HEPATITIS B INFECTION

DIAGNOSIS AND INTERPRETATION

Dr.T.V.Rao MD

DR.T.V.RAO MD

HEPATITIS B IN THE WORLD 2 billion people have been infected (1 out of 3 people). 400 million people are chronically infected. 10-30 million will become infected each year. An estimated 1 million people die each year from hepatitis B and its complications. Approximately 2 people die each minute from hepatitis B.
DR.T.V.RAO MD

PREVALENCE OF HEPATITIS B CARRIERS

. Worldwide prevalence of hepatitis B carriers and primary hepatocellular carcinoma. (Courtesy Centers for Disease Control and Prevention, Atlanta.)
From Murray et. al., Medical Microbiology 5th edition, 2005, Chapter 66, published by Mosby Philadelphia,,

1PROPERTIES

OF HBV

A member of the hepadnavirus group

Circular partially double-stranded DNA viruses Replication involves a reverse transcriptase. Endemic in the human population and hyper endemic in many parts of the world. A number of variants It has not yet been possible to propagate the virus in cell culture
DR.T.V.RAO MD

HEPATITIS B
Hepadnaviridae family DNA virus Double-shelled particles Outer lipoprotein envelope (surface Ag) Inner viral nucleocapsid (core)
seven genotypes four major subtypes. All HBV subtypes share one common antigenic determinant - "a. Thus, antibodies to the "a" determinant confer protection to all HBV subtypes
Diagrammatic representation of the hepatitis B virion and the surface antigen components

EM of Hepatitis B viron

HEPATITIS B VIRUS A MAJOR CAUSE OF HEPATITIS

DR.T.V.RAO MD

HEPATITIS B
DNA virus hepadnavirus
3200 bp
Compact - uses overlapping genes Complicated replication has a ssDNA component to RNA to DNA Difficult to grow Liver damage may be due to host immunity

DR.T.V.RAO MD

STRUCTURE OF HEPATITIS B VIRUS

DR.T.V.RAO MD

HBV STRUCTURE & ANTIGENS

Dane particle

HBsAg = surface (coat) protein ( 4 phenotypes : adw, adr, ayw and ayr) HBcAg = inner core protein (a single serotype) HBeAg = secreted protein; function unknown DR.T.V.RAO MD

SURFACE PARTICLES
HBsAg-containing particles are released into the serum of infected people and outnumber the actual virions. Spherical or filamentous They are immunogenic and were processed into the first commercial vaccine against HBV.
DR.T.V.RAO MD

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HEPATITIS B
Structure and major antigens:
22 nm most abundant extra viral envelope protein
- spheres and tubes 42 nm double-shelled intact virus

Both covered by HBsAg see in blood

Disrupt 42 nm with mild detergent get 27nm core particle covered by HBcAg never see in blood HBeAg soluble binds to the smooth ER and gets exported into the circulation see in blood
DR.T.V.RAO MD

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Open Reading Frames

There are 4 open reading frames derived from the same strand (the incomplete + strand)

S - the 3 polypeptides of the surface antigen (preS1, preS2 and S - produced from alternative translation start sites.
C - the core protein P - the polymerase X - a transactivator of viral transcription (and cellular genes?). HBx is conserved in all mammalian (but not avian) hepadnavirus. Though not essential in transfected cells, it is required for infection in vivo.
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HBV SEROLOGY INTERPRETATION

Acute infection
HBsAg positive and anti-HBcAg IGM Rarely, IgM anti-HBc only marker
Usually seen in acute fulminate Hep B

Chronic infection
HBsAg positive and anti-HBcAg

Previous Infection
HBsAg negative anti-HBs positive IgG anti-HBc positive

ETIOLOGY
HBcAganti-HBc system
HBcAg can be found in the nuclei of liver cells, no free HBcAg in serum HBcAg is the marker of replication of HBV The stage called window phase Anti-HBc IgM is a marker of acute infection and acute attack of chronic infection of HBV. Anti-HBc IgG is the marker of past infection, high titer means low level replication of HBV

DR.T.V.RAO MD

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HEPATITIS B VIRUS E ANTIGEN

Secretory protein that is processed from the precore protein Elevated early in infection and usually coverts to antibody early on. Traditionally used as a marker for viral load as viral load was undetectable with early assays when Ag was absent.
However, certain variants of the Hep B virus do not create the HBeAg as it has no known function.

