Viral load

Last updated

Viral load, also known as viral burden, is a numerical expression of the quantity of virus in a given volume of fluid, including biological and environmental specimens. It is not to be confused with viral titre or viral titer, which depends on the assay. When an assay for measuring the infective virus particle is done (Plaque assay, Focus assay), viral titre often refers to the concentration of infectious viral particles, which is different from the total viral particles. Viral load is measured using body fluids sputum [1] and blood plasma. [2] As an example of environmental specimens, the viral load of norovirus can be determined from run-off water on garden produce. [3] Norovirus has not only prolonged viral shedding and has the ability to survive in the environment but a minuscule infectious dose is required to produce infection in humans: less than 100 viral particles. [4]

Contents

Viral load is often expressed as viral particles, (virions) or infectious particles per mL depending on the type of assay. A higher viral burden, titre, or viral load often correlates with the severity of an active viral infection. The quantity of virus per mL can be calculated by estimating the live amount of virus in an involved fluid. For example, it can be given in RNA copies per millilitre of blood plasma.

Tracking viral load is used to monitor therapy during chronic viral infections, and in immunocompromised patients such as those recovering from bone marrow or solid organ transplantation. Currently, routine testing is available for HIV-1, cytomegalovirus, hepatitis B virus, and hepatitis C virus. Viral load monitoring for HIV is of particular interest in the treatment of people with HIV, as this is continually discussed in the context of management of HIV/AIDS. An undetectable viral load does not implicate a lack of infection. HIV positive patients on long-term combination antiretroviral therapy may present with an undetectable viral load on most clinical assays since the concentration of virus particles is below the limit of detection (LOD).

Technologies for viral load testing

A 2010 review study by Puren et al. [2] categorizes viral load testing into three types: (1) nucleic acid amplification based tests (NATs or NAATs) commercially available in the United States with Food and Drug Administration (FDA) approval, or on the market in the European Economic Area (EEA) with the CE marking; (2) "Home–brew" or in-house NATs; (3) non-nucleic acid-based test.[ citation needed ]

Nucleic acid-based tests (NATs)

There are many different molecular based test methods for quantifying the viral load using NATs. The starting material for amplification can be used to divide these molecular methods into three groups: [5]

  1. Target amplification which uses the nucleic acid itself. Just a few of the more common methods
    • The polymerase chain reaction (PCR) method of in vitro DNA synthesis uses a DNA template, polymerase, buffers, primers, and nucleotides to multiply the HIV in the blood sample. Then a chemical reaction marks the virus. The markers are measured and used to calculate the amount of virus. PCR is used to quantify integrated DNA.
    • Reverse transcription polymerase chain reaction (RT-PCR) is a variation of PCR that can be used to quantify viral RNA. RNA is used as the starting material for this method and converted to double-stranded DNA, using the enzyme reverse transcriptase (RT) for PCR.
    • The nucleic acid sequence-based amplification (NASBA) method is a transcription-based amplification system (TAS) variation of PCR. RNA is used as the target and a DNA copy is made. The DNA copy is then transcribed into RNA and amplified. Several TAS commercial variations are available including; transcription-mediated amplification (TMA), and self-sustaining sequence replication (3SR).
  2. Probe specific amplification uses synthetic probes that preferentially bind to a target sequence. The probes are then amplified
  3. Signal amplification uses large amounts of signal bound to an unamplified target originally present in the sample. One commonly used method:
    • The branched DNA (bDNA) method can use either DNA or RNA as the target nucleic acid. Short probes attached to a solid support and capture the target nucleic acid. Additional extender probes also bind to the target nucleic acid and to numerous reporter molecules which are used to increase the signal intensity, which is converted to a viral count.

Plasma specimens

EDTA Plasma, from and EDTA blood sample is a good source of cell-free viral RNA for RNA-based viral load testing. Extraction of RNA from plasma requires specialized equipment, reagents and training, which might out of reach for medium to small laboratories. A large sample (> 1 mL of plasma) is needed requiring venipuncture.

Storage

EDTA blood can be stored at room temperature for 30 hours, and separated plasma for extended periods of time at -70 °C without significant decreases in viral load.

