L’hétérogénéité de l’histoire naturelle de l’hépatite C est expliquée par l’existence de facteurs environnementaux ou liés au malade qui influencent l’évolution de la maladie. L’obtention d’une réponse virologique soutenue est l’objectif principal de la prise en charge thérapeutique car c’est la seule façon de réduire l’incidence de la cirrhose et la mortalité liée au virus de l’hépatite C. Pour être efficaces, les stratégies thérapeutiques doivent être élaborées à deux niveaux. A l’échelle individuelle, elles doivent optimaliser les chances de réponse virologique tout en limitant l’exposition aux effets secondaires. A l’échelle d’une population, la meilleure stratégie est celle qui aura l’impact le plus important sur l’incidence de la cirrhose et sur la mortalité liées au virus de l’hépatite C.<p>Les travaux réalisés dans le cadre de cette thèse ont permis d’identifier des critères virologiques autorisant l’arrêt d’un traitement inefficace dès le terme de la 4ème semaine chez les malades présentant des transaminases normales et chez les malades non répondeurs à un premier traitement, de quantifier la perte de chance de réponse virologique lorsque la durée du traitement est limitée à 24 semaines chez les malades infectés par un génotype 1, d’évaluer la place de l’amantadine dans l’arsenal thérapeutique, de quantifier l’impact d’une insulino-résistance sur le taux de réponse virologique, de contribuer à l’élaboration d’une stratégie thérapeutique permettant une meilleure tolérance hématologique chez les malades hémodialysés et de quantifier l’impact des polymorphismes de l’interleukine 28B sur le taux réponse virologique des malades infectés par un génotype 2 ou 3. Nos travaux ont également permis de mesurer l’impact d’une consommation excessive d’alcool sur la morbi-mortalité liée au virus de l’hépatite C à l’échelle d’une population et de quantifier l’impact des mesures thérapeutiques actuelles et de stratégies thérapeutiques alternatives sur cette morbi-mortalité. <p>Au cours de la prochaine décennie, le traitement de l’hépatite chronique C sera articulé autour des molécules antivirales spécifiques agissant directement contre le virus de l’hépatite C. De nouvelles stratégies thérapeutiques intégrant la cinétique virale et les marqueurs génétiques prédictifs de la réponse virologique soutenue devront être élaborées afin d’offrir les meilleures chances d’éradication virologique au plus grand nombre de malades. / Doctorat en sciences médicales / info:eu-repo/semantics/nonPublished

Accès limité / Doctorat en Sciences biomédicales et pharmaceutiques / info:eu-repo/semantics/nonPublished

La surinfection par HDV/ HBV est la forme la plus grave d'hépatite virale chronique et affecte entre 15-20 millions de patients au niveau mondial. HDV n'est pas susceptible aux traitements anti-HBV et le taux de réponse à l'IFNα est <25%. Malgré une progression plus rapide de la maladie hépatique, la majorité des patients présente une suppression de la réplication du HBV. Les détails des interactions entre HDV, HBV et le système immunitaire inné des cellules infectées restent inconnus. Les objectifs de ces travaux de thèse ont été: i) l'étude de l'infection par HDV et son interaction avec la réponse innée cellulaire; ii) l'identification de nouvelles stratégies thérapeutiques anti-HDV; iii) l'exploration de l'interaction entre HDV et HBV. L'approche expérimentale a été basée sur l'infection de cellules dHepaRG, capables d´entretenir des cycles réplicatifs complets de HBV et HDV et ayant une réponse immunitaire innée physiologique. Nous avons observé que: i) l'infection par HDV est associée à un réplication forte dans un nombre limité de cellules, et à une induction de l'expression des ISGs; ii) le traitement des cellules infectées par HDV avec de l'IFNα ne conduit pas à une induction accrue des ISGs et a une faible activité antivirale. Quelques agonistes de PRR, notamment activant la voie NF-kB, induisent une forte diminution de la réplication de HDV; iii) malgré le faible nombre de cellules infectées, HDV et ses protéines induisent une diminution de la réplication de HBV. Ces travaux ouvrent des perspectives importantes concernant la caractérisation de la pathogénèse de l'hépatite delta et l'identification de nouvelles stratégies thérapeutiques immuno modulatrices / HDV/HBV superinfection is the most aggressive form of chronic viral hepatitis and is estimated to affect 15-20 million patients worldwide. HDV is not susceptible to available direct anti-HBV drugs and sustained response to IFNα therapy occurs in less than 1/4 of patients. Despite the faster progression of liver disease, most HDV/ HBV infected patients present a suppression of HBV replication. The details of the interactions between HDV, HBV and the host cell innate immune response remain largely unexplored and research efforts have been limited by the lack of infection models. The aims of this thesis work were: i) to study HDV infection and the interplay with the host innate immune response; ii) to identify novel therapeutic strategies for the inhibition of HDV; iii) to further explore HDV/ HBV interference. The experimental strategy was based on infection of dHepaRG cells, which are known to be permissive to both HBV and HDV full replicative cycles and to present physiological innate immune responses. We observed that: i) HDV infection is associated with a strong, yet transient replication, a potent induction of the expression of ISGs; ii) IFN-α treatment of HDVinfected cells does not induce a further increase of ISG expression and has a modest antiviral activity. Conversely, some PRR agonists, in particular those inducing the NFkB pathway, induce a strong decline in HDV replication; iii) despite the low number of coinfected cells, HDV as well as its encoded proteins exert a repressive effect on HBV replication. Our work opens an array of perspectives on the pathogenesis of hepatitis delta and the identification of novel immune modulatory therapeutic strategies

