Hepatitis B: global importance and need for control

A reinvestigation of seroconversion rates in hepatits B-vaccinated individuals

The purpose of this study was to examine whether the hepatitis B seroconversion rates in a small sample of subjects reflected that of the published rates, regardless of HIV status, after a hepatitis B vaccination series was completed while following strict vaccine protocols. The study, which had a nonexperimental, correlational cross-sectional design, took place at a community clinic in Laguna Beach, CA. Participants comprised 100, predominantly White, men aged 18-65 years (mean 39.2 years) who were hepatitis B naive, regardless of immune status. After receiving a primary vaccine series for hepatitis B, participants were tested for seroconversion to immune status. Seroconversion to the immune state occurred in 78.6% of the non-immunocompromised, HIV-negative participants (n = 50), who had received the standard three-dose regimen of the vaccine, and in 77% of the immunocompromised, HIV-positive participants (n = 48), who had received the recommended modified three-double-dose regimen. The manufacturer-published rates of seroconversion are 90-100%, depending upon the population. These findings highlight a need for further study to validate or reveal deficits in current vaccine protocols for individuals who are vaccinated against hepatitis B, including health care workers, the immune-compromised and other high-risk populations.

Fatal hepatitis B reactivation due to everolimus in metastatic breast cancer: case report and review of literature

Hepatitis B reactivation can occur with cytotoxic chemotherapy in patients with hepatitis B and cancer. Reactivation can occur in a patient with chronic hepatitis, an inactive carrier, or one with resolved hepatitis. Clinical presentation may range from subclinical elevation of liver enzymes to fatal fulminant hepatic failure. Mammalian target of rapamycin inhibitors, which include everolimus, are a new generation of targeted agents that are currently approved for many cancers (since March 2009) including advanced hormone receptor positive, human epidermal growth factor receptor 2-negative breast cancer, in conjunction with exemestane (as of July 2012). We are therefore still learning the various adverse events that occur with this new class of agents. Here, we present an unfortunate case of fatal hepatitis B reactivation in a woman with metastatic breast cancer treated with everolimus and exemestane. We have detailed the controversies around hepatitis B screening prior to immunosuppressive therapy. Clinicians and patients should be aware of this rare but fatal complication prior to everolimus use, and a detailed history, screening for hepatitis B and prophylactic antiviral treatment should be considered.

Long-term efficacy of the hepatitis B vaccine in a high-risk group

Chronic infection with hepatitis B virus (HBV) is a global health problem. In an attempt to control infection, worldwide HBV vaccination programs have been established. Saudi Arabia, an endemic area for HBV infection, established an HBV immunization program in 1989. This cross-sectional study evaluates the long-term protection of HBV vaccination 14-24 years after primary immunization in a high-risk group (clinical year medical students) at King Abdulaziz University Hospital in Jeddah, Saudi Arabia. All participants had complete HBV immunization at birth or in early childhood. Hepatitis B surface antibody (anti-HBs) levels were obtained. An anti-HBs titer of <10 mIU/ml indicated no protection, while a titer of >10 mIU/ml was considered to represent protective immune status. A total of 238 students were included; they were predominantly females (n = 182, 76.5%). Mean age was 22.2 ± 1.1 years. Duration since primary vaccination was 19.8 ± 2.3 years. Female students were more likely to maintain long-term protection compared to males (62.1% and 58.8%, respectively). Anti-HBs levels were significantly low in many students after primary immunization. Testing medical students for anti-HBs levels may be warranted as they represent a high-risk population. The higher rate of vaccine failure in males than females requires further investigation as it may explain the higher prevalence of HBV in the male population.

Prevalence of HBc-Ab among HBs-Ag negative healthy blood donors in south of Iran

Background:

The risk of infection with transfusion-transmitted viruses, such as Hepatitis B virus (HBV), has been reduced markedly. However, a zero-risk blood supply remains a popular goal. Anti-hepatitis B core antigen (anti-HBc) is considered to be an effective marker for occult HBV infection, and it has served a significant role in improving blood safety. The purpose of this study was to determine the seroprevalence of anti-HBc antibodies among blood donors.

Methods:

During a period of six months in 2012, 1000 blood donors in Bandar Abbas were investigated for the presence of HBV infection markers. We used ELISA for the detection of HBsAg and chemiluminescence for the detection of HBsAb and anti-HBc antibodies.

Results:

The prevalence of positive anti-HBc among the 1000 donors was 8.3%. Almost 2.3% of the donors were reactive for anti-HBc and negative for HBsAg.

Conclusions:

The study showed that more than 2% of healthy blood donors in Bandar Abbas already have been exposed to HBV, although their HBsAg tests were negative. We suggest screening for anti-HBc to improve the safety of the blood supply.

Recent trends in hepatitis B virus infection in the general Korean population

BACKGROUND/AIMS

Hepatitis B virus (HBV) is the major cause of chronic liver disease in Korea, but viral prevalence has decreased because of hepatitis B vaccination programs. In this study, we investigated longitudinal changes in HBV in fection in the general Korean population.

METHODS

HBV surface antigen (hepatitis B surface antigen, HBsAg) seropositivity was assessed from the Korea National Health and Nutrition Examination Survey (I to V). In total, 50,140 subjects were tested for serum HBsAg positivity over a period of 12 years (1998 to 2010).

RESULTS

The prevalence of HBsAg seropositivity decreased over the study period. The rates of HBsAg carriers were 4.61% in 1998, 4.60% in 2001, 3.69% in 2005, 3.01% in 2008, and 2.98% in 2010 (p < 0.0001). The reduction in HBV infection rates was more prominent in younger age groups. Among teenagers (10 to 19 years), the percentage of HBsAg carriers decreased from 2.2% in 1998 to 0.12% in 2010 (p < 0.0001). Among those aged 10 to 39 years, the percentage of HBV infection decreased from 4.72% in 1998 to 2.29% in 2010 (p < 0.0001). However, no decreasing trend in HBsAg positivity was observed among those aged 50 or older (p > 0.05). Neither gender nor socioeconomic status were associated with the decreased prevalence of HBsAg carriers.

