Hepatitis B

Jay H. Hoofnagle, M.D.

Division of Digestive Diseases
and Nutrition
National Institute of Diabetes and Digestive and
Kidney Diseases
National Institutes of Health

FDA Advisory Panel Meeting: August 7, 2002

 Hepatitis B
• HBV, small double stranded DNA virus
• Hepadnaviridae
• Infection restricted to humans and higher apes
• High levels in blood (102 to 1010 copies/ml)
• Causes both acute and chronic hepatitis
• Parenteral, sexual and maternal-infant spread
• Marked geographic variation in incidence
• Common in Asia & Africa, uncommon in the
United States and Western Europe
 Hepatitis B Virus
HBeAg

HBsAg

HBcAg HBsAg Sphere

HBsAg

Dane Particle Tubule

Hepatitis B Virus RNAs
2.1kb RNA

2.4kb RNA Pre-S1 Pre-S2

-strand
ORF-S
+strand

3.5kb RNA
5’
ORF-C DR1
ORF-P
A A
A A
A AA A 5’
A AA DR2
A
Pre-C

ORF-X
0.7kb RNA
 Hepatitis B Viral Genome
• Circular, partially doubled-stranded DNA
• Four open reading frames
– HBsAg (pre-S1, pre-S2 and S)
– HBcAg (pre-core & core)
– Polymerase (multifunctional)
– HBxAg (transactivating factor)
• Replicates largely in liver
• Through RNA intermediate and reverse
transcription
Infectious cycle of hepatitis B virus

Y
Y
degradation
Y

Y
Y
- antigen-specific
Y - non-specific

Y
Virus - half-life: 1-2 days
-production: 1011 -1013 /day
mutation rate: 1-3 x 10-5 /site/yr
cell death
Zeuzem et al: 2000
 Hepatitis B Virus Mutants

• Variations in nucleotide sequence in one of

the HBV genes can result in change in the
virological and, in some cases, clinical
features of the infection.
• S gene: vaccine or HBIG escape mutants
• C gene: can affect disease severity or
serological and clinical manifestations
• P gene: can effect replicative efficiency and
resistance to antiviral therapy
 Hepatitis B Core Antigen Mutants

Nucleocapsid region: Pre-core and Core

• Pre-core: May result in inability to produce
HBeAg. HBeAg-negative mutants. Most
frequently, G→A at nt 1896.
• Core: Substitutions in core region are frequent
among pts with severe disease or resistance to
interferon, in areas of major B cell and T cell
epitopes, thus important in T cell cytotoxicity
and viral clearance
 HBeAg-negative Variants
• G→A at nt 1896 creates a stop codon in the pre-
core region that therefore blocks the synthesis of
HBeAg.
• nt 1896 is in the highly structured stem-loop 
encapsidation signal region of HBV RNA and
base-pairs with nt 1858
• If nt 1858 is a T (ayw, adr, some adw), stem loop
of  is maintained by either G or A; if it is a C
(adw), stem loop is disrupted by A and
replication is stopped.
• Thus HBeAg-negative variants are more common
with genotypes B, C and D than genotype A
 Outcome of Hepatitis B Virus Infection
35%
65% Acute Hepatitis B <1%

Asymptomatic Fulminant Hepatitis

subclinical infection
5%
Chronic Hepatitis B
30%
50%
Inactive Carrier State Cirrhosis

?
Liver Cancer
 Typical Acute Hepatitis B

1000 HBsAg
900
HBeAg
IU/L and million copies/ml

800
700 ALT
ALT and HBV DNA

600
500 Symptoms
400
HBV DNA
300
200
100
Normal
0
0 1 2 3 4 5 6 12 24 36 48 60

Months After Exposure

 Typical Chronic Hepatitis B

HBsAg
800
HBeAg
IU/L or million copies/ml

700
600
ALT and HBV DNA

500
HBV DNA
400
300
200 ALT

100
Normal
0
0 1 2 3 4 5 6 12 24 36 48 60
Months After Exposure
 Chronic Hepatitis B:
Transition to Inactive Carrier State
800
HBsAg ``
700
IU/L and million copies/ml

HBeAg
600
ALT and HBV DNA

500
400 HBV DNA
Anti-HBe
300
200
ALT
100
Normal
0
0 1 2 3 4 5 6 12 24 36 48 60 72 80
Months After Exposure
 Evolution of HBeAg Negative
Mutant
HBsAg
HBeAg Anti-HBe
450
IU/L and million copies/ml