O objetivo principal deste estudo foi avaliar a frequência de cepas do HBV com mutações de resistência aos análogos nucleos(t)ídeos (AN) utilizados no tratamento da hepatite B entre indivíduos cronicamente infectados, não submetidos a tratamento, procedentes de diferentes regiões do Brasil. Além disso, foram avaliadas a presença de mutações que alteram a antigenicidade do HBsAg promovendo escape dos anticorpos anti-HBs; mutações nos genes pré-core/core e a associação dos diferentes subgenótipos com as mutações encontradas e características demográficas e laboratoriais dos pacientes. Foram incluídas 779 amostras de soro de pacientes com infecção crônica pelo HBV e virgens de tratamento com AN ou interferon, as quais foram coletadas no período de 2006 a 2011. Os pacientes eram procedentes dos seguintes estados brasileiros: Pará, Maranhão, Bahia, Minas Gerais, São Paulo, Paraná e Rio Grande do Sul. O DNA do HBV foi extraído das amostras de soro utilizando o Kit QIAamp DNA Blood Mini Kit (Qiagen) e posteriormente foi realizada a amplificação das regiões S/polimerase (S/P) e pré-core/core (PCC) do genoma viral por nested PCR. O fragmento amplificado foi submetido a sequenciamento direto em sequenciador automático de DNA (ABI 3500) e as sequências obtidas foram analisadas para identificação dos genótipos e subgenótipos do HBV, pesquisa de mutações na polimerase, no HBsAg e nos genes pré-core/core. A região S/Pol foi amplificada e sequenciada com sucesso em 702 amostras, as quais foram incluídas para atender aos objetivos deste estudo. Entre as 702 amostras analisadas sete genótipos e 12 subgenótipos do HBV foram identificados. O subgenótipo A1 foi o mais frequente (63,7%, 447/702), seguido pelo HBV/D3 (14,5%, 102/702). Os demais genótipos e subgenótipos encontrados e suas frequências foram as seguintes: A2 (3,3%, 23/702), A3 (0,1%, 1/702), B1 (0,1%, 1/702), B2 (0,1%, 1/702), C2 (0,9%, 6/702), D1 (0,9%, 6/702), D2 (4,6%, 32/702), D4 (5,1%, 36/702), D com subgenótipo não identificado (0,7%, 5/702), E (0,6%, 4/702), F2a (4,6%, 32/702), F4 (0,4%, 3/702), e G (0,4%, 3/702). Cepas do HBV com mutações de resistência (rtS202G, rtM204V/I, rtA194T, rtM250I, rtA181T/S, rtT184S) associadas ou não a mutações compensatórias (rtL80I, rtV173L, rtL180M, rtV207I) foram identificadas em 1,6% (11/702) das amostras analisadas. Cepas com mutações potencialmente associadas com resistência ao adefovir (rtS85A, rtL217R, rtI233V, rtN238T, rtN238D, rtN248H, rtV214A,e rtQ215S) ou ao entecavir (rtS219A) foram identificadas em 7,7% (54/702) e 2,6% (16/702) dos pacientes, respectivamente. Cinquenta e sete (8,5%) amostras apresentaram cepas do HBV com mutações na principal região hidrofílica do HBsAg previamente relacionadas com escape dos anticorpos anti-HBs ou com prejuízo na secreção do HBsAg. Foram feitas análises estatísticas para avaliar a correlação entre os subgenótipos do HBV mais frequentes na casuística (A1, A2, D1, D2, D3, D4 e F2a) e a presença de mutações nos genes PCC. Dentre as mutações nos genes PCC associadas com redução ou falha na expressão do HBeAg, as mutações A1762T/T1764A estiveram associadas aos subgenótipos A1 e F2a; G1862T e mutações nas posições 1809-1812 ao subgenótipo A1; G1896A e/ou G1899A aos subgenótipos D2, D3 e D4. Mutações associadas com evolução da doença foram detectadas e entre essas as mutações C1766T e T1768A estiveram associadas aos subgenótipos A1 e F2a, e a mutação G1888A foi associada ao subgenótipo A1. As cepas do HBV que circulam nas diferentes regiões brasileiras estudadas apresentam grande variabilidade genética e a distribuição dos genótipos e subgenótipos reflete a formação histórica de cada região e do fluxo migratório mais recente. A frequência de cepas do HBV com mutações de resistência aos AN circulando entre pacientes virgens de tratamento com esses medicamentos nas diferentes regiões do Brasil estudadas é baixa, sendo que o perfil de mutações que confere resistência total à lamivudina e parcial ao entecavir parece ser o mais disseminado. Embora tenham sido detectados casos de infecção com cepas do HBV portando mutações com grande impacto na antigenicidade dessa proteína todas as amostras apresentaram HBsAg detectável. Pacientes com HBeAg negativo foram mais frequentes na casuística estudada, independente do subgenótipo. As mutações encontradas nos genes PCC sugerem que há perfis de mutações diferentes envolvidos na negatividade do HBeAg para cada subgenótipo / The main aim of this study was to evaluate the frequency of HBV strains harboring mutations that confer resistance to nucleos(t)ide analogues (NA) used to hepatitis B treatment among treatment-naïve patients with chronic hepatitis B from different Brazilian region. Furthermore, we evaluated the presence of mutations that alter the antigenicity of HBsAg causing anti-HBs escape; mutations in genes pre-core/core and the association of different subgenotypes with the mutations detected and demographic and laboratory characteristics of the patients. Serum samples from 779 treatment-naïve