ORIGINAL
ARTICLE
Rela ion
o
hepa i is
C
i us geno ypes
o
isk
ac o s
and hepa ic disease
in
Spanish pa ien s
l?
Alonso Alonsol,
A.
O duh?,
A.
San Miguel',
E.
Dominguexl,
M.
A.
B a o?,
M.
P
Gu ie ex'?,
J.
M.
Ei e?,
L.
Inglada3,
J.
111.
Gonxalex He nandez4
and
A.
Rod iguez
?i, es2
'Labo a o y, Regional Hospi al, Mon o e de Lemos, Lugo, 2Mic obiology Depa men and
Clinical-Epidemiological Resea ch Uni , Uni e si y Hospi al, Facul y o Medicine, Valladolid,
31n e nal Medicine, Regional Hospi al, Medma del Campo, Valladolid, and 41n e nal Medicine,
RJO
Ho ega Hospi al, Valladolid, Spain
Objec i e:
To asce ain he p e alence o hepa i is C i us (HCV) geno ypes in Spain and hei dis ibu ion by isk ac o s.
Me hods:
The s udy co e ed 216 pa ien s wi h hepa i is
C.
O hese, 63 we e in a enous d ug use s (IVDU), 44 had
ecei ed ans usions, and
30
we e hemodialyzed, and in 79 he isk ac o s we e unknown. An ibodies agains HCV we e
de ec ed by second-gene a ion enzyme immunoassay (EIA) and con i med
by
immunoblo . HCV RNA p esence was
in es iga ed by e e se ansc ip ion-polyme ase chain eac ion (RT-PCR), and a e e se hyb idiza ion es o he
ampli ica ions was used o he geno yping.
Resul s:
The mos equen ly encoun e ed geno ypes we e
Ib
(48.1%), la (21.3%) and 3a (11.1%). HCV geno ypes la
(42.8%) and 3a (20.6%) we e he mos p e alen geno ypes in IVDU pa ien s, while
Ib
was he mos equen in pa ien s
wi h unknown isk ac o s (62.0%), ans used pa ien s (68.1%) and hemodialyzed pa ien s (50.0%). Mixed in ec ions we e
de ec ed in nine cases (4.1%); h ee appea ed in IVDU pa ien s (4.7% o he o al IVDUs), wo in ans used pa ien s (4.5%)
and ou (50%) in pa ien s wi h unknown isk ac o s. No s a is ically signi ican di e ences we e ound in a e age ages
o he IVDU pa ien s wi h di e en geno ypes. Non-IVDU pa ien s ha ing geno ype 3a p esen ed he lowes a e age age
o all. No signi ican s a is ical di e ences we e obse ed in alanine a nino ans e ase le els among pa ien g oups wi h
di e en geno ypes
(p0.05
in all cases). Sub ype
Ib
was p esen in six o he se en cases o ci hosis (85.7%) and in
nine o he 18 cases o ac i e ch onic hepa i is (50.0%).
Key
wo ds:
Hepa i is C, HCV geno ypes, epidemiology
INTRO
D
U
CTlO
N
Since he disco e y o he hepa i is C i us (HCV) in
1989
by in es iga o s a Chi on Co po a ion
[l],
a
g ea
deal o in o ma ion abou he gene ic di e si y o HCV
has appea ed in wo ld li e a u e. The i s e idence o
hs
di e si y a ose &om he compa ison o
a
Japanese
isola e (HCV J1) and an Ame ican one (HCV-1) [2],
Co esponding au ho and ep in eques s:
An onio O du ia, Depa amen o de Mic obiologia, Facul ad
de Medicina, C/ Ramon y Cajal s/n, 47005 Valladolid, Spain
Tel:
+34 983 42 30 63
Accep ed 7 June 1997
+34 983 42 30 66
which e ealed di e ences in he
NS3
and
NS4
egions. La e on, di e ences we e demons a ed in he
NS5
[3]
and en elope
[4]
egions, sugges ing he
exis ence o mul iple HCV ypes.
The immedia e consequence o disco e ing he
exis ence
o
HCV geno ypes was he in es iga ion o
hei ela ion o a ied aspec s o he in ec ion. One o
he aspec s mos s udied has been he geog aphic dis i-
bu ion o he di e en geno ypes, which ha e been
ound o be widely sp ead.
