What Do You Think About This Scary Study?

Study: Patients With Resolved Hepatitis C Likely Still Contagious


Patients with chronic hepatitis C that has been resolved through therapy or immune response may still be able to infect others with the virus. That finding is from a new study in the May issue of Hepatology, a journal published by John Wiley & Sons on behalf of the American Association for the Study of Liver Diseases (AASLD). The article is also available online at Wiley Interscience (www.interscience.wiley.com).



About 170 million people worldwide are infected with hepatitis C virus, which can progress to chronic hepatitis, cirrhosis and even liver cancer. In some individuals, the infection seems to resolve, either spontaneously from the efforts of the immune system, or after treatment with interferon and ribavirin.



Patients who achieve a sustained viral response show no clinical or biochemical evidence of liver disease and standard tests can no longer detect the virus in their blood. However, more sensitive research tests are finding that such patients often still have miniscule amounts of the virus in their bodies. No one knows if these trace remainders are infectious.



Researchers led by Tomasz I. Michalak of Memorial University of Newfoundland, Canada examined this question using a system that allows for propagation of HCV in human T cells in vitro.



They began with nine patients with HCV who had achieved a sustained viral response that persisted for at least two years after treatment. HCV RNA was detectable in their blood only with the more sensitive tests.



The researchers set up twelve cultures of lymphoid cells from healthy donors, and exposed them to plasma or to supernatants of cultured circulating lymphoid cells from the HCV patients. Eleven of the cell cultures became HCV RNA positive. Furthermore, HCV from three of the nine patients was able to establish active HCV replication in the cultures.



“These findings provide in vitro evidence that trace quantities of HCV persisting in the circulation for a long time after therapeutically induced resolution of CHC can remain infectious,” the authors report.



Interestingly, HCV replication in the T cells was prevented after neutralization of the virus, and by treatment with interferon.



This study is the first to investigate the infectivity of HCV traces that remain when the infection is occult. It agrees with previous animal studies of the same question.  



“Our present findings reveal that HCV circulating in some individuals with resolved hepatitis C is capable of inducing productive infection in vitro at doses of 20 to 50 copies,” the authors conclude. “This can be interpreted as a strong indication of potential virus infectivity in vivo.”



Article: “Hepatitis C Virus Persisting at Low Levels after Clinically Apparent Sustained Virological Reponse to Antiviral Therapy Retains Its Infectivity in Vitro.” MacParland, Sonya A.; Pham, Tram N.Q.; Guy, Clifford S.; Michalak, Tomasz I. Hepatology; May 2009.

[nygirl7]

I've never really understood occult virus so I still don't understand how you can pass on something you no longer have but if the idea is that the interferon trains our immune systems to keep fighting any virus that might be left down to undetectible levels and it's not really GONE I still can't understand how someone could infect somebody else...unless they weren't at undetectible levels of "1" and it's that "1" that does it.

I've never heard of anyone who is SVR infecting anyone else before but all of this type stuff is WAY over my head anyway.  I'm not too worried about it myself as I'm not going to be IVDu'ing with anybody and I think that's the only way you could get pass it on anyway.

[JennyPenny]

I'm with you, nygirl. If I were undetected I wouldn't worry about it either. I also have never heard of anyone infecting someone else when they are SVR (which I consider cured). I think that maybe there may be a very very small amount of virus left in some SVR people....not enough to be infective, or counted in the bloodstream,  unless something happened that drove their immune systems so low the virus was able to overcome them.

[Willy50]

What do I think?  I hate to see it but it exists and we may not be able to deny it's existence.  We will have to be very careful of the way that we..... laymen....both interpret or attempt to re-communicate this evidence.  I think that we will be far more likely to come to a possibly false conclusion of the ramifications of this study than a virolgist.

I think one question that it poses if to how communicable the virus is post SVR.  I don't think it attempts to convey an answer to us and so I hope that we don't "fly off the handle" at this and can continue for the present time to obsess about the swine flu.  ; )

Many of us will be able to do what we have always done; maintain a safe and normal lifestyle without fear of transmission.  Might it be unsafe to share a needle with a past HCV positive but currently SVR person?  It appears that we might want to re-think that.  : )  I think normal day to day situations might remain unchanged.

best,
Willy

[apache1]

Hey JennyPenny

Could you please post a link to this study.
Went to
www.interscience.wiley.com
as in your first post and could not find it.

apache

[Rockerforlife]

I think to able to infect someone after one aquires SVR .you would have to injesct a full syringe of blood into the other person to catch it....if the virus is occult and is in muniscle amounts...i think it would be very hard to transmit.....like nygirl says....you would proberly have to on a 2 week shooting gallery bindge of partying to get it...im happy if i get SVR...i dont care waht they say...if my damage is stopped ....i doubt ill be spreading the C

[newleaf09]

I think "in vitro" is the key to understanding this.  They can make it infectious in a test tube.  Not the same thing as a human system.

I asked my doctor (an HCV researcher) about the virus re-activating about a month ago.  He said: The genome (the genetic material) of the virus remains in the liver.  It is unable to replicate (reproduce) because the treatment left behind a much stronger immune system (interferon induces killer T cell production).

IF you were to suppress your immune system (say with meds for one of the autoimmune diseases like lupus or rheumatoid arthritis or immunosuppressants for a transplant) it would be possible for the virus genome to begin replicating again.  I saw a study that suggested cured HCV patients wait at least 6 months before using such drugs.  I think I will just avoid everything like that until I am in dire need and hopefully by then they will have the whole business better figured out (kinder HCV treatment, more specifically targeted immunosuppressants).

I think we all know to exclude our livers from donor organs we may give some day.  I don't intend to worry about it all.  I've already changed my life this much and don't think I'll have much trouble refusing unneccessary prescriptions in the future.  It would be a good idea to mention past HCV infection to your other doctors so, hopefully, they will not prescribe immunosuppressive drugs to you for cassual reasons.

[mikesimon]

You wrote: "IF you were to suppress your immune system (say with meds for one of the autoimmune diseases like lupus or rheumatoid arthritis or immunosuppressants for a transplant) it would be possible for the virus genome to begin replicating again."

I don't necessarily disagree that it might be possible but I am not sure enough to say that it is possible either. I am immunosuppressed and have been since I achieved SVR in 2004. I test monthly with Heptimax and I am always undetectable. At one point in 2006 my anti-rejection dose was increased significantly for several months and there was no detectable virus then or since then.
I have really studied this subject and I don't know the answer. I have citations that suggest that the virus can become detectable with extreme imnunosuppression and other articles that say differently.
Mike

[apache1]

Without being able to read the whole study, many questioned persist for me.

===========================================================
"They began with nine patients with HCV who had achieved a sustained viral response that persisted for at least two years after treatment. HCV RNA was detectable in their blood only with the more sensitive tests. "

'Researchers led by Tomasz I. Michalak of Memorial University of Newfoundland, Canada examined this question using a system that allows for
'propagation'  
of HCV in human T cells in vitro."

===========================================================
What more sensitive tests where done ?
What strand of RNA did they detect, + or - ? was it a full strand ? or crippled ?

Sounds like this research team put what ever remnant they found on life support in the lab till they got it to bloom again.


First many researches call any remnant mutated disabled crippled partial strand of something resembling hcv 'occult virus'.
I have been told this is not entirely correct labeling, since it confuses 'hBv' occult virus that is a very real occult virus just at low levels, and HBV does and can come back full force infection, and is transmisable.
This has never been the case with SVR HCV occult or otherwise, in any study I have ever read. SVR for HCV is durable. Not so for occult HBV.
If anyone has a study to show occult hcv was transmitted or came back in a new infection I would like to see it.

Also, many of us have all types of other virus remnants in our systems from previous infections...mumps, chicken pox, etc is this occult virus ?.... These other remnants do not cause reinfection or are transmissible to others in a real world situation. Unlike a petri dish lab experiment.

Many right on this forum are SVR and on current immune therapy for their tp liver or other organs.
Some even went on tx after they were on immune suppressants and got SVR. Have never seen or heard of a documented case of virus breakthrough or reinfection for any of these immune suppressed SVR people. I have read studies verifying this also.

jmo
apache

[portann]

Dear Jenny,

Thanks for posting this article. Very interesting and disquieting topic.

I found a similar thread from an earlier Polish study, to which Mike replied with various other studies:

http://www.medhelp.org/posts/Hepatitis-C/SVR-personsPersistence-of-HCV-After-Successful-Treatment-of-Chronic-Hepatitis-C-Is-HCV-Infection-for-Life---/show/98641

Forgive me if the link is not apropos today. I thought it was a clever and cute move on Mike's part but I confess I skipped the reading requirement.

