ARTICLES
Interferon alfa-2a in Japanese encephalitis: a randomised
double-blind placebo-controlled trial
Tom Solomon, Nguyen Minh Dung, Bridget Wills, Rachel Kneen, Mary Gainsborough, Tran Vinh Diet, Tran Thi Nhu Thuy,
Ha Thi Loan, Vo Cong Khanh, David W Vaughn, Nicholas J White, Jeremy J Farrar
Summary
Background Japanese encephalitis virus (JEV), although
confined to Asia, causes about 35 000–50 000 cases and
10 000 deaths every year, and is the most important cause
of encephalitis worldwide. There is no known antiviral
treatment for any flavivirus. Results from in-vitro studies and
work in animals have shown inteferon alfa has antiviral
activity on Japanese encephalitis and other flaviviruses;
therefore, we aimed to assess the efficacy of inteferon alfa-
2a in Japanese encephalitis.
Methods We did a randomised double-blind placebo-
controlled trial of interferon alfa-2a (10 million units/m2, daily
for 7 days) in 112 Vietnamese children with suspected
Japanese encephalitis, 87 of whom had serologically
confirmed infections. Our primary endpoints were hospital
death or severe sequelae at discharge. Analysis was by
intention to treat.
Findings Overall, 21 children (19%) died, and 17 (15%) had
severe sequelae. Outcome at discharge and 3 months did
not differ between the two treatment groups; 20 children in
the interferon group had a poor outcome (death or severe
sequelae), compared with 18 in the placebo group (p=0·85,
difference 0·1%, 95% CI –17·5 to 17·6%), there were no long-
term side effects of interferon.
Interpretation The doses of interferon alfa-2a given in this
regimen did not improve the outcome of patients with
Japanese encephalitis.
Lancet 2003; 361: 821–26
Published online February 11, 2003
http://image.thelancet.com/extras/02art9329web.pdf
Department of Neurological Science, University of Liverpool,
Walton Centre for Neurology and Neurosurgery, Liverpool, UK
(T Solomon MRCP); Centre for Tropical Medicine, Nuffield
Department of Clinical Medicine, University of Oxford, Oxford, UK
(B Wills MRCP, Prof N J White FRCP, J J Farrar FRCP); Roald Dahl EEG
Unit, Royal Liverpool Children’s NHS Trust, Liverpool, UK
(R Kneen, MRCP); Hospital for Tropical Diseases, Ho Chi Minh City,
Vietnam (N M Dung MD, T V Diet MD, H T Loan MD, V C Khanh MD,
T T N Thuy MD); University of Oxford-Wellcome Trust Clinical
Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City
(T Solomon, BWills, R Kneen, M Gainsborough MRCP, J J Farrar);
Department of Virology, US Army Medical Component, Armed
Forces Research Institute of Medical Sciences, Bangkok, Thailand
(D W Vaughn MD); Wellcome Trust-Mahidol University-Oxford
Tropical Medicine Research Programme, Faculty of Tropical
Medicine, Mahidol University, Bangkok (N J White).
Correspondence to: Dr Tom Solomon, Department of Neurological
Science, University of Liverpool, Walton Centre for Neurology and
Neurosurgery, Lower Lane, Fazakerley, Liverpool L9 7LJ, UK.
(e-mail: tsolomon@liv.ac.uk)
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For personal use. Only reproduce with permission from The Lancet Publishing Group.
