Hepatitis B-Virus and Cancer of the Liver
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Transcript: English(auto-generated)
00:10
Count Bernadotte, distinguished guests, students, colleagues, ladies and gentlemen. Very little is known about the primary prevention of cancer, with the exception of the very
00:25
important link between cigarette smoking and cancer of the lung. According to the present understanding, the cessation of smoking could eventually result in the near elimination of cancer of the lung, which is said to represent up to about 40%
00:44
of cancers in some communities. To my knowledge, there is not at present any known association of a pollutant with a cancer which occurs in very high frequency, although for theoretical reasons, it is very
01:01
well worthwhile continuing to investigate this possibility. I'd like today to discuss the association between hepatitis B and primary cancer of the liver. If the present findings, which I'll report on, are sustained on this possible ideological
01:23
connection between hepatitis B and cancer of the liver, then it may be possible in due course to prevent a cancer which is probably, again, one of the very common cancers of the world. The work which I'll be reporting on, some of which has been done in our laboratory,
01:45
was done over the course of the last 10 or more years in collaboration with my colleagues Dr. London, Sutnick, Millman, Lustbader, Werner, Drew, and others. In a paper presented in 1974, we pointed out that for many years, workers in Africa
02:06
and elsewhere had suspected that hepatitis infection might predispose or cause the subsequent development of primary cancer of the liver. When these suggestions were made, it was not possible to test the hypothesis since
02:22
methods for the detection of the virus in occult and hidden infections were not available, and it was known that many patients became infected without any clinical evidence of the disease. With the discovery of Australia antigen and its subsequent identification with the surface
02:43
antigen of hepatitis B virus, and particularly with the development of the sensitive methods, for example, radioimmunoassay or in particular radioimmunoassay, it became possible to look at this question directly. Since the publication of this paper in 1974, which included a discussion of the information
03:05
that was then available, a large body of data bearing on this subject has become available. Today, I'd like to present the evidence which supports the hypothesis that in many parts of the world, chronic infection with hepatitis B virus is a necessary condition
03:25
for the subsequent development of primary cancer of the liver. If this evidence is convincing, then it follows that planning for public health measures for prevention of chronic infection should be investigated. And this raises the problems that are associated with all extensive public health projects,
03:46
namely anything that you do in order to prevent disease has other consequences. And as scientists, we have a responsibility to try to learn as much as we possibly can about these possible consequences in order to deal with them most effectively if the
04:04
measures, the control measures are undertaken. Now, I propose to present this evidence in a kind of using the technique of parallel evidence that is showing you several bodies of data, all of which presumably would converge
04:28
on this hypothesis that I've stated. This, incidentally, I've learned recently was a technique used very much by Darwin in building up his convincing evidence relating to relativity and in many ways,
04:44
an important introduction which he made into scientific process. Before presenting this evidence, I'd like to quickly summarize the information available on the nature of the hepatitis B virus. In the first slide is a diagram of the Dane particle, which is thought to be the whole
05:13
particle of the hepatitis B virus. It consists of an inner core which contains within it a DNA and in addition, a specific
05:27
DNA polymerase. There is a specific antigen associated with the core, hepatitis B core antigen. Surrounding that is the surface antigen, which also has a specificity, hepatitis B
05:46
surface antigen. There, as far as we know, is no cross-reactivity between the core antigen and the surface antigen. The coexistence of the DNA and the DNA polymerase in the same location apparently is an unusual
06:02
feature of viruses of this kind. Antibodies to the hepatitis B surface antigen can be identified in peripheral blood. These appear to be highly protective. People who develop titers of antibody to the surface antigen are unlikely to become reinfected with the hepatitis B virus.
06:22
Antibodies to the core antigen may also be detected in the peripheral blood and is nearly always found when the individual is a carrier of the hepatitis B virus. Antibodies to the core does not protect against subsequent infection as far as is known. There are different determinants on the surface of the hepatitis B surface antigen,
06:46
and they have a rather odd characteristic similar to serum protein polymorphisms. All viruses have a common determinant A. In addition, there are allelic determinants D and Y.
