Risk factors for acute hepatitis B and its progression to chronic hepatitis in Shanghai, China

Opportunistic screening using point-of-care testing leads to successful linkage to care of HBV-infected migrant populations in a low endemic country

Background and aims

In low endemic countries, screening for hepatitis B surface antigen (HBsAg) in migrants is cost-effective in reducing the disease burden of hepatitis B virus (HBV) infections, but linkage to care (LTC) remains a challenge. This study aims to guide future screening initiatives, with 3 objectives: 1. to compare LTC between different ethnic groups screened for HBsAg with point-of-care testing (POCT) in an outreach setting; 2. to estimate the proportion of HBsAg seropositivity for ethnic minorities; and 3. to investigate the association between seropositivity and HBV risk factors.

Methods

Opportunistic outreach screenings using finger prick HBsAg tests were performed at civic integration programmes between 11/2017 and 09/2022. If an individual tested positive, an appointment was given immediately at the outpatient hepatology clinic for follow-up and confirmation of HBsAg positivity in blood. Dedicated personnel contacted these individuals to motivate them for further LTC, which was defined as being assessed by a hepatologist, a blood test and an abdominal ultrasound.

Results

A total of 677 people from different ethnicities (Asian, Middle Eastern and African) were serologically screened using POCT. The observed positivity for HBsAg was 3.4 % (95% CI 2.17-5.05, 23/677). Apart from ethnicity and male sex, none of the surveyed HBV risk factors were associated with HBsAg seropositivity. All HBsAg positive individuals were linked to care and assessed by a hepatologist, despite the COVID-19 pandemic increase in time to follow-up of 82 days (95% CI 51-112 days) vs. 24 days (95% CI 5-43 days, p = 0.008)).Among HBV-infected patients, 31.8% (7/22), 100 % (22/22) and 26.1% (6/23) met the criteria for treatment indication, intrafamilial transmission risk and need for hepatocellular carcinoma surveillance, respectively.

Conclusion

The proportion of HBsAg seropositivity in ethnic minorities was 3.4%. POCT and commitment of dedicated personnel can overcome previously identified barriers resulting in a 100% LTC.

Changing incidence of hepatitis B and persistent infection risk in adults: a population-based follow-up study from 2011 in China

BACKGROUND

This study aimed to estimate hepatitis B incidence and chronicity risk in rural adults in China under the background of eliminating viral hepatitis.

METHODS

Hepatitis B surface antigen (HBsAg) screening was conducted every 2 years in demonstration areas since 2011. Individuals with baseline HBsAg-negative were included. Incidence was calculated as the number of HBsAg-positive cases divided by the total person-times. HBsAg-positive individuals were followed up to study the persistent infection (> 6 months), chronic infection (> 12 months), and recovery with hepatitis B surface antibody (anti-HBs). The chi-square test and cox proportional regression analysis were performed.

RESULTS

There were 8,942 incident cases over 2,138,532 person-years, yielding an average incidence of 0.42 per 100 person-years. HBV incidence decreased rapidly in both genders and all age groups and then kept stable. Male gender, low population density, low gross domestic product per capita, and islanders were associated with higher incidence. Of the positive cases, 4,989 (55.8%) patients were followed up. The persistent infection, chronic infection, and recovery with anti-HBs rates were 32.3%, 31.0%, and 31.4%, respectively. Persistent or chronic infection was more common in younger adults and males, while seroconversion had no concern with gender or age.

CONCLUSIONS

HBV incidence in adult rural residents was decreasing and stayed low. The chronicity rate was relatively high and protective antibodies were induced in only one third. The importance of population-based screening and vaccination for susceptible individuals should be addressed.

The effects of the interactions of STAT4 rs7574865 with HBV mutations on the risk of hepatocellular carcinoma

Signal transducer and activator of transcription 4 (STAT4) is closely related to liver diseases and affects the processes of inflammation and carcinogenesis by regulating immune responses. A single-nucleotide polymorphism rs7574865 (T > G) in STAT4 has been reported to be associated with the risk of hepatocellular carcinoma (HCC). In addition, hepatitis B virus (HBV) mutations are crucial risk factors for HBV-induced HCC. However, the effects of the interactions of STAT4 rs7574865 with HBV mutations on the risk of HCC remain unknown. Rs7574865 was genotyped in 846 healthy controls (HCs), 968 chronic hepatitis B (CHB) subjects, 316 liver cirrhosis (LC) subjects and 1021 HCC subjects using Sequenom MassArray. HBV mutations were detected via direct sequencing. Multivariate logistic regression analysis was used to evaluate the effects of the interactions of STAT4 rs7574865 with HBV mutations on the risk of HCC. We found that the rs7574865 TT genotype was significantly associated with HBeAg seroconversion (TT vs. GG, p = 0.012; TT vs. GT, p = 0.033). The rs7574865 GG genotype was significantly associated with increased risks of CHB (p = 0.048), LC (p = 0.005) and HCC (p < 0.001). The interaction term between rs7574865 and HBV C1913A significantly increased the risk of progression from CHB to HCC (p = 0.038), while the interaction term between rs7574865 and HBV T1674C significantly increased the risk of progression from LC to HCC (p = 0.023). STAT4 rs7574865 is significantly associated with the risks of CHB, LC and HCC. The interactions of rs7574865 with HBV C1913A and T1674C mutations significantly increase the risk of HCC, which have the potential to identify HBV-infected individuals who tend to progress from CHB or LC to HCC.

Establishment of an inducible cell line for Hepatitis B virus genotype C2 and its pharmacological responses to interferons

Hepatitis B virus (HBV) genotype C is closely associated with poor prognosis, contributing greatly to heavy chronic hepatitis B (CHB)-related liver disease burden in China and worldwide. However, the mechanistic studies on genotype C of HBV remain largely limited, partially because of a long-term lack of genotype C HBV-based stable cell tools. According to a bioinformatic analysis on the sub-genotype C2 HBV that is predominantly endemic in China, we selected 17.3 strain as a representative isolate. With a Tet-off gene expression system, an inducible viral replication and virion production of genotype C2 HBV were achieved in a cell line carrying persistent rcDNA-cccDNA recycling, termed HepG2-17.3, can be useful for virological studies on genotype C2 HBV. Additionally, this cell line has been formatted into cell-based assay that permits particular pharmacological screening of drug candidates, such as interferon regimens, for evaluations of the inhibitory effects on genotype C2 HBV replication.

Genotype E: The neglected genotype of hepatitis B virus

Hepatitis B virus (HBV) (sub)genotypes A1, D3 and E circulate in sub-Saharan Africa, the region with one of the highest incidences of HBV-associated hepatocellular carcinoma globally. Although genotype E was identified more than 20 years ago, and is the most widespread genotype in Africa, it has not been extensively studied. The current knowledge status and gaps in its origin and evolution, natural history of infection, disease progression, response to antiviral therapy and vaccination are discussed. Genotype E is an African genotype, with unique molecular characteristics that is found mainly in Western and Central Africa and rarely outside Africa except in individuals of African descent. The low prevalence of this genotype in the African descendant populations in the New World, phylogeographic analyses, the low genetic diversity and evidence of remnants of genotype E in ancient HBV samples suggests the relatively recent re-introduction into the population. There is scarcity of information on the clinical and virological characteristics of genotype E-infected patients, disease progression and outcomes and efficacy of anti-HBV drugs. Individuals infected with genotype E have been characterised with high hepatitis B e antigen-positivity and high viral load with a lower end of treatment response to interferon-alpha. A minority of genotype E-infected participants have been included in studies in which treatment response was monitored. Of concern is that current guidelines do not consider patients infected with genotype E. Thus, there is an urgent need for further large-scale investigations into genotype E, the neglected genotype of HBV.

Incidence and Influencing Factors of New Hepatitis B Infections and Spontaneous Clearance: A Large-Scale, Community-Based Study in China

Background: Hepatitis B surface antigen (HBsAg) is widely used in hepatitis B screening, and HBsAg seroclearance indicates hepatitis B eradication. Few studies have explored the incidence of and determinants for spontaneous seroclearance using a long-term follow-up cohort study. Our research aimed to examine the incidence of and influencing factors for hepatitis B virus infection and spontaneous clearance of HBsAg from a large-scale cohort in China.

Methods: A total of 151,926 resident individuals in Tongxiang underwent HBsAg screening at least thrice in a 7-year period. Serum samples collected at baseline and follow-up examinations were tested for HBsAg. Cox proportional hazard models were used to analyze determinants of HBsAg seroclearance and persistent HBsAg presence.

Results: Among the 151,926 participants, new hepatitis B infections occurred in 4,497 participants, yielding an incidence rate of 571.38 per 100,000 person-years. The incidence rate for males was higher than that for females. In the multivariate Cox regression analysis, female gender, alcohol drinking history, hepatitis family history and middle-age group were predictors for persistent positive HBsAg status.

