Journal of Clinical Virology 103 (2018) 48–56

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Journal of Clinical Virology

journal homepage: www.elsevier.com/locate/jcv

Frequency of hepatitis B surface antigen variants (HBsAg) in hepatitis B T

virus genotype B and C infected East- and Southeast Asian patients:
Detection by the Elecsys® HBsAg II assay
Hyon Suk Kima, Xinyue Chenb, Min Xuc, Cunling Yand, Yali Liub, Haohui Dengc, Bui Huu Hoange,
Pham Thi Thu Thuyf, Terry Wangg, Yiwen Yang, Zhen Zengg, Mikael Gencayh,
Gaston Westergaardh, Stephan Pabingeri, Albert Kriegnerj, Markus Nauckk,1, Anja Seffnerl,
⁎
Peter Gohlk, Kirsten Hübnerk, Wolfgang E. Kaminskik,
a
Department of Laboratory Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, South Korea
b
Department of Liver Diseases, You’an Hospital, Capital Medical University, Beijing, China
c
Hepatology Department, Guangzhou No. 8 People’s Hospital, Guangzhou, China
d
Department of Clinical Laboratory, Peking University First Hospital, Beijing, China
e
Gastroenterology Department, Ho Chi Minh City University Medical Center, Ho Chi Minh City, Vietnam
f
Hepatology Department, Medic Medical Center, Ho Chi Minh City, Vietnam
g
Roche Diagnostics Ltd., Shanghai, China
h
Roche Diagnostics International Ltd., Rotkreuz, Switzerland
i
AIT Austrian Institute of Technology, Molecular Diagnostics, Center for Health and Bioresources, Vienna, Austria
j
Platomics GmbH, Vienna, Austria
k
Bioscientia Institute for Medical Diagnostics GmbH, Ingelheim, Germany
l
MVZ Labor Dr. Limbach & Kollegen GbR, Department of Molecular Genetics and Microbiology, Heidelberg, Germany

A R T I C LE I N FO A B S T R A C T

Keywords: Background: To avoid false negative results, hepatitis B surface antigen (HBsAg) assays need to detect samples
Hepatitis B with mutations in the immunodominant ‘a’ determinant region, which vary by ethnographic region.
HBsAg mutations Objective: We evaluated the prevalence and type of HBsAg mutations in a hepatitis B virus (HBV)-infected East-
Detection and Southeast Asian population, and the diagnostic performance of the Elecsys® HBsAg II Qualitative assay.
Screening
Study design: We analyzed 898 samples from patients with HBV infection from four sites (China [Beijing and
Immunoassay
Immunodominant ‘a’ determinant region
Guangzhou], Korea and Vietnam). HBsAg mutations were detected and sequenced using highly sensitive ultra-
deep sequencing and compared between the first (amino acids 124–137) and second (amino acids 139–147)
loops of the ‘a’ determinant region using the Elecsys® HBsAg II Qualitative assay.
Results: Overall, 237 distinct amino acid mutations in the major hydrophilic region were identified; mutations
were present in 660 of 898 HBV-infected patient samples (73.5%). Within the pool of 237 distinct mutations, the
majority of the amino acid mutations were found in HBV genotype C (64.8%). We identified 25 previously
unknown distinct mutations, mostly prevalent in genotype C-infected Korean patients (n = 18) followed by
Chinese (n = 12) patients. All 898 samples were correctly identified by the Elecsys® HBsAg II Qualitative assay.
Conclusions: We observed 237 distinct (including 25 novel) mutations, demonstrating the complexity of HBsAg
variants in HBV-infected East- and Southeast Asian patients. The Elecsys® HBsAg II Qualitative assay can reliably
detect HBV-positive samples and is suitable for routine diagnostic use in East and Southeast Asia.

