Occult hepatitis B virus infection in Egypt

The emerging evidence of the potentially clinical importance of occult hepatitis B virus (HBV) infection (OBI) increases the interest in this topic. OBI may impact in several clinical contexts, which include the possible transmission of the infection, the contribution to liver disease progression, the development of hepatocellular carcinoma, and the risk of reactivation. There are several articles that have published on OBI in Egyptian populations. A review of MEDLINE database was undertaken for relevant articles to clarify the epidemiology of OBI in Egypt. HBV genotype D is the only detectable genotype among Egyptian OBI patients. Higher rates of OBI reported among Egyptian chronic HCV, hemodialysis, children with malignant disorders, and cryptogenic liver disease patients. There is an evidence of OBI reactivation after treatment with chemotherapy. The available data suggested that screening for OBI must be a routine practice in these groups of patients. Further studies needed for better understand of the epidemiology of OBI among Egyptian young generations after the era of hepatitis B vaccination.     

The role of transplacental hepatitis B core antibody in the mother-to-infant transmission of hepatitis B virus

Aims/Methods: To investigate the influence of transplacental hepatitis B core antibody (anti-HBc) on perinatal hepatitis B virus (HBV) transmission, we studied the anti-HBc titers in 294 mother-neonate pairs.Results: The anti-HBc titer was highest (10^5.13±0.80 to 10^4.36±0.97 in mothers, 10^5.13±0.76 to 10^5.52±0.98 in infants) in the 200 hepatitis B e antigen (HBeAg) positive hepatitis B surface antigen (HBsAg) carrier mothers and their infants, second highest (10^4.51±0.76 and 10^4.68±0.76) in the 60 HBeAg-negative HBsAg carrier mothers and their infants, and lowest (10^3.11±0.76 and 10^3.24±0.83) in the 34 non-carrier mothers and their infants (p<0.05). One hundred and ninety-two infants of HBeAg-positive carrier mothers received hepatitis B immunoglobulin as well as hepatitis B vaccines, and were followed prospectively from birth. Ten infants became HBsAg carriers, and their mothers had significantly lower anti-HBc titers than those of the mothers of 182 infants who did not become carriers (p=0.003), while maternal serum hepatitis B virus DNA levels (29.9±23.6 versus 39.9±58.1 pg/10 ml) did not differ in those two gruops (p>0.25). The same trend was observed in the infants' anti-HBc titers in those two groups (p=0.0006).Conclusions: The association of lower anti-HBc titers in HBeAg-positive carrier mother-infant pairs and the development of carrier status in the infants suggests a positive role of anti-HBc in the modulation of mother-to-infant transmission of HBV. A high maternal anti-HBc level in serum may be a negative predictor of immunoprophylaxis failure in high-risk infants.     

Novel insights in the prevention of perinatal transmission of hepatitis B

Perinatal transmission of hepatitis B virus(HBV) infection is major contributor to the growing burden of chronic hepatitis B worldwide. Administration of HBV immunoglobulin and HBV vaccination as soon after pregnancy as possible are the mainstay of prevention of perinatal transmission of HBV infection. In women with high viral loads, antiviral prophylaxis also appears to be useful. Lamivudine, telbivudine and tenofovir have been shown to be both safe and effective in this setting but tenofovir is the first-line option due to its low potential for resistance and more favorable safety profile.     

A nested case-control study of maternal-neonatal transmission of hepatitis B virus in a Chinese population

AIM:To examine the determinants of maternal-neonatal transmission of hepatitis B virus(HBV) METHODS:A nested case-control study was conducted in Changsha,Hunan,People's Republic of China from January 1,2005 to September 31,2006 To avoid potential maternal blood contamination,we collected vein blood of newborns immediately after birth and before initial hepatitis B vaccination to determine the HBV infection status of the newborn For each HBsAg-positive infant,one HBsAg-negative infant born to an HBsAg-positi...     

Diagnostic strategy for occult hepatitis B virus infection

In 2008,the European Association for the study of the liver(EASL) defined occult hepatitis B virus infection (OBI) as thepresence of hepatitis B virus(HBV) DNA in the liver(with detectable or undetectable HBV DNA in the serum) of individuals testing hepatitis B surface antigen(HBsAg) negative by currently available assays.Several aspects of occult HBV infection are still poorly understood,including the definition itself and a standardized approach for laboratory-based detection,which is the purpose of this ...     