Conclusions: The incidence rate of new hepatitis B infections was 571.38 per 100,000 person-years. Male and aged people in this community cohort have a higher infection rate. Alcohol drinking and hepatitis family history were risk factor leading to chronic infection. Female and middle-aged people were prone to persistent positive HBsAg status.

Overt Acute Hepatitis B Deteriorates in Females: Destructive Immunity With an Exaggerated Interleukin-17 Pathway

Background and Aims

We previously showed that overt acute hepatitis B (AHB) was more severe in female patients. Using the same cohort and AHB mouse model, we examined the underlying mechanism.

Methods

Baseline biochemistry, virological and cytokine assays, and T helper (Th)1 and Th2 immune markers of 118 consecutive patients were analyzed. The decompensated livers of AHB and chronic hepatitis B (CHB) patients who underwent liver transplantation were analyzed immunohistochemically. B6 mice were hydrodynamically injected with pHBV1.3 plasmids.

Results

Decompensated AHB patients (n=41) were older, more often female, and had higher alanine aminotransferase (ALT), soluble programmed cell death protein 1 (sPD-1) levels, and neutrophil-lymphocyte ratios but lower rates of HBeAg positivity and quantitative HBsAg, interferon (IFN)-γ-inducible protein 10 (IP-10), IFN-γ, and interleukin-4 (IL-4) levels than the compensated patients. Female sex (95% CI OR=1.07~54.9), age (1.06~1.40), and ALT levels (1.001~1.004) were associated with hepatic decompensation. Higher sPD-1 but lower IFN-γ and IL-4 levels were observed in female patients. Compared to CHB, decompensated AHB livers had more IL-17-positive cells but fewer HBsAg-positive cells and lower CD4/CD8 ratios. Higher serum IL-17 levels were noted in the female AHB mice than those in the males.

Conclusions

Females predominated in decompensated AHB, in which downregulated IFN-γ and IL-4 with augmented hepatic IL-17-positive cell development indicated accelerating destructive immunity to enhance viral clearance. The early surge of serum IL-17 was confirmed in the female AHB mice. Targeting the pathway involving IFN-γ, IL-4, and IL-17 might prevent liver transplantation or fatality in decompensated AHB.

Cancer Evo-Dev: A Theory of Inflammation-Induced Oncogenesis

Chronic inflammation is a prerequisite for the development of cancers. Here, we present the framework of a novel theory termed as Cancer Evolution-Development (Cancer Evo-Dev) based on the current understanding of inflammation-related carcinogenesis, especially hepatocarcinogenesis induced by chronic infection with hepatitis B virus. The interaction between genetic predispositions and environmental exposures, such as viral infection, maintains chronic non-resolving inflammation. Pollution, metabolic syndrome, physical inactivity, ageing, and adverse psychosocial exposure also increase the risk of cancer via inducing chronic low-grade smoldering inflammation. Under the microenvironment of non-resolving inflammation, pro-inflammatory factors facilitate the generation of somatic mutations and viral mutations by inducing the imbalance between the mutagenic forces such as cytidine deaminases and mutation-correcting forces including uracil-DNA glycosylase. Most cells with somatic mutations and mutated viruses are eliminated in survival competition. Only a small percentage of mutated cells survive, adapt to the hostile environment, retro-differentiate, and function as cancer-initiating cells via altering signaling pathways. These cancer-initiating cells acquire stem-ness, reprogram metabolic patterns, and affect the microenvironment. The carcinogenic process follows the law of "mutation-selection-adaptation". Chronic physical activity reduces the levels of inflammation via upregulating the activity and numbers of NK cells and lymphocytes and lengthening leukocyte telomere; downregulating proinflammatory cytokines including interleukin-6 and senescent lymphocytes especially in aged population. Anti-inflammation medication reduces the occurrence and recurrence of cancers. Targeting cancer stemness signaling pathways might lead to cancer eradication. Cancer Evo-Dev not only helps understand the mechanisms by which inflammation promotes the development of cancers, but also lays the foundation for effective prophylaxis and targeted therapy of various cancers.

Risk Factors for Hepatitis B Virus Transmission in Oman

Objectives

Hepatitis B virus (HBV) is a major public health problem worldwide. The prevalence of HBV is dependent on the modes of transmission. Chronic hepatitis B (CHB) infection can progress to liver cirrhosis and hepatocellular carcinoma. Oman is regarded as an intermediate endemic region and has had a neonatal vaccine against HBV since 1990. However, little research has been conducted regarding risk factors for HBV transmission. Our study aimed to identify the prevalence of major risk factors for acquiring HBV in Oman.

Methods

We conducted a retrospective chart review of all adult Omani patients diagnosed with CHB at two tertiary hospitals in Oman, Sultan Qaboos University Hospital and Armed Forces Hospital, between February 2009 and July 2013. The prevalence of major risk factors was identified by interviewing CHB patients using a standard questionnaire during their follow-up visits to the hepatology clinic at both hospitals. The risk factor frequency was stratified by age, gender, and educational level.

Results

A total of 274 patients were interviewed; 52.2% of the participants were males. The median age for men was 35.9 years and 35.1 years for women, with 75.5% aged 20–39 years old. The antenatal screening was the most common means of identifying HBV infection in females, and pre-blood donation screening was the most common in males. Intra-familial contact with HBV infected persons and behavioral risks such as body piercing (females) and barber shaving (males) were more common than nosocomial risk factors. Knowledge about HBV infection was scarce among our participants. More than half of the participants had a positive family history of HBV infection. There was a significant association between HBV infection and age groups, and educational levels (p < 0.050 and p < 0.001, respectively). Among those who were infected due to intra-familial contact or behavioral risk, there was a significant difference between the two sexes (p < 0.020) and between the three age groups (< 23, 23–28, >28) of HBV positive mothers (33.3%, 14.3%, and 6.6%, respectively; p < 0.050). There was also a statistically significant difference among different educational levels (p < 0.050).

Conclusions

Direct contact of infected individuals within a family and exposure to high-risk behaviors such as piercing and barber shaving are the main reported risk factors for HBV infection in Omani patients. Reducing the vertical and horizontal transmission of HBV in Oman could be improved by implementing routine antenatal screening of pregnant women and a greater focus on contact screening, respectively.

Molecular Mechanisms during Hepatitis B Infection and the Effects of the Virus Variability

The immunopathogenesis and molecular mechanisms involved during a hepatitis B virus (HBV) infection have made the approaches for research complex, especially concerning the patients’ responses in the course of the early acute stage. The study of molecular bases involved in the viral clearance or persistence of the infection is complicated due to the difficulty to detect patients at the most adequate points of the disease, especially in the time lapse between the onset of the infection and the viral emergence. Despite this, there is valuable data obtained from animal and in vitro models, which have helped to clarify some aspects of the early immune response against HBV infection. The diversity of the HBV (genotypes and variants) has been proven to be associated not only with the development and outcome of the disease but also with the response to treatments. That is why factors involved in the virus evolution need to be considered while studying hepatitis B infection. This review brings together some of the published data to try to explain the immunological and molecular mechanisms involved in the different stages of the infection, clinical outcomes, viral persistence, and the impact of the variants of HBV in these processes.

Hepatitis B surface antigen and antibody positivity among women of childbearing age after three decades of universal vaccination in South Korea

OBJECTIVES

We estimated the impact of universal hepatitis B immunization using 18-year data of women who are of childbearing age in South Korea.

METHODS

We used hepatitis B surface antigen (HBsAg) and antibody (anti-HBs) data of 145,993 women aged 20-49 years during 2001-2018 at the Gangnam CHA Medical Center. Annual prevalences of HBsAg and anti-HBs positivity were calculated and tested for linear trend. We conducted age-period-cohort (APC) analysis to obtain period and cohort effect.

RESULTS

Overall proportion of HBsAg positivity was 3.5% (n = 5050) and anti-HBs positivity was 75.3% (n = 109,907) during the study period. HBsAg positivity percentage decreased from 5.1% in 2001 to 2.5% in 2018 (P < 0.001) while anti-HBs positivity increased from 59.9% to 75.8% (P = 0.002). Average annual percent change of HBsAg positivity was -5.9% (95% confidence interval (CI): -6.9%, -4.8%). The period and cohort RR curve identified a consistent decrease in HBsAg positivity over time and across generations.

CONCLUSIONS

We observed a concurrent decrease in HBsAg and an increase in anti-HBs seropositivity among Korean women of childbearing age, implicating success in preventing vertical transmission.