Measuring

Viral load is reported as copies of HIV RNA in a millilitre (mL) of blood. Changes in viral load are usually reported as a log change (in powers of 10). For example, a three log increase in viral load (3 log10) is an increase of 103 or 1,000 times the previously reported level, while a drop from 500,000 to 500 copies would be a three-log-drop (also 3 log10).[ citation needed ]

Other factors that affect viral load

Different test methods often give different results for the same patient sample. To be comparable the same test method (target amplification, probe specific amplification, or signal amplification) should be used each time a patient specimen is run. Ideally patient testing should be conducted at the same medical laboratory, using the same viral load test and analyzer.

See also

Related Research Articles

<span class="mw-page-title-main">Complementary DNA</span> Single-stranded DNA synthesized from RNA

In genetics, complementary DNA (cDNA) is DNA synthesized from a single-stranded RNA template in a reaction catalyzed by the enzyme reverse transcriptase. cDNA is often used to express a specific protein in a cell that does not normally express that protein, or to sequence or quantify mRNA molecules using DNA based methods. cDNA that codes for a specific protein can be transferred to a recipient cell for expression, often bacterial or yeast expression systems. cDNA is also generated to analyze transcriptomic profiles in bulk tissue, single cells, or single nuclei in assays such as microarrays, qPCR, and RNA-seq.

<span class="mw-page-title-main">Polymerase chain reaction</span> Laboratory technique to multiply a DNA sample for study

The polymerase chain reaction (PCR) is a method widely used to make millions to billions of copies of a specific DNA sample rapidly, allowing scientists to amplify a very small sample of DNA sufficiently to enable detailed study. PCR was invented in 1983 by American biochemist Kary Mullis at Cetus Corporation; Mullis and biochemist Michael Smith, who had developed other essential ways of manipulating DNA; the creation for which they were jointly awarded the Nobel Prize in Chemistry in 1993.

<span class="mw-page-title-main">Virology</span> Study of viruses

Virology is the scientific study of biological viruses. It is a subfield of microbiology that focuses on their detection, structure, classification and evolution, their methods of infection and exploitation of host cells for reproduction, their interaction with host organism physiology and immunity, the diseases they cause, the techniques to isolate and culture them, and their use in research and therapy.

<span class="mw-page-title-main">Reverse transcription polymerase chain reaction</span> Laboratory technique to multiply an RNA sample for study

Reverse transcription polymerase chain reaction (RT-PCR) is a laboratory technique combining reverse transcription of RNA into DNA and amplification of specific DNA targets using polymerase chain reaction (PCR). It is primarily used to measure the amount of a specific RNA. This is achieved by monitoring the amplification reaction using fluorescence, a technique called real-time PCR or quantitative PCR (qPCR). Combined RT-PCR and qPCR are routinely used for analysis of gene expression and quantification of viral RNA in research and clinical settings.

<span class="mw-page-title-main">Diagnosis of HIV/AIDS</span> Immunological test

HIV tests are used to detect the presence of the human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS), in serum, saliva, or urine. Such tests may detect antibodies, antigens, or RNA.

An assay is an investigative (analytic) procedure in laboratory medicine, mining, pharmacology, environmental biology and molecular biology for qualitatively assessing or quantitatively measuring the presence, amount, or functional activity of a target entity. The measured entity is often called the analyte, the measurand, or the target of the assay. The analyte can be a drug, biochemical substance, chemical element or compound, or cell in an organism or organic sample. An assay usually aims to measure an analyte's intensive property and express it in the relevant measurement unit.

In molecular biology, an amplicon is a piece of DNA or RNA that is the source and/or product of amplification or replication events. It can be formed artificially, using various methods including polymerase chain reactions (PCR) or ligase chain reactions (LCR), or naturally through gene duplication. In this context, amplification refers to the production of one or more copies of a genetic fragment or target sequence, specifically the amplicon. As it refers to the product of an amplification reaction, amplicon is used interchangeably with common laboratory terms, such as "PCR product."