patients with chronic HBV infection were included in this study. The samples were collected between 2006 to 2011 and the patients were from the following states: Pará, Maranhão, Bahia, Minas Gerais, São Paulo, Paraná and Rio Grande do Sul. HBV DNA was extracted from serum samples using the QIAamp DNA Blood Mini Kit (Qiagen) and amplification of S/polymerase (S/Pol) and pre-core/core (PCC) regions were performed by nested PCR. The amplified PCR products were submitted to sequencing in an automatic DNA sequencer (ABI 3500). The sequences obtained were analyzed to classify HBV genotypes/subgenotypes and to analyze the presence of mutations. S/Pol region was amplified and sequenced successfully from 702 samples, which were included in this study. Among these 702 samples, seven genotypes and 12 subgenotypes have been identified. HBV subgenotype A1 was the most frequent (63.7%, 447/702), followed by HBV/D3 (14.5%; 102/ 702). The remaining genotypes and subgenotypes identified and their frequencies were as follows: A2 (3.3%, 23/702), A3 (0.1%, 1/702), B1 (0.1%, 1/702), B2 (0.1%, 1/702), C2 (0.9%, 6/702), D1 (0.9%, 6/702), D2 (4.6%, 32/702), D4 (5.1%, 36/702), D unclassified subgenotype (0.7%, 5/702), E (0.6%, 4/702), F2a (4.6%, 32/702), F4 (0.4%, 3/702), and G (0.4%, 3/702). HBV strains harboring mutations conferring NA resistance alone (rtS202G, rtM204V/I, rtA194T, rtM250I, rtA181T/S, rtT184S) or combined with compensatory mutations (rtL80I, rtV173L, rtL180M, rtV207I) were identified in 1.6% (11/702) of the patients. Isolates harboring mutations potentially associated with adefovir resistance (rtS85A, rtL217R, rtI233V, rtN238T, rtN238D, rtN248H, rtV214A, and rtQ215S) or entecavir resistance (rtS219A) were identified in 7.7% (54/702) and 2.6% (16/702) of the patients, respectively. HBV with HBsAg mutations previous related with anti-HBs escape or impaired secretion were detected in 8.5% (57/702) of the samples. Statistical analyzes were performed to assess the correlation between the more frequent HBV subgenotypes found in this study (A1, A2, D1, D2, D3, D4 and F2a ) and mutations in PCC genes. Among the mutations found in these genes that were associated with reduction or failure in HBeAg synthesis, A1762T/T1764A mutations were associated to subgenotypes A1 and F2a; G1862T and mutations at positions 1809-1812 to subgenotype A1; G1896A and/or G1899A to subgenotypes D2, D3 and D4. Other mutations associated with disease progression were found: C1766T and T1768A mutations were associated with subgenotypes A1 and F2a, and the G1888A mutation was associated with subgenotype A1. HBV strains circulating in different Brazilian regions studied showed high genetic variability and distribution of genotypes and subgenotypes reflects the population formation history of each region and the occurrence of recent events of migration. The frequency of HBV strains with NA resistance mutations circulating among treatment-naive patients in different regions of Brazil studied is low and the profile of mutations that confer total resistance to lamivudine and partial resistance to entecavir is more widespread. Although some cases of infection have been detected with HBV strains carrying mutations associated with major impact on the antigenicity of this protein, all samples had detectable HBsAg. HBeAg negative cases were more frequent in the studied population, regardless of subgenotype. Different pattern of mutations were found in PCC genes, suggesting that different mechanisms are involved in HBeAg negativity for each subgenotype

Orientador: Marjorie de Assis Golim / Resumo: A infecção crônica pelo vírus da hepatite B (VHB) é a principal causa de cronificação da hepatite, cirrose hepática e carcinoma hepatocelular em humanos. A vacinação contra hepatite B é essencial a saúde da população, sendo a medida de menor custo e maior eficiência para controlar o vírus. A vacina desencadeia resposta imune com produção de anticorpos contra o antígeno de superfície do VHB (anti-HBs), contudo, alguns indivíduos não desenvolvem imunidade efetiva, havendo necessidade de doses adicionais. Assim, estimular a resposta imune nos indivíduos já vacinados, porém pouco respondedores ou não respondedores previamente, poderia contribuir para o aumento da produção de anticorpos e persistência dos mesmos ao longo do tempo. Considerando o potencial imunomodulador de β-glucanas, inclusive no aumento da ativação de células T e B em resposta a antígenos, propôs-se neste estudo avaliar a influência do uso de β-glucanas como suplemento alimentar em indivíduos com imunidade não efetiva pós-vacina, que necessitassem de dose booster. Foram incluídos 46 doadores de sangue do Hemocentro de Botucatu, com idade entre 18 anos e 25 anos completos, do sexo masculino, vacinados com três doses para hepatite B na primeira infância. Aqueles que apresentaram anti-HBs<10UI/L foram considerados não imunes, sendo mantidos no estudo (n=31) e divididos em dois grupos de forma aleatória. Ambos os grupos receberam booster da vacina, sendo um grupo suplementado via oral com cápsulas de amido (n=11; pl... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Chronic hepatitis B virus (HBV) infection is the main cause of hepatitis chronification, liver cirrhosis and hepatocellular carcinoma in humans. Vaccination against hepatitis B is essential to the health of the population, being the least costly and most efficient measure to control the virus. The vaccine triggers an immune response with the production of antibodies against HBV surface antigen (Anti-HBs), however, some individuals do not develop effective immunity, requiring additional doses. Thus, stimulating the immune response in individuals who have already been vaccinated, but with little or no previous response, could contribute to increased antibody production and persistence over time. Considering the immunomodulatory potential of β-glucans, including the increased activation of T and B cells in response to antigens, it was proposed in this study to evaluate the influence of the use of βglucans as a food supplement in individuals with post-vaccine ineffective immunity , who needed a booster dose. 46 blood donors from the Hemocenter of Botucatu, aged between 18 and 25 years old, male, who received three doses of hepatitis B vaccine in childhood were included. Those who had anti-HBs <10 IU / L were considered non-immune, being maintained in the study (n = 31) and randomly divided into two groups. Both groups received a vaccine booster, one group supplemented orally with starch capsules (n = 11; placebo - 500mg / day), and the other with β-glucans (n = 20; 500mg / day) f... (Complete abstract click electronic access below) / Mestre

L’hépatite B est une maladie du foie qui pose un problème majeur de santé publique. Il n’existe à ce jour aucun traitement permettant de guérir complètement de l’infection, et de nouvelles thérapies ont besoin d’être développées. Étant donné son rôle clé dans le cycle de vie du virus de l’hépatite B (VHB), la protéine core qui forme la capside virale est aujourd’hui l’une des cibles avec le plus grand potentiel thérapeutique. Nos recherches sont focalisées sur la caractérisation des capsides du VHB dans différents états conformationnels en utilisant des techniques de biochimie et de RMN du solide, afin de révéler leur conformation précise sous différentes conditions, incluant l’interaction des capsides avec des antiviraux, et la relation entre la conformation de la capside et la maturation du virus. Un système d’expression bactérienne ainsi qu’un système acellulaire de synthèse de protéine à base de germes de blé ont été établis au laboratoire pour produire les capsides, et des protocoles pour désassembler puis réassembler les capsides en présence de différents types d’ARN ont été implémentés. Des échantillons de capsides formées dans E. coli et réassemblées in vitro ont été analysés par RMN. Les différentes formes de capsides observées incluent les protéines tronquées Cp140 et Cp149, la protéine entière Cp183, phosphorylée P-Cp183, et enfin des mutants. Dans un premier temps, nous avons préparé des échantillons pour l’attribution séquentielle de la protéine core par RMN du solide. L’utilisation de la détection carbone en RMN requiert plusieurs dizaines de milligrammes d’échantillon, qui ont pu être produits en utilisant l’expressions bactérienne en milieu minimum contenant des isotopes marqués. Les attributions séquentielles ont été réalisées sur la protéine tronquée Cp149, qui donne des spectres très similaires à Cp183. Cet échantillon a également été utilisé pour identifier les différences conformationnelles entre les 4 monomères de la capside, qui sont provoquées par la symétrie icosaédrale T=4. Ensuite, l’objet principal de cette thèse a été l’investigation et la comparaison d’une large variété de capsides, dans leur forme autoassemblée dans les bactéries E. coli, ainsi que dans leur forme réassemblée. Pour le réassemblage de la protéine entière, qui requiert la présence d’acides nucléiques, nous avons testé différents types d’ARN y compris l’ARN viral prégénomique. Nous avons étudié différentes symétries (T=3 et T=4), ainsi que les états d’oxydation de la capside, et comparé les différences de conformation grâce aux perturbations de déplacements chimiques observées dans les spectres RMN. Nous avons pu identifier les acides aminés impliqués dans les changements conformationnels majeurs entre les différentes préparations. La RMN du solide en détection proton à 100 kHz a récemment émergé comme un outils important pour l’analyse de protéines produites en quantités moindres. Nous avons appliqué cette stratégie à l’analyse des capsides de Cp149 afin d’obtenir l’attribution des protons amides. La détection proton par RMN du solide peut être combinée avec succès à la synthèse des protéines en système acellulaire, qui donne de faibles rendements par rapport aux cultures en bactéries. Cette approche est particulièrement intéressante pour analyser la modulation de l’assemblage des capsides induite par la présence de drogues. Bien que nous ayons commencé à étudier l’impact de modulateurs d’assemblage par RMN en détection carbone sur des capsides formées dans E. coli et réassemblées (données préliminaires non montrées dans ce manuscrit), la détection proton ouvre la voie vers l’analyse de l’impact de ces modulateurs sur l’assemblage des protéines core directement à la sortie du ribosome / Hepatitis B is a widely spread liver disease which causes a heavy burden for human health, with 257 millions of people affected by chronic infection and about 780,000 deaths per year. Yet, infected patients can not be completely cured by current treatments using notably nucleos(t)ide analogues and interferons. In order to achieve the goal of the World Health Assembly (WHA), who wishes to eliminate hepatitis B by 2030, new therapies need to be developed. Given its critical role for the Hepatitis B virus (HBV) life cycle, the core protein (Cp) is today one of the antiviral targets