When present, it does correlate with elevated viral load and seroconversion the antibody usually correlates with a decrease in viral load by a magnitude of 4-5.

THREE ANTIGEN-ANTIBODY SYSTEM

Include HBsAg, anti-HBs, pre-s1,s2 antigen and anti-pres1, s2 HBsAg appears 1-2 weeks (late to 11-12 weeks) after exposure, persists for 1-6 weeks( even 5 months) in acute hepatitis B. In chronic patients or carrier, HBsAg persist many years HBsAg antigencity but no infectivity

DR.T.V.RAO MD

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CLINICAL OUTCOMES OF HEPATITIS B INFECTIONS

. Clinical outcomes of acute hepatitis B infection. (Redrawn from White DO, Fenner F: Medical virology, ed 3, New York, 1986, Academic Press
From Murray et. al., Medical Microbiology 5th edition, 2005, Chapter 62, published by Mosby Philadelphia,,

DETERMINANTS OR ACUTE AND CHRONIC HBV INFECTION

Figure 66-7

From Murray et. al., Medical Microbiology 5th edition, 2005, Chapter 66, published by Mosby Philadelphia,,

SCREENING WHO?
Who should be screened
Persons born in hyper endemic areas Men who have sex with men Injection drug users Patients on dialysis HIV infected patients Pregnant women Family and household contacts and sexual contacts of HBV-infected persons. Testing should be performed by obtaining an HBsAg and antiHBs.

SEROLOGICAL MARKERS

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HEPATITIS B MARKERS:
HBsAg:Present in acute or chronic infection.

HBsAb:Present in recovery or immunization.

Anti -HB Core: May be Total (IgG&IgM) or IgM. Lifelong marker of past and active infection in either acute or chronic. HBeAg:Acute infection, and extremely infectious.

Anti-Hbe: Usually prognostic for resolution.

DR.T.V.RAO MD

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ETIOLOGY
HBcAganti-HBc system HBcAg can be found in the nuclei of liver cells, no free HBcAg in serum HBcAg is the marker of replication of HBV The stage called window phase Anti-HBc IgM is a marker of acute infection and acute attack of chronic infection of HBV. Anti-HBc IgG is the marker of past infection, high titer means low level replication of HBV

DR.T.V.RAO MD

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Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course

Symptoms HBeAg anti-HBe

Total anti-HBc

Titre
HBsAg IgM anti-HBc anti-HBs

0
DR.T.V.RAO MD

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16

20

24

28

32

36

52

100
23

Weeks after Exposure

Acute HBV Infection with Progression to Chronic Infection: Typical Serologic Course
Acute
(6 months)

Chronic
(Years)

HBeAg

Anti-HBe

HBsAg Total anti-HBc

IgM anti-HBc

0 4
DR.T.V.RAO MD

8 12 16 20 24 28 32 36

52

Years
24

Weeks after Exposure

HEPATITIS B
Serologic Markers During Acute HBV Hepatitis and Recovery
60 50 40
Titer Anti-HBcAb HBsAg Window HBeAg

30 20 10 0 1 2
Incubation

Anti-HBsAb
Anti-HBeAb

4 5 6 7 Months after exposure

Jaundice Recovery

9
IMMUNE

10

Elevated ALT
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ETIOLOGY
HBcAganti-HBc system
HBcAg can be found in the nuclei of liver cells, no free HBcAg in serum
HBcAg is the marker of replication of HBV

The stage called window phase

Anti-HBc IgM is a marker of acute infection and acute attack of chronic infection of HBV. Anti-HBc IgG is the marker of past infection, high titer means low level replication of HBV
DR.T.V.RAO MD

