492

adherence of E. coli to uroepithelial cells. It has been

suggested that locally formed antibodies coat the bac-teria in saliva and gastrointestinal and vaginal secre-tions, thus blocking their sites for attachment. Unat-tached bacteria may be swept away by the flow of secre-tions bathing mucosal surfaces, thus preventing closecontact with the host tissue.2 19

We thank Dr H. A. Hansson for his valuable help with the scanningelectron microscopy and B. Eriksson for the statistical evaluation.This work was supported by grants from the faculty of medicine, Uni-versity of Goteborg, the Swedish Medical Research Council (projectNo. 215) and the Ellen, Walter and Lennart Hesselman Foundationfor Scientific Research.

Requests for reprints should be sent to C.S.E., Department of Im-munology, Guldhedsgatan 10, S-413 46 Goteborg, Sweden.

REFERENCES

1. McNeish, A. S., Turner, P., Fleming, J., Evans, N. Lancet, 1975, ii, 946.2. Ellen, R. P., Gibbons, R. J. Infect. Immun. 1974, 9, 85.3. Punsalang, A., Sawyer, W. ibid. 1973, 8, 255.4. Powell, D., Hu, P., Wilson, M., Collier, A., Baseman, J. ibid. 1976, 13, 959.5. Jodal, U., Lindberg, U., Lincoln, K. Acta pœdiat. scand. 1975, 64, 201.6. Hanson, L. Å., Ahlstedt, S., Fasth, A., Jodal, U., Kaijser, B., Larsson, P.,

Lindberg, U., Olling, S., Sohl Åkerlund, A., Svanborg Eden, C. J. infect.Dis. (in the press).

7. Lindberg, U., Claësson, I., Hanson, L. A., Jodal, U. Acta pœdiat. scand.1975, 64, 425.

8. Ström, J. Scand. J. infect. Dis. 1973, 5, 209.9. King, D. W., Paulson, S. R., Puchett, N. L., Krebs, A. T.Am. J. Path. 1959,

35, 1067.10. Svanborg Edén, C. Unpublished.11. Engvall, E., Perlmann, P.J. Immun. 1972, 109, 129.12. Hanson, L. A.J. infect. Dis. 1973, 127, 726.13. Mabeck, C. E., Ørskov, F.,Ørskov, I. Lancet, 1971, i, 1312.14. Kaijser, B.J. infect. Dis. 1973, 127, 670.15. Lindberg, U., Hanson, L. Å., Jodal, U., Lidin-Janson, G., Lincoln, K., Oil-

ing, S. Acta pœdiat. scand. 1975, 64, 432.16. Hanson, L. A., Ahlstedt, S., Carlsson, B., Jodal, U., Lindberg, U., Sohl, A.

Adv. exp. Med. Biol. 1974, 45, 399.17. Jodal, U., Ahlstedt, S., Carlsson, B., Hanson, L. A., Lindberg, U. Sohl, A.

Int. Archs. Allergy, 1974, 47, 539.18. Hanson, L. A., Åhlstedt, S., Jodal, U., Kaijser, B., Larsson, P., Lidin-Janson,

G., Lincoln, K., Lindberg, U., Mattsby, I., Olling, S., Peterson, H., Sohl,A. Kidney Int. 1975, 8, 28.

19. Fubara, E. S., Freter, R.J. Immun. 1973, 111, 395.

RELATION OF e ANTIGEN TO INFECTIVITY OF

HBsAg-POSITIVE INOCULATIONS AMONGMEDICAL PERSONNEL*

U.S. National Heart and Lung Institute Collaborative StudyGroup and Phoenix Laboratories Division, Bureau of

Epidemiology, Center for Disease Control

Summary Hepatitis-B surface antigen (HBsAg)-positive blood which contained e

antigen, when accidentally inoculated into medical per-sonnel, resulted in hepatitis B or an anti-HBs responsein 60% compared to 31% when e antigen was notdetected in the inoculum. e antigen was detected in 74%of inocula sustained on chronic renal dialysis and trans-plantation units compared to 20% on other services andthe resultant incidence of hepatitis B varied according-ly—i.e., 22% and 6% respectively. Tests for e antigen