with the highest potential. Our research focuses on the characterization of HBV capsids in different conformational states using biochemistry and solid-state NMR, aiming at revealing their precise conformation under different conditions, including the interaction of capsids with antivirals, and the correlation between capsid conformation and viral maturation. For sample preparation, both a bacterial expression system and a wheat germ cell-free protein synthesis system have been established in the laboratory to produce HBV capsids, and protocols to disassemble and reassemble capsids with different nucleic acids have been implemented. Both capsids preformed in E. coli and capsids reassembled in vitro were addressed to NMR studies. Different capsids forms include the truncated versions Cp140 and Cp149, the full length protein Cp183, the phosphorylated P-Cp183 and mutant forms. First, we have prepared samples for the sequential assignment of the protein using solid-state NMR. The use of carbon-13 detection asks for several tens of milligrams of sample, which were produced using labeled isotopes and bacterial expression in minimal media. Sequential assignments were performed using the truncated capsid Cp149, which showed highly similar spectra to Cp183. This sample was also used to identify conformational differences between the four different monomers in the capsid, which are due to the T=4 icosahedral symmetry. Then, the main body of the thesis is the investigation and comparison of a variety of different capsid forms, including Cp183, P-Cp183, Cp149, Cp140, another truncated form resulting in mainly T=3 icosahedral assemblies, and Cp140 C61A and Cp183 F97L mutants. We investigated all samples in both the E. coli-produced and reassembled forms, which needs for the full-length protein the presence of nucleic acids, of which we tested several, including the viral pregenomic RNA. We investigated different symmetries, as well as oxidation states of the capsid, and compared the differences via chemical shift perturbations observed in NMR spectra. We reported in a site-specific manner the major conformational changes observed between the different preparations. Proton-detected solid-state NMR at 100 kHz has recently emerged as a tool for analyzing proteins with the need of less sample amount. We have applied this strategy to the analysis of the Cp149 capsids, in order to obtain sequential assignments of the amide proton resonances. For this, deuteration of the protein in bacteria was used as well, needing adaptation of sample preparation protocols. Proton detection can be successfully combined with cell-free protein synthesis, which gives low yields compared to bacterial expression. This approach is of potential interest to analyze capsid assembly modulation induced by the presence of drugs. While we have started in the framework of this thesis to analyze the capsid in presence of different capsid assembly modulators by carbon-13 detected NMR on E. coli and reassembled capsids (preliminary results not reported here), proton detection opens the way to an analysis of the impact of capsid modulation directly on the exit of the core proteins from the ribosome, on assembly. We showed that cell-free expression combined with proton-detection solid-state NMR can be used to analyze capsid chemical shifts, and thus in future work the conformational modulations

Die Virushepatitis gehört weltweit zu einer der häufigsten viralen Erkrankungen. Doch durch die Entwicklung von immer effizienteren Impfstoffen kann bei einer frühzeitigen Immunisierung eine Infektion verhindert werden. Ziel dieser Arbeit war es, ein Patientenkollektiv zu untersuchen, welches eine Impfung mit einem Hepatitis B-Impfstoff erhalten hatte, und dieses mit Probanden zu vergleichen, die nicht immunisiert waren. Diese Proben wurden auf ihre serologische und zelluläre Reaktivität mittels ELISA und ELISpot untersucht. Im ELISA zeigte sich bei 95 % der geimpften Personen eine positive Serokonversion nach zurückliegender Hepatitis B-Impfung. Um den Impfstatus genauer zu analysieren und bei seronegativen geimpften Probanden den zellulären Arm des Immun-systems zu verifizieren, wurde mittels ELISpot die IFN-γ-Sekretion von HBs-reaktiven T-Zellen untersucht und mit den Ergebnissen, welche in der Serologie gewonnen wurden, verglichen. Dabei zeigte sich, dass die zelluläre Untersuchung bei 43 von 94 untersuchten Patientenproben (46 %) ein positives Ergebnis aufwies. Zweiundzwanzig der 48 geimpften Patienten (46 %) hatten eine antigenspezifische IFN-γ-Sekretion und 21 der 46 Proben der aktuell nicht geimpften Patienten fielen im ELISpot positiv aus. Bei zwei seronegativ geimpften Patienten konnte jeweils ein positives Ergebnis im ELISpot gezeigt werden. Ein direkter Zusammenhang zwischen der Höhe des anti-HBs-Titers im ELISA und Anzahl der spot-bildenden Zellen im ELISpot konnte nicht gezeigt werden. Die Ergebnisse dieser Arbeit zeigen, dass die serologische Untersuchung mittels ELISA weiterhin als Goldstandard verwendet werden soll, um den aktuellen Schutz gegenüber einer Hepatitis B-Infektion zu verifizieren. Durch die zelluläre Untersuchung mit dem ELISpot-Verfahren kann bei weiterer Testoptimierung in Zukunft eine Nachweismethode für seronegative Geimpfte entwickelt werden. Vor allem sollten diese mit Hilfe des ELISpots genauer analysiert werden, um gegebenenfalls bei nicht vorhandener humoralen Immunität und einer ebenfalls fehlenden zellulären Immunität prophylaktische Maßnahmen einzuleiten.