Genetic variation of occult hepatitis B virus infection

Occult hepatitis B virus infection(OBI), characterized as the persistence of hepatitis B virus(HBV) surface antigen(HBs Ag) seronegativity and low viral load in blood or liver, is a special form of HBV infection. OBI may be related mainly to mutations in the HBV genome, although the underlying mechanism of it remains to be clarified. Mutations especially within the immunodominant "α" determinant of S protein are "hot spots" that could contribute to the occurrence of OBI via affecting antigenicity and immunogenicity of HBs Ag or replication and secretion of virion. Clinical reports account for a large proportion of previous studies on OBI, while functional analyses, especially those based on full-length HBV genome, are rare.     

预防HBV母婴传播中值得注意的几个问题

母婴传播是HBV的主要传播途径,特别是高地方性流行地区。婴儿出生时注射乙型肝炎免疫球蛋白和乙型肝炎疫苗,并随后完成全程接种,可预防约95%HBsAg阳性母亲将HBV传播给其婴儿,但仍可有5%~10%高水平病毒血症母亲的婴儿为免疫预防失败。现已证明,在孕晚期给予高病毒载量孕妇核苷和核苷酸类药物抗病毒治疗,可进一步降低HBV母婴传播。本文讨论了抗病毒治疗预防母婴传播的标准,包括孕妇HBV DNA的阈值、开始治疗时间、停药时间、用药种类,以及乙型肝炎疫苗的接种途径等值得注意的几个问题。     

Missed opportunities for prevention of perinatal transmission of hepatitis B: A retrospective cohort study

BACKGROUND:

Perinatal transmission of hepatitis B virus (HBV) can occur despite postexposure prophylaxis (PEP). Recent literature suggests that antiviral treatment during pregnancy when maternal HBV DNA levels are elevated can further decrease vertical transmission. However, HBV DNA screening is not routinely performed antenatally.

OBJECTIVE:

To determine the rates of HBV prevalence and perinatal transmission in an antenatal cohort.

METHODS:

A retrospective review of public health records (December 2008 to December 2010) was performed for both mothers and newborns.

RESULTS:

A total of 725 mother-infant pairs were included. Of these, 574 of 715 (80%) women had antenatal hepatitis B e antigen (HBeAg) testing performed, and 127 of 574 (22%) were HBeAg positive (HBeAg+). Of babies born to hepatitis B surface antigen-positive (HBsAg+) mothers, only 573 of 725 (79%) received complete PEP. In addition, 172 of 725 (24%) infants did not receive post-PEP blood testing or were lost to follow-up. Of the 552 infants with results available, seven cases (1.3%) of mother-to-child HBV transmission were observed, six of which involved infants born to HBeAg+ women.

CONCLUSIONS:

Our findings suggest that routine HBeAg screening could identify a subset of mother-infant pairs among HBsAg+ pregnant women who are at higher risk for vertical HBV transmission. Determination of viral load in expectant HBeAg+ mothers may provide more precise insight into HBV transmission to their infants.     

Relationship of hepatitis B virus infection of placental barrier and hepatitis B virus intra-uterine transmission mechanism

AIM： To explore the mechanism of intra-uterine transmission, the HBV infection status of placental tissue and in vitro cultured placental trophoblastic cells was tested through in vivo and in vitro experiments. METHODS： A variety of methods, such as ELISA, RT- PCR, IHC staining and immunofluorescent staining were employed to test the HBV marker positive pregnant women＇s placenta and in vitro cultured placental trophoblastic cells. RESULTS： The HBV DNA levels in pregnant women＇s serum and fetal cord blood were correlated. For those cord blood samples positive for HBV DNA, their maternal blood levels of HBV DNA were at a high level. The HBsAg IHC staining positive cells could be seen in the placental tissues and the presence of HBV DNA detected. After coincubating the trophoblastic cells and HBV DNA positive serum in vitro, the expressions of both HBsAg and HBV DNA could be detected. CONCLUSION： The mechanism of HBV intra-uterine infection may be due to that HBV breaches the placental barrier and infects the fetus.     