1. Background (HBV) infection, which can lead to long-term complications, such as

cirrhosis, liver failure and hepatocellular carcinoma [1,2]. HBV is dif-
Nearly 250 million people worldwide have chronic hepatitis B virus ferentiated into a number of genotypes, which are characterized by

Abbreviations: HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; MHR, major hydrophilic region
⁎
Corresponding author.
E-mail address: wolfgang.kaminski@bioscientia.de (W.E. Kaminski).
1
Professor Nauck is recently deceased.

https://doi.org/10.1016/j.jcv.2018.04.005
Received 22 January 2018; Received in revised form 29 March 2018; Accepted 4 April 2018
1386-6532/ © 2018 Roche Diagnostics International Ltd. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
H.S. Kim et al. Journal of Clinical Virology 103 (2018) 48–56

Table 1 Table 1 (continued)

Most frequent MHR mutations (occurring in ≥5 patient samples) in the East-
and Southeast Asian cohort by HBV genotype (A–G). Location of mutation HBV Genotype

Location of mutation HBV Genotype Sum A B C D E F G

Sum A B C D E F G D144E 5 0 0 5 0 0 0 0
S136Y 5 0 0 5 0 0 0 0
K122R 201 0 186 15 0 0 0 0 G119R 5 0 1 4 0 0 0 0
I126T 187 0 0 187 0 0 0 0
I126S 97 0 0 97 0 0 0 0
Y161F 55 0 55 0 0 0 0 0
differences of > 8% in genome sequence; 10 HBV genotypes (A–J) have
M133T 46 0 12 34 0 0 0 0
T131N 41 0 6 35 0 0 0 0 been identified to date, with distinct geographic distributions [3]. For
T140I 41 0 39 2 0 0 0 0 example, genotype C is primarily found in South-East Asia, and geno-
R160K 38 0 0 38 0 0 0 0 type I has been reported in Vietnam and Laos [3]. In China, genotype B
A159V 35 0 13 22 0 0 0 0 is more prevalent in the south of the country, whereas genotype C is
G145R 34 0 6 28 0 0 0 0
Q101R 31 0 3 28 0 0 0 0
more prevalent in the north [4,5]. These genotypes are clinically im-
T126A 29 0 29 0 0 0 0 0 portant, as they are associated with differences in genetic mutations
I110L 28 0 28 0 0 0 0 0 (defined herein as amino acid substitutions that differ from the geno-
P127T 28 0 19 9 0 0 0 0 type-specific consensus sequence), disease progression and treatment
V168A 26 0 5 20 0 0 0 1
response [3].
Y100C 26 0 3 23 0 0 0 0
L109P 21 0 16 5 0 0 0 0 HBV is transmitted via blood and other bodily fluids and so can
I126V 20 0 0 20 0 0 0 0 threaten the safety of blood transfusion services, particularly in coun-
Q101K 18 0 0 18 0 0 0 0 tries where HBV is endemic [6,7]. The hepatitis B surface antigen
P120T 18 0 6 12 0 0 0 0 (HBsAg) is the primary serologic marker for HBV detection [8,9]. The
M133L 17 0 14 3 0 0 0 0
P120S 17 0 15 2 0 0 0 0
majority of HBsAg immunoassays target the immunodominant ‘a’ de-
T113S 16 0 0 16 0 0 0 0 terminant region, which is located in the major hydrophilic region
I126N 15 0 0 15 0 0 0 0 (MHR) and is divided into two loops of amino acid residues (the first
T123A 15 0 8 7 0 0 0 0 loop comprises amino acids 124–137; the second loop comprises amino
T123N 14 0 0 14 0 0 0 0
acids 139–147) [8,10]. Commercially available HBsAg assays must be
M103I 14 0 0 14 0 0 0 0
G145A 14 0 0 14 0 0 0 0 able to accurately detect samples with known mutations in the ‘a’ de-