07:01
That is, a virus can be either D or Y, rarely both, rarely neither. And there is also W and R. And again, the virus can be either W or R, rarely both, and rarely neither. There are highly specific geographic localizations for these specificities, and they don't travel
07:23
well. That is, you don't find rapid spread of particular geographically associated viruses from one location to the next the way you do with, let's say, influenza virus, which can start in Hong Kong and within a period of months or a half year or so spread throughout
07:41
the world. So the hepatitis B virus specificities stay close to home. Next to Dia Bitta. This is a projection of an electron micrograph showing the three forms in the three sort of flavors that hepatitis B particles come in.
08:02
The large particle here is the whole DNA virus, the so-called Dane particle named after the British investigator who first saw this. These smaller particles consist entirely of the hepatitis B surface antigen and apparently
08:25
do not contain any nucleic acid. They are found in very large quantities in the peripheral blood and are essentially always identified in the peripheral blood of people who are carriers of the hepatitis B virus.
08:41
By carriers, we mean that the person is infected with the virus, the virus or the surface antigen is detectable in the peripheral blood, usually in extremely large amounts, but the individual himself does not have any apparent signs of illness. There are in addition these elongated particles also made up, as far as we know, entirely
09:04
of hepatitis B surface antigen and there the function of these rather strange particles are not known, although there is some intimation, they may be a kind of a transitional phase, but very little is known about these. Now, later on, I'll talk about work on the vaccine.
09:24
The process of making the vaccine is an unusual one, different from the production of any other vaccine. In it, the surface antigen particles, which occur in very high frequency, are separated from the Dane particles and then they are treated in such a way to kill any whole
09:48
virus particles that may have been left in the preparation. Then the surface antigen produced in this manner from the peripheral blood of carriers is used as the vaccine.
10:01
Now, this vaccine has now been tested in animals. The initial study test in humans have now been done and planning for field trials is now in progress. So far, the results are very encouraging. If this vaccine proves to be effective and safe, then it may have a very important role
10:25
in the prevention of infection with hepatitis B. And if what I'm about to tell you is true, it may have a role in the prevention of cancer of the liver. That is, it would represent a kind of a vaccine, which in the long run may have an effect on the development of cancer.
10:42
Next slide, please. There's a very unusual characteristic to the DNA associated with the Dane particle, the large virus particle. Most viruses have DNA, which is either double-stranded or single-stranded. The DNA of the Dane particle, of the hepatitis B virus, is sort of, again, has two forms.
11:07
It's both single-stranded in part and double-stranded in part. The length of the single-stranded section varies from literally from virus to virus and appears to be polymorphic for this characteristic.
11:23
Again, a rather unusual feature of a virus. The next slide, please. These photographs are taken by my colleague, Dr. Summers, at the Institute for Cancer Research in Philadelphia, and these were done with Dr. Kelly in Baltimore.
11:43
In order to demonstrate the single-strandedness, they used, in effect, a kind of a stain of protein removed from E. coli, which will adhere only to single-stranded sections of a DNA circle, but does not adhere to double-stranded areas.
12:05
This is a control virus which is totally double-stranded. These are hepatitis B viruses with the stain indicating that the single-stranded portion is different in the different viruses which are shown here.
12:24
So again, this is an unusual feature of the hepatitis B virus. The biological significance of this is not clear, but I guess you can say intuitively that if there are advantages to being double-stranded and there are also advantages to being single-stranded, then this has both advantages and both sets of advantages and both sets of disadvantages.
12:45
However, it has prepared it to cope very well with its environment, since the virus has developed many kinds of vectors and can be transmitted in a very large number of ways. This will come up during the course of the discussion.
13:02
Next bit. In these following slides, I've listed these independent points, which I hope to make. So I'll follow a course which I was advised to do by Dr. Schultz of our institute, who
13:21
told me that when giving a scientific paper, the first thing you do is say what you're going to say, and then say it, and then say what you've said afterwards. In that way, there's a possibility that what you have to say will actually get across. So what I plan to do is to list the topics that I would like to discuss.
