.4 years (range 1-11). Spontaneous elimination of both HBsAg and HBeAg occurred in 10 (21.7%) of the 46 patients; 16 (34.8%) cleared HBeAg alone. Co-existing liver disease occurred in 18 (25.7%); hypocomplementaemia (low C3 and C4) in 22 (47.8%) and 5 (10.9%) of these 46 children respectively. Sixty-five (92.9%) of the 70 patients had normal renal function; 1(1.4%) impaired renal function; 3 (4.3%) chronic renal insufficiency and 1(1.4%) end stage renal disease at last hospital visit. Twelve (17.1%) of the 70 patients were in remission; all having cleared HBeAg. HBVMN was clinically indistinguishable from 24 children with idiopathic MN although biochemical characteristics were different. There were 23 patients with histological lesions other than MN. Forty patients with clinical, biochemical and serological findings similar to those with HBVMN and the other histological types, were unbiopsied. This report delineates the natural history of HBV infection in black South African children with NS, the majority of whom have MN. Disease remission in HBVMN parallels elimination of HBV antigens, particularly HBeAg. Comparison of HBVMN with idiopathic MN revealed clinically indistinguishable characteristics but unexplained biochemical differences [14]. Little is understood of the biosocial context in which HBV-associated nephropathy (particularly MN) develops. In the next two studies we evaluated HBV status and proteinuria in family members and household contacts of index children with HBVMN to test the hypothesis that HBV carriage and asymptomatic proteinuria are closely linked and may be causally associated. In the first of these two studies, thirty-one black children with biopsy-proven HBVMN were the index cases. One hundred and fifty-two family members and 43 black household contacts were the subjects of this study. We assessed HBV carrier status by testing for HBV antigens and antibodies using enzyme-linked immunosorbent assays (ELISA) and for HBV DNA by using slot-blot hybridisation and nested polymerase chain reaction. Sequencing of the precore HBV region of HBV was done in a subset of both index cases and subjects. Proteinuria was assessed by measuring the urinary protein: creatinine ratio. Seventy-two (37%) of the 197 family members and household contacts were HBV carriers, and 53 (27%) had a protein: creatinine ratio greater than the physiological limit (protein: creatinine ratio <0.2). Abnormal proteinuria was defined by a protein: creatinine ratio 0.2. Continuous data was compared using analysis of variance. Categorical data were compared using Chi-square test or Fisher’s exact test where appropriate. A probability of <0.05 was considered significant. The frequency of abnormal proteinuria was not significantly different in those with [22 (30.5%) of 72] or without [33 (32%) of 104] HBV carriage. This lack of association remained when carriers were classified into those who were HBsAg positive only and those with active viral replication (HBsAg and/or HBeAg and/or HBV DNA; p = 0.01). Family members were more predisposed to HBV carriage than household contacts, but abnormal proteinuria was present with equal frequency (p = 0.48). Age had a significant impact on proteinuria, with children less than five years being more likely to have abnormal proteinuria (p = 0.008). The prevalence of abnormal proteinuria in family members and household contacts of the index cases was more than in community-based controls. The 10 index HBVMN cases and 14 family members and household contacts that were tested all had HBV of genotype A. The results suggest that the family members and household contacts of children with HBVMN are at very high risk of HBV carriage; they also have asymptomatic proteinuria at a significantly higher rate than community-based controls. The HBV carrier status was not associated with proteinuria. This lack of association was a finding supported by peak prevalences of proteinuria in those under five years but no corresponding peak of HBV carriage. Proteinuria may indicate glomerular basement membrane dysfunction. Environmental and social factors may underpin development of these two disorders, but are insufficient to account for the index cases of HBVMN. The emergence of children with HBVMN from such households additionally depends on unidentified and possibly genetic factors [17]. In the second study of the biosocial background in which the HBV carrier-state with MN develops, we used the same subjects. One hundred and