Does this study mean I have to take extra precautions not to mingle my liver with my husband's during sex? :)

[oneatenuff]

Interesting.... ("strong indication")  though I've never understood fully the "occult", either.  I've understood what I thought was the basic worry  (that it's been detected in certain body tissues such as lymph and that what we though was "gone"  isn't really gone.)   My doc at Duke said that for practical purposes there's no need to worry about occult HCV and gave the explanation as to why, but I can't remember why - I recall not understanding it fully when he was explaining it then, which was a few years ago.  Point being - there is "occult", it's very confusing, but from his standpoint at that time it was totally not worth any consideration with respect to treatment  (the worth of it - even though there is the "occult HCV" that is being researched and being found)  ..... or something like that - lol..  

There's no telling what's going to be learned about HCV in the next 10-20 years  (hopefully enough in the next 5 years that will speed things along to a vaccine, even.)    

Interesting read.  Thanks for posting it.  

[Rockerforlife]

if i get SVR at 12 and 6 months EOT....thats all that really matters...the rest is hog wash

[jmjm530]

I echo other comments on being careful to draw real world conclusions from an in vitro study. Same on Mike's thoughts on the role of the immune system plays in SVRs. The fact that we therefore don't see more relapses because of suppressed immune systems seems to suggest that whatever remnants may be leftover are not viable enough for transmission.

-- Jim

[Bill1954]

This may just be an issue involving typos, but I was about to mention the same thing; that in vitro results are much different than in vivo. However, they must feel this evidence is compelling enough to directly quote at the end of their summation “This can be interpreted as a strong indication of potential virus infectivity in vivo.” Pham has been involved with these phenomena for quite a while; he’s listed as coauthor in this work.

I’d personally like to see more studies; although an in vivo study is going to be difficult to perform given the obvious ethical restraints in place. Possibly with chimp models? Very interesting. For those so inclined, TnHepGuy_ and others have assembled a page dedicated to the investigation of occult/persistent HCV:

http://www.medhelp.org/health_pages/Hepatitis/Occult-Hepatitis-C/show/54?cid=64

Bill

[jmjm530]

last sentence should have read: The fact that we therefore don't see more relapses because of suppressed immune systems seems to suggest that whatever remnants may be leftover are not viable enough for relapse and/or transmission.

-- Jim

[newleaf09]

I'm not a researcher so could not make claims of veracity for ANY of the studies.  I think we've all read some that are obviously bad science but managed to get published anyway.  I took graduate statistics and found it depressing that you can make your point by choosing specific statistical analyses that push the proof in a specific direction.  Just repeating what my doctor told me.

Mike, thanks for encouraging us with your personal experience with immunosuppression.

Apache, you are making me wonder about all virusses leaving remnants, not just antibodies.  Chicken pox does cause shingles in older people.

[JennyPenny]

last sentence should have read: The fact that we therefore don't see more relapses because of suppressed immune systems seems to suggest that whatever remnants may be leftover are not viable enough for relapse and/or transmission.
-------------------------------
This is what I believe also after thinking about it for a while. It's an interesting thing to discuss, but none of us has seen this type of thing happening in the real world.

[JennyPenny]

Here you go: http://www3.interscience.wiley.com/journal/106570044/home

[jmjm530]

One thing that came into my mind after reading was all the magical things scientists can do in the lab with let's say infertile couples who cannot otherwise reproduce in the real world, but if you try hard enough you can produce something in a test tube. The reality is that CHC s not very efficiently transmitted in the real world. Needle stick accidents around 3% transmission and sexual transmission either rare or non-existent in monagamous hetero couples depending on who you talk to. And that's with a viral count usually in the millions or tens of millions, not the so called occult which is below the detection range.

[Rockerforlife]

To contract HVC from  SVR patient,you would have to a vampire and drink a gallon of their blood

[desrt]

"...HCV RNA was detectable in their blood only with the more sensitive tests..."

That requires some clarification. What tests showed "detectable" and what did they show.

[willing]

This paper got a discussed a bit in a thread portann started about a month ago

http://www.medhelp.org/posts/Hepatitis-C/Cell-in-top-100-of-past-century/show/918781

I was surprised it didn't generate much discussion since it seemed a pretty interesting find, but assumed most people were just bored with occult hcv. The detection issues are not the news here.  The tests are standard RT-PCRs with a sensitivity of 2vge/ml, comparable to the NGI superquant, but with an important distinction: they examine extract from whole cells (lymphocytes and hepatocytes) whereas commercial tests only consider serum. In addition to detecting the coding (+) and replicative intermediate (-) RNA strands, they detected viral proteins via immuno-staining.

None of this is new. What is new is the demonstration that  residual, post-SVR virus is capable of infecting other cells, ie the has-been virus, though only a shadow of its former itself,  can still manage the basics. There are qualifications : not all patients were  able to yield infective virus and infectivity was demonstrated in  an in-vitro setting where the recipient lymphocytes were artificially stimulated/manipulated.

Whether in-vivo infectivity can be shown will be revealed in the next installment. I assume the Pham/Michalak lab is presently  working on those experiments. As noted in the above thread however, in some sense that experiment has been going on for a while :

"On a different tack, it seems some evidence should already be available, anecdotally, in human  organ-donation data.  How many cases of HCV transmission from SVR-donated organs have been recorded? "

[Rockerforlife]

AMAZING QUESTION

How many cases of HCV transmission from SVR-donated organs have been recorded? "

[JennyPenny]

That's an interesting question. But I thought that HCV organ donations are only given to people who are HCV positive. I don't think there is too much to worry about here. And it seems that you all agree. I was wondering if the SVR is a cure faction would feel the same as the SVR is just remission people would think differently.

Oh, I just got a note from someone named Ugly (very appropriate I might add) who called me a fear mongering internet babble something or other. Had my laugh for the day.

Have a great night everyone.

[apache1]

Thanks for the link Jenny

This article did mention much collected data that did not directly apply to this particular study of 9 patients.
Such as PBMC and liver vl.  Imo no reason to mention in this article other test methods that were NOT used on these 9 test subjects... seems misleading to me, maybe purposely ?

After reading this study in full, my laymen conclusion is, this study used patients with less than satisfactory viral load SVR testing. The tests used for the
9 "clinically apparent SVR" study patients, only went down to
***500 iu/ml.****

Then the study lab used very sensitive tests of <2 or <10 for those 9 study patients, and came up with blood serum vl loads of <40-400 .
These patients were now labeled as having occult hcv with vl of <40-400.


=============================================================
Nine patients who achieved SVR after completion of IFN or IFN/ribavirin therapy, as defined by repeated serum HCV RNA negativity by the Roche Amplicor HCV version 2.0 assay

****(sensitivity, 500 IU/mL or 1000 vge/mL****

; Roche Molecular Diagnostics, Pleasanton, CA) and normal liver function tests assessed at 6- to 12-month intervals, were investigated in this study (Table 1). All patients were anti-HCV antibody-positive by enzyme immunoassay (Abbott Diagnostics, Mississauga, Canada). The follow-up period after SVR ranged from 24 to 72 months. All nine individuals were found to carry HCV RNA at the time of this study when total RNA isolated from 500 L of serum was assayed by highly sensitive RT-PCR/NAH (sensitivity of 10 vge/mL or 2 IU/mL) that was previously established.[2] The estimated HCV

***RNA loads in the patients' sera ranged from <40 to 400 vge/mL***

==============================================================


Now we as patients have better vl tests available to us here in the USA.
Quest has the Heptimax good to <5
LabCorp has the NGI <2

So if we all get the sensitive tests done at 6 month post eot, then this complete study, regardless of its accuracy,  is null and void for any one that shows negative on sensitive commercially available viral load blood tests.

apache

[CanaryParker]

Perhaps that's why a small % of people who obtained an svr continue to have liver damage and other symptoms?
And to be on the safe side, even with a successful and long term non-detectable that one cannot ever donate blood or be considered a healthy transplant donor?
As in Hep b, west nile, lymes, (some cancers?) and other diseases.

[oneatenuff]

lol on the ugly note!!  (I'm sorry - I know I should not be laughing or think it was funny .... it's really not funny, but ..... I guess after you've been around so long and know what touchy subjects can do.... it's just.... dunno - it  just made me laugh out loud to get to your note and see that .... ut oh.... someone is so riled they're firing off ugly notes to Jenny!  I've gotten plenty ugly ones before and so I hope you'll just consider I'm laughing with you (certainly not at you.)  I had just written a note on the other thread started about this and then (when my screen reloaded)  I saw this thread was active and had new  notes, and I was catching up here reading.....  (sheeezh!)   Had to at least share the laugh - I think they could have come up with a better name though, like something more occult - not just plain obviously ugly.  