Ths
is
especially ue
o
geno ype
Ib,
which seems o ha e he g ea es wo ld-
wide p e alence [5]. Howe e , egional d e ences in
geno ype dm ibu ion ha e been obse ed. In Japan,
China and Taiwan, geno ypes lb, 2a and 2b cons i u e
he as majo i y o a ian s ound [5,6], geno ype
la
647
648
Clinical Mic obiology and In ec ion, Volume
3
Numbe
6,
Decembe
1997
being e y in equen . In con as , in sou heas Asia
geno ypes
la
and 3 a e equen ly ound [7]. Al hough
he in o ma ion a ailable on geno ype ds ibu ion in
Ah-ica is limi ed, i seems ha geno ype 4 p edomina es
in wide zones o his con inen [6,8,9]. Howe e , Sou h
Ah-ica cons i u es an excep ion,
as
geno ype
5
is he
mos equen a ie y he e [6,10,11]. In Occiden al
coun ies (Eu ope, he USA and Aus alia) and in
Sou h Ame ica geno ypes
1,
2 and
3
a e he mos
p e alen [5,6,8,12-141.
Ano he aspec s udied has been he ela ion o
p e alences o isk ac o s, wi h h e ences being
e ealed by he s udies pe o med. Okamo o e al [7]
ound h e en p e alences o geno ypes lb and 2a in
blood dono s and Japanese pa ien s wi h non-A, non-
B hepa i is. D iesel e
al
[15] desc ibed an ele a ed
p e alence o ype 3a in IVDU pa ien s.
The objec i e o ou s udy was o asce ain he
p e alence o di e en HCV geno ypes in ou heal h
a ea,
as
well
as
he possible in luence o isk ac o s on
hei dis ibu ion and hei ela ion o hepa ic disease.
PATIENTS AND METHODS
In
his
s udy, 216 pa ien s diagnosed
as
ha ing hepa i is
C we e included.
All
o hem p esen ed an ibodies
agains HCV (an i-HCV) and HCV RNA de ec able
in se a by e e se ansc ip ion-polyme ase chain
eac ion (RT-PCR). Li e biopsy was pe o med in 37
pa ien s.
The dis ibu ion o pa ien s by isk ac o s was
as
ollows: 63 (29.1%) we e in a enous d ug use s
(IVDUs) (30.5k4.6 yea s), 44 (20.3%) had ecei ed
ans usions (48.3k14.9 yea s) and 30 (13.8%) we e
he nodialyzed (52.4k15.5 yea s), and in 79 cases
(36.5%) no known isk ac o was ound (55.6k15.4
yea s).
All
pa ien s unde wen es ing o he p esence
o
HBs
an igen and IgM agains hepa i is A i us (IMx,
Abbo Labo a o ies, Chicago,
IL,
USA); he esul s
we e nega i e in bo h cases o
all
subjec s.
A second-gene a ion enzyme immunoassay (EIA)
(Abbo Labo a o ies, Chicago, IL, USA) was used o
sc een o an ibodies agains HCV. Immunoblo
(Deciscan HCV, Sano i Diagnos ics Pas eu , Ma nes-la-
Coque e, F ance) was used o con i m an ibodies
agains HCV This es uses ecombinan p o eins
de i ed om he co e (Cl) and NS3 egions, and
syn he ic pep ides de i ed &om he co e (C2) and NS4
egions. To de ec HCV RNA, an RT-PCR
(Amplico HCV, Roche Diagnos ic Sys ems, Inc.,
B anchbu g, NJ, USA) was used. A e e se hyb idiza-
ion es o he ampli ica ion ob ained by RT-PCR
(INNO-LiPA
HCV,
Innogene ics, Belgium) was used
o HCV geno yping. Speci ic oligonucleo ide p obes
de i ed &om he non-codmg egion
5‘
a e immobi-
lized on ni ocellulose s ips by a poly-T glue. The
ampli ica ions, p e iously ma ked wi h bio in, a e
incuba ed wi h he s ips a 50°C o pe mi hei
hyb idiza ion wi h he bound p obes. A e washing,
hey a e incuba ed wi h s ep a idin conjuga ed wi h
alkaline phospha ase a oom empe a u e. Colo
de elopmen is pe o med by addi ion o ni oblue
e azolium (NBT) and b omochlo oindol phospha e
(BCIP). Each s ip has
a
o al o 15 bands. The i s is
used
as
a
con ol o he adh ion o conjuga e. The
second con ains
a
uni e sal p obe which hyb idizes
wi h he ampli ica ions o any geno ype. The ollowing
13 bands allow di e en ia ion o he ollowing HCV
geno ypes and sub ypes acco ding o he scheme o
Simmonds e al [16]: 1, la, lb, 2, 2a/2c, 2b, 3a, 3b, 4a
and 5a.