CONCLUSIONS

HBV infection has decreased in the Korean population since the advent of vaccination programs. However, the decrease is limited to the younger population, and viral persistence remains in the middle-aged and older population.

Hepatitis B Infection among high risk population: a seroepidemiological survey in Southwest of Iran

BACKGROUND

Hepatitis B virus (HBV) infection remains a major global health problem. This study aimed to assess the prevalence and risk behaviors for HBV infection among high risk groups in Kohgiloyeh and Boyerahmad province, in Southwest of Iran.

METHODS

Blood samples were collected from 2009 subjects, between 2009 and 2010 in Kohgiloyeh and Boyerahmad province, in southwest of Iran. Recruited subjects were the high risk groups for HBV infection, including inmates, injecting drug users, health care workers, patients on maintenance haemodialysis, hemophilic patients and patients with a history of blood transfusion. Their serum samples were tested for the presence of antibodies to hepatitis B core antigen (HBc IgM, IgG) by enzyme-linked immunosorbent assay (ELISA). Seropositive specimens were tested for HBsAg. Demographic features of participants were recorded during sample collecting.

RESULTS

HBsAg was detected in 24 of the 2009 subjects, giving an overall prevalence of 1.2%. All HBsAg positive cases were males. The prevalence of HBsAg among injection drug users was 3.2%. Significant correlation was found between HBV infection and drug abuse, level of education and place of residence (p<0.05), while no significant correlation was found between HBV infection and previous history of blood transfusion, unprotected sexual behavior, and thalassemia.

CONCLUSION

Based on the findings of this study, incarceration and drug abuse are the most important risk factors for acquiring HBV infection in this region. Modifying behavior, improving the individual education and expanding the HBV vaccination coverage may reduce the rate of infection in the region.

Hepatitis B virus and human immunodeficiency virus drugs in pregnancy: findings from the Antiretroviral Pregnancy Registry

BACKGROUND & AIMS

Fetal safety of antiviral therapies is important given the long-term treatment of women with chronic hepatitis B (CHB) infection who may become pregnant. We analyzed neonatal safety data from the Antiretroviral Pregnancy Registry (APR), the largest safety database in pregnancy for antivirals used for HIV and CHB.

METHODS

Data were extracted from APR cases prospectively enrolled between 1989 and 2011. Primary outcomes were major birth defects rates with exposure to all antivirals, individual classes, and drugs compared to population-based controls. Relevant to CHB, only lamivudine (LAM) and tenofovir disoproxil fumarate (TDF) had sufficient individual data for review (≥200 cases).

RESULTS

Of 13,711 cases analyzed, the overall birth defect prevalence (2.8%, 95% CI 2.6-3.1%) was comparable to Centers for Disease Control population-based data (2.72%, 2.68-2.76%, p=0.87) and two prospective antiretroviral exposed newborn cohorts (2.8%, 2.5-3.2%, p=0.90 and 1.5%, 1.1-2.0%, p<0.001). The birth defects prevalence between first and second/third trimesters exposure was similar (3.0% vs. 2.7%). No increased risk of major birth defects with LAM or TDF exposure compared to population-based controls was observed. No specific pattern of major birth defects was observed for individual antivirals or overall.

CONCLUSIONS

No increased risk of major birth defects including in non-live births was observed for pregnant women exposed to antivirals relevant to CHB treatment overall or to LAM or TDF compared to population-based controls. Continued safety and efficacy reporting on antivirals in pregnancy are essential to inform patients on their risks and benefits during pregnancy.

Antenatal lamivudine to reduce perinatal hepatitis B transmission: a cost-effectiveness analysis

OBJECTIVES

This study aimed to determine whether administration of lamivudine to pregnant women with chronic hepatitis B in the third trimester is a cost-effective strategy in preventing perinatal transmission.

STUDY DESIGN

We developed a decision analysis model to compare the cost-effectiveness of 2 management strategies for chronic hepatitis B in pregnancy: (1) expectant management or (2) lamivudine administration in the third trimester. We assumed that lamivudine reduced perinatal transmission by 62%.

RESULTS

Our Markov model demonstrated that lamivudine administration is the dominant strategy. For every 1000 infected pregnant women treated with lamivudine, $337,000 is saved and 314 quality-adjusted life-years are gained. For every 1000 pregnancies with maternal hepatitis B, lamivudine prevents 21 cases of hepatocellular carcinoma and 5 liver transplants in the offspring. The model remained robust in sensitivity analysis.

CONCLUSION

Antenatal lamivudine administration to pregnant patients with hepatitis B is cost-effective, and frequently cost-saving, under a wide range of circumstances.

Extrahepatic manifestations of hepatitis B virus infection: Addison's disease and myelofibrosis in a patient with persistent hepatitis B surface antigenemia

A 60-year-old white male patient was admitted to the hospital with acute abdominal pain, seemingly a self-limited ileus. He was found to be hepatitis B surface antigen (HBsAg)-positive. Previous dental treatment was suspected to be the initial source of the infection with hepatitis B virus. Five months later he was re-admitted with a diagnosis of adrenal insufficiency (Addison's disease) which responded well to steroids. Four years later he developed fever and leucocytosis. A bone marrow biopsy revealed myelofibrosis. He had several episodes of pyrexia during his lifetime. After a 12-year period the patient suffered a fatal myocardial infarction. At autopsy the adrenal glands were reduced to scarred remnants and HBsAg was found to be present in the residual adrenocortical cells by immunoflouresence methods. Bone marrow at autopsy revealed myelosclerosis as well HBsAg (via immunofluoresence). Hepatitis B virus was therefore closely correlated with the development of Addison's disease and myelofibrosis in this case.