不同剂量乙肝免疫球蛋白联合乙肝疫苗阻断乙肝病毒母婴传播的疗效比较

目的比较不同剂量乙肝免疫球蛋白(HBIG)联合乙肝疫苗阻断乙肝病毒母婴传播的疗效。方法将HBs Ag阳性孕妇分娩的新生儿124例分为双阳组60例和单阳组64例。双阳组按家长的意愿分为双阳大剂量组30例和双阳小剂量组30例,单阳组亦分为单阳大剂量组和单阳小剂量组各32例。新生儿出生后6 h内,大剂量组予肌注HBIG 200 U,小剂量组予肌注HBIG 100 U;同时联合应用乙肝疫苗。一周岁时检测HBV血清学标志物(乙肝五项)。结果在双阳组中大剂量和小剂量HBIG的乙肝母婴阻断率分别为93.3%和83.3%;在单阳组中大剂量和小剂量HBIG的乙肝母婴阻断率分别为100.0%和96.9%,差异无统计学意义(P0.05)。结论孕妇HBs Ag阳性时,新生儿出生后要及时注射HBIG,用量100 U或200 U均可。     

Prediction of occult hepatitis B virus infection in liver transplant donors through hepatitis B virus blood markers

Background

Occult hepatitis B virus infection is defined as detectable HBV-DNA in liver of HBsAg-negative individuals, with or without detectable serum HBV-DNA. In deceased liver donors, results of tissue analysis cannot be obtained prior to allocation for liver transplantation.

Aims

we investigated prevalence and predictability of occult hepatitis B using blood markers of viral exposure/infection in deceased liver donors.

Methods

In 50 consecutive HBsAg-negative/anti-HBc-positive and 20 age-matched HBsAg-negative/anti-HBc-negative donors, a nested-PCR assay was employed in liver biopsies for diagnosis of occult hepatitis B according to Taormina criteria. All donors were characterized for plasma HBV-DNA and serum anti-HBs/anti-HBe.

Results

In liver tissue, occult hepatitis B was present in 30/50 anti-HBc-positive (60%) and in 0/20 anti-HBc-negative donors (p < 0.0001). All anti-HBc-positive donors with detectable HBV-DNA in plasma (n = 5) or anti-HBs > 1,000 mIU/mL (n = 5) eventually showed occult infection, i.e, 10/30 occult hepatitis B-positive donors which could have been identified prior to transplantation. In the remaining 40 anti-HBc-positive donors, probability of occult infection was 62% for anti-HBe-positive and/or anti-HBs ≥ 58 mIU/mL; 29% for anti-HBe-negative and anti-HBs < 58 mIU/mL.

Conclusions

In deceased donors, combining anti-HBc with other blood markers of hepatitis B exposure/infection allows to predict occult hepatitis B with certainty and speed in one third of cases. These findings might help refine the allocation of livers from anti-HBc-positive donors.     

乙型肝炎病毒垂直传播机制的研究进展

垂直传播是乙型肝炎病毒(HBV)的主要传播途径之一。狭义的垂直传播,指患者的生殖细胞受病毒感染,在受精时由精子或卵细胞作为载体,将病毒基因带入胚胎进而使子代患病。迄今为止,文献中提到的垂直传播多指广义的垂直传播,即感染HBV的父亲和(或)母亲与婴儿之间,经生殖细胞、宫内感染、分娩及产后接触等途径所实现的HBV传播。     

胎盘滋养层细胞的乙型肝炎病毒感染与宫内感染机制

目的：检测HBV对胎盘、胎肝和滋养层细胞的感染情况，探讨HBV的宫内感染机制。方法：研究对象包括20例孕妇胎盘组织、6例引产胎儿胎肝组织及体外培养的胎盘滋养层细胞。ELISA法检测孕妇外周血、胎儿脐血和6个月婴儿外周血HBV标志物；荧光定量PCR法检测血清和滋养层细胞中的HBV DNA；免疫组织化学法和免疫荧光法检测胎盘、胎肝组织及滋养层细胞中HBV标志物的表达；末端脱氧核糖核酸转移酶介导的缺口标记法（TUNEL）检测胎盘和滋养层细胞凋亡情况。结果：孕妇血清HBV DNA水平与胎儿脐血HBV DNA水平相关，脐血HBV DNA阳性者其母血HBV DNA〉1.0×10^7拷贝／mL；6例胎盘组织和3例引产胎儿胎肝组织中可见HBsAg免疫组织化学染色阳性细胞，其中1例胎肝组织中发现HBcAg阳性细胞；体外培养滋养层细胞与HBV DNA阳性血清共孵育后，可检测到HBsAg的表达，亦可检测到HBV DNA。体内和体外实验均检测到HBV感染后滋养层细胞凋亡呈增加趋势，且胎盘细胞的凋亡与脐血HBV DNA水平相关。体外实验结果显示，随感染时间的延长，滋养层细胞凋亡呈增加趋势。6个月后，12例新生儿有1例血清HBsAg、HBeAg和抗-HBc阳性，6例抗-HBs阳性。结论：HBV宫内感染的机制可能是通过HBV感染胎盘屏障而使胎儿发生HBV宫内感染。HBV在胎儿组织器官内的定位和复制可能是新生儿发生慢性HBV感染的重要因素。滋养层细胞凋亡可能是胎盘屏障阻断HBV宫内传播的一种保护性机制。     

