Clinical characteristics and current management of hepatitis B and C in China

Overview of Hepatitis B Vaccine Non-Response and Associated B Cell Amnesia: A Scoping Review

BACKGROUND

The advent of the hepatitis B vaccine has achieved tremendous success in eradicating and reducing the burden of hepatitis B infection, which is the main culprit for hepatocellular carcinoma-one of the most fatal malignancies globally. Response to the vaccine is achieved in about 90-95% of healthy individuals and up to only 50% in immunocompromised patients. This review aimed to provide an overview of hepatitis B vaccine non-response, the mechanisms involved, B cell amnesia, and strategies to overcome it.

METHODS

Databases, including Google Scholar, PubMed, Scopus, Cochrane, and ClinicalTrials.org, were used to search and retrieve articles using keywords on hepatitis B vaccine non-response and B cell amnesia. The PRISMA guideline was followed in identifying studies, screening, selection, and reporting of findings.

RESULTS

A total of 133 studies on hepatitis B vaccine non-response, mechanisms, and prevention/management strategies were included in the review after screening and final selection. Factors responsible for hepatitis B vaccine non-response were found to include genetic, immunological factors, and B cell amnesia in healthy individuals. The genetic factors were sex, HLA haplotypes, and genetic polymorphisms in immune response markers (cytokines). Non-response was common in conditions of immunodeficiency, such as renal failure, haemodialysis, celiac disease, inflammatory bowel disease, hepatitis C co-infection, and latent hepatitis B infection. Others included diabetes mellitus and HIV infection. The mechanisms involved were impaired immune response by suppression of response (T helper cells) or induced suppression of response (through regulatory B and T cells).

DISCUSSION

A comprehensive and careful understanding of the patient factors and the nature of the vaccine contributes to developing effective preventive measures. These include revaccination or booster dose, vaccine administration through the intradermal route, and the use of adjuvants in the vaccine.

Progression of liver fibrosis and associated factors among chronic hepatitis B patients at a general hospital in Northern Vietnam

Evaluation of liver fibrosis is necessary to make the therapeutic decision and assess the prognosis of CHB patients. The current study aimed to describe the progression and identify some influencing factors in patients with chronic hepatitis B at a General Hospital in Northern Vietnam. The longitudinal study included 55 eligible subjects diagnosed Hepatitis-B-virus. Dependent variable was the aspartate aminotransferase/platelet ratio index and we collected some demographic variables and disease related and behaviour variables. Bayesian Model Averaging was used to select variables into model. Mixed-effect linear models were used to evaluate the change of the aspartate aminotransferase/platelet ratio index over time and identify related factors. the aspartate aminotransferase/platelet ratio index differences between examinations, age of participants, working status were statistically significant. This pattern indicated that the average the aspartate aminotransferase/platelet ratio index of the population decreased by 0.005 (95% CI=-0.009; -0.001) after each patient's visit, and increased by 0.013 if the patient's age increased by 1 year (95% CI=0.005; 0.0219). For non-working patients, the aspartate aminotransferase/platelet ratio index was lower, coefficient was -0.054 (95% CI=-0.108; 0.001). Other variables such as gender, education level, time for disease detection, drinking tea, alcohol consumption, forgetting to take medicine and the aspartate aminotransferase/platelet ratio index were not significantly different. The study showed that the majority of study subjects had average the aspartate aminotransferase/platelet ratio index, and were relatively well controlled and treated during the study. Age and working status are factors that influence the the aspartate aminotransferase/platelet ratio index.

Estimating the proportion of people with chronic hepatitis B virus infection eligible for hepatitis B antiviral treatment worldwide: a systematic review and meta-analysis

BACKGROUND

In 2016, of the estimated 257 million people living with chronic hepatitis B virus (HBV) infection worldwide, only a small proportion was diagnosed and treated. The insufficiency of information on the proportion of people infected with HBV who are eligible for treatment limits the interpretation of global treatment coverage. We aimed to estimate the proportion of people with chronic HBV infection who were eligible for antiviral treatment worldwide, based on the WHO 2015 guidelines.

METHODS

In this systematic review and meta-analysis, we searched Medline, EMBASE, and the Cochrane databases from Jan 1, 2007, to Jan 31, 2018, for studies describing HBsAg-positive people in the population or health-care facilities. We extracted information from published studies using a standardised form to estimate the frequency of cirrhosis, abnormal alanine aminotransferase (ALT), HBV DNA exceeding 2000 IU/mL or 20 000 IU/mL, presence of HBeAg, and eligibility for treatment as per WHO and other guidelines as reported in the studies. We pooled proportions through meta-analysis with random effects. The study was registered with PROSPERO, CRD42020132345.

