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Article ; Online: Changing epidemiology of parvovirus B19 in the Netherlands since 1990, including its re-emergence after the COVID-19 pandemic.

Russcher, Anne / van Boven, Michiel / Benincà, Elisa / Verweij, E J T Joanne / Molenaar-de Backer, Marijke W A / Zaaijer, Hans L / Vossen, Ann C T M / Kroes, Aloys C M

Scientific reports

2024 Volume 14, Issue 1, Page(s) 9630

Abstract: Parvovirus B19V (B19V) infection during pregnancy can be complicated by potentially life-threatening fetal hydrops, which can be managed by intrauterine transfusion (IUT). This study investigates the long-term temporal patterns in the epidemiology of ... ...

Abstract	Parvovirus B19V (B19V) infection during pregnancy can be complicated by potentially life-threatening fetal hydrops, which can be managed by intrauterine transfusion (IUT). This study investigates the long-term temporal patterns in the epidemiology of B19V and evaluates the impact on fetal hydrops, by combining data on B19V infections from the Dutch Sentinel Surveillance system in the period 1990 to 2023, Dutch blood banking data and hospital data on fetal hydrops. Using wavelet analysis, we identified annual epidemic cycles in the Netherlands in the period 1990-2019 and we identified superimposed multiannual cycles in the period 1990-2009. After 2009, no multiannual cycle could be identified, although the incidence fluctuated and correlates with number of IUT performed. As of 2020, weekly reports of B19V infection demonstrated a historically low incidence and B19V-DNA positive blood donors were nearly absent. From May 2020 to May 2023, no IUT for B19V-related hydrops was performed. In the spring of 2023, B19V infections re-emerged, reaching pre-pandemic epidemic levels. Due to the changes in B19V epidemiology over the last 30 years and the near-absence of B19V during the COVID-19 pandemic, the resulting low immunity levels may lead to rebound outbreaks. Alertness to severe complications such as fetal hydrops is warranted.
MeSH term(s)	Humans ; Netherlands/epidemiology ; COVID-19/epidemiology ; COVID-19/virology ; Parvovirus B19, Human ; Female ; Pregnancy ; Hydrops Fetalis/epidemiology ; Hydrops Fetalis/virology ; Incidence ; Parvoviridae Infections/epidemiology ; Pregnancy Complications, Infectious/epidemiology ; Pregnancy Complications, Infectious/virology ; SARS-CoV-2/isolation & purification ; Pandemics ; Erythema Infectiosum/epidemiology ; Blood Transfusion, Intrauterine ; Adult
Language	English
Publishing date	2024-04-26
Publishing country	England
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	2615211-3
ISSN	2045-2322 ; 2045-2322
ISSN (online)	2045-2322
ISSN	2045-2322
DOI	10.1038/s41598-024-59582-7
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Article ; Online: In vitro alternative for reactogenicity assessment of outer membrane vesicle based vaccines.

Molenaar-de Backer, Marijke W A / Doodeman, Paulien / Rezai, Fereshte / Verhagen, Lisa M / van der Ark, Arno / Plagmeijer, Els M / Metz, Bernard / van Vlies, Naomi / Ophorst, Olga / Raeven, René H M

Scientific reports

2023 Volume 13, Issue 1, Page(s) 12675

Abstract: Intrinsic or added immune activating molecules are key for most vaccines to provide desired immunity profiles but may increase systemic reactogenicity. Regulatory agencies require rabbit pyrogen testing (RPT) for demonstration of vaccine reactogenicity. ... ...