The genetic polymorphism down-regulating HLA-DRB1 enhancer activity facilitates HBV persistence, evolution and hepatocarcinogenesis in the Chinese Han population

Genetic predisposition of human leucocyte antigen (HLA)-DR has been linked to nonresponse to hepatitis B virus (HBV) vaccination. We sought to reveal their effects on chronic infection and evolution of HBV and development of hepatocellular carcinoma (HCC). Genetic polymorphisms at HLA-DR enhancer regions were genotyped in 4588 participants using quantitative PCR. HBV mutations were determined by sequencing. A dual-luciferase assay was applied to detect the enhancer activity. Associations between HLA-DR polymorphisms and postoperative prognosis were investigated in another cohort of 397 HBV-infected HCC patients. Variant alleles (rs3135395-T, rs3135338-C and rs477515-T) were significantly associated with a decreased risk of HBV persistence in Chinese patients. rs3135395-T, rs3135338-C, rs477515-T and rs2395178-G also significantly decreased HCC risk. rs3135395-T, rs477515-T and rs2395178-G were inversely associated with the generation of A1762T/G1764A, T1753V and C1653T, the HCC-risk HBV mutations. Multiplicative interactions of the variant genotypes with the HCC-risk HBV mutations were significantly associated with a decreased risk of HCC. In multivariate Cox analysis, rs477515-T independently predicted a favourable prognosis, with a hazard ratio of 0.48 (P = .002). The activity of the HLA-DRB1 enhancer with rs477515-T was significantly higher than that with rs477515-C. The activity of the HLA-DRB1 enhancer with rs477515-T and that with rs477515-C was significantly up-regulated by interferon-γ and interleukin-4, respectively. Interleukin-6 significantly inhibited the HLA-DRB1 enhancer activity, and this effect was more evident in those carrying rs477515-T. Polymorphisms predisposing to down-regulation of HLA-DR facilitate the Th1-to-Th2 transition and promote HCC development, possibly via selecting the HCC-risk HBV mutations. This can be transformed into specific prophylaxis of HCC.

Seroepidemiology and Risk Factors of Hepatitis B Virus Infection: A Population-Based Azar Cohort Study

BACKGROUND

Hepatitis B is a major global health problem. It can cause chronic infections and put people at high risk of death from cirrhosis and hepatocellular carcinoma. The aim of this study was to report the epidemiological features of hepatitis B virus (HBV) infection and risk factors based on the data from Azar Cohort.

METHODS

The population of this study comprised the people in the age range of 35-70 yr from Azar cohort, East Azerbaijan Province, Iran between 2015 and 2016. Based on cluster sampling, 4,949 people were selected and invited to complete the questionnaire and perform the tests. Blood samples were analyzed for serum HBV markers (HBsAg, HBsAb and HBcAb) by ELFA method. The data were analyzed using SPSS statistical software.

RESULTS

The mean (SD) age of the participants was 49.15 ± 9.02 years. The frequency rates of HBsAg, HBsAb and HBcAb were estimated as 1.03%, 16.9% and 24.95%, respectively. There was statistically significant association between family history of hepatitis (P<0.001) and jaundice history (P<0.001) with the presence of HBsAg. There was also a positive correlation between marital status (P=0.002), history of hospitalization (P<0.001), smoking (P=0.001), dental procedures (P<0.001), foreign travels (P=0.005), occupation status (P=0.002) and the presence of HBcAb.

CONCLUSION

The frequency of hepatitis B in Azar Cohort was 1.03% which is a lower rate compared with other reports from Iran. The association of the population studied and the increase of public awareness in this area can probably prevent this disease.

Gamma-glutamyl transpeptidase-to-platelet ratio and the fibrosis-4 index in predicting hepatitis B virus-related hepatocellular carcinoma development in elderly chronic hepatitis B patients in China: A single-center retrospective study

Gamma-glutamyl transpeptidase-to-platelet ratio (GPR) and fibrosis-4 (FIB-4) index have been reported to be useful predictors in predicting hepatocellular carcinoma (HCC) development in chronic hepatitis B (CHB) patients. However, their predictive performances on HCC development have not been validated in elderly patients. Thus, the aim of this study was to evaluate the predictive values of the GPR and FIB-4 index on HCC in elderly CHB patients with in China.Between January 2007 and December 2016, 1011 CHB patients older than 60 years were enrolled in the study, and their data were retrospectively analyzed. Receiver-operating characteristic (ROC) curve analysis was used to determine the optimal cutoff points of GPR and the FIB-4 index. Cumulative HCC incidence rates were calculated by the Kaplan-Meier method and compared by the log-rank test. Univariate and multivariate analyses were performed to detect risk factors for HCC development. The prediction performances of GPR and FIB-4 index were compared based on time-dependent ROC analyses.After a median follow-up of 6.8 (interquartile range 3.9-8.4) years, 39 (3.9%) patients developed HCC. The ROC analysis of GPR and the FIB-4 index at the 5-year time point revealed that the optimal cutoff point was 0.23 for GPR and 4.15 for the FIB-4 index. When stratified by low and high GPR values and FIB-4 indices, the patients' subgroups showed significantly different cumulative incidences of HCC. The multivariate analysis revealed that high GPR (hazard ratio [HR] 4.224; 95% confidence interval [CI] 1.891-9.434, P < .001) was an independent risk factor for HCC development, whereas a high FIB-4 index was not (HR 0.470; 95% CI 0.212-1.043; P = .063). In the time-dependent ROC analysis, GPR showed higher area under curve (AUC) values than the FIB-4 index did at all time points and reached statistical significance at the 5-, 7-, and 10-year time points (GPR vs FIB-4 index, AUC 0.725 vs 0.549 at 5 years, P = .005; GPR vs FIB-4 index, AUC 0.733 vs 0.578 at 7 years, P = .001; GPR vs FIB-4 index, AUC 0.837 vs 0.475 at 10 years, P < .001).In conclusion, our study suggests GPR is superior to the FIB-4 index in predicting HCC development in elderly CHB patients in China.

Management of Fulminant Hepatitis B

Purpose of Review

Acute HBV infection and acute exacerbations of chronic HBV infection can cause acute liver injury (ALI) or fulminant hepatitis (FH). At this stage, spontaneous survival is poor, less than 25%. The purpose of this review is to provide an overview of specific management of patients with HBV-ALI/FH.

Recent Findings

Acute HBVinfection and acute exacerbations of chronic HBVinfection can cause acute liver injury (ALI) or fulminant hepatitis (FH). Spontaneous survival at this stage is poor. It is urgent to distinguish between these two entities so that antiviral therapy can be initiated rapidly. Although the indications for antiviral therapy are clear for HBV reactivation, there is no true consensus regarding ALI/FH related to acute HBV infection. The global management of HBV-related FH does not differ from that implemented for other causes of FH, i.e. close cardiorespiratory and neurological monitoring, treatment with acetylcysteine, organ support in the event of organ failure (haemodynamic, renal, respiratory) and albumin dialysis. Liver transplantation remains the only alternative when certain criteria for a poor prognosis are met. A recurrence of HBV infection on the graft can be prevented post-transplant by the administration of HBIG and antiviral therapy for HBV, the modalities varying depending on the risk of recurrence.

Genetic Polymorphisms Predisposing the Interleukin 6-Induced APOBEC3B-UNG Imbalance Increase HCC Risk via Promoting the Generation of APOBEC-Signature HBV Mutations

PURPOSE

APOBEC3-UNG imbalance contributes to hepatitis B virus (HBV) inhibition and somatic mutations. We aimed to explore the associations between hepatocellular carcinoma (HCC) risk and genetic polymorphisms predisposing the imbalance.Experimental Design: Genetic polymorphisms at APOBEC3 promoter and UNG enhancer regions were genotyped in 5,621 participants using quantitative PCR. HBV mutations (nt.1600-nt.1945, nt.2848-nt.155) were determined by Sanger sequencing. Dual-luciferase reporter assay was applied to detect the transcriptional activity. Effects of APOBEC3B/UNG SNPs and expression levels on HCC prognosis were evaluated with a cohort of 400 patients with HCC and public databases, respectively.

RESULTS

APOBEC3B rs2267401-G allele and UNG rs3890995-C allele significantly increased HCC risk. rs2267401-G allele was significantly associated with the generation of APOBEC-signature HBV mutation whose frequency consecutively increased from asymptomatic HBV carriers to patients with HCC. Multiplicative interaction of rs2267401-G allele with rs3890995-C allele increased HCC risk, with an adjusted OR (95% confidence interval) of 1.90 (1.34-2.81). rs2267401 T-to-G and rs3890995 T-to-C conferred increased activities of APOBEC3B promoter and UNG enhancer, respectively. IL6 significantly increased APOBEC3B promoter activity and inhibited UNG enhancer activity, and these effects were more evident in those carrying rs2267401-G and rs3890995-C, respectively. APOBEC3B rs2267401-GG genotype, higher APOBEC3B expression, and higher APOBEC3B/UNG expression ratio in HCCs indicated poor prognosis. APOBEC-signature somatic mutation predicts poor prognosis in HBV-free HCCs rather than in HBV-positive ones.

CONCLUSIONS

Polymorphic genotypes predisposing the APOBEC3B-UNG imbalance in IL6-presenting microenvironment promote HCC development, possibly via promoting the generation of high-risk HBV mutations. This can be transformed into specific prophylaxis of HBV-caused HCC.