隐匿性乙型肝炎病毒感染者血清表面抗体性质鉴定

目的 了解隐匿性HBV感染者抗-HBs的特性及其与HBsAg的结合能力.方法 对2例抗-HBs阳性的隐匿性HBV感染者进行长期随访,使用多种试剂盒对患者血清进行多次HBsAg检测,利用不同血清型HBsAg对患者血清进行中和反应,了解血清中抗体亚型情况.PCR扩增S基因构建真核表达质粒,分析S基因变异情况,并将质粒转染HepG2细胞,取培养上清液及转染细胞分别混合进行HBsAg检测.使用患者血清及抗-HBs阳性血清(对照组)对部分HBsAg阳性克隆上清液进行中和反应.不同组间数据比较采用t检验.结果 多种试剂盒进行的多次检测结果均表明患者血清HBsAg为阴性;HBsAg的3种不同血清型(adr、adw、ay)均能够中和患者血清中大部分抗-HBs(82.1%～100.0%).S基因序列分析表明核苷酸同源性和氨基酸同源性分别为95.13%～97.79%和92.04%～95.58%;培养上清液和转染细胞裂解液中HBsAg定量分别为对照组的48.1%和59.3%,上清液/细胞裂解液比值分别为0.85和0.38.中和试验结果显示转染上清液中HBsAg定量较混合前有所降低,但是仍然可以检测到,而对照组检测不到HBsAg,差异均有统计学意义(F值分别为353.6和645.2,P值均<0.01).结论 抗-HBs阳性隐匿性HBV感染者体内HBsAg的抗原性及分泌能力有所下降,抗HBs主要针对不同血清型HBsAg的共同表位,但可能与疫苗注射产生的抗-HBs有所不同.

Abstract：

Objective To investigate the properties of HBsAb in occult hepatitis B virus infection and its affinity to different serotypes of hepatitis B virus surface antigen (HBsAg). Methods Long-term follow-up was conducted in 2 HBsAb positive patients with occult hepatitis B virus infection. HBsAg was detected using multiple diagnostic kits and the HBsAb subtype was determined by performing neutralization experiments with different serotypes of HBsAg. The viral S gene was PCR-amplified and mutation analysis was conducted. Plasmids expressing HBsAgs were constructed by inserting these PCR products into an eukaryotic expression vector and were then transfected into HepG2 cells. The cell culture supernatant and cellular extracts were detected for HBsAg respectively. Neutralization experiments were carried out in the cell culture supernatant from HBsAg plasmids transfected HepG2 cells and serum samples from these patients and others who had been confirmed to be positive for HBsAb. Results Multiple tests using various diagnostic kits showed that the 2 patients were negative for HBsAg and the three different serotypes of HBsAg (adr, adw, ay) could neutralize 82.1%-100% of HBsAb existed in the 2 patients. Sequence analysis of S gene cloned from these patients revealed that the homology to reference strain were 95.13%-97.79% and 92.04%-95.58% respectively at the nucleotide and amino acid levels. Quantitation of HBsAg showed that the expression levels of HBsAg from the two patients were 41.1% and 22.6% respectively of that of control HBsAg in cell culture supernatant and 48.1% and 59.3% respectively in cellular extract, and the supernatant/cell lysate ratios were 0.85 and 0.38 respectively. In neutralization experiments, HBsAg could be totally absorbed by control serum, whereas could only be partially neutralized by HBsAbs from the two patients (F = 353.6 and 645.2, P < 0.01). Conclusion Both the antigenicity and the ability of HBsAg secreted outside of the cells are decresed in these HBsAb-positive patients with occult HBV infection. The HBsAbs are mainly specific for common epitopes among different serotypes of HBsAg and are probably different as compared with those produced by vaccine inoculation.     