13:44
The first point is that there's a high prevalence of chronic carriers of hepatitis B virus in the areas of the world where primary hepatocellular carcinoma is common. In Northern Europe, the United States, the frequency of carriers is of the order of 0.1,
14:05
0.2, 0.3 percent, one or two or three out of a thousand. However, in many tropical regions of the world, in Southeast Asia and Oceania, in South Asia and Malaysia, the frequencies may reach up to 4, 5, 10, 15, and even 15 or
14:25
higher percentages of the population are carriers of the hepatitis B virus. That means that there are probably several hundred million carriers of hepatitis B virus in the world. It's in those regions where hepatitis B virus is common that primary hepatocellular
14:44
carcinoma is common. If in these regions one examines people who have primary hepatocellular carcinoma, then they have a higher frequency of carriers than appropriate controls from the same region. I'll show you the data on these items shortly.
15:01
The third point is that primary hepatocellular carcinoma usually arises in a liver which is already diseased with cirrhosis, chronic hepatitis of various kinds. The frequency of underlying cirrhosis or chronic hepatitis varies from place to place.
15:24
But where it's been studied very carefully indeed, it's very often the region of 70, 80, 90, or even 100 percent of the cases will have an underlying chronic liver disease. In these diseases, that is the chronic liver disease and the cirrhosis, there is also
15:41
a high prevalence of carriers of hepatitis B virus. That is the disease which in effect precedes cancer of the liver also has a high association with the presence of carriers of the hepatitis B virus. Next a bit. Now what I've told you, what I've mentioned so far are retrospective studies, are studies
16:02
taken at a point in time. There are now several prospective studies in progress to determine what happens if you look at people who have hepatitis B virus to see what happens to them in the future. Since these studies have just begun, the results are very early, but I'll tell you
16:21
about these to indicate the kinds of studies that are being undertaken. In one study in Japan, cirrhosis patients who had cancer, who had chronic liver disease and cirrhosis were compared depending on whether they had hepatitis B virus or did not. Those with hepatitis B virus were the ones who developed cancer.
16:43
A similar study, prospective study, was done in asymptomatic individuals who were chronic carriers of hepatitis B virus, and again, based on very small numbers, the much higher probability of the development of cancer in the liver was demonstrated in those. I'll show you these data shortly.
17:01
Seventh point, in several studies now, it's been shown that by histological techniques that liver tissue which contains primary hepatocellular carcinoma also contains evidence of infection with hepatitis B virus. That is, if hepatitis B virus were concerned with the development of cancer of the liver,
17:21
you would expect to find it in the liver, and you do find it in the liver. The eighth point is that the specific hepatitis B virus DNA has been isolated from the majority of livers with, with PHC that have been tested, and it's not found in controls. Again, that's what you would expect if the virus were involved in the illness.
17:45
A further point is that there is a family clustering of hepatitis B virus carriers and chronic liver disease, including primary hepatocellular carcinoma. And in particular, there's a very high frequency of carriers among the mothers of
18:01
people who get, who have primary hepatocellular carcinoma. And we'll get back to all these points now, or some of these points to show you some of the data. Next a bit. Now, there have been a very large number of studies demonstrating the third point that I told you,
18:20
namely that there's a, in areas where primary hepatocellular carcinoma is common and where carriers of hepatitis B virus are common, then in those areas, the frequency of hepatitis B virus is much more common in the people with the cancer than in what appeared to be appropriate controls.