Introduction
Encephalitis caused by arthropod-borne viruses
(arboviruses) is recognised as an increasingly important
problem.1 For example during 2002, West Nile virus, a
member of the genus Flavivirus family Flaviviridae, caused
its largest ever encephalitis outbreak with more than 3800
cases and 225 deaths, in North America.2 However the
most important member of this serogroup wordwide is
the closely related flavivirus, Japanese encephalitis
virus (JEV) which causes about 35 000–50 000 cases and
10 000 deaths per year.3 JEV is a small single-stranded
positive-sense RNA virus transmitted between birds, pigs,
and other vertebrate hosts by mosquitoes, mainly Culex
tritaeniorhynchus. JEV occurs in southeast Asia, China, the
pacific rim, and Asian subcontinent, but its geographical
range is expanding, with recent outbreaks in Nepal and
northern Australia.4 In rural Asian countries most people
are infected during childhood, but few infections in
human beings result in symptoms. If disease does occur,
patients usually present with severe meningoencephalitis,
which is often associated with seizures.5 A smaller
proportion present with aseptic meningitis, or a
poliomyelitis-like acute flaccid paralysis.6 Roughly 30% of
patients with Japanese encephalitis die, and half of
survivors have severe neurological sequelae, which
imposes a large socioeconomic burden in the poor rural
settings where Japanese encephalitis occurs.
In addition to JEV and West Nile virus, other
flaviviruses that cause encephalitis include: St Louis
encephalitis virus, which is endemic in the Americas;
Murray Valley encephalitis virus, present in Australasia;
and tick-borne encephalitis virus that occurs across
Europe and the former Soviet Union.7 There is no known
effective antiviral treatment for these or any of the other
diseases caused by flaviviruses, such as dengue and yellow
fever. Indeed, until now, none has been assessed in a
controlled trial. For many years, corticosteroids have been
used for Japanese encephalitis, but a randomised placebo-
controlled trial of dexamethasone in 40 patients showed
no benefit of this treatment.8
Interferon alfa is a glycoprotein cytokine that is
produced naturally in response to viral infections,
including Japanese encaphalitis.9 Interferons are not
directly antiviral, but induce production of effector
proteins in cells, which inhibit various stages of viral
replication, assembly, or release.10 Recombinant interfer-
on alfa has become the standard treatment for chronic
hepatitis B and C. In tissue culture, recombinant
interferon is effective against JEV and other arboviruses,
including West Nile virus.11,12 This treatment has been
given to 14 Thai patients with Japanese encephalitis, and
although there has been a suggestion of benefit,13,14 there
have been no randomised double-blind trials of
interferon alfa in any viral encephalitis. We aimed to
assess the efficacy of interferon alfa-2a for Japanese
encaphalitis.
821
ARTICLES
Methods
Patients
Patients were recruited from the paediatric intensive-care
unit at the Centre for Tropical Diseases, an infectious
diseases referral centre for southern Vietnam in Ho Chi
Minh city. The study protocol was approved by the
hospital’s scientific and ethical committee, and informed
consent was obtained from the accompanying relative.
Between October, 1996 and October, 1999, we recruited
children aged between 1 and 15 years who had clinically
diagnosed viral encephalitis. On the basis of results from
previous studies,5,6,15 encephalitis was diagnosed clinically in
children who had a history of fever that lasted less than 14
days, and who had either convulsions or altered
consciousness (Glasgow coma score ⬍15,16 or for children
younger than 6 years, Blantyre coma score ⬍517); and a
cerebrospinal fluid (CSF) cell count less than 1000 cells per
␮L, a ratio of cerebrospinal fluid to plasma glucose greater
than 40%, and a negative CSF gram stain. JEV was
confirmed by virological tests. We excluded children aged
between 6 months and 5 years who had had simple febrile
convulsion.18,19 We also excluded those with epilepsy, a
positive blood slide for asexual Plasmodium falciparum
parasites or malaria pigment,20 and those referred from a
peripheral health centre who had features suggestive of
bacterial meningitis and for whom antibiotic treatment was
documented.
Procedures
Because patients with severe neurological sequelae make
an important contribution to the disease burden of
Japanese encephalitis, we decided that to have death as the
only primary endpoint was not appropriate. Therefore,
primary endpoints were hospital deaths or severe sequelae
at discharge. We assessed patients at discharge for
disability in a range of activities (speech, comprehension,
feeding, sitting, standing, walking, urinary continence, and
faecal continence) and did neurological examinations.