Cycling probe technology (CPT) is a molecular biological technique for detecting specific DNA sequences. CPT operates under isothermal conditions. In some applications, CPT offers an alternative to PCR. However, unlike PCR, CPT does not generate multiple copies of the target DNA itself, and the amplification of the signal is linear, in contrast to the exponential amplification of the target DNA in PCR. CPT uses a sequence specific chimeric probe which hybridizes to a complementary target DNA sequence and becomes a substrate for RNase H. Cleavage occurs at the RNA internucleotide linkages and results in dissociation of the probe from the target, thereby making it available for the next probe molecule. Integrated electrokinetic systems have been developed for use in CPT.

<span class="mw-page-title-main">Real-time polymerase chain reaction</span> Laboratory technique of molecular biology

A real-time polymerase chain reaction is a laboratory technique of molecular biology based on the polymerase chain reaction (PCR). It monitors the amplification of a targeted DNA molecule during the PCR, not at its end, as in conventional PCR. Real-time PCR can be used quantitatively and semi-quantitatively.

In biology, a branched DNA assay is a signal amplification assay that is used to detect nucleic acid molecules.

Multiplex ligation-dependent probe amplification (MLPA) is a variation of the multiplex polymerase chain reaction that permits amplification of multiple targets with only a single primer pair. It detects copy number changes at the molecular level, and software programs are used for analysis. Identification of deletions or duplications can indicate pathogenic mutations, thus MLPA is an important diagnostic tool used in clinical pathology laboratories worldwide.

An allele-specific oligonucleotide (ASO) is a short piece of synthetic DNA complementary to the sequence of a variable target DNA. It acts as a probe for the presence of the target in a Southern blot assay or, more commonly, in the simpler dot blot assay. It is a common tool used in genetic testing, forensics, and molecular biology research.

Digital polymerase chain reaction is a biotechnological refinement of conventional polymerase chain reaction methods that can be used to directly quantify and clonally amplify nucleic acids strands including DNA, cDNA, or RNA. The key difference between dPCR and traditional PCR lies in the method of measuring nucleic acids amounts, with the former being a more precise method than PCR, though also more prone to error in the hands of inexperienced users. A "digital" measurement quantitatively and discretely measures a certain variable, whereas an “analog” measurement extrapolates certain measurements based on measured patterns. PCR carries out one reaction per single sample. dPCR also carries out a single reaction within a sample, however the sample is separated into a large number of partitions and the reaction is carried out in each partition individually. This separation allows a more reliable collection and sensitive measurement of nucleic acid amounts. The method has been demonstrated as useful for studying variations in gene sequences — such as copy number variants and point mutations — and it is routinely used for clonal amplification of samples for next-generation sequencing.

Loop-mediated isothermal amplification (LAMP) is a single-tube technique for the amplification of DNA and a low-cost alternative to detect certain diseases. Reverse transcription loop-mediated isothermal amplification (RT-LAMP) combines LAMP with a reverse transcription step to allow the detection of RNA.

<span class="mw-page-title-main">Nucleic acid test</span> Group of techniques to detect a particular nucleic acid sequence

A nucleic acid test (NAT) is a technique used to detect a particular nucleic acid sequence and thus usually to detect and identify a particular species or subspecies of organism, often a virus or bacterium that acts as a pathogen in blood, tissue, urine, etc. NATs differ from other tests in that they detect genetic materials rather than antigens or antibodies. Detection of genetic materials allows an early diagnosis of a disease because the detection of antigens and/or antibodies requires time for them to start appearing in the bloodstream. Since the amount of a certain genetic material is usually very small, many NATs include a step that amplifies the genetic material—that is, makes many copies of it. Such NATs are called nucleic acid amplification tests (NAATs). There are several ways of amplification, including polymerase chain reaction (PCR), strand displacement assay (SDA), or transcription mediated assay (TMA).

Virus quantification is counting or calculating the number of virus particles (virions) in a sample to determine the virus concentration. It is used in both research and development (R&D) in academic and commercial laboratories as well as in production situations where the quantity of virus at various steps is an important variable that must be monitored. For example, the production of virus-based vaccines, recombinant proteins using viral vectors, and viral antigens all require virus quantification to continually monitor and/or modify the process in order to optimize product quality and production yields and to respond to ever changing demands and applications. Other examples of specific instances where viruses need to be quantified include clone screening, multiplicity of infection (MOI) optimization, and adaptation of methods to cell culture.