*Report prepared by G. F. GRADY. Members of the U.S. National Heart andLung Institute Collaborative Study Group include G. L. GITNICK (Los Angeles),A. M. PRINCE (New York), M. M. KAPLAN and K. A. FAWAZ (Boston), G. N.VYAS and R. SCHMID (San Francisco), M. D. LEvnrr (Minneapolis), J. T.GALAMBOS (Atlanta), T. E. BYNUM (Houston), J. R. SENIOR (Philadelphia), K.AKDAMAR (New Orleans), J. W. SINGLETON (Denver), B. F. CLOWDUS and F.STEIGMANN (Chicago), R. D. AACH (St. Louis), G. M. SCHIFF (Cincinnati), E. I.WINKELMAN (Cleveland), and T. HERSH (Providence). Members of the PhoenixLaboratories Division, Bureau of Epidemiology, Center for Disease Control in-clude B. L. MURPHY, S. H. HINDMAN, and J. E. MAYNARD.

can identify the relative infectivity of groups of HBsAgcarriers; technical improvements should result in valu-able applications to individual cases.

Introduction

e antigen, a soluble protein1 identified by Magniusand Espmark2 in sera containing hepatitis-B surfaceantigen (HBsAg), appears to be a marker of infectivityin maternal-fetal transmission of hepatitis B. A com-parable association with horizontal transmission hasbeen postulated on the basis of the high prevalence of eantigen in patients on renal dialysis units where staff

acquired hepatitis B most frequently.2 Conversely, a

retrospective study of recipients of blood from chronically HBsAg-positive donors whose sera containedanti-e instead of e revealed no evidence of transmissionof hepatitis B.4 An opportunity for prospective evalua-tion of the relation of e antigen and infectivity hasarisen incidental to studies of hepatitis-B immune globu-lin among medical personnels and is the basis for thisreport.

Subjects and MethodsMedical personnel sustaining an accidental exposure to

HBsAg-positive blood between June 28, 1972 and Dec, 31,1974 were followed fortnightly for development of HBsAg.anti-HBs, and raised alanine-aminotransferase levels.’ HBsAgand anti-HBs were measured by radioimmunoassay (AusRIAII and AusAb, Abbott Laboratories). Follow-up of exposed sub-jects, continued for 6 months and an additional serum speci-men was obtained at 9 months unless hepatitis had already de-veloped. At the time of the exposure, serum from the sourceof exposure (hereafter called "donor") was obtained and storedat -20°C. In the current analysis, exposed subjects were notsegregated according to the anti-HBs titre of the immune

serum-globulin group to which they had been assigned becausethe incidence of hepatitis B was the same in all three treatmentgroups 9 months after exposure.5 A total of 47 cases of hepa-titis B (including 39 noted in the preliminary report’) wereidentified by an independent review panel and all occurred

among the 435 exposed subjects who were anti-HBs-negativeat the time of the inoculation with HBsAg-positive blood, Ananti-HBs response was defined as a crescendo-decrescendo pat.tem involving at least 3 specimens including a peak value ofat least 4 times the baseline c.p.m., or a single value at 9months of at least 10 times the baseline value.

Among the 435 donors to the exposed subjects noted above130 were patients on chronic renal dialysis or transplantationunits; sera from 101 of them remained available and weretested for e antigen. The 101 included 27 of the 29 donor.causing hepatitis in this group. Sera were also tested on all1i 16of the donors from other clinical services who gave rise to

hepatitis B, and for comparison purposes, on 5 consecutive

available donors following each of the 18 implicated donorswithin the same study center. Of an expected total of 90 sera.84 were available which along with those from the 18 impcated donors totalled 102 in this group.A standard anti-e reagent which exhibited both anti-e, and

anti-e2 reactivity was employed for detection of e antigen -’modified gel rheophoresis plates (Abbott Laboratories) as pviously described.6 A standard e reagent which exhibited be1 and e2 reactivity was used as a positive control and detection of anti-e in donor sera. Precipitin lines were read’.a person unaware of the clinical response associated with the

specimen.