twenty-three unrelated individuals from the communities of the index cases, negative for HBV, served as controls. In this study, proteinuria was assessed using sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) and protein: creatinine ratios. Patterns of proteinuria on SDS-PAGE were classified as glomerular, tubular or mixed; IgG and haptoglobulin were suggestive of MN. Seventy-two (36.9%) of the 195 family members and household contacts were HBV carriers; 21 (29.2%) of these carriers had evidence of proteinuria using SDS-PAGE. Twenty-eight (41.2%) of the sixty-eight members of the study group who were HBV negative and 26.8% of the controls also showed proteinuria on SDS-PAGE. This lack of association between HBV carriage and proteinuria remained when controlled for gender and family relationship. Also, HBV was not protective against the development of proteinuria. Age was associated directly with a glomerular pattern of proteinuria (p = 0.007). Those having a pattern of proteinuria suggestive of MN were more likely to have an abnormal protein: creatinine ratio (p = 0.001). Ten (59%) subjects with a membranous pattern of proteinuria and 19 (47.5%) with a non-membranous pattern of proteinuria had microscopic haematuria. Such a pattern of proteinuria was not significantly different between subjects and community based controls (8.7% vs. 6.5%, p = 0.5). Environmental exposures in these subjects may be responsible for the proteinuria, which probably reflects underlying glomerular basement membrane damage. Discordance between the HBV carrier-state and patterns of proteinuria in the study group suggest that interaction between specifically vulnerable individuals and HBV group suggest HBV and MN may not be causally related or that it reflects exceptional interaction between specifically vulnerable individuals and HBV [18]. From the above two studies we inferred that the pathogenetic mechanisms by which individuals with chronic HBV infection develop MN are probably dependent on interactions between viral, host and environmental factors; some evidence suggests a genetic predisposition. We therefore undertook another two studies to explore HLA associations in black children with HBVMN. In the first of these two studies, thirty black children, age range 2 to 16 years, with biospy-proven HBVMN, were the subjects of this study. HLA A, B and C antigens were determined using a two-stage lymphocytotoxic test. HLA DRB1* and DQB1* typing was done using sequence-specific primers. HLA class I and II antigen frequencies of the study subjects were compared to controls that were randomly chosen healthy blood donors from the same population. HLA DQB1*0603 was increased in patients with HBVMN compared to controls (chi-square 13.65, RR 4.3). DRB1*07 and DQB1*02 were increased in frequency in the study subjects but failed to reach statistical significance. There was no significant difference in the frequencies of class I antigens in the study group compared to controls. This study is the first report of HLA associations in black patients with HBVMN in whom Class I and II antigens were determined using molecular methodology. It shows a high frequency of DQB1*0603 in black children with HBVMN compared to controls suggesting a possible genetic predisposition to the development of HBVMN [19]. Following our findings of an HLA Class II association in black children with HBVMN, we proceeded to determine if HLA DQB1*0603 predisposes to HBV carriage and development of abnormal proteinuria in the second study. We studied 70 family members of 14 children with HBVMN positive for HLA DQB1*0603 selected from the first study. Associations of HLA DQB1*0603 to HBV carriage and abnormal proteinuria were determined using the mean probability ratio (LOD scores). Forty-seven of the 70 (67%) family members were positive for HBV infection. Nineteen (27%) had abnormal range proteinuria. LOD scores in the study subjects with DQB1*0603 who were HBV negative vs. those with DQB1*0603 who were HBV positive was not significant (anti-log sum = 2.0559 and average 0.23). When a similar calculation was done for abnormal proteinuria, there were no significant findings (anti-log sum = 3.8587 and average 0.43). This lack of association between HLA DQB1*0603 with either HBV carriage or abnormal proteinuria in family members suggests that additional factors may play a role in predisposing children to chronic HBV carriage and the development of MN. We therefore conclude that the main effect of HLA