Current prevalence of hepatitis delta virus (HDV) infection and the range of HDV genotypes in Lebanon

Elimination of HDV: Epidemiologic implications and public health perspectives

Hepatitis delta virus (HDV) infection causes the severest form of viral hepatitis in humans. Discovered in 1977, it was considered an infection prevalent in the eastern Mediterranean region. Today it is recognized as a global infection of public health importance, however accurate prevalence remains uncertain because of lack of good epidemiological studies. Under-screening for HDV is the single most important factor in under-estimating the true burden of infection. Urgent efforts are therefore needed to apply reliable screening tools and robust surveillance methodologies to study HDV. There is now a move by major hepatology societies to recommend HDV antibody testing in all persons with HBV infection. Important differences also need to be recognized between countries considered endemic or non-endemic countries. While the endemic infections likely spread horizontally in the general population, and is quite often nosocomial, in non-endemic countries special populations may carry the greater burden, such as persons with injection drug use and various sexual exposures. Even in endemic countries, HDV often exists in significant pockets of the general population. HDV has been categorized as an orphan infection due to lack of approved therapies. Recently there have significant advances in therapy and further clinical trials continue. However, as new therapies are approved, equitable access to the medications will become a major public health issue, particularly because most HDV patients live in low or low middle income countries.

Hepatitis delta virus infection prevalence, diagnosis and treatment in the Middle East: A scoping review

Hepatitis D virus (HDV) infection is a global public health concern, especially because of its unique existence in the presence of hepatitis B virus infection. HDV infection is estimated to affect 12 million people globally. Having a clearer understanding of its prevalence in all regions of the world is essential for helping direct preventive and early interventional treatment. This mini-review assessed the literature over the last 10 years to determine the prevalence, diagnostic means and treatment guidelines available for HDV in the Middle East. The search found limited data available in 21 articles, of which 18 were studies focused on Iran. Prevalence rates ranged dramatically among the countries, and none of the 12 countries included in the search had specific HDV guidelines. This review highlights the urgent need for more precise data for the Middle East region to help establish early diagnosis and treatment options for HDV.

Characterization of Hepatitis Delta Virus Among Pregnant Women of Pakistan

Hepatitis delta virus (HDV) is a highly pathogenic virus and causes rapid disease progression from fulminant hepatitis to development of hepatocellular carcinoma in patients infected with hepatitis B virus (HBV). HDV is endemic in Pakistan; however, there are no available data on HDV prevalence among the high-risk group of HBV-infected pregnant women. A total of 1,394 pregnant women, visiting different public-sector hospitals in Lahore, were enrolled in this study. Their demographic data and blood samples were collected from May 2016 to July 2017. Samples were screened for both HBsAg and anti-HDV. Anti-HDV positive samples were tested for HDV RNA, and samples positive for HDV RNA were further sequenced to determine the HDV genotype. Of the 1,394 samples, HBsAg was positive in 63 (4.5%). Of these 63 HBsAg-positive samples, 13 (20.63%) were positive for anti-HDV. Of the 13 HBsAg/anti-HDV positive samples, HDV RNA was detected in 4 (30.8%) samples and all 4 carried HDV genotype 1. The age of enrolled women varied from 20 to 40 years, with most of the women living in urban areas, having education more than secondary school level, belonging to middle class, and being housewives. Majority of the tested women were of age from 25 to 30 years (39.2%); however, the prevalence of HBV was higher in age group 31-35 years (10.7%, confidence interval [CI]: 4.73-16.67); however, anti-HDV prevalence was 1.9% (CI: -0.7 to 4.7). This study is the first report on HDV prevalence among pregnant women in Pakistan. Our study showed a high predominance of HDV (20.63%) in HBV-infected pregnant women and the prevalence of HDV genotype 1 infection. The findings contribute to a better understanding of the HDV/HBV coinfection among pregnant women and circulating HDV genotypes in the country.

Hepatitis D virus infection among hepatitis B virus surface antigen positive individuals in Upper Egypt: Prevalence and clinical features

BACKGROUND/PURPOSE

About 248 million people are chronic HBV surface antigen carriers in the world. Hepatitis D virus (HDV) infection present in more than 15 million people worldwide. HDV needs hepatitis B surface antigen (HBsAg) to help its replication. We aimed to estimate the prevalence of HDV infection among HBsAg positive individuals and to determine the clinical, laboratory and virological characters of HDV infected patients.