Q101H 13 0 1 12 0 0 0 0 terminant region, such as the common vaccine-induced immune-escape
Y100S 12 0 4 8 0 0 0 0 variant G145R [8], to avoid false-negative results [10–12].
T125M 12 0 1 11 0 0 0 0 In a recent global study of 1553 HBsAg-positive blood samples from
E164G 12 0 10 2 0 0 0 0
L110I 12 0 0 12 0 0 0 0
20 countries across Africa, America, Asia and Europe, we observed
S114A 11 0 1 10 0 0 0 0 HBsAg MHR mutations in 72.8% of sequenced samples, three times
G130R 11 0 1 10 0 0 0 0 higher than previously reported. The highest prevalence of mutations in
F170S 11 0 1 10 0 0 0 0 the ‘a’ determinant region was observed among samples from Asia [13].
F134I 10 0 2 8 0 0 0 0
We also demonstrated that the Elecsys® HBsAg II Qualitative assay can
F134L 10 0 1 9 0 0 0 0
T116N 10 0 1 9 0 0 0 0 reliably detect HBV-positive samples with known in vivo mutations in
A166V 10 0 6 4 0 0 0 0 the ‘a’ determinant region.
M133I 9 0 2 7 0 0 0 0
T126S 8 0 8 0 0 0 0 0
G130N 8 0 0 8 0 0 0 0 2. Objectives
Q129N 8 0 1 7 0 0 0 0
W156G 8 0 0 8 0 0 0 0 We sought to evaluate the prevalence of HBsAg mutations in an
S114T 7 0 2 5 0 0 0 0
East- and Southeast Asian chronic HBV-infected population. This con-
G145E 7 0 0 7 0 0 0 0
F134S 7 0 3 4 0 0 0 0 sisted of Korean and Vietnamese patients from the global study [13],
T118K 7 0 0 7 0 0 0 0 and a new cohort of patients from China. A further objective was to
T131P 7 0 1 6 0 0 0 0 determine the diagnostic performance of the Elecsys® HBsAg II Quali-
E164D 7 0 0 7 0 0 0 0 tative assay in these patients. This East- and Southeast Asian population
T140S 7 0 1 6 0 0 0 0
T131I 6 0 1 5 0 0 0 0
was chosen due to the high rates of endemic HBV infection in the re-
Y100F 6 0 4 2 0 0 0 0 gion; a systematic review of articles published between 1965 and 2013
S167L 6 0 3 3 0 0 0 0 reported an estimated prevalence of HBsAg seropositivity in China,
F134V 6 0 1 5 0 0 0 0 Korea and Vietnam of 5.49%, 4.36% and 10.79%, respectively, com-
G130E 6 0 1 5 0 0 0 0
pared with a global prevalence of 3.61% [1].
Q129H 6 0 5 1 0 0 0 0
W156L 6 0 2 4 0 0 0 0
Q129R 6 0 4 2 0 0 0 0 3. Study design
Y161S 6 0 6 0 0 0 0 0
S154P 6 0 1 5 0 0 0 0
P111L 6 0 0 6 0 0 0 0 The global study included samples from 1553 patients with HBV
A128V 5 0 0 5 0 0 0 0 infection obtained between January 2007 and February 2015 (Africa,
S143T 5 0 0 5 0 0 0 0 n = 435; Asia, n = 653; Europe, n = 72; Latin America, n = 35; Middle
S113T 5 0 4 0 1 0 0 0
East, n = 79; USA, n = 234; unknown, n = 45) excluding the samples
T113N 5 0 0 5 0 0 0 0
T143M 5 0 5 0 0 0 0 0 (n = 407) collected in China [13]. Of these, 562 samples were from
T116A 5 0 0 5 0 0 0 0 patients with chronic HBV infection (diagnosed with HBV > 6 months
C147Y 5 0 0 5 0 0 0 0 before enrollment) and 991 samples were defined as unselected random
S136F 5 0 0 5 0 0 0 0 HBV (samples with HBV DNA [ > 100 IU/ml] or HBsAg positivity ob-
tained from clinical settings in Europe, South Africa and the USA). The

49
H.S. Kim et al. Journal of Clinical Virology 103 (2018) 48–56

Fig. 1. Distribution of location-specific mutations in the ‘a' determinant region (amino acids 124–147) according to HBV genotype in A) Beijing, B) Guangzhou, C)
Korea and D) Vietnam, respectively.

