Immunization with heterologous flaviviruses protective against fatal West Nile encephalitis. (Research).Prior immunization immunization: see immunity; vaccination. of hamsters with three heterologous heterologous /het·er·ol·o·gous/ (het?er-ol´ah-gus) 1. made up of tissue not normal to the part. 2. xenogeneic. het·er·ol·o·gous adj. 1. flaviviruses (Japanese encephalitis Japanese Encephalitis Definition Japanese encephalitis is an infection of the brain caused by a virus. The virus is transmitted to humans by mosquitoes. virus [JEV JEV Jesuit European Volunteers JEV Joinville Eau Vive (France) ] SA14-2-8 vaccine, wild-type St. Louis encephalitis St. Louis encephalitis see St. Louis encephalitis. virus [SLEV SLEV Saint Louis Encephalitis Virus SLEV Surround Level ], and Yellow fever virus yellow fever virus n. An arbovirus of the genus Flavivirus that causes yellow fever and is transmitted by mosquitoes. [YFV YFV Yellow Fever Virus ] 17D vaccine) reduces the severity of subsequent West Nile virus West Nile virus, microorganism and the infection resulting from it, which typically produces no symptoms or a flulike condition. The virus is a flavivirus and is related to a number of viruses that cause encephalitis. (WNV WNV West Nile Virus WNV World Net Visions ) infection. Groups of adult hamsters were immunized with each of the heterologous flaviviruses; approximately 30 days later, the animals were injected intraperitoneally with a virulent New York New York, state, United States New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of strain of WNV. Subsequent levels of viremia viremia /vi·re·mia/ (vi-re´me-ah) the presence of viruses in the blood. vi·re·mi·a n. The presence of viruses in the bloodstream. , antibody response, and deaths were compared with those in nonimmune (control) hamsters. Immunity to JEV and SLEV was protective against clinical encephalitis encephalitis (ĕnsĕf'əlī`təs), general term used to describe a diffuse inflammation of the brain and spinal cord, usually of viral origin, often transmitted by mosquitoes, in contrast to a bacterial infection of the meninges and death after challenge with WNV. The antibody response in the sequentially infected hamsters also illustrates the difficulty in making a serologic se·rol·o·gy n. pl. se·rol·o·gies 1. The science that deals with the properties and reactions of serums, especially blood serum. 2. diagnosis of WNV infection in animals (or humans) with preexisting pre·ex·ist or pre-ex·ist v. pre·ex·ist·ed, pre·ex·ist·ing, pre·ex·ists v.tr. To exist before (something); precede: Dinosaurs preexisted humans. v.intr. Flavivirus immunity. ********** West Nile virus (WNV) was detected for the first time in North America in summer of 1999, during an outbreak involving humans, equines, and birds in the New York City New York City: see New York, city. New York City City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. metropolitan area (1). Persistence of the virus and its spread to other states on the eastern seaboard during 2000 and 2001 suggest that WNV is now endemic in the United States and that its geographic range probably will continue to expand until it extends over much of the continent (2). Although many WNV infections in humans are asymptomatic or unrecognized, some patients have an acute dengue-like illness, and a small percentage have encephalitis or meningoencephalitis meningoencephalitis /me·nin·go·en·ceph·a·li·tis/ (me-ning?go-en-sef?ah-li´tis) inflammation of the brain and meninges. toxoplasmic meningoencephalitis (1-5). The latter complication is most common among the elderly, with recent reported case-fatality rates from 4% to 11% (3-9). No specific treatment is available for WNV encephalitis, and no licensed vaccine is available for its prevention. WNV is a positive-stranded RNA virus RNA virus n. Any of a group of viruses whose nucleic acid core is composed of RNA, including the picornaviruses, retroviruses, and paramyxoviruses. ; based on its antigenic and genetic characteristics, it is included in the Japanese encephalitis virus (JEV) serocomplex of the genus Flavivirus, family Flaviviridae (10). The JEV serocomplex includes four antigenically related viruses that are important causes of encephalitis in humans: JEV, WNV, St. Louis encephalitis virus (SLEV), and Murray Valley encephalitis virus Murray Valley encephalitis virus (MVEV) is a zoonotic flavivirus endemic to northern Australia and Papua New Guinea. It is the causal agent of Murray Valley encephalitis (previously known as Australian encephalitis) and in humans can cause permanent neurological disease or death. (MVEV). In addition to their antigenic and genetic relatedness, these four viruses have many epidemiologic similarities (3,11). Because of the close antigenic relationships among many viruses in this genus, Flavivirus infections are difficult to differentiate by most serologic techniques, especially in persons or animals having a second or sequential Flavivirus infection (12-14). Considerable attention has been focused on the immune response immune response n. An integrated bodily response to an antigen, especially one mediated by lymphocytes and involving recognition of antigens by specific antibodies or previously sensitized lymphocytes. in primary and secondary Flavivirus infection and the role of immunopathogenesis in the etiology of severe Flavivirus disease (11,15,16). In the case of dengue dengue or breakbone fever or dandy fever Infectious, disabling mosquito-borne fever. Other symptoms include extreme joint pain and stiffness, intense pain behind the eyes, a return of fever after brief pause, and a characteristic rash. , enhancement of virus replication by heterologous flavivirus antibodies and T-cell activation are thought to occur in some patients during a second or sequential dengue infection, resulting in hemorrhagic fever hemorrhagic fever (hĕm'ərăj`ĭk), any of a group of viral diseases characterized by sudden onset, muscle and joint pain, fever, bleeding, and shock from loss of blood. or shock (15,16). In contrast, animal data indicate that prior infection with a heterologous Flavivirus reduces the severity of subsequent challenge with WNV. Results of experimental studies with rodents, monkeys, and pigs (17-21) suggest that heterologous Flavivirus antibodies protect against or modify subsequent infection with WNV. This phenomenon could be important in vaccine development against WNV infection and in determining the ultimate geographic distribution and public health importance of WNV if it is introduced into areas of Central and South America where other