I guess it was good to be able find something to laugh about regards the occult.

later : -)  

[willing]

>this complete study, regardless of its accuracy,  is null and void for any one
>that shows negative on sensitive commercially available viral load blood tests.

It's a very valid point that the authors would have improved the paper by applying more sensitive commercial VL tests to the 9 subjects.  However to throw out their results because of that omission seems extreme. You'd have to assume these 9, randomly selected SVRs, were all relapsers who managed to keep their VL in a range between 2 and 500 iu 24 to 72 months after reaching SVR -  very unlikely.

As for the reliability of their RT-PCR protocol, it's also important to look at all the other data presented: Fig 2 demonstrates detection of viral protein NS5a; Fig. 1 shows gel bands that match the expected  244bp amplicon; Fig 4 shows variation in the genomic sequence of virus obtained from the donors and recipients (exactly as one would expect if the virus was mutating as it replicated).

[JennyPenny]

I'm glad you got a good laugh also. I know you were laughing at the situation and not at me.

Have a great night.

[DoubleDose]

Of course this subject is one that I have taken quite a lot of criticism and even mocking for in the past, for saying basically the same thing that this study demonstrated.  In other words, when people say its absolutely GONE after SVR and that we are silly to think that there is a remaining, low level virus in some cells, organs, or even blood...I have always felt that much of this sentiment was based on wishful thinking, and a degree of denial.  I don't know how harmful or how infective the remaining virus might be, but the reams of studies over recent years, and the growing collection of 'occult' or 'persistent' HCV research makes it almost impossible to hide from the fact that the virus is still there, in SVR's and spontaneous clearers....but just in much more minute amounts.

How this phenomenon actually works, what it means to our health or infectivity...are all open questions, as I have intimated many times.  I do not need to make these arguments anymore though, because every month there is a new study verifying the phenomenon once again.  One day we will better understand the whole 'occult/persistent' issue, but until we do...let's all keep an open mind...and ask the tough questions.  I know that we would all love to consider ourselves totally virus-free...eradicated....but if that is not the reality...then trying to persuade ourselves with glib reassurances really makes little difference.  The good thing is that SVR seems to mitigate a substantial portion of the HCV damage to our livers, and possibly to our general health.  Let's take that as no small victory...but a major accomplishment.  Its just that there may be a Part II and Part III to the SVR story.  , Still more to learn.

DoubleDose

[Facta_non_verba]

Perfect! I agree completely with your comments. For now I will take SVR as something extremely positive. I believe we will continue to see studies that show persistent viral particles in those who have achieved SVR and also studies that show ongoing signs of imflammation. Nonetheless, I think it's pretty clear that attaining SVR stops, delays or attenuates continued liver damage.

Sometime in the future I believe there will be drugs that will eradicate the virus completely. Until then SVR will remain the holy grail.

Jeff
Facta non Verba

[apache1]

Hey willing.
Not throwing out their results at all...am sure results are valid, ONLY In the people that have DO HAVE
40-400IU/ML viral load after SVR, which makes them 'occult relapser's', as per this studies protocol.

Just saying for you or me, or anyone that takes a sensitive VL test 6 month or more post tx and comes up consistently negative DOES NOT fit this study protocol of 40-400iu/ml occult relapser.

http://www3.interscience.wiley.com/journal/106570044/home

In table 1 of this study, ALL but one (8 out of 9) occult relapser patient had OVER 40iu/ml. The one had between 2-40iu/ml. Thats hcv positive as far as I know. Not Resolved Hepatitis, as the study title says.
No real surprise they could find and cultivate Viremia from these hcv positive patients.

This has me wondering, is this common to have 40-400 vl after svr ?
Just where did this study find these 9 red herrings with 40-400 vl after svr ?

Has any one here ever seen a forum member report a confirmed 40-400iu/ml viral load after svr. Not a false positiive, but a confirmed consistant 40-400 vl. ?

I know most get vl test every year for at least a few years after SVR.
Might start a post to ask all SVR to post there vl results since they got a SVR. Hopefully some will have multiply tests. Maybe we can see if any in our forum fit this study protocol.

apache

[Rockerforlife]

Heres a thought,maybe the PI drugs will totally eliminate the virus...leaving absoulty no trace..no occullt or other..until then it now looks as tho we are still infectious,even it we SVR...not good to hear ,but hey,,,,you cant have your cake and eat it too....so i guess this means the fear and stigma will remain for us....until they can prove otherwise.

[DoubleDose]

It would be nice if the PI drugs do indeed end up having a real shot at total eradication.  We will see.  Maybe though, when the virus gets to a certain level, it just goes into a remission mode, and the internal immune system takes over, whether using traditional TX drugs or PI's.  Hard to guess what the difference will be.  

Although the title of the thread involves another "scarey study", I am not sure that residual, persistent or occult virus is all that scary anymore.  I am pretty accustomed to the concept, as I am sure are many others.  It just seems to be another of the mysteries involving HCV, which are many...and involve a wide range of open questions..relating to things like...eradication, persistence, effects on other systems and organs, brain involvement, cellular immunity, spontaneous clearance, diabetes, arthritis, memory issues, behavioral changes, depression, infectivity, etc., etc.  

The list of unanswered questions goes on and on.  The persistence riddle is only one of many.  Sometimes the use of the tag 'HCV', or 'liver virus' only serves to simplify a subject that is actually multi-faceted, not fully understood, and ultimately ends up being very complex and shaded in grey.  Its why I continue to monitor the Forum, and to read as much scientific literature on the subject as possible...while still not obsessing on the virus or my own past history.  I feel oddly detached from it in many ways, and seek to learn more about what we have been living with, and now what the real nature is regarding our SVR status.  More analytic these days than emotional.  Best to all of you.

DoubleDose

[merryBe]

what I'm wondering is whether they determined that the viron observed replicating was the same identical virus that the person originally had.
I mean they've got subgroups of subgroups of subgroups with type 4....could this be a similar anomaly?

It seems a little incongruous that even a well trained immune system would keep at bay something as virulent as type 1a for instance, which from what I undestand usually comes back with a vengenge if it comes back. Unless the immune system is exceptional.  I beleive MikeSimon said his doctor thought he would "always have a little virus" (if that wasn't you Mike, forgive me) but that hardly makes sense either since he is on antirejection drugs for his TP he should be more vunerable to mass reinfection while immunosuppressed.....yet that's not the case.
I'll admit all these anomalies have me fairly stumped.

The observation that they somehow came up randomly with 9 people able to maintain that low level has me puzzled as well.
Obviously they are positive, with some type, or subtype.
I'd just be surprised if it weren't a weaker form, a new subgroup if you will, otherwise how could they maintain that low VL for 2 years.

As HR would probably say, they weren't ever UNDetetable to begin with...so no surprise if there's virus there....but how is it staying so low?

What was the mean age of the patients I wonder?
And did they varify tht it was the identical RNA and not asubgroup...weakened virus?Just trying to understand this.

mb

[Rockerforlife]

There has to be a way to find out if we are still infectious or not,after SVR....how bout doing this test...after one gets SVR....draw blood and reiject it back.....if you are still UD after that...well...doesnt that say something?

[willing]

apache: the serum vl units in table1 are vge/ml (viral genome equivalent). Their assay has a vge-iu conversion factor of 5 so those 9 SVRs showed detectable serum from under 8iu/mL  up, close to threshold of the Heptimax (tma) and above the ngi superquant. Agreed that it would definitely  improve the paper if they ran those tests. The participating  SVRs are presumably still SVR  so this can be done at any time. As things stand, one gets to choose from three options:

1) the authors scoured the woods of Newfoundland  and managed to find 9 very, very rare relapsers who maintain VL at the threshold of detectability
2) vl detection at the threshold by commercial clinical assays is unreliable; ie those SVRs would all show und on a heptimax or superquant
3) the 9 SVRs really are serum-UND and the authors'  in-house RT-PCR/NAH protocol is unreliable

(1) is utterly implausible. (3) has been the "conventional-wisdom" of most of  the medical community , at least up to now. However as one looks at the paper, they go considerable trouble to show the same thing over and over, by different assays independent of serum VL. They also show that infectivity is blocked by ifn treatment  and ABs, as one would expect if measuring actual infection vs contamination.  I expect those 9 patients are aware of the study and its findings.. it would be interesting to hear their thoughts

mb: Their Fig 4 shows  sequences obtained by cloning the 5'UTR of virus from donors and recipients

rocker: There is no absolute immunity from hcv infection, but I believe several tests in IVDUs and chimps have shown that those who spontaneously clear are much less susceptible to future infection; no idea whether this applies to tx-based resolution.