50
H.S. Kim et al. Journal of Clinical Virology 103 (2018) 48–56

Fig. 1. (continued)

global study did not include the 407 samples from Chinese HBV-in- from the global study of patients from Korea (Severance Hospital,
fected patients that are reported in this current analysis. Seoul, Korea) and Vietnam (Ho Chi Minh City University Medical
We report the results for a combined population with chronic HBV Center, Ho Chi Minh City, Vietnam); and a new cohort of HBV-infected
infection from four sites in East- and Southeast Asia: two subgroups patients from two sites in China (You’an Hospital, Capital Medical

51
H.S. Kim et al.
Table 2
Selected mutations with clinical impact and their within one-sample mutation frequency by region/country.
Location of mutation Beijing
P120T 4 (0.058–0.269)
G145R 13 (0.055–0.358)
M133L 3 (0.052–0.996
Q129H 1 (0.119–0.119)
G130N 3 (0.185–0.347)
S143L – –
T126S 3 (0.094–0.322)
D144A – 1
T131I 2 (0.05–0.181)
P142S – –
Data are presented as number of samples (minimum frequency–maximum freqnouency).
University Beijing and Guangzhou No. 8 People’s Hospital, Guangzhou,
China). Blood samples were collected with informed consent from each
patient between January 2007 and February 2015. The study protocol
was approved by the Ethics Committees of the participating hospitals.
The detection and sequencing of HBsAg mutations was conducted as
previously described using highly sensitive ultra-deep sequencing [13].
The HBV genotypes of samples were determined by phylogenetic ana-
lysis [14,15]. The mutation rates of the first and second loops of the
immunodominant ‘a’ determinant region (amino acids 124–137 and
139–147, respectively) were compared to explore location-dependent
aspects of the mutations; genotype-specific reference sequences used for
bioinformatic analyses are listed in Supplementary Table 1 [16]. The
frequency of occult HBV infection-associated Y100C mutations was also
assessed.
Samples with and without mutated HBsAg were tested using the
fully automated Roche Elecsys® HBsAg II Qualitative assay (Roche
Diagnostics GmbH, Mannheim, Germany) according to the manu-
facturer’s recommendations. The results were interpreted using the
following cut-off reference values: < 0.9, negative; ≥1.0, positive;
≥0.9 to < 1.0, borderline. Confirmatory testing was not performed as
all samples were obtained from HBV DNA-positive patients.
All statistical analyzes were conducted independently by the AIT
Austrian Institute of Technology (Vienna, Austria) using a multistep
approach (R, Python version 2.7.6 scripts using the NumPy package).
The matplotlib package was used for graphical visualizations.
4. Results
A total of 898 blood samples from patients with chronic HBV in-
fection were included: 407 samples from China (Beijing, n = 281;
Guangzhou, n = 126); 233 samples from Korea; and 258 samples from
Vietnam. Mutations were present in 660 of these samples (73.5%). In
total, 237 distinct amino acid mutations in the MHR were identified.
The most frequently occurring mutations in the whole East- and
Southeast Asian cohort (≥5 samples) are presented in Table 1 and a
comprehensive list of all mutations identified, and those identified in
each region/country cohort, are provided in Supplementary Tables 2–6.
Three patients (two from Guangzhou and one from Vietnam) were co-
infected with multiple HBV genotypes containing mutations, these pa-
tients were counted in results for both genotypes and details of variants
are presented in Supplementary Table 7.
The majority of samples from Chinese patients were HBV genotype
B or C (Beijing: 67 [24%] and 212 [75%], respectively; Guangzhou: 82
[65%] and 45 [36%], respectively). Of the 407 samples analyzed, 281
(69%) contained a total of 664 mutations (Supplementary Tables 3 and
4). In the Beijing and Guangzhou samples, respectively, 231 and 112
mutations were located in the immunodominant ‘a’ determinant region.
The distribution of mutations in the ‘a’ determinant region in the