flaviviruses, such as Dengue virus dengue virus n. A virus of the genus Flavivirus that is the cause of dengue. (DENV DENV Department of Environment (Canada) ), Yellow fever virus (YFV), SLEV, and Ilheus virus (ILHV), are endemic. To determine more precisely the degree of cross-protection among members of the JEV serocomplex and the possibility that this phenomenon could be used to protect against severe WNV infection, a series of experiments was carried out with three heterologous flaviruses and a recently described model (22) of WNV encephalitis. We report the results of these studies, which indicate that prior immunization of hamsters with a JEV vaccine strain and a wild-type SLEV--and to a lesser extent the 17-D YFV vaccine--modify subsequent WNV infection and protect the animals from fatal encephalitis. Materials and Methods Four flaviviruses were used in this study: WNV strain 385-99, isolated from a dead snowy owl at the Bronx Zoo during the 1999 epizootic ep·i·zo·ot·ic adj. Affecting a large number of animals at the same time within a particular region or geographic area. Used of a disease. ep in New York City (23); live attenuated Attenuated Alive but weakened; an attenuated microorganism can no longer produce disease. Mentioned in: Tuberculin Skin Test attenuated having undergone a process of attenuation. SA14-2-8 vaccine strain of JEV (24,25); 17-D live attenuated vaccine live attenuated vaccine A vaccine that induces an immune response, which more closely resembles that of a natural infection, than that elicited by killed vaccines, as the organisms contained therein actively reproduce until held in check by the recipient's own strain of YFV (26); and SLEV strain Be Ar 23379 (27), originally isolated from mosquitoes (Sabethes belisarioi) in Para, Brazil, in 1961. The hamsters used in our studies were adult (70 g to 100 g) female Syrian golden hamsters (Mesocricetus auratus Mesocricetus auratus see cricetus. ) (Harlan Sprague Dawley, Indianapolis, IN). Animals were cared for in accordance with the guidelines of the Committee on Care and Use of Laboratory Animals (Institute of Laboratory Animal Resources, National Research Council) under an animal use protocol approved by the University of Texas Medical Branch "UTMB" redirects here. For other system schools, see University of Texas System. The University of Texas Medical Branch (UTMB) is a component of the University of Texas System located in Galveston, Texas, about 50 miles (80 km) southeast of downtown Houston. . All work with infected animals was carried out in bio-safety level-3 facilities. All virus titrations were done in cultures of the C6/36 clone of Aedes albopictus cells (28), with the presence or absence of viral antigen viral antigen n. Abbr. VA An antigen with multiple antigenicities that is protein in nature, strain-specific, and closely associated with the virus particle. by immunofluorescence Immunofluorescence A technique that uses a fluorochrome to indicate the occurrence of a specific antigen-antibody reaction. The fluorochrome labels either an antigen or an antibody. as the endpoint, as described (22,29,30). To determine the quantity of infectious virus in blood samples taken daily after WNV infection, each hamster blood specimen was titrated ti·trate tr. & intr.v. ti·trat·ed, ti·trat·ing, ti·trates To determine the concentration of (a solution) by titration or perform the operation of titration. in 24-well tissue culture plates seeded with C6/36 cells. Serial 10-fold dilutions from [10.sup.-1] to [10.sup.-7] were made of each sample in phosphate-buffered saline, pH 7.4 (PBS PBS in full Public Broadcasting Service Private, nonprofit U.S. corporation of public television stations. PBS provides its member stations, which are supported by public funds and private contributions rather than by commercials, with educational, cultural, ), containing 10% fetal bovine serum Fetal bovine serum ( or foetal bovine serum) is serum taken from the fetuses of cows. Fetal Bovine Serum (or FBS) is the most widely used serum in the culturing of cells. In some papers the expression foetal calf serum is used. ; 0.1 mL of each dilution was added to four wells of a tissue culture plate. Following absorption at 28 [degrees] C for 2 hours, 1.5 mL of maintenance medium (29) was added to each well, and the plates were incubated at 28 [degrees] C in a 5% C[O.sub.2] atmosphere for 6 days. On day 6, 20 mL of a cell suspension from each well was added to a single spot on 12-spot glass microscope slides (Cell-Line Associates, Inc., Newfield, NJ). After drying at room temperature, the slides were immersed in cold acetone acetone (ăs`ĭtōn), dimethyl ketone (dīmĕth`əl kē`tōn), or 2-propanone (prō`pənōn), CH3COCH3 for 10 minutes; the cells were subsequently examined for the presence of WNV antigen by indirect fluorescent antibody test Fluorescent antibody test (FA test) A test in which a fluorescent dye is linked to an antibody for diagnostic purposes. Mentioned in: Rabies by using a WNV-specific mouse immune ascitic as·ci·tes n. pl. ascites An abnormal accumulation of serous fluid in the abdominal cavity. [Middle English aschites, from Late Latin asc fluid and a commercially prepared fluorescein-conjugated, goat antimouse immunoglobulin (Sigma, St. Louis, MO). WNV titers were calculated as the tissue culture infectious [dose.sub.50] (TCI (Trustworthy Computing Initiative) An umbrella term from Microsoft for its efforts to improve security in Windows. TCI was announced in 2002 after viruses such as Code Red and Nimda had succeeded in attacking numerous Windows computers. [D.sub.50]) per mL of specimen by the method of Reed and Muench (31). Experimental Infection of Animals Hamsters were infected by the intraperitoneal (IP) or subcutaneous (SC) routes, depending on the virulence of the infecting virus for the animals. WNV and YFV were injected IP; JEV and SLEV were administered SC. Infecting doses of the viruses were as follows: WNV [10.sup.4.0] TCI[D.sub.50], YFV [10.sup.6.0] TCI[D.sub.50], JEV [10.sup.6.5] TCI[D.sub.50]' and SLEV [10.sup.6.0] TCI[D.sub.50]. Immune Reagents A mouse immune ascitic fluid to WNV was prepared in adult mice. The immunogen was a crude homogenate homogenate /ho·mog·e·nate/ (ho-moj´in-at) material obtained by homogenization. homogenate material obtained by homogenization. of brain (10% W/V in PBS) from newborn mice injected intracerebrally (IC) with the B956 prototype strain of WNV (32). The adult immunization adult immunization The administration of vaccines to prevent clinical infection in adulthood; 'The contrast between the impact of vaccine- preventable diseases of adults compared with those of children is striking. Each yr, < 500 persons in the U.S. schedule consisted of four IP injections of the immunogen mixed with Freund's adjuvant Freund's adjuvant n. A substance consisting of killed microorganisms, such as mycobacteria, in an oil and water emulsion that is administered to induce and enhance the formation of antibodies. , given at weekly intervals. Sarcoma sarcoma (särkō`mə), highly malignant tumor arising in connective- and muscle-cell tissue. It is the result of oncogenes (the cancer causing genes of some viruses) and proto-oncogenes (cancer causing genes in human cells). 