Patient outcomes were then classified into one of five
predetermined outcome categories:5,21 (1) death; (2) severe
sequelae (at least one disability that would make the child
unable to function independently); (3) moderate sequelae
(disability that affects function, but would not render the
child dependent, or epilepsy not controlled with drugs);
(4) minor sequelae (abnormality detected by neurological
examination only, personality change as reported by
parents, or epilepsy controlled with drugs); and (5) full
recovery. 9 months after the study began, because we
became increasingly aware that flaccid paralysis makes an
important contribution to the morbidity of Japanese
encephalitis,6 we decided to distinguish between the
patients with moderate sequelae who could walk, and
those who could not. For analysis, children who died or
who had severe sequelae were defined as having poor
outcome, whereas those who made a full recovery, or had
moderate or mild sequelae were the better outcome
group.5
Results from a preliminary prospective pilot study of 50
patients with Japanese encephalitis seen over 12 months
showed that 44% had poor outcome.21 Our study was
designed to show a two-thirds reduction in this proportion
to 15%, with 95% confidence and 80% power, and
allowance for a dropout rate of 10%. Time to death, to
recover from coma, to sit independently, to stand
independently, to walk at least 5 m independently, and to
leave hospital were chosen as secondary outcome measures.
Furthermore, we modified the Denver developmental
assessment test22 to a simple score by awarding 1–4 points
according to whether a child was normal or abnormal for
822
For personal use. Only reproduce with permission from The Lancet Publishing Group.
their age for each of the following categories: gross motor
skills, fine motor skills and vision, hearing and speech, and
social skills. An interim analysis was done by the study
monitor after 40 patients.
We randomly allocated patients to a treatment using
blocks of 20, and the code for each patient was kept in a
sealed envelope in a locked cupboard on a separate ward.
Once a patient was enrolled, technicians who were not
otherwise connected with the study, opened the envelope,
drew up the study drug, and delivered it to the study ward,
where nurses gave the treatment. Children received either
interferon alfa-2a (Roche Pharmaceuticals, Basel,
Switzerland) at a dose of 10 million units/m2 of body
surface area, or the same volume of sterile water as an
intramuscular injection daily for 7 days. We used a
normogram to calculate body surface area from patient
height and weight. The two substances used in the study
were identical in colour, viscosity, and volume. A second
sealed envelope was kept at the back of each patient’s study
notes incase a physician urgently needed to know which
drug a patient had received.
We took a detailed history and a member of the study
team did daily clinical and neurological examinations (or
more frequently if needed) until death, stabilisation, or
discharge. Information was recorded on standardised
forms. On admission, we did a lumbar puncture with
patients in the left lateral position, and if the patient was
calm the opening pressure was measured with a spinal-fluid
manometer. This procedure was delayed in patients who
were convulsing, or those with clinical signs of raised
intracranial pressure.5 If a patient died before lumbar
puncture could be done, cerebrospinal fluid was taken
immediately after death for diagnosis. We did cell counts
and differentials, measured protein, glucose, lactate, did
gram stain, and bacterial culture on the CSF. Blood was
tested for packed cell volume, malaria parasites, platelet
and differential white cell counts, and we did glucose,
lactate, and biochemical screens, and viral serological tests.