DQB1*0603 which distinguishes HBVMN from family members is the degree of proteinuria which is a reflection of the severity of glomerular basement membrane damage in the latter [20]. In the next study we proceed to investigate the efficacy of Interferon alpha 2b (INTRON A ®) in the treatment of HBV-associated nephropathy in black children. Twenty-four black children with biopsy-proven HBV-associated nephropathy were recruited into the study during the period April 1997 to June 1999. Five defaulted treatment and were excluded from the primary analysis. IFN 2b was administered for 16 weeks. Response to treatment was defined as loss of HBeAg, decrease in proteinuria, and prevention of deterioration in renal and liver function. A control group of 20 patients was followed up for the same period. Ten (52.6%) of the treated children responded with clearance of HBeAg by 40 weeks. None cleared HBsAg. All responders showed remission of proteinuria, 90% maintained normal renal function and 1 (10%) showed improvement of renal function. HBV DNA levels decreased in this group. Nine patients did not clear HBeAg; none showed remission of proteinuria, 2 showed deterioration of renal function. Liver enzymes rose during treatment but subsequently declined irrespective of response to therapy. No serious side effects were encountered. Only 5% of controls showed spontaneous clearance of HBeAg, and none had remission of proteinuria. Black children with HBV-associated nephropathy show accelerated clearance of HBeAg with remission of proteinuria following treatment with IFN 2b. IFN 2b was well-tolerated [21]. We then went on to investigate the impact of HBV vaccination in South Africa over 6 years on HBV-associated MN. HBV vaccine has resulted in a decline in the incidence of HBV carriage and hepatocellular carcinoma in South East Asia. Vaccine efficacy in Africa has not been adequately assessed. King Edward VIII Hospital, Durban, South Africa, is the only tertiary referral centre for the province of KwaZulu/Natal for children with renal diseases. HBV vaccine was introduced into the Extended Programme on Immunisation (EPI) in April 1995; vaccine coverage rates between 1995-2001 for children for the first, second and third doses were 85.4%, 78.2% and 62.0% respectively. HBV status was determined using radioimmunoassay (1984 – 1991) or ELISA. MN was confirmed on renal biopsy. The hospital average annual incidence of HBVMN was compared pre and post-vaccination, and according to age groups. Between 1984 and 2001 there were 119 children with HBVMN; the mean age was 7 years (range 1 to 14 years) and 101(85%) were males. The average annual rate ratio (aRR) per 105 child population was 0.25. The aRR of 0.03 for the years 2000-2001, was significantly lower than the aRR of 0.22 during the pre-immunisation period (1984 – 1994) [p = 0.003; RR = 0.12 (95% CI: 0.03 – 0.5)]. The aRR in 2000-2001 for children 0 – 4 years (0.00) and 5 – 10 years (0.09) were significantly lower than in the pre-vaccination years (0.16 and 0.46, p = 0.01 and 0.02 respectively). Thus, HBV vaccine, even at low coverage for the full EPI schedule, reduced the hospital incidence of HBVMN by six years [22]. From this series of studies we concluded that prior to the introduction of the HBV vaccine into the Expanded Programme on Immunisation in Children, HBV-associated nephropathy, particularly MN was the commonest form of NS in black children. Several studies have suggested on the basis of epidemiological, clinical and immunological evidence a causal association between chronic HBV carriage and the development of nephropathy. In our present series of studies we have findings that lend further support to the causal association between HBV carriage and development of nephropathy, particularly MN, in black children. We have shown that genetic and other environmental factors may also play a role in determining the degree of proteinuria. Those children with abnormal range proteinuria less than the nephrotic range show no association with HBV carriage or genetic factors with regard to HLA linkage. The efficacy of interferon treatment in elimination of the HBV and abrogation of proteinuria following clearance of the virus (particularly the HBeAg) as well as the impact of routine HBV immunisation in preventing HBV carriage and subsequent development of nephropathy lends further support to our findings. The impact of viral load has yet to be investigated. / Thesis (Ph.D.)-University of Natal, Durban, 2002.

