Identification and phylogenetic analysis of hepatitis C virus in forensic blood samples obtained from injecting drug users

Injecting drug users (IDUs) are a high-risk group for contracting hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections. In Japan, data on the prevalence of those blood-borne viruses among IDUs are very limited. Blood samples were obtained from 12 cadavers of IDUs sent to Nagoya City University for the purpose of judicious autopsy and two alive IDUs with hepatitis C referred to a local hospital at the same period. The viruses were detected by polymerase chain reaction and phylogenetic analysis was performed. Two (16.6%) of the 12 autopsy cases were positive for HCV, but no case was positive for either HBV or HIV. Phylogenetic analysis of the two HCV isolates revealed that one was classified into genotype 1b and another was genotype 2b. Furthermore, nucleotide sequences of two isolates recovered from IDUs with hepatitis C were identical, that indicated the transmission of HCV between them, and those HCV were phylogenetically classified into genotype 2a. The prevalence of HCV infection among IDUs in Japan, despite the case of judicious autopsy, seems to be high, but HIV infection seems to be rare. The transmission of HCV between IDUs was demonstrated, and this indicates that phylogenetic analysis would applicable to also forensic analysis. HCV isolates identified in this study did not phylogenetically segregate, thus multiple transmission route of HCV among IDUs seems be exist in Japan.     

Postmortem Detection of Hepatitis B,C, and Human Immunodeficiency Virus Genomes in Blood Samples from Drug‐Related Deaths in Denmark*

Abstract: Blood‐borne viral infections are widespread among injecting drug users; however, it is difficult to include these patients in serological surveys. Therefore, we developed a national surveillance program based on postmortem testing of persons whose deaths were drug related. Blood collected at autopsy was tested for anti‐HBc, anti‐HBs, anti‐hepatits C virus (HCV), or anti‐human immunodeficiency virus (HIV) antibodies using commercial kits. Subsets of seropositive samples were screened for viral genomes using sensitive in‐house and commercial polymerase chain reaction (PCR) assays. Hepatitis B virus (HBV) DNA was detected in 20% (3/15) of anti‐HBc‐positive/anti‐HBs‐negative samples, HCV RNA was found in 64% (16/25) of anti‐HCV‐positive samples, and HIV RNA was detected in 40% (6/15) of anti‐HIV‐positive samples. The postmortem and antemortem prevalences of HBV DNA and HCV RNA were similar. Postmortem HIV RNA testing was less sensitive than antemortem testing. Thus, postmortem PCR analysis for HBV and HBC infection is feasible and relevant for demonstrating ongoing infections at death or for transmission analysis during outbreaks.     

Current good manufacturing practice for blood and blood components; notification of consignees and transfusion recipients receiving blood and blood components at increased risk of transmitting hepatitis C virus infection ("lookback"). Final rule

The Food and Drug Administration (FDA) is requiring establishments collecting Whole Blood or blood components, including Source Plasma and Source Leukocytes, to establish, maintain, and follow an appropriate system for identifying blood and blood components previously donated by a donor who tests reactive for evidence of hepatitis C virus (HCV) infection on a subsequent donation identified either by current testing or after a review of historical testing records, or when the collecting establishment is made aware of other reliable test results or information indicating evidence of HCV infection. Such collections may be at increased risk of transmitting HCV infection. FDA is requiring collecting establishments to quarantine prior in-date blood and blood components from such a donor, to notify consignees of prior in-date blood and blood components from such a donor for quarantine purposes, and to perform further testing on the donor. FDA is also requiring consignees to notify transfusion recipients of blood and blood components from such a donor, as appropriate. In addition, FDA is revising the human immunodeficiency virus (HIV) "lookback" requirements for greater consistency with the HCV "lookback" requirements, and extending the record retention period to 10 years. FDA is taking this action to help ensure the continued safety of the blood supply and to help ensure that information is provided to recipients of blood and blood components that may have been at increased risk of transmitting HIV or HCV infection. Elsewhere in this issue of the Federal Register, FDA is announcing the availability of a guidance document entitled "Guidance for Industry: 'Lookback' for Hepatitis C Virus (HCV): Product Quarantine, Consignee Notification, Further Testing, Product Disposition, and Notification of Transfusion Recipients Based on Donor Test Results Indicating Infection with HCV' (the "lookback" guidance). We are also issuing this final rule in conjunction with a companion interim final rule published by the Centers for Medicare and Medicaid Services (CMS) elsewhere in this issue of the Federal Register.     