Prevalence of hepatitis B virus infection in a highly endemic area of southern China after catch-up immunization

The Chinese national goals for control of hepatitis B virus (HBV) infection were to achieve a prevalence of HBsAg below 7% for the entire population, and 1% for children under 5-year old, by 2010. To determine whether Guangxi, a multi-minority province with a low socio-economic status and a very high prevalence of HBV, achieved this goal, a seroepidemiological survey of HBV infection was carried out using stratified, random cluster sampling. The results show that the overall prevalence of HBsAg is 9.16% [95% confidence interval (CI) = 8.32-10%]. The prevalence in males (10.96%, 95% CI = 9.64-12.28%) is significantly higher than in females (7.71%, 95% CI = 6.64-8.78%; χ(2) = 10.5923, P < 0.05). The prevalence in children under 5-year old is 3.62% (95% CI = 0.60-6.64%) and increases with age. The prevalence of HBsAg in non-immunized individuals is significantly higher than in those immunized completely, although not within 24 hr of birth (χ(2) = 31.426, P < 0.05); a significant difference was found in those below the age of 20 years but not in older persons. Gender, age, immunization history, and familial HBsAg carriers are risk factors for infection. In conclusion, this study indicates that Guangxi has not reached the goal for the control of HBV infection. Catch-up HBV immunization may not protect adults effectively against infection in highly endemic regions.

HBV genotypes: relevance to natural history, pathogenesis and treatment of chronic hepatitis B

Although chronic HBV infection is the leading cause of chronic liver disease and death worldwide, there are substantial differences in its clinical courses regarding prevalence, mode of transmission, characteristics of each phase, responses to antiviral therapy, and development of cirrhosis and hepatocellular carcinoma, according to geographical areas (Asia versus Western Europe and North America versus Africa). Furthermore, the clinical course in infected individuals depends on a complex interplay among various factors including viral, host, environmental and other factors. Recently, understanding of molecular characteristics of the prevailing HBV genotypes, frequently accompanied mutations and their clinical implications might explain these geographical differences more pertinently. Hence, in this article, we review the global epidemiology and the natural history of HBV infection, with emphasis on summarizing the different HBV genotypes according to regions.

Comparison of cryoglobulinemia in children and adults

BACKGROUND/PURPOSE

Cryoglobulinemic vasculitis is a systemic vasculitis resulting from circulating immune complex deposition in the small vessels and is characterized by variable clinical features, including purpura, Raynaud's syndrome, ulcerations, arthralgia, glomerulonephritis, and peripheral neuropathy. Cryoglobulinemia can also result from hepatitis C virus (HCV) infection. The clinical spectrum and associated or underlying diseases of cryoglobulinemia in different age groups is not well understood. This study investigated the demographic, clinical, serologic features, and associated or underlying diseases in children and adult patients with cryoglobulinemia.

METHODS

The retrospective study included 114 patients (18 children, 96 adults) who presented with cryoglobulinemia between 2000 and 2010 at the Chang Gung Memorial Hospital. Their medical records were reviewed and serological and virologic assessments were analyzed.

RESULTS

In this group of patients, children had a significantly higher prevalence of prolonged fever (16.7% vs. 3.13%; p=0.018), arthralgia (66.67% vs. 16.67%; p<0.001), arthritis (66.67% vs. 15.63%; p<0.001) and cutaneous involvement (77.78% vs. 50%; p=0.03) compared with adults. Both the adult and children groups had a greater frequency of hepatitis B virus (HBV) infection (20.8% and 5.6%, respectively), than HCV infection (12.5% and 0%, respectively).

CONCLUSIONS

Children with cryoglobulinemia had a significantly higher prevalence of prolonged fever, arthralgia, arthritis and cutaneous involvement compared with adults.

Incidence of acute hepatitis B in patients with spinal cord injury

STUDY DESIGN

Retrospective case survey.

OBJECTIVE

To examine incidence and clinical characteristics of hepatitis B infection in individuals with spinal cord injury (SCI).

SETTING

Inpatient clinic within a physical medicine and rehabilitation hospital specialized in rehabilitation.

PARTICIPANTS

A total of 161 patients with SCI.

INTERVENTIONS

Patients' records were investigated and the status of hepatitis B surface antigen (HBsAg), anti-hepatitis C virus (HCV), anti-hepatitis B surface antigen positivity, alanine aminotransferase levels, duration of hospitalization and cost were recorded.

MAIN OUTCOME MEASURES

Incidence of acute hepatitis B.

RESULTS

Six patients were diagnosed with acute hepatitis B on the first hospitalization for rehabilitation. A total of 11 patients (4.2%) were HBsAg positive with a previously established diagnosis of hepatitis B virus infection, 1 patient (0.4%) was anti-HCV positive. After a follow-up of 6 months, three of the acute hepatitis B patients progressed into chronic hepatitis B stage. In acute hepatitis B patients' initiation of the rehabilitation was delayed, duration of hospitalization was increased.

CONCLUSIONS

After SCI, patients are at high risk of acute hepatitis B infection. A high rate of chronicity may be associated with impaired immune response, secondary to neurological deficit. Screening and vaccination protocols may prevent the spread of the hepatitis B infection, healthcare losses and financial loss.

Hepatitis B vaccination status and needlestick injuries among healthcare workers in syria

Background:

Although a majority of countries in the Middle East show intermediate or high endemicity of hepatitis B virus (HBV) infection, which clearly poses a serious public health problem in the region, the situation in the Republic of Syria remains unclear. The aim of this study is to determine the hepatitis B vaccination status, to assess the number of vaccinations administered, and to estimate the annual incidence of needlestick injuries (NSIs) among healthcare workers (HCWs) in Aleppo University hospitals.

Materials and Methods:

A cross-sectional design with a survey questionnaire was used for exploring details of NSIs during 2008, hepatitis B vaccination status, and HBV infection among a random stratified sample of HCWs in three tertiary hospitals in Aleppo (n = 321).

Results:

Two hundred and forty-six (76.6%) HCWs had sustained at least one NSI during 2008. Nine (2.8%) had HBV chronic infection and 75 HCWs (23.4%) were never vaccinated. Anesthesiology technicians had the greatest exposure risk when compared to office workers [OR = 16,95% CI (2.55-100), P < 0.01], doctors [OR = 10,95% CI (2.1 47.57), P < 0.01], and nurses [OR = 6.75,95% CI (1.56-29.03), P = 0.01]. HCWs under 25 and between the age of 25 and 35 years were at increased risk for NSI when compared to HCWs older than 45 years [OR = 3.12,95% CI (1.19-8.19), P = 0.02] and [OR = 3.05,95% CI (1.42-6.57), P < 0.01], respectively.