180 cells were given after the final injection to induce ascites Ascites Definition Ascites is an abnormal accumulation of fluid in the abdomen. Description Rapidly developing (acute) ascites can occur as a complication of trauma, perforated ulcer, appendicitis, or inflammation of the colon or other formation. Antibody Determinations Serum antibodies to WNV and the other three flaviviruses were measured by hemagglutination-inhibition (HI) test and to WNV by immunoglobulin (Ig) M antibody capture enzyme immunoassay Immunoassay An assay that quantifies antigen or antibody by immunochemical means. The antigen can be a relatively simple substance such as a drug, or a complex one such as a protein or a virus. (MAC-ELISA) (33). Antigens for both serologic tests were prepared from brains of newborn mice injected IC with each of the flaviviruses; the infected brains were treated by the sucrose-acetone extraction method (33). Hamster sera were tested by HI at serial twofold dilutions from 1:20 to 1:5120 at pH 6.6 (WNV, JEV, and SLEV) or 6.4 (YFV) with 4 units of antigen and a 1:200 dilution of goose erythrocytes Erythrocytes Red blood cells. Mentioned in: Bartonellosis erythrocytes (ē·rithˑ·rō·sīts), n.pl red blood cells. , following established protocols (33). For the MAC-ELISA, microtiter plates were coated with a commercial goat anti-rat IgM (capture) antibody (Kirkegaard & Perry Laboratories, Inc., Gaithersburg, MD), diluted 1:500 in carbonate buffer, pH 9.6. All hamster sera were screened at a 1:40 dilution. The WNV antigen was also used at a 1:40 dilution. The secondary (detecter) antibody was a mouse, anti-Flavivirus, peroxidase-conjugated monoclonal antibody monoclonal antibody, an antibody that is mass produced in the laboratory from a single clone and that recognizes only one antigen. Monoclonal antibodies are typically made by fusing a normally short-lived, antibody-producing B cell (see immunity) to a fast-growing (6B6C-1) at a dilution of 1:6000. Results were read with a SPECTRA shell reader (SLT SLT Salut (French) SLT Sri Lanka Telecom SLT Senior Leadership Team SLT Something Like That SLT Selective Laser Trabeculoplasty SLT South Lake Tahoe (California) SLT Single Line Telephone Labininstruments, Salzburg, Austria). Specimens wells were recorded as positive when the absorbance absorbance /ab·sor·bance/ (-sor´bans) 1. in analytical chemistry, a measure of the light that a solution does not transmit compared to a pure solution. Symbol . 2. values at optical [density.sub.405] nm of the specimen wells exceeded 0.20 after subtraction of average background absorbance of control wells (33). Results Infection of Nonimmune Hamsters with WNV Several groups of Flavivirus-naive (control) hamsters were inoculated IP with [10.sup.4] TCI[D.sub.50] of WNV to determine the subsequent level and duration of viremia, immune response, and death rate. Table 1 and the Figure show the results of an experiment with a group of 10 hamsters that were bled daily for 6 consecutive days after infection with WNV. Moderate levels of virus were detected in the animals' blood within 24 hours and persisted for 5 or 6 days. The highest blood virus titers were detected on days 2 and 3 after infection (means [10.sup.5.2] and [10.sup.5.1], respectively). HI antibodies were detected in all the animals by day 5, and the titers had increased substantially by day 6. In general, WNV-specific IgM, as detected by MAC-ELISA, appeared at approximately the same time as the HI antibodies (data not shown). Table 2 shows the results of a second experiment in which 13 hamsters were infected with WNV. All the animals were bled 6 days after injection, and a subset was bled again at 31, 60, and 90 days. Six days after infection, all the animals had specific HI antibodies to WNV antigen and were negative to the other three flaviviral antigens tested (YFV, SLEV, and JEV). At this time, the animals also had a strongly positive IgM antibody response by MAC-ELISA. Thirty-one days after infection, the HI antibody response had become broadly cross-reactive with the four Flavivirus antigens, although the highest titer was still to WNV, and the IgM antibody had begun to decrease. A similar HI antibody pattern was observed at 60 and 90 days after infection, although by 90 days the HI titers were decreasing. Six of the nine WNV-infected hamsters gave a negative reaction in the WNV MAC-ELISA when tested 60 and 90 days after infection. Five of the 13 hamsters infected in this second experiment died of WNV encephalitis 7 to 14 days after infection (Table 2). Overall, 14 (47%) of 30 adult hamsters injected IP with [10.sup.4] TCI[D.sub.50] of WNV died of encephalitis (Table 3). The pathologic reaction of the WNV hamster model has been described (22). Infection of JEV-Immune Hamsters with WNV The Figure and Table 4 show the results from another experiment in which 30 adult hamsters were given a single SC injection of approximately [10.sup.6.4] TCI[D.sub.50] of the live attenuated JEV SA14-2-8 vaccine strain. Thirty-eight days later, the animals were injected (challenged) IP with [10.sup.4] TCI[D.sub.50] of WNV; 10 of the hamsters in this group were bled daily for 6 consecutive days. These blood samples were subsequently titrated to determine the level of WNV viremia. The resulting viremia in the JEV-immune animals was markedly lower than in the naive hamsters (Figure). Furthermore, the JEV-immune hamsters responded to challenge with WNV by developing a secondary (sequential) type of Flavivirus antibody response. Table 4 shows the HI antibody titers to JEV and WNV antigens in sera of 10 of the SA14-2-8 vaccinated hamsters, 30 days after their JEV immunization. At this time the HI antibody titers to JEV and WNV antigens were characteristic of a primary Flavivirus infection (13,14). On day 38, the animals were challenged with WNV; 6 days later, their sera were tested for HI and WNV-specific IgM antibodies. The boost in HI antibody titers that was observed 6 days after challenge with WNV was typical of a secondary antibody response to Flavivirus infection (13,14). In contrast, IgM antibody response to the second Flavivirus (WNV) infection was minimal (Table 4). All the JEV-immune hamsters (n = 30) survived challenge with WNV (Table 3). Their infection with WNV was confirmed by the presence of low-level viremia (Figure) and the secondary Flavivirus antibody response following challenge (Table 4). None of these hamsters appeared clinically ill after infection with WNV, in contrast to the naive animals. Many of the nonimmune hamsters had clinical signs of acute central nervous system injury (somnolence somnolence /som·no·lence/ (som´no-lens) drowsiness or sleepiness, particularly in excess. som·no·lence n. 1. A state of drowsiness; sleepiness. 