FINDINGS

Of the 13 497 studies, 162 were eligible and included in our analysis. These studies included 145 789 participants. The pooled estimate of the proportion of cirrhosis was 9% (95% CI 8-10), ranging from 6% (4-8) in community settings to 10% (9-11) in clinic settings. Examining the proportion of participants who had characteristics used to determine eligibility in the WHO guidelines, 1750 (10·1%) of 17 394 had HBV DNA exceeding 20 000 IU/mL, and 20 425 (30·8%) of 66 235 had ALT above the upper limit of normal. 32 studies reported eligibility for treatment according to WHO or any other guidelines, with a pooled estimate of eligibility at 19% (95% CI 18-20), ranging from 12% (6-18) for studies in community settings to 25% (19-30) in clinic settings.

INTERPRETATION

Many studies described people with HBV infection, but few reported information in a way that allowed assessment of eligibility for treatment. Although about one in ten of the 257 million people with HBV infection (26 million) might be in urgent need of treatment because of cirrhosis, a larger proportion (12-25%) is eligible for treatment in accordance with different guidelines. Future studies describing people with HBV infection should report on treatment eligibility, according to broadly agreed definitions.

FUNDING

WHO and US Centers for Disease Control and Prevention.

Antiviral drug utilization and annual expenditures for patients with chronic HBV infection in Guangzhou, China, in 2008-2015

BACKGROUND

The aims of this study were to describe antiviral drug (AD) utilization and costs in patients with chronic HBV infection.

METHODS

We conducted a retrospective study of patients in the hospital and calculated annual proportions of AD utilization and costs among patients. A two-part model was used to estimate adjusted odds ratio (OR) for antiviral therapy and cost ratios for antiviral costs associated with demographics.

RESULTS

Of a total of 14,920 records, 143,658 records were involved in the analysis. The annual proportions of AD utilization were 56.99% (45.65%) for inpatients (outpatients) during 2008-2015 and increased annually. Entecavir (ETV), in particular, increased from 11.08% to 70.26% (11.05% to 49.35%) for inpatients (outpatients). The patients with medical insurance were more likely to use AD than patients without insurance, and the adjusted OR was 1.11 (95% CI: 1.03, 1.19) for inpatients and 1.66 (1.59, 1.73) for outpatients. With the disease progressing, the proportion of antiviral costs in total direct medical costs decreased from 13.91% to 4.07% (71.29% to 49.29%) for inpatients (outpatients).

CONCLUSIONS

The use of AD for chronic HBV infection was less than expected based on established guidelines, and only half of patients received antiviral treatment. However, the AD utilization, especially ETV, increased annually. Reimbursement policy was the most important factor affecting antiviral treatment. Antiviral therapy was an important part of the direct medical costs, especially in the early stage of disease.

How would China achieve WHO's target of eliminating HCV by 2030?

Introduction: Hepatitis C virus (HCV) infection is a major global health concern on the rise, prompting unprecedented efforts by the World Health Organization (WHO) to eliminate this epidemic by 2030. Being the country with the largest HCV-infected population in the world, China has been faced with a general lack of awareness for HCV, low treatment uptake and subpar collaborations among healthcare providers and stakeholders. Areas covered: This review discusses the epidemiological situations of HCV infection and the challenges in HCV management in China. This review also explores micro-elimination strategies in China, identifying potential sub-populations for concerted efforts in eliminating HCV. As DAAs are increasingly recognized as a more effective alternative to traditional regimens, the cost-effectiveness and budget impacts of bringing more DAAs into the reimbursement lists are also addressed. Several small-scale targeted literature searches were conducted in PubMed for various topics covered in the article, and hand searching was performed to fill any data gaps. More recent data were used wherever possible. Expert opinion: Considering the unique socioeconomical landscape of China, micro-elimination strategies might be more effective and should be targeted at high-risk populations. Varying regional needs in HCV care across the country necessitate decentralized approaches in research and policy-making.