METHODS

This study was prospective cross-sectional analytic one including 186 HBsAg positive cases. Anti-HBc total, IgM and HBV PCR were done for all of these cases. Anti-HDV ELISA analysis was done for all cases. Positive samples for Anti-HDV by ELISA were then tested by HDV PCR.

RESULTS

Of the 186 HBsAg positive cases, 80 were reactive for anti-HDV antibodies, resulting in an overall anti-HDV seropositivity of 43%. Higher prevalence of liver cirrhosis (43.8%), HCC on top of cirrhosis (8.8%) were found in anti-HDV positive compared to anti-HDV negative cases (17.9%) and (3.8%) respectively (p value<0.001). Portal hypertension and Child-Pugh grade B, C were significantly higher in anti-HDV-positive cases as compared to the anti-HDV-negative ones (47.5% versus 18.9%) and (11.3% versus 6.6%); (16.3% versus 3.8%) respectively (p value<0.001 for each). HDV RNA was positive in 25 out of 80 anti-HDV-positive cases (31.3%).

CONCLUSION

Anti-HDV was seropositive in 43% among HBsAg positive cases in Upper Egypt. HDV RNA was positive by PCR in 25 out of 80 anti-HDV-positive cases (31.3%). HDV prevalence using PCR was 25/186 (13.4%) in Upper Egypt.

Hepatitis B virus and hepatitis delta virus subtypes circulating in Algeria and seroprevalence of HDV infection

BACKGROUND

Little is known about molecular characteristics of HBV strains circulating in Algeria and there are few data regarding HDV infection.

OBJECTIVES

The aim of this study is to describe the genetic diversity of HBV and HDV strains existing in Algeria and to determine the seroprevalence of HDV infection.

STUDY DESIGN

Plasma samples from 134 patients were analyzed by enzyme immunoassay method for HBV and HDV serological markers. Genotyping of HBV and HDV strains were performed using direct sequencing followed by phylogenetic analyses of the PreS1 and R0 region of the HBV and HDV genome respectively.

RESULTS

The PreS1 gene was successfully amplified in 119 patients (82 males and 37 females). Phylogenetic analysis of HBV strains revealed the presence of genotypes D (86.5%) and A2 (11.76%). The subgenotypes D are distributed as follows: HBV/D7 (43.5%), HBV/D3 (24.75%), HBV/D1 (16.8%) and HBV/D2 (14.85%). A recombinant between genotypes A, E and D was found. The seroprevalence of HDV infection among HBV carriers was less than 5.35%. Only one isolate of HDV genotype 1 was identified.

CONCLUSIONS

Our data indicate the predominance of HBV subgenotype D7 and a low prevalence of HDV infection.

Molecular characterization of hepatitis D virus genotypes circulating in Iran

Aim: To determine the molecular epidemiology and characterization of hepatitis D virus (HDV) genotypes circulating in different provinces of Iran. Patients & methods: In this study, the presence of HDV RNA was tested in sera that were positive for hepatitis B surface antigen and HDV antibody by nested-PCR. HDV genotypes were subsequently analyzed using restriction fragment length polymorphism (RFLP) assay and then confirmed by sequencing. Results: 86.5% of positive PCR patients had genotype I and 8.1% had genotype II while the genotype of 5.4% of the patients remained undetermined by RFLP. Sequencing followed by phylogenetic analysis demonstrated that all the Iranian isolates were from genotype I. Conclusion: Although analyzing the RFLP of RT-PCR is a simpler method, the gold standard of genotyping of HDV is the phylogenetic analysis based on sequencing.

Characterization of hepatitis B and delta coinfection in Israel

BACKGROUND

Characteristics of hepatitis B (HBV) and delta (HDV) coinfection in various geographical regions, including Israel, remain unclear. Here we studied HDV seroprevalence in Israel, assessed HDV/HBV viral loads, circulating genotypes and hepatitis delta antigen (HDAg) conservation.

METHODS

Serological anti HDV IgG results from 8969 HBsAg positive individuals tested in 2010-2015 were retrospectively analyzed to determine HDV seroprevalence. In a cohort of HBV/HDV coinfected (n=58) and HBV monoinfected (n=27) patients, quantitative real-time PCR (qRT-PCR) and sequencing were performed to determine viral loads, genotypes and hepatitis delta antigen (HDAg) protein sequence.