Chinese samples according to genotype is shown in Fig. 1A and B. The
most common variant identified was I126T, which was observed in 90
samples (Beijing, n = 61; Guangzhou, n = 29); all of these samples
Journal of Clinical Virology 103 (2018) 48–56
Guangzhou Korea Vietnam
4 (0.084–0.228) 6 (0.136–0.653) 4 (0.102–0.989)
4 (0.055–0.297) 9 (0.051–0.968) 8 (0.051–0.271)
2 (0.056–0.970) 2 (0.12–0.163) 10 (0.063–0.991)
3 (0.693–0.995) – 2 (0.256–0.996)
1 (0.612–0.612) 4 (0.099–0.966) –
1 (0.067–0.067) –
2 (0.197–0.997) – 3 (0.219–0.285)
(0.061–0.061) 1 (0.068–0.068) 1 (0.094–0.094)
– 3 (0.057–0.296) 1 (0.996–0.996)
1 (0.174–0.174) –
were genotype C. The vaccine-induced immune-escape mutation G145R
was identified in 17 samples (Beijing, n = 13; Guangzhou, n = 4). Se-
lected mutations associated with a clinical impact, and their within one-
sample mutation frequency, are shown in Table 2. Occult HBV infec-
tion-associated Y100C mutations, which are located outside the ‘a’
determinant region, were identified in 12 samples (Beijing, n = 10;
Guangzhou, n = 2). The distribution of 317 mutations (Beijing,
n = 164; Guangzhou, n = 153) outside the ‘a’ determinant region in the
Chinese samples, according to amino acid position, is shown in Fig. 2A
and B.
All of the samples from Korean patients were genotype C, except for
one, which was genotype B. Of the 233 samples analyzed, 146 (63%)
contained a total of 604 mutations (Supplementary Table 5); 323 mu-
tations were located in the ‘a’ determinant region (Fig. 1C) and 272
mutations were found outside the ‘a’ determinant region (Fig. 2C). The
most common variant was I126T, which was observed in 74 samples, all
with genotype C. The vaccine-induced immune-escape mutation G145R
was identified in nine samples and occult HBV infection-associated
Y100C mutations were identified in six samples. Selected mutations
associated with a clinical impact, and their within one-sample mutation
frequency, are shown in Table 2.
The majority of samples from Vietnamese patients were genotype B
(196 [76%]), followed by genotype C (61 [24%]). Of the 258 samples
analyzed, 233 (90%) contained a total of 493 mutations
(Supplementary Table 6), of which 152 mutations were observed in the
‘a’ determinant region (Fig. 1D) and 260 mutations were located out-
side the ‘a’ determinant region (Fig. 2D). The most common variant was
K122R, which was observed in 179 samples; all of these samples were
genotype B. G145R and Y100C mutations were each identified in eight
samples. Some selected mutations associated with a clinical impact, and
their within one-sample mutation frequency, are shown in Table 2.
Comparison of immunodominant ‘a’ determinant region mutations
of genotype B- and C-infected subjects revealed some differences de-
pending on the country of origin. Investigation of the individual gen-
otype-B immunodominant ‘a’ region mutations revealed that positions
131, 133, 134 and 143 were more frequently mutated in Vietnamese
subjects than in Chinese subjects. The individual mutations’ rates were
7.1%, 22.6%, 13.1% and 4.8%, respectively, in Vietnamese patients
compared with 2.0%, 8.8%, 1.0% and 2.9%, respectively, in Chinese
patients. However, amino acid mutations in position 126 were higher in
Chinese genotype B-infected patients, with a rate of 30.4%, compared
with 8.3% in Vietnamese genotype B-infected patients.
Genotype C-infected Korean subjects had a higher rate of amino acid
changes at positions 131 (8.3%), 133 (10.8%) and 136 (3.1%) com-
pared with genotype C-infected Chinese subjects. Compared with gen-
otype C-infected Vietnamese subjects, Korean subjects had a higher
mutation rate at positions 133 (10.8%), 134 (6.5%) and 136 (3.1%).
The classical G145R immune escape mutant [17,18] was observed
in 4.2%, 3.8% and 3.1% of Chinese, Korean and Vietnamese subjects,
respectively, and mostly in genotype C-infected subjects. In general, the
mutation rate was higher in loop 1, with no significant difference
52
H.S. Kim et al. Journal of Clinical Virology 103 (2018) 48–56