Abstract	Intrinsic or added immune activating molecules are key for most vaccines to provide desired immunity profiles but may increase systemic reactogenicity. Regulatory agencies require rabbit pyrogen testing (RPT) for demonstration of vaccine reactogenicity. Recently, the monocyte activation test (MAT) gained popularity as in vitro alternative, yet this assay was primarily designed to test pyrogen-free products. The aim was to adjust the MAT to enable testing of pyrogen containing vaccines in an early stage of development where no reference batch is yet available. The MAT and RPT were compared for assessing unknown safety profiles of pertussis outer membrane vesicle (OMV) vaccine candidates to those of Bexsero as surrogate reference vaccine. Pertussis OMVs with wild-type LPS predominantly activated TLR2 and TLR4 and were more reactogenic than Bexsero. However, this reactogenicity profile for pertussis OMVs could be equalized or drastically reduced compared to Bexsero or a whole-cell pertussis vaccine, respectively by dose changing, modifying the LPS, intranasal administration, or a combination of these. Importantly, except for LPS modified products, reactogenicity profiles obtained with the RPT and MAT were comparable. Overall, we demonstrated that this pertussis OMV vaccine candidate has an acceptable safety profile. Furthermore, the MAT proved its applicability to assess reactogenicity levels of pyrogen containing vaccines at multiple stages of vaccine development and could eventually replace rabbit pyrogen testing.
MeSH term(s)	Animals ; Rabbits ; Lipopolysaccharides/pharmacology ; Whooping Cough ; Pyrogens ; Monocytes ; Biological Assay
Chemical Substances	Lipopolysaccharides ; Pyrogens
Language	English
Publishing date	2023-08-04
Publishing country	England
Document type	Journal Article
ZDB-ID	2615211-3
ISSN	2045-2322 ; 2045-2322
ISSN (online)	2045-2322
ISSN	2045-2322
DOI	10.1038/s41598-023-39908-7
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Article ; Online: Lower Incidence of Parvovirus-B19 Infections in Dutch Blood Donors during SARS-CoV-2 Pandemic.

Molenaar-de Backer, M W / Hogema, B M / Koppelman, M H / van de Laar, T J / Slot, E / Zaaijer, H L

Microbiology spectrum

2021 Volume 9, Issue 2, Page(s) e0025321

MeSH term(s)	Asymptomatic Infections/epidemiology ; Blood Donors/statistics & numerical data ; Blood Transfusion ; COVID-19/epidemiology ; Carrier State/virology ; Humans ; Netherlands/epidemiology ; Parvoviridae Infections/epidemiology ; Parvoviridae Infections/transmission ; Parvovirus B19, Human/isolation & purification ; SARS-CoV-2/isolation & purification
Language	English
Publishing date	2021-09-15
Publishing country	United States
Document type	Letter ; Research Support, Non-U.S. Gov't
ZDB-ID	2807133-5
ISSN	2165-0497 ; 2165-0497
ISSN (online)	2165-0497
ISSN	2165-0497
DOI	10.1128/Spectrum.00253-21
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Article ; Online: Parvovirus B19 DNA detectable in hearts of patients with dilated cardiomyopathy, but absent or inactive in blood.

Russcher, Anne / Verdonschot, Job / Molenaar-de Backer, Marijke W A / Heymans, Stephane R B / Kroes, Aloys C M / Zaaijer, Hans L

ESC heart failure

2021 Volume 8, Issue 4, Page(s) 2723–2730

Abstract: Aims: Parvovirus B19 (B19V) is often assumed to be a cause of dilated cardiomyopathy (DCM), based on the quantification of B19V DNA in endomyocardial biopsies (EMB). Whether the presence of B19V DNA correlates with active infection is still debated. ... ...

Abstract	Aims: Parvovirus B19 (B19V) is often assumed to be a cause of dilated cardiomyopathy (DCM), based on the quantification of B19V DNA in endomyocardial biopsies (EMB). Whether the presence of B19V DNA correlates with active infection is still debated. Application of the enzyme endonuclease to blood samples results in degradation of B19V DNA remnants but leaves viral particles intact, which enables differentiation between active and past infection. In this study, the susceptibility to degradation by endonuclease of B19V DNA in blood was compared between DCM patients and a control group of recent B19V infections. Methods and results: Twenty blood samples from 20 adult patients with DCM, who previously tested positive for B19V DNA in EMB and/or blood, were tested with B19V PCR before and after application of endonuclease to the samples. Six blood samples tested positive for B19V DNA with a mean viral load of 2.3 × 10 Conclusion: During recent B19V infection, viral DNA levels in blood were unaffected by endonuclease. In contrast, B19V DNA in blood in patients with DCM became undetectable or strongly reduced after application of endonuclease. Circulating viral DNA in this subset of patients with presumed parvovirus-associated DCM does not consist of intact viral particles. Viral replicative activity cannot be assumed from demonstrating B19V DNA in cardiac tissue or in blood in DCM patients.
MeSH term(s)	Adult ; Cardiomyopathy, Dilated ; DNA, Viral ; Heart ; Humans ; Parvoviridae Infections/diagnosis ; Parvovirus B19, Human/genetics
Chemical Substances	DNA, Viral
Language	English
Publishing date	2021-05-01
Publishing country	England
Document type	Journal Article
ZDB-ID	2814355-3
ISSN	2055-5822 ; 2055-5822
ISSN (online)	2055-5822
ISSN	2055-5822
DOI	10.1002/ehf2.13341
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Article ; Online: Blood donor screening in the Netherlands: Universal anti-HBc screening in combination with HBV nucleic acid amplification testing may allow discontinuation of hepatitis B virus antigen testing.