18:42
These are illustrations from two of the studies that we've done in Africa, in West Africa. And these were done in conjunction with Professor Payette from University of Dakar and University of Paris, Drs. Larose, Samov, Barrois, Thoret, and Professor Sankely,
19:04
a large group of the French, American, and Senegalese co-workers. In the Mali study, the frequency of hepatitis B surface antigen was 47% as compared to
19:23
about 5% in controls. The frequency of antibody against the core, which is thought to be an indication of active infection, was 75% in the patients, 25% in controls. The frequency of antibody was actually rather less in the patients with hepatitis B virus,
19:44
with patients with cancer than in the controls. The overall infection rate was high in both groups, but higher in the patients with hepatitis B virus, patients with cancer, excuse me, pardon me. But again, the important point is that there's a much higher frequency of carriers
20:02
in the patients as compared to the controls. The data from Senegal are similar in the same direction and rather higher than in the Mali study. Now these studies, these two studies, are representative of about, let's say, 15 studies
20:23
of the same kind, and they're essentially all in the same direction. Next a bit. Now to deal with the point number four, I believe it was, in which I said that the patients who get primary hepatocellular carcinoma, it's superimposed on an underlying chronic
20:46
liver disease, including chronic active hepatitis, cirrhosis, here's PHC, and then controls. These were studies done in South Korea by Dr. Han Hae Won Han from Philadelphia Laboratory
21:03
and Professor Kim from the medical school in Seoul. In this study, they found that there's a very much higher frequency of hepatitis B surface antigen, 58.6%, than in the control groups, 2% and 6%, 3% and 6%.
21:25
Also of cirrhosis, a very high frequency of hepatitis B surface antigen, 93% compared to 6%, and again, a very high frequency of the surface antigen in patients with primary hepatocellular carcinoma than controls.
21:41
On the contrary, the frequency of antibody against the surface antigen, that is the protective antibody, is lower in the patients with these various diseases than in controls, and this again has been seen wherever this where it's been studied.
22:02
The suggestion being that the patients who go on to develop chronic liver disease and primary hepatocellular carcinoma have a rather different immune response when they're infected with the hepatitis B virus. They're more likely to become carriers and incidentally at the same time form antibody
22:21
against the core of the virus. That is, they're more likely to become carriers than they are to develop antibody against the surface antigen. Now, it's not quite appropriate to say that they're immune deficient since they're quite able to form antibody against the core. They're sort of immune specific, that is they're more likely to become carriers and
22:46
form antibody against the core than they are to form antibody against the surface antigen. So there's, again, they cannot be characterized as deficient, but rather as different from the individuals who don't go on to develop these chronic illnesses.
23:03
Next to Pitta. Now, this is an illustration of the prospective study that has been done in Japan, and this is illustrative of what is similar studies which are going on elsewhere in Asia and in Taiwan and People's Republic of China and in Seoul.
23:26
In this study, some 80 or so patients with cirrhosis were identified by the Japanese workers. They then found that 25 of these had hepatitis B surface antigen, 17 had antibody against
23:46
the surface antigen, and 43 were apparently uninfected. Now, if the hypothesis were correct, one would project that the people who had surface antigen would be more likely to develop primary hepatocellular carcinoma than the
24:04
people in the other two groups. The follow-up has now taken place for about three and a half years, and seven cases of primary hepatocellular carcinoma developed in this 80 or so people, incidentally an incredibly high-risk group, and also a very rapid development of cancer.
24:23
Six of them fell into the hepatitis B surface antigen group, that is the one predicted by the hypothesis, and one in the uninfected group. Again, this is close, even though the numbers are quite small, it corresponds very closely to the expectation generated by the hypothesis.
24:44
It also discloses an extraordinarily high-risk group for cancer of the liver, namely people with cirrhosis who are carriers of hepatitis B virus. Now I apologize for this slide, it contains more detail than is necessary so you can
25:03
forget about the material below the line. And I'll lead you by the hand through the other portions of the slide. This was a study done again in Japan on the national railway system, where regular
25:25
physical examinations are done on a very large number of employees. As part of this examination, they collected blood on some 18,195 individuals and tested them for the presence of hepatitis B surface antigen or other manifestations of infection
25:44
with hepatitis B virus. They found that 341 of these people were carriers of hepatitis B surface antigen, and these number were not. Now, they followed these people for a period of about half a year to three and a half years,
26:03
that is a relatively short time. Now again, these were asymptomatic individuals who were healthy coming in for a regular physical examination. Now again, the prediction from the hypothesis would be that the individuals who were carriers of hepatitis B virus, even though asymptomatic, were at a measurably higher risk of developing
26:24
PHC, primary hepatocellular carcinoma, than those normal individuals who were not carriers, who were not occult carriers. Three cases have developed in this relatively short time, and all of them fall in the category of individuals who were hepatitis B carriers.