2. , muscle weakness, paralysis, tremors, and loss of balance) beginning around day 6 after infection, and approximately half died (22). Thus, prior immunization with JEV vaccine reduced the severity of subsequent WNV infection and prevented death. Infection of SLEV-Immune Hamsters with WNV The Figure and Table 5 summarize the results of another experiment in which 32 adult hamsters were given a single SC injection of approximately [10.sup.6] TCI[D.sub.50] of SLEV strain BeAr 23379. This wild-type SLEV strain was selected for immunization, since it is not lethal to hamsters. Thirty-two days after injection with SLEV, the animals were inoculated IP with [10.sup.4] TCI[D.sub.50] of WNV. After this WNV challenge, the hamsters were bled daily for 6 consecutive days, as before. Antibody determinations were also done on blood samples taken 6 days after challenge with WNV. Titration titration (tītrā`shən), gradual addition of an acidic solution to a basic solution or vice versa (see acids and bases); titrations are used to determine the concentration of acids or bases in solution. of daily blood samples from the SLEV-immune hamsters gave results similar to those in the JEV-immune animals. After challenge with WNV, 7 of the 10 SLEV-immune hamsters had brief, low-level viremia (Figure). However, three hamsters had no detectable viremia. Serologic studies on blood samples taken 30 days after SLEV infection indicated that all the tested animals had been infected (Table 5). The HI response at 30 days was characteristic of primary Flavivirus infection. Six days after WNV infection, HI antibody titers had increased, indicating a secondary flavivirus antibody response. As with the JEV-immune hamsters, the IgM response of the SLEV-immune animals was minimal following the second flavivirus (WNV) infection (Tables 4,5). Consistent with the low levels of WNV viremia (Figure), all the SLEV-immune hamsters (n = 32) survived subsequent challenge with WNV (Table 3). These animals did not appear clinically ill. These results indicate that prior immunity to SLEV also protected the hamsters from WNV encephalitis and death. Infection of YFV-Immune Hamsters with WNV Based on the results obtained with JEV- and SLEV-immune hamsters, we tested the effect of prior immunization with a non-JEV serocomplex Flavivirus on subsequent WNV infection. Accordingly, a group of 30 hamsters was inoculated IP with [10.sup.6.0] TCI[D.sub.50] of the live attenuated 17D YFV strain. Thirty days after immunization, nine of the animals were bled and tested for HI antibodies to YFV and WNV (Table 6). Six days later (36 days after 17D vaccination), the hamsters were inoculated IP with [10.sup.4] TCI[D.sub.50] of WNV. Ten of these animals were bled daily for 6 consecutive days to determine the level of viremia and subsequent antibody response (Figure) (Table 6). Following challenge with WNV, YFV-immune hamsters had an intermediate level of viremia (Figure). The mean WNV titers in the YFV-immune hamsters were higher than in the JEV- and SLEV-immune groups, but the titers were lower than in the Flavivirus-naive (control) hamsters. The death rate in the YFV-immune hamsters was also lower; 4 (13%) of 30 YFV-immune hamsters died after challenge with WNV, compared with 47% in the control group (Table 3). The HI antibody response after vaccination with YFV 17-D virus (Table 6) was less intense than the primary antibody responses to the other three flaviviruses (Tables 1,2,4,5). Monath (26,34) also observed that immunization with 17-D virus induces a weaker HI and complement-fixing antibody complement-fixing antibody n. An antibody that combines with and sensitizes an antigen, leading to activation of complement and sometimes lysis. response than infection with a wild-type YFV strain. Nonetheless, 6 days after challenge with WNV, the animals previously immunized with 17-D virus demonstrated a strong secondary-type Flavivirus antibody response. Interestingly, the 17-D immune animals also had a stronger IgM response to WNV infection. These data indicate that 17-D vaccine gives only partial protection against challenge with WNV. Discussion The results of these hamster studies provide new information that may be useful in predicting the eventual geographic spread and public health importance of WNV in the Americas, as well as in developing novel methods for its control. The results also demonstrate the difficulty in making a serologic diagnosis of WNV infection in human or animal populations exposed to other flaviviruses. First, our results clearly demonstrate that prior infection (and immunity) to JEV and SLEV protects hamsters from fatal WNV encephalitis (Table 3) and diminishes the severity of WNV infection (Figure). Other investigators (17-20) have reported similar findings in experimentally infected hamsters, pigs, and monkeys. The SA14-2-8 JEV strain used in our studies is one of several live attenuated JEV vaccines originally derived from the JEV SA14 wild-type parent strain (35,36); two of these vaccine derivatives, SA14-2-8 and SA14-14-2, have been widely used in China to immunize im·mu·nize v. 1. To render immune. 