[apache1]

Hey willing,

I disagree with your conclusion of
'close to threshold of the Heptimax (tma) and above the ngi superquant."
Actually its almost twice the threshold of the Heptimax and 4 times that of the NGI. And thats only for the 2 patients that had 40 vg/ml ...or,,, drum roll... 8 IU/ml

===============================================================
Their assay has a vge-iu conversion factor of 5 so those 9 SVRs showed detectable serum from under 8iu/mL  up, close to threshold of the Heptimax (tma) and above the ngi superquant.
===============================================================

True, it is IU/ml not vg/ml.
I did see that, but did not want to confuse the matter since the the first line in the study section 'Patients and Methods'  has the test sensitivity they used.
Looked like a conversion factor of 2, when it was convenient for them to use a totally ridiculously LOW sensitivity test to 'prove' svr
****"500 IU/mL or 1000 vge/mL"****sensitivity

Then they turn around and use their very sensitive <10vge/mL OR <2 IU/ml,,, to test and prove 'occult' ...with a vge/mL to IU/ml conversion factor of 5
Even with all their smoke and mirrors, we are still well within the detectable range  using a <5 vl test with 8 IU/ml so a <5Heptimax and NGI <2 should easily detect this amount of virus, don't you think ?
Not to mention, out of the 8 they documented (where is #9 in table1 ?)
1 had 1.6 × 103 viral load
1 had 400          viral load
2 had 100          viral load
2 had 50            viral load
2 had 40            viral load

Only 2 had 40 vg/ml or 8 IU/ml.
So all the others were high enough that a <10 test would find virus, don't ya think ?  A <50vl test for some of their patients would be more than sufficient.

If we use HR's universal conversion factor of 2.5, that he told us to use even when it said 5.2 factor, we are still well within the detectable range of even a <10 vl test of 16 IU/ml so a <5Heptimax and NGI <2 should easily detect this amount of virus, don't you think ?

From what I gather, even a good < 50 test vl will more than likely show at least a positive but not countable result when a smaller vl load is present, to some extinct. Hence they had to use a ridiculously LOW sensitivity test to 'prove svr' in the first place, or all the rest of their study was worthless with no occult patients.

HR said in a past post of his that the ngi <2 vl tests are actually much more accurate than they advertise. The <2 NGI that advertises <2 is probably good to <1, if I understood his post correctly. Didn't HR help research and develop the <2 NGI ?
I tend to think HR knows a thing or 2 about vl testing, probably at lest similar to this studies coordinators.
Not sure if what he said about ngi <2 translates to the Heptimax also, but would assume its at least as good as they advertise, <5

apache

[merryBe]

well I wish I had access to the whole abstract...

but minus that, how they clone the virus does not really answer the question of whether it was a wild strain or not, does it?

I mean, they are cloning whatever was left IN the person, which may be the original strain, or it may be a mutant wild strain with far less virulence.

The fact that it replicates in vitro, whether in T-cells or any other type of culture, does not really tell the tale of how susceptible the virus is to death in the immune systems of the donors where there aren't hundreds but millions of cells to come against it.

2 things strike me ....1. "Eleven of the cell cultures became HCV RNA positive. Furthermore, HCV from three of the nine patients was able to establish active HCV replication in the cultures."

(that they tested positive, that means that in all but one culture an immune response occured and antibodies were formed....
3 of the nine had sustained viral application means that absent the immune system in total some could develop the virus. It still doesn't tell us how virulent or not that virus is.)
( I mean, the first thing one thinks of with a wild strain is a resistant strain, but what if due to the treatment it's the other way around, and it's an easily defeated strain? This to me would help explain why the people were carrying it for years with no measurable growth....although that's the problem here also is that no one tested accurately enough to say...were these individuals having a slow escalation over those 2 years.

secondly, they remark as follows " Interestingly, HCV replication in the T cells was prevented after neutralization of the virus, and by treatment with interferon."
By what means were they neutralizing, other than interferon...because it sounds like they did 2 separate things...were they things possible in the human body? They went from 50% clearance average in 1a to 100% in vitro....I'm not sure what this proves.
Not how the virus will act in vivo.

as to their finding, that " a strong indication of potential virus infectivity in vivo.”

how could they conclude otherwise? Based on that data it's a no brainer...yet I'm reminded also that when a person is transfused they have to make jillions of new antibodies for all the diseases that the other person carries...like chicken pox, herpes and dozens more.

The thing is, you make an interesting query: What would the nine patients have to say:

If I may presume to speak as ONE of them, I would rather be "marked" as an HCV carrier for life than to go back into the donor system with any chance whatsoever of giving this to someone else. Not this disease, and NOT this treatment...no one should suffer either.
Some may not feel that way, wanting to be rid of the stigma, but until we really know one way or the other, better safe than sorry.
After all, I got this from plasma....and I'm not at all comfortable thinking that our medical system would allow donors who once carried HIV or HCV, or HBV for that matter back into the general donor pool while the verdict is still out.

However, I'd be much more comfortable with that being my resolve if they were to say create some animal models and produce the same results. Harder than a petre yes, but much more informative as to real life situations.

The issue as I understand it at present, is that even in the most sensitive PCR  >1 the one that HR himself invented the test and machine for, he says the possibility of floaters still exists.
Meaning someone could test UND in an PCR >1 and still be carrying virus.

So I'm concluding that it will be a long while yet before we know for certain what is gone versus what is just what we call it SVR....Sustained Viral Response....not neccessarily gone but no longer an issue either at least for the well honed immune system that carries it...but still not neccessarily safe for an unexposed person.

I think those infected need to ask themselves, if you weren't infected right now, would you want an possibly infectious organ or blood put in you?
Probably not, so even if we aren't sure yet whether any of the science is accurate, we are sure that some disturbing occurances have developed, and we should all walk circumspect and accordingly until things prove otherwise.
If not, we become as antequated as those backwoods physicians who refused handwashing for 50 years past when germs were discovered and viewed under the microscope.
They refused to believe what was in front of their eyes, and thousands died needlessly due to their ignorance.
As patients we can also be as ignorant, to err is human, and some things are scary, true.
But, if I die tomorrow I want my strong heart to help someone else live, not to make them sicker.

mb

[willing]

apache: sorry if my wording above wasn't clear; what I meant to say was that  VL ranged from close to threshold of the Heptimax and up with all tests being above the superquant. In any event there's no arguing that at least the superquant, if it performs as expected, should detect VL in all patients.

Furthemore, VL in patient 6 (59/F) with a VL of 1600 vge should have been picked up even the Roche Amplicor v2. This discussion and the paper's  lack of comment on the discrepancy in VL tests is making me see the paper in a new light: apart from the main result being reported, the paper is a shot across the bow of all the sensitive VL testing technology.  

In essence, the subtext of the paper seems to be saying : never mind the arguments about contamination, amplification technology, dilution, linear range, copy number, etc. We now have a straightforward test to check for the presence of virus : can you infect healthy cells ? If  infection is possible, and they demonstrate infection  seven ways from sunday, you have virus.

Perhaps I'm reading too much into this, but the lack of discussion in the paper, or the lack of any accompanying editorial comment in the journal is striking. It certainly would be interesting to hear HR's thoughts on the topic.

mb : I believe JP gave a link to the full text above

[CoWriter]

"How many cases of HCV transmission from SVR-donated organs have been recorded? "

------------

I doubt there have been many SVR-donated organs used....because of the possibility of interferon treatment having caused autoimmune problems, etc.  

Co

[Rockerforlife]

I hate the idea its possible i may be still infectious.even if i do SVR..i know its not 100% proven,but it sure puts a grey cloud over it all.

[merryBe]

nope she didn't..it's a link to an abreviated version.

the test is in the MAy Hepatologist, which one must subscribe to...

anyway, it leaves the rest of us guessing when we can't see the full study.

[mikesimon]

"How many cases of HCV transmission from SVR-donated organs have been recorded? "

------------

"I doubt there have been many SVR-donated organs used....because of the possibility of interferon treatment having caused autoimmune problems, etc."  

You may be right that few SVR organs have been transplanted but I strongly doubt that the reason is "the possibility of autoimmune problems". It's more likely due to scarcity of SVR livers. If you have any evidence to support that statement please post what you have. HCV positive organs have been transplanted and I would assume that an SVR liver would be preferable to HCV+ liver. I could go on but I won't.

Mike

[CoWriter]

It's just my opinion.  I've actually never seen any studies on SVR liver transplants.


"HCV positive organs have been transplanted and I would assume that an SVR liver would be preferable to HCV+ liver. I could go on but I won't. "
-------------------------

Not necessarily.  Several studies have shown that the survival rates using hepatitis-C-infected or uninfected livers are comparable.


The Optimal Liver for Transplant in Hepatitis-C Patients: Presented at DDW
By Bruce Sylvester

WASHINGTON, DC -- May 22, 2007 -- New research suggests that hepatitis-C- (HCV) infected patients receiving livers from HCV-infected donors have a slower rate of fibrosis progression at 1 year than those receiving uninfected livers.