AU
es s we e pe o med acco ding o he
manu ac u e s’ ins uc ions.
S a is ical analysis o he esul s was pe o med by
he SAS p og am o pe sonal compu e s (SAS Ins i u e
Inc., Ca y, NC, USA). Fishe ’s exac es ( wo- ail) was
used o compa ison o p opo ions in he s anda d
wo-way con ingency ables. Non-pa ame ic es s
(ANOVA-based anks) we e used in compa ison o
measu emen s. Values o
p<
0.05
we e conside ed
s a is ically signi ican .
RESULTS
The dominan geno ype was ype
1,
ound in 164 o
he pa ien s s udied (75.9%); he nex mos equen
was 3a, p esen in 24 pa ien s
(1 1
.l%)
(Table
1).
Geno-
ypes 4a and 2 we e seldom ound, being p esen in
only eigh (3.7%) and
wo
(0.9%) pa ien s espec i ely.
In nine cases (4.1%), he geno ype was impossible o
de e mine wi h he es used. Wi hin geno ype
1
he
g ea es p e alence co esponded o sub ype lb, p esen
in 104 pa ien s (48.1%), whde sub ype
la
was ound in
46 pa ien s (21.3%). In 14 cases (6.4%) classi ied
as
geno ype
1
i was impossible o de e mine he sub ype.
Likewise, in one o he
wo
pa ien s in whom geno ype
2 was ound, he sub ype could no be de e mined, and
he emaining case belonged o sub ype 2a/2c. A mixed
in ec ion was ound in nine pa ien s (4.1%): in one
case
wi h geno ypes
1
and 2, ou cases wi h sub ypes
la
and
lb, and ou cases wi h geno ypes
la
and 4a.
Table
1
shows geno ype dis ibu ion acco ding o
isk ac o s. Geno ype
1
was dominan in
all
g oups,
wi h pe cen ages a ying om 60.3% in he
IVDU
pa ien s o 100% in he he nodialyzed pa ien s. Analysis
o he dis ibu ion o sub ypes
la
and lb by isk ac o
showed ha he sub ype p edominan in IVDU pa ien s
was
la
(42.8%). Howe e , sub ype lb was he mos
p e alen in pa ien s o unknown isk (62.0%) and in
Alonso
Alonso
e al: Hepa i is
C
i us
geno ypes and
isk
ac o s
649
Table
1
Geno ype dls ibu ion
by
isk
ac o s
IVDU
T ans used Hemodialysis Unknown To al
Geno ype No.
(‘h)
No.
(‘YO)
No.
(%)
No.
(%)
No
(%)
1
1-NS
13
lb
2
2-NS
2a/2c
3a
4a
NG
Mixed
la+lb
la+4a
1+2
To al
38 ((60.3)
1
l(l.5)
27 (,42.8)
10 (15.8)
1 (1.5)
1 (1.5)
13
(20.6)
5
(7.9)
3
(4.7)
3
(4.7)
3
(4.7)
63
(100)
37 (84.0)
3
(6.8)
30 (68.1)
4
(9.0)
1
(2.2)
1 (2.2)
I
(2.2)
1
(2.2)
2 (4.5)
2 (4.5)
2 (4.5)
44
(100)
30 (100)
59
(74.6)
3
(10.0) 7
(8.8)
12
(40.0)
3
(3.8)
15 (50.0) 49 (62.0)
10 (12.6)
2
(2.5)
4
(5.0)
4
(5.0)
1
(1.2)
1 (1.2)
30 (100) 79 (100)
2 (2.5)
164 (75.9)
14 (6.4)
46
(21.3)
104 (48.1)
2
(0.9)
1
(0.4)
l(0.4)
24 (11.1)
9
(4.1)
0
(4.1)
8 (3.7)
4
(1.8)
4
(1.8)
1 (0.4)
216 (100)
l-NS,
2-NS=geno ypes 1 o 2 non-sub ypeable wi h he es
used.