2. To produce immunity in, as by inoculation. im humans, equines, and pigs (24,25,35). Consequently, considerable information is already available on their biological and genetic characteristics, immunogenicity immunogenicity /im·mu·no·ge·nic·i·ty/ (-je-nis´it-e) the property enabling a substance to provoke an immune response, or the degree to which a substance possesses this property. , safety, efficacy, and duration of immunity (24,25,35-37). The SA14 vaccine derivatives were obtained by serial passage (>100 times) in primary hamster kidney (PHK PHK Pink Honor Key (International Order of DeMolay) ) cell cultures. Because the PHK cell substrate has not been approved by the World Health Organization as a vaccine substrate for use in humans, it is doubtful that the SA14 vaccine derivatives could be used in people in the United States or in other western countries. However, SA14-2-8 live attenuated JEV vaccine has been used successfully in > 1 million horses in China (BQ Chen, pers. comm.) (25), and potentially it could be used in equines in the United States to protect against WNV encephalitis. We are testing a commercial inactivated inactivated rendered inactive; the activity is destroyed. inactivated viruses treated so that they are no longer able to produce evidence of growth or damaging effect on tissue. JEV vaccine (JE-VAX) that is already licensed for human use in the United States. If the licensed inactivated JEV vaccine protects hamsters in a manner similar to the SA14-2-8 attenuated vaccine, it might be considered as an interim WNV vaccine for groups of humans at high risk of exposure, such as laboratory workers and veterinarians, to protect against WNV encephalitis until a specific WNV vaccine is available. Several potential human WNV vaccines are now under development (38,39); however, it will probably be years before the testing and approval process is completed and they are licensed for human use. A second potentially important finding from our hamster studies was that animals previously infected with JEV or SLEV viruses had a much lower viremia on challenge with WNV, compared with nonimmune animals (Table 1) (Figure). If a similar reduction in the level of viremia occurred in JEV-and SLEV-immune animals of other species (i.e., birds and pigs), such animals would probably be inefficient amplifying hosts for WNV virus. Interference from heterologous antibodies to other JEV-serocomplex viruses in birds and other vertebrate hosts may help explain the unique and largely nonoverlapping geographic distribution of the various members of this medically important Flavivirus complex (40,41). To date, the spread of WNV in North America has been limited to areas that are largely free of other endemic JEV complex flaviviruses (41-43). However, as WNV moves into South Florida and the Gulf Coast or into the Midwest, regions where SLEV is endemic (43), WNV could be restricted by heterologous antibodies to SLEV in the resident avian population. SLEV is also endemic in tropical America (44), so potentially the spread of WNV into that region might also be restricted for the same reason. It will be interesting to observe how this natural experiment unfolds. A third important finding of our study concerns the difficulty in making a serologic diagnosis of recent WNV infection. The antigenic cross-reactivity of Flavivirus antibodies is well known, especially after a second or sequential Flavivirus infection in the same host (11-15). As noted, until now most WNV infections in humans and animals in North America have occurred in areas largely free of SLEV. In the northeastern region of the United States, serologic diagnosis of recent WNV infection has been relatively easy, since most people and animals were experiencing their first Flavivirus infection. However, as WNV spreads into geographic regions where people and animals have other preexisting Flavivirus antibodies (i.e., SLEV, YFV, DENV), the interpretation of HI, MAC-ELISA, and even neutralization test neutralization test n. See protection test. results will be more difficult. As we have shown (Tables 4, 5, and 6), hamsters with prior immunity to JEV, SLEV, or YFV had a broadly reacting HI antibody response after a second (sequential) WNV infection. Most of the JEV- and SLEV-immune hamsters did not develop specific IgM antibodies after WNV infection. Consequently, the WNV MAC-ELISA also may be of little diagnostic value in such human or animal cases. The HI test and MAC-ELISA are the two serologic tests most commonly used by public health and veterinary diagnostic laboratories in the United States to screen for WNV infection (42). Our data suggest that these tests may give equivocal results in regions where more than one Flavivirus is active and that other, more specific diagnostic techniques are needed.
Table 1. Pattern of viremia and hemagglutination inhibition
(HI) antibody response in 10 adult Flavivirus-naive (control)
hamsters, following intraperitoneal inoculation of [10.sup.4]
TCI[D.sub.50] of West Nile virus (WNV)
Day postinoculation
Animal No. D-1 D-2 D-3
8001 4.3 (a) (0) 5.0 (0) 5.0 (0)
8002 4.7 (0) 5.5 (0) 5.2 (0)
8003 5.3 (0) 5.3 (0) 5.0 (0)
8004 2.0 (0) 5.0 (0) 5.0 (0)
8005 4.0 (0) 5.0 (0) 5.5 (0)
8006 4.6 (0) 5.2 (0) 5.7 (0)
8007 4.3 (0) 5.7 (0) 4.6 (0)
8008 4.2 (0) 5.8 (0) 4.8 (0)
8009 5.2 (0) 5.2 (0) 5.0 (0)
8010 4.7 (0) 4.7 (0) 5.5 (0)
Mean 4.3 5.2 5.1
SD 0.92 0.34 0.34
Day postinoculation
Animal No. D-4 D-5 D-6
8001 3.3 (0) 1.0 (1:80) 1.0 (1:320)
8002 3.5 (0) 2.5 (1:40) 0 (1:320)
8003 3.5 (0) 2.5 (1:40) 0 (1:320)
8004 4.3 (0) 2.5 (1:40) 1.0 (1:160)
8005 3.7 (0) 1.7 (1:80) 1.0 (1:320)
8006 4.3 (0) 2.7 (1:80) 0 (1:320)
8007 4.0 (0) 2.0 (1:80) 1.0 (1:320)
8008 1.8 (0) 2.0 (1:80) 0 (1:320)
8009 3.2 (0) 2.8 (1:80) 0 (1:320)
8010 3.5 (0) 1.8 (1:80) 0.7 (1:320)
Mean 3.5 2.1 0.5
SD 0.71 0.54 0.50
(a) WNV titer expressed as [log.sub.10] TCI[D.sub.50]/mL of blood
[less than or equal to] 0 <0.7. (HI antibody titer; [less than or
equal to] 0 <1:20)
Table 2. Serologic response of adult hamsters to West Nile virus
(WNV), Yellow fever virus (YFV), St. Louis encephalitis virus (SLEV),
and Japanese encephalitis virus (JEV) antigens, at various intervals
after intraperitoneal inoculation of [10.sup.4.0] TCI[D.sub.50] of WNV
HI antibody titer
WN
Animal no. WNV YFV SLEV JEV MAC-ELISA
Day 6
8251(D (a)) 1:40 0 (b) 0 0 0.633 (c)
8252 1:80 0 0 0 1.013
8253(D) 1:160 0 0 0 0.878
8254 1:160 0 0 0 1.090
8255 1:80 0 0 0 0.848
8256 1:80 0 0 0 0.840
8257(D) 1:160 0 0 0 1.291
8258 1:80 0 0 0 0.869
8259(D) 1:160 0 0 0 0.939
8260 1:80 0 0 0 0.992
8262 1:80 0 0 0 0.748
8263 1:80 0 0 0 0.797
8264(D) 1:80 0 0 0 0.827
Day 31
8252 1:1,280 1:320 1:320 1:320 0.401
8254 1:1,280 1:320 1:320 1:320 0.427
8255 1:640 1:160 1:320 1:160 0.488
8256 1:640 1:160 1:160 1:160 0.582
8258 1:640 1:160 1:160 1:160 0.376
8260 1:1,280 1:320 1:320 1:320 0.420
8262 1:1,280 1:320 1:320 1:320 0.246
Day 60
8252 1:2,560 1:640 1:640 1:640 0.269
8255 1:2,560 1:640 1:640 1:640 0.216
8256 1:640 1:160 1:160 1:160 0.162
8258 1:1,280 1:320 1:320 1:320 0.161
8260 1:320 1:80 1:80 1:40 0.179
8262 1:640 1:160 1:160 1:160 0.181
Day 90
8260 1:640 1:80 1:80 1:80 0.217
8262 1:640 1:80 1:160 1:160 0.184
(a) (D): Hamster died of encephalitis 7 to 14 days
after infection. HI = hemagglutination inhibition.