Recombinase polymerase amplification (RPA) is a single tube, isothermal alternative to the polymerase chain reaction (PCR). By adding a reverse transcriptase enzyme to an RPA reaction it can detect RNA as well as DNA, without the need for a separate step to produce cDNA,. Because it is isothermal, RPA can use much simpler equipment than PCR, which requires a thermal cycler. Operating best at temperatures of 37–42 °C and still working, albeit more slowly, at room temperature means RPA reactions can in theory be run quickly simply by holding a tube. This makes RPA an excellent candidate for developing low-cost, rapid, point-of-care molecular tests. An international quality assessment of molecular detection of Rift Valley fever virus performed as well as the best RT-PCR tests, detecting less concentrated samples missed by some PCR tests and an RT-LAMP test. RPA was developed and launched by TwistDx Ltd., a biotechnology company based in Cambridge, UK.

<span class="mw-page-title-main">Reverse Transcription Loop-mediated Isothermal Amplification</span>

Reverse transcription loop-mediated isothermal amplification (RT-LAMP) is a one step nucleic acid amplification method to multiply specific sequences of RNA. It is used to diagnose infectious disease caused by RNA viruses.

Viral load monitoring for HIV is the regular measurement of the viral load of individual HIV-positive people as part of their personal plan for treatment of HIV/AIDS. A count of the viral load is routine before the start of HIV treatment.

Clinical metagenomic next-generation sequencing (mNGS) is the comprehensive analysis of microbial and host genetic material in clinical samples from patients by next-generation sequencing. It uses the techniques of metagenomics to identify and characterize the genome of bacteria, fungi, parasites, and viruses without the need for a prior knowledge of a specific pathogen directly from clinical specimens. The capacity to detect all the potential pathogens in a sample makes metagenomic next generation sequencing a potent tool in the diagnosis of infectious disease especially when other more directed assays, such as PCR, fail. Its limitations include clinical utility, laboratory validity, sense and sensitivity, cost and regulatory considerations.

References

  1. Wölfel, Roman; Corman, Victor M.; Guggemos, Wolfgang; Seilmaier, Michael; Zange, Sabine; Müller, Marcel A.; Niemeyer, Daniela; Jones, Terry C.; Vollmar, Patrick; Rothe, Camilla; Hoelscher, Michael; Bleicker, Tobias; Brünink, Sebastian; Schneider, Julia; Ehmann, Rosina; Zwirglmaier, Katrin; Drosten, Christian; Wendtner, Clemens (2020). "Virological assessment of hospitalized patients with COVID-2019". Nature. 581 (7809): 465–469. Bibcode:2020Natur.581..465W. doi: 10.1038/s41586-020-2196-x . PMID   32235945.
  2. 1 2 Puren, Adrian; Gerlach, Jay L.; Weigl, Bernhard H.; Kelso, David M.; Domingo, Gonzalo J. (2010). "Laboratory Operations, Specimen Processing, and Handling for Viral Load Testing and Surveillance". The Journal of Infectious Diseases. 201: S27–36. doi: 10.1086/650390 . PMID   20225943.
  3. Shaheen, Mohamed N. F.; Elmahdy, Elmahdy M.; Chawla-Sarkar, Mamta (2019). "Quantitative PCR-based identification of enteric viruses contaminating fresh produce and surface water used for irrigation in Egypt". Environmental Science and Pollution Research. 26 (21): 21619–21628. doi:10.1007/s11356-019-05435-0. PMID   31129895. S2CID   167210903.
  4. Robilotti, Elizabeth; Deresinski, Stan; Pinsky, Benjamin A. (2015). "Norovirus". Clinical Microbiology Reviews. 28 (1): 134–164. doi:10.1128/CMR.00075-14. PMC   4284304 . PMID   25567225.
  5. Buckingham, L.; Flaws, M.L. (2007). Molecular Diagnostics Fundamentals, Methods, & Clinical Applications (PDF). F.A. Davis Company. pp. 121–154. ISBN   9780803616592 . Retrieved 7 September 2020.