Results

Table i shows that of the 203 donor sera tested. 1’

493

IHBLE I-RESPONSE OF MEDICAL PERSONNEL TO ACCIDENTAL

y LATION WITH HBSAg-POSITIVE BLOOD ACCORDING TO WHETHER e

I ANTIGEN WAS ALSO DETECTED IN THE DONOR’S BLOOD

were e-positive and 62 (60%) of these were associatedwith development of hepatitis B or anti-HBs in exposed

subjects. A similar response was seen approximately halfas often when the donor sera did not contain detectablee antigen.

, Although essentially equal numbers of donors fromrenal dialysis/transplant units and other services (102)

were studied, the 104 e-positive sera were found princi-pally among the former group as indicated in table n.

TABLE II—CORRELATION OF PREVALENCE OF e ANTIGEN AND INFECTION

RATES OF HEPATITIS B ON CHRONIC RENAL DIALYSIS/TRANSPLANT UNITSAND OTHER MEDICAL SERVICES

were e-positive and 62 (60%) of these were associatedwith development of hepatitis B or anti-HBs in exposed

subjects. A similar response was seen approximately halfas often when the donor sera did not contain detectablee antigen.

, Although essentially equal numbers of donors fromrenal dialysis/transplant units and other services (102)

were studied, the 104 e-positive sera were found princi-pally among the former group as indicated in table II.

TABLE II—CORRELATION OF PREVALENCE OF e ANTIGEN AND INFECTION, RATES OF HEPATITIS B ON CHRONIC RENAL DIALYSIS/TRANSPLANT UNITS

AND OTHER MEDICAL SERVICES

Prevalence of Incidence ofe antigen in hepatitis B

"donor" serum among exposed subjects

Renal dialysrs and 75/101 (74%) 29/130 (22%)transplantation units

Other medical services 29/102 (28%) 18/305 (6%)Totals 104/203 (51%) 47/435 (11%)

The higher prevalence of e antigen (74%) as comparedto 28% in the latter group was paralleled by the respec-tive incidence of hepatitis among exposed subjects in thetwo groups. Because these differences introduce skewingin the results and can distort pooled data, an additionalanalysis was carried out separating the exposed subjectsaccording to the setting in which the accidental inocula-tion took place.Table III shows that 83% of renal dialysis/transplan-

TABLE III—PREVALENCE OF e ANTIGEN IN HBSAg POSITIVE SERA INRELATION TO THE RESPONSE OF MEDICAL PERSONNEL ACCIDENTALLY

INOCULATED ON CHRONIC RENAL DIALYSIS/TRANSPLANT UNITS ANDOTHER MEDICAL SERVICES

’B) and percent) of mocula which were e-antigen-positive.

tation unit donors associated with evidence of hepati-us-B infection in the exposed subject were e-positive.This proportion is significantly greater (P=0.03) thanthe 63% among non-implicated donors but practical dis-tmctions are limited by the high prevalence of e antigenamong all the dialysis/transplant donors studied. On thether medical services, implicated donors were e-positivein 40% of the instances examined as compared to 22%among those not associated with evidence of hepatitistransmission (P=0.05).

Anti-e was detected too infrequently for significanttrends to be discerned. None of the 9 anti-e-positivedonor sera were implicated in transmission of hepatitisB but an anti-HBs response occurred in two of the res-

pective exposed subjects.