(b) 0 [less than or equal to] 1:20.
(c) Optical density value ([greater than or equal to]
0.200 is positive).
Table 3. Infection and mortality rates, following intraperitoneal
inoculation of [10.sup.4] TCI[D.sub.50] of West Nile virus (WNV),
in nonimmune (control) hamsters, and in hamsters previously
immunized with Japanese encephalitis (JE) SA14-2-8 vaccine, St.
Louis encephalitis virus (SLEV) strain BeAr 23379, or yellow
fever (YF) 17D vaccine
No. infected
Immune group with WNV No. infected (%) (a) No. died (%)
Nonimmune 30 30 (100) 14 (47)
JEV SA14-2-8 30 30 (100) 0 (0)
SLEV BeAr 23379 32 32 (100) 0 (0)
YFV 17D 30 30 (100) 4 (13)
(a) Total number of animals infected
or dead after being infected with WNV.
Table 4. Serologic response of hamsters following immunization
with the SA14-2-8 vaccine strain of Japanese encephalitis virus
(JEV) and subsequent challenge with West Nile virus (WNV)
HI antibody
30 days after HI antibody 6 days WN MAC-
JEV immunization after WNV challenge ELISA
6 days
after WNV
Hamster no. JEV WNV JEV WNV challenge
8236 1:80 1:80 1:640 1:640 0.166 (a)
8237 1:40 1:80 1:320 1:320 0.205
8238 1:80 1:80 1:640 1:640 0.239
8239 1:80 1:80 1:640 1:640 0.173
8240 1:80 1:80 1:640 1:640 0.245
8241 1:80 1:80 1:320 1:640 0.271
8242 1:80 1:80 1:1,280 1:1,280 0.209
8243 1:40 1:80 1:160 1:160 0.205
8244 1:40 1:80 1:320 1:320 0.229
8245 1:80 1:80 1:160 1:160 NT
(a) Optical density value ([greater than or equal to] S0.200
is positive). HI = hemagglutination inhibition. NT = not tested.
Table 5. Serologic response of hamsters following infection with St.
Louis encephalitis virus (SLEV) strain Be Ar 23379 and subsequent
challenge with West Nile virus (WNV)
HI antibody titer 6
HI antibody 30 days days after WN MAC-
after SLEV infection WNV challenge ELISA 6 days
after WNV
Hamster no. SLEV WNV SLEV WNV challenge
8276 NT NT 1:320 1:640 0.202 (a)
8277 NT NT 1:320 1:640 0.185
8278 1:80 1:80 1:160 1:160 0.141
8279 1:80 1:80 1:160 1:160 0.165
8280 1:80 1:80 1:640 1:640 0.276
8281 1:40 1:20 1:640 1:640 0.555
8282 1:80 1:40 1:160 1:80 0.177
8283 1:80 1:80 1:160 1:160 0.166
8298 1:160 1:80 1:320 1:320 0.139
8299 1:320 1:320 1:640 1:640 0.240
NT = not tested. HI = hemagglutination inhibition.
(a) Optical density value ([greater
than or equal to] 0.200 is positive).
Table 6. Serologic response of hamsters following immunization with
the 17D yellow fever (YF) vaccine and subsequent challenge with
West Nile virus (WNV)
HI antibody HI antibody
titer 30 days titer 6 days
after YF after WNV WN MAC-
immunization challenge ELISA 6 days
after WNV
Hamster no. YF WNV YF WNV challenge
8226 1:20 1:20 1:320 1:320 0.783 (a)
8227 1:40 1:20 1:320 1:320 0.484
8228 1:80 1:40 1:640 1:640 0.378
8229 <1:20 1:20 1:640 1:640 0.311
8230 <1:20 1:20 1:320 1:320 0.694
8231 1:40 1:20 1:640 1:640 0.511
8233 1:40 1:20 1:320 1:320 0.345
8234 1:20 1:20 1:640 1:640 0.418
8235 1:40 1:40 1:320 1:320 0.658
(a) Optical density value ([greater than or equal to]
0.200 is positive). HI = hemagglutination inhibition.