26:42
Now all three of them, incidentally, were people who had relatively low SGPT elevations. They were slightly above normal, but not very high. Now, if this prospective study is sustained, it provides considerable support for the hypothesis
27:01
for which I've been accumulating this evidence. And as I said, such studies are now in progress elsewhere. Next to Bitta, Dr. Nayak and his colleagues in India did an extensive and comprehensive
27:22
study of liver taking from autopsies of people with various liver diseases, including primary hepatocellular carcinoma, cirrhosis, and in addition, people who died for reasons that were unconnected with liver disease.
27:43
There are various methods of detecting manifestations of hepatitis B virus in tissue. These include fluorescent techniques where fluorescent material is bound to specific antibody. That is, fluorescent material would be bound to antibody against surface antigen.
28:04
Fluorescent material could be bound to antibody against core antigen. In addition, you can see the particles, and they can be identified by the use of ferritin-labeled antibodies so that under the electron microscope, their actual location there can be shown.
28:23
Now using these various techniques, Dr. Nayak and his colleagues found the following. In the patients with primary hepatocellular carcinoma, 94% of them had evidence that hepatitis B surface antigen was present in the liver, which was infected, the liver
28:44
where there was cancer of the liver, 71% of the patients with cirrhosis, and 2% of controls. Hepatitis B core antigen was again found in high frequency in the primary hepatocellular carcinoma patients, in the cirrhosis patients, but not in the controls.
29:02
There was also some cases where both surface antigen and core antigen are found, and again in much higher frequency in the patients with cancer and those with cirrhosis, and again none in the controls. So again, the virus is where you would expect it to be if the virus is associated with
29:21
cancer of the liver. Now generally speaking, in these studies, the presence of the virus is shown not in the cancer cells themselves, that is the transformed cells, but in the cells immediately surrounding the transformed or the cancerous cells, and in many cases in the general,
29:44
in the liver tissue in general. There has so far been no evidence, according to my colleague Dr. Summers has investigated this and he has said that there's no evidence of incorporation of the DNA of the virus
30:00
into the DNA of the liver cells, or I believe nobody else has found any evidence for this. Occasionally you do find the virus actually within the cancer cells, but the general finding is that it's in the surrounding tissue. Next up, Peter. Now the specific DNA can be identified by traditional methods, and Dr. Summers has
30:31
used the hepatitis B virus DNA as a probe to look at the tissues taken from livers of people who have cancer of the liver.
30:41
He's found the DNA present in such a tissue, and it's not present in controls. Within the group of PHC patients, he looked specifically at individuals who had surface antigen and had primary hepatic cellular carcinoma, and those few individuals with
31:04
cancer of the liver who had antibody against the surface antigen. The DNA, specific DNA, was identified in 10 of the 11 cases where there were carriers, but in only one of the four where the people had antibody.
31:25
The significance of having cancer of the liver with antibody against surface antigen is unclear, but as you may recall from the previous studies, that represents a smaller percentage than the individuals who have cancer and are carriers of the virus.
31:43
Next up, Peter. Now our work started out as a consequence of a genetic investigation. We were studying polymorphisms in blood, and as a consequence, a lot of the focus of our work has been on families.
32:00
In human genetics, you study families. So you get very kind of family oriented. One of the investigations which we did rather early on was to study the families of people with who are carriers of hepatitis B virus and found that there was a very much higher frequency of carriers among the offspring when the mother was a carrier of the hepatitis
32:25
virus than when the father was the carrier of the hepatitis virus. This was consistent with the notion that the mother could transmit the hepatitis B virus to her children if she were a carrier. Subsequently, workers in many areas, particularly in Asia, have found that a very high frequency
32:47
of children born to mothers who were carriers will become carriers within a few weeks or months, and some 50% of them will be carriers. They may not become carriers directly at the time of birth, but the carrier state may
33:01
develop subsequently. In some cases, the hepatitis B virus is found in the cord blood. Based on this and now a large number of observations, it appears that hepatitis B virus may be transmitted from mother to child during an effect any time of their association with
33:25
each other. For example, it conceivably could occur even before conception, that is if the egg became infected. It could occur during conception by passage through the placenta. It's very likely that it could occur at the moment of birth.