HBV mutations in EnhII/BCP/PC region contribute to the prognosis of hepatocellular carcinoma

Background

Accompanied by HBV infection, HBV mutations gradually occur because HBV polymerase appears proofread deficiencies. In our previous study, we have identified that EnhII/BCP/PC mutations and genotype C of HBV DNA were associated with hepatocellular carcinoma (HCC) risk. In this study, we extend our research to explore HCC prognosis associated genotype and mutations in EnhII/BCP/PC regions.

Methods

We designed a case‐cohort study of 331 HCC patients to evaluate the effects of the HBV genotypes and mutations on HCC survival. Log‐rank test and Cox proportional hazard models were used for the analyses.

Results

Results showed that genotype C, which was more frequent in HBV‐related HCC (77.4%), presented a negative signal with HCC survival. Interestingly, we detected a significant association between EnhII/BCP/PC mutation nt1753 and HCC prognosis (Log‐rank P = 0.034). Subgroup analysis revealed that this risk effect was more pronounced in non‐B genotype (P = 0.090 for heterogeneity test). We also detected a borderline multiplicative interaction between genotypes of nt1753 and HBV genotype on HCC survival (P for interaction = 0.069).

Conclusions

These findings indicated that, in Chinese population, nt1753 in EnhII/BCP/PC region might be a novel marker for HCC prognosis.

Understanding Risk Behaviors of Vietnamese Adults with Chronic Hepatitis B in an Urban Setting

Cigarette smoking and alcohol consumption can be considered as risk factors that increase the progression of chronic liver disease. Meanwhile, unprotected sex is one of the main causes of hepatitis B infection. This study aimed to explore drinking, smoking, and risky sexual behaviors among people with chronic hepatitis B virus (HBV) in a Vietnamese urban setting, as well as investigating potential associated factors. A cross-sectional study was performed in October 2018 in Viet-Tiep Hospital, Hai Phong, Vietnam. A total of 298 patients who had been diagnosed with chronic hepatitis B reported their smoking status, alcohol use, and sexual risk behavior in the last 12 months. A multivariate logistic regression model was used to identify the associated factors. It was identified that 82.5% of participants never used alcohol. The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) positive result among male patients was 7.4% (0% in female patients). In addition, 14.5% of participants were current smokers and the mean number of cigarettes per day was 7.4 (SD = 3.4). It was found that 35.4% of male patients had sex with two or more sex partners. Furthermore, 66.7% and 74.1% of participants used condoms when having sex with casual partners/one-night stands and sex workers, respectively. There was a positive correlation between monthly drinking and currently smoking. White-collar workers were less likely to have multiple sex partners within the last 12 months. Our study highlights the need for integrating counseling sessions and educational programs with treatment services.

Association between miRNA-146a rs2910164 (G/C) polymorphism with the susceptibility to chronic HBV infection and spontaneous viral clearance in an Iranian population

Hepatitis B virus (HBV) infection is one of the clinical dilemmas in chronic liver diseases. MicroRNAs (miRNAs) are small noncoding RNA molecules that play an important role in the pathogenesis of liver diseases and single nucleotide polymorphisms (SNPs) in miRNA genes affect the clinical course of HBV infection. Previous studies have shown that miRNA-146a rs2910164 polymorphism can be associated with the pathogenesis of liver diseases such as hepatocellular carcinoma. The present study investigated the association between miRNA-146a rs2910164 polymorphism and susceptibility to HBV infection in an Iranian population. The study comprised 266 patients with chronic HBV infection, 172 patients with spontaneous viral clearance (SVC) after acute HBV infection, and 266 healthy control adjusted for sex and age. The genotyping of the miRNA-146a rs2910164 polymorphism was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. Our data revealed that GG genotype and G allele of miRNA-146a rs2910164 SNP is dominated (P < 0.001) in patients with chronic HBV infection (Odds ratio [OR] = 3.92; 95% confidence interval [CI] = 2.1-7.32). miRNA-146a rs2910164 polymorphism showed a statistically significant association (P < 0.001) between CC genotype and allele C with SVC (OR = 2.92; 95% CI = 1.56-546). Our findings suggest miRNA-146a SNP (C/G) in our population may be associated with the susceptibility to HBV infection and CC genotype is associated with SVC. Also, the GG genotype and G allele at miRNA-146a rs2910164 is associated with chronic HBV infection in our population.

Chronic hepatitis B genotype E in African migrants: response to nucleos(t)ide treatment in real clinical practice

Background

Hepatitis B virus (HBV) genotype E is a poorly studied genotype that almost exclusively occurs in African people. It seems to harbour intrinsic potential oncogenic activity and virological characteristics of immune scape but a paucity of information is available on clinical and virological characteristic of HBV genotype E-infected patients as well as on the efficacy of anti-HBV drugs for such patients. The increasing flow of migrants from high endemic HBV sub-Saharan Africa, where genotype E is the predominant one, to Western countries makes improving such knowledge critical in order to deliver proper medical care.

Methods

Prospective observational study of naïve patients of sub-Saharan origin treated for chronic HBV genotype E infection at a Tropical Medicine clinic sited in Spain from February 2004 to January 2018. The aim of the study was to describe the response of chronic HBV genotype E infection to nucleos(t)ide analogues (NA), entecavir or tenofovir, in real clinical practice.

Results

During the study period, 2209 sub-Saharan patients were assisted at our Tropical Medicine Unit and 609 (27.6%) had chronic HBV (CHB) infection. Genotype information was available for 55 naïve patients initiating treatment with NA (entecavir or tenofovir), 43 (84.3%) of them being genotype E, although 15 were excluded because they did not meet study inclusion criteria. Thus, a total of 28 CHB genotype E patients were included and followed for 24 months at least. Twenty-one patients were in HBeAg-negative chronic hepatitis phase and 7 patients in HBeAg-positive chronic hepatitis phase. After one year of treatment, among those with good adherence, 89.4% (17/19) of the HBeAg-negative patients and 80% of the HBeAg-positive ones had undetectable viral loads. Response rates reached 100% in both groups after 15–18 months of follow-up. Out of the 7 HBeAg-positive patients, 6 (85.7%) presented HBeAg loss in a median time of 31.8 months. Neither serious adverse effects nor hepatocarcinoma cases happened during the study period.

Conclusions

HBV genotype may influence disease progression and antiviral response. Our study provides precious information on the efficacy and safety of NA treatment for CHB genotype E infection, a fairly unknown genotype with and increasing epidemiological impact.

Type I Interferon Signaling Prevents Hepatitis B Virus-Specific T Cell Responses by Reducing Antigen Expression

Robust virus-specific CD8⁺ T cell responses are required for the clearance of hepatitis B virus (HBV). However, the factors that determine the magnitude of HBV-specific CD8⁺ T cell responses are poorly understood. To examine the impact of genetic variations of HBV on HBV-specific CD8⁺ T cell responses, we introduced three HBV clones (Aa_IND [Aa], C_JPN22 [C22], and D_IND60 [D60]) that express various amounts of HBV antigens into the livers of C57BL/6 (B6) (H-2b) mice and B10.D2 (H-2d) mice. In B6 mice, clone C22 barely induced HBV-specific CD8⁺ T cell responses and persisted the longest, while clone D60 elicited strong HBV-specific CD8⁺ T cell responses and was rapidly cleared. These differences between HBV clones largely diminished in H-2d mice. Interestingly, the magnitude of HBV-specific CD8⁺ T cell responses in B6 mice was associated with the HB core antigen expression level during the early phase of HBV transduction. Surprisingly, robust HBV-specific CD8⁺ T cell responses to clone C22 were induced in interferon-α/β receptor-deficient (IFN-αβR^-/-) (H-2b) mice. The induction of HBV-specific CD8⁺ T cell responses to C22 in IFN-αβR^-/- mice reflects enhanced HBV antigen expression because the suppression of antigen expression by HBV-specific small interfering RNA (siRNA) attenuated HBV-specific T cell responses in IFN-αβR^-/- mice and prolonged HBV expression. Collectively, these results suggest that HBV genetic variation and type I interferon signaling determine the magnitude of HBV-specific CD8⁺ T cell responses by regulating the initial antigen expression levels.IMPORTANCE Hepatitis B virus (HBV) causes acute and chronic infection, and approximately 240 million people are chronically infected with HBV worldwide. It is generally believed that virus-specific CD8⁺ T cell responses are required for the clearance of HBV. However, the relative contributions of genetic variation and innate immune responses to the induction of HBV-specific CD8⁺ T cell responses are not fully understood. In this study, we discovered that different clearance rates between HBV clones after hydrodynamic transduction were associated with the magnitude of HBV-specific CD8⁺ T cell responses and initial HB core antigen expression. Surprisingly, type I interferon signaling negatively regulated HBV-specific CD8⁺ T cell responses by reducing early HBV antigen expression. These results show that the magnitude of the HBV-specific CD8⁺ T cell response is regulated primarily by the initial antigen expression level.

