Hepatitis B Virus

Diagnostic Update
 Hepatitis B
Hepatitis B infection is caused by hepatitis B virus
(HBV), an enveloped DNA virus that infects the liver
and causes hepatocellular necrosis and inflammation.
HBV is also a recognized oncogenic virus that
confers a higher risk of developing HCC.

Worldwide, at least nine genotypes of HBV (A

through I) have been identified. Higher rates of HCC
have been found in persons infected with genotypes
C and F (compared with genotypes B or D), and in
those infected with certain subtypes of genotype A.

Acute hepatitis B is usually a self-limiting disease

marked by acute inflammation and hepatocellular
necrosis, with a case fatality rate of 0.51%.

Chronic hepatitis B (CHB) infection encompasses a

spectrum of disease, and is defined as persistent
HBV infection (the presence of detectable hepatitis B
surface antigen [HBsAg] in the blood or serum for
longer than six months), with or without associated
active viral replication and evidence of hepatocellular
injury and inflammation. CHB can be divided into e
antigen- (HBeAg) +ve or HBeAg -ve disease based
on the presence or absence of e antigen.

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 HBV Epidemiology
Indian Scenario
HBV is the second most common cause of acute viral hepatitis after HEV in India.

India harbors 1015% of the entire pool of HBV carriers of the world. With a 3.7% point
prevalence, that is, over 40 million HBV carriers, India is considered to have an intermediate level
of HBV endemicity.

About 1525% of HBsAg carriers are likely to suffer from cirrhosis and liver cancer and may die
prematurely. Infections occurring during infancy and childhood have the greatest risk of becoming
chronic. Of the 2.6 Crore (26 million) infants born every year in India, approximately 10 Lakhs (1
million) run the life-time risk of developing chronic HBV infection and about 100,000 die from HBV
infection.

Global endemicity to HBV infection;

darker shades suggest areas with
greater seroprevalence of HBV
Hwang and Cheung NAJMS.
2011;4(1):7-13

A, C, D Genotypes
prevalent in India

NCDC Newsletter; January-March 2014 Volume 3, Issue 1 3

J Clin Exp Hepatol. 2014 Dec; 4(4): 312319
Natural History of Chronic HBV
Infection

NICE 2013. Hepatitis B (chronic) : diagnosis and management (CG165) 4

 Phases of CHB
Phase HBeAg serological Pattern Indications for
status Treatment
Stage seen in many HBeAg-positive children and young Treatment not
adults, particularly among those infected at birth generally
1. Immune HBeAg +ve
High levels of HBV replication (HBV DNA levels >200 000 indicated, but
tolerant
IU/mL)) monitoring
Persistently normal ALT required
Minimal histological disease

2. Immune HBeAg +ve; may Abnormal or intermittently abnormal ALT Treatment not
active develop anti-HBe High or fluctuating levels of HBV replication (HBV DNA generally
(HBeAg- levels >2000 IU/mL) indicated, but
positive Histological necroinflammatory activity present monitoring
chronic HBeAg to anti-HBe seroconversion possible, with required for
hepatitis) normalization of ALT leading to immune-control phase reactivation &
HCC
3. Inactive
chronic
hepatitis HBeAg -ve, anti-HBe Persistently normal ALT Treatment
Immune +ve Low or undetectable HBV DNA ( HBV DNA levels <2000 maybe indicated
control IU/mL)
(previously Risk of cirrhosis and HCC reduced
called inactive May develop HBeAg-negative disease
carrier)

WHO 2015 Guidelines for Prevention, Care & Treatment of Persons with CHB Infection 5
 Phases of CHB
Phase HBeAg serological Pattern Indications for
status Treatment
4. Immune HBeAg -ve, with or HBeAg negative and anti-HBe positive Treatment
escape (HBeAg- without being anti- Abnormal ALT (persistent or intermittently abnormal) may be
negative chronic HBe +ve Moderate to high levels of HBV replication (HBV DNA levels Indicated
hepatitis) >20 000 IU/mL)
Older persons especially at risk for progressive disease
(fibrosis/cirrhosis)

5.Reactivation Can occur spontaneously or be precipitated by Treatment

or acute- immunosuppression from chemo or immunosuppressive indicated
HBeAg +ve or -ve
onchronic therapy, HIV infection or transplantation, development of
hepatitis 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

WHO 2015 Guidelines for Prevention, Care & Treatment of Persons with CHB Infection 6
Assessment of Severity of Liver
Disease
A full assessment includes clinical evaluation for features
of cirrhosis and evidence of decompensation, and
measurement of serum bilirubin, albumin, globulins, ALT,
AST, gamma-glutamyl transpeptidase (GGT), alkaline
phosphatase (ALP), and prothrombin time; as well as full
blood count, including platelet count.