33:42
The moment of birth is a very dangerous time in one's life, a very exciting time, and also very dangerous. In particular, there's a breakdown of the barrier between the circulations of the mother and child, and it's possible for quite large things to get across both ways.
34:05
On the basis of what we know about incubation period, it appears that infection of the child by the mother may occur at that time. And we've heard from Dr. Timburgen about the possibilities of damage to individuals
34:21
in this very crucial period in our lives. Now, it also appears that transmission from the mothers to the children may occur during the early period of their close intimacy. In all cultures, mothers and children are very close to each other during their first months and years, much closer than they are later on.
34:42
And it's probable that transmission could occur then. As a consequence of the importance of maternal transmission, or parental effect, I think we'd say, we've devoted a lot of time to studying mother-child interactions, or
35:00
as a matter of fact, family interactions, using these ethological techniques that we've heard about this week. And my student of mine, Ms. Dickey, has made observations in the New Hebrides on newborn children and their mothers, making the behavioral observations, the nature of which we've heard
35:22
about, that have been done so much on animals, to see how mothers and children interact with each other in relation to behavior patterns that might lead to the transmission of a virus from one to the other, primarily from the mother to the child. And we're hoping to learn something about this, since it may have an important bearing
35:42
on control techniques. In the studies in Senegal, we examined the mothers of patients with primary hepatocellular carcinoma and compared them to the mothers of controls. The controls were mostly people who were asymptomatic carriers of hepatitis B virus.
36:02
We found that there was a much higher frequency of hepatitis B surface antigen in the mothers of the patients than in the mothers of the controls. We also found that there was a much higher, there was a much lower frequency of antibody against the surface antigen in the fathers of the patients than in the fathers of the
36:25
controls. And this study has not been repeated. If it is supported, this suggests that there's a parental effect, that there may be transmission from the mother to the child, and the nature of the response that the child has
36:42
will be conditioned by some characteristic that they either inherit or acquire from their father. Now I should say in discussing this, this raises some very important psychological problems. If in fact there is maternal transmission, which in due course may lead to serious illness
37:04
in children, this could represent a very difficult psychological burden for parents. When children are sick, parents are very concerned, of course. And if there's any implication that they somehow had a role in it, then this could have a very
37:24
serious effect on their psyche and their relations with each other and with the children, particularly conceivably between parents. Obviously there's no guilt wrapped up in a situation of this kind, but I think it's very important for us to try to understand this process as well as we possibly can in
37:46
order to, first of all, deal with preventive measures if that becomes possible, and certainly so that we can understand it sufficiently to deal with the questions raised by parents. It's been my experience that ethical issues usually require more information.
38:04
If you have an ethical problem, what you usually need is more knowledge and less argument, I think, but more knowledge in order to be able to deal with it. And in many cases, the ethical question, it doesn't exactly go away, but it changes into something else, which you then have to deal with also.
38:22
But at any rate, you're in another place. Next slide is a diagram of what we think, a very rough diagram of what we think may be happening in the transmission, in the development of primary hepatocellular carcinoma.
38:42
We think that children may become infected early in life, and it's possible that the infection may occur from the mother, probably with some effect, some effect of the father in developing the carrier state. Some of these then will go on to become chronic carriers of hepatitis B virus.