Molecular evolution and genomics of hepatitis B virus subgenotype C2 strain predominant in the chronic patients in Bangladesh

Evolution of hepatitis B virus (HBV) is a mystery and caused mainly by genomic mutations as well as recombination. Viral evolution may be responsible for increasing disease severity and render resistance to the existing treatment processes. HBV/C2 strain is associated with chronicity, which may progress to the liver cirrhosis and hepatocellular carcinoma. Furthermore, HBV/C2 strain is highly prevalent in the chronic hepatitis B patients in Bangladesh. Hence, the molecular evolution of that strain and its disease pattern need to be uncovered. Herein, the purpose of this study is to determine the potential mutations of HBV complete genome sequences isolated in Bangladesh and the molecular evolution of HBV/C2 strain. Mutation analysis of the total 57 complete genome sequences of HBV in Bangladesh revealed that 42.11%, 12.28%, 7.02% and 3.51% of the strains were vaccine resistant, HBsAg detection escape, HBV immunoglobulin escape, multi-drug resistant respectively. Furthermore, of the vaccine resistant strains, 16.67% were observed resistant to both vaccine, HBsAg detection and immunoglobulin escape. Bayesian skyline analysis with 462 HBV/C2 strains from 2000 to 2017 revealed the evolution of the strain was in nineteenth century with two rapid sharp increases in the genetic diversity at the end of the twentieth century and then a sudden decrease in the early twenty-first century as observed in C and X gene analysis. This study may help researchers and clinicians to get a better knowledge about the emergence and evolution of HBV/C2 strain that may help to find a proper treatment strategy against hepatitis B.

Progression from acute to chronic hepatitis B is more common in older adults

PURPOSE

The rate of progression of acute Hepatitis B (HBV) to chronic disease is quoted as <10%. The purpose of this study was to determine the rate of progression from acute to chronic HBV in Northern Ireland (NI), assessing the influence of age, gender and biochemical parameters.

METHODS

All "acute" HBV cases diagnosed in NI between 2011 and 2015 were reviewed. Inclusion criteria: 1). positive HBsAg and positive HBV core IgM; 2). in the absence of positive HBV core IgM, positive HBsAg with a recent negative HBsAg. Patient age, HBsAg, HBV core IgM, peak bilirubin and peak ALT were recorded, along with date and result of repeat HbsAg testing. Mann-Whitney U test was used to compare mean age, peak ALT and bilirubin between clearing and non-clearing groups. Fisher's exact test was used to compare progression to chronicity according to gender and age less than or greater than 50yrs.

RESULTS

Of 80 identified cases, 4 incorrectly categorised cases were excluded. Of the remaining 76, (15 female (mean age 37.27yr), 61 male (mean age 47.39yr)) follow-up data was available for 71 patients (15 female (mean age 37.27yr), 56 male (48.59yr)). All female patients cleared HBV. 42 of 61 males cleared HBV (p=0.0313).Overall the chronicity rate was 18.42% The mean age of those clearing the virus was 43.88 years, versus 55.64 years for those going on to develop chronic HBV (Mann-Whitney U test, z= -2.68, p=0.0037). Clearance rate was 83.72% in patients aged <50yrs and 63.64% in patients 50yrs (p=0.0068).Mean peak ALT (U/L) and peak bilirubin (µmol/L) for the clearing group were 2130 and 174 respectively compared to 656 and 100 for the non-clearing group (z= -3.51, p=0.0002, z= -2.35, p=0.009).

CONCLUSION

Our results suggest a higher than expected rate of progression from acute to chronic HBV with a significantly higher risk for those over 50yrs. This suggests a need to revise information provided to older patients with acute HBV regarding the likelihood of progression.

Progress of research on the immune tolerance of chronic HBV infection

Immune tolerance is a specific lack or negative response of T and B lymphocytes to antigen. According to different formation periods, immune tolerance can be divided into central and peripheral tolerances. The immune tolerance of the body to hepatitis B virus (HBV) after infection is the main cause of chronic HBV infection. In this paper, the functional defects of hepatitis B virus e antigen and dendritic cells, hyporesponsiveness of cytotoxic T lymphocyte, variation of helper T lymphocytes and cytokines, HBV genotype and genome, and the role of host gene polymorphism in the formation of immune tolerance in chronic HBV infection and its related research progress are introduced briefly.

Sero-prevalence of hepatitis B virus infection and associated factors among health care workers and medical waste handlers in primary hospitals of North-west Ethiopia

Objective

The aim of this cross-sectional study was to determined the sero-prevalence of HBV infection and associated factors among health care workers and medical waste handlers in primary hospitals of North-west Ethiopia.

Results

A total of 388 study participants were included in this study. Of which, 268 (69%) were health care workers and 120 (31%) were medical waste handlers. Males accounted 54.9% and the mean age for all study participants was 28.3 (standard deviation = 6.9). Hepatitis B virus surface antigen (HBsAg) was detected in 2.6% health care workers and 2.5% medical waste handlers and the overall hepatitis B virus infection was 10 (2.6%). High rate of hepatitis B virus infection was detected in single participants and those in the age group of 30–40 years were more infected (6.6%). History of contact with HBV infected case (8.3%) (AOR = 6.8, 95% CI = 1.6–28.5, P = 0.009) and history of jaundice (15.4%) (AOR = 10.5, 95% CI = 2.1–12.2, P = 0.03) were statistically associated factors for HBV infection. More than half (54.4%) of the study participants did not take training on infection and 9 (4.3%) of them were positive for HBsAg (COR = 1.3, 95% CI = 0.0.02–1.02, P = 0.052).

Genotyping of hepatitis B virus isolates from Lahaul and Spiti district in Himachal Pradesh, India

Hepatitis B virus (HBV) has several genotypes. In the Indian population, genotypes A and D are the most frequent. HBV infection is hyper-endemic in the Lahaul and Spiti district in Himachal Pradesh; however, the virus genotype in this area is not known. We sequenced a 398-nucleotide segment of HBV genome that included parts of pre-S1/S2 and polymerase genes from 17 specimens from this district, and assigned a viral genotype to these. Of the 17 specimens studied, 13 (76% [95% confidence interval = 50-92%]) showed the presence of genotype C HBV; the remaining four were genotype D (n = 4; 24%) HBV. Prevalence of genotype C HBV was much higher in the district than in other parts of India. This may reflect the historical mixing of this population with that in China. Since genotype C has a higher risk of chronicity and mother-to-child transmission, prevention of HBV infection may need particular emphasis in this area.

Hepatitis B virus genotypes, expression quantitative trait loci for ZNRD1-AS1 and their interactions in hepatocellular carcinoma

Genetic variants in zinc ribbon domain-containing 1 antisense RNA 1 (ZNRD1-AS1) have been reported to be associated with development of hepatocellular carcinoma (HCC). We sought to determine the influences of ZNRD1-AS1 polymorphisms and their interactions with Hepatitis B virus (HBV) genotypes on the risk of HCC. In this study, we conducted a large population case-control study with 1,507 HBV-related HCC cases and 1,560 HBV persistent carriers. Three single-nucleotide polymorphisms (SNPs) in ZNRD1-AS1 (rs3757328, rs6940552 and rs9261204) were genotyped using a TaqMan allelic discrimination assay, and the HBV genotypes were identified by multiplex PCR. We found consistently significant associations between the ZNRD1-AS1 rs6940552 and rs9261204 SNPs with an increased risk of HCC (additive genetic model: adjusted OR = 1.16, 95% CI = 1.03-1.32 for rs6940552; adjusted OR =1.20, 95% CI = 1.06-1.35 for rs9261204) and found a borderline association between rs3757328 and HCC risk. Besides, we observed a dose-dependent relationship between increasing numbers of variant alleles of the SNPs and HCC risk (P for trend <0.001). Moreover, we observed a stronger combined effect of the three SNPs on HCC risk among the subjects infected with non-B genotype HBV (adjusted OR = 1.26, 95% CI = 1.05-1.50) compared with HBV B-related genotypes (adjusted OR = 0.89, 95% CI = 0.69-1.15; P= 0.029 for heterogeneity test). We also found that a multiplicative interaction between the variant alleles and the HBV genotype significantly affected HCC susceptibility (P = 0.030). Together, these results indicate that ZNRD1-AS1 may influence HCC risk accompanied by HBV genotypes.

How viral genetic variants and genotypes influence disease and treatment outcome of chronic hepatitis B. Time for an individualised approach?

Chronic hepatitis B virus (HBV) infection remains a global problem. Several HBV genotypes exist with different biology and geographical prevalence. Whilst the future aim of HBV treatment remains viral eradication, current treatment strategies aim to suppress the virus and prevent the progression of liver disease. Current strategies also involve identification of patients for treatment, namely those at risk of progressive liver disease. Identification of HBV genotype, HBV mutants and other predictive factors allow for tailoured treatments, and risk-surveillance pathways, such as hepatocellular cancer screening. In the future, these factors may enable stratification not only of treatment decisions, but also of patients at risk of higher relapse rates when current therapies are discontinued. Newer technologies, such as next-generation sequencing, to assess drug-resistant or immune escape variants and quasi-species heterogeneity in patients, may allow for more information-based treatment decisions between the clinician and the patient. This article serves to discuss how HBV genotypes and genetic variants impact not only upon the disease course and outcomes, but also current treatment strategies. Adopting a personalised genotypic approach may play a role in future strategies to combat the disease. Herein, we discuss new technologies that may allow more informed decision-making for response guided therapy in the battle against HBV.