RESULTS

6.5% (587/8969) of the HBsAg positive patients were positive for anti HDV antibodies. HDV viral load was >2 log copies/ml higher than HBV viral load in most of the coinfected patients with detectable HDV RNA (86%, 50/58). HDV genotype 1 was identified in all patients, most of whom did not express HBV. While 66.6% (4/6) of the HBV/HDV co-expressing patients carried HBV-D2 only 18.5% (5/27) of the HBV monoinfections had HBV-D2 (p=0.03). Higher genetic variability in the HDAg protein sequence was associated with higher HDV viral load.

CONCLUSIONS

The overall significant prevalence of HDV (6.5%) mandates HDV RNA testing for all coinfected patients. Patients positive for HDV RNA (characterized by low HBV DNA blood levels) carried HDV genotype 1. Taken together, the significant HDV seroprevalence and the lack of effective anti-HDV therapy, necessitates strict clinical surveillance especially in patients with higher HDV viral loads and increased viral evolution.

Prevalence and risk factors of hepatitis D virus infection in patients with chronic hepatitis B infection attending the three main tertiary hospitals in Libya

BACKGROUND AND STUDY AIMS

Globally, More than 350 million individuals are chronically infected with hepatitis B virus (HBV), and >20 million of them are co-infected with hepatitis D virus (HDV). The aim of this study was to determine the pattern of HDV infection in patients with chronic hepatitis B in three main tertiary hospitals in Tripoli and Benghazi, Libya.

PATIENTS AND METHODS

This cross sectional and descriptive study was conducted on 162 patients with chronic hepatitis B positive for more than six months) who were followed up at hepatitis clinics of the three main tertiary hospitals in Tripoli city (88 patients from Tripoli Medical Centre and Tripoli Central Hospital) and Benghazi city (74 patients from Aljomhoria Hospital) during the period from January 2010 to June 2012. HBV and HDV markers were detected by enzyme linked fluorescent assay (ELFA) or enzyme-linked immunosorbent assay and HBV-DNA was quantified by real-time PCR techniques.

RESULTS

The mean age of patients was 36,92 ± 15,35. One hundred and three (63.6%) of them were males and 59 (36,4%) were females. Four patients (2,5%) were tested positive for anti-HD antibodies, all of them have had clinical and/or histological diagnosis of cirrhosis. In multivariable regression analysis, age (p = .04), elevation of serum ALT (p = .03), elevation of serum AST (p = .04), and presence of cirrhosis (p = .003) were significantly related to HDV seropositivity.

CONCLUSION

Although the study demonstrated that Libya has low to moderate prevalence of HDV (2,5%), it is important for policy makers and health care providers to continue the preventive measures for HDV spread, and HBV prevention program including utilization of HBV vaccine. Furthermore, it is imperative to screen chronic HBV patients for HDV for close observation for early diagnosis of subsequent development of liver cirrhosis. Moreover, further epidemiologic and genetic studies are needed to explore the trend for HDV infection in Libya.

Delta hepatitis within the Veterans Affairs medical system in the United States: Prevalence, risk factors, and outcomes

BACKGROUND & AIMS

Low hepatitis delta prevalence estimates in the United States are likely biased due to low testing rates. The objectives of this study were to quantify the prevalence of testing and identify factors associated with hepatitis D positive status among chronic hepatitis B patients in the Veterans Health Administration.

METHODS

We performed a nationwide retrospective study of all veterans who tested positive for HBsAg from October 1999 to December 2013. Hepatitis D antibody testing results were used to stratify patients into three groups: HDV-positive, HDV-negative, and HDV-not tested. Demographics, comorbidities, additional laboratory data and clinical outcomes were compared across these groups of patients using standard statistical approaches.

RESULTS

Among 25,603 patients with a positive hepatitis B surface antigen, 2175 (8.5%) were tested for HDV; 73 (3.4%) patients tested positive. Receiving HDV testing was associated with receipt of testing for HBV, HIV, and HCV. Predictors of positive HDV results included substance abuse and cirrhosis. Fitting a predefined high-risk profile (abnormal ALT with suppressed HBV DNA titers) was strongly associated with testing positive for HDV (OR 3.2, 95%CI 1.4-7.5). Most (59%) of HDV-positive patients were HCV co-infected. HDV-positive subjects had higher risks of all-cause mortality. Incidence rates of HCC were 2.9 fold higher in HDV-positive relative to HDV-negative individuals (p=0.002). In adjusted analyses, HDV was independently associated with HCC (OR 2.1, 95%CI 1.1-3.9).