van de Laar, Thijs J / Hogema, Boris M / Molenaar-de Backer, Marijke W / Marijt-van der Kreek, Tanneke / Zaaijer, Hans L

Transfusion

2021 Volume 61, Issue 7, Page(s) 2116–2124

Abstract: Background: In the Netherlands, blood donor screening for hepatitis B virus (HBV) consists of HBsAg screening since the 1970s, HBV DNA minipool testing (MP-NAT) since 2008, and anti-HBc screening since 2011. Anti-HBc reactivity causes deferral only if ... ...

Abstract	Background: In the Netherlands, blood donor screening for hepatitis B virus (HBV) consists of HBsAg screening since the 1970s, HBV DNA minipool testing (MP-NAT) since 2008, and anti-HBc screening since 2011. Anti-HBc reactivity causes deferral only if anti-HBs titers are <200 IU/mL, or when anti-HBc was acquired during follow-up. Study design and methods: Over 5.5 million donations from 582,459 Dutch donors were screened for HBV DNA, HBsAg, anti-HBc, and, if anti-HBc positive, also for anti-HBs. The added value, expressed as the yield of (potentially) infectious and/or recent HBV infections versus unnecessary donor loss, was evaluated for each of the three HBV screening tests. Results: HBV donor screening identified 89 HBV-infected donors with at least two reactive HBV markers (MP-NAT, HBsAg and/or anti-HBc). Single HBV-marker yield was: 5 MP-NAT-only, 0 HBsAg-only, and 20 anti-HBc-only donors. In addition, anti-HBc screening yielded 1,067 potentially infectious donors at risk for occult HBV infection (OBI). In total, 4,126 (0.71%) donors were anti-HBc-reactive at first-time screening, and 1,098 (0.19%) seroconverted during follow-up. Anti-HBc-related donor loss was limited to 2,627 (0.45%) donors using anti-HBs titers and two-strike programs. Donor loss due to MP-NAT and HBsAg screening was extremely low: 0 and 128 donors, respectively. Conclusion: HBV donor screening could be limited to MP-NAT and anti-HBc screening. MP-NAT and anti-HBc improved blood safety by intercepting infectious donations from donors with recent infection or OBI, while HBsAg did not. Unnecessary donor loss related to anti-HBc screening is substantial but does not endanger the continuity of the blood supply.
MeSH term(s)	Adult ; Blood Donors ; Blood Safety ; DNA, Viral/blood ; Donor Selection ; Hepatitis B/blood ; Hepatitis B/diagnosis ; Hepatitis B/prevention & control ; Hepatitis B Antibodies/blood ; Hepatitis B Core Antigens/immunology ; Hepatitis B Surface Antigens/blood ; Hepatitis B virus/genetics ; Hepatitis B virus/immunology ; Hepatitis B virus/isolation & purification ; Humans ; Netherlands ; Nucleic Acid Amplification Techniques ; Unnecessary Procedures ; Viremia/blood ; Viremia/diagnosis ; Viremia/virology
Chemical Substances	DNA, Viral ; Hepatitis B Antibodies ; Hepatitis B Core Antigens ; Hepatitis B Surface Antigens
Language	English
Publishing date	2021-04-26
Publishing country	United States
Document type	Journal Article
ZDB-ID	208417-x
ISSN	1537-2995 ; 0041-1132
ISSN (online)	1537-2995
ISSN	0041-1132
DOI	10.1111/trf.16420
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Article: Performance of monocyte activation test supplemented with human serum compared to fetal bovine serum.

Molenaar-de Backer, Marijke W A / Gitz, Eelo / Dieker, Miranda / Doodeman, Paulien / Ten Brinke, Anja

ALTEX

2020 Volume 38, Issue 2, Page(s) 307–315

Abstract: The monocyte activation test (MAT) is used to detect pyrogens in pharmaceutical products and serves as replacement of the rabbit pyrogen test. The peripheral blood mononuclear cell-based MAT assay requires the addition of serum to the medium and is ... ...