Life history tradeoffs of pathogens and the treatment principle of antibiogenesis

There are no eternal individual lives so life continues by relaying with reproduction. Consequently, lifespan and fecundity are two essential genetic traits of life. The life history tradeoffs theory holds that there is an inverse relationship between lifespan and fecundity. This paper proposes two new concepts, i.e., "lifespan of pathogens" and treatment of infections by "antibiogenesis". The lifespan of pathogens is the time limitation of those tiny lives just as other large creatures. Notably, the lifespan of bacterium is the time interval from the cell division by which it is produced to next division by then its life ends and transforms to two new lives, or dies. Antibiogenesis means inhibiting generation of new lives. By the principle of life history tradeoffs, the lifespan of pathogens determines the speed of their proliferations and consequently the modality of infection. The treatment principle of antibiogenesis requires the duration of treatment to be determined by the lifespan of infected pathogens. The life history tradeoffs theory and the two concepts are helpful to understanding the pathobiology and shaping the clinical aspects of infectious diseases.

The virological aspects of hepatitis B

Human hepatitis B virus (HBV) is a hepatotropic virus that is responsible for a significant burden of disease, causing liver disease and hepatocellular carcinoma. It is a small DNA virus with a replication strategy that is similar to that of a retrovirus. HBV is prone to mutagenesis and under the influence of diverse selection pressures, has evolved into a pool of quasispecies, genotypes and mutants, which confers a significant survival advantage. The genome is small, circular, and compact but has a complex replication strategy. The viral life cycle involves the formation of a covalently closed circular DNA (cccDNA), which is organized into a minichromosome that is the template for the synthesis of viral mRNA. HBV DNA (double-stranded linear form) can also integrate into the host genome, ensuring lifelong persistence of the virus. To date, despite great advances in therapeutics, once HBV is chronically established, it is incurable. This is by virtue of many aspects of its virological structure and viral life cycle. In this review, we aim to discuss important aspects of the virology of HBV with a focus on clinical implications.

Current Condition of Chronic Hepatitis B Virus Infection in Cuban Adults

BACKGROUND

The reduction of the incidence of hepatitis B virus (HBV) infection in Cuba can be attributed to the effectiveness of the national immunization program. However, the number of patients with chronic HBV observed in clinical practice is not negligible.

OBJECTIVE

A cross-sectional study was conducted to describe the main clinical characteristics of patients with chronic hepatitis B virus infection.

METHODS

A total of 146 patients who had at least a 6-month history of hepatitis B surface antigen positivity were recruited between 2013 and 2015. Descriptive statistical analysis of the epidemiologic, clinical, biochemical, and virologic variables was performed.

RESULTS

Men accounted for 67.8% of patients, and the median age was 43 years. The median time since diagnosis of infection was 9 years. Among the patients, 59% had chronic hepatitis, 34% had liver cirrhosis, and 7% were inactive carriers. Concomitant diagnoses demonstrated that 16.4% of patients had malignancies, predominantly lymphoma. Only 64.4% of patients had received antiviral treatment, and lamivudine was the most commonly used (61.6%) drug. Moreover, 70% of patients were identified during an inactive phase.

CONCLUSIONS

Patients with chronic HBV infection are still a health problem in the adult Cuban population, especially in patients with concomitant malignancies.

The Envelope Gene of Hepatitis B Virus Is Implicated in Both Differential Virion Secretion and Genome Replication Capacities between Genotype B and Genotype C Isolates

Chronic infection by hepatitis B virus (HBV) genotype C is associated with a prolonged replicative phase and an increased risk of liver cancer, compared with genotype B infection. We previously found lower replication capacity but more efficient virion secretion by genotype C than genotype B isolates. Virion secretion requires interaction between core particles and ENVELOPE proteins. In the present study, chimeric constructs between genotype B and genotype C clones were generated to identify the structural basis for differential virion secretion. In addition to dimeric constructs, we also employed 1.1mer constructs, where the cytomegalovirus (CMV) promoter drove pregenomic RNA transcription. Through transient transfection experiments in Huh7 cells, we found that exchanging the entire envelope gene or just its S region could enhance virion secretion by genotype B clones while diminishing virion secretion by genotype C. Site-directed mutagenesis established the contribution of genotype-specific divergence at codons 108 and 115 in the preS1 region, as well as codon 126 in the S region, to differential virion secretion. Surprisingly, exchanging the envelope gene or just its S region, but not the core gene or 3′ S region, could markedly increase intracellular replicative DNA for genotype C clones but diminish that for genotype B, although the underlying mechanism remains to be clarified.

Inequality in the hepatitis B awareness level in rural residents from 7 provinces in China

The hepatitis B (HB) awareness level is an important factor affecting the rates of HB virus vaccination. To better understand income-related inequalities in the HB awareness level, it is imperative to identify the sources of inequalities and assess the contribution rates of these influential factors. This study analyzed the unequal distribution of the HB awareness level and the contributions of various influential factors. We performed a cross-sectional household survey with questionnaire-based, face-to-face interviews in 7 Chinese provinces. Responses from 7271 respondents were used in this analysis. Multinomial logistic regression was used for the analysis of contributing factors, and the concentration index was used as a measure of HB awareness inequalities. The HB awareness level varied across participants with different characteristics. Multinomial logistic regression of the explanatory factors of the HB awareness level showed that several estimated coefficients and relative risk ratios were statistically significant for middle- and high-level awareness, except for sex, occupation, and household income. The concentration index of the HB knowledge score was 0.140, indicating inequality gradients disadvantageous to the poor. The contribution rate of socioeconomic factors was the largest (60.8%), followed by demographic characteristics (29.0%) and geographic factors (4.3%). Demographic, socioeconomic, and geographic factors are associated with the HB awareness inequality. Therefore, to reduce inequality, HB-related health education targeting individuals with low socioeconomic status should be performed. Less-developed provinces, especially with high proportions of poor residents, warrant particular attention. Our findings may be beneficial to improve the HB virus vaccination rate for individuals with low socioeconomic status.

Virological and serological features of acute hepatitis B in adults

Various viral kinetics among patients with acute hepatitis B (AHB) have been observed in clinical practice. This study investigated the virological, biochemical, and serological characteristics of AHB in adults.A total of 192 adult patients with AHB were recruited between December 2010 and January 2014. The quantification of biochemical and serologic markers for hepatitis B virus (HBV) infection was monitored from the onset.Of the 192 patients, 113 patients were followed up. One patient died due to acute liver failure, 2 developed chronic HBV infection. Clinical recovery was observed in 110 patients; 92.7% (102/110) achieved clinical recovery within 24 weeks, and 7.3% (8/110) between 24 and 44 weeks. There were 3 different viral kinetics patterns among the patients with AHB: the clearance of HBV DNA preceded hepatitis B e antigen (HBeAg) and hepatitis B surface antigen (HBsAg), the clearance of HBeAg preceded HBV DNA and HBsAg, the clearance of HBsAg preceded HBV DNA and HBeAg.In the absence of HBV DNA clearance within 13 weeks, the risk of development of chronic HBV infection increased. The serologic HBV markers clearance occurred between 24 and 44 weeks (6-11 months) from the onset in 8 of the AHB patients, which was longer than 6 months. Thus, AHB may be redefined as HBV DNA undetectable, HBsAg and HBeAg seroconversion within 44 weeks.

Risk for hepatitis B and C virus transmission in nail salons and barbershops and state regulatory requirements to prevent such transmission in the United States

CONTEXT

The potential for hepatitis B and C virus (HBV/HCV) transmission in nail salons and barbershops has been reported, but a systematic review has not been conducted. These businesses are regulated by state cosmetology or barbering boards, but adequacy of sanitary requirements has not been evaluated.

OBJECTIVES

To conduct literature review to assess risk for HBV/HCV transmission in nail salons and barbershops and to evaluate sanitary requirements in HBV/HCV prevention in these businesses in 50 states and District of Columbia.

DESIGN

Several search engines were used for literature search. Studies that quantified risks associated with manicuring, pedicuring, or barbering were included. State requirements for disinfection and sterilization were reviewed and evaluated.

MAIN OUTCOME MEASURE

For literature review, odds ratios, 95% confidence intervals, and confounding adjustment were extracted and evaluated. For regulation review, requirements for disinfection or sterilization for multiuse items in nail salons and barbershops were assessed according to the US federal guidelines.

RESULTS

Forty-six studies were identified and 36 were included in this study. Overall, the results were not consistent on risk for HBV/HCV transmission in nail salons and barbershops. For sanitary requirements, disinfection with an Environmental Protection Agency-registered disinfectant is required in 39 states for nail salons and in 26 states for barbershops. Sterilization was described in 15 states for nail salons and in 11 states for barbershops, but the majority of these states listed it as an optional approach. Sanitary requirements are consistent in states where 1 board regulates both businesses but are substantially discrepant in states with separate boards.