输血与丙型肝炎因果关系鉴定及相关法律问题探讨

丙型肝炎病毒（ＨＣＶ）已成为输血后非甲非乙型肝炎的主要致病因子，但是要确定患者所感染的丙型肝炎与某次输血有必然的因果关系仍很困难。本文通过对一个案例进行研究，提出鉴定方法，即收集病人的所有住院病历，查阅病人输血前、输血后或者以后一段时间转氨酶的变化情况，尤其是伤后近期查出的转氨酶水平，基本上可代表伤前的水平。结合抗－ＨＣＶ抗体的变化，确定输血与肝炎间的因果关系。作者还结合我国法律，提出输血后感染丙型肝炎的患者可以“严格责任原则”起诉医院或者血库，医院或者血库承担举证责任，举证的内容包括其所提供血液的献血员来源合法，已作了法定的筛选检测，同时提供所有法定的记录档案，否则血库或者医院将承担败诉的民事责任。     

Medicare and Medicaid programs; hospital conditions of participation: laboratory services. Final rule

This final rule finalizes the hospital conditions of participation requirements for hospitals that transfuse blood and blood components. It requires hospitals to: Prepare and follow written procedures for appropriate action when it is determined that blood and blood components the hospitals received and transfused are at increased risk for transmitting hepatitis C virus (HCV); quarantine prior collections from a donor who is at increased risk for transmitting HCV infection; notify transfusion recipients, as appropriate, of the need for HCV testing and counseling; and extend the records retention period for transfusion-related data to 10 years. The intent is to aid in the prevention of HCV infection and to create opportunities for disease prevention that, in most cases, can occur many years after recipient exposure to a donor.     

Medicare and Medicaid programs; hospital conditions of participation: laboratory services. Interim final rule with comment period

This interim final rule with comment period requires hospitals that transfuse blood and blood components to: Prepare and follow written procedures for appropriate action when it is determined that blood and blood components the hospitals received and transfused are at increased risk for transmitting hepatitis C virus (HCV); quarantine prior collections from a donor who is at increased risk for transmitting HCV infection; notify transfusion recipients, as appropriate, of the need for HCV testing and counseling; and extend the records retention period for transfusion-related data to 10 years. These changes are based on recommendations by the Secretary's Advisory Committee on Blood Safety and Availability and are being published in conjunction with the Food and Drug Administration's (FDA) Final Rule, "Current Good Manufacturing Practice for Blood and Blood Components; Notification of Consignees and Transfusion Recipients Receiving Blood and Blood Components at Increased Risk of Transmitting HCV Infection" ("lookback") found elsewhere in this issue of the Federal Register. The intent is to aid in the prevention of HCV infection and to create opportunities for disease prevention that, in most cases, can occur many years after recipient exposure to a donor.     

Genotypic Polymorphisms of Hepatitis B Virus Provide Useful Information for Estimating Geographical Origin or Place of Long‐term Residence of Unidentified Cadavers

Increasing numbers of unidentified cadavers are a major problem. We have developed a new method for providing identification information that can determine the geographical origin or place of long‐term residence of unidentified cadavers based on genotypic polymorphisms of hepatitis B virus (HBV) known to correlate with their geographical distribution. PCR of serum samples detected HBV DNA from 4 (3.9%) of 102 randomly selected Japanese forensic cadavers. Multiplex PCR did not detect multiple HBV genotypes from any single cadaver, confirming the absence of coinfection. Phylogenetic tree analysis based on a 485‐bp mutant region of the HBV S gene successfully classified the HBV genotypes into A to J. Among 10 HBV‐infected cadavers, 8 had genotype Ce/C2, a genotype prevalent in East Asia, and 2 had genotype Bj/B1, a Japanese‐specific genotype. HBV genotypic polymorphisms correlate with the geographical distribution of the virus and thus provide important information for identifying unidentified cadavers infected with HBV.     

Legal,Technical, and Interpretational Considerations in the Forensic Analysis of Viruses

The forensic evaluation of viruses presents new challenges to the forensic science community. Although many criminal cases have been adjudicated involving the deliberate transmission of viruses, especially HIV, this review provides a general approach to viral forensics, especially in light of significant biodefense challenges. Newly emerging techniques of nucleic acid sequencing are discussed in a forensic context. Human mitochondrial DNA analysis, wherein mixed profiles are routinely assessed in a forensic context, provides the groundwork for an interpretational approach to the issue of mixed DNA sequences. The importance of phylogenetic classification is discussed as both providing an integrated graphical depiction of the structure of viral nucleic acid variation as well as offering a tool that can be used to assess the relatedness of complex populations of nucleic acids.     