Background: In times of limited organs for transplantation, anti-HBc positive organs can be accepted for lung transplantation to increase the number of donors. Transplant recipients should be vaccinated against hepatitis B to prevent HBV infection. However, response after HBV vaccination has only been poorly evaluated in patients with end-stage pulmonary disease. Material/Methods: Anti-HBs titers of 40 anti-HBc negative patients with end-stage pulmonary disease evaluated for lung transplantation were analyzed with the Architect® system (Abbott, Germany). Responders, partial responders, or non-responders after HBV vaccination were defined by anti-HBs titers >100 IU/L, 10–100 IU/L, and <10 IU/L, respectively. Results: There were 34/40 individuals (85%) vaccinated against hepatitis B, and 6 were not vaccinated. Response, partial response, and non-response after vaccination were observed in 10/34 (29.4%), 11/34 (32.4%), and 13/34 (38.2%) of patients, respectively. Response to vaccination did not correlate with sex, pulmonary disease, comorbidities, immunosuppressive therapy, or smoking status. Conclusions: Although 85% of patients evaluated for lung transplantation were vaccinated against hepatitis B, 38.2% did not show an anti-HBs titer >10 IU/L. Thus, anti-HBs titers should be regularly monitored. Nonresponders should be considered for booster vaccinations, alternative vaccination schedules, or prophylactic treatment with a nucleos(t)ide analogue in case of transplantation of an anti-HBc–positive organ.

Introduction Hepatitis E is a worldwide distributed disease, which is caused by the hepatitis E virus (HEV). In addition to humans, domestic pigs, wild boars, rabbits and dromedaries can be subclinically infected as reservoir animals with the zoonotic HEV genotypes 3, 4 and 7. In addition, HEV and HEV-like viruses have been described sporadically in other mammals, as well as in birds and fish, although their distinct role as reservoirs or carriers of the virus is still unclear. Aims The aim of the study was therefore to analyse in more detail the importance of different mammalian species, which do not belong to the known HEV reservoirs, for the epidemiology of HEV infections, thus enabling a better assessment of the risk of virus transmission by these animal species. Material and Methods Fourteen non-human primate species and 66 other mammal species, as well as Norway rats (Rattus norvegicus) and feeder rats (Rattus norvegicus forma domestica) from German zoos were selected for the investigations. In total 259 individual non-human primate sera and 244 individual mammalian sera of clinically healthy zoo animals were analysed for the presence of HEV-specific antibodies (ab) using a species-independent double-antigen sandwich ELISA. The non-human primate sera were additionally examined using a commercial human ELISA. Real-time reverse-transcription (RT)-PCR, nested broad-spectrum RT-PCR and a rat HEV-specific RT-PCR were used to detect the HEV genome in sera of mammals and rat liver samples. A commercial and an in-house method were used for the DNA sequencing. Results HEV-specific ab were detected in 3.9% (10/259) of the non-human primate sera (4 species) and 11.5% (28/244) of the mammalian sera (16 species). The highest detection rates were recorded with 33.3% (9/27) in porcines and with 27.0% (10/37) in carnivores. HEV-RNA was detected in a clinically healthy female Syrian brown bear (Ursus arctos syriacus) and in 8 of the investigated Norway rats. Sequence analysis identified the virus as rat HEV; the viruses from the bear and the free-ranging rats from the same zoo showed a high nucleotide sequence identity (94.6%–97.8%). Because of the small number of samples due to the small populations within the individual zoos, further statistical evaluations were not carried out. Conclusions The results show that non-human primates in zoos may be infected with HEV or HEV-like viruses; however, the low ab detection rates together with the negative genome detection argue against a high risk of virus transmission to humans. The study in other zoo-housed mammalian species was able to significantly increase the number of animal species with indications of HEV infections. In most animal species, only rare evidence and low detection rates were available, which can best be explained by “spillover-infections”. In addition to the expected high detection rate in porcine species, the high percentage of HEV antibody-positive carnivores is remarkable. Their role as possible HEV reservoir animals should therefore be clarified in further investigations. The detection of rat HEV in the serum of the bear and its high nucleotide sequence identity with the HEVs