Acknowledgments We thank Tracy McNamara for providing the 385-99 virus strain, D.J. Gubler for supplying the 6B6C-1 anti-Flavivirus monoclonal antibody, and Dora Salinas Salinas, city, United States Salinas (səlē`nəs), city (1990 pop. 108,777), seat of Monterey co., W Calif.; inc. 1874. It is the shipping and processing center of a fertile valley famous for its grain and lettuce. for help in preparing the manuscript. This work was supported by grants AI-10984 and AI-39800 from the National Institutes of Health. References (1.) Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. . Update: West Nile-like viral encephalitis--New York, 1999. MMWR MMWR Morbidity & Mortality Weekly Report Epidemiology A news bulletin published by the CDC, which provides epidemiologic data–eg, statistics on the incidence of AIDS, rabies, rubella, STDs and other communicable diseases, causes of mortality–eg, Morb Mortal Wkly Rep 1999;48:890-2. (2.) Centers for Disease Control and Prevention. Weekly update: West Nile virus activity-United States, November 14-20, 2001. MMWR Morb Mortal Wkly Rep 2001;50:1061-3. (3.) Hayes CG. West Nile fever West Nile fever West Nile meningoencephalitis Infectious disease An acute, mosquito-borne flaviviral infection endemic–rarely, epidemic–in the Near East, Africa, former Soviet Union, India Clinical After a 3-6 day incubation, children present with a . In: Monath TP, editor. The arboviruses arboviruses (ar´bōvī´r n. : epidemiology and ecology. Vol 5. Boca Raton (FL): CRC (Cyclical Redundancy Checking) An error checking technique used to ensure the accuracy of transmitting digital data. The transmitted messages are divided into predetermined lengths which, used as dividends, are divided by a fixed divisor. Press; 1989. p. 60-82. (4.) Hubalek Z, Halouzka J. West Nile fever: a reemerging mosquito-borne viral disease in Europe. Emerg Infect Dis 1999;5:643-50. (5.) Sampson BA, Ambrosi C, Chariot A, Reiber K, Veress JF, Armbrustmacher V. The pathology of human West Nile virus infection. Hum Pathol 2000;31:527-31. (6.) Asnis DS, Conetta R, Teixeira AA, Waldman G, Sampson BA. The West Nile virus outbreak of 1999 in New York: the Flushing Hospital experience. Clin Infect Dis 2000;30:413-8. (7.) Tsai TF, Popovici F, Cernescu C, Campbell GL, Nedelcu NI. West Nile encephalitis epidemic in southeastern Romania. Lancet 1998;352:767-71. (8.) Komar N. West Nile encephalitis. Rev Sci Tech 2000;19:166-76. (9.) Platonov AE, Shipulin GA, Shipulina OY, Tyutyunnik EN, Frolochkina TI, Lanciotti RS, et al. Outbreak of West Nile virus infection, Volgograd Region, Russia, 1999. Emerg Infect Dis 2001;7:128-32. (10.) Heinz FX, Collett MS, Purcell RH, Gould EA, Howard CR, Houghton M, et al. Family Flaviviridae. In: van Regenmortel MHV MHV mouse hepatitis virus. , Fauquet CM, Bishop DHL DHL abbr. 1. Doctor of Hebrew Letters 2. Doctor of Hebrew Literature , Carstens EB, Estes MK, Lemon SM, et al., editors. Virus taxonomy: classification and nomenclature of viruses. San Diego: Academic Press; 2000. p. 859-78. (11.) Monath TP, Heinz FX. Flaviviruses. In: Fields BN, Knipe DM, Howley PM, Chanock RM, Melnick JL, Monath TP, et al., editors. Fields virology virology, study of viruses and their role in disease. Many viruses, such as animal RNA viruses and viruses that infect bacteria, or bacteriophages, have become useful laboratory tools in genetic studies and in work on the cellular metabolic control of gene expression . 3rd ed. Vol 1. Philadelphia: Lippincott-Raven; 1996. p. 961-1034. (12.) Theiler M, Downs WG. The arthropod-borne viruses of vertebrates. New Haven: Yale University Press; 1973. (13.) Casals J. The arthropod-borne group of animal viruses. Trans NY Acad Sci 1957;19:219-35. (14.) Calisher CH, Karabatsos N, Dalrymple JM, Shope RE, Porterfield JS, Westaway EG, et al. Antigenic relationships between flaviviruses as determined by cross-neutralization tests with polyclonal polyclonal /poly·clo·nal/ (-klon´'l) 1. derived from different cells. 2. pertaining to several clones. polyclonal derived from different cells; pertaining to several clones. antisera. J Gen Virol 1989;70:37-43. (15.) Halstead SB. Antibody, macrophages Macrophages White blood cells whose job is to destroy invading microorganisms. Listeria monocytogenes avoids being killed and can multiply within the macrophage. , dengue virus infection, shock and hemorrhage: a pathogenetic cascade. Rev Infect Dis 1989;11(Suppl 44):S830-9. (16.) Kurane I, Ennis FA. Immunopathogenesis of dengue virus infections. In: Gubler DJ, Kuno G, editors. Dengue and dengue hemorrhagic fever. New York: CAB international; 1997. p. 273-90. (17.) Hammon WMcD, Sather GE. Immunity of hamsters to West Nile and Murray Valley viruses following immunization with St. Louis and Japanese B. Proc Soc Exp Biol Med 1956;91:521-4. (18.) Goverdhan MK, Kulkarni AB, Gupta AK, Tupe CD, Rodrigues JJ. Two-way cross-protection between West Nile and Japanese encephalitis viruses in bonnet macaques. Acta Virol 1992;36:277-83. (19.) Ilkal MA, Prasanna Y, Jacob PG, Geevarchese G, Banerjee K. Experimental studies on the susceptibility of domestic pigs to West Nile virus followed by Japanese encephalitis virus infection and vice versa VICE VERSA. On the contrary; on opposite sides. . Acta Virol 1994;38:157-61. (20.) Price WH, Thind IS. Protection against West Nile virus induced by a previous injection with dengue virus. Am J Epidemiol 1971;94:596-607. (21.) Hubalek Z. European experience with the West Nile virus ecology and epidemiology: could it be relevant for the New World? Viral Immunol 2000;13:415-26. (22.) Xiao S-Y, Guzman H, Zhang H, Travassos da Rosa APA (All Points Addressable) Refers to an array (bitmapped screen, matrix, etc.) in which all bits or cells can be individually manipulated. APA - Application Portability Architecture , Tesh RB. West Nile virus infection in the golden hamster (Mesocricetus auratus): a model for West Nile encephalitis. Emerg Infect Dis 2001 ;7:714-21. (23.) Steele KE, Linn MJ, Schoepp RJ, Komar N, Geisbert TW, Manduca RM, et al. Pathology of fatal West Nile virus infections in native and exotic birds during the 1999 outbreak in New York City, New York. Vet Pathol 2000;37:208-24. (24.) Chen BQ, Wang IM. Studies on attenuated Japanese B encephalitis virus Japanese B encephalitis virus n. A mosquito-borne virus of the genus Flavivirus capable of causing febrile response and sometimes encephalitis. vaccine. I. Method for obtaining the attenuated 2-8 strain and its biological characteristics. Acta Microbiol Sinica 1974;14:176-84. (25.) Han GS, Chen BQ, Huang CH. Studies on attenuated Japanese B encephalitis virus vaccine. II. Safety, epidemiological and serological serological pertaining to or emanating from serology. serological test one involving examination of blood serum usually for antibody. evaluation of attenuated 2-8 strain vaccine after immunization of horses. Acta Microbiol Sinica 1974; 14:185-90. (26.) Monath TB. Yellow fever yellow fever, acute infectious disease endemic in tropical Africa and many areas of South America. Epidemics have extended into subtropical and temperate regions during warm seasons. . In: Plotkin SA, Orenstein WA, editors. Vaccines. 3rd ed. Philadelphia: WB Saunders Company; 1999. p. 815-79. (27.) Monath TP, Cropp CV, Bowen GS, Kemp GE, Mitchell CJ, Gardner JJ. Variation in virulence for mice and rhesus monkeys among St. Louis encephalitis virus strains of different origin. Am J Trop Med Hyg 1980;29:948-62. (28.) Igarashi A. Isolation of a Singh's Aedes albopictus cell clone sensitive to dengue and chikungunya