Fig. 2. Distribution of MHR mutations located outside the ‘a' determinant region (amino acids 99–119 and 148–170) in A) Beijing, B) Guangzhou, C) Korea and D)
Vietnam.

53
H.S. Kim et al. Journal of Clinical Virology 103 (2018) 48–56

Fig. 2. (continued)

between the genotypes B- and C-infected subjects. The sensitivity of the Elecsys® HBsAg II Qualitative assay was 100%
A total of 25 novel mutations were identified in three countries (95% CI: 99.59–100.0) for all 898 samples with and without mutations.
(Table 3). These were most prevalent in genotype C-infected Korean All 898 samples were correctly identified by the Elecsys® HBsAg II
patients (n = 18) followed by Chinese (n = 12) patients. Qualitative assay, including samples with common diagnostic and

54
H.S. Kim et al.
Table 3
Synopsis of novel mutations.
Beijing Guangzhou Vietnam Korea
C107* T118I D99A C139F
P111T W156S F134Q D99A
S114* G112Q F170Y
S114N P111N G145*
S167* G145V
Y100* K122G
K122S†
L110P
P108L
P111A
P120I
T113K
T115K
T118Q
vaccine-induced escape-associated mutants (P120T, G145R, M133L,
M133T, Q129H, G130N, T126S and D144A) and occult HBV infection-
associated Y100C mutations.
5. Discussion
The global prevalence and structural complexity of HBsAg muta-
tions is substantially higher than previously thought [13]. Here, we
report results for a combined East- and Southeast Asian population with
chronic HBV infection, comprising a new cohort of patients from China
and two subgroups from the global study of patients from Korea and
Vietnam. In the Chinese cohort, mutations were present in 69% of
samples, and over half of the mutations were located in the im-
munodominant ‘a’ determinant region; eight were novel mutations.
Among the Korean and Vietnamese samples, we observed mutations in
63% and 90% of samples, respectively, and 53% and 31% of the mu-
tations were observed in the ‘a’ determinant region, respectively.
To our knowledge, this combined East- and Southeast Asian popu-
lation is the largest to be included in a single study investigating HBsAg
genotyping. Previous studies have reported mutation frequencies in the
MHR among HBsAg-positive adults in China of 17.1–51.3% [19–23],
and a mutation rate of 9.9% in the ‘a’ determinant region [24]. Muta-
tion frequencies of 46.5% and 36.6% have been reported in Korean
adults with HBsAg seropositivity [25,26], and a study of Vietnamese
patients with chronic HBV found a prevalence of ‘a’ determinant region
mutations of 25.0% [27]. The relatively high mutation rate observed in
our study highlights the complexity of in vivo HBsAg mutations and the
need for HBV diagnostic assays to be able to detect known HBsAg
variants to avoid false-negative results.
The Elecsys® HBsAg II Qualitative assay can reliably detect the
majority of clinically and diagnostically relevant HBV mutations in
global and South African population studies [13]. In this current ana-
lysis, the Elecsys® HBsAg II Qualitative assay successfully detected the
presence of HBV infection in 898 samples, including samples with
known vaccine-induced immune-escape mutations, such as G145R, and
novel mutations. This is in line with previous evaluations of the per-
formance of the Elecsys® HBsAg II Qualitative assay using native sam-
ples from patients with HBV infection [28,29]. From these findings, it
can be inferred that the Elecsys® HBsAg II Qualitative assay may also be
able to detect additional, as yet unknown, variants in other ethno-
geographic regions. The Elecsys® HBsAg II Qualitative assay uses four
antibodies (three monoclonal and one polyclonal) to detect HBsAg; all
three monoclonal antibodies are able to bind to the HBsAg simulta-
neously and recognize different epitopes. This may give the Elecsys®
HBsAg II Qualitative assay an advantage over other commercially
available assays that use monoclonal capture and tracer antibodies