Abstract	The monocyte activation test (MAT) is used to detect pyrogens in pharmaceutical products and serves as replacement of the rabbit pyrogen test. The peripheral blood mononuclear cell-based MAT assay requires the addition of serum to the medium and is performed with either fetal bovine serum (FBS) or human serum (HS). Since the capacity to detect non-endotoxin pyrogens (NEPs) in a sensitive manner is an important strength of MAT compared to the bacterial endotoxin test, the performance of the MAT using FBS and HS was compared using endotoxin and several NEPs. The MAT was more sensitive for endotoxin when FBS was used, however for most NEPs the MAT was more sensitive when performed in HS. Furthermore, heat-inactivation of FBS affected the performance of the MAT for endotoxin to some extent but not for the NEPs. Interestingly, heat-inactivation of HS led to an almost complete loss of reactivity towards endotoxin, reduced the response towards heat-killed Staphylococcus aureus and peptidoglycan, but had minor or no effects on the responses towards R848, flagellin, and Pam3CSK4. Product testing of a human blood-derived product in MAT using HS was beneficial since endotoxin spike recoveries were improved. This product is therefore currently batch released with the HS-based MAT assay. Overall, to guarantee optimal performance of MAT, heat-inactivated serum should be avoided. The HS-based MAT appears to be the first choice to replace the rabbit pyrogen test, while in some cases the FBS-based MAT may be favored.
MeSH term(s)	Animals ; Endotoxins ; Humans ; Leukocytes, Mononuclear ; Monocytes ; Pyrogens ; Rabbits ; Serum ; Serum Albumin, Bovine/pharmacology
Chemical Substances	Endotoxins ; Pyrogens ; Serum Albumin, Bovine (27432CM55Q)
Language	English
Publishing date	2020-10-28
Publishing country	Germany
Document type	Journal Article
ZDB-ID	165707-0
ISSN	1868-596X ; 1018-4562 ; 0946-7785
ISSN	1868-596X ; 1018-4562 ; 0946-7785
DOI	10.14573/altex.2008261
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Article ; Online: Validation of new real-time polymerase chain reaction assays for detection of hepatitis A virus RNA and parvovirus B19 DNA.

Molenaar-de Backer, Marijke W A / de Waal, Mirjam / Sjerps, Margret C / Koppelman, Marco H G M

Transfusion

2016 Volume 56, Issue 2, Page(s) 440–448

Abstract: Background: To meet European guidelines for plasma for fractionation, plasma fractionators have implemented parvovirus B19 (B19V) and hepatitis A virus (HAV) nucleic acid test (NAT) screening on test pools. In this study we evaluate recently developed ... ...

Abstract	Background: To meet European guidelines for plasma for fractionation, plasma fractionators have implemented parvovirus B19 (B19V) and hepatitis A virus (HAV) nucleic acid test (NAT) screening on test pools. In this study we evaluate recently developed in-house NAT assays for B19V DNA and HAV RNA. The B19V NAT was designed to target two different regions of the B19V genome. Study design and methods: The B19V DNA and HAV RNA tests were validated according to commonly used guidelines. The performance of the B19V and HAV assays was evaluated during routine screening of more than 2 × 10(6) donations. Results: The 95% lower limit of detection (LLD) of the HAV NAT was 1.34 IU/mL. The 95% LLD for B19V was 39.1 IU/mL for the NS1 region and 76.9 IU/mL for the VP2 region. The B19V test showed good accuracy, precision, robustness, and no cross-contamination was observed. Both assays detected B19V Genotypes 1 to 3 and HAV Genotypes I to III. During routine screening 103 donations showed B19V DNA loads of more than 1.25 × 10(6) IU/mL and one donation was reactive in the HAV NAT. Conclusion: The dual-target B19V polymerase chain reaction (PCR) showed good accuracy (<0.1 log IU/mL) at the crucial concentration of 10 IU/µL for the NS1 and the VP2 region of the B19V genome and detected all known genotypes with similar sensitivity for each genotype. In addition, the dual target format reduces the chance that molecular variants of B19V are wrongly quantified. The HAV RNA assay showed high sensitivity for Genotypes I to III. Both new PCR assays have been successfully introduced for plasma screening in test pools of 480 or 96 donations.
MeSH term(s)	DNA, Viral/blood ; Donor Selection/methods ; Hepatitis A virus ; Humans ; Parvovirus B19, Human ; Practice Guidelines as Topic ; RNA, Viral/blood ; Real-Time Polymerase Chain Reaction/methods ; Sensitivity and Specificity
Chemical Substances	DNA, Viral ; RNA, Viral
Language	English
Publishing date	2016-02
Publishing country	United States
Document type	Journal Article ; Validation Studies
ZDB-ID	208417-x
ISSN	1537-2995 ; 0041-1132
ISSN (online)	1537-2995
ISSN	0041-1132
DOI	10.1111/trf.13334
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Article ; Online: Validation of the monocyte activation test with three therapeutic monoclonal antibodies.