39:01
Some will go off in another direction and will not become carriers of hepatitis B virus. Some of those who are chronic carriers of hepatitis B virus will go on to the development of chronic hepatitis. Some of them will go on to no effect, that is, they won't know they've ever been infected unless they're tested. Some of those with chronic hepatitis will go on to the development of post-nechronic
39:23
cirrhosis, which in itself is a very serious disease and is life-shortening. Some of those with post-nechronic cirrhosis will go on to die of that. Others will go on to the development of primary hepatocellular carcinoma. Now, it's patent, it's obvious, it's clear, that there must be other factors involved
39:43
in the development in following this unfortunate course. About 10% of the people in Senegal, let's say, are carriers of hepatitis B virus, whereas only even in high-frequency countries, for PHC, the frequency is 100 per 100,000, let's
40:02
say the order of 50 per 100,000. So obviously, there are other factors which are involved in the development of the cancer. Aplitoxins have been implicated. Nutritional factors have been suggested. Other edible materials, toxins, have also been suggested as necessary for the development
40:25
of PHC, of primary hepatocellular carcinoma. Could we have the lights, please? The Licht-and-Bitte. We're trying to determine what the other factors involved in the development of the
40:44
cancer is. But it's a very interesting characteristic of preventative medicine, and as a matter of fact, an extremely hopeful one, that you don't have to know everything in order to prevent disease.
41:00
Now, I don't want to sound like a Philistine, that is to say that I'm not advocating not learning things. Quite the contrary. The more you know, the more effective control methods could be. But medicine is a very emergent business. You're dealing with lives and deaths, or deaths in this case, and if some method of
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prevention is known and it can be executed, then there's a kind of an obligation to use it as soon as possible, but at the same time exerting all the precautions not to do as little damage to the general population and to the people who were subjected to these
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preventive methods. But there is an obligation. You can't sort of not do anything, because that's the equivalent of doing something. Well, I want to remind you that in preventive medicine, it has been possible to go ahead with rather fragmentary knowledge, and a classic example is that of Snow in the cholera epidemic
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in London, who found that people who were drinking from a particular well were more likely to get cholera than those who weren't drinking from that well. People who worked at a brewery in the same region and drank their own beer or had water from another source. This, he therefore decided that you shouldn't drink from that well, and he removed the
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handle of the well as a preventative measure, and now this was done before any knowledge of the germ theory of disease and well before the discovery of the agent that causes cholera. Nevertheless, it was effective in preventing the spread, further spread of this illness
42:43
and it died out in that region. So again, I want to emphasize that we do have an obligation to learn as much as we can about a problem, obviously, particularly so that it can be done in the most effective and least harmful way, but at the same time, I think anyone who has seen these
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people dying, cancer of the liver is a terrible disease, and there's no treatment for it. There's very little that can be done for these people, and a kind of urgency develops. Now if this vaccine that I mentioned is effective, and as we learn more about the control measures,
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about the methods of transmission, it may, I think we're now kind of ready to start thinking about design. Again, I think it's kind of an obligation that we have to learn more about the biology of hepatitis B virus in order to deal with this problem in the most effective way.
43:41
Now as physicians, we always, we have, viruses and bacteria have a kind of rather bad name in medicine because we only see the worst things that they do, like disease. You know, that's the end of the spectrum we see. We have a rather distorted view of life, we have a distorted, terribly distorted view of viruses and microorganisms.
44:02
Just think of all the nice beer that we wouldn't have if we didn't have microorganisms. They do all sorts of things. But we tend to think about their negative aspects. But obviously that can, in terms of the viruses' attitudes, if they do have such things, that can only be a very small part of what they deal with.
44:21
I'd like to tell you about some, in a very brief way, about some of the studies we've done on how viruses, on one biological aspect of the virus, namely how it interacts differently with males and females, human males and females. The next, uh, uh, dia, uh, bita, is a, uh, is taken from a study by, uh, my colleague
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Dr. London and Jean Drew, where a group of individuals on a renal dialysis unit in Philadelphia was studied. There's a very high infection rate for hepatitis B virus in renal dialysis unit, and this particular unit has been organized so that all the carriers in the Delaware Valley,
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the area around Philadelphia, are kept in this unit. So there's a very high infection rate in this unit. Now they asked the question, what happens if a person is infected with hepatitis B virus? What's the likelihood of their becoming carriers or their likelihood of developing antibody?
