Transfusion transmission of hepatitis B virus: still learning more about it

Hepatitis B transmission by cell and tissue allografts: How safe is safe enough?

More than 2 million human tissue transplants (bone, tendon, cartilage, skin, cornea, amniotic membrane, stem cells, heart valve, blood vessel, etc.), are performed worldwide every year. Cells and tissues are shared between countries which have different regulations and laboratory equipment and represent a risk of hepatitis B virus (HBV) transmission that has become a global safety concern. While the risk of transfusion-transmitted HBV infection from blood donations has been estimated, the rate of HBV transmission from donors to recipients of allografts is unknown and varies between different tissues. There are various important ways of reducing the transmission risk, but donor screening and donor testing are still the main factors for preventing HBV transmission. HBV detection is included in the routine screening tests for cell and tissue donors. The standard test for preventing transplant-transmitted hepatitis B is the hepatitis B surface antigen. The implementation of methods involving nucleic acid amplification and the new generation of reactives to detect viral antibodies or antigens with an immunoassay, has increased the sensitivity and the specificity of the screening tests. The objective of our research was to review the literature and critically analyse the different steps for avoiding HBV transmission in cell and tissue donors, focusing on the screening tests performed.

Ultrio and Ultrio Plus non-discriminating reactives: false reactives or not?

BACKGROUND

The low, fluctuating levels of DNA characteristic of occult hepatitis B infection make its detection by nucleic acid testing (NAT) a challenge.

METHODS

Four year's routine use of the Ultrio and Ultrio Plus assays in blood donations in New Zealand was analysed.

RESULTS

0·09% of donations tested with Ultrio and Ultrio Plus assays showed reactivity in the multiplex assay, but non-reactivity in all three discriminatory assays and relevant mandatory serological assays (anti-HIV, anti-HCV, HBsAg). These donations were more likely to be anti-HBc reactive (Ultrio, 13%; Ultrio Plus, 57%; random donors, 6·8%). Thirty-four per cent of these anti-HBc-reactive donations were also reactive in either an alternate NAT assay or on repeat multiplex testing. Thirteen per cent of the donors of the discriminatory-negative, anti-HBc-reactive donations who had given other Ultrio- or Ultrio Plus-tested donations had at least one other multiplex reactive donation.

CONCLUSION

These findings suggest that their HBV DNA levels are around the assay's limit of detection, that false reactivity cannot be presumed when a donor fails to discriminate and that caution should be applied when deciding whether to continue accepting donations from such donors.

Hepatitis B virus in transfusion medicine: still a problem?

Hepatitis B virus (HBV) has probably evolved with humans for nearly 35,000 years. HBV diversified into 9 genotypes (A-I) presenting specific features directing epidemiology, clinical expression and testing. Genotypes E and C are more infectious and carry higher risk of chronicity and cancer. HBsAg blood screening implemented 40 years ago enormously decreased the risk of transfusion transmission but the remaining risk requires extremely sensitive nucleic acid testing (NAT) to be removed. Limitations of the host immune system, the impact of immunodeficiency and the mechanisms utilised for viral persistence were recently identified. HBV replication produces excess HBsAg and infectious and defective viral particles but screening assays for HBsAg or viral particles alone do not allow fully efficient detection, making necessary screening for both. The host immune system fails to completely control the virus that escapes and persists unrecognized at very low levels or as immuno-selected variants. Variants may not be identified by assays, explaining false negative results. Specific mutations may affect post-transcriptional mechanisms including HBV RNA splicing. Asymptomatic HBV infected blood donors are at risk of long-term complications through mechanisms to be understood for appropriate counselling. Infectivity of occult HBV infection (OBI) by transfusion appears low, anti-HBc (anti-core antigen) only being more infectious than anti-HBs (anti-S protein) positive units.

Challenges in hepatitis B detection among blood donors

PURPOSE OF REVIEW

The availability of hepatitis B virus (HBV) nucleic acid testing (NAT) for donor blood screening led to its implementation in low prevalence and high prevalence countries. Genomic detection was a substantial addition to HBV surface protein (HBsAg) screening by detecting window period infections and 'occult' HBV infections (OBIs), characterized by undetectable HBsAg, low viral load and presence of serological markers (anti-HBc and/or anti-HBs). OBIs are the result of multiple, poorly understood mechanisms including incomplete immune control mutations of the HBsAg antigenic determinants; abnormal expression of S gene; and inhibition of genome transcription. Infectivity for the recipient is high for window period blood and relatively low for OBIs.

RECENT FINDINGS

The number of cases identified by NAT ranges between 1 : 1000 and 1 : 50 000, depending on epidemiology and assay sensitivity whether NAT is implemented in individual donations or pools of samples. OBI donors are generally older than 45 years except in Africa, carry very low viral load (median 11-25  IU/ml) and have normal alanine transaminase levels. Cases carrying anti-HBc alone are more infectious than those with low level of anti-HBs. Evidence of HBsAg escape mutants that are undetected by commercial assays has been published. Inhibition of HBsAg mRNA production and export are potential mechanisms of OBI occurrence.

SUMMARY

HBV blood safety is improved by NAT for HBV DNA when applied to individual donations. Until the sensitivity of NAT is improved, both this method and HBsAg screening are needed to eliminate potentially infectious blood donations. Occult HBV characterization clarifies new facets of HBV natural history.