HEPATITIS B

Dr. Ruqaiyah Nadeem

Dr.Ruqaiyah 1
 Introduction
• Hepatitis was first described as early as 5th century.
• First documented blood borne outbreak occurred in
Bremen, Germany in 1883.
• 1947:MacCallum and Bauer introduced the term
Hepatitis B , later adopted by WHO(1973)
• 1965:Blumberg and his coworkers described the a
protein antigen: Australia antigen
• 1970:Dane and his coworkers described the
complete Hepatitis B or Dane particle.
• 1972: Magnius and Espmark described the HBeAg.

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 Taxonomy
• Group: Group VII(ds DNA RT)
• Order: Unassigned
• Family:

Hepadnaviridae Avihepadnaviridae Not assingned

• Genus: Orthohepadnavirus
• Species:

Hepatitis B Ground Squirrel Wood Chuck Wolly Monkey

Hepa. Hepa. Hepa.
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Morphology

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 Continued….
• Three distinct
morphological entities in
various proportions are
seen:
 Small,pleomorphic,spherical
particles(22nm):most
abundant
 Tubular or filamentous
(200nm long)
 Complete HBV virion(42nm)

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 Viral antigens
• HbsAg
• HbcAg
• HbeAg
• Anti- HBs
• Anti- HBc
• Anti- Hbe

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• HBsAg is antigenically complex
• Group reactive antigen- a
• Type specific antigen- d/y and w/r

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Typing of HBV
Serotypes
• Its divided into 4 serotypes adr, adw, ayr, ayw

Genotypes
• Eight genotypes A- H

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 Genome
Gene Regions Antigen
S S Major protein(S) HBsAg

(Having 3 regions S,S1,Pre S2) S+ Pre S2 Middle protein(M)

S+ Pre S1& S2 Large protein(L):Present only in virion

C C HBcAg

(Having 2 regions C & Pre C) C+ Pre C HBeAg

P DNA Polymerase

X HBxAg(Not particulate antigen)

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 Genome
• Genome is approx. 3200 base long and contains
overlapping genes.

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Virus Replication

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 Epidemiology
• Reservoir of infection
– Cases
– Carriers
• Carriers
– Simple carriers
– Super carriers
• Prevalence
– Low endemicity- <2 %. Nepal, SriLanka
– Intermediate endemicity- 2-8%. India, bhutan,
Indonesia, Maldives
– High endemicity- >8 %. Bangladesh, korea
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• 2 billion people have been infected (1 out of 3
people).
• 350 million people are chronically infected.
• An estimated 6 lakh people die each year from
hepatitis B and its complications.

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 In India
• The average estimated carrier rate of hepatitis B
virus (HBV) is 3.7%.
• An approximate total of 40 million HBV carriers
• South indians have high carrier rates
• Second most common cause of acute hepatitis after
HEV.

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Age
• Chance of developing acute hepatitis is directly
related to age
• 1% (perinatal)
• 10 % (early childhood)
• 30 % ( late childhood)
• Chance of developing chronic hepatitis is inversely
proportional to age
• 80-90 % (perinatal)
• 30% (early childhood)
• 5% (late childhood)

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 Clinical manifestations
• Incubation period 30-180 days
• It is indistinguishable from other hepatitis viruses
• Pre-icteric phase- nausea, vomiting
• Icteric phase- jaundice
• Hepatic complications- fulminant hepatitis, cirrhosis,
HCC

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 Phase HBeAg serological status Pattern Indications for treatment

1. “Immune tolerant” HBeAg positive • Stage seen in many HBeAg-positive children and young Treatment not generally

Continued…
adults, particularly among those infected at birth
• High levels of HBV replication (HBV DNA levels >200 000
IU/mL))
indicated, but monitoring
required