Prevalence of Hepatitis B Virus Infection in Shenzhen, China, 2015-2018

China has nearly 10% of the general HBV carrier population in the world; this infection is the most common cause of chronic liver disease. Understanding HBV epidemiology is essential for future infection control, evaluation, and treatment. This study determined the prevalence of HBV infection in Shenzhen by serological testing and analysis in 282,166 HBV screening cases for the following: HBcAb, indicative of previous HBV infection; HBsAg, indicative of chronic (current) infection; HBsAb, indicative of immunity from vaccination; and 34,368 HBV etiological screening cases for HBV-DNA, indicative of virus carriage, in which 1,204 cases were genotyped and mutation analyzed for drug-resistance evaluation. Shenzhen was a highly endemic area of HBV throughout the study period (prevalence 9.69%). HBV infections were almost entirely in the 20 and older age groups with a male-to-female ratio of 1.16:1 which is approximately the same as the male-to-female ratio of the general population in China. However, only 71.25% of the general population retained HBV immune protection. Genotype B and C were identified as the most common agents; recombinant B/C and B/D also existed; some cases, however, could not be genotyped. NAs resistant mutation occurrence patterns were multitudinous; single mutation patterns of rtM204I/V and rtL180M occurrences accounted for majority, followed by the combinational mutation pattern L180M + M204I/V. Drug-resistance was prevalent, mainly occurring in the cross resistance patterns LAM + LdT and LAM + LdT + ETV, and significantly more critical in males. These results demonstrate that all people free from HBV infection should obtain injections of the vaccine or booster shots, and conventional virologic detection in a clinical laboratory center should incorporate genotype and mutation alongside the serological factors for etiology and develop better classification methods, such as sequencing.

Hepatitis C virus cure with direct acting antivirals: Clinical, economic, societal and patient value for China

About 10 million people in China are infected with hepatitis C virus (HCV), with the seroprevalence of anti-HCV in the general population estimated at 0.6%. Delaying effective treatment of chronic hepatitis C (CHC) is associated with liver disease progression, cirrhosis, hepatocellular carcinoma, and liver-related mortality. The extrahepatic manifestations of CHC further add to the disease burden of patients. Managing CHC-related advanced liver diseases and systemic manifestations are costly for both the healthcare system and society. Loss of work productivity due to reduced well-being and quality of life in CHC patients further compounds the economic burden of the disease. Traditionally, pegylated-interferon plus ribavirin (PR) was the standard of care. However, a substantial number of patients are ineligible for PR treatment, and only 40%-75% achieved sustained virologic response. Furthermore, PR is associated with impairment of patient-reported outcomes (PROs), high rates of adverse events, and poor adherence. With the advent of direct acting antivirals (DAAs), the treatment of CHC patients has been revolutionized. DAAs have broader eligible patient populations, higher efficacy, better PRO profiles, fewer adverse events, and better adherence rates, thereby making it possible to cure a large proportion of all CHC patients. This article aims to provide a comprehensive evaluation on the value of effective, curative hepatitis C treatment from the clinical, economic, societal, and patient experience perspectives, with a focus on recent data from China, supplemented with other Asian and international experiences where China data are not available.

Barriers to the Prevention and Control of Hepatitis B and Hepatitis C in the Community of Southwestern China: A Qualitative Research

Objective viral hepatitis is a big challenge in China. However, few studies have focused on mapping the difficulties from a broader view. This study aimed to identify the barriers to the prevention and control of hepatitis B and hepatitis C in communities from the perspectives of hepatitis patients, residents, and healthcare providers. A total of 26 participants were recruited through purposive sampling. Data were collected by in-depth face-to-face interviews from September 2015 to May 2016 in two communities from Chongqing and Chengdu, China. A thematic framework was applied to analyze the qualitative data from the interviews. The critical factors of barriers to hepatitis prevention and control in the districts included poor cognition of residents regarding hepatitis B and hepatitis C, severe stigma in society, inadequate health education, and the provision of unsatisfactory medical services. Strengthening health education and improving services for treating patients with hepatitis are suggested to make further progress. A substantial gap remains between the need and currently available services for hepatitis patients and residents. Delivering quality prevention and control health services, improving health education, and reducing stigma in society are recommended to improve the prevention and control program for hepatitis B and C in communities.

Antiviral Therapy for AECHB and Severe Hepatitis B (Liver Failure)

This chapter describes the principles of antiviral therapy, treatment strategies, medications and recommendations for AECHB, HBV-ACLF, HBV-related liver cirrhosis, HBV-related HCC, and liver transplantation.

Severe exacerbation of chronic hepatitis B is closely related to continuous HBV replication. Therefore, inhibiting HBV replication to reduce viral load may block disease progression and improve the quality of life of these patients. ETV or TDF has been recommend first-line drug for the treatment of AECHB.

A hyperactive immune response due to continuous HBV replication is the main mechanism for development of severe hepatitis B. In addition to comprehensive treatment, early administration of potent nucleoside analogs can rapidly reduce HBV DNA concentration, relieve immune injury induced by HBV, and reduce liver inflammation and patient mortality. Antiviral agents have become important in the treatment of severe exacerbation of chronic hepatitis B.