To diagnose JEV we measured anti-JEV IgM and IgG
antibodies in serum, and CSF with a double sandwich
capture ELISA that distinguishes between JEV antibodies
and dengue antibodies.23,24
To monitor side-effects of interferon treatment, we did a
full blood count daily, and liver function test twice a week
during the admission. We planned to stop the study drug if
a patient became neutropenic, and give these patients
broad spectrum antibiotics. Other adverse events were
graded according to WHO recommendations.25 Electro-
encephalography was done on admission, day 2, day 7, and
as indicated clinically. We took a second serum and
cerobrospinal fluid sample on day 7 to increase the chance
of detection of JEV IgM antibodies.23
There were no onsite facilities for acute CT or MRI,
but some patients were referred to a local centre for such
imaging once their condition had stabilised. Prolonged or
repeated seizures were treated with diazepam
(0·25 mg/kg), followed if necessary by intravenous
phenobarbital (10 mg/kg), but we did not have the
facilities to paralyse and electively ventilate patients in
status epilepticus. Mannitol (0·5–1 g/kg) was given at the
discretion of the admitting physician, and suspected
septicaemia was treated with broad-spectrum antibiotics.
At discharge and at 3-months’ follow up, we did a
physical and neurological examination, and assessed
development. Patients who did not return for follow-up
were reminded by letter, and if they were unable to return
to the hospital, we did the examination at their home. At
follow-up, we took particular note of seizures, progress at
school, and changes in personality.
THE LANCET • Vol 361 • March 8, 2003 • www.thelancet.com
 ARTICLES

Statistical analysies Interferon Placebo

The analysis was by intention to treat. Normally distributed (n=59) (n=53)
data were compared with Student’s t test; those that were Demographics and history
not normally distributed were compared with the Mann- Boys 32 (54%) 33 (62%)
Whitney U test. We tested differences between proportions Age (years) 6 (1–14) 8 (1.9–14)
using the ␹2 test with Yates’ correction or Fisher’s exact From rural location 53 (90%) 45 (85%)
test. Time to death and recovery times were analysed by Length of illness (days) 5 (2–11) 5 (1–13)
⭓7 days illness 17 (29%) 11 (21%)
survival analysis with the Peto-Peto-Wilcoxon test (Epi Info Headache 35 (59%) 37 (70%)
version 6 and StatView 4.02). Rigor 21 (36%) 18 (34%)
Vomiting 33 (57%) 35 (67%)
Role of the funding source Neck stiffness 26 (45%) 26 (49%)
The sponsors of this study had no role in study design, Rigidity spasm 17 (29%) 14 (27%)
Convulsion 34 (59%) 25 (47%)
data collection, data analysis, data interpretation, or >one convulsion 17 (29%) 17 (32%)
writing of the report.
Signs on admission
Temperature 38·5º (37-40) 38.0º (37-41)
Results Pulse (beats per minute) 120 (80-200) 120 (60-160)
Between Oct 1, 1996, and Oct 15, 1999, 117 patients met Respiration (breaths per minute) 28 (20-60) 28 (20-65)
the entry criteria. 61 (52%) were randomly allocated to Response to menace 21 (35%) 23 (43%)
receive interferon and 56 (48%) to receive placebo Coma* 46 (78%) 34 (64%)
(figure 1). Five patients (two in the interferon group) were Able to localise pain 24 (41%) 27 (51%)
Seizure 8 (14%) 3 (6%)
transferred to other hospitals when other diagnoses Rigidity spasm 15 (25%) 12 (23%)
became apparent, and thus data from these patients could Meningism 32 (54%) 36 (68%)
not be included in analyses. Three of these patients had Facial nerve palsy 7 (12%) 2 (4%)
tuberculous meningitis, one had a cerebral haematoma, Hemiparesis 8 (14%) 4 (8%)
and one had cerebral effusion revealed by CT. Thus, 59 Flaccid limbs 13 (22%) 10 (19%)
Absent abdominal reflex 45 (76%) 38 (72%)
patients in the interferon group, and 53 in the placebo
Increased limb tone 26 (44%) 25 (47%)
group could be assessed. Our analyses included one Clonus 12 (20%) 4 (8%)
patient who died, and two who had fully recovered Opisthotonus 3 (5%) 4 (8%)
consciousness before the study drug could be given, and Decerebrate/decorticate posturing 14 (24%) 12 (23%)
one for whom the drug was not available. There was one Investigations
breach of the randomisation protocol when the wrong Positive for Japanese 45 (76%) 42 (79%)
envelope was opened for a patient. However, because encephalitis virus
treatment allocation remained concealed from the patient Admission WCC⫻109/L 12·5 (5.0–37.5) 13.8 (1.6–33.8)
Admission AST (U/L) 420 (160–2000) 460 (150–1790)
and those treating her, we did not exclude her results; she
CSF opening pressure (cm CSF)† 17 (5–33·5) 17 (6–33·0)
was given placebo and analysed in the placebo group. The CSF WCC/mL 90 (0–540) 40 (0–492)
code did not need to be broken for any patient, but the
*Coma defined as Glasgow coma score <15 or for children aged <6 years,
study drug was discontinued in one patient (in the Blantyre coma score <5. †Opening pressure was measured for 48 (81%) of the
placebo group) when we noted that his creatinine interferon group, and 38 (72%) of the placebo group. WCC=white cell count.
