Hepatitis B virus epidemiology

Bioinformatics and system biology approach to discover the common pathogenetic processes between COVID-19 and chronic hepatitis B

INTRODUCTION

The ongoing coronavirus disease 2019 (COVID-19) pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), presents a significant global public health threat. Concurrently, hepatitis B virus (HBV) remains a significant public health challenge. While previous studies have indicated an association between COVID-19 and chronic hepatitis B, the common underlying pathogenesis of these diseases remains incompletely understood.

METHODS

To investigate the shared molecular mechanisms between chronic HBV infection and COVID-19, a comprehensive investigation was conducted using bioinformatics and systems biology. Specifically, we utilized RNA-seq datasets (GSE196822 and GSE83148) to identify differentially expressed genes (DEGs) associated with both SARS-CoV-2 and HBV infection. Subsequently, these common DEGs were utilized to identify shared pathways, hub genes, transcriptional regulatory networks, and potential drugs. The differential expression of hub genes in both COVID-19 and HBV was verified using the GSE171110 and GSE94660 datasets, respectively.

RESULTS

From the 106 shared DEGs identified, immune-related pathways were found to play a role in the development and progression of chronic hepatitis B and COVID-19. Protein-protein interaction (PPI) network analysis revealed 8 hub genes: CDK1, E2F7, E2F8, TYMS, KIF20A, CENPE, TPX2, HMMR, CD8A, GZMA. In the validation set, the expression of hub genes was statistically significant in both the COVID-19 group and the HBV group compared with the healthy control group. Transcriptional regulatory network analysis identified 155 microRNAs (miRNAs) and 43 transcription factors (TFs) as potential regulatory signals. Notably, we identified potential therapeutic drugs for HBV chronic infection and COVID-19, including progesterone, estradiol, dasatinib, aspirin, etoposide, irinotecan hydrochloride, phorbol 12-myristate 13-acetate, lucanthone, calcitriol.

CONCLUSION

This research elucidates potential molecular targets, signaling pathways, and promising small molecule compounds that could aid in the treatment of chronic HBV infection