Long-term antiviral treatment with nucleoside analogs can delay or reverse the progress of liver cirrhosis. Virologic response, viral resistance and adverse drug reactions should be closely monitored during treatment. The treatment should be optimized for maximum effect based on each patient’s responses.

Effective antiviral therapy can suppress HBV replication and reduce the incidence of HBV-related HCC. Patients with HBV-related HCC should receive individualized and optimal multidisciplinary comprehensive treatment. Anti-viral drugs with high efficacy, low resistance and low adverse drug reactions should be selected to improve the patient’s quality of life and prolong survival time.

Methods to prevent HBV reinfection after liver transplantation include passive immunization (HBIG), antiviral treatment (nucleoside analogs) and active immunization (hepatitis B vaccine).

Clinical trials involving sequential combination therapy with NUC and Peg-IFN have shown statistically significant decline in HBsAg levels on treatment and high rates of sustained post-treatment serologic response. Combination therapy with novel DAA and immunotherapeutic approach may hold promise to overcome both cccDNA persistence and immune escape, representing a critical step towards HBV cure.

Patients with chronic hepatitis C receiving sofosbuvir and ribavirin-based treatment, with or without interferon in Zhejiang, China: An observational study

Hepatitis C virus (HCV) is one of the most important virus as the cause of liver disease in China. The aim of the present study was to explore whether sofosbuvir and ribavirin-based treatment can cure patients with chronic hepatitis C in eastern China. We examined a cohort of HCV-monoinfected patients and 9 patients agreed to participate in our treatment and research. The patients were diagnosed with chronic hepatitis C with or without cirrhosis. Nine patients including 4 female and 5 male met the requirements for selection and were willing to participate in this experiment. Sofosbuvir and ribavirin-based treatment with or without interferon was given to the patients. Viral loads, cytokines, and chemokines were recorded during treatment and after treatment. After 2 weeks of sofosbuvir and ribavirin-based treatment, the viral load of patients decreased to limits of detection. Eight patients were cured. Patients had rapid virological response (RVR) with undetectable viral load at week 4 and sustained virological response (SVR). The interferon-inducible protein-10 (IP-10) decreased after the treatment. However, the patient with cirrhosis failed, as the virus reappeared during SVR4. At the same time, the IP-10 dramatically increased as the relapse of the HCV virus. In summary, the IP-10 has the potential to be the biomarker for the prognostic of HCV.

Epidemiology of hepatitis B and the role of vaccination

Hepatitis B virus (HBV) is a major cause of morbidity and mortality with a disproportionate impact on Asia and Africa. Current guidelines recommend screening at-risk populations for chronic HBV infection so that diagnosed individuals can be linked to appropriate hepatitis care. The vast majority of infected individuals are undiagnosed and untreated, and are at risk of developing cirrhosis, liver failure, and hepatocellular carcinoma. In individuals who are not yet infected, the HBV vaccine is safe and highly effective at preventing disease transmission. Countries with successful vaccination programs have been able to dramatically reduce their HBV prevalence. A concerted effort to screen, treat, and vaccinate at-risk individuals has the potential to eliminate HBV as a public health threat by 2030.

Logistic regression analysis of factors influencing virological response to nucleos(t)ide analog therapy in previously untreated chronic hepatitis B patients

AIM: To investigate the factors influencing virological response to nucleoside analog therapy in previously untreated chronic hepatitis B patients.

METHODS: Two hundred and twelve previously untreated patients with chronic hepatitis B who received nucleos(t)ide analogue monotherapy were enrolled in this study. According to HBV DNA load after 24 wk of treatment, the patients were divided into three groups: patients with complete virological response, those with partial virologic response, and those with primary treatment failure. Logistic regression method was used to analyze the relationship between baseline indicators and virological response.

RESULTS: The choice of nucleos(t)ide analogue (P = 0.008) and sex (P = 0.023) were factors affecting primary treatment failure; ADV was associated a higher rate of primary treatment failure than other three antiviral drugs, and male gender was also associated a higher rate of primary treatment failure. HBeAg status (P = 0.028) and AST/ALT ratio (P = 0.018) were factors affecting partial virological response. HBeAg positivity and higher AST/ALT ratio were associated with a higher rate of partial virological response.

CONCLUSION: The choice of ADV and male gender are associated with a higher rate of primary treatment failure. HBeAg positivity and higher AST/ALT ratio are associated with a higher rate of partial virological response.