Conclusion:

HCWs at Aleppo University hospitals are frequently exposed to blood-borne infections. Precautions and protection from NSIs are important in preventing infection of HCWs. Education about the transmission of blood-borne infections, vaccination, and post-exposure prophylaxis must be implemented and strictly monitored.

Autoimmune bullous diseases the spectrum of infectious agent antibodies and review of the literature

Pemphigus and bullous pemphigoid are two autoimmune diseases that have a similar pathogenesis. Both have a genetic predisposition which promotes the production of auto-antibodies targeted against different components of the epidermal desmosome and hemidesmosome. Environmental factors play an important role in the pathogenesis of this autoimmune disease. Among these, the role of infectious agents was debated as a causative factor. We sought to determine a possible connection between various infectious agents and autoimmune bullous disease (ABD). A cohort of 148 serum samples of patients with pemphigus, bullous pemphigoid and controls was screened for evidence of a prior infection with HBV, HCV, EBV, CMV, Helicobacter pylori, Toxoplasma gondii and Treponema pallidum, utilizing the Bio-Rad BioPlex 2200 system as well as ELISA assays to complete the panel. HBV, HCV, H. pylori, T. gondii and CMV were demonstrated to have significantly higher prevalence of antibodies in patients with pemphigus and bullous pemphigoid in comparison to controls. Among them, we found a novel association between H. pylori and ABD. Our study suggests a contributing role for HBV, HCV, H. pylori, T. gondii and CMV in inducing ABD in the genetically susceptible host.

An argument for the universal prophylaxis of hepatitis B infection in patients receiving rituximab: a 7-year institutional experience of hepatitis screening

Reactivation of hepatitis B virus (HBV) replication in patients receiving rituximab is well described. Current international guidelines recommend HBV screening prior to the commencement of immunosuppressive therapy. However, adherence to such protocols has not previously been studied. We therefore audited screening practices and clinical outcomes in patients prescribed rituximab since its introduction in a large metropolitan health service. All patients receiving rituximab over an 88-month period were identified via pharmacy records. Medical records and laboratory results were reviewed to determine the timing and type of hepatitis screening. HBV flares were identified and correlated with clinical outcomes and any screening or prophylaxis given. Rituximab was given to 355 patients over 88 months (average age, 61 years; 51% male, 48% born overseas); 83% received rituximab for treatment of a hematological malignancy. HBV screening occurred in 31% of patients and, of these, 66% had pre-emptive screening. Five patients given cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab experienced HBV flares. Four died from viral reactivation. None received antiviral prophylaxis. Hepatitis screening rates in patients receiving rituximab in this study were lower than recommended in clinical guidelines. The identification of five patients with clinically important flares and four deaths in this group highlight the critical need to identify at-risk patients and provide timely prophylactic antiviral therapy to prevent serious morbidity and mortality. Even those with evidence of HBV seroconversion are at risk for fatal flares without active prophylactic antiviral therapy.

Infectious immune status in an obstetric population of Pakistani immigrants in Norway

Aim: To investigate cytomegalovirus, rubella, varicella, toxoplasma, and hepatitis B immune status and factors associated with susceptibility for infections among Pakistani pregnant women in Norway. Methods: A total of 206 pregnant Pakistani women living in Norway participated in the evaluation. Blood samples were collected during pregnancy and tested for IgG antibodies against cytomegalovirus, rubella virus, varicella-zoster virus, Toxoplasma gondii, and hepatitis B (HB) virus. Results: All women had IgG antibodies against cytomegalovirus. Positivity for rubella IgG was 92%, 93% had varicella IgG antibodies, while 17% had toxoplasma IgG. Eleven per cent were anti-HBc positive, one of whom was HBsAg positive, which means that blood and cervix secretions are infectious with risk of virus transmission to the baby at the time of birth. Six women were only anti-HBc positive, they may have low-level HB infection, and risk of transmission cannot be excluded. Age younger than 25 years, having less than two children, and having lived less than 5 years in Norway were factors significantly associated with varicella-seronegative status, and thus susceptible for primary infection. Conclusions: To decrease the incidence of neonatal and maternal morbidity related to rubella, varicella, toxoplasma, and hepatitis B in our Pakistani immigrant population, we should intensify our rubella antenatal screening programme and focus upon rubella vaccination postpartum. We should offer varicella-seronegative women immunisation, advise toxoplasma-seronegative women to avoid visit to their home country during pregnancy, and give hepatitis B vaccine to all newborns regardless of maternal HBsAg status.

Prediction of compensated liver cirrhosis by ultrasonography and routine blood tests in patients with chronic viral hepatitis

BACKGROUND/AIMS

Liver biopsy is a standard method for diagnosis of liver cirrhosis in patients with chronic hepatitis. Because liver biopsy is an invasive method, non-invasive methods have been used for diagnosis of compensated liver cirrhosis in patients with chronic hepatitis. The current study was designed to evaluate the usefulness of ultrasonography and routine blood tests for diagnosis of compensated liver cirrhosis in patients with chronic viral hepatitis.

METHODS

Two hundred three patients with chronic viral hepatitis who underwent liver biopsy were included in this study and ultrasonography and routine blood tests were analyzed retrospectively. Ultrasonographic findings, including surface nodularity, parenchyma echogenecity, and spleen size, were evaluated. The diagnostic accuracy of ultrasonography and routine blood tests were examined.

RESULTS

Discriminant analysis with forward stepwise selection of variables showed that liver surface nodularity, platelet count, and albumin level were independently associated with compensated liver cirrhosis (p<0.05). Cross-tabulation revealed that the following 4 variables had >95% specificity: platelet count <100,000 /uL; albumin level <3.5 g/dL; INR >1.3; and surface nodularity. If at least one of the four variables exists in a patient with chronic viral hepatitis, we can predict liver cirrhosis with 90% specificity and 61% sensitivity.