of the pest rodents provides first evidence of transmission of this virus species between rodents and carnivores.:List of content List of figures List of tables List of abbreviations 1 General introduction 1.1 Discovery of HEV 1.2 Taxonomy 1.3 Morphology 1.4 Genomic organisation 1.5 Viral replication 1.6 Hepatitis E in humans 1.7 Tools for HEV diagnosis 1.8 Therapy 1.9 Animal infections with HEV and HEV-like viruses 1.10 Experimental infections of animals 1.11 Geographical distribution 1.12 Transmission pathways 1.13 Epidemiology 1.14 Prevention 2 Aims of the study 3 Publications 3.1 Publication I 3.1.1 Summary of Publication I 3.1.2 Key messages of Publication I 3.1.3 Own contribution to Publication I 3.2 Publication II 3.2.1 Summary of Publication II 3.2.2 Key messages of Publication II 3.2.3 Own contribution to Publication II 3.3 Publication III 3.3.1 Summary of Publication III 3.3.2 Key messages of Publication III 3.3.3 Own contribution to Publication III 4 General discussion 4.1 HEV infections in various animal species 4.2 Prevalence of natural HEV infections in non-human primates 4.3 Prevalence of natural HEV infections in other zoo-housed mammals 4.4 Transmission pathways of HEV in a zoo-setting 4.5 Risk of virus transmission from zoo animals to humans 5 Conclusion and perspectives 6 Summary 7 Zusammenfassung 8 References List of animals investigated in the study List of publications Acknowledgements / Einleitung Hepatitis E ist eine durch das Hepatitis E-Virus (HEV) verursachte, weltweit verbreitete Erkrankung. Neben dem Menschen können Hausschwein, Wildschwein, Kaninchen und Dromedar als Reservoirtiere subklinisch mit den zoonotischen HEV-Genotypen 3, 4 und 7 infiziert werden. Darüber hinaus wurden HEV und HEV-ähnliche Viren vereinzelt bei weiteren Säugetieren, sowie Vögeln und Fischen beschrieben, wobei deren genaue Rolle als Reservoir oder Überträger des Virus bislang unklar ist. Ziele Ziel der Arbeit war es deshalb, die Bedeutung verschiedener Säugetierarten, die nicht zu den bekannten HEV-Reservoiren gehören, für die Epidemiologie der HEV-Infektionen besser zu erfassen und dadurch das Risiko einer Virusübertragung durch diese Tierarten besser abzuschätzen. Material und Methoden Vierzehn Affenarten und 66 weitere Säugetierarten, sowie Wanderratten (Rattus norvegicus) und Futterratten (Rattus norvegicus forma domestica) aus deutschen Zoos wurden für die Untersuchungen ausgewählt. Insgesamt wurden 259 individuelle Affenseren und 244 individuelle Säugerseren klinisch gesunder Zootiere mittels eines Spezies-unabhängigen Doppel-Antigen-Sandwich-ELISAs auf das Vorhandensein von HEV-spezifischen Antikörpern (AK) untersucht. Die Affenseren wurden zusätzlich mittels eines kommerziellen humanen ELISAs untersucht. Real-time reverse-transcription (RT)-PCR, nested broad-spectrum RT-PCR sowie eine Ratten-HEV-spezifische RT-PCR wurden für den HEV-Genomnachweis in Seren der Säuger und in Ratten-Lebern verwendet. Für die DNA-Sequenzierungen wurden eine kommerzielle und eine In-house-Methode verwendet. Ergebnisse In 3,9% (10/259) der Affenseren (4 Arten) und 11,5% (28/244) der Säugerseren (16 Arten) wurden HEV-spezifische AK nachgewiesen. Die höchsten Nachweisraten wurden mit 33,3% (9/27) in Schweineartigen und 27,0% (10/37) in Fleischfressern ermittelt. HEV-RNA wurde in einer klinisch gesunden Syrischen Braunbärin (Ursus arctos syriacus), sowie in 8 der untersuchten Wanderratten nachgewiesen. Die Sequenzanalyse identifizierte das Virus als Ratten-HEV; die Viren aus der Bärin und aus den wildlebenden Ratten desselben Zoos zeigten eine hohe Nukleotidsequenz-Identität (94,6%–97,8%). Weitergehende statistische Auswertungen wurden wegen der geringen Probenzahlen aufgrund der kleinen Populationen innerhalb der einzelnen Zoos nicht durchgeführt. Schlussfolgerungen Die Ergebnisse zeigen, dass Affen in Zoos mit HEV oder HEV-ähnlichen Viren infiziert sein können, jedoch sprechen die geringen AK-Nachweisraten zusammen mit den negativen Genomnachweisen gegen ein hohes Übertragungsrisiko auf den Menschen. Die Studie an anderen Säugetierarten in Zoos konnte die Zahl der Tierarten mit Hinweisen auf HEV-Infektionen deutlich erhöhen. Bei den meisten Tierarten lagen nur seltene Nachweise und niedrige Detektionsraten vor, die am besten durch „Spillover-Infektionen“ erklärt werden können. Neben der erwarteten hohen Nachweisrate bei Schweineartigen ist der hohe Prozentsatz an HEV AK-positiven Fleischfressern bemerkenswert, weshalb deren Rolle als mögliche HEV-Reservoirtiere in weiteren Untersuchungen geklärt werden sollte. Der Ratten-HEV-Nachweis im Serum der Bärin, sowie dessen hohe Nukleotidsequenz-Identität zu den HEVs der Schadnager geben erstmals Hinweise