(29.) Tesh RB. A method for the isolation of dengue viruses, using mosquito cell cultures. Am J Trop Med Hyg 1979;28:1053-9. (30.) Tesh RB, Guzman H, Travassos da Rosa APA, Vasconcelos PFC PFC abbr. private first class Noun 1. PFC - a powerful greenhouse gas emitted during the production of aluminum perfluorocarbon , Dias LB, Bunnell JE, et al. Experimental yellow fever virus infection in the golden hamster (Mesocricetus auratus). 1. Virologic, biochemical and immunologic studies. J Infect Dis 2001; 183:1431-6. (31.) Reed LJ, Muench H. A simple method of estimating fifty percent endpoints. Am J Hyg 1938;27:493-7. (32.) Smithburn KC, Hughes T, Burke A, Paul J. A neurotropic neurotropic pertaining to or emanating from neurotrophy, e.g. neurotropic osteopathy. virus isolated from the blood of a native of Uganda. Am J Trop Med Hyg 1940;20:47192. (33.) Beaty BJ, Calisher CH, Shope RE. Arboviruses. In: Lennette EH, Lennette DA, Lennette ET, editors. Diagnostic procedures for viral, rickettsial rickettsial /rick·ett·si·al/ (ri-ket´se-al) pertaining to or caused by rickettsiae. rick·ett·si·al adj. Relating to, or caused by a member of the genus Rickettsia. and chlamydial chlamydial pertaining to members of the family Chlamydiaceae. chlamydial abortion abortion in cows, ewes, sows and goat does caused by Chlamydophila abortus and C. pecorum. See enzootic abortion of ewes. infections. 7th ed. Washington: American Public Health Association The American Public Health Association (APHA) is Washington, D.C.-based professional organization for public health professionals in the United States. Founded in 1872 by Dr. Stephen Smith, APHA has more than 30,000 members worldwide. ; 1995. p. 189-212. (34.) Monath TPC (Transaction Processing Performance Council, San Francisco, CA, www.tpc.org) An organization devoted to benchmarking transaction processing systems. In order to derive the number of transactions that can be processed in a given time frame, TPC benchmarks measure the total performance of . Neutralizing antibody neu·tral·iz·ing antibody n. An antibody that reacts with an infectious agent, usually a virus, and destroys or inhibits its infectiveness and virulence. responses in the major immunoglobulin classes to yellow fever 17D vaccination of humans. Am J Epidemiol 1971;93:122-9. (35.) Tsai TF, Chang G-JJ, Yu YX. Japanese encephalitis vaccines. In: Plotkin SA, Orenstein WA, editors. Vaccines. 3rd ed. Philadelphia: WB Saunders Company; 1999. p. 672-710. (36.) Ni H, Watowich SJ, Barrett ADT (Asynchronous Data Transfer) A transmission technique used in ISDN PBXs that dynamically allocates bandwidth. See also abstract data type. ADT - abstract data type . Molecular basis of attenuation Loss of signal power in a transmission. Attenuation The reduction in level of a transmitted quantity as a function of a parameter, usually distance. It is applied mainly to acoustic or electromagnetic waves and is expressed as the ratio of power densities. and virulence of Japanese encephalitis virus. In: Saluzzo JF, Dodet B, editors. Factors in the emergence of arbovirus arbovirus Any of a large group of viruses that develop in arthropods (chiefly mosquitoes and ticks). The name derives from “arthropod-borne virus.” The spheroidal virus particle is encased in a fatty membrane and contains RNA; it causes no apparent harm to the diseases. Paris: Elsevier 1997; p. 203-11. (37.) Chen BQ, Beaty BJ. Japanese encephalitis vaccine (2-8 strain) and parent (SA 14 strain) viruses in Culex tritaeniorhynchus mosquitoes. Am J Trop Med Hyg 1982;31:403-7. (38.) Arroyo J, Miller CA, Catalan J, Monath TP. Yellow fever vector live-virus vaccines: West Nile virus vaccine development. Trends in Molecular Medicine 2001 ;7:350-4. (39.) Davis BS, Chang G-JJ, Cropp B, Roehrig JT, Martin DA, Mitchell C J, et al. West Nile virus recombinant DNA vaccine protects mouse and horse from virus challenge and expresses in vitro a noninfectious recombinant antigen that can be used in enzyme-linked immunosorbent assays. J Virol 2001;75:4040-7. (40.) Work TH. On the Japanese B-West Nile virus complex: an arbovirus problem on six continents. Am J Trop Med Hyg 1971 ;20:169-86. (41.) Karabatsos N, editor. International catalogue of arboviruses including certain other viruses of vertebrates. 3rd ed. San Antonio: American Society of Tropical Medicine and Hygiene; 1985. (42.) Centers for Disease Control and Prevention. Epidemic/epizootic West Nile virus in the United States: revised guidelines for surveillance, prevention, and control. Fort Collins: U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979 Health and Human Services, HHS ; April 2001. (43.) Monath TP. Epidemiology. In: Monath TP, editor. St. Louis encephalitis. Washington: American Public Health Association; 1980. p. 239-312. (44.) Spence LP. St. Louis encephalitis in tropical America. In: Monath TP, editor. St. Louis encephalitis. Washington: American Public Health Association; 1980. p. 451-72. Robert B. Tesh, * Amelia P.A. Travassos da Rosa, * Hilda Guzman, * Tais P. Araujo, * and Shu-Yuan Xiao * * University of Texas Medical Branch, Galveston, Texas, USA Dr. Tesh is Professor of Pathology and a member of the Center for Tropical Diseases at the University of Texas Medical Branch. His research interests focus on the epidemiology and pathology of arthropod-borne and rodent-associated viral diseases. Address for correspondence: Robert B. Tesh, Department of Pathology, University of Texas Medical Branch, 301 University Boulevard, Galveston, Texas 77555-0609, USA; fax: 409-747-2429; e-mail: rtesh@utmb.edu |
|
||||||||||||||||||||

Printer friendly
Cite/link
Email
Feedback
Reader Opinion