• Persistently normal ALT

• Minimal histological disease

• 4 phases
2. “Immune active” HBeAg positive; may • Abnormal or intermittently abnormal ALT Treatment may be
(HBeAg-positivea develop anti-HBe • High or fluctuating levels of HBV replication (HBV DNA indicated
 Immuno tolerancelevels
chronic hepatitis) >2000 IU/mL)
Histological necroinflammatory activity present
• HBeAg to anti-HBe seroconversion possible, with
 Immuno clearancenormalization of ALT leading to “immune-control” phase
3. Inactive chronic HBeAg negative, anti- • Persistently normal ALT Treatment not generally

control”  Inactive HBsAg carrier

hepatitis “Immune HBe positive • Low or undetectable HBV DNA ( HBV DNA levels <2000 indicated, but monitoring
IU/mL) required for reactivation
(previously called • Risk of cirrhosis and HCC reduced and HCC
 HBeAg
inactive carrier)
4. “Immune escape”
– CHB • May develop HBeAg-negative disease
HBeAg negative, with or • HBeAg negative and anti-HBe positive Treatment may be
(HBeAg-negative without being anti-HBe • Abnormal ALT (persistent or intermittently abnormal) indicated
 Occult Hepatitis B•>20
chronic hepatitis) positive Moderate to high levels of HBV replication (HBV DNA levels
000 IU/mL)
• Older persons especially at risk for progressive disease
(fibrosis/cirrhosis)

5.“Reactivation” or HBeAg positive or • Can occur spontaneously or be precipitated by Treatment indicated

“acute-on-chronic negative immunosuppression from chemo– or immunosuppressive
hepatitis” therapy, HIV infection or transplantation, development of
antiviral resistance, or withdrawal of antiviral therapy
• Abnormal ALT
• Moderate to high levels of HBV replication
• Seroreversion to HBeAg positivity can occur if HBeAg
negative
• High risk of decompensation in presence of cirrhosis
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 Collection, Transport and Storage
of Specimens
• HBV infection is diagnosed by serological and
molecular methods using serum and plasma.
• In general HBV antigens and antibodies are stable at
room temperature for several hours to days,can be
stored at 4ᴼC for months and can be frozen at -20ᴼC
to -70ᴼC for many years.

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Lab diagnosis

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 HBsAg
• Appears in 1-12 weeks of infection (8-12 wks)
• Presence indicates onset of infectivity
• Becomes undetectable 1-2 months after
jaundice
• Used to calculate prevalence

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 HBeAg and HBV DNA
• Appear shortly after appearance of HBsAg
• They are markers of-
– Active viral replication
– High viral infectivity
• They cannot differentiate stages

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 HBcAg
• Non-secretory
• Hepatocytes by immunofluorescence

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 Anti-HBc IgM
• Appears 1-2 wks after HBsAg and lasts for 3-6
month
• Indicates acute infection

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 Anti- HBc IgG
• Appears in late stage and remains positive
indefinitely
• Chronic stage
• Carrier stage
• Recovery

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 Total Anti HBc
• Negative indicates that a person has not been
infected with HBV.
• Indicate Acute: (HBsAg +ve; IgM Anti HBc +ve)
Resolved(HBsAg –ve)
Chronic(HBsAg +ve)

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 Anti- HBe
• Appear after clearance of HBeAg
• Indicates diminished replication and
decreased infectivity

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 Anti -HBs
• Appears after clearance of HBsAg remains
indifinetly
• Indicates recovery, immunity, non infectivity
• Marker of hepatitis B vaccination

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Detection Methods

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Detection Methods:

Antigenic

Molecular

Serological

Others: Biochem,Microscopy,Culture

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 Microscopy

• Microscopic detection of HBV does not play a specific

role in the Diagnosis of disease.
• However liver Biopsy is typically used to assess the
extent of Histologic involvement and damage as well
as a response to therapy.

Culture
• Athough HBV can infect hepatocytes in vitro,culture
of HBV is not used for the diagnosis of infection.