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HEPATITIS B
Serology: - acute:
HBsAg+ (HBsAb-) = acute infection or chronic carrier HBeAg+ = highly infectious HBsAb = immune naturally or vaccine Window = HBsAg- and HBsAbwill be HBcAb+ (IgM acute)

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ETIOLOGY
HBeAganti-HBe system
HBeAg is a soluble antigen HBeAg is a reliable indicator of active replication of HBV Anti-HBe is a marker of reduced infectivity. If exist long may be a marker of integration of HBV into liver cell

DR.T.V.RAO MD

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Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course

Acute
(6 months)

Chronic
(Years)

HBeAg

anti-HBe

HBsAg Total anti-HBc

IgM anti-HBc

12 16 20 24 28 32 36

52

DR.T.V.RAO MD

Weeks after Exposure

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ETIOLOGY
The marker of molecular biology of HBV HBV-DNA
The direct indicator of HBV infection Can integrate into the genome of hepatocytes

HBV DNA polymerase Possesses the ability of reverse transcriptase and the indicator of the ability of replication of HBV
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Possible Outcomes of HBV Infection

Acute hepatitis B infection
3-5% of adult-acquired infections Chronic HBV infection 95% of infant-acquired infections

Chronic hepatitis 12-25% in 5 years

6-15% in 5 years
Hepatocellular

Cirrhosis

20-23% in 5 years Liver failure

carcinoma
DR.T.V.RAO MD

Death

Liver transplant

Death

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PRACTICE!!!!!!!!!!!!!!!
HBsAg HBcAB (TOTAL) HBsAB HAV-IGM HCV N. N. N. N. N.

NO evidence of viral hepatitis viruses.

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SOLVING THE PROBLEMS HBsAG HBcAB (TOTAL) HBsAB HAV-IGM HCV N. P. P. N. N.

PAST INFECTION.

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IMMUNIZED FOR HBV INFECTION

HBsAg HBcAB (total) HBsAB HAV-IGM HCV N. N.

P.
N. N.

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PRACTICE..
HBsAg P

HBcAB (Total)
HBsAB HAV-IGM HCV

P
N N N

MAY BE ACUTE OR CHRONIC. Order Hep. B Core IgM to clarify. The IgM will be positive , If Acute.

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CO INFECTION WITH HBV, HAV, AND HCV

HBsAg HBcAB (TOTAL)

P P

HBsAB
HAV-IGM

N
P

HCV
DR.T.V.RAO MD

P
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PAST INFECTION WITH RECOVERY, AND THEN RE-INFECTION THAT HAS BECOME CHRONIC, THIS IS VERY RARE BUT DOES HAPPEN.

HBsAG HBcAB (total) HBsAB HAV-IGM HCV

.

P P

P
N N

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HEPATITIS B PERSISTENT INFECTION

Persistent viral load that declines over time HBeAg declines overtime, converting eventually to anti-HBe antibody
Seroconversion correlates with rise in LFTs and 5 order of magnitude decline in viral load.
Classically, to Anti-HBe antibody = no viral DNA circulating, which is incorrect

0.5% clear HBsAg annually

MOLECULAR ADVANCES IN DIAGNOSIS OF HBV INFECTION

Recent diagnostic developments including HBV genotyping and precore/core promoter assays that could well play important future roles in HBV patient management

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EMERGING TOOLS IN DIAGNOSIS OF HBV INFECTION

Current HBV DNA assays make use of differing technologies and can generally be divided into (i) signal amplification assays (liquid phase hybridization, antibody capture approach, branched DNA) and (ii) DNA amplification tests based on the polymerase chain reaction (PCR) . Signal amplification assays have sensitivities approaching 1 pg of DNA (10 5-106 genome copies) or even to 103 genome copies. Alternatively, HBV DNA detection based on a nested PCR approach can detect as few as 102-103 genome copies.
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 Programme created by Dr.T.V.Rao MD for Health care workers in the Developing world
Email

doctortvrao@gmail.com

DR.T.V.RAO MD

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