Discussion

Epidemiological evidence linking e antigen to infecti-vity has been less extensive than evidence associating itwith chronicity of hepatic inflammatory activity.7-10However, both concepts are bolstered by several labora-tory studies showing that e-positive sera are more likelythan e-negative sera to contain elements directly relatedto hepatitis-B virions-e.g., Dane particles, hepatitis-Bcore antigen, and D.N.A. polymerase.4 6 10-12 The experi-mental design of the current clinical trial and technicallimitations in measuring e antigen may have prejudicedappreciation of the correlation of e antigen and infecti-vity. It is likely that many of the HBsAg-positive (ande-positive) inocula were too superficial to induce any evi-dence of infection even though sensitive tests for

acquired anti-HBs were performed. Conversely, the rela-tive insensitivity of the gel-diffusion method for detect-ing e antigen may have accounted for the apparent enegativity of some implicated sera. Exposed subjectswho developed hepatitis even though their "donor ofrecord" was e-negative could have acquired the infectionfrom another, unrecognised exposure which was e-posi-tive. In spite of all these possibilities for confounding in-terpretations, our experience must be fairly representa-tive of what one would expect to encounter in any seriesof accidental inoculations among which tests for e

antigen might be used to predict the response in theexposed subject.

If the correlation of e antigen and infectivity is indeedmore perfect than this study indicates, and the correla-tion is not merely an indirect reflection of some morespecifically associated phenomenon, improvements in

sensitivity of the test will be of great value. Potentialuses would not be limited to counselling accidentally in-oculated individuals or guiding the usage of limited sup-plies of hepatitis-B immune globulin. Many categories ofchronic HBsAg-positive individuals would be in a betterposition to judge their potential infectivity for others.The most spectacular examples include HBsAg-positiveoral surgeons and other practitioners whose careers

could be at stake.

This study was supported by contract NIH-NHLI-72-2951B fromthe Blood Resources Branch, Division of Blood Diseases andResources, National Heart and Lung Institute.

Requests for reprints should be addressed to G. F. G., M.D., StateLaboratory Institute, Massachusetts Department of Public Health,305 South Street, Boston, Massachusetts 02130, U.S.A.

REFERENCES

1. Magnius, L. O. Clin. Exp. Immun. 1975, 20, 209.2. Magnius, L. O., Espmark, J. A.J. Immun. 1972, 109, 1017.3. Magnius, L. O., Lindholm, A., Lundin, P., Iwarson, S. J. Am. med. Ass.

1975, 231, 356.4. Okada, K., Kamiyama, I., Inomata, M., Mitsunobu, I., Miyakawa, Y.,

Mayumi, M. New Engl.J. Med. 1976, 294, 746.5. Grady, G. F., Lee, V. L., N.H.L.I. Collaborative Study Group. ibid. 1975,

293, 1067.6. Maynard, J. E., Barrett, D. H., Murphy, B. L., Bradley, D. W., Berquist,

K. R., Bender, T. R.J. infect. Dis. 1976, 133, 339.7. Nielsen, J. O., Dietrichson, O., Juhl, E. Lancet, 1974, ii, 913.8. Eleftheriou, N., Thomas, H. C., Heathcote, J., Sherlock, S. ibid. 1975, ii,

1171

494

9. Feinman, S. V., Berris, B., Sinclair, J. C., Wrobel, D. M., Murphy, B. L.,Maynard, J. E. ibid. p. 1173.

10. El Sheikh, N., Woolf, I. L., Galbraith, R. M., Eddleston, A. L. W. F.,Dymock, I. W., Williams, R. Br. med. J. 1975, iv, 252.

11. Nordenfelt, E., Kjellen, L. Intervirology, 1975, 5, 225.12. Murphy, B. L., Peterson, J. M., Smith, J. L., Gitnick, G. L., Auslander, M.

O., Berquist, K. R., Maynard, J. E., Purcell, R. H. Infection Immunity1976, 13, 296.

Preliminary Communication

PRODUCTION OF PANCREATITIS IN RABBITSBY INTESTINAL RE-INSTILLATION OFSTIMULATED PANCREATIC SECRETION

HERMANN GOTZE S. S. ROTHMAN

Department of Physiology, University of California,San Francisco, California 94143, U.S.A.