The findings were presented at a press briefing here at Digestive Diseases Week (DDW).

"The implications are potentially highly important," said presenter and investigator Paul Kwo, MD, associate professor of medicine and medical director of liver transplantation, Indiana University School of Medicine, Indianapolis.

"Many people live 'peacefully' with hepatitis C infection, but when they die of other causes, their livers have not been considered to be eligible for transplantation. Our study suggests that survival rates for recipients are at least as good with cadaveric hepatitis-C-infected, noncirrhotic livers as with uninfected livers. This could mean the availability of many more cadaveric livers for transplant, where there is a critical shortage now," said Dr. Kwo.

The investigators compared transplant outcomes for liver recipients from HCV-infected donors to those for standard, nonextended criteria (ECD) donors. They analyzed data from 38 liver recipients and 76 ECD donors, data extracted from a transplant center registry, UNOS (United Network for Organ Sharing), and original on-site donor data charts.

Thirty percent of all donors met non-ECD criteria (standard donors) and were included as potential matches for the case-control study. The researchers matched each HCV-positive liver donor recipient to 2 standard donor recipients

They then analyzed recipient data for graft survival and patient survival at 3 months, 1 year, and 2 years. They also noted perioperative death, HCV recurrence, and 4-month and 1-year fibrosis.

The researchers discovered that when HCV-positive livers were used, there was no difference in survival rates compared with patients receiving uninfected livers. And they reported that the rate of fibrosis appeared to be slower in recipients of HCV-infected livers.

"The use of HCV-positive donors may be considered as a first-line therapy to increase the available donor pool of organs in those undergoing OLT for HCV-related cirrhosis," the authors concluded.

"We need more organ options for hepatitis-C patients," added press briefing moderator John Vierling, MD, professor of medicine, chief of hepatology, and director of Baylor Liver Health, Baylor University College of Medicine in Houston, Texas. "This could go a long way to meeting the need for more donors."


Here's one more.....

"In addition, the study showed that, among the patients receiving an HCV-positive liver, those in whom the donor strain of the virus prevailed remained disease-free for a significantly longer period of time than patients who retained their original viral strain. "Disease-free" was defined as patients showing no recurrence of hepatitis and no significant liver disease."

http://www.gastro.org/wmspage.cfm?parm1=474

Co

[ladybug52]

Your comparison of lingering hep C remnants to chickenpox and shingles was brilliant I think.

Course I'm not one of the brighter bulbs on the forum but still, it was a great analogy!

However, I have to point out that although shingles is more prevalent in older people, young adults and children are also susceptible, (my daughter had shingles in the fifth grade.)

[Trish77]

"I doubt there have been many SVR-donated organs used....because of the possibility of interferon treatment having caused autoimmune problems, etc. "

"It's just my opinion.  I've actually never seen any studies on SVR liver transplants. "

Autoimmune diseases can be detected by tests.  Thyroid, AIH, etc.  Not every person going through treatment picks up an autoimmune problem - it happens to be in the minority.  I don't see any issue whatsoever with an SVR liver on those grounds if the presence of autoimmune issues have been ruled out by testing.  

[jmjm530]

What Do You Think About This Scary Study?
-----------------
Honestly, unless you're a healthy specimen of serum in one of MacParland's petri dishes, I don't think there's anything at all to be scared about :) Did you read what they had to do to those poor serum specimens to "infect" them !

Regardless of what you think about the study and its methods, the  fact remains that hepatitis C is very inefficiently transmitted. For that reason, the CDC doesn't even recommend condoms for monogamous couples excluding anal or rough sex. Even needle stick accidents only account for around a 3% transmission risk. And keep in mind this is for someone with  full-blown HCV were viral load can be in the TENS OF MILLIONS..

So where does that leave the real-real world transmission risk for an SVR where viral load is either zero or under the radar of the most sensitive commercial tests, depending on who you read?

For those interested, the complete study is available for free online at the "Hepatology" website. Simply scroll down, find the article, then click on "HTML Full Text".

-- Jim

[jmjm530]

For those that missed it, here is what "HR" had to say about "occult" tramission by SVRs....
-------------------------


"    - What are the possibilities of occult SVR's being able to transmit the virus?
-----------------------------

(HR): Most likely negligible, since not even full blown VLs with fit virus in the 5o Million/ml range are very transmissible in the sexual context.


"- And if the majority of occult infection is made of 'unfit' viral remnants, how might the immune system of an uninfected individual who became exposed (via transfusion, IV drug use, needle stick, etc) respond? Would you expect their immune system to 'trap' and treat it in the same way - creating a low level 'balance' with a chronic infection remaining? Or might a healthy immune system be able to fully 'knock back' the occult infection to the point where negative strand replication no longer takes place? "

(HR): Such an infection will probably not take hold to any degree that matters. It has become a "non-pathogenic' virus, a lame and tame dog out of a Wolfe....
Questions like that will also have a very low chance of being investigated, since they are very difficult to examine and have a clinical impact too low to matter in a world filled with more obvious diseases and dilemmas.

http://www.medhelp.org/posts/Hepatitis-C/New-Occult-Hep-C-paper-from-Pham-et-al/show/763749?post_id=post_4022709

[mikesimon]

I've seen all of that and I still would bet that you're wrong. And I have seen other recent studies which don't support the position that HCV+ livers have better outcomes than HCV- livers. As you said, it's your opinion, and I don't think you're right. But, we're both probably safe because there isn't any documented examples to site. I'm sensitive about transplantation and SVR so I am less apt to speculate in this area or see speculation without responding.
Mike

[apache1]

***So where does that leave the real-real world transmission risk for an SVR***
where viral load is either zero or under the radar of the most sensitive commercial tests, depending on who you read?
============================================================
Well, as long as you asked Jim...
Imo, it leaves a UNDETECTABLE real world transmission chance.

apache

[Rockerforlife]

I would say the odds of an SVR`er passing it on to another has to be very low...the  new sensitve tests they use to detect the virus in an SVR patient can only be done in liver samples...until the new sensitive tests can be done on blood serum...we wont know for 100%...just my thinking

[willing]

co/mike/trish: I've never heard of past ifn tx as grounds for rejecting a potential organ donor, though it's not an area I've read anything about (any references?)  As Trish points out,  auto-immune disorders, possibly ifn-triggered, could be readily diagnosed so excluding donors (living or dead) on the grounds of ifn exposure seems limiting

The MacParland paper's refs 13-17 address the organ infectivity topic. Though I didn't see any answer to my question above about transmission from SVR-donated organs one of the refs
http://www.ncbi.nlm.nih.gov/pubmed/12942451
may be relevant. They considered *aggressive* (5MU daily!!) pre-transplant tx of 20 pts to clear hcv to avoid re-infection. Among  the 12 SVRs, only four "did not have evidence of HCV recurrence after OLT" implying that in most cases SVR status was not sufficient to prevent re-infection.

mb: as jim points out, the paper at the hepatology journal site should be free-access. My understanding of the use  of the Ab and IFN tests in inhibiting infection was simply to demonstrate that their assays do in fact reflect infection rather than spurious results. If the PCR and viral protein detection assays were picking up junk, they would continue to do regardless of whether you incubated with Abs/ifn; infection on the other hand would be expected to be blocked, as it is.

jim/apache: regardless of the scary headline, I don't believe possible transmission  by svrs was the point of the article (good reason to read the paper rather the summary). The main results seem to be (1) residual virus has demonstrated ability to infect (an open question up to now) and  (2) the ability of commercial/clinical VL tests to detect complete absence of virus is suspect (and there is now  a separate test for determining presence of virus that does not rely entirely on RNA amplification).

The fact that they had to stimulate PBMCs as part of the detection and infection protocols doesn't seem unusual. We know immune cells are not the virus' preferred hunting ground so having to stimulate those cells to raise viral activity to detectable levels seems  reasonable.

[jmjm530]

jim/apache: regardless of the scary headline, I don't believe possible transmission  by svrs was the point of the article (
-----------------------------
That was mostly our point. Indeed, it certainly wasn't what was proved and therefore I question how responsible they were in some of the inferences.

[JennyPenny]

I have the whole study if anyone wants it just email me....

[JennyPenny]

I've been edited. PM me if you want the whole study. I have it. This place has more rules than a trafffic cop.

[jmjm530]

Full-text is online here for free:

http://www3.interscience.wiley.com/cgi-bin/fulltext/121581244/HTMLSTART

[JennyPenny]

Thanks Jim.