400
ALT
350
ALT and HBV DNA

300
250 HBV DNA
200
150
100
50
0 Normal ALT levels
0 3 6 9 12 15 18 21 24 27 30 33 36

Months
 Chronic Hepatitis B:
Three Clinical Forms:
• HBeAg Positive Chronic Hepatitis B
• HBeAg, raised ALT, HBV DNA in serum and
chronic hepatitis on biopsy
• HBeAg Negative Chronic Hepatitis B
• Anti-HBe, raised ALT and HBV DNA in serum,
chronic hepatitis on biopsy
• Inactive HBsAg Carrier State
• Anti-HBe, normal ALT & no HBV DNA, minimal
nonspecific changes on biopsy
 Chronic Hepatitis B:
Clinical Forms: HBV DNA levels

●HBeAg Positive Chronic Hepatitis B

107 to 1011 copies per ml
●HBeAg Negative Chronic Hepatitis B
104 to 108 copies per ml
●Inactive HBsAg Carrier State
< 101 to 104 copies per ml
 HBV DNA Detection
10 35,000

8 350
Log10 copies/mL

pg/mL
6 3.5

.035
4

2 .0035

qualitative PCR quantitative PCR bDNA (Versant) Hybridization Hybridization

(Amplicor) (Abbott) (Digene)

Dynamic Range of Detection of HBV DNA: 5 Assays

 Genotypes of Hepatitis B Virus
Type Subtype Geographical Distribution

A adw, adw2, ayw1 US, Northern Europe, Africa

B adw2, ayw1 China, Indonesia, Vietnam
C adr, ayr China, Korea, Japan, Vietnam
D ayw2, ayw3 Mediterranian, Middle East, India
E ayw4 West Africa
F adw4 Polynesia, US (rare)
G Europe, US (rare)
 Acute Hepatitis B
Sentinel County Study: 1982-98
• Currently, HBV causes 34% of viral hepatitis
• Decline in incidence by 76% between 1987-98
• 20% hospitalized, 1% fatal
• Gradual rise in median age (27 to 32 yrs)
• More common in men than women
• African-Americans > Hispanic whites > whites
• Current proportions with risk factors
 Injection drug use: 14%
 Men who has sex with men: 15%
 Heterosexual activity: 40%
 Occupational exposure: 2%

Goldstein et al: 2002

 Acute Hepatitis B Incidence in the U.S.: 1978-1998
HBsAg screening
of pregnant
Vaccine women
Routine infant
licensed immunization
200
Infections per 100,000

150 OSHA Rule

Routine
adolescent
immunization
100

Decline in high-risk
heterosexuals
50
Decline in Decline in injecting drug users
MSM & HCW
0
78 80 82 84 86 88 90 92 94 96 98
Year
Alter et al: CDC
 Chronic Liver Disease:
United States 1999

Othe
He
pa

r
titi
NASH

sB
10%

Hepatitis C
Alcohol 57%
25%

Hepatitis B accounted
for only 4.4% of newly-
diagnosed chronic liver Bell et al 2001
disease
 Chronic Hepatitis B
Long-Term Complications