concentration at admission was 10 g/L. The daily median AST=aspartate aminotransferase. Data are number (%) or median (range).
dose of interferon in the treatment group was 7·6 (range Table 1: Patients’ data at admission
4·8–14·2) million units, which is equivalent to 10·9
(10·4–11·2) million units/m2 daily.
Table 1 shows that baseline characteristics between the
117 patients two groups did not differ, with the exception of white-cell
randomised count in CSF, which was higher in the treatment group
than it was in placebo (p=0·037). Seven patients (six who
tested positive for JEV, three in the interferon group) had
initially presented fully conscious with acute flaccid
61 assigned 56 assigned paralysis, but were entered into the study when their level
interferon alfa 2a placebo of consciousness dropped. 45 (76%) patients in the
interferon group, and 42 (79%) in the placebo group were
positive for JEV. In 78 patients, we diagnosed Japanese
2 transferred to 3 transferred to
another hospital another hospital
encephalitis on the basis of raised anti-JEV IgM in serum
1 with haematoma 2 with tuberculous
1 with tuberculous meningitis At discharge* 3 months’ follow-up†
meningitis 1 with effusion
Interferon Placebo Interferon Placebo
(n=59) (n=53) (n=57) (n=50)
59 analysed at 53 analysed at Poor outcome 20 (34%) 18 (34%) 16 (28) 13 (26)
discharge discharge Death 10 (17%) 11 (21%) 10 (18%) 11 (22%)
Severe sequelae 10 (17%) 7 (13%) 6 (11%) 2 (4%
Better outcome 39 (66%) 35 (66%) 41 (72%) 37 (74%)
10 died 11 died
Moderate sequelae
2 lost to follow-up 3 lost to follow-up
Unable to walk‡ 2 (3%) 2 (4%) 1 (2%) 1 (2%)
Able to walk‡ 11 (19%) 11 (21%) 7 (12%) 7 (14%)
47 alive and 39 alive and Minor sequelae 16 (27%) 11 (21%) 15 (26%) 10 (20%)
followed-up at followed-up at Full recovery 10 (17%) 11 (21%) 18 (32%) 19 (38%)
3 months 3 months *␹2=1·233, p=0·942. †␹2=2·628, p=0·757. ‡Defined as ability to walk 5 m
independently.