[apache1]

willing,
We hashed this over before,
remember 8 of 9pateints were over 40vl...and  you wrote:
=============================================================
" Furthemore, VL in patient 6 (59/F) with a VL of 1600 vge should have been picked up even the Roche Amplicor v2. This discussion and the paper's  lack of comment on the discrepancy in VL tests is making me
***see the paper in a new light:***
apart from the main result being reported, the paper is a shot across the bow of all the sensitive VL testing technology. "
=============================================================

Has some new study caused you to  'lose the light'  on this willing ?

So once again, researchers take patients that are not SVR (by current available vl tests), and show that they have virus that can replicate when stimulated in a laboratory test tube.
Is this a big surprise, or even a new finding ???

apache

[Mr Liver]

I think this topic has sure had legs. I'm willing to bet Pham would happily concur since he's been making a living trying to prove something unsuccessfully for twenty years.

I've wondered for some time why his research seems to avoid employing techniques
that would bolster his findings. Now, I may have missed something and its been awhile but the following are problem points I have with his studies.

He has hung his hat for a long time on the proposition that the neg strand is a sign of replication, ergo, its existence indicates ongoing viral infectivity.  To my knowledge its presence is an indication of replication but its discovery is meaningless by itself. This presence of the neg strand does not indicate completion of the replicative process.  It is exactly what it is called---an intermediate step (necessary for replication). The pos strand is also an intermediate necessary for the neg strand to do its part in the process. By measuring the presence of both pos and neg strands a ratio of +/- can be estimated and compared to known ratios. I don't believe I've seen this in his studies.

Macrophages (part of the family of white cells known as PBMC) collect viral debris from our blood. By collecting these macrophages and stimulating them to divide at a much faster rate  poses some problems for me. Cell division can result in the release of some cell contents each and every time it divides. Along with the crushed cells done by centrifuge one can artificially create a scenario that only exists in vitro and not in nature. The released contents of these cells includes RNA fragments which alone have no ability to infect. However with a large enough sample it can then be amplified by RT-PCR whereby it would detect the presence of the RNA indicating active virus.

I've offered the same challenge for nearly ten years now---just show me one documented case of relapse beyond 3 years SVR which is verifiable and has been  peer-reviewed by a reputable scientific body and published. So far no one has been able to do so. This, I'm afraid is the big elephant in Pham's lab.

If I have misinterpeted, misread, or misunderstood, I am prepared to modify my views. I haven'tlooked over any of these studies for some time and I'm working with less than optimum memory lately so its a distinct possibility.
ML

[jmjm530]

ML: -just show me one documented case of relapse beyond 3 years SVR which is verifiable and has been  peer-reviewed by a reputable scientific body and published. So far no one has been able to do so. This, I'm afraid is the big elephant in Pham's lab.
------------
Yes, because if the virus is not truly gone like Pham suggests, then it must be the immune system keeping an SVR from relapse. Yet, we don't see relapses in SVRs even in immune compromised individuals. So what's keeping the virus "under the radar"? One explanation is that what they are seeing really isn't the replicative/infectious virus that is known as HCV but some sort of partial/impotent imposter.

[Rockerforlife]

We are seeing one badly beaten monster thats afraid of rearing its ugly head.

[JennyPenny]

Or, infecting a cell in a laboratory setting, is different than infecting a cell in a human body.

[willing]

apache:
> So once again, researchers take patients that are not SVR (by current
> available vl tests)
as far as I know the current dogma is that SVR only comes in one flavor: if  the 12w post-eot test is UND you are SVR, more or less for life, with all the privileges appurtenant thereto. Sensitivity of the post-eot test is irrelevant insofar  as, if there is a class of relapsers with VL consistently  below detectable levels, it has not yet been detected/reported (apart from the occult papers).  These pts  repeatedly measured  VL UND and have  normal enzymes. If they're not SVR how would you describe them?

The twist to the paper I hadn't caught until you brought up more more sensitive testing  is that even the Amplicor v2, *if it performs as advertised*,  should have detected VL in patient 6 but didn't. Clearly one of those two PCR tests is lying.

ml:
>show me one documented case of relapse beyond 3 years SVR
> which is verifiable and has been  peer-reviewed by a
> reputable scientific body and published
among long-term follow ups in the general population there's
Pradat'07 which found  a 7% late relapse rate
"Ninety-three per cent of the HCV patients who had cleared the virus (spontaneously or after antiviral therapy) remained HCV-RNA-negative during follow up"
( from http://www.ncbi.nlm.nih.gov/pubmed/17650289 )
and among potentially immunocompromised OLT recipients there's
"Two patients with SVR developed late virological relapse. "
(from http://www.ncbi.nlm.nih.gov/pubmed/15996238 )
However, there's no way of distinguishing  late-relapse from re-infection so the rate is probably even lower than what is reported.

On the plus side, experts in the field are as confused on this topic as we are. A careful compilation of all available data was published by Welker and Zeuzem in Feb:
"Occult hepatitis C: how convincing are the current data?"
http://www.ncbi.nlm.nih.gov/pubmed/19105211
which  includes tables distinguishing  different classes of  late relapse. This triggered  a prompt response from Carreno et al, citing MacParland's paper among others. Zeuzem ( reply pending publication) is still not convinced
" If clinical significant replication of HCV takes place in patient with “occult” HCV infection and sustained virologic response (SVR) after interferon-alfa (IFN) based antiviral therapy for chronic HCV infection, high late virologic relapse rates may be expected. However, late  virologic relapse rates are overall very low in patients with SVR, irrespective whether their immune system is impaired or not (1)."

his strongest bit of ammunition, IMHO,  is a recent careful study, Marukian'09, which goes directly against the MacParland/Michalak results.
http://www.ncbi.nlm.nih.gov/pubmed/19003912
These guys were flat out unable to get HCV to infect PBMCs, even when they transfected the cells with HCV RNA. Only one of MacParland and Marukian can be right... and they both seem to have done very careful work.

As for your points about the methods in the MacParland paper (and I believe Pham's first paper was only '04), the relative ratio of +/- strands is  unlikely to be reliable because (a) errors in quantification of very low RNA levels (b) ignorance about the quantitative details of viral replication. We know one, unsheathed, genomic (+) strand yields one antigenomic (-) strand which is then multiply transcribed to yield progeny virions, but as far as I know this is very poorly characterised (eg see Bartenschalger'04
http://www.ncbi.nlm.nih.gov/pubed/15530561)

Also mitogen stimulation is a routine technique in immunology.
It's worth noting that MacParland's paper uses multiple forms of evidence, presumably in part to deflect the old 'contamination' objections. Along with the RNA pcrs shown in Figs 1 and 3, they include fluorescence microscopy-based evidence of HCV protein NS5 detection in Fig 3, sequencing results in Fig 4, and electron-microscopy evidence of binding to viral particles via HCV E2 protein in Fig 7.

jim:
>some sort of partial/impotent imposter.

aye, the old evil twin plot twist... is this really different from the broken down has-been hypothesis? But we now know the impostor can infect (and can be prevented from infecting). Also, comparing top and bottom lines in Fig 4 suggests the impostor looks an awful lot like real HCV (at least in this snippet, which admittedly is in the most conserved part of the viral genome).

[jmjm530]

A more germane quote per this thread title rom the Zeuzem study you referenced above, would be:

"In conclusion, HCV-infected patients with no detectable HCV RNA in serum 24 weeks after the end of treatment should remain to be considered noninfectious and cured of their infection..."

[Mr Liver]

Thanks for the reply and the interesting notes. You know I can't let a nearly 10 year challenge fall at the hands of something like the Pradat study. ;) The obvious limitations of testing sensitivities, the adjunctive nature of the finding, and possible re-infection which you mentioned, could have all affected the results. The other study you linked to was indeed relapsers under immunosuppression therapy but even putting that aside they did not fall into my criteria as their relapse was earlier than 3 years--"During the long-term follow-up period, serum HCV-RNA was persistently undetectable in 32 of 34 (94%) patients with SVR. Two patients developed virological relapse at 8 and 15 months."

Here is a discussion of findings from Medscape concerning Pradat which details the reasons why Pradat does not rise to the challenge:

"Discussion
Among patients classified in 1996 as resolving acute hepatitis, 6% became HCV-RNA positive by PCR during the follow-up period. Similarly, among patients classified as sustained virological responders after antiviral therapy, 8% were found HCV-RNA-positive during follow up.

Because of progress in virological testing, one cannot exclude that some of these late "relapses" were not positive but were missed by the lower sensitivity of the HCV-RNA detection methods used 5-7 years earlier. It is indeed possible that if re-tested using current methods with higher sensitivity, some of the initial samples regarded as being negative for HCV-RNA, would turn out to be positive at very low levels. A recent study has shown that minimal residual viraemia could be detected by a transcription-mediated amplification (TMA) method.[13] The authors showed that among patients who were repeatedly HCV-RNA-negative by PCR at the end of therapy, 12.5% were found HCV-RNA-positive by TMA. Among these latter, 96% were relapsers after therapy withdrawal. In the present study, the possibility of re-infection cannot be ruled out because data on risk behaviour during follow up and concordance of genotypes were not available.
                        