CONCLUSIONS

These results suggest that four variables (platelet count <100,000 /uL, albumin level <3.5 g/dL, INR >1.3, and surface nodularity) can be used for identification of liver cirrhosis in patients with chronic viral hepatitis with high specificity.

Sexually transmitted infections among Pakistani pregnant women and their husbands in Norway

Aim

To assess frequency and determine the factors associated with Chlamydia trachomatis, herpes simplex virus type 2, and hepatitis B seropositivity among Pakistani pregnant women and their husbands in Norway.

Methods

All together 112 couples of Pakistani origin living in Norway participated in our study. Blood samples were tested for immunoglobulin G (IgG) antibodies against C. trachomatis, herpes simplex virus type 2, and hepatitis B.

Results

Pakistani women had significantly lower age, education level, and years of residence in Norway compared to their male partners. Among the men, 12% had positive chlamydial IgG antibodies in contrast to 1% of the women. These couples were discordant, meaning that the 13 wives of positive men were not infected with C. trachomatis, and the husband of one positive woman was not infected either. Four percent of women and 2% of men were positive for herpes simplex type 2. Only one couple was concordantly positive for herpes simplex type 2, the remaining four couples were discordant. Twelve percent of women and 21% of men were, or had been, infected with hepatitis B.

Conclusion

Sexually transmitted infections did not seem to be prevalent in Pakistani immigrant couples in Norway. However, it was striking that most couples were discordant. Pakistani immigrants should be offered hepatitis B vaccine.

Extended lamivudine consolidation therapy in hepatitis B e antigen-positive chronic hepatitis B patients improves sustained hepatitis B e antigen seroconversion

OBJECTIVES

Longer lamivudine (LAM) consolidation therapy after hepatitis B e antigen (HBeAg) seroconversion has been demonstrated to reduce the cumulative relapse rate. However, the optimal interval of LAM consolidation therapy remains controversial. We evaluated the post-treatment durability of LAM-induced HBeAg seroconversion and the length of LAM consolidation therapy required to maintain sustained HBeAg seroconversion.

MATERIAL AND METHODS

This retrospective study included 401 naive HBeAg-positive chronic hepatitis B patients who were treated with LAM 100 mg daily for at least 24 weeks (range 24-258 weeks). Among them, 124 patients who achieved a complete response (HBeAg seroconversion, alanine aminotransferase normalization, hepatitis B virus DNA < 200 copies/ml) at the end of LAM therapy were followed up for at least 48 weeks (range 48-350 weeks).

RESULTS

Of the 124 complete responders, 42 (33.87%) achieved a sustained response (persistent response >or= 48 weeks). However, the cumulative relapse rates at 48 and 96 weeks post-treatment were 54.03% and 68.4%, respectively. Multivariate analysis revealed pretreatment age <or= 34 years [hazard ratio (HR) 2.25; 95% confidence interval (CI) 1.40-3.62; p < 0.001] and LAM consolidation therapy >or= 48 weeks (HR 2.44; 95% CI 1.35-4.40; p = 0.003) to be independent factors for predicting a sustained response.

CONCLUSIONS

LAM-induced HBeAg seroconversion is not durable in Taiwan. However, a duration of LAM consolidation therapy > 48 weeks may be favorable for maintaining durable HBeAg seroconversion.

[Hepatitis B vaccination: a major player in the control of primary liver cancer]

In worst cases, chronic hepatitis B ultimately leads to primary liver cancer. Populations the more at risk to develop hepatocellular carcinoma (HCC), i.e. patients infected perinatally, reside essentially in Asia. A quarter of century after its introduction in medical practice, data coming from Eastern Asia demonstrate a strong impact of the vaccine on HCC incidence. Strikingly, universal immunization of Taiwanese newborns reduced fourfold pediatric HCC incidence. However, residual cases still appear though among children infected at birth by HBe antigen-carrying mothers. Epidemiologic models indicate that the continuation of universal vaccination policy will reduce chronic hepatitis B endemicity 50-fold in three generations. Recently, mutant forms of HBV potentially escaping to vaccine appeared as a potential consequence of large-scale vaccination. Finally, lack of early immunization of newborns in developing countries still represents a major limitation to the progresses against liver cancer.

Effectiveness of a bivalent Haemophilus influenzae type B-hepatitis B vaccine in preventing hepatitis B virus infection among children born to hepatitis B e antigen-positive carrier mothers

BACKGROUND

This observational study evaluated a modified immunoprophylactic regimen (hepatitis B immune globulin [HBIG]) and a dose of thimerosal-free monovalent hepatitis B (HB) vaccine shortly after birth followed by doses of thimerosal-free bivalent Haemophilus influenzae type b (Hib)-HB vaccine at 2 and 4 months of age, and a booster at 12 months of age) in infants at high risk of hepatitis B virus (HBV) infection (mothers HBeAg+).

METHODS

Children >or=6 months of age vaccinated in routine clinical practice were tested twice (>or=6 months apart) for HBV antigens surface antigen (HBsAg) and "e" antigen, and for antibody to HBsAg. Partial nucleotide sequence analysis was performed on HBV DNA isolated from infants identified with a breakthrough chronic HBV infection. A fully sequential statistical design was used to maximize patient safety and study efficiency.

RESULTS

Four of 60 children developed chronic HBV infection despite vaccination, but at no point did the cumulative number of cases reach the boundary of statistical significance. Overall, the analysis adjusted for sequential testing yielded an estimated breakthrough rate of 6.7% (90% CI: 2.3%-14.6%). In a subset of uninfected children tested for antibody to HBsAg 1 to 4 months after the second dose of Hib-HB vaccine, 90% (9/10) had >or=10 milli-International Units per milliliter (mIU/mL). The third dose of Hib-HB vaccine induced a secondary increase in the level of antibody; 94.7% (18/19) of a second group developed >or=100 mIU/mL, with a geometric mean concentration of 771 mIU/mL (95% CI: 351.4-1692.1 mIU/mL).