Figure 1: Trial profile Table 2: Outcome at discharge and at 3 months

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ARTICLES

1 Interferon alfa-2a Children in the interferon group took slightly longer to

talk, achieve a normal coma score, sit independently, walk
0·8 independently, and to leave hospital than did those in the
Cunulative survival

placebo group, although these differences were not

Placebo
0·6
0·4 p=0·516
0·2
0 Of the 17 patients with severe sequelae at discharge,
0 20 40 60 80
Time since randomisation (days)
Figure 2: Kaplan-Meier survival curve
and cerebrospinal fluid, and in eight patients, the diagnosis
was made on the basis of such concentrations in serum
only. One patient had a primary, and one had a probable
secondary dengue virus infection.15 Serological
investigations were inconclusive in four patients who died
soon after admission (two in the interferon group), because
we had only admission serum samples. Results from
serological analysis excluded flavivirus infections in 18
patients: one was diagnosed clinically with probable herpes
encephalitis, two with epilepsy, and one with acute motor
axonal neuropathy and encephalopathy. For the remaining
14 patients, the cause of their neurological disease was
not identified. At discharge, 38 patients had poor outcome
(21 died, 17 had severe sequelae), and 74 were in the
better outcome group (26 with moderate sequelae, 27 with
minor sequelae, and 21 who seemed to have made a full
recovery). Overall outcome at discharge did not differ
between the treatment groups (table 2); 20 (33·9%) in
the interferon group, and 18 (34·0%) in the placebo group
had a poor outcome (difference 0·1, 95% CI–17·5 to 17·6,
p=0·85). Likewise, results of subgroup analysis of the
87 JEV-positive patients showed little difference in
outcome between the two treatments (16 [35%] of
45 given interferon had poor outcome vs 14 [33%] of
42 on placebo, difference 2·2, 95% CI [–17·8 to 22·2]
p=0·99) or in the 109 patients who received study drug.
There was a trend towards a longer time to death in
the interferon group than in the placebo group (median
120 h [range 7–1632] vs 28 [1–2064]; p=0·091); although
Kaplan-Meier analysis showed no significant difference in
overall survival between the two groups (figure 2).
significant (table 3). 48 patients were given diazepam for
convulsions or spasms, 39 received phenobarbital, and five
phenytoin. 82 patients were treated with mannitol, five
received dexamethasone, four were given major
tranquillisers, and 68 were treated with antibiotics.
However, frequency of these ancillary treatments did not
differ between the two groups.
14 had severe cognitive impairment (eight of whom also
100 had severe motor impairment), one patient had continuing
confusion, and two had gross flaccid paralysis. 18 of the
26 patients with moderate sequelae had motor problems:
nine spastic, five flaccid, three cerebellar, and one with
dysarthria. Of the remaining eight with moderate sequelae,
there were four with mild cognitive impairment, two who,
despite treatment, had continuing convulsions, and two
with a homonomous hemianopia. 17 of the 27 patients
with mild sequelae had pyramidal tract, cerebellar signs, or
both, that did not affect function. For the remaining ten
cases, the child’s parents reported a change in affect
or behaviour (eg, child was slow to answer questions or
had disinhibited behaviour). Overall, 11 patients had
extrapyramidal motor signs—seven cerebellar, three with
Parkinsonian features, and one with hemiballismus.
86 (95%) of 91 non-fatal cases were assessed at
3 months’ follow-up. One of these children was still in
hospital at this time, but died there 6 months later. The
five children who were not followed up included one with
severe sequelae and four with mild or no sequelae at
discharge. Median time to follow-up was 92 days
(40–186), and did not differ between treatment groups.