alone [28,30].
There were a number of strengths to this study. We included a large
55
Journal of Clinical Virology 103 (2018) 48–56
number of samples from HBV-infected patients from different geo-
graphic locations across South-East Asia, and a wide range of known
HBsAg mutations were captured in the samples. Highly sensitive next-
generation sequencing methods were used for the sequencing and
mutation detection of the samples [13]. Unlike previous studies, which
have routinely used recombinant HBsAg mutants to validate the per-
formance of detection assays [11], we used native samples, which
better reflect the complexities of HBsAg mutations occurring in clinical
practice and provide a more accurate evaluation of the real-world
performance of detection assays. A potential limitation of our study is
that samples were evaluated for HBsAg-positivity using a different de-
tection assay from the Elecsys® HBsAg II Qualitative assay, which may
have introduced selection bias. This could be improved by selecting
samples that were HBsAg-positive on nucleic acid testing and HBsAg-
negative using an alternative detection assay.
In conclusion, in the largest cohort of HBV-positive patients from
East- and Southeast Asia to be genotyped by next-generation sequen-
cing, we observed 25 novel mutations, demonstrating the complexity of
HBsAg variants in an East- and Southeast Asian HBV-infected patient
population. The Elecsys® HBsAg II Qualitative assay can reliably detect
HBV-positive samples despite known mutations located in the im-
munodominant ‘a’ determinant region; previous studies have shown
assay specificities of 99.97% and 99.88% when analyzing daily routine
specimens and unselected blood donations, respectively [29]. Thus, the
Elecsys® HBsAg II Qualitative assay is suitable for HBV diagnosis and
management in HBV-infected East- and Southeast Asian patients.
Funding
This work was supported by Roche Diagnostics.
Competing interests
Hyon Suk Kim, Xinyue Chen, Min Xu, Cunling Yan, Yali Liu, Haohui
Deng, Bui Huu Hoang, Pham Thi Thu Thuy, Zhen Zeng, Stephan
Pabinger, Albert Kriegner, Anja Seffner, Peter Gohl, Kirsten Hübner and
Wolfgang E. Kaminski have no conflicts of interest to declare. Terry
Wang, Yiwen Yan, Mikael Gencay and Gaston Westergaard are em-
ployees of Roche and own stocks/shares in Roche.
Ethical approval
The study protocol was approved by the Ethics Committees of the
participating hospitals.
Author contributions
All authors contributed to the conception and design of this study,
were involved in the interpretation of the data, and the development
and approval of the manuscript.
Role of funding source
This research was sponsored and funded in full by Roche
Diagnostics. The sponsor and all authors contributed to the design of
the study. Employees of Roche Diagnostics were involved in review of
this manuscript. Final decisions on the analysis and interpretation of
the data, and the development and approval of the manuscript for
submission remained with the authors.
Acknowledgments
The authors would like to thank the participating investigators,
their study staff, and the individuals who provided their blood samples.
The authors would also like to thank Christine Reinsch (Roche
Diagnostics Deutschland GmbH) for her support in establishing
H.S. Kim et al.
sequencing methods and providing technical support to study sites in
Germany. Editorial support, in the form of development of a draft
manuscript in consultation with the authors and preparation of the
tables and figures, was provided by Chloe Fletcher, MSc, and Lucy
Carrier, PhD, Gardiner-Caldwell Communications, Macclesfield, UK,
and was funded by Roche Diagnostics.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in the
online version, at https://doi.org/10.1016/j.jcv.2018.04.005.
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