CONCLUSIONS

Current literature cannot confirm or exclude the risk for HBV/HCV transmission in nail salons and barbershops. Existing sanitary requirements are adequate in the majority of states, but compliance is needed to prevent HBV/HCV transmission in these businesses.

Stronger enhancer II/core promoter activities of hepatitis B virus isolates of B2 subgenotype than those of C2 subgenotype

Hepatitis B virus (HBV) genotype C causes prolonged chronic infection and increased risk for liver cancer than genotype B. Our previous work revealed lower replication capacity of wild-type genotype C2 than B2 isolates. HBV DNA replication is driven by pregenomic RNA, which is controlled by core promoter (CP) and further augmented by enhancer I (ENI) and enhancer II (ENII). DNA fragments covering these regulatory elements were amplified from B2 and C2 isolates to generate luciferase reporter constructs. As ENII is fully embedded in CP, we inserted HBV DNA fragments in the sense orientation to determine their combined activities, and in the antisense orientation to measure enhancer activities alone. Genotype B2 isolates displayed higher ENI+ENII+CP, ENII+CP, and ENII activities, but not ENI or ENI+ENII activity, than C2 isolates. The higher ENII+CP activity was partly attributable to 4 positions displaying genotype-specific variability. Exchanging CP region was sufficient to revert the replication phenotypes of several B2 and C2 clones tested. These results suggest that a weaker ENII and/or CP at least partly accounts for the lower replication capacities of wild-type C2 isolates, which could drive the subsequent acquisition of CP mutations. Such mutations increase genome replication and are implicated in liver cancer development.

Hepatitis B virus genotypes: epidemiological and clinical relevance in Asia

Hepatitis B virus (HBV) is characterized by a high genetic heterogeneity since it replicates via a reverse transcriptase that lacks proofreading ability. Up to now, ten genotypes (A-J) have been described, with genotype A and D being ubiquitous but most prevalent in Europe and Africa, genotype B and C being confined to Asia and Oceania. Infections with other genotypes such as E, F, G and H are also occasionally observed in Asia. Genotype I is rare and can be found in Laos, Vietnam, India and China, whereas genotype J has been described in Japan and Ryukyu. Novel variants generated by recombination and co-infection with other genotypes have gradually gotten worldwide attention and may be correlated with certain clinical features. There are substantial differences in HBV infection regarding prevalence, clinical manifestation, disease progression and response to antiviral therapy. Due to the complex interplay among viral, host and environmental factors, the relationship between HBV genotypes and clinical profiles remains incompletely revealed. In general, genotype A is associated with better response to interferon therapy; genotype C, and to lesser extent B, usually represent a risk factor for perinatal infection and are associated with advanced liver diseases such as cirrhosis and hepatocellular carcinoma; genotype D may be linked with poor response to interferon therapy. Future studies with better design and larger sample size are warranted to further clarify the controversial issues and guide the day-to-day clinical practice.

Epidemiology of hepatitis B and associated liver diseases in china

Hepatitis B virus (HBV) infection has long been a critical public health challenge in China. National surveys revealed a prevalence of approximate 10% for chronic HBV infection in general population. HBV has been the leading cause of chronic hepatitis, cirrhosis, and liver cancers in Chinese population and a common pathogen of acute viral hepatitis. Meanwhile, the epidemic provided important opportunities to research the natural history, public health impact, and therapeutic and preventive interventions for HBV in China. In this review, we summarized the selected key epidemiological studies since 1970s regarding HBV infection and its associated liver diseases in China, and provided considerations for future research, prevention and treatment of HBV.

Polymorphisms in sodium taurocholate cotransporting polypeptide are not associated with hepatitis B virus clearance in Chinese Tibetans and Uygurs

An association between polymorphisms in the sodium taurocholate cotransporting polypeptide (NTCP) and the natural course of hepatitis B virus (HBV) infection in the Chinese Han population has been noted. However, it is not known whether these polymorphisms are associated with the risk of developing chronic HBV infection in other racial or ethnic populations. Accordingly, we conducted a candidate single nucleotide polymorphism (SNP) association study in Tibetan and Uygur HBV-infected patients. A total of 1302 subjects including 871 Tibetans and 431 Uygurs were recruited. According to their serological and clinical characteristics, each ethnic group was divided into two groups comprising spontaneous clearance individuals and persistently infected patients. Three SNPs were genotyped by a high resolution melting curve methodology. Among the SNPs, rs2296651 exhibited a minor allele frequency of <0.01. The frequency of allele A at rs4646287 was much higher in Tibetans (9.4% for Tibetans and 4.6% for Uygurs, p<0.001) than in Uygurs, but the frequency of allele A at rs7154439 was the opposite (15.7% for Tibetans and 20.5% for Uygurs, p=0.002). Irrespective of race, no significant differences in the frequency distributions of the three SNP alleles or genotypes were observed between the case and clearance groups. Moreover, none of the NTCP haplotypes were statistically different between the two groups. Data from the Tibetan patients could be grouped by HBeAg status, viral load and HBV genotype; however, no significant differences were found in the SNP genotype distribution for each characteristic. In conclusion, the NTCP polymorphisms we identified tended to be ethnicity-dependent. For Tibetans and Uygurs, no association of the three SNPs (rs7154439, rs4646287 and rs2296651) and their haplotypes with HBV chronicity was observed. Examination of SNPs in NTCP for their specific associations with the course of HBV infection in other ethnic minority groups is now required.

Hepatitis B virus genotype, mutations, human leukocyte antigen polymorphisms and their interactions in hepatocellular carcinoma: a multi-centre case-control study

Three genome-wide association studies (GWAS) have been conducted on the genetic susceptibility of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC), two of which consistently identified tagging single nucleotide polymorphisms (SNPs) around HLA-DQ/DR. In contrast, large multi-centre association studies between HBV genotype, mutations and the risk of HCC are relatively rare, and their interactions with host variants are even less. We performed a multi-centre study of 1,507 HBV-related HCC cases and 1,560 HBV persistent carriers as controls to evaluate the effects of HBV genotype, mutations, GWAS-identified HLA-DQ/DR SNPs (rs9272105 and rs9275319) and their interactions on HCC risk. We found HBV genotype C was more frequent in HBV-related HCC. And 11 HBV hotspot mutations were independently and significantly associated with HCC risk. We also detected significant interactions of rs9272105 with both the HBV genotype and mutations. Through stepwise regression analysis, HBV genotype, the 11 mutations, HLA-DQ/DR SNPs, and the interaction of rs9272105 with mutation A1752G were all entered into the HCC prediction model, and the area under the curve for the panel including the HLA-DQ/DR SNPs, HBV genotype and mutations was 0.840. The HBV genotype, the mutations and the HLA-DQ/DR SNPs may serve as biomarkers for the surveillance of HBV persistent carriers.

Virological Characteristics of Acute Hepatitis B in Eastern India: Critical Differences with Chronic Infection

Hepatitis B Virus (HBV) manifests high genetic variability and is classifiable into ten genotypes (A-J). HBV infection can lead to variable clinical outcomes, ranging from self-limiting acute hepatitis to active chronic hepatitis, cirrhosis and hepatocellular carcinoma. The present study characterizes HBV strains circulating among patients with acute (AHB) and chronic HBV infection (CHB). Among a total of 653 HBsAg positive cases, 40 manifested acute infection. After sequencing the surface(S), basal core promoter/pre-core(BCP/PC) and the X gene regions, phylogenetic tree was constructed using MEGA4 by neighbor-joining method. Statistical robustness was established with bootstrap analysis. Nucleotide diversity was determined by Shannon entropy per site using the Entropy program of the Los Alamos National Laboratories. Analyses of acute patients revealed that HBV/D2 is the major circulating sub-genotype and commonly associated with sexual promiscuity and the age group between15-30 years. Comparison of AHB and CHB patients revealed that HBeAg positivity, ALT levels and genotype D were significantly high in AHB, whereas CHB patients were predominantly male, had a high viral load, and were commonly associated with genotype C. The frequencies of mutations in the S, BCP/PC, and X gene were low in AHB as compared to CHB. Drug resistant mutations were not detectable in the polymerase gene of AHB. Average nucleotide diversity in AHB was considerably low as compared to CHB. Further, the highest average ΔH (average difference in entropy between chronic and acute infection) was observed in the BCP/PC region implying that this region was most vulnerable to mutations upon HBV persistence, especially in case of genotype C. Additionally, among all substitutions, the A1762T and G1764A BCP mutations were the strongest indicators of chronicity. In conclusion, the study exhibits a general portrait of HBV strains circulating among acute hepatitis B patients in Eastern India and their intricate differences with chronic patients which should be useful from the clinical point of view.