auf eine Übertragung dieser Virusart zwischen Nagern und Fleischfressern.:List of content List of figures List of tables List of abbreviations 1 General introduction 1.1 Discovery of HEV 1.2 Taxonomy 1.3 Morphology 1.4 Genomic organisation 1.5 Viral replication 1.6 Hepatitis E in humans 1.7 Tools for HEV diagnosis 1.8 Therapy 1.9 Animal infections with HEV and HEV-like viruses 1.10 Experimental infections of animals 1.11 Geographical distribution 1.12 Transmission pathways 1.13 Epidemiology 1.14 Prevention 2 Aims of the study 3 Publications 3.1 Publication I 3.1.1 Summary of Publication I 3.1.2 Key messages of Publication I 3.1.3 Own contribution to Publication I 3.2 Publication II 3.2.1 Summary of Publication II 3.2.2 Key messages of Publication II 3.2.3 Own contribution to Publication II 3.3 Publication III 3.3.1 Summary of Publication III 3.3.2 Key messages of Publication III 3.3.3 Own contribution to Publication III 4 General discussion 4.1 HEV infections in various animal species 4.2 Prevalence of natural HEV infections in non-human primates 4.3 Prevalence of natural HEV infections in other zoo-housed mammals 4.4 Transmission pathways of HEV in a zoo-setting 4.5 Risk of virus transmission from zoo animals to humans 5 Conclusion and perspectives 6 Summary 7 Zusammenfassung 8 References List of animals investigated in the study List of publications Acknowledgements

Es gibt wenige Erkenntnisse über den Zusammenhang zwischen Lamivudin induzierten Resistenzmutationen und Hepatitis B Genotypen. Die vorliegende Studie untersucht das Verhältnis zwischen diesen Mutationen und den Hepatitis B Genotypen A-D. Die Datenbank der US-amerikanischen Kongressbibliothek (Pubmed) wurde nach den Begriffen „HBV OR hepatitis B”, „YMDD”, „genotype”, und „lamivudine” durchsucht. Alle in dieser Suche gefundenen Arbeiten, die bis Juni 2009 veröffentlicht worden waren, wurden in die Studie eingeschlossen. Die Ergebnisse der Literaturanalyse wurden mit den Hepatitis B-Genomdaten zweier Referenzlabore in Tübingen und Melbourne verglichen. Insgesamt konnten 29 Arbeiten aus der Datenbankrecherche in die Literaturanalyse eingeschlossen werden. Diese Studien enthielten Daten zu insgesamt 827 Patienten, deren Hepatitis B Genotyp bekannt war und die eine Lamivudinresistenzmutation aufwiesen. In statistischen Untersuchungen konnte nachgewiesen werden, dass die rtM204V-Mutation die dominierende Mutation bei Infektionen mit Genotyp A ist. Dieses Ergebnis konnte durch die Analyse der Genomdaten der Referenzlabore bestätigt werden. Ferner konnte gezeigt werden, dass bei den Genotypen A, B, und D die rtL180M-Mutation hochsignifikant mit der rtM204V-Mutation verknüpft ist. Die Dissertationsschrift enthält neben dem Artikel „Mutation pattern of lamivudine resistance in relation to hepatitis B genotypes: hepatitis B genotypes differ in their lamivudine resistance associated mutation pattern“ (Damerow, H, Yuen L et al.; J Med Virol. 2010 Nov; 82(11):1850-8) eine Einführung in die Rationale der Studie, eine Zusammenfassung der Ergebnisse sowie ein Fazit.:1. Einleitung 1.1. Bibliografische Beschreibung und Kurzzusammenfassung, Seite 4 1.2. Inhalt und Aufbau der Arbeit, Seite 5 2. Hintergründe und Rationale 2.1. Therapie der chronischen Hepatitis B-Infektion, Seite 6 2.2. Resistenzen unter Therapie mit Nukleos(t)idanaloga, Seite 7 2.3. Hepatitis B-Genotypen, Seite 9 2.4. Die vorliegende Studie 2.4.1. Rationale der Studie, Seite 10 2.4.2. Arbeitsverteilung, Seite 11 3. Studie “Mutation pattern of lamivudine resistance in relation to hepatitis B genotypes: hepatitis B genotypes differ in their lamivudine resistance associated mutation pattern” 3.1. Abstract, Seite 14 3.2. Introduction, Seite 15 3.3. Methods, Seite 16 3.4. Results, Seite 17 3.5. Discussion, Seite 20 3.6. Reference List, Seite 22 3.7. Appendix, Seite 25 4. Zusammenfassung der vorliegenden Studie 4.1. Mutationsverhalten im YMDD-Motiv 4.1.1. Literaturanalyse, Seite 31 4.1.2. SeqHepB-Datenbank, Seite 32 4.1.3. Tübinger Datenbank, Seite 32 4.2. rtL180M-Mutation in Relation zu HBV-Genotyp und rtM204I/V-Mutation 4.2.1. Literaturanalyse, Seite 34 4.2.2. SeqHepB-Datenbank, Seite 34 4.2.3. Tübinger Datenbank, Seite 35 4.3. Analyse der Polymerase-Mutationen rtL80I/V, rtV173L und rtA181V/T in Abhängigkeit vom HBV-Genotyp, Seite 35 4.4. Analyse der Mutationen im Surface-Antigen, die mit Polymerasemutationen assoziiert sind, Seite 36 5. Fazit 5.1. Literaturübersicht, Seite 37 5.2. Mögliche klinische Relevanz, Seite 38 6. Anhang 6.1. Literaturverzeichnis, Seite 41 6.2. Abbildungs- und Tabellenverzeichnis, Seite 45 6.3.Selbstständigkeitserklärung, Seite 47 6.4. Publikationsverzeichnis, Seite 48 6.5. Danksagungen, Seite 49