CONCLUSIONS

Testing rates for hepatitis delta in chronic hepatitis B patients in the United States are inappropriately low. Approaches to increase testing for HDV particularly in high-risk subsets should be explored.

Characterization of the Genotypic Profile of Hepatitis Delta Virus: Isolation of HDV Genotype-1 in the Western Amazon Region of Brazil

The hepatitis delta virus (HDV) is a hepatotropic subvirus that is dependent on the hepatitis B virus (HBV) and supplies the viral envelope containing the surface antigen of hepatitis B. Viral genetic diversity is related to the geographical origin of the isolates, and there are at least eight genotypes that are referred to as HDV-1 through HDV-8. HDV-3 is responsible for epidemics of severe and fulminant hepatitis, which are common in northeastern South America. HDV-3 is prevalent in the Brazilian Amazon and is associated with the increased aggressiveness of HDV infections. Although isolated, the characteristics of the clinical presentation of HDV-1 in the Amazon region have not yet been clearly reported.

OBJECTIVE

This study aims to assess the genotypic and clinical characteristics of individuals with the HDV-1 genotype in the western Amazon region.

METHODS

The HDV was genotyped by nested PCR-RFLP and sequencing from serum samples of 56 patients with HBV/HDV infection. The genotypes were correlated with the clinical characteristics presented by patients with HBV/HDV infection.

RESULTS

A prevalence of 92.3% for the HDV-3 genotype (n = 48) and 7.6% (n = 4) for the HDV-1 genotype was observed.

CONCLUSION

To date, this is the most extensive clinical study of HDV-1 genotype infections in the nonindigenous population of Western Amazonia.

Hepatitis delta virus genotype-1 alone cocirculates with hepatitis B virus genotypes A and D in Pakistan

INTRODUCTION

Hepatitis delta virus (HDV) and hepatitis B virus (HBV) have been identified as major causes of morbidity and mortality in Pakistan because HDV causes infection only in the presence of HBV. Coinfection with both hepatitis viruses can lead to a more severe acute form of disease and to an increased risk of fulminant hepatitis. HDV infection differs in its distribution and severity depending on the geographical distribution, and several genotypes of HDV have been identified so far.

OBJECTIVES

The aim of the present study was to establish the HDV and HBV genotypes in chronically infected Pakistani patients and to determine whether there is any correlation between HDV and HBV genotypes.

PATIENTS AND METHODS

We studied samples from a total of 46 chronically infected HBV and HDV patients for HBV and HDV genotype analysis out of a total of 75 chronic HBV carriers enrolled. HBV and HDV genotypes were determined using type-specific PCR, followed by sequencing of PCR amplified products.

RESULTS

The results of HBV genotyping showed that 33 of 46 (71.7%) patients had genotype D, five (10.9%) had A+D mixed genotypes, whereas eight (17.3) samples were untypable. We could detect only one HDV genotype (HDV-1) prevalent in the Pakistani population. The HDV-1 genotype isolate was associated with HBV genotype D alone or in combination with A (HBV-A+D).

CONCLUSION

The present study concludes that HDV/HBV coinfection is very high in the Pakistani population and was previously underestimated. The most prevalent circulating genotypes of HBV and HDV are HDV-1 and HBV-D, respectively, in the studied area. There is no specific interaction between HBV and HDV genotypes as suggested by HDV-1/HBV-D or HDV-1/HBV-A+D coinfection. Coinfection of HDV-1 and HBV-D simply reflects the most frequent genotypes circulating in this specific geographical region of the world.

Prevalence of hepatitis delta virus (HDV) infection in chronic hepatitis B patients with unusual clinical pictures

BACKGROUND

Probably 5% of the HBV carriers have HDV super infection. The risk of fulminant hepatitis, cirrhosis and hepatocellular carcinoma is higher in superinfection than the settings when HBV is alone.