NG=noii-geno ypeable wi h he es used.
pa ien s wi h blood- ans usion an eceden s (68.1%). In
he 30 he nodialyzed pa ien s he p e alence o sub ype
la
was 40.0% and ha o sub ype lb was 50.0%. On
compa ing he p e alence o sub ypes
la
and lb in he
di e en isk g oups s udied, we ound ha he p e a-
lence o sub ype
la
was signi ican ly highe in IVDU
pa ien s (42.8%) han in pa ien s wi h ans usion an e-
ceden s (9.0%) (p<O.O01) o in hose wi h unknown
isk ac o s (3.8%)
(p<<O.OOl).
In hese las wo g oups,
sub ype lb p edomina ed. In he es o he com-
pa isons, no s a is ically signi ican di e ences
(p>
0.05)
we e ound. Likewise, when he p e alence o geno-
ype 3a in IVDU pa ien s
(20.6%)
was compa ed wi h
ha
in
unknown isk ac o pa ien s (12.6%), no s a is-
ically signi ican di e ences (p=0.253) we e ound.
Howe e , compa ing ype 3a p e alence in IVDU
pa ien s (20.6%) wi h ha in non-IVDU pa ien s
(7.6%) did yield s a is ically signi ican di e ences
(p
=
0.01 6).
On he o he hand, pa ien s wi h geno ype 3a
p esen ed he lowes a e age age (32.7k8.1 yea s). In
addi ion, geno ype 3a was associa ed wi h lowe
a e age age han ha o pa ien s wi h geno ype
1
non-
sub ypeable (54.7k14.9 yea s), geno ype lb (53.1
k15.8 yea s) and mixed geno ype la+lb (61.2k11.3
yea s) (p<0.05 in
all
cases) (Table 2). Sub ype
la
was
de ec ed in
a
younge age g oup (37.95 15.5 yea s) han
was sub ype lb (p<0.05). In addi ion, he ela ion
be ween geno ypes and age in IVDU and non-IVDU
pa ien s was analyzed. Non-IVDU pa ien s ha ing
geno ype 3a showed lowe a e age age (36.4k9.4
yea s) han non-IVDU pa ien s in ec ed wi h o he
geno ypes. Fu he mo e, ype 3a was associa ed wi h
a
lowe a e age age han in ec ion wi h geno ype lb
(55.5k14.6 yea s) (p<0.05). Howe e , no s a is ically
signi ican di e ences we e ound be ween he a e age
ages o he IVDU pa ien s wi h he di e en geno ypes
(Table 2).
On he o he hand, we analyzed he ela ionship
be ween geno ypes and
ALT
le els in pa ien s wi h
Table
2
A e age
age
o
pa ien s
g ouped
by
geno ype
IVTIU
Non-IVDU
To al
Mean2
SII
Mean
SL>
Mean
k
SII
Geno nes
(no.)
(no.) (no.)
1 -NS
la
lb
2-NS
2a/2c
33
4a
NG
la+lb
la+4a
1 +2
To l
28
(1)
30.624.6 (27)
30.424.1 (10)
-
30 (1)
29
625.6
(13)
34.222.3
(5)
27.6 5.5
(3)
31.6ki.5
(3)
~
-
30.5k4.6
(63)
56.8k13.3
(13)
48.2k19.S (19)
.5.5.52
14.6 (94)
32 (1)
36.4k9.4*
(11)
53.6+11.1 (3)
49.5514.1
(6)
61.2k11.3
(4)
42
(1)
47
(1)
52.9215.5 (153)
54.7k14.9
(14)
37.9k15.5 (46)
53.1k15.8 (104)
32
(I)
30
(1)
32.7+8.1** (24)
41.5k11.8
(8)
42.2215.8
(9)
61.2211.3 (4)
34.226.8 (4)
47 (1)
46.4k 16.7 (216)
l-NS,
2-NS=geno ypes 1
o
2 non-sub ypeable wi h he
es
used.
NG=iion-geno ypeable wi h he es used.
*p
<
0.05 ype
3a
e sus ype lb.
**p
<
0.05
ype
3a
c sus
I-NS,
e sus
lh,
e sus la+lb.
