On completion of this workshop, the students should be able to understand/answer the

following:
The pathogenesis of a number of the following viral infections; HIV, hepatitis and
influenza
The public health significance of pre-mentioned viral infections
The antigenic variation displayed by viruses


In order to prepare for the workshop, you should revise the lecture notes, the recommended
textbook AND read following references (all freely available from the web). These articles
provided are the starting point for your understanding of the subject.

Traditional and new influenza vaccines.
Wong SS, Webby RJ.
Clin Microbiol Rev. 2013 Jul;26(3):476-92. Review

HIV infection: epidemiology, pathogenesis, treatment, and prevention.
Maartens G, Celum C, Lewin SR.
Lancet. 2014 Jul 19;384(9939):258-71.

New challenges in viral hepatitis.
Thomas D, Zoulim F.
Gut. 2012 May;61 Suppl 1:i1-5.

Research the following topics, answer the questions and come to the Workshop prepared to
discuss

3012BPS Infectious Diseases 2014
Workshop 2
Viral Infections
Section A: HIV

1. Discuss why HIV is so good at persisting in the body.
- Structure contain glycoproteins- enable HIV virus to recognise surface proteins of special
immune cells and to enter the cell. Bind to- CD4 is the main receptor (found on T cells).
Bind co-receptors CCR5 and CXCR4. Sequence variation in GP results in cell tropism
(growth). Virus enters cell through receptor mediated Endocytosis. RNA converted to DNA
through RV transcriptase, then replicated. DNA enters nucleus and binds with host DNA.
mRNA is created (carries instructions for making new viral proteins and leaves nucleus. Uses
host cell enzymes to make new viruses. New virions exit the cell through exocytosis to infect
other cells (cell isnt destroyed). High genetic variability. High error rate in RT. Rapid
reproduction. Large population within host. Antigenic variation allows virus to avoid
immune recognition promoting persistence. Problem for vaccine development.

2. How many types of HIV are there? How are they different?
- Two subtypes:
HIV-1: related to chimpanzees and gorillas. Most common infection
HIV-2: not widely seen outside of Africa, most closely related to a monkey virus, less
severe.
When clinical progression occurs, both diseases demonstrate very similar pathological processes, although progression in HIV-2 occurs at
higher CD4 counts. Plasma viral loads are consistently lower in HIV-2, as are average levels of immune activation. Significant differences
exist between the two infections in all components of the immune system. For example, cellular responses to HIV-2 tend to be more
polyfunctional and produce more IL-2; humoral responses appear broader with lower magnitude intratype neutralisation responses; innate
responses appear more robust, possibly through differential effects of tripartite motif protein isoform 5 alpha. Overall, the immune response
to HIV-2 appears more protective against disease progression suggesting that pivotal immune factors limit viral pathology. If such immune
responses could be replicated or induced in HIV-1 infected patients, they might extend survival and reduce requirements for antiretroviral
therapy.

3. Which immune cells are the target of HIV chronic infection and what is the main
receptor they use for entry? Discuss why persistent infection of these cells is
important for the progression of HIV into AIDS.
- T (helper) cells, CD4 is the main receptor.
HIV continues to reproduce, CD4 count gradually declines from its normal value of 500-
1200. Once CD4 count drops below 500, HIV infected person at risk for opportunistic
infections. The following diseases are predictive of the progression to AIDS: persistent
herpes-zoster infection (shingles), oral candidiasis (thrush), oral hairy leukoplakia, Kaposis
sarcoma (KS).

4. Discuss the challenges that must be faced in developing a vaccine against HIV.
- An HIV vaccine cannot consist of attenuated, actively replicating (live) HIV, due to possible reactivation.
- Killed whole virus (like the polio vaccine) might also be dangerous because one could not be sure one has killed all viral
particles. A killed whole virus vaccine had also worked poorly in animal studies.
- There were successful vaccines that use subunits of viruses such as individual proteins: an example was the hepatitis B
vaccine. However medical science was less experienced with them.
- We do not know with certainty which immune response will provide protection; this is a major problem. Pre-efficacy
studies of vaccines in monkeys and humans used correlates of immunogenicity such as CD8 cell response, but we do not
know whether this immune response is in fact a correlate of efficacy.
- We have never before attempted to develop a vaccine against a retrovirus like HIV. Retroviruses, by integrating
their genome into ours, are able to hide completely from immune surveillance within quiescent lymphocytes. This
means that any vaccine has a small window of opportunity in which to prevent infection and would have to be
extremely effective, repelling all attempts by HIV to attach to and infect host cells.
- HIV is capable of developing immunity to the CD8 cellular response.

5. Does HIV directly kill the infected patient? If not what does? Discuss.
- If CD4 count drops below 50: Mycobacterium avium, Cytomegalovirus, infections,
lymphoma, dementia. Most deaths occur with CD4 counts below 50. As disease progresses
antibody levels decrease. Decrease in CD4 cells due to virus budding from cells,
fusion of uninfected cells with virally infected cells and apoptosis. B cells have decreased
response to antigens possibly due to blockage of T cell/B cell interaction by binding of
viral proteins to CD4 site. CD8 cells initially increase and may remain elevated. As HIV
infection progresses, CD4 T cells drop resulting in immunosuppression and
susceptibility to opportunistic infections -> Death arises from immuno-incompetence
(not being able to mount a sufficient immune response to foreign antigen).


Section B: Influenza

1. Which two glycoproteins used for viral cell entry, important in the immune response,
are found on the outer envelope of the influenza virus?
-Hemagglutinin (HA) 17 types, highly variable. Neutralising antibody against it is
important for immunity.
-Neuramidase (N) 9 types, also important in immune recognition.


2. Which of the three influenza types infects the most types of animals? Which animals
are of most concern to humans and why.
- Influenza A: Birds, Pigs and Horses. Most avian influenza viruses do not infect humans;
however some, such as A(H5N1) and A(H7N9), have caused serious infections in people.
Swine flue outbreak, from dead poultry not cooked chicken- also pigs. Hendra virus- Bat
to Horse to Human.

3. Discuss how antigenic shift results in influenza pandemics.
New antigenic strains of influenza A emerge via 2 mechanisms.
- Shift: arising through genetic recombination (reassortment).
- Drift: random point mutations in RNA during transcription
Mixed infection allows exchange of viral segments coding for either the
H or N glycoproteins (possible animal origin)
New types emerge every 10-15 years allowing escape from herd immunity

*Antigenic Shift results in the appearance of virus with complete change in antigenic
properties. *No immunological experience. *HA or NA has most impact in influenza

4. Why is it important to monitor the prevalent influenza strains circulating from a
vaccine perspective?
- Refer to above answer.


5. Discuss the disadvantages of this current influenza trivalent vaccine and its
production process.
- Strains are selected. Grown in eggs and the. Virus is harvested. Virus is inactivated with
formalin, HA and NA are released by lysing lipid envelope. Strains are combined and
packaged together. One egg = one dose of vaccine. Dependent on growth and yield of
each virus strain.
Section C: Hepatitis

1. Discuss from a public health perspective why HCV is a concern.
Hence, the virus establishes as a chronic, persistent infection in ~70% of those infected
(cf. 10% hepatitis B infections). Hepatitis is one of the most prevalent and serious infectious
conditions in the world, but many people - including health policy makers - remain unaware of its
staggering toll on global health. About 1 million deaths per year are attributed to viral hepatitis
infections. Together, hepatitis B virus (HBV) and hepatitis C (HCV) are the leading cause of liver
cancer in the world, accounting for 78 percent of cases.

2. Give some examples of the important risk factors in developing countries for HCV
infection.
- Hep A/B- the majority of cases are among men who have sex with other men, persons who
use illegal drugs, and international travellers. Hep B- neonatal, needles, breastfeeding,
open wounds, Hep C- Factors Promoting Progression or Severity, Increased alcohol intake,
Age > 40 years at time of infection, HIV co-infection, Other co-infections (eg. HBV).


3. Discuss some of the conditions that result in increased susceptibility to more severe
HCV disease?
- Hep C: Factors Promoting Progression or Severity, Increased alcohol intake, Age > 40
years at time of infection, HIV co-infection, Other co-infections (eg. HBV). HCV from
Blood transfusion has decreased 95% from 1989.


4. What two antiviral treatments are taken together for HCV? When is antiviral
treatment considered successful?
- Interferon-alpha and the retroviral Ribavirin (Virazole). Persistent elevation of ALT
(alanine aminotransferase, a liver enzyme in the blood)- Therefore decreased? High levels
of HCV RNA in the blood Evidence of early fibrosis (scarring) or moderate inflammation
and injury of liver cells on liver biopsy- Therefore decreased?




5. Discuss some of the challenges surrounding HBV?
- Hepatitis B vaccine is available (3 doses) but Cannot be grown in tissue culture.
- Many people living with chronic hepatitis B in Australia have not yet been diagnosed.
- HBV Replicates prolifically. Immune response helps control but also causes damage. Leads
to the presence of excess HBsAg in the circulation (acute disease). HBsAg persists in
chronic disease. HBsAg used in Hepatitis B vaccine.