• Cirrhosis
• Hepatocellular carcinoma
• Glomerulonephritis
• Polyarteritis Nodosa
 Chronic Hepatitis B
Histology
• Necroinflammatory Changes (Grade)
• Periportal inflammation and necrosis
(piecemeal necrosis, interface hepatitis)
• Lobular inflammation and single cell necrosis
• Portal inflammation
• Fibrosis (Stage)
• Portal
• Septa formation
• Bridging fibrosis
• Cirrhosis
 Chronic Hepatitis B
Histology Scoring Systems
• Histology Activity Index (Knodell) :
• Periportal necrosis & inflammation (0-10)
• Lobular necrosis & inflammation (0-4)
• Portal inflammation (0-4)
• Fibrosis
• None = 0
• Portal fibrosis = 1
• Bridging fibrosis = 3
• Cirrhosis = 4
 Chronic Hepatitis B
Histology Scoring Systems
• Histology Activity Index (Ishak) :
• Periportal necrosis & inflammation (0-4)
• Bridging necrosis (0-6)
• Lobular necrosis & inflammation (0-4)
• Portal inflammation (0-4)
• Fibrosis
• None = 0
• Portal fibrosis = 1 or 2
• Bridging fibrosis = 3 or 4
• Cirrhosis = 5 or 6
 Therapy
of
Hepatitis B
 Chronic Hepatitis B
Goals of Therapy
• Improve symptoms and quality of life
• Decrease infectivity
• Prevent progression of disease
• Hepatic Decompensation
• Death from liver disease
What surrogate end-points
correlate with these outcomes ?
 Therapy of Chronic
Hepatitis B: Major Issues
■ What are appropriate end-points?
■ Are they the same for different forms of HBV?
 Loss of HBeAg
 Loss of HBsAg
 Loss of HBV DNA (fall below 105 copies/ml)
 Normalization of ALT
 Improvement in histology
■ What amount of follow up is appropriate in
assessing benefit of therapy?
 Definition of Responses to
Therapy in Chronic Hepatitis B
 Type:
■Virological: Loss of HBeAg and/or HBV DNA
■Biochemical: Normal ALT
■Histological: Improvement in histology scores
■Complete: All of above & loss of HBsAg
 Timing:
■Initial: within first 6 mo of therapy
■End-of-therapy: when therapy is stopped
■Sustained: 6 or 12 mo after stopping
■Maintained: present while continuing therapy
 Virological Response in
Chronic Hepatitis B
Loss of HBeAg and fall of HBV DNA levels to
below 105 copies/mL
■Occurs in 25-48% of patients given a 4-5
month course of alpha interferon
■Occurs in 20-32% of patients given a 12
month course of lamivudine
■Occurs in 8-12% of patients on no therapy
■Is this response durable and does it result
in long-term improvement in disease and
lack of progression to cirrhosis and HCC?
 Virological Response in
Chronic Hepatitis B
Loss of HBeAg cannot be used as an endpoint in
patients with HBeAg-negative disease
■Generally rely upon decrease in HBV DNA to
below 105 copies/ml
■HBV DNA levels, however, can fluctuate
widely, and with nucleoside therapy will
rapidly return to baseline when treatment is
stopped.
■How durable is decrease in HBV DNA
without other changes in viral status?
 Virological Response in
Chronic Hepatitis B
Loss of HBsAg and development of anti-HBs
■Occurs in 8% of patients given a 4-5 month
course of alpha interferon
■Occurs in 1-2% of patients given a 12 month
course of lamivudine
■Occurs in <1% of patients on no therapy
■Extremely rare in treatment trials of HBeAg-
negative chronic hepatitis B
■This response is durable and associated
with resolution of liver disease
 Biochemical Response in
Chronic Hepatitis B

Fall of ALT levels into the Normal Range

■Often accompanies loss of HBeAg or
decrease in HBV DNA to below 105 copies/mL
■Not durable unless the decrease in HBV DNA
is durable.
■Surrogate, indirect marker for decrease in
necroinflammatory disease
 Histological Response in
Chronic Hepatitis B
Improvements in Histology
■Used in virtually all studies of antiviral therapy
■Typically, improvement is called a > 2 point
improvement in HAI score (0-22) compared to
baseline
■However, necroinflammatory scores can
change rapidly and improve and worsen
■Fibrosis scores represent best evidence for
progression of disease and are unlikely to
improve with treatment
 Alpha Interferon
■Human cytokine made by lymphocytes
in response to viral infection
■Acts through cell-surface receptors
■Activates Jak/Stat system
■Induces transcription of proteins with
antiviral activity (2-5 OAS, PKR, eIF2)
■Recombinant human alpha interferon
■Pegylated forms now available
 Chronic Hepatitis B
Long-term Response to Interferon
Alpha Interferon
500
ALT
400
HBV DNA (dot blot) Anti-HBe
ALT (U/L)

300
HBeAg
Anti-HBs
200
HBsAg
100

0
-2 0 1 2 3 4 5 6 9 12 18 24

Months After Start of Therapy

Patient A
 Chronic Hepatitis B
Response to Interferon & Relapse
Alpha Interferon
1400
1200 ALT
1000
ALT (U/L)

800 HBeAg Anti-HBe HBeAg

600
400 HBsAg
200
0
-4 -2 0 1 2 3 4 5 6 9 12 18 24

Months After Start of Therapy

Patient B
 HBeAg-Negative Chronic Hepatitis B
Response to Interferon and Relapse

800 Alpha Interferon

700
HBV DNA 600 + + - - - + +
ALT (U/L)

500
400 HBsAg
300 ALT
200 Anti-HBe
100
0
-12 -8 -4 -2 -1 0 1 2 3 4 5 6 9 12 18 24