Other routine investigations include ultrasonography and

alpha-fetoprotein (AFP) measurement for periodic
surveillance for HCC.

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Diagnosis of HBV Infection
Previous HBV infection is characterized by the presence of
antibodies (anti-HBs and anti-HBc). Immunity to HBV infection after
vaccination is characterized by the presence of only anti-HBs.

CHB is defined as the persistence of HBsAg for more than 6

months. Recently, quantitative HBsAg level determination has been
proposed to differentiate inactive HBsAg carriers from persons with
active disease.

This generally includes assessment of:

Additional serological markers of HBV infection (HBeAg)
Measuring aminotransferase levels to help determine liver inflammation
Quantification of HBV DNA levels
Quantification of stage of liver fibrosis by non-invasive tests (NITs) like
FibroMeters

WHO 2015 Guidelines for Prevention, Care & Treatment of Persons with CHB Infection 8
Liver Biopsy & Role of Non-
Invasive Tests (NITs)
Liver biopsy is considered the gold standard method to stage liver disease and
assess for the degree of necroinflammation and fibrosis, and to help guide the
decision to treat. However, limitations of biopsy include
Invasive
Sampling error
Subjectivity in reporting/ Intraobserver variation
High costs
Risks of pain, hypotension, bleeding, pneumothorax, infection
Discomfort to patient
Need for training and infrastructure
Pathological features of CHB on liver biopsy depends on stage of disease, host immune
response and degree of virus replication

Non-invasive tests (NITs) for assessing stage of liver disease are supplanting liver
biopsy and have been validated in adults with CHB. Blood and serum markers for
fibrosis like FibroMeters can be performed to rule out advanced fibrosis. Advantages
include
Non-invasive
Based on blood or serum indices
Evaluates and stages liver fibrosis
Useful in patients who cannot undergo biopsy
Reduces the need for liver biopsy
Can be used to serially monitor disease progression
Helps with optimal selection of persons with CHB for antiviral therapy 9
Non-Invasive Tests
Fibrometers
3 FibroMeter Assays
Chronic viral hepatitis (HBC, HCV, HIV- Constituents
co-infection) 1. Platelet count
Alcoholic liver disease 2. PT index
Non-alcoholic fatty liver disease 3. ALT
Provides scores for 4. AST
Fibrosis stage (Metavir)
5. GGT
Inflammation (in FMV only)
Area of fibrosis (percent, in NAFLD and 6. 2 macroglobulin
ALD only) 7. Hyaluronic acid
Results evaluated by an expert system 8. Ferritin
to detect discordant results of component 9. Glucose
tests 10.Urea
Eliminates analyte from algorithm to
correct possible false-positive/negative
results

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HBV Genotyping
Clinical Implications
Disease severity and HCC development: Disease severity is influenced
by genotype. Incidence of HCC is influenced by HBV genotype, HBV DNA
level, sex, age, pre-core A1896 mutation, and basal core promoter
T1762/A1764 mutation.
Antiviral therapy: HBV genotypes influence response to therapy.
Disease chronicity: Various genotypes have different prevalence rates in
acute and chronic hepatitis patients.
HBV transmission: Certain genotypes are associated with patients
infected through sexual contact, while others through blood transfusion/
injection drug use and still others with perinatal/ verticle transmission.
Liver transplantation: Some genotypes are associated with higher HBV
recurrence and mortality after transplantation, higher acute cellular rejection
rate, more severe graft damage compared to others.
Occult HBV: Occult HBV infection is a special form of hepatitis B infection
where patients are -ve for HBsAg, while at the same time being +ve for HBV
DNA. Association between HBV genotypes and occult infectionhas been
found.

Guirgis BSS. Inter J Infect Dis 14 (2010) e941e953 11

HBV Drug Resistance Testing
Recommended if treatment failure (primary or secondary) is suspected.
Treatment failure may be:
Primary: Defined as failure of an antiviral drug to reduce HBV DNA levels by 1
x log10 IU/mL within 3 months of initiating therapy.
Secondary: Defined as a rebound of HBV DNA levels of 1 x log10 IU/mL from
the nadir in persons with an initial antiviral treatment effect (1 x log10 IU/mL
decrease in serum HBV DNA).

Confirmation of antiviral drug failure can be established by sequencing the

HBV DNA polymerase and identifying specific genetic markers of antiviral
drug resistance.