OBJECTIVES

The aim of this study was to evaluate the prevalence of HDV in Iranian HBV isolates and to compare their clinical and virological pictures as well as their HDV genetic variations with other worldwide isolates.

PATIENTS AND METHODS

81 carriers with positive results for HBsAg with upper limit ranges of ALT and low or undetectable levels of HBV viral load who did not respond to HBV therapy were selected. After RT amplification of HDV Delta antigen, direct sequencing and phylogenetic study were performed to explore the genotype(s) and nucleotide/amino acid variations.

RESULTS

12 (14.8%) patients had positive results for both HDV RNA and anti-HDV. The mean ALT level was higher in HDV positive patients (75.9 U/ML) than HBV-mono-infected individuals; however, the mean HBV viral load was lower in coinfected patients than HBV-mono-infected patients. Phylogenetically, genotype I was the only detected genotype, and the most closely related isolates were of Turkish, Italian and Mongolian origin. Within the delta Ag, there were 326 nucleotide mutations, of which 111 and 215 were silent and missense, respectively. The total number of amino acid substitution was 148; most were located in known functional/epitopic domains. There was no correlation between the numbers of amino acid mutations, with clinical, virological status of the patients.

CONCLUSIONS

HDV should be suspected in HBV carriers with unusual clinical and virological pictures. Relatedness of Iranian HDV isolates to Italian and Turkish sequences proposed a common Caucasian origin for the distribution of HDV genotype I in this ethnic group.

Hepatitis delta: the rediscovery

Hepatitis D is returning to western Europe through immigration. The clinical presentation recapitulates the typical features of a florid hepatitis D. Hepatitis D is also being rediscovered in the developing world and in the United States. Hepatitis D virus (HDV) remains endemic in many countries and efforts are underway to map the infection at local levels and improve the medical alert to hepatitis D. In the United States it is generally thought that HDV has gone and hepatitis D is no longer a problem. Awareness of hepatitis D in the country has recently been revived.

Hepatitis B virus in the Arab world: where do we stand?

The epidemiology of viral hepatitis is of great importance for planning and managing health provision for all the countries in the Arab world. However, data on viral hepatitis are not readily available in a large percentage of Arab countries. Hepatitis B virus (HBV) is considered to be one of the most important causes of chronic hepatitis, cirrhosis and hepatocellular carcinoma. A systematic electronic search of published literature was conducted to extract data on epidemiology and risk factors for the analysis of HBV infection among the countries in the Arab world. The prevalence of chronic HBV infection was found to be decreasing in some Arab countries although it was still unacceptably high. This was particularly evident in the Arabian Gulf region, in Lebanon, Egypt and Libya. The age-specific prevalence varied from country to country with decline in prevalence being noted among children in the Gulf States and among Libyan women. These declines in prevalence are most likely to be related to the Expanded Immunization Programme. The alarmingly high prevalence of chronically infected patients in some areas and the widespread differences in HBV prevalence between Arab nations may be explained by the variation in risk factors involved. This situation calls for targeted approaches to tackle HBV-related mortality and morbidity. Precise HBV infection prevalence data are needed at the national and the sub-national level to estimate the disease burden, guide health intervention programmes and evaluate vaccine efficiency.

Frequency and Genotype of Hepatitis D Virus Infection in Patients Infected with HIV and Those Undergoing Hemodialysis

BACKGROUND

Hepatitis D virus (HDV) is a defective virus dependent on hepatitis B virus (HBV) for its replication. Due to HDV transmission routes, patients undergoing hemodialysis and those with HIV infection are at risk of acquiring HDV.

OBJECTIVES

This study was aimed to determine the frequency and genotype of HDV infection among patients with HIV infection and those undergoing hemodialysis.

PATIENTS AND METHODS

720 cases including 120 patients undergoing hemodialysis, and 600 patients with HIV infection were studied. All cases with positive results for HBsAg were evaluated for the presence of anti-HDV antibodies. Samples with Anti-HDV positive results were subjected to nested PCR for HDV-RNA confirmation, and sequenced for HDV genotype determination.