CONCLUSION

The tested regimen is comparably effective to historical experience with a standard one employing HBIG plus monovalent thimerosal-containing HB vaccine given at 0, 1, and 6 months of age.

Occult hepatitis B virus infection increases hepatocellular carcinogenesis by eight times in patients with non-B, non-C liver cirrhosis: a cohort study

An impact of serum hepatitis B virus (HBV) DNA on hepatocarcinogenesis has not been investigated in a cohort of patients with non-B, non-C cirrhosis. Eighty-two consecutive Japanese patients with cirrhosis, who showed negative hepatitis B surface antigen and negative anti-hepatitis C virus, were observed for a median of 5.8 years. Hepatitis B virus core (HBc) region and HBx region were assayed with nested polymerase chain reaction. Both of HBc and HBx DNA were positive in 9 patients (11.0%) and both were negative in 73. Carcinogenesis rates in the whole patients were 13.5% at the end of the 5th year and 24.6% at the 10th year. The carcinogenesis rates in the patients with positive DNA group and negative DNA group were 27.0% and 11.8% at the end of the 5th year, and 100% and 17.6% at the 10th year, respectively (P = 0.0078). Multivariate analysis showed that men (P = 0.04), presence of HBc and HBx DNA (hazard ratio: 8.25, P = 0.003), less total alcohol intake (P = 0.010), older age (P = 0.010), and association of diabetes (P = 0.005) were independently associated with hepatocellular carcinogenesis. Existence of serum HBV DNA predicted a high hepatocellular carcinogenesis rate in a cohort of patients with non-B, non-C cirrhosis.

Prevalence of non-cardiac findings in a large series of patients undergoing cardiac multi-detector computed tomography scans

The purpose of our study was to determine the prevalence of non-cardiac findings in a large series of patients undergoing contrast-enhanced cardiac multi-detector computed tomography (MDCT) scans. Non-cardiac findings were classified according to the organ of involvement and level of significance. We retrospectively reviewed scans and reports of 1,061 patients performed between 1 April 2004 and 31 April 2006. Non-cardiac findings were considered significant if they warranted further radiological or clinical follow-up. A total of 103 non-cardiac findings were reported in 85 (8.0%) of the 1,061 patients. Of these lesions, 48 (46.7%) were significant and 55 (53.3%) were not. The significant lesions were found in 33 of the 1,061 patients (3.1%). Among the significant abnormalities, the three most common were pulmonary nodules (16.7%), emphysema (16.7%) and possible hepatic carcinomas (12.6%). Patients with non-cardiac findings were significantly older than those without (mean age 60 +/- 6 years vs. 55 +/- 8 years; P < 0.0001). The prevalence of active smoking was significantly higher in patients with non-cardiac findings (28.2 vs. 17.8%; P = 0.03). The prevalence of non-cardiac abnormalities detected by cardiac MDCT was 8% and about half of these findings were deemed significant. These lesions commonly occurred in the lungs and the liver. Age and active smoking were predictive of the presence of non-cardiac abnormalities.

Management of hepatitis B reactivation in patients with lupus nephritis

Hepatitis B is endemic in many Asian countries and immunosuppression may precipitate hepatitic flare. There is little data on the treatment of hepatitis B in patients with systemic lupus erythematosus. We monitored serial transaminase and HBV DNA levels in our HBsAg-positive patients with a history of lupus nephritis and instituted anti-viral treatment in patients who showed virological reactivation. This retrospective pilot study reports the data with this pre-emptive management strategy. Amongst 228 patients with lupus nephritis, eight (3.51%) were HBsAg-positive and five had received Lamivudine treatment for hepatitis B. In two patients the virological flares were preceded by lupus flares that necessitated an increase in immunosuppressive treatment. Median HBV DNA level was 1.9 x 10(7) copies/mL (range 1.2 x 10(4)-1.0 x 10(9) copies/mL) at baseline, and it decreased by 2-5 logs after treatment. Four patients had abnormal transaminase levels at baseline, with mean alanine aminotransferase at 125.0 +/- 67.4 U/L, and all achieved normalisation after 3-24 months (median 13 months) of treatment. Discontinuation of Lamivudine treatment was attempted in three patients after 9-15 months. In one patient treatment was recommenced because of virological flare. For the remaining two patients in whom treatment was not interrupted, one showed sustained viral suppression and one developed drug resistance. All antiviral treatments were well-tolerated. These results indicate the importance of serial monitoring of HBV DNA and transaminase levels, and prompt anti-viral therapy, in the management of HBsAg-positive lupus patients. Also, it may be feasible to discontinue treatment in stable patients to avoid the selection of drug-resistant variants.

Infection outcomes in splenectomized patients with hemoglobinopathies in Australia

OBJECTIVE

To assess the infection risk of splenectomized persons with hemoglobinopathies in Australia.

METHODS

This was an Australia cohort study of infections and vaccinations in 63 patients with hemoglobinopathies followed longitudinally from 1967 to 2006, and an investigation into the risk factors for poor outcome.

RESULTS

There were 28 cases of bacterial infection that necessitated hospitalization in the cohort, resulting in an incidence of 1.4 bacterial infections per 100 patient-years. There was one death (1.6%) as a direct result of bacterial infection. Hepatitis C was diagnosed in 28 patients (44%). The spectrum of infection included pneumonia (6/28), cellulitis (6/28), bacteremia (4/28), and skin abscess (3/28). Notably, Klebsiella species organisms were isolated in 9/28 cultures.

CONCLUSIONS

Infectious complications in this group of patients cause serious morbidity and mortality. This cohort may be a target for novel preventive strategies such as more immunogenic vaccines, patient registries, and/or education programs.

Clinical significance of antibody to hepatitis B core antigen in multitransfused hemodialysis patients

BACKGROUND

In spite of the progress made in the prevention of transfusion transmitted infections over the last few years, transmission of HBV infection through transfusion of HBsAg negative blood has been documented.

OBJECTIVES

To assess the frequency and clinical significance of anti-HBc in multitransfused hemodialysis patients.