Summary Pathological changes reminiscent ofacute pancreatitis in man were observed

in rabbits as a result of the intestinal instillation of pan-creatic secretion produced by continuous cholinergic stim-ulation. Both the cause and nature of the pathologicalchanges suggest a bloodborne disease produced by theabsorption of digestive enzyme. It is proposed that acutepancreatitis can be the consequence of the absorption ofactive digestive enzyme in quantities and at rates suffi-cient to overwhelm natural defence mechanisms.

INTRODUCTION

THE initiation of acute hsemorrhagic pancreatitis inman is incompletely understood. One possibility becameapparent to us while we were studying the extent of theenteropancreatic circulation of digestive enzyme (i.e.,the movement of enzyme from the intestine to blood to

pancreas and back into the intestine) in rabbits.1 2 Inthese experiments pancreatic secretion was divertedfrom the intestine while digestive enzyme secretion wascontinuously stimulated. We postulated that if enzymecirculation occurred in quantity, then reintroducing thecollected secretion back into the intestine, as normallyoccurs, might substantially augment subsequent proteinsecretion by the gland. This prediction was confirmed.2In an attempt to optimise the transfer of enzyme fromthe intestinal lumen to blood, we added large amountsof albumin to instilled pancreatic secretion in order tokeep enzyme auto-degradation to a minimum.3 Underthese conditions over 50% of the animals died within the5 h course of the experiment and, in addition, pathologi-cal changes quite similar to acute haemorrhagic pancrea-titis in man were seen in some animals. This result

prompted us to look at the mortality-rate for earlierexperiments in which digestive enzyme had been rein-stilled without albumin.2 Similarly, 50% of these ani-mals had not survived the experiment.

METHODS

The details of the experimental procedure have been

reported elsewhere.2 Briefly, pancreatic secretion was collectedat 15 min intervals from anaesthetised rabbits under con-tinuous stimulation (half-hourly subcutaneous injections) with

acetyl-&bgr;-methylcholine chloride (05 mg/kg body-weight) plusintravenous secretin (10 Ivy dog unit/kg body-weight). Aftera sample was taken for protein measurements, the secrenor.was immediately reintroduced into the upper duodenum l1acannula. In control studies-i.e., enzyme-diverted—equalamounts of albumin dissolved in 0 15 mol/1 sodium chloridewere introduced into the duodenal lumen in place of pancrea-tic secretion. In some experiments albumin was added to thsreintroduced secretion in amounts equal to ten times theamount of protein in the collected secretion (as determined babsorbance at 280 nm). Particular care was taken to secure thecannula in the duodenum so intestinal contents could not leakinto the peritoneal cavity.

RESULTS

Mortality-ratesAnimals subject to continuous stimulation, but whose

secretion was diverted from the intestine, generally sur-vived the 300 min course of the experiment (92.8% sur-vival) (fig. 1). However, when pancreatic secretion was

T muumm

Fig. 1—Mortatity-rates of rabbits in which continuously stimulated pmcreatic secretion was either diverted from the intestine, reinstilled, orreintroduced along with ten times its protein concentration of bovintalbumin.

When the unmodified pancreatic juice was allowed to follow its

natural path into the intestines, mortality during the 300 min expen-ment increased approximately 6-fold. Differences in mortality betweenthe diverted and two different reinstilled groups were evaluated staus-

tically by a Rank test. Numbers of animals are given in parentheses

reinstilled, either alone or with a high concentration ofalbumin, over half of the rabbits died before the studywas complete (446% survival with albumin and 50%without) (fig. 1). To test for an albumin-dependent con-tribution to mortality we compared mean survival-timesin experiments in which digestive enzyme was reinstilledwith or without albumin. Albumin significantly reducethe mean survival-time (fig. 2).

PathologyIn some cases the pathological findings were dramatic

and varied, while in others there were no gross abnormfindings in the abdominal cavity even though the animidied. The following abnormalities were observed: 1

considerable amounts (5-10 ml) of foul-smellinghaemorrhagic ascites; (2) discrete and diffuse hxmorrhs’gic areas on the abdominal wall; (3) bloody and foamy