However, although the sensitivity of current conventional laboratory assays approved for HCV-RNA detection has substantially increased, it remains possible that low levels of HCV in serum or within white blood cells still escape detection. Two recent studies[14,15] have indeed shown evidence of the long-term persistence of HCV genomes in sera and circulating lymphoid cells in individuals considered to be clinically and serologically cleared of HCV infection. However, the clinical impact of such low levels of residual virus remains unknown but appears of limited significance".


I'm aware of the use of mitogen stimulation in vaccine development but I am not familiar with its use in that setting. The problem I have with this method is macrophages, for instance, make up some of the PBMC . Their job is to capture viral fragments from our sera, primarily. Cell division has been shown to 'leak'  cytoplasm during the process which also allows for the release of any viral fragments including RNA genomic material which is non-infective and could have been harbored within the cell. Artificial stimulation to promote rapid cell division is a process that could result in the release of larger amounts of viral fragments, including genomic RNA. If you increase the amount of viral RNA fragments artificially to a sufficient amount to be amplified by PCR the suggested finding might not be accurate, in my view.

Here is a study by Halfon that finds no such thing as infected PBMCs post SVR. Carreno et al fired a quick letter back to Halfon and then they were counter-punched by Halfon and colleagues with another letter back from them to Carreno. I like this competitive spirit between researchers - it can only be seen as a pos for those with HCV. This goes to your point of experts disagreeing on this subject.

Study - http://jcm.asm.org/cgi/content/full/46/6/2106

Letters - http://jcm.asm.org/cgi/content/full/46/10/3550

I'll try to remember to post about some studies involving +/- strand ratios later. I think it would be just another way to either bolster or diminish findings concerning the significance of the presence of neg strand for some researchers. I also have a study done with electron microscopy that I'll post. I have to leave right now.

I don't know where my '20' yr comment came from. And I may never know-lol

Thanks again for the reply and information.
ML

[Mr Liver]

Jim I have never been stellar in mathematics but I do believe I have enough grasp of the subject to ascertain that the real world results do not jibe with the test tube results when extrapolated. We should all be up to our you-know-whats in medical literature detailing late relapses if the test tube results of occult research were anything close to an accurate description of real world conditions.  We just don't see the results we would expect to see if so many people  who have treated successfully (SVR) worldwide were actually still infected. Good to see you post. Hope all is well in your part of the world.
ML

[jmjm530]

That's an important point about test tube results versus real world relevance.

As technology advances, motivated scientists will be able to find and discover things unseen before.

Who knows what remnants the human body harbors when you get beyond the cellular level and keep looking and looking.  It may turn out that everybody has some remnant of HCV (or most every other disease) if you magnify and extrapolate enough. But again, what is the clinical relevance?

What we do know is what you just said " We just don't see the results we would expect to see if so many people  who have treated successfully (SVR) worldwide were actually still infected. Fortunately, we live in the real world and not in a Petri dish." This is not to diminish the importance of these studies, just a comment on their relevancy in terms of the real world concerns many have expressed in this thread.

Hope all is good  in your part of the world as well.

- Jim

[jmjm530]

the quote attributed above to ML, above, should have been abbreviated as such:

" We just don't see the results we would expect to see if so many people  who have treated successfully (SVR) worldwide were actually still infected." Fortunately, we live in the real world and not in a Petri dish.

[willing]

It's a bit hard to understand why a 36 month late relapse (after the 24w check period) is more significant than a 15 month late relapse, particularly when the additional note

" the reappearance of HCV RNA occurred 3 months after two treatments with steroid bolus therapy for severe rejection"

clearly suggests virus was present but maintained UND by a functioning immune system. Nevertheless, here's another:

"SUSTAINED VIROLOGIC RESPONSE AFTER PEGINTERFERON ALFA-2B AND RIBAVIRIN TREATMENT PREDICTS LONG-TERM CLEARANCE OF HCV AT 5-YEAR FOLLOW-UP"
abstract 804 by Manns et al from the 08 EASLD (available at J. of Hepatology site)
Of 366 SVRs from PEG/RBV tx followed for 5 years:

" Four SRs relapsed during the 5-year follow-up period (2 at year 1, 1 at year 2, and 1 at year 5)"

This is ref 150 in the Zeuzem survey cited above. Their table 2 gives a comprehensive list of data in the area. The criticisms of Pradat are legitimate but I believe are intrinsic to follow ups in the general population where it is essentially impossible to distinguish late relapse from re-infection, check for false positives, etc. Data that indicates causality between immuno-suppression and late relapse, as in the case above or a similar one:

http://www.ncbi.nlm.nih.gov/pubmed/18626242

argues pretty convincingly to my mind that SVR, notwithstanding undisputed durability, does not always equate to eradication.

Thanks for the link to the Hafon letter exchange - when I get a bit of time I want to go through the duelling PCR details - the discrepancies are frustrating! A similar exchange is a Pham Michalak  letter in response to the Bernandin study finding no HCV in PBMCs.

http://www.ncbi.nlm.nih.gov/pubmed/18537176

among other things they criticised the Bernandin authors for omission of mitogen stimulation:

"a brief culture of PBMCs with mitogens and cytokines that activated immune cells facilitated HCV RNA detection in as much as 75% of initially HCV-negative cases.[7] Further, in up to 20% of cases, the HCV genome can be found in stimulated PBMCs but not in parallel serum. The simultaneous detection of an HCV RNA replicative strand, HCV protein, and unique HCV variants served to authenticate active virus replication in PBMCs, irrespective of serum HCV RNA status, as our recent study reassured.[6] The above approach to HCV RNA identification was not employed by Bernardin and colleagues.[1] Thus, as they alluded, it remains a distinct possibility that ex vivo stimulation of PBMCs might have augmented HCV detection in their study."

tellingly, the authors in their response, don't dispute the point:

"We clearly acknowledged[1] that in chronically viremic subjects, PBMCs could be a site of HCV replication and that in vitro mitogen plus cytokine treatment might increase PBMC-associated HCV levels.[8-10]"

also the lymphocytes in the MacParland paper were paper were T cells, not macrophages. Mitogen stimulation is basically an augmentation technique which after all is what a PCR is; it may not reflect in-vivo conditions but enables detection of trace levels.

Overall, I've never understood why SVR durability is an argument against low-level viral persistence; the data seems to strongly support both. Every relapser who remains UND by the most sensitive tests for 36 weeks or more knows this...

[jmjm530]

Overall, I've never understood why SVR durability is an argument against low-level viral persistence;
----------------
because, if the low-level virus is found in the occult studies was truly a whole, virulent virus, then why wouldn't it keep replicating to the point where one would have a full-blown relapse. If the argument is that it's the immune system preventing this, then why doesn't this happen more often in immune compromised individuals? it seems to me at least that it's because what they're seeing is not the same kind of virus that gave us HCV in the 1st place. perhaps just some sort of lesser remnant.

[DoubleDose]

Willing said:

" Overall, I've never understood why SVR durability is an argument against low-level viral persistence; the data seems to strongly support both. Every relapser who remains UND by the most sensitive tests for 36 weeks or more knows this... "


My comment:  I agree with this statement.  I have always felt that SVR is very highly durable, but, that there is still documented persistent HCV virus left in SVR's, that we don't fully understand.  The research pretty much confirms this in study after study.

What we do not know is just how dangerous this residual virus might be.  It does indeed appear, from several cited examples, that a few individuals have relapsed years after confirmed SVR's, after heavy immuno-suppressive therapy.  Yes Jim, I understand that not everyone who receives immuno-suppressive tx relapses, but the fact that some have relapsed, tells me that the exception might just be the rule...but only in extreme circumstance.  

What if we really ARE in a somewhat permanent state of viral remission, rather than complete eradication?  Are you absolutely certain that this is not the case Jim?  Because I do not believe that even the best researchers in the world are sure what is going on.  My point is just this:  I think we have some open questions and not clearly understood behaviors with this virus, and many researchers continue to try to hone in, and figure out what it all means.  

Of course we could all just ASSUME that the virus is completely gone, in spite of research findings, and we could just ASSUME that any possible residual infection, or remission behavior of this virus, is totally benign, and will not cause any future problems....but I personally do not believe that this is a scientifically sound choice to make.   I want to have clearer answers, and I really want to know whether a possible 'persistent infection', under the radar so to speak, might have consequences for our immune systems, out long term health, and even our level of infectivity, if there is any infectivity to be concerned about.