RESULTS

HBsAg was found in 9 (7.5%) of 120 patients undergoing hemodialysis, and 9 (1.5%) of 600 patients with HIV infection. 3 (33.3%) of patients undergoing hemodialysis with positive results for HBsAg, and 5 (55.5%) of cases with HIV infection and positive results for HBsAg, had positive findings for anti-HDV which were then subjected to nested PCR. The amplification results confirmed that in 3 (37.5%) samples HDV-RNA was detected. Overall 2.5% of patients undergoing hemodialysis, and 0.8% of cases infected with HIV had positive results for anti-HDV and 1.7% and 0.2% of cases undergoing hemodialysis and patients infected with HIV had positive findings for HDV-RNA respectively. All of the HDV isolates were clustered in clade 1.

CONCLUSIONS

The survey showed that overall HDV frequency was not high in our high risk cases. Therefore, practitioners and health care managers should become aware of the risk of dual infection with HBV and HDV especially in high risk patients.

Prevalence of hepatitis d in the eastern mediterranean region: systematic review and meta analysis

BACKGROUND

Hepatitis D Virus (HDV) causes the most threatening form of chronic viral hepatitis. To date, there is no overall estimation of HDV prevalence in the Eastern Mediterranean Region Office of WHO (EMRO) countries.

OBJECTIVES

To provide a clear estimation of HDV prevalence in the aforementioned region.

PATIENTS AND METHODS

In the current systematic review, databases such as PubMed, Embase, Web of sciences and Google scholar were searched Until December 2010. The summary estimate of HDV prevalence in the EMRO region was calculated as an average of the pooled infection prevalence of each country weighted by the ratio of the country's HBV population to the study's sample size in the survey data analysis.

RESULTS

We included 62 eligible studies. The weighted mean of HDV prevalence in the EMRO region was 14.74% (95% CI: 14.73 - 14.77), 27.8% (95% CI: 27.78 - 27.82), 36.57% (95% CI: 36.55 - 36.59) and 16.44%. (95% CI: 16.42 - 16.46) in asymptomatic HBsAg positive carriers, chronic hepatitis patients, cirrhosis/ hepatocellular carcinoma, and high risk group, respectively. Among the asymptomatic HBsAg positive group, HDV prevalence was increased by years in older patients in Saudi Arabia but its prevalence was decreased in Iran. No specific pattern was seen according to chronological analysis during years among the EMRO countries.

CONCLUSIONS

HDV infection is endemic in the EMRO countries and it is more common among patients with severe forms of hepatitis. Due to the high HDV infection rates in the EMRO countries, we recommend blood screening for HDV infection in this region.

Hepatitis D: Scenario in the Asia-Pacific region

Hepatitis D virus (HDV) infection is present worldwide and affects all age groups. Around 18 million people are estimated to be infected with HDV. An important trend in HDV infection is global decline. HDV prevalence has decreased significantly in Europe since the 1970s and 1980s when it was first reported. The Asia-Pacific region now seems to be where HDV is a major health concern. There is a lack of available data from most of the countries from this region; hence, the true status of HDV cannot be determined. In South Asia, most of the countries have conditions that are favorable for the spread of hepatitis B and other related infections. Countries like Pakistan and Iran have shown an increase in HDV prevalence over a period of time. Other countries and region like China, Turkey, Australia, Japan, India and Taiwan, some of which had very high HDV prevalence in the past, have shown a decline in the incidence, but high prevalence persists in some. Intravenous drug abusers, homosexual men and women, prostitutes, and people on hemodialysis are the groups with very high HDV prevalence.

Molecular epidemiology of hepatitis delta virus (HDV) in Iran: a preliminary report

To identify hepatitis delta virus (HDV) genetic variability and its circulating genotypes amongst infected Iranian patients, 25 patients with positive anti-HDV status from different parts of Iran were enrolled in this cross-sectional study. A portion of the HDV delta antigen was amplified, sequenced, and subjected to molecular and phylogenetic analysis. Clinical features and virological markers were evaluated. HDV RNA could be detected in 88% of anti-HDV positive cases (22 patients) with chronic hepatitis B virus (HBV) infection and liver cirrhosis. Phylogenetic analysis revealed that all Iranian patients were infected by genotype I (clade 1) of HDV, supported by a high bootstrap value (100%, 1,000 replicates). All HDV-positive patients were coinfected with genotype D1 of HBV. No significant association was determined between demographic, clinical, and virological variables in the population studied. In conclusion, the present molecular epidemiology survey reveals that clade 1 of HDV is predominant among coinfected HBV patients in Iran.