Outcome at 3 months did not differ significantly between
the two treatment groups (table 2). 16 (28%) in the
interferon group, and 13 (26%) in the placebo group had a
poor outcome (difference 2·1, [95% CI –14·8 to 18·9],
p=0·98) 43 (50%) children had no change in outcome
score, 39 (45%) had improved, and four (5%) had
deteriorated. For three children whose condition had
worsened, changes in short-term memory, personality, or
both had become apparent; the fourth showed striking
deterioration in motor and cognitive abilities. In total, for
21 children (ten placebo, 11 interferon) who seemed to
have made a full or almost full physical recovery at
discharge, parents reported personality changes (eg, easily

Interferon (n=59) Placebo (n=53) Relative risk (95%CI) p

Adverse effects of treatment
Highest temperature in first 24 h (mean [SD]) 39·1 (0·8) 38·8 (1·1) ·· 0·115
Highest temperature first 48 h (mean [SD]) 39·4 (0·8) 39·3 (0·9) ·· 0·72
Pneumonia 21 (36) 13 (25) 1·45 (0·81–2·6) 0·286
Minimum WCC⫻109/L (median [range]) 5·45 (1·8–17·37) 6·52 (1·6–22·6) ·· 0·001
Leucopenia (number [%]) 15 (25) 3 (5) 4·49 (1·38-14·66) 0·01
AST doubled (number [%]) 17 (29) 5 (10) 3·05 91·21–7·71) 0·019
AST rose to >60 U/L 38 (64) 23 (43) 1·48 (1·03–2·13) 0·041
Maximum AST (median [range]) 95·1 (20-593) 59·0 (20–187) ·· 0·018
Day of maximum AST (median [range]) 4 (1-8) 1 (1–8) ·· 0·005
Recovery*
Days (median [range], number of patients) to:
Full coma score 7 (1–107), 44 5 (1–94), 39 ·· 0·1
Talk 6 (1–107), 44 5 (1–96), 39 ·· 0·181
Sit independently 9·5 (1–103), 45 8 (1–42), 40 ·· 0·41
Walk at least 5 m unaided 10·5 (1–97), 42 9·5 (3–96), 38 ·· 0·377
Leave hospital 22·5 (9–272), 39 20 (8–115), 32 ·· 0·243
Time for fever to remain <37·5º for 24 h 5 (1–14), 52 6 (1–14), 45 0·707
WCC=white cell count, AST=aspartate aminotransferase *Median recovery times are shown only for patients that recovered, but all children were inlcuded in survival
analysis (p values).
Table 3: Recovery and adverse events

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becoming upset or angry), difficulties with short-term
memory, or concentration at school. Developmental scores
were below normal for age in 18 (21%) of 86 patients.
In the patient for whom the study drug had to be
stopped, creatinine concentration rose further to 14·7 g/L,
but returned to normal after peritoneal dialysis. No patient
in either group developed neutropenia, but leucopenia and
raised aspartate aminotransferase were significantly more
common in the interferon group (table 3). However, only
three patients (in the interferon group) had an AST
concentration greater than 200 U/L which was returning to
normal at the time of discharge. Pneumonia was frequent
in both groups. Three children in the interferon group had
urinary tract infections, two (one in each group) had skin
infections, and two (one in each group) had measles. No
patient had reactions at the injection site. One patient in
the interferon group developed a transient maculopapular
rash on the last day of treatment, which resolved
spontaneously.
Discussion
Our results show that intramuscular interferon alfa-2a did
not improve the outcome of children with Japanese
encephalitis, either at discharge or at 3 months’ follow-up.
Although the overall death rate (19%) was lower than that
generally reported for Japanese encephalitis,4 both
mortality and morbidity were similar to those expected on
the basis of our previous work.5 Patients given interferon
were significantly more likely to develop leucopenia and
have raised transaminases, but they were no more likely to
develop nosocomial infections or other serious
complications. Patients on interferon treatment are more
likely to feel febrile and unwell, which can lead to
unblinding and bias in some studies. However, in our
study all patients were febrile and comatose, so this was
not an issue. However, the patients in the interferon
treatment group tended to have longer recovery times for
coma score, talking, sitting, walking, and leaving hospital,
which might have been related to these non-specific effects
of interferon treatment.
We chose outcome at discharge as our primary endpoint
because we were not sure how many patients we would be
able to follow up, but 95% of patients were followed up at
3 months, As expected, most patients improved between
discharge and follow-up, but for many of those who were
apparently normal, or who had only mild physical
disability at discharge, other difficulties became evident.
Therefore, what has previously been considered a good
outcome in Japanese encephalitis might not be so. To
provide further information about the long-term effects of
this disease, longer follow-up and more detailed
developmental assessments are needed.