650
Clinical Mic obiology and In ec ion, Volume
3
Numbe
6,
Decembe
1997
Table
3
Pa ien s
wi h
pa hologic
ALT
le els
and
a e age
ALT
le els
by
geno ype
DISCUSSION
ALTb
Geno aes” No. MeankSD
1-NS 12 166.9k 152.3
la
33 116.2k66.5
lb 85 125.1k85.5
2a/2c
1
48
3a
23 148.4k81.9
4a
5
203.4
208.0
NG 7 98.0k35.1
la+lb 4 155.0k77.2
la+4a 3 149.3k97.7
’l-NS=geno ype 1 non-sub ypeahle wi h he es used.
NG=non-geno ypeable wi h he es
used.
bA e age ALT le els in pa ien s wi h ele a ed ALT
(J
<
0.05
in
all
cases).
Table
4
Dis ibu ion
o
hepa ic
biopsy
pa e ns
by
geno ype
CH MC PCH ACH Ci hosis Ca cinoma GH
Geno ype No No No No No. No
No
1-NS
la
lh
2-NS
3a
4a
la+lb
la+4a
To al
~~
3
1
21 1
21
9
6
1
1
12
1
1
1
1
2
13618 7
1
1
CH
=
ch onic hepa i is
o
non-speci ied his ologic deg ee;
MC=minimal changes; PCH =pe sis en ch onic hepa i is;
ACH =ac i e ch onic hepa i is; GH
=g anuloma ous
hepa i is;
LNS, 2-NS=non-sub ypeahle wi h he es used.
pa hologic le els o
ALT.
No
signi ican di e ences
we e ound (p>0.05 in
all
cases) when he
ALT
le els
we e compa ed in he same geno ype g oups (Table 3).
Li e biopsy was pe o med in 37 pa ien s. In
18
(48.6%) o hese,
a
pa e n o ac i e ch onic hepa i is
was ound, in se en (18.9%) hepa ic ci hosis, in
six
(16.2%) pe sis en ch onic hepa i is, and in ano he
h ee only minimal changes (8.1%). Finally, one case
each o hepa oca cinoma, o g anuloma ous ch onic
hepa i is (p obably due o oxici y h ough isoniazid)
and o non-classi ied ch onic hepa i is was ound. Table
4 p esen s he dis ibu ion o his ologic pa e ns
acco ding o geno ype. Geno ype lb was ound in
six
o he se en cases o ci hosis (85.7%) and in nine o
he 18 cases (50.0%) o ac i e ch onic hepa i is.
Ou
esul s show ha in he Spanish popula ion he
highes p e alence co esponded o geno ype lb, wi h
48.1% o he cases, ollowed by geno ype la, wi h
22.3%, and geno ype 3a, wi h
11.1%.
These da a show
he g ea e p e alence o geno ype lb in Spain, jus
as
in o he Occiden al coun ies [5,6,17,18], apa kom
he USA [5] and he no h o Eu ope [6,1Y] whe e
geno ype
la
is he mos equen ly desc ibed. In
con as o ou esul s, B a o e al [lY] ound geno ype
la
o
be he mos p e alen , al hough his di e ence
could be due o he small numbe o non-IVDU
pa ien s in hei s udy (18 cases). On he o he hand,
al hough in ou s udy geno ype 3a was he hi d mos
equen ( ollowing ypes lb and
la),
i s p e alence was
lowe han ha ound in o he Eu opean coun ies such
as
Sco land [12], Sweden [19] o F ance [18], whe e
geno ype 3a p e alence is o e 20%.
Geno ype 2
is
p esen only a ely in ou heal h
a ea. The p esence o geno ype 4a among Spanish
people (eigh cases, 3.7%) is wo h no ing,
as
i is a ely
desc ibed in coun ies o wes e n Eu ope [6,
8,
12, 181.
The p esence o in ec ion by mo e han one geno-
ype was inkequen in ou s udy (nine cases, 4.1%), in
con as o he esul s o B a o e
a1
[20], who ound
43.8% mul iple in ec ions. Mixed in ec ions a e a ely
men ioned in he li e a u e, and he majo i y o au ho s
epo mul iple in ec ion pe cen ages simila o ou s
[17,18,21,22]. Howe e , he signi icance o mul iple
in ec ions
is
deba able: on he one hand,
a
la ge numbe
o mixed pa e ns a e due o c oss- eac ions, while on
he o he hand, cu en geno yping echniques do no
de ec mul iple in ec ions eliably and end
o
iden i j.
p incipally he dominan geno ypes [23].