This thesis examines cancer and mortality rates among people diagnosed with hepatitis B (HBV) and C (HCV) infection in New South Wales (NSW) from 1990 through 2002, by linking hepatitis notifications with the NSW Central Cancer Registry (CCR) and National Death Index. Of the 39101 HBV, 75834 HCV and 2604 HBV/HCV co-infection notifications included 1052, 1761 and 85 were linked to cancer notifications and 1233, 4008 and 186 were linked to death notifications respectively. Of 2072 hepatocellular carcinoma (HCC) notifications to the CCR 323, 267 and 85 were linked to HBV, HCV and HBV/HCV co-infection notifications. Incidence of HCC was 6.5, 4.0 and 5.9 per 1000 person years for HBV, HCV and HBV/HCV co-infected groups. Risk of HCC in those diagnosed with hepatitis was 20 to 30 times greater than the standard population. There was a marginally statistically significant increased risk of immunoproliferative malignancies associated with HCV infection (SIR=5.6 95% CI 1.8 ???17.5). Risk of death for those with hepatitis was significantly greater, 1.5 to 5 fold, than the general population with the greatest risk among those with HBV/HCV co-infection. The primary cause of HBV deaths was liver related, particularly HCC, whereas in the HCV groups drug related deaths were most frequent. Among people with HCV, risk of dying from drug related causes was significantly greater than from liver related causes (p=0.012), with the greatest increased risk in females age 15- 24 years (SMR 56.9, 95%CI 39.2???79.9). Median age at diagnosis of HCC varied markedly by country of birth and hepatitis group: HBV 66, 63 and 57years ; HCV 51, 68 and 71 years; unlinked 69, 70 and 64 years for Australian, European, and Asian-born groups, respectively (P<0.0001 for all groups). While the risk of cancer, particularly HCC, is elevated among people with HBV and HCV infection, the absolute risk remains low. Young people with HCV face a higher mortality risk from continued drug use than from liver damage related to their HCV infection. The influence of IDU in the epidemiology of HCC in New South Wales was possibly reflected in the varying distributions of age and country of birth.

La découverte d’adjuvants de vaccination est en pleine expansion dans un contexte règlementaire de plus en plus strict. L’objectif de ce travail de thèse a été de proposer un adjuvant hautement caractérisé de la famille de la lysophosphatidylcholine (LPC) pour un développement clinique. Il avait été précédemment montré que la LPC d’oeuf de poule présentait des propriétés adjuvantes in vitro et in Vivo. Cependant, il s’agit d’un mélange hétérogène d’espèces moléculaires de LPC peu exploitable en clinique. Nous avons donc cherché à 1/ cribler in vitro 5 différentes espèces moléculaires de LPC ayant des activités adjuvantes, et 2/ évaluer chez la souris l’aptitude des molécules sélectionnées à induire des réponses humorales et cellulaires.Deux candidats, les LPC C16 :0 et C18 :0, induisent in vitro la maturation de cellules dendritiques humaines caractérisée par l’augmentation de l’expression des marqueurs de surface, la production de chimiokines pro-Th1 et l’engagement vers un profil Th1 de lymphocytes T CD4+. Chez la souris, l’injection i. v. des candidats induit une réponse inflammatoire transitoire et modérée au profil Th2 (IL-5, IL-6). De plus, ces espèces induisen une réponse humorale spécifique contre 3 antigènes viraux après injection s. c. ou i. m. (NS3du VHC, HBsAg du VHB et gp120 du VIH), proche de celle obtenue avec l’alun et à des doses faibles supposées non toxiques. Dans ces modèles, en revanche, les LPC individuelles ne semblent pas induire de réponses cellulaires spécifiques.L’ensemble de ces résultats ouvre d’intéressantes perspectives pour l’utilisation des LPC C16 :0 et C18 :0 en tant qu’adjuvants de vaccination de réponses immunitaires humorales. / The evaluation of new vaccine adjuvants is growing fast in a stringent regulatory environment. The aim of this thesis project was to propose a highly defined adjuvant derived from the lysophosphatidylcholine (LPC) for clinical development. It has been previously shown that an egg-derived LPC has in vitro and in Vivo adjuvant features. However, it is composed of a heterogeneous mixture of molecular species of LPC, thus precluding itsclinical evaluation. Therefore, we decided to 1/ screen in vitro 5 single species of LPC fortheir adjuvant properties, and 2/ evaluate in the mouse model the ability of selected compounds to induce humoral and cellular responses.Two candidates, the C16:0- and C18:0-LPC, induce in vitro