MATERIALS AND METHODS

One hundred and forty-three hemodialysis patients who had been receiving blood regularly with an average of 39.4 +/- 7.579 months on hemodialysis were enrolled in this study. HBV markers (HBsAg, anti-HBc, anti-HBs) were measured in these patients and in 100 healthy controls by the ELISA technique. The following data were obtained for all patients: socio demographic data, number of blood transfusions and some laboratory investigations.

RESULTS

In our patients, anti-HBc was positive in 9%, anti HBs in 7%, coexistant HbsAg/anti-HBc in 2.8% and anti HBc/anti HBs in 18.9%, meanwhile no patients were positive for HBsAg alone. In patients with only positive anti-HBc, the levels of anti-HBc were significantly related to abnormal results of liver function. In patients with positive anti-HBs/anti-HBc (n = 27), 18 patients had abnormal liver function, and 9 patients had normal liver function with no significant difference between them.

CONCLUSIONS

This study suggests that hepatitis B prevalence in our multitransfused hemodialysis patients is far in excess of that anticipated on the basis of HBsAg prevalence. Absence of HBsAg in the blood of hemodialyzed patients may not be sufficient to ensure lack of circulating HBV, and isolated positivity of anti-HBc may be a possible indicator of active hepatitis B infection.

What can be revealed by extending the sensitivity of HBsAg detection to below the present limit?

BACKGROUND/AIMS

We investigated what can be revealed by extending the sensitivity of HBsAg detection to below the present limit.

METHODS

We examined the sensitivity of this immunoassay in comparison with real-time PCR detection of HBV DNA using serially diluted sera from HBV carriers. Low HBsAg was measured in 210 healthy volunteers and 368 patients with non-B chronic liver diseases who were negative for HBsAg by a standard EIA method.

RESULTS

The radical immunoassay was able to detect HBsAg at a concentration of 0.025 ng/ml. Low HBsAg was positive in 6 of 210 normal volunteers (2.86%), 5 of 65 non-B, non-C cirrhosis patients (7.69%), 6 of 62 non-B, non-C hepatocellular carcinoma patients (9.68%: p=0.04 vs. volunteers), 12 of 134 chronic hepatitis C patients (8.96%: p<0.02 vs. volunteers), and 11 of 107 hepatocellular carcinoma patients complicated by chronic hepatitis C (10.28%: p<0.008 vs. volunteers). Although no HBV DNA was positive in healthy volunteers, 9 patients with non-B chronic liver diseases were positive for HBV DNA by real-time PCR analysis.

CONCLUSIONS

Increasing the sensitivity of HBsAg detection to below the present limit has revealed that infection with HBV, including occult HBV, is far more endemic than suspected previously.

The incidence and clinical outcome of YMDD mutants in hepatitis B surface antigen-positive renal allograft recipients after prolonged lamivudine therapy

Although lamivudine (LAM) is a potent inhibitor of hepatitis B virus (HBV), prolonged therapy may induce the development of LAM-resistant strains, YMDD mutants. Although YMDD mutants have impaired replication that leads to a benign clinical course compared with wild-type virus, some immunosuppressive agents may enhance replication of YMDD mutants, causing a severe hepatitis flare. We retrospectively investigated the incidence and clinical outcomes of YMDD mutants in renal allograft recipients on immunosuppressive treatment. Clinical records of 25 renal allograft recipients, who underwent renal transplantation between December 1997 and February 2006 were hepatitis B surface antigen positive at the time of transplantation, were reviewed. All patients received LAM treatment after renal transplantation. Over 9 to 98 months of follow-up, 16 patients (64.0%) maintained undetectable HBV DNA levels; however, 9 patients (36.0%) showed persistent or increased levels of HBV DNA. Seven were identified as having developed YMDD mutants. Although genotypic analysis was not performed, YMDD mutants were strongly suspected in another two patients, who developed severe hepatic dysfunction combined with high levels of HBV viremia at close to 2 years of LAM therapy. One patient recovered after hepatic transplantation and another patient died of hepatic failure. In conclusion, the incidence of YMDD mutants was similar to that of nonimmunosuppressed individuals; however, the presence of these mutants made it more likely for severe liver disease to develop in renal transplant recipients. Therefore, close monitoring for the development of YMDD mutants should be performed during LAM treatment, especially in this group of patients.

Review of hepatitis B surface antigen-1018 ISS adjuvant-containing vaccine safety and efficacy

Existing hepatitis B virus (HBV) vaccines produce seroprotective titers in > 90% of healthy adult recipients following 3 doses administered over 6 months. The durability of this response is variable. Vaccine efficacy is greatly diminished in immune compromised patients. Given the high worldwide prevalence and burden of disease produced by chronic HBV infection, vaccines capable of producing high rates of durable seroprotective HBV surface antibody titers are required. Immunostimulatory sequences (ISS) containing repeating sequences of cytosine phosphoguanosine (CpG) dinucleotide motifs have emerged as useful tools for modulating immune responses. Dynavax Technologies produced a synthetic oligodexynucleotide (ODN) containing these motifs, resulting in an unmethylated cytosine and phosphoguanosine ODN called 1018 ISS. Dynavax's hepatitis B virus vaccine HEPLISAV is comprised of 1018 ISS mixed with recombinant hepatitis B surface antigen. Clinical trials, to date, have shown that HEPLISAV produces rapid, high titer, sustained seroprotection in healthy adults and vaccine hyporesponsive populations. Although additional supporting data are required, this represents a promising strategy to facilitate worldwide HBV prevention efforts.

Genotyping and genomic sequencing in clinical practice

The global prevalence of chronic hepatitis B and its associated serious sequelae demand technologically advanced techniques of management. Nucleic acid testing (NAT) plays a key role in the diagnosis, surveillance, and treatment of chronic hepatitis B. NAT includes quantitative PCR-based HBV DNA assays, HBV genotyping, tests for mutations associated with resistance to antiviral medications, and assays to detect precore and core promoter mutations. This article reviews the uses of NAT in the diagnosis and management of chronic hepatitis B.