Daniels, Ruth / Van der Elst, Wim / Dieltjens, Nele / Appels, Tinne / So, Chi K / Nys, Thomas / Voeten, Liesbeth / Breugelmans, Philip / Molenaar-de Backer, Marijke W A / Gitz, Eelo / Poole, Stephen / Patel, Mehul

ALTEX

2022 Volume 39, Issue 4, Page(s) 621–635

Abstract: Pharmaceutical products intended for parenteral use must be free from pyrogenic (fever-inducing) contamination. Pyrogens comprise endotoxins from Gram-negative bacteria and non-endotoxin pyrogens from Gram-positive bacteria, viruses, and ... ...

Abstract	Pharmaceutical products intended for parenteral use must be free from pyrogenic (fever-inducing) contamination. Pyrogens comprise endotoxins from Gram-negative bacteria and non-endotoxin pyrogens from Gram-positive bacteria, viruses, and fungi. The longstanding compendial test for pyrogens is the rabbit pyrogen test, but in 2010 the monocyte acti-vation test (MAT) for pyrogenic and pro-inflammatory contaminants was introduced into the European Pharmacopoeia (Ph. Eur.) as a non-animal replacement for the rabbit pyrogen test. The present study describes the first product-specific Good Manufacturing Practice validation of Ph. Eur. MAT, Quantitative Test, Method A for the testing of three therapeutic monoclonal antibodies. The study used the MAT version with cryo-preserved peripheral blood mononuclear cells and interleukin-6 as the readout. Much of the data presented here for one of the antibodies was included in a successful product license application to the European Medicines Agency.
MeSH term(s)	Animals ; Rabbits ; Pyrogens ; Monocytes ; Antibodies, Monoclonal/pharmacology ; Leukocytes, Mononuclear ; Animal Testing Alternatives ; Endotoxins
Chemical Substances	Pyrogens ; Antibodies, Monoclonal ; Endotoxins
Language	English
Publishing date	2022-04-14
Publishing country	Germany
Document type	Journal Article
ZDB-ID	165707-0
ISSN	1868-8551 ; 1018-4562 ; 0946-7785
ISSN (online)	1868-8551
ISSN	1018-4562 ; 0946-7785
DOI	10.14573/altex.2111301
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Article ; Online: Detection of parvovirus B19 DNA in blood: Viruses or DNA remnants?

Molenaar-de Backer, M W A / Russcher, A / Kroes, A C M / Koppelman, M H G M / Lanfermeijer, M / Zaaijer, H L

Journal of clinical virology : the official publication of the Pan American Society for Clinical Virology

2016 Volume 84, Page(s) 19–23

Abstract: Background: Parvovirus B19 (B19V) DNA can be detected in blood over a long period after acute infection. Several reports associate the presence of B19V DNA with disease, irrespective of timing of the initial B19V infection.: Objectives: This study ... ...