Of the six approved NAs (lamivudine, adefovir, entecavir, telbivudine, tenofovir,

emtricitabine), lamivudine is associated with the highest rate of drug
resistance, entecavir with very low rates of resistance (except in persons
previously exposed to lamivudine and adefovir), and currently none with
tenofovir.

WHO 2015 Guidelines

 Algorithm on Management of
CIRRHOSIS
Clinical criteria Persons with Chronic
HBsAg positive
Non-Invasive Tests Hepatitis B Infection
ASSESSMENT FOR TREATMENT
(WHO 2015)
Yes No
AGE: >30 years AGE: 30 years

ALT: Persistently ALT: Intermittently ALT: Persistently ALT: Persistently

abnormal abnormal normal normal

HBV DNA HBV DNA HBV DNA HBV DNA

>20 000 IU/mL 200020 000 IU/mL <2000 IU/mL <2000 IU/mL

INITIATE NA THERAPY DEFER TREATMENT AND MONITOR

AND MONITOR
Tenofovir or entecavir
Entecavir in children Every 6 months DETECTION OF HCC
aged 211 years (persons with cirrhosis or HCC family history)
MONITORING

DISEASE PROGRESSION AND/OR TREATMENT RESPONSE

IN ALL
Every 12 months Adherence at each visit, if on treatment
ALT, HBV DNA and HBeAg
Clinical criteria and Non-Invasive Tests

Baseline and TOXICITY MONITORING IN PERSONS ON TREATMENT

every 12 months Renal functiong and risk factors for renal dysfunction
TREATMENT
STOPPING

NO CIRRHOSIS
and HBeAg loss and seroconversion to anti-HBe and after completion of at
CIRRHOSIS: Lifelong least one additional year of treatment
treatment and persistently normal ALT
and persistently undetectable HBV DNA 13
Some Recommendations
Measurement of baseline renal function and assessment of baseline risk
for renal dysfunction should be considered in all persons prior to initiation of
antiviral therapy

Measurement of HBV DNA levels and testing for drug resistance are
fundamental to confirming treatment failure and genotypic HBV resistance

HBsAg should be checked at 12-month intervals after anti-HBe

seroconversion if HBV DNA is undetectable, as the rate of HBsAg loss
increases over time. Patients who become HBsAg negative should be
tested for anti-HBs.

In HBeAg-negative patients, serum HBV DNA levels should be measured

at 6 and 12 months of treatment and at 6 and 12 months post-treatment.

WHO 2015 Guidelines for Prevention, Care & Treatment of Persons with CHB Infection
EASL Clinical Practice Guidelines. J Hepatol 2012: 57; 167185
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 Tests Offered by SRL
Test Name Method Test Code

LIVER PROFILE #2 (Bilirubin, Total, Protein Total, Albumin,

SPECTROPHOTOMETRY /ECLIA/ CLOT BASED 1389
Globulin, AST, ALT, Bilirubin Direct, HBsAg, PT, ALP)
ALPHA-FETOPROTEIN / LIVER CANCER MONITOR CHEMILUMINESCENCE 3109
HEPATITIS B CORE TOTAL ANTIBODIES CMIA 2452
HEPATITIS B SURFACE ANTIBODIES (HBsAb), TOTAL
CMIA 2453QN
WITH TITRE
HEPATITIS Be VIRUS ANTIGEN CMIA 2456

HEPATITIS Be VIRUS TOTAL ANTIBODIES CMIA 2455

HEPATITIS Be VIRUS ANTIGEN / ANTIBODY EVALUATION CMIA 2462

HEPATITIS B SURFACE ANTIGEN NEUTRALIZATION
CMIA 2449
(WITH CONFIRMATION)
HEPATITIS B VIRUS CORE IgM ANTIBODIES CMIA 2457
HBV GENOTYPING PCR SEQUENCING 7474
NESTED PCR
HBV BASAL CORE PROMOTER MUTATION 7475
SEQUENCING
NESTED PCR
HBV PRECORE MUTATION 7476
SEQUENCING
HBV QUALITATIVE REAL TIME PCR 8141
HBV VIRAL LOAD REAL TIME PCR 9973
HBV QUANTITATIVE COBAS TAQMAN 8136
HBV DRUG RESISTANCE (Lamivudine, Telbivudine, NESTED PCR
RD1305
Adefovir, Tenofovir and Entecavir) SEQUENCING
SPECTROPHOTOMETRY/ NEPHELOMETRY/
FIBROMETER VIRUS 4590 15
HEMATOLOGY
Thank You

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