I prefer to believe that the real truth will become fully understood as time goes on, and further research is done.  I do not want to jump to conclusions on any aspect of this issue.  But I still do believe that a few documented cases of legitimate relapse more or less disprove the 'rule' that SVR equals eradication, no matter how rare, AND that these cases beckon us to further study this viral behavion, and the HCV persistence observations, so that we can all be better prepared to deal with the realities, or potential consequences.

Hopefully its all just smoke, and is totally benign, as you often claim....but I will feel much more comfortable after we get a much deeper understanding of what it all means.  I won't rehash past observations regarding immunosuppressed relapsers, and fluctuating positive PCR's after SVR, only to disappear again, etc. other than to state that much of what we read about, and see in these cases fit a model of 'remission' much better than eradication.

The virus might behave more like Herpes Zoster, and could possibly go away, only to cause different sorts of damage way down the road.  Maybe even just immune system disruption, cytokine storms, etc.  We just don't have all the answers yet, in spite of your certainty on the subject.  That is something I feel really comfortable betting on!  I respect your views nonetheless.

DoubleDose

[willing]

DD: I know you haven't received much support here on this topic, but I think in some ways you've been ahead of your time. Hepatology's accepted articles/early view section includes yet another published  letter exchange on this topic ( the 3rd in a year). This one is a response by Carreno et al to the review by Welker/Zeuzem listed above along with Zeuzem's reply. Carreno references a forthcoming paper with the title (" Hepatitis C Virus Infection in the Family Setting of Patients with Occult Hepatitis C. ", J Med Virol. In press. Castillo et al '09) and states

"family members of patients with occult HCV infection show serological markers of HCV infection even more frequently than those of patients with chronic hepatitis C"

Zeuzem, of course, is skeptical

"These data may be interpreted in detail after full publication, but prima facie it seems difficult to understand why immune responses to HCV in family members of subjects with undetectable HCV-RNA in serum was more frequently than in family members of patients with detectable HCV-RNA."

we'll have to wait and see...

Jim: I'm not sure any published paper has ever argued that occult is "a whole, virulent virus". It may in fact be, though I agree that seems unlikely. The simple truth is that we know very little about whatever it is :

- it shares enough sequence similarity with wild-type that PCRs using standard 5'utr  primers detect it
- its proteins (at least ns5 and e2)  shares affinity for antibodies to standard viral proteins
- it is capable of infecting other cells in an artificial in-vitro setting
- it can trigger elevated cytokine levels in the host

However it seems more honest and consistent to acknowledge this ignorance than to disregard available data and/or claim we already know the remnants to be benign. Acknowledging  we don't yet understand why SVR remains durable in the presence of residual virus seems a good 1st step...

[jmjm530]

Willing:  I'm not sure any published paper has ever argued that occult is "a whole, virulent virus". It may in fact be, though I agree that seems unlikely....However it seems more honest and consistent to acknowledge this ignorance than to disregard available data and/or claim we already know the remnants to be benign....
--------------
As with many topics, I really don't think you and I are very far apart. I consider your statement above simply splitting hairs something that you and I tend to do with each other :) my opinions and to some extent the way they are expressed are consistent with most leading hepatologists as well as the quotes extracted from HR earlier in the thread. I don't think any of us are disregarding herbal little lameanything but simply formulating an opinion as we see it. if you the wording sounds a bit too certain given the data, that is your interpretation. Some of us feel that the speculation on the other side is also a bit much. Again, I don't think we're that far apart.

[jmjm530]

forgive the garble from my speech recognition software LOL the third sentence from the bottom should have read:

I don't think any of us are disregarding or belittling anything but simply formulating an opinion as we see it.

[DoubleDose]

Thanks very much for your referenced article, and the comment on some of my past views.  I appreciate your understanding and open minded approach.  I certainly have never made comments just to be controversial, but only in response to personal observations, experiences, etc.  The family member issue that you referenced (and I am anxious to review the details of the article you cited) is an issue that I have observed, first hand, for years...all the while trying to convince myself that what I was seeing might NOT be connected to HCV.  I still continue to see specific symptoms in family members that reflect my past extrahepatic symptoms, AND they also seem to be increasingly apparent over the past five years!   I will copy and paste the quote from your post above:

"family members of patients with occult HCV infection show serological markers of HCV infection even more frequently than those of patients with chronic hepatitis C

I used to just think there might be some connection, but in the past few years I have come to be certain of it...even if it cannot be proven, or demonstrated by standard lab testing.  I am pretty sure that if they had testing done for HCV cellular immunity (different than serum antibody testing for HCV) that it would show up in all of my intimate contacts and family members.  I could go into  much detail on why I believe this, but it would still be only anecdotal.  I think that some very surprising things about HCV will be discovered in the future....not the least of which will be familial cellular immunity.  

I personally think the infection may exist in other states than a typical, full blown blood/liver infection...and the family member cellular immunity, and serological markers are the tip off that something is going on.  I see it from an experiential, and symptom based perspective....the researchers will discover the same, from a lab and cellular standpoint.

I also want to make clear that I do not like to argue, or refute other peoples opinions.  So, Jim, if I sometimes seem argumentative, its only that I am stating my beliefs, and resisting being pushed into accepting either a dogma, or having to agree with the mainstream thinking, if I really have come to a different conclusion.  All in all, I appreciate everyones' viewpoints.

Thanks for all of your references, and scientific interpretations of the research Willing.  You help keep us grounded in factual information.

Have a great day, all of you!!

DoubleDose

[jmjm530]

also want to make clear that I do not like to argue, or refute other peoples opinions.  So, Jim, if I sometimes seem argumentative, its only that I am stating my beliefs, and resisting being pushed into accepting either a dogma, or having to agree with the mainstream thinking, if I really have come to a different conclusion.  All in all, I appreciate everyones' viewpoints.
----------------
I certainly appreciate that statement and in the future will try and accept some of your opinions ( even though they are often directed at me for some reason LOL) as not being  argumentative or personal but rather as furthering the discussion. Hopefully, you will do the same with me. And while we obviously have some differences, we also agree on many core matters including that more work is needed in the area of post treatment side effects.

Be well,

-- Jim

[willing]

I finally got around to reading Marukian'08

http://www.ncbi.nlm.nih.gov/pubmed/19003912

which Zeuzem had referenced as challenging the conclusions of the MacParland paper that started this thread, and overall I think he may be right...As Goofydad has noted, it's all about penetration, or the extent thereof.  The approach in the two papers is similar, both set out to infect PBMCs derived from healthy patients, exposed the cells to virus and then checked for viral rna and proteins in  the infected cells. Both used standard techniques of limiting infection as controls.

MacParland was testing whether residual virus from SVRs could infect healthy cells. Marukian used a cell culture system widely used to study viral entry/replication:

http://www.ncbi.nlm.nih.gov/pubmed/15947137

to see if PBMCs could be infected.


However, the key difference is that Marukian tracked increases in the level of RNA in the infected cells - if the virus is really replicating the amount of RNA should increase. What she found was that in huh7 cells (a commonly used line of liver cancer cells)  RNA levels grew as a function of time, about 100 fold increase in 3 days, whereas in PBMCs the level of RNA remained flat, as it did if cells were treated with a drug, CMA, that blocked replication (Fig 2.)

They went on to show that viral entry in PBMCs (and broke these out into B/T lymphocytes, macrophages etc.) is very unlikely because of failure to express cell receptors needed for viral entry (over the past couple of years researchers have finally tracked down in detail how it gets into cells).

However, their results may also explain MacParland's data:

"We tested the ability of HCVcc to replicate in cmDCs (Fig. 2C), M (Fig. 2D), peripheral blood DCs (pbDCs) (Fig. 2E), monocytes (Fig. 2F), and T/natural killer (NK) cells (Fig. 2G). As for B cells, HCV RNA was detected in cultures of these cell types after 24 hours incubation with HCVcc and extensive washing. The level of HCV RNA associated with the cultures was <1% of the input; this declined or remained stable after washing away input viral RNA. In all PBMC subsets, the level of HCV RNA associated with cells and tissue culture supernatants was unaffected by 2CMA. Although no increase in HCV RNA was detected in PBMC subsets or in 2CMA-treated Huh-7.5 cells, viral RNA persisted for many days in culture. Longer cultures of up to 14 days also showed no increase in HCV RNA (data not shown)."

in other words, it seems virions are tightly and determinedly clinging to PBMCs but not necessarily getting in and replicating. Even when they introduced viral RNA directly into PBMCs no translation was detected, whereas it was in liver cells.

I assume MacParland's group has already checked whether infectivity of SVR-derived virus as measured by RNA increase, occurs in liver cells. It'll be interesting to hear the next installment.