Long-term follow-up and suboptimal treatment rates of treatment-eligible chronic hepatitis B patients in diverse practice settings: a gap in linkage to care

Background and aims

Despite available effective therapies, only a minority of patients with chronic hepatitis B (CHB) receive treatment. Our goal is to study treatment rates and time to treatment initiation in patients who meet treatment criteria on long-term follow-up.

Methods

We performed a retrospective cohort study of 608 consecutive treatment-eligible patients with CHB (by 2008 US Panel or 2009 American Association for the Study of Liver Disease (AASLD) criteria) at a US community gastroenterology clinic and a university liver clinic between 2007 and 2011. Patients were observed until they started treatment or last follow-up if untreated.

Results

Mean age was 44 and most were Asian (96%) with community patients being younger and having lower alanine aminotransferase (ALT) levels. A total of 62% started treatment, and 38% remained untreated after median follow-up of 17 months (IQR=1–40 months). Overall, treatment rate was significantly higher at university liver clinic than in the community (66.7% vs 59.9%, p=0.01). In multivariate analysis, older age (HR 1.02, p=0.002), male gender (HR 1.37, p=0.02), and baseline ALT >45 U/L for males and >29 U/L for females (HR 2.24, p<0.0001) were significant predictors of treatment initiation, but not practice setting.

Conclusions

Approximately 40% of treatment-eligible patients still have not started treatment on longer follow-up. Treatment rates were higher at university clinics, but practice setting was not a predictor for treatment, but older age, male gender, and higher ALT levels were. Further studies are needed to determine the barriers for treatment initiation and to improve treatment rates in treatment-eligible patients.

Sustained Changes of Treg and Th17 Cells During Interferon-α Therapy in Patients with Chronic Hepatitis B

Chronic hepatitis B (CHB) is a worldwide infectious disease caused by hepatitis B virus (HBV). HBV mainly damages liver cells through immune response. The purpose of this study was to determine whether there were dynamic changes of Treg and Th17 cells and to judge the value of these indicators to antiviral treatment. Twenty-two CHB patients and selected 30 healthy adults were enrolled. Results showed that the expression of Treg (5.72±0.46 vs. 4.42±0.17, p=0.0019) and Th17 (3.94±0.64 vs. 2.66±3.12, p=0.0436) cells was significantly increased in CHB patients, as well as the level of interleukin-17 (IL-17) (16.88±5.37 vs. 8.59±3.31; p=0.004). Then, we monitored longitudinally the impact of the treatment with interferon-α and found that the suppression of viral replication induced by interferon-α resulted in a decrease in Treg, Th17 cells, and IL-17; we also found that the percentage of Treg and Th17 cells went up without clear evidence of clinical autoimmune disease at the end of treatment. Thus, Treg and Th17 cells might play an important role in interferon-α treatment to eliminate HBV. The level of changes may be served to determine the antiviral efficacy of interferon-α therapy.

Lymphocyte CD64 increased in patients with chronic HBV infection

CD64 was up-regulated in infection diseases, but there was no report about the change of CD64 in chronic hepatitis B virus (HBV) infection. The purpose of this study was to determine whether there was a dynamic change of CD 64 index and to judge the value to antiviral treatment. 96 CHB patients were enrolled and selected 33 healthy adults as control. We detected the level of CD64, found the level of CD64 were significantly increased in chronic HBV infection patients, especially the lymphocyte CD64 (8.12 ± 0.23 vs. 6.25 ± 0.27; P < 0.001). Further, we proved CD64 index was increased in various stages of chronic HBV infection. ROC curve analysis showed the level of lymphocyte CD64 had higher AUC value than neutrophil or monocyte. Then we monitor longitudinally the impact of the treatment with interferon-α and found that the suppression of viral replication induced by interferon-α resulted in a decrease in CD64 index. In conclusion, this study showed that CD64 index was increased in chronic HBV infection patients and changed with the course of disease, the therapy of interferon-α would correct it, and analysis prompted that the level of lymphocyte CD64 would be more suitable for as a biomarker to judge the condition of chronic HBV infection and the curative effect of interferon-α treatment.

Role of the Aspartate Transaminase and Platelet Ratio Index in Assessing Hepatic Fibrosis and Liver Inflammation in Adolescent Patients with HBeAg-Positive Chronic Hepatitis B

This study described an index of aspartate aminotransferase-to-platelet ratio index (APRI) to assess hepatic fibrosis with limited expense and widespread availability compared to the liver biopsy in adolescent patients with CHB.