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And the patient, the data was broken down into whether the patients were females or males. So the two things that can happen that can be measured, that were measured, were whether you became a carrier of hepatitis B virus or whether you developed the protective antibody, antibody against the surface antigen. Bloods were collected over the course of several years now, every two months, and
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all were tested. People who were known to have been infected were identified. This indicates the probability of remaining a carrier after one is infected for this number of months. So, for example, if a female is infected at the time of the first infection, the probability that she would become and remain a carrier is about something over 30%.
46:04
If a male is infected, then the probability of his becoming a carrier is more than twice as much. And this difference exists for other lengths of time of infection. So following infection, males are more likely to become carriers and females, as we'll see,
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next to bitter. This is sort of the obverse of this. If a person is once infected, what's the probability of their developing antibody against the surface antigen? Females are much more likely to develop antibody once infected than males. So from this we can say that once infected, males are more likely to become carriers,
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females more likely to develop antibody. Now this may explain the rather unusual male preponderance of diseases associated with hepatitis B virus. Cancer of the liver occurs in seven or eight times as many males as females.
47:01
Chronic liver disease associated with hepatitis B virus is much more common in males than in females. Now if males, once infected, are more likely to become carriers of hepatitis B virus, then they are much more likely to develop diseases associated with chronic infection, i.e. primary cancer of the liver, chronic liver disease, and a whole variety of other diseases
47:23
associated with this illness. So this may offer one of the most perplexing problems in medicine for certain diseases why males are more likely to get them than females and in some cases vice versa. Now another interesting interaction between the virus and humans in respect to males and
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females is shown in the next slide, please, which is a summary of data collected in a small community of Platte in Macedonia, in North Greece. This was selected because it was a very, quite a homogeneous community in many respects,
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but also they had one of the highest infection rates for hepatitis B virus in the Greek populations, which we surveyed with our Greek colleagues, Dr. Economedou and Hadzianis and others. Now the whole village or most of the village was tested.
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The parents were all classified into three groups, whether the parent was a carrier of hepatitis B surface antigen and did not have antibody, that's one class. Second class were parents who did not have carriers, were not carriers, but who did develop antibody against the surface antigen, and then a third class, individuals who had no
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evidence of infection. Then the number of children they had and the sex of the children was determined, and the sex ratio was computed for each of these groups separately. Sex ratio is the number of male live births over the number of female live births.
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This is the secondary sex ratio, the sex ratio at birth. The primary sex ratio is the ratio at conception. There was a highly significant difference between the sex ratio of the parents and of the families where the parents were carriers compared to the families where the parents had developed antibody, and an intermediate ratio in the families where neither had any
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evidence of infection. Now we've subsequently tested the same hypothesis in an island called Karkar, which is in the north coast of New Guinea, in two communities in Greenland, a place called Skorsby Sund and Amalansic, and then in Mali.
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And in each of these communities, none of the data have rejected the hypothesis, the observations generated by this first study, namely that we can, if this data is
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supported by subsequent studies, then it suggests that the virus has a very important kind of interaction with humans, which is different than causing disease. I'm not exactly sure how you'd classify it, that is the determination of sex ratio,
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but it's certainly not disease. So again, if these data are sustained by other investigators, and that hasn't happened yet, by the way, that is, it hasn't been rejected, but I don't think it's been tested. But if it is supported, then this says that this virus has a very important interaction
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with a human characteristic, which is of great importance to us. That is where the people are males and females. And this has a great effect, a great psychological, economic, sociological effect on the makeup of populations. Now, there are other biological characteristics associated with this virus that we'd like
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to learn more about while we're preparing for public health measures, in the hope that we'll be able to deal very effectively with this prevention, this illness, and do as little damage as possible. I think we always, in medical work in particular, have to kind of balance possible advantages
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against possible disadvantages. There's nothing that happens in life is without risk, and what we want to do is maximize the benefit and minimize the disadvantage. Thank you.