Knowledge of and risky behaviours towards hepatitis B virus infection among Egyptian school children

BACKGROUND AND STUDY AIMS

Success in the prevention of hepatitis B virus (HBV) depends to a large extent on the adolescents' HBV knowledge and their risky behaviours. This study aims to assess the knowledge of and the risky behaviours towards HBV among school students and to determine the significant predictors affecting their knowledge.

PATIENTS AND METHODS

A cross-sectional study was approved in four Egyptian governorates (Dakahleya, Gharbeya, Cairo, and Beni-Suef) on 574 students aged 11-17years. A questionnaire was filled through a face-to-face interview to collect data about the socio-demographic character, HBV knowledge, and risky behaviours among children who were chosen for this study.

RESULTS

While 75% of students had poor levels of HBV knowledge, 1.7% had good levels of knowledge. As regards gender, more than 60% of students shared scissors and went to dental clinic with no significant difference. While boys reported a significant history of hospitalisation (50.2%) and wound stitches (36%), girls reported a lesser degree of the same (40.2% and 22.6, respectively), p<0.01. During logistic regression analysis, the most important predictors of poor HBV knowledge were age <15years and living in Cairo governorate, with adjusted odds ratio (AOR) 1.5 and 5.0, respectively.

CONCLUSION

The majority of students chosen for the study had low levels of knowledge and high risky behaviours towards viral hepatitis. In order to minimise the risky behaviours among adolescents, health education programmes should be conducted concerning the mode of transmission and prevention of viral hepatitis.

Phosphatase and tensin homologue genetic polymorphisms and their interactions with viral mutations on the risk of hepatocellular carcinoma

Background:

Chronic hepatitis B virus (HBV) infection is the major cause of hepatocellular carcinoma (HCC). Some HBV mutants and dysregulation of phosphatase and tensin homolog (PTEN) may promote the development of HCC synergistically. We aimed to test the effects of PTEN genetic polymorphisms and their interactions with important HBV mutations on the development of HCC in HBV-infected subjects.

Methods:

Quantitative polymerase chain reaction was applied to genotype PTEN polymorphisms (rs1234220, rs2299939, rs1234213) in 1012 healthy controls, 302 natural clearance subjects, and 2011 chronic HBV-infected subjects including 1021 HCC patients. HBV mutations were determined by sequencing. The associations of PTEN polymorphisms and their interactions with HBV mutations with HCC risk were assessed using multivariate logistic regression analysis.

Results:

Rs1234220 C allele was significantly associated with HCC risk compared to healthy controls (adjusted odds ratio [AOR] = 1.35, 95% confidence interval [CI] = 1.07–1.69) and HCC-free HBV-infected subjects (AOR = 1.27, 95% CI = 1.01–1.57). rs1234220 C allele was significantly associated with increased frequencies of HCC-risk A1652G, C1673T, and C1730G mutations in genotype B HBV-infected subjects. Rs2299939 GT genotype was inversely associated with HCC risk in HBV-infected patients (AOR = 0.75, 95% CI = 0.62–0.92). The interaction of rs2299939 variant genotypes (GT+TT) with A3054T mutation significantly increased HCC risk (AOR = 2.41, 95% CI = 1.08–5.35); whereas its interaction with C3116T mutation significantly reduced HCC risk (AOR = 0.34, 95% CI = 0.18–0.66). These significant effects were only evident in males after stratification.

Conclusions:

PTEN polymorphisms and their interactions with HBV mutations may contribute to hepatocarcinogenesis in males. The host-virus interactions are important in identifying HBV-infected subjects who are more likely to develop HCC.

Characterization of Acute and Chronic Hepatitis B Virus Genotypes in Canada

Objective

The prevalence and distribution of hepatitis B virus (HBV) genotypes in Canada is not known. Genotypic analysis may contribute to a better understanding of HBV strain distribution and transmission risk.

Methods

HBV surface antigen (HBsAg) positive samples of acute (n = 152) and chronic (n = 1533) HBV submitted for strain analysis or reference genotype testing between 2006 and 2012 were analyzed. The HBsAg coding region was amplified to determine the HBV genotype by INNO-LiPA assay or sequence analysis. Single and multivariate analyses were used to describe genotypes’ associations with known demographic and behavioral risk factors for 126 linked cases of acute HBV.

Results

Nine genotypes were detected (A to I), including mixed infections. Genotype C (HBV/C) dominated within chronic infections while HBV/D and A prevailed among acute HBV cases. History of incarceration and residing with a chronic HBV carrier or injection drug user were the most frequently reported risks for acute HBV infection. Over time, HBV/A increased among both acute and chronic infections, and HBV/C and HBV/D decreased among chronic infections.

Conclusion

Chronic and acute HBV genotypes in Canada differ in the relative distribution and their associations with known risk factors, suggesting different routes of transmission and clinical progression of infection.

Is mother-to-infant transmission the most important factor for persistent HBV infection?

Of the infants born to hepatitis B surface antigen (HBsAg)-positive mothers globally, 42.1% who did not receive hepatitis B virus (HBV) passive-active immunoprophylaxis and 2.9% of infants who received the immunoprophylaxis acquired HBV infection perinatally. Moreover, perinatal infection occurred in 84.2% (18.8%-100%) and 8.7% (0.0-21.0%) of infants born to hepatitis B e-antigen (HBeAg)-positive mothers who did not and did receive immunoprophylaxis, respectively; by contrast, the infection rates were 6.7% (0.0-15.4%) and 0.4% (0.0-2.5%) for infants born to HBeAg-negative-carrier mothers, respectively. The chronicity rates of HBV infection acquired perinatally were 28.2% (17.4%-33.9%) in infants born to HBeAg-negative mothers and 64.5% (53.5%-100%) in infants born to HBeAg-positive mothers. HBV mother-to-child transmission was more frequent in East Asia relative to other areas. In addition to differences in the endemic HBV genotype, the interchange of allelic dominance in genetic polymorphisms in HLA class II and NF-κB between the Chinese and European populations may explain why chronic HBV infection frequently affects the Chinese. The risk of progressing into chronic infection was inversely related to the age of children at the time of horizontal transmission. To further diminish HBV chronic infection, it is necessary to enforce antiviral treatment after the 28th week of gestation for HBeAg-positive mothers and to improve the health habits of carrier mothers and household sanitary conditions.

Genotypes and viral variants in chronic hepatitis B: A review of epidemiology and clinical relevance

The Hepatitis B Virus (HBV) has a worldwide distribution and is endemic in many populations. It is constantly evolving and 10 genotypic strains have been identified with varying prevalences in different geographic regions. Numerous stable mutations in the core gene and in the surface gene of the HBV have also been identified in untreated HBV populations. The genotypes and viral variants have been associated with certain clinical features of HBV related liver disease and Hepatocellular carcinoma. For example Genotype C is associated with later hepatitis B e antigen (HBeAg) seroconversion, and more advanced liver disease. Genotype A is associated with a greater risk of progression to chronicity in adult acquired HBV infections. Genotype D is particularly associated with the precore mutation and HBeAg negative chronic hepatitis B (CHB). The genotypes prevalent in parts of West Africa, Central and South America, E, F and H respectively, are less well studied. Viral variants especially the Basal Core Promotor mutation is associated with increased risk of fibrosis and cancer of the liver. Although not currently part of routine clinical care, evaluation of genotype and viral variants may provide useful adjunctive information in predicting risk about liver related morbidity in patients with CHB.

Somatic mutations, viral integration and epigenetic modification in the evolution of hepatitis B virus-induced hepatocellular carcinoma

Liver cancer in men is the second leading cause of cancer death and hepatocellular carcinoma (HCC) accounts for 70%-85% of the total liver cancer worldwide. Chronic infection with hepatitis B virus (HBV) is the major cause of HCC. Chronic, intermittently active inflammation provides “fertile field” for “mutation, selection, and adaptation” of HBV and the infected hepatocytes, a long-term evolutionary process during HBV-induced carcinogenesis. HBV mutations, which are positively selected by insufficient immunity, can promote and predict the occurrence of HCC. Recently, advanced sequencing technologies including whole genome sequencing, exome sequencing, and RNA sequencing provide opportunities to better under-stand the insight of how somatic mutations, structure variations, HBV integrations, and epigenetic modifications contribute to HCC development. Genomic variations of HCC caused by various etiological factors may be different, but the common driver mutations are important to elucidate the HCC evolutionary process. Genome-wide analyses of HBV integrations are helpful in clarifying the targeted genes of HBV in carcinogenesis and disease progression. RNA sequencing can identify key molecules whose expressions are epigenetically modified during HCC evolution. In this review, we summarized the current findings of next generation sequencings for HBV-HCC and proposed a theory framework of Cancer Evolution and Development based on the current knowledge of HBV-induced HCC to characterize and interpret evolutionary mechanisms of HCC and possible other cancers. Understanding the key viral and genomic variations involved in HCC evolution is essential for generating effective diagnostic, prognostic, and predictive biomarkers as well as therapeutic targets for the interventions of HBV-HCC.