On he o he hand, an associa ion o some geno-
ypes wi h speci ic isk g oups seems o exis . In Japan
Okamo o e al [7] ound geno ype lb (I11 o Okamo o)
o be mo e p e alen in pa ien s wi h non-A, non-B
hepa i is. These au ho s also ound geno ype
la
o be
mo e 6-equen in hemophiliacs, a ibu ing his o he
US o igin o he coagula ion ac o s ecei ed. In
a
g oup
o Ge man pa ien s, D iesel e al [15] ound geno ype
lb o be he mos equen among
all
he pa ien s, wi h
an ele a ed p e alence
o
geno ype 3a in he IVDU
g oup. In ou s udy we ha e ound
a
clea dis ibu ion
o geno ypes acco ding o isk ac o s: among pa ien s
o unknown isk and hose wi h blood- ans usion
an eceden s, geno ype lb was he mos p e alen (62.0%
and 68.1%, espec i ely); among hemodialyzed pa ien s
no s a is ical di e ences we e ound be ween geno ypes
la
and Ib (40.0% and 50.0% espec i ely), while among
IVDU pa ien s geno ypes
la
(42.8% o
all
cases) and 3a
(21.6%) we e he mos p e alen .
Alonso Alonso e al: Hepa i is
C
i us geno ypes and isk ac o s
65
1
The low p e alence o geno ype 3a
in
IVDU
pa ien s ound bo h in ou s udy and in ha o B a o
e al [20] (11.5%) s a ids ou in con as o he p e a-
lence obse ed in o he nea by Eu opean coun ies
such
as
F ance (63%) [18] and I aly (64.3%) [21].
Simila di e ences a e ound i we compa e he p e a-
lences o geno ype
3a
among he non-IVDU pa ien s
o hese coun ies wi h ou esul s. We eel ha he low
p e alence o ype 3a compa ed wi h he le els exis ing
in o he Eu opean coun ies may be due o he la e
in oduc ion o his geno ype in o Spain. This could be
suppo ed by he ac ha pa ien s ha ing geno ype
3a
p esen ed he lowes a e age age (32.728.1 yea s),
whe he he o ali y o pa ien s s udied
is
conside ed o
he non-IVDU (36.429.4 yea s) and
IVDU
(30.6-+
5.6)
pa ien g oups a e analyzed sepa a ely.
The disco e y o he gene ic di e si y o
HCV
ga e ise o he hypo hesis ha he g ea e o lesse
se e i y o he clinical pic u e and i s e olu ion we e
ela ed o speci ic geno ypes [24]. The s udies pe -
o med o da e a e no : conclusi e. McOmish e al [13]
ound
a
g ea e equency o abno mali ies o hepa ic
unc ion in pa ien s in ec ed wi h ype 3 han in hose
in ec ed wi h ypes
1
and 2, al hough hey doub he
ue pa hogenic signi icance o his ac . Dusheiko e
a1
[S] sugges he associa ion o geno ype
1
wi h mo e
se ious his ologic lesions in he li e . In con as , o he
au ho s [25] sugges ha
a
ela ion be ween geno ypes
and se e i y o hepa ic disease
is
no e y likely. On he
o he hand, al hough he equency wi h which
dis inc deg ees
o
his ologic lesions a e ound a ies
among he di e en s udies published [17,26-281, in
conjunc ion pe sis en ch onic hepa i is
(PCH)
and
ac i e ch onic hepa i is (ACH) a e he mos equen
lesions, ollowed by ci hosis [29]. In
ou
s udy, ACH
was he mos equen (18 o 37 cases), ollowed by
ci hosis (se en cases), bu
PCH
was ound in only i e
cases. Geno ype lb in ec ion has also been equen ly
associa ed wi h he mos se e e his ologic lesions o he
li e (especially ci hosis and hepa ocellula ca cinoma)
[22,24,30,31]. We ha e ound simila esul s,
as
he
six
ci hosis pa ien s we e in ec ed by geno ype lb.