Months After Start of Therapy

Patient C
 Interferon for Chronic Hepatitis B:
Problems
• Effective in only 1/3rd of cases
• Expensive
• Side effects are common and can be severe
• Not appropriate for many categories of pts:
– Immune suppressed
– Renal failure or dialysis
– Solid organ transplant
– Decompensated liver disease
 Lamivudine
■Negative enantiomer of 3-thiacytidine
■Both an unnatural nucleoside and
chain terminator
■Highly active against HBV in vitro
■Dose: 100 mg, once daily by mouth
■Approved for use in chronic hepatitis B
as one year course of therapy
■Continuous, long-term use is common
but must be considered experimental
 Lamivudine Therapy
Maintained Response

600 Therapy with Lamivudine (100 mg/d)

500
ALT 108

HBV DNA Levels

ALT Levels (U/L)

HAI Scores:
400 Pre: 14
HBV DNA
Yr 1: 4 106
300
Yr 4: 1
HBeAg
200 104
HBsAg
100
102
0
-2 0 2 4 6 8 10 12 18 24 30 36 42 48

M onths After Starting Therapy

Patient B
 HBeAg-Negative Chronic Hepatitis B
Lamivudine
Liver Biopsy HAI = 13 HAI = 4 HAI = 1
HBV DNA 53.1 million 200 copies/ml <100 copies/ml
600 copies/ml
500
400
ALT (U/L)

ALT
300
200 HBsAg and Anti-HBe

100
0
-4 -2 0 3 6 9 12 15 18 21 24 30 36 42 48 54
Months After Start of Therapy

Patient C
 Lamivudine Therapy:
Viral Resistance
Therapy with Lamivudine (100 mg)
600
500 wt 1010

HBV DNA Levels

ALT Levels (U/L)

400 108
HBV DNA
YVDD
300
106
200
ALT 104
100
0 Normal 102

Pre 0 2 4 6 8 10 12 18 24 30 36 42 48
HAI Scores:
Months After Starting Therapy Pre: 14
Yr 1: 10
Patient D Yr 4: 17 (Cirrhosis)
 Lamivudine for Chronic Hepatitis B
Histology Activity Index Scores

Pre 1 year 4 years

12
Total HAI Scores (0 to 18)

9.8 9.9
10
8.4
8 7.1

4
2.5
2 1.3 9 9 9
13 13
4
0
Maintained Resistance
 Lamivudine for Chronic Hepatitis B:
Fibrosis Scores
Pre 1 year 4 years
6
Fibrosis Score (0 to 6)

5
4.2 3.9 4.3
4 3.3
2.9
3

2
1.3
1 9 9 9
13 13
4
0
Maintained Resistance
 Lamivudine Therapy
Late Relapse
600
500 Therapy with Lamivudine (100 mg/d)
ALT Levels (U/L)

400 ALT 108

HBV DNA Levels

HAI Scores:
300 HBV DNA Pre: 14
Yr 1: 4 106
200 HBeAg Yr 4: 1
104
100 HBsAg
0 102
-2 0 2 4 6 8 10 12 18 24 30 36 42 48 54 60

Months After Starting Therapy

Patient B
 100
85%
p = 0.001
Percent with Resistance (%)

80
HBeAg +

60
50%

40

HBeAg -
20

0
0 6 12 18 24 30 36 42 48
Months of Therapy
 Lamivudine
■The major shortcoming of long-term
lamivudine therapy for hepatitis B is
emergence of lamivudine resistance
■Occurs in 20%-30% of patients per yr,
approaching 90% by 5 yrs
■Loss of HBsAg, but not loss of HBeAg,
appears to reliably predict long-term
benefit & ability to stop lamivudine
■Future studies should focus on
combinations that might prevent resistance
 Optimal Therapy of Hepatitis B?

 Monotherapy or combination therapy?

For a defined period (48 wks) or continuous?
For all pts or only those with mod-severe disease?
If monotherapy, which agent?
If combination, which combination?
Standard interferon and lamivudine
Pegylated interferon and lamivudine
Lamivudine and adefovir
Lamivudine and entecavir
 Management of Hepatitis B
●Initial evaluation: Routine liver tests, HBsAg,
HBeAg & anti-HBe, HBV DNA, anti-HDV,
abdominal US
●If ALT elevated & HBV DNA present: liver
biopsy and assess for therapy
●Reserve therapy for patients with significant
underlying liver disease
●Therapy?

Lok, Heathcote & Hoofnagle: 2001

Therapy of Chronic Hepatitis B:
Future Directions
■Focus must be on combination therapy
■Long term outcomes with histological
verification of long-term benefit
■Loss of HBsAg might be a gold standard
■Appropriate directions:
 Combinations of alpha interferon & lamivudine
 Nucleoside combinations without cross-reactive
resistance (lamivudine & adefovir or entecavir)
 Novel approaches: immunological or molecular