Long-term results of interferon alpha monotherapy in patients with HBeAg-negative chronic hepatitis B

We sought to evaluate the long-term results of interferon-alpha (IFN-alpha) therapy in patients with hepatitis B e antigen (HBeAg)-negative chronic hepatitis B. Eighty HBeAg-negative naive patients (62 men; mean age, 39.9 years) who received IFN-alpha for 6 months were studied. Alanine aminotransferase normalization with undetectable HBV-DNA by molecular hybridization was accepted as response. All patients but 1 were precirrhotic stage. At the end of treatment, 44 (55%) patients responded, and they were followed for a mean of 59.5 months (range, 18-132). Twenty-seven patients (61.4%) showed recurrence (63% in first year). Responses at 6 months and at the end of the follow-up period 42.5% and 30% (including 7 patients without end treatment response), respectively. Recurrence of HBV replication was not detected after the 2-years follow-up period. Histologic improvement was observed in 83.3% patients with end-of-follow-up response. HBsAg became negative in 4 patients (5%). On multivariate analysis, younger age (P = .04) and lower GGT level (P = .037) were independent factors for prediction of end-of-follow-up response. Nearly half of the patients with HBeAg-negative chronic hepatitis B responds to IFN-alpha at the end of therapy. Despite the high recurrence rates, response continues in about one third of patients after a mean of 59.5 months.

Hepatitis B awareness, knowledge, and screening among Asian Americans

BACKGROUND

Due to the high prevalence of hepatitis B, Asian Americans have high rates of liver cancer. Screening for hepatitis B leads to monitoring and treatment and prevent further infection through vaccination of contacts.

METHODS

We reviewed the published literature up to 2006 on hepatitis B awareness, knowledge, and screening among Asian Americans.

RESULTS

Many Asian Americans lack knowledge about hepatitis B and have not been screened. Sociodemographics, knowledge, beliefs, and health care variables are associated with screening.

CONCLUSIONS

Further research and health policy changes are needed to address the problem of hepatitis B and liver cancer among Asian Americans.

HepSEQ: International Public Health Repository for Hepatitis B

HepSEQ is a repository for an extensive library of public health and molecular data relating to hepatitis B virus (HBV) infection collected from international sources. It is hosted by the Centre for Infections, Health Protection Agency (HPA), England, United Kingdom. This repository has been developed as a web-enabled, quality-controlled database to act as a tool for surveillance, HBV case management and for research. The web front-end for the database system can be accessed from . The format of the database system allows for comprehensive molecular, clinical and epidemiological data to be deposited into a functional database, to search and manipulate the stored data and to extract and visualize the information on epidemiological, virological, clinical, nucleotide sequence and mutational aspects of HBV infection through web front-end. Specific tools, built into the database, can be utilized to analyse deposited data and provide information on HBV genotype, identify mutations with known clinical significance (e.g. vaccine escape, precore and antiviral-resistant mutations) and carry out sequence homology searches against other deposited strains. Further mechanisms are also in place to allow specific tailored searches of the database to be undertaken.

A cross-sectional analysis of acute hepatitis B virus reported to the Vancouver Coastal Health Authority from 2000 to 2003

BACKGROUND

Acute hepatitis B virus (HBV) transmission remains a significant public health problem despite effective vaccination and prophylaxis strategies. Vancouver, British Columbia, has a large ethnic community from endemic areas, which may further impact on the epidemiology of acute HBV. A cross-sectional study of factors associated with acute HBV cases reported to the Vancouver Coastal Health Authority (Vancouver, British Columbia) from 2000 to 2003 is reported.

METHODS

New seropositive cases of hepatitis B surface antigen were reported to the Vancouver Coastal Health Authority Office of Communicable Disease Control. Patients meeting both clinical and laboratory criteria for acute HBV were interviewed by telephone for demographic and risk behaviour information. Risk behaviours within the last six months before disease onset were ranked on efficiency of transmission in a mutually exclusive risk category.

RESULTS

There were 78 patients of identified acute HBV in Vancouver from 2000 to 2003. The overall incidence rate was 3.38 per 100,000 person years. Outside of Canada, Asia was the most common place of birth (29.5%). The three most frequently identified risk factors were men who have sex with men (21.9%), heterosexual activity with two or more partners (14.0%) and intravenous drug use (14.0%). Sexual contact with an HBV carrier was identified in 9.4% of patients.

CONCLUSIONS

Sexual transmission is a major mode in the spread of HBV in Vancouver. Existing public education, surveillance and vaccination strategies for HBV need to be strengthened to address those engaging in risky behaviours.

Prevalence of serological markers of hepatitis B virus in pregnant women from Paraná State, Brazil

The prevalence of hepatitis B virus (HBV) in Brazil increases from South to North but moderate to elevated prevalence has been detected in the Southwest of Paraná State. The prevalence of serological markers of HBV was evaluated in 3188 pregnant women from different counties in Paraná State and relevant epidemiological features were described. The prevalence of HBV markers in pregnant women for the state as a whole was 18.5% (95% CI = 17.2-19.9), ranging from 7.2% in Curitiba to 38.5% in Francisco Beltrão. The endemicity of HBV marker prevalence in pregnant women was intermediate in Cascavel, Foz do Iguaçu, and Francisco Beltrão, and low in Curitiba, Londrina, Maringá, and Paranaguá. Multiple logistic regression showed that HBV marker prevalence increased with age, was higher among black women, among women of Italian and German descent, and among women who had family members in neighboring Rio Grande do Sul State. Univariate analysis showed that HBV marker prevalence was also higher among women with no education or only primary education, with a lower family income and whose families originated from the South Region of Brazil. Pregnant women not having positive HBV markers (anti-HBc, HBsAg or anti-HBs detected by ELISA) corresponded to 73.7% of the population studied, implying that HBV vaccination needs to be reinforced in Paraná State. The highest prevalence was found in three counties that received the largest number of families from Santa Catarina and Rio Grande do Sul, where most immigrants were of German or Italian ascendance. This finding probably indicates that immigrants that came to this area brought HBV infection to Southwestern Paraná State.