maturation of human dendritic cells as defined by an up regulation of the expression of surface markers, production of pro-Th1 chemokines, and engagement of CD4+ T lymphocytes towards a Th1 profile. Inmice, i. v. injection of both candidates triggers a transient and moderate inflammatory response with a Th2 profile (IL-5, IL-6). In addition, these species initiate specific humoral responses against 3 viral antigens following s. c. or i. m. injection (NS3 from HCV, HBsAgfrom HBV and gp120 from HIV), close to what is achieved with alum and at low doses expected to be safe in humans. In these models, however, single LPC do not mediatespecific cellular responses. Over all, these results open interesting perspectives for the single

Introdução: este documento trata de questões relativas à vigilância epidemiológica das hepatites B e C em doadores de sangue que foram notificados no SINAN NET no ano de 2007 no estado do Rio Grande do Sul. Faz parte uma revisão bibliográfica sobre os marcadores sorológicos e técnicas utilizadas pelos laboratórios do banco de sangue e vigilância epidemiológica. Relata as definições e os fluxos estabelecidos pelo PNHV e um artigo que compara os resultados do laboratório do banco de sangue com o laboratório da vigilância epidemiológica. Método: Discute os resultados obtidos neste estudo transversal, com as evidencias levantadas na revisão bibliográfica e busca responder as questões que serviram de estímulo para realização deste estudo. Os resultados concordam? Quanto se gasta para repetir os marcadores? Quanto tempo leva para um doador definir sua situação em relação à doença? Qual a proporção de doadores no quantitativo dos casos notificados de hepatites virais? Resultados: o coeficiente Kappa para o marcador HBsAg foi de 0,74 para o Anti-HBc 0,72 , para HBsAg e Anti-HBc associados foi 0,98 e para o Anti-HCV foi de 0,82. O gasto para repetição destes marcadores foi de R$ 28.956,55. O tempo de espera para o doador definir sua situação em relação à doença foi de uma mediana de 162 dias. A proporção de doadores notificados foi de 7,90%. Conclusão e considerações finais: Os resultados obtidos evidenciam que esta concordância existe, variando de substancial a concordância quase perfeita, para os casos de interesse da vigilância epidemiológica. O tempo de espera evidencia o não atendimento de um critério básico da vigilância epidemiológica, o da oportunidade. A vigilância epidemiológica aceitando o resultado dos laboratórios do banco de sangue como suficientes estará evitando gastos para o sistema de saúde, agilizando o processo de vigilância, aumentando a capacidade operacional do laboratório da vigilância bem como encurtando o tempo de espera do doador para definir sua situação de saúde. / Introduction: This document addresses issues related to epidemiological surveillance of hepatitis B and C in blood donors have been reported in SINAN NET in 2007 in Rio Grande do Sul is composed of a literature review on the serological markers and techniques used by the laboratories of the blood bank and epidemiological surveillance. On definitions and flows down the PNHV and an article comparing the results of laboratory blood bank with laboratory surveillance. Method: Discusses the results of this cross-sectional study, with the evidence raised in the review and seeks to answer the questions that served as a stimulus for this study. The results agree? How much is spent to repeat the markers? How long does it take for a donor set their status in relation to the disease? What proportion of donors in the quantity of reported cases of viral hepatitis? Results: Kappa coefficient for the marker HBsAg was 0.74 to 0.72 Anti-HBc, HBsAg and Anti-HBc was associated with 0.98 and the Anti-HCV was 0.82. Spending for repetition of these markers was $ 28,956.55 real. The waiting time for donors to define their status in relation to the disease was a median of 162 days. The proportion of donors reported was 7.90%. Conclusion and final remarks: The results show that this correlation exists, ranging from substantial to almost perfect agreement, for cases of interest for epidemiological surveillance. The waiting time shows the non-fulfillment of a basic criterion of epidemiological surveillance of opportunity. Epidemiological surveillance accepting the results of laboratory blood bank as insufficient, it will avoid costly to the health system, streamlining the process of monitoring, increasing the operational capacity of the laboratory surveillance as well as shortening the time for a donor to define their health situation.