Howe e , gi en ha geno ype lb is p edominan in
ou heal h a ea, i is o be expec ed ha his geno ype
would appea wi h g ea e equency in his ype o
his ologic lesion. In any case, i
is
impo an
o
poin
ou ha all he pa ien s wi h hepa ic ci hosis p esen ed
geno ype lb.
Acknowledgmen s
We wish o hank D F ancisco Ma in Rod iguez o
his assis ance in he elabo a ion and in e p e a ion
o
he s a is ical s udy, and C.
J.
Nolan o he help in
ansla ing.
Re e ences
1.
Choo
Q-L,
Kuo
G,
Weine AJ, O e by
LR,
B adley DW,
Hough on
M.
Isola ion o
a
cDNA clone de i ed om a
blood-bo ne non-A, non-B i al hepa i is genome. Science
2.
Kubo
Y,
Takeuchi
K,
Boonma
S,
e
al.
A cDNA Gagmen
o hepa i is C i us isola ed om an implica ed dono o
pos - ans usion non-A, non-B hepa i is in Japan. Nucleic
Acids Res
1989; 17: 10367-72.
3.
Takeuchi
K,
Boonma
S,
Kubo
Y,
e al. Hepa i is C i al
cDNA clones isola ed om a heal hy ca ie dono impli-
ca ed in pos ans usion non-A, non-B hepa i is. Gene
1990;
4.
Takeuchi
K,
Kubo
Y,
Boonma
S,
e al. Nucleo ide sequence
o co e and en elope genes o he hepa i is
C
i us genome
de i ed di ec ly om human heal hy ca ie s. Nucleic Acids
Res
1990; 18: 4626.
5.
Takada N, Takase
S,
Takada A, Takayasu D. Di e ences
in he hepa i is C i us geno ypes in di e en coun ies.
J Hepa ol
1993; 17: 277-83.
6.
Da idson
F,
Simmonds
P,
Fe gu son JC, e al. Su ey o
majo geno ypes and sub ypes
o
hepa i is C i us using
RFLP
o
sequences ampli ied om he
5’
non-coding
egion.
J
Gen Vi ol
1995; 76: 1197-204.
7.
Okamo o H, Sugiyama
Y,
Okada
S,
e al. Typing hepa i is
C i us by polyme ase chain eac ion wi h ype-speci ic
p ime s: applica ion o clinical su eys and acing in ec ious
sou ces.
J
Gen Vi ol
1992; 73: 673-9.
8.
Dusheiko G, Schdo i z-Weiss H, B own D, e al. Hepa i is
C i us geno ypes: an in es iga ion
o
ype-speci ic m e -
ences in geog aphic o igin and dlsease. Hepa ology
1994;
9.
Bukh
J,
Pu cell RH, Mille RH. A leas
12
geno ypes
o hepa i is C i us p edic ed by sequence analysis
o
he
pu a i e
El
gene
o
isola es collec ed wo ldwide. P oc Na l
Acad Sci
USA
1993; 90: 8234-8.
0.
Simmonds
P,
Holmes EC, Cha TA, e al. Classi ica ion o
hepa i is C i us in o six majo geno ypes and a se ies
o
sub ypes by phylogene ic analysis o he
NS-5
egion.
J
Gen
Vi ol
1993; 74: 2391-9.
1.
Cha TA, Beall
E,
I ina B, e al. A leas i e ela ed, bu
dis inc , hepa i is C i al geno ypes exis . P oc Na l Acad Sci
USA
1992; 89: 7144-8.
2.
McOmish
E
Yap
PL,
Dow BC, Folle EAC, Saleed
AA,
Simnionds P. Geog aphical ds ibu ion
o
hepa i is C i us
geno ypes in blood dono s-an in e na ional collabo a i e
su ey.
J
Clin Mic obiol
1994; 32: 884-92.
13.
McOmish F, Chan
S-W,
Dow BC, e
al.
De ec ion
o
h ee
ypes o hepa i is C i us in blood dono s: in es iga ion o
ype-speci ic dl e ences in se ological eac i i y and a e o
alanine amino ans e ase abno mah ies. T ans usion
1993;
14.
Pon isso
P,
Ru ole o MG, Nicole i M, e al. Dis ibu ion
o h ee majo hepa i is C i us geno ypes in I aly A
mul icen e s udy
o
495
pa ien s wi h ch onic hepa i is C. J
Vi al Hepa i is
1995; 2: 33-8.
15.