Results from work in animals have shown that JEV
produces a severe acute inflammatory reaction similar to
that seen in people. In vitro, and in animal models,
interferon and interferon-inducers have antiviral activity
against JEV.26 For example in LLC-Mk2 cells (from
rhesus-monkey kidney) infected with JEV, interferon at a
concentration of 9·1 units/100 µL gave 50% inhibition of
cytopathic effects.27 To achieve this concentration in an
average child with volume of distribution of 4 L would
require a total dose of 0·4 million units. In an open study,
interferon alfa was given to two Thai children with
Japanese encephalitis at doses of about 2·5–7·5 million
units/m2 per day. Our aim was to give the maximum dose
of interferon alfa that we thought could be tolerated
(10 million units/m2 per day), which should have been
more than sufficient to inhibit viral replication. However,
although these quantities would be therapeutic in serum,
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ARTICLES
whether this translates to therapeutic doses in the brain
parenchyma is not known. The proportion of interferon
alfa detected in the cerebrospinal fluid after parenteral
administration is usually low,28 although it could be higher
when the blood-brain barrier is disrupted, as happens in
meningoencephalitis. In our study the trend for interferon
to delay death by about 90 h could have been the result of
an effect of the drug on viral replication.
Although interferon treatment was not effective in our
small study, it might be effective if given in higher doses,
via alternative routes, or in combination with other
antiviral drugs. Other compounds shown to have some
efficacy against neurogenic flaviviruses in vitro, or in
animal models include isoquinolones, monoclonal
antibodies, the lymphocyte modulator concanavalin A, the
fungal metabolite brefeldin A, nitric oxide, and nucleoside
analogues, including ribavirin.29 In cases of rabies
encephalitis, up to 100 million units/m2 of interferon has
been given intravenously, in combination with
intraventricular interferon and intraventricular and
intravenous ribavirin.30 In a similar approach,
intraventricular interferon was used in combination with
ribavirin and inosine pranobex in subacute sclerosing
panencephalitis.31 However, in both these diseases the
outcome for patients was disappointing. Interferon was
given via the intraventricular route to one of the two Thai
children with Japanese encephalitis,13 but this route is not
practical in most of the areas where the disease occurs.
However, such approaches might be suitable for
encephalitis caused by flaviviruses in other settings, for
example West Nile encephalitis in the USA.
Our results show no evidence of any benefit from
interferon alfa in the treatment of Japanese encephalitis.
Whether treatment with higher doses via alternative routes,
perhaps in combination with other drugs, and possibly
earlier in the disease, would be beneficial in flavivirus
encephalitis remains to be seen—although the cost of such
treatments in areas where Japanese encephalitis is endemic
is likely to be prohibitive. Despite the availability of
vaccines, Japanese encephalitis continues to cause high
morbidity and mortality in southern and eastern Asia. In
view of the continuing spread of JEV, West Nile virus, and
other closely related viruses, there is an urgent need for
more research into the treatment of flavivirus encephalitis.
Contributors
T Solomon, N M Dung, R Kneen, H T Loan, and N J White conceived
the idea for, and designed, the study. T Solomon, N M Dung, R Kneen,
B Wills, M Gainsborough, T V Diet, T T N Thuy, V C Khanh,
D W Vaughn, N J White, and J Farrar interpreted the findings and wrote
the manuscript.
Conflict of interest statement
None declared.
Acknowledgments
We thank the director and staff of the Centre for Tropical Diseases
for their support, in particular Tran Tinh Hien and the doctors and nurses
of the paediatric intensive care units, and ward Nhiem C, Delia Bethell,
Christopher Parry, and John Wain; Nick Day, Tim Endy, Jane Cardosa,
and David Chadwick for their helpful advice; Ananda Nisalak,
Nguyen Thi Thu Qugen, Pham Thi Doan, and Michael Humphries
provided laboratory support. The study was funded by the Wellcome
Trust of Great Britain. The Roche Asian Research Foundation provided
the Roferon used.
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