对中国乙型肝炎病毒母婴传播防治指南(2019年版)的商榷

中华医学会感染病学分会和GRADE中国中心最近发布了《中国乙型肝炎病毒母婴传播防治指南(2019年版)》。该指南存在参考文献引用不当,对预防乙型肝炎病毒母婴传播的部分关键策略缺乏推荐意见,部分推荐意见证据不足或缺乏证据等问题。本着学术争鸣原则,现对该指南提出一些管见,愿与作者和读者商榷。     

Measurement of hepatitis B virus core-related antigen as predicting factor for relapse after cessation of lamivudine therapy for chronic hepatitis B virus infection

Background

Prolonged lamivudine therapy has two major problems: breakthrough hepatitis during treatment and relapse of aminotransferase (ALT) after cessation of the therapy. The aim of this study was to examine factors that could predict ALT flare after stopping lamivudine therapy.

Methods

We analyzed 22 Japanese patients with chronic hepatitis B infection, in whom lamivudine therapy was stopped after HBV DNA level had been gone undetectable (<3.7 LGE/ml) during at least six consecutive months. The post-treatment followed up was carried for 28 months in median (range 9–41). HBV core-related antigen (HBcrAg) assay was assessed using newly developed assay.

Results

After cessation of lamivudine therapy, 11 patients (50%) had relapsed (reactivation of serum ALT >80 IU/l, relapsers) and remaining 11 (50%) did not relapse (non-relapsers). In the univariate comparison of relapsers versus non-relapsers, HBcrAg level at lamivudine cessation point (4.5 ± 1.0 versus 3.4 ± 0.9; p = 0.0145) has been shown as a significant predictive factor for non-relapse. All patients with HBcrAg <3.0 log U/ml at the cessation point had no ALT flares. Multivariate analysis on effects of 10 factors (age, sex, cirrhosis, pretreatment ALT level, HBV DNA level, HBcrAg level, mean months till undetectable HBV DNA, duration of undetectable HBV DNA and HBcrAg level at lamivudine cessation point), indicated that HBcrAg level at lamivudine cessation point <3.4 log U/ml was the only independent predictive factor for absence of the post-treatment relapse.

Conclusions

HBcrAg level at lamivudine cessation point might be useful as a prognostic predictor of response to lamivudine therapy cessation. The measurement of HBcrAg is a useful additional test for monitoring chronic HBV infection.     

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

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

HBsAg阳性的1355名孕妇乙型肝炎病毒母婴传播的随访调查

目的 观察HBsAg阳性孕妇所分娩婴儿的HBV感染情况.方法 前瞻性收集血清HBsAg阳性孕妇1355名及其所分娩的新生儿1360名(包括5名双胎)的资料,所有新生儿均于出生6h内注射乙型肝炎免疫球蛋白200U,并按0-1-6方案接种重组酵母乙型肝炎疫苗10μg,随访新生儿至12月龄,检测0、7、12月龄婴儿外周血HBV血清学标志物和HBV DNA定量.定量资料采用t检验,定性资料采用卡方检验、秩和检验或Fisher确切概率法.结果 1360名婴儿随访至12月龄时,21名发生HBV感染,总的宫内感染率为1.54％.其中母亲为HBeAg阳性者的宫内感染率为4.44％,HBeAg阴性者未发生宫内感染(x2=35.99,P＜0.05);母亲为HBV DNA阳性者的宫内感染率为3.13％,阴性者也未发生宫内感染(x2=21.84,P＜0.05).母亲血清HBV DNA≥1×107IU/mL者的宫内感染率为6.01％,较HBV DNA＜1×107IU/mL者明显升高(x2=39.43,P＜0.05).结论 新生儿经严格的主-被动联合免疫后,仍存在HBV的宫内感染.其中母亲为HBeAg阳性者及HBV DNA高复制水平者的宫内感染率明显增高;宫内感染是导致HBV母婴传播免疫阻断失败的主要原因.