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 Antigen Detection
• A marker of active viral replication is the detection of
HBsAg and/or HBeAg during primary infection and
during Chronic HBV infection.
• Both the antigens are produced in excess by the
infected hepatocytes.
• Detected by:
 ELISA
 Immunochromatographic tests
 Enzyme inmmunoassays Detects >=0.1ng/ml
 Radio immunoassays
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 HBsAg
• Approved by FDA for Diagnostic use only.
• Any specimen nonreactive for HBsAg are considered
negative and do not require further testing.
• Those reactive must be repeated to verify the
positive test by a Neutralization assay.
• If the neutralization assay comes negative then a
new specimen should be requested and/or a
recommendation that the patient be tested for other
markers of infection.
• Some mutant HBsAg can be missed by commercial
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 Nucleic Acid Detection:Quantitative
• Recommended for initial evaluation of Chronic
Hepatitis B and during management, particularly in
the decision making to initiate treatment and in
therapeutic monitoring.
 Criteria for Chronic HB:>=20,000IU/ml

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 HBV genotyping
• HBV genotype potential influence the outcome of
Chronic Hepatitis B and the success of antiviral therapy.
• Genotype B has more favorable outcome than C.
• Genotyping is more important for IFN therapy as A
have more changes of seroconversion than D.
• Methods:
 Genome Sequencing
 RFLP
 Genotype specific Amplification techniques
 Hybridization techniques

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 Detecting Core promoter/Pre core
mutation
• PCR plus hybridisation format detects
 Basal core promoter nucleotide 1762
 Basal core promoter nucleotide 1964
 Precore codon 28
• Hybridisation/direct sequencing
 Basal core promoter nucleotide 1964
 Precore codon 28

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 Biochemistry
• Serum Transaminases
 ALT> AST but this reverses once Cirrhosis sets in.
• Direct and Total Bilirubin
 0.3- 1 mg/100ml
• Albumin and Total protein
 Albumin 4-5.5 mg/100ml
• Coagulation tests
 Prothrombin time(11-12.5 sec) increases
• Alpha feto protein

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Evaluation, Interpretation and
Reporting of Results

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 HBV Markers in different Stages:
Stage of HBV HBsAg HBeAg Anti- Anti- Anti- Anti-
infection DNA HBc HBc HBe HBs
Ig M Total

Susceptible _ _ _ _ _ _ _

Early + _ _ _ _ _ _
incubation

Late + + +/_ _ _ _ _
incubation

Acute + + + + _ _ _
infection

Recent _/+ _ _ + + + +++

infection
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Stage of HBV DNA HBsAg HBeAg Anti-HBc Anti- Anti- Anti-
infection Ig M HBc HBe HBs
Total
Remote _ or very _ _ _ + +/_ +
infection low
HBsAg-ve _ _ _ + + _ _
Acute infect

HBsAg _/+ _ _/+ +/_ + _ _

variant
infect.
Immune ++ + _/+ _/+ +++ _ _
active
carrier
Healthy _ + _ _ + + _
HBsAg
carrier
Vaccination _ _ _ _ _ _ +
response
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 Treatment
• 99% previously healthy person recover and
treatment is not required
• Indicated in fulminant hepatitis or severe
chronic hepatitis
– Interferon
– Nucleoside/ nucleotide analogues- lamuvidine,
adefovir, entecavir, telbivudine, tenofovir

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 Prophylaxis
• Recombinant subunit vaccine
• HBsAg is used as a vaccine candidate in
baker’s yeast by DNA recombinant technology
• Route- I/M
• Dosage- 10-20 μg/kg
• Schedule 0,1,6 and 6,10, 14
• Marker of protection- anti- HBs titer more
than 10 IU/ml

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• Booster after 5 yr for high risk group or
antibody titer falls below 10 IU/ml

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 Passive immunisation
• HBIG should be given within 6 hrs but not
later than 48 hrs
• Dose- 0.05-.07 ml/kg
• Two doses 30 days apart

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Thank you….
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