D iesel
G,
Wi h
D,
S o k
K,
Baungo en
R,
Sucke
U,
Sch eie
E.
Hepa i is C i us (NCV) geno ype dis ibu ion
1989; 244: 359-62.
91: 287-91.
19: 13-18.
33: 7-13.

652
Clinical Mic obiology and In ec ion, Volume
3
Numbe
6,
Decembe
1997
in Ge man isola es: s udies on he sequence a iabili y in he
E2
and
NS5
egion. A ch Vi ol
1994; 139: 379-88.
16.
Simmonds
P,
Albe i A, Al e HJ, e al. A p oposed
sys em o he nomencla u e o hepa i is C i al geno ypes.
Hepa ology
1994; 19: 1321-4.
17.
Nousbaum JB, Pol
S,
Nalpas
B,
Laudais
P,
Be helo
P,
B echo C. Hepa i is C i us ype Ib (11) in ec ion in F ance
and I aly Collabo a i e s udy g oup. Ann In e n Med
1995;
18.
Pawlo sky JM, Tsaki is L, Roudo -Tho a al
F,
e al.
Rela ionship be ween hepa i is C i us geno yping and
sou ces o in ec ion in pa ien s wi h ch onic hepa i is C. J
In ec Dis
1995; 171: 1607-10.
19.
B a o
R,
So iano
V,
Ga cia-Samaniego J, e al. Hepa i is C
i us geno ypes in dl e en isk popula ions in Spain. J In ec
Dis
1996; 183: 509-10.
20.
She
S,
Widell A, Fobe g
U,
e
al.
HCV geno ypes in
Swedish blood dono s as co ela ed
o
epidemiology, li e
dlsease and hepa i is C i us an ibody p o ile. In ec ion
21.
Ra aggi A, Rossini A, Mazza C, Puo i M, Ma in MG,
Ca iani E. Hepa i is
C
i us geno ypes in No he n I aly:
clinical and i ological ea u es. J Clin Mic obiol
1996; 34:
22.
Shni
E,
Bono F, Ci idmi A, e
al.
Di e en ial dls ibu ion
o hepa i is C i us geno ypes in pa ien s wi h and wi hou
li e unc ion abno mali ies. Hepa ology
1995; 21
:
285-90.
122: 161-8.
1995; 23: 253-7.
2922-5.
23.
Lau JYN,
Mizokami
M, Kolbe g JA, e al. Applica ion
o
six
hepa i is C i us geno yping sys ems o se a &om ch onic
hepa i is C pa ien s in he Uni ed S a es. J In ec Dis
1995;
24.
Simmonds P. Va iabili y o hepa i is C i us genome. In
Reesink HW, ed. Hepa i is C i us. Basel: Ka ge ,
1994:
25.
Yamada M, Kakumu
S,
Yoshioka K, e
al.
Hepa i is C i us
geno ypes a e no esponsible o de elopmen o se ious
li e disease. Dig Dis Sci
1994; 39: 234-9.
26.
Al e HJ. Ch onic consequences o non-A, non-B hepa i is.
In See LB, Lewis JH, eds. Cu en pe spec i es in
hepa ology. New Yo k: Plenum Publislng Co po a ion,
27.
Es eban JI, Ldpez-Tala e a JC, Genesca J, e al. High a e o
in ec i i y and li e disease in blood dono s wi h an ibodes
o hepa i is C i us. Ann In e n Med
1991; 115: 443-9.
28.
Genesca J, Es eban JL, Al e HJ. Blood-bo ne nod, nod3
hepa i is: hepa i is C. Semin Li e Dis
1991; 11: 14744.
29.
Co doba J, Camps J. Es eban JI. The clinical pic u e o acu e
and ch onic hepa i is C. In Reesink HW, ed. Hepa i is C
i us. Basel: Ka ge ,
1994: 69-88.
30.
Pozza o G, Kaneko
S,
Mo e i M, e
al.
Di e en se e i y o
ch onic li e dlsease. J Med Vi ol
1994; 43: 291-6.
31.
Fe ay C,' Gigou M, Samuel D e al. In luence o he
geno ypes o hepa i is
C
i us on he se e i y o ecu en
li e dlsease a e li e ansplan a ion. Gas oen e ology
171: 281-9.
12-35.
1989: 83-97.
1995; 108: 1088-96.