As hepatites virais são grave problema no Brasil e a vacina é eficaz para a sua prevenção. O Inquérito de Cobertura Vacinal nas Áreas Urbanas das Capitais dos Estados do Brasil (2007) identificou em Porto Alegre cobertura vacinal contra hepatite B de 87,4 %, abaixo da recomendação. A vacinação na cidade está inserida em serviços com diferentes vínculos institucionais. Este estudo ecológico, subanálise do Inquérito de Cobertura Vacinal nas Áreas Urbanas das Capitais dos Estados do Brasil, objetiva analisar a distribuição espacial das coberturas da vacina contra hepatite B, sua associação com diferentes tipos e utilização de serviços de saúde em Porto Alegre. A cobertura vacinal não obteve diferenças significativas entre os diferentes estratos sociais; a utilização de um mesmo serviço para vacinação, realização das últimas vacinas em serviço público, utilização de serviço privado e utilização exclusiva de serviços privados para vacinação obtiveram diferenças significativas entre os diferentes estratos sociais. / Viral hepatitis is a major concern in Brazil and its vaccine is effective in its prevention. The Survey of Vaccine Coverage in the Urban Areas of the State Capitals of Brazil (2007) identified that in Porto Alegre, State of Rio Grande do Sul, the hepatitis B vaccine coverage was 87.4% lower than the recommended values. In this city, vaccination is part of services with different institutional links. The present ecological study, a subanalysis of the Survey of Vaccine Coverage in the Urban Areas of the State Capitals of Brazil, has the objective to analyze the spatial distribution of hepatitis B vaccine coverage; its relationship to different types of healthcare services and the use of healthcare services in Porto Alegre. The vaccine coverage did not differ significantly between the different social strata. The use of the same vaccination service, the performance of the last vaccines in public service, the use of private service and the exclusive use of private services for vaccination significantly differed among the different social strata.

The diploma thesis Infectious diseases of drug users is focused on monitoring the trend in the incidence of selected infectious diseases associated with the drug usage for a certain period of time. I have chosen viral hepatitis B and C for this monitoring because they belong to the most common infections typical for drug addicts at all. The issue of infectious diseases associated with intravenous drug usage is quite extensive therefore I tried to mention the most important information. Transmission of infectious diseases through intravenous drug usage is particularly insidious due to irrelevant length depending on time. The risk on non-compliance of basic hygiene measures is possible after a single application (using a sterile needle and syringe, a separate drug solution etc.). Another serious risk is that the viral hepatitis B and C can pass into the chronic stage, which significantly affects the quality of life and can also significantly reduce it. HIV infection is still incurable so it ends with the early death of the patient. If the syphilis is not treated and passes into the third stage it can ends up fatally. Infectious endocarditis is a serious life-threatening illness if not recognized and treated early. The diploma thesis has theoretical and practical part. In the theoretical part of this thesis I deal with various infectious diseases related to drug usage. I chose the most common disease according to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA): viral hepatitis A, B, C, infections transmitted by sexual contact (syphilis, gonorrhea), HIV / AIDS, tuberculosis, infectious endocarditis and infections of the skin and soft tissues. Individual infections are divided into several chapters where the causative agent is described, mode of transmission, clinical picture, disease diagnosis, treatment and epidemiological measures. In the theoretical part I drew inspiration from the literature, internet sources and valid legal legislation. In the practical part I paid attention to the issue of occurrence of viral hepatitis B and C in the Pilsen Region for a certain period of time typical for intravenous drug users and the rest of the population. I compare these figures to the incidence of viral hepatitis in other regions of the Czech Republic for the same years. Data are analysed using quantitative research technique of secondary data analysis. Data are obtained from the information reporting system and records of transmissible diseases EPIDAT and from annual reports of the Czech Republic. The diploma thesis has one objective: to characterize and compare the trends of selected infectious diseases among drug users and the general population of the Pilsen Region in 2003-2011. Four hypotheses were defined: H1: The incidence of infectious diseases among drug users has been growing. H2: The frequency of infectious diseases among drug users in the Pilsen Region in the period 2003-2011 is comparable to the incidence of infectious diseases among drug users in the Czech Republic in the same time period. H3: The sickness rate of viral hepatitis B among drug users in the Pilsen Region in the period 2003-2011 is statistically more significant than among the general population of the Pilsen Region in the same time period. H4: The sickness rate of viral hepatitis C among drug users in the Pilsen Region in the period 2003-2011 is statistically more significant than among the general population of the Pilsen Region in the same time period. Due to lack of information in 2002, the objective of this diploma thesis and individual hypotheses had to be modified. Therefore the period relates to the year 2003-2011. Individual hypotheses were statistically tested to determine the statistical significance. The first and second hypothesis was refuted. A third hypothesis and fourth hypothesis was confirmed.