Abstract	Background: Parvovirus B19 (B19V) DNA can be detected in blood over a long period after acute infection. Several reports associate the presence of B19V DNA with disease, irrespective of timing of the initial B19V infection. Objectives: This study aims to analyze the properties of B19V DNA in blood, differentiating between bare, non-infectious strands of DNA and B19V DNA in viable virions. Study design: Ten blood donors with asymptomatic acute B19V infection were followed and sampled up to 22 months after infection. The samples were treated with and without an endonuclease and tested for B19V DNA, to distinguish between DNA in virions and naked DNA. Results: In the acute phase of infection, high levels of B19V DNA were detected, concurrent with B19V IgM antibodies. B19V DNA apparently was encapsidated, as indicated by resistance to endonuclease degradation. Subsequently, B19V DNA remained detectable for more than one year in all donors at low levels (<10 Discussion: Detection of B19V DNA in blood by PCR does not necessarily imply that B19V replication takes place and that infectious B19V virions are present. We propose that remnant B19V DNA strands can be released from tissues without active replication. This finding urges to reconsider an assumed role of B19V infection mainly based on B19V DNA detection in blood, a much debated subject in clinical syndromes such as myocarditis and arthritis.
MeSH term(s)	Antibodies, Viral/blood ; Arthritis/diagnosis ; Arthritis/virology ; Blood Donors ; DNA, Viral/blood ; DNA, Viral/genetics ; Humans ; Immunoglobulin G/blood ; Immunoglobulin M/blood ; Myocarditis/diagnosis ; Myocarditis/virology ; Parvoviridae Infections/diagnosis ; Parvoviridae Infections/virology ; Parvovirus B19, Human/genetics ; Parvovirus B19, Human/immunology ; Parvovirus B19, Human/isolation & purification ; Polymerase Chain Reaction ; Time Factors ; Virus Replication
Chemical Substances	Antibodies, Viral ; DNA, Viral ; Immunoglobulin G ; Immunoglobulin M
Language	English
Publishing date	2016
Publishing country	Netherlands
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	1446080-4
ISSN	1873-5967 ; 1386-6532
ISSN (online)	1873-5967
ISSN	1386-6532
DOI	10.1016/j.jcv.2016.09.004
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Article ; Online: Surface antigen-negative hepatitis B virus infection in Dutch blood donors.

Lieshout-Krikke, R W / Molenaar-de Backer, M W A / van Swieten, P / Zaaijer, H L

European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology

2013 Volume 33, Issue 1, Page(s) 69–77

Abstract: Hepatitis B virus (HBV) surface antigen (HBsAg) is a reliable marker for HBV infection, but HBsAg-negative forms of HBV infection occur. The introduction of HBV DNA screening of Dutch blood donors, which were not preselected for absence of HBV core ... ...

Abstract	Hepatitis B virus (HBV) surface antigen (HBsAg) is a reliable marker for HBV infection, but HBsAg-negative forms of HBV infection occur. The introduction of HBV DNA screening of Dutch blood donors, which were not preselected for absence of HBV core antibodies, enabled the characterization of HBsAg-negative HBV infection in healthy persons and a comparison of the HBV genomes involved. The screening of 4.4 million Dutch blood donations identified 23 HBsAg-negative, HBV DNA-positive persons. Serological testing of the index donations, follow-up samples and archived earlier samples was performed to determine the nature of each HBV DNA-only case. Despite low viral loads HBV DNA could be sequenced in 14 out of 23 donors, allowing HBV genotyping and the analysis of mutations in the HBV surface gene. Four types of HBsAg-negative HBV infection were detected: infection in the early stage before occurrence of HBsAg; suppressed infection after vaccination; HBV genotype G infection with decreased HBsAg production; and chronic occult (HBsAg negative) HBV infection. In the donors with occult HBV genotype D infection the HBV surface gene showed multiple "escape" mutations in the HBsAg a-determinant and CTL epitopes, while in an occult genotype A case the surface gene showed no mutations. HBsAg-negative forms of HBV infection in healthy blood donors explain the ongoing transmission of HBV via blood transfusion, if donor screening is limited to HBsAg. The screening of blood donors for HBV DNA and HBV core antibodies seems to cover all stages and variants of HBV infection.
MeSH term(s)	Adult ; Aged ; Antigens, Surface/blood ; Antigens, Surface/genetics ; Blood Donors ; DNA, Viral/blood ; DNA, Viral/genetics ; Female ; Hepatitis B/diagnosis ; Hepatitis B/virology ; Hepatitis B virus/genetics ; Hepatitis B virus/isolation & purification ; Humans ; Male ; Middle Aged ; Mutation, Missense ; Netherlands
Chemical Substances	Antigens, Surface ; DNA, Viral
Language	English
Publishing date	2013-09-13
Publishing country	Germany
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	603155-9
ISSN	1435-4373 ; 0934-9723 ; 0722-2211
ISSN (online)	1435-4373
ISSN	0934-9723 ; 0722-2211
DOI	10.1007/s10096-013-1930-9
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