Differential diagnostics of stomach contents showing blue discoloration

A 42-year-old man evidently had died from an intoxication. On the basis of the findings at scene it was primarily assumed that the man had ingested a larger quantity of an ethylene glycol-containing antifreeze for suicidal purposes. The man was said to have had an alcohol problem and did not only consume drinking alcohol, but also other alcoholic liquids. At autopsy, a bluish liquid with an aromatic smell was found in the oesophagus and stomach. However, toxicological analyses did not furnish evidence of ethylene glycol--as expected--but a potentially fatal concentration of ethanol (blood alcohol concentration 4.01 per mille). The blue colour (patent blue C.I.42051) came from a liquid used in the wind-screen washer system in winter, which now contains ethanol (denatured with 2-butanone) instead of ethylene glycol. The results of the toxicological findings including the analysis of congener alcohols and the differential diagnostics of blue-coloured stomach contents are discussed.     

论输血及血液制品感染的侵权责任——基于日本法上的经验

在医学界,血液被称为"生命的源泉"。然而,近年来,随着临床用血和血液制品使用的大量增加,患者感染梅毒、肝炎、甚至艾滋病的案例已屡见不鲜。而上世纪末,我们的邻国日本也曾遭遇过同样的"血液之殇",日本司法实践在处理诸如"东大梅毒事件"、"药害肝炎事件"、"药害艾滋事件"上的成功经验会带给我国怎样的启示,以下将对日本法上血液的法律属性、医疗过失的判断标准、因果关系的证明以及医药产品责任主体的责任分配等进行分析,并结合我国《侵权责任法》相关规定,从法解释学的角度出发,针对我国司法现状,探讨日本法对我国在法律解释适用方面的借鉴意义。     

Retrospective epidemiological analysis of occupational infection morbidity of employees in state forensic-medical expert institutions in 1990-2005

The results of a retrospective epidemiological analysis of occupational tuberculosis and hemocontact virus hepatitis morbidity among forensic-medical examiners demonstrate that tuberculosis and virus hepatitis B and C morbidity among the examiners is ten times and more higher than among RF population and has a trend to further rise. This points to necessity for urgent prophylactic measures among personnel of the state forensic-medical institutions.     

Effect of influenza virus infection on arachidonic acid cascade in mouse thrombocytes

Prostaglandins (PGs) are essential for many physiological and pathological processes. As they are not stored in tissue, their presence and actions therefore result from de novo synthesis and release. Although platelets themselves appear to have the ability to synthesize TxA2, PGD2, arachidonic acid may also be metabolized in the lipoxygenase pathway in platelets, producing 12-hydroperoxy/12-hydroxy-5,8,10,14-eicosatetraenoic acid (12-HPETE/12-HETE). CFLP mice were infected intranasally with A/H3N2/Hong Kong (1/68) influenza virus. Platelets were isolated from the control (saline treated) and infected mice 3-13 days after virus application. Platelets were isolated from the diluted arterial blood of the mice. Metabolites of arachidonate cascade were determined using 1-14C-arachidonic acid (2035 MBq/mM spec. act.) as substrate. All incubations were carried out in TC Medium 199 (pH 7.4) at 37 degrees C for 10 min. Radiolabelled products were separated and quantitatively determined. The synthesis of TxA2 in the platelets of animals was found to be significantly increased 7 days after the virus infection. The 12-hydroxy-heptadecatrienoic acid level was higher on the 10th and 13th days of infection, as were the products of the lipoxygenase pathway.     

New tainted-blood class actions in Québec and Alberta

In two cases in Québec and Alberta, people infected with HIV and HCV through infected blood and blood products have successfully defended motions to strike out all or parts of their legal actions against federal and provincial governments and the Canadian Red Cross Society (CRCS). On 16 January 2003, the Québec Superior Court ruled that the plaintiffs in a class action could rely on the Krever Commission Report in their application for certification of a class proceeding. On 20 February 2003, the Alberta Court of Queen's Bench dismissed an application brought by the Canadian and Alberta governments to strike out the legal action brought against them. These cases illustrate that the settlement schemes proposed by the federal and provincial governments and the CRCS, and approved by the courts, have not put an end to the civil and constitutional claims brought by people seeking compensation for infection through tainted blood.     

Neuropathology of human immunodeficiency virus infection: a forensic autopsy study in Dar Es Salaam, Tanzania

The objective of this study was to examine the neuropathological changes in the brain of patients infected with human immunodeficiency virus (HIV) in the Tanzanian capital Dar Es Salaam, and investigate whether the prevalence of different forms of HIV-related neuropathology varies from other countries. The subjects were patients with risk factors for HIV infection in whom forensic autopsies were performed between 1997 and 1999. In Dar Es Salaam, forensic autopsy constitutes more than 90% of all autopsies, because hospital autopsy is limited due to socio-cultural and religious reasons. HIV infection was identified in 52 of 143 patients selected from forensic autopsies. Neuropathological findings were observed in 31 of 52 HIV-infected patients; these include lymphocytic meningitis 19, bacterial meningitis 3, tuberculous brain abscess 3, cryptococcal meningitis 3, basal ganglia calcification 3, and toxoplasma encephalitis 1. HIV encephalitis, lymphoma, and cytomegalovirus encephalitis could not be found in this study. Whereas the findings should be interpreted cautiously because of possible autopsy bias and a low percentage of cases examined compared to the total number of HIV-infected patients in Tanzania, our observations provide information on the likely diagnostic possibilities to be considered in the evaluation and management of HIV-infected patients with neurological symptoms in Tanzania. In the face of decreased hospital autopsy, most studies have focused mainly on the end-stage HIV disease; forensic autopsy is a potential source of materials for studies on HIV disease spectrum at different stages.     

Ireland: HIV and hepatitis C in prisons

Two studies from the Department of Community Health and General Practice at Trinity College, Dublin, have highlighted the extent of the HIV and hepatitis C (HCV) crisis in Irish prisons. The studies confirm that rates of HIV and HCV are disproportionately high in Irish prisons, and that high risk behaviours are commonplace.     

HIV-positive person who did not disclose status convicted of attempted aggravated assault

On 18 September 2003, the Supreme Court of Canada released its unanimous decision in Williams. This is the first case on the issue of criminal liability for HIV exposure decided by the court since its 1998 decision in the Cuerrier case. Williams raised the issue of whether persons with HIV who have unprotected sexual intercourse without disclosing their status to a sexual partner who might already have been infected with the virus, can be convicted of aggravated assault or attempted aggravated assault. The Supreme Court decided that only a charge of attempted aggravated assault could stand. The decision is also significant because the Supreme Court's comments on two ancillary issues may lead to a significant extension of the criminal law related to HIV transmission or exposure.     

Possession, use, and transfer of select agents and toxins--reconstructed replication competent forms of the 1918 pandemic influenza virus containing any portion of the coding regions of all eight gene segments. Interim final rule

We are adding reconstructed replication competent forms of the 1918 pandemic influenza virus containing any portion of the coding regions of all eight gene segments to the list of HHS select agents and toxins. We are taking this action for several reasons. First the pandemic influenza virus of 1918-19 killed up to 50 million people worldwide, including an estimated 675,000 deaths in the United States. Also, the complete coding sequence for the 1918 pandemic influenza A H1N1 virus was recently identified, which will make it possible for those with knowledge of reverse genetics to reconstruct this virus. In addition, the first published study on a reconstructed 1918 pandemic influenza virus demonstrated the high virulence of this virus in cell culture, embryonated eggs, and in mice relative to other human influenza viruses. Therefore, we have determined that the reconstructed replication competent forms of the 1918 pandemic influenza virus containing any portion of the coding regions of all eight gene segments have the potential to pose a severe threat to public health and safety.     

California expands the duty to warn patients exposed to and infected with HIV. Reisner v. Regents of the University of California

There is still no general definitive guide for hospitals and other health care providers concerning the extent of their duty to warn third parties of a patient's HIV status. However, even in states like California that have statutorily eliminated any duty to directly inform third parties, the Reisner case clearly indicates that liability to third parties may arise indirectly based on a failure to warn HIV-exposed or -infected patients of their status and the risks of communicating the virus to others. Accordingly, health care providers should take several actions: 1. Ascertain, with the assistance of legal counsel, the precise dictates of applicable state statutes and case law regarding (a) a provider's obligation to warn HIV-exposed or -infected individuals of the potential of communicating the virus to others; (b) additional statutory requirements such as notification of public health authorities; and (c) whether notice to third parties at risk of exposure from the patient is required or even permitted. 2. Develop and implement written policies regarding notification and counseling of exposed or infected patients, including counseling patients on the risks of communicating the virus to third parties; and 3. Develop and implement written policies regarding permissive or mandatory notification and counseling of exposed or infected third parties. In this context, providers should be aware that patient confidentiality and privacy laws may prohibit disclosure of the identity of exposed or infected patients to third parties.     

Over-the-counter vaginal contraceptive and spermicide drug products containing nonoxynol 9; required labeling. Final rule

The Food and Drug Administration (FDA) is issuing a final rule establishing new warning statements and other labeling information for all over-the-counter (OTC) vaginal contraceptive drug products (also known as spermicides, hereinafter referred to as vaginal contraceptives or vaginal contraceptives/spermicides) containing nonoxynol 9 (N9). These warning statements will advise consumers that vaginal contraceptives/spermicides containing N9 do not protect against infection from the human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS), or against getting other sexually transmitted diseases (STDs). The warnings and labeling information will also advise consumers that use of vaginal contraceptives and spermicides containing N9 can irritate the vagina and rectum and may increase the risk of getting the AIDS virus (HIV) from an infected partner. This final rule is part of FDA's ongoing review of OTC drug products. FDA is issuing this final rule after considering public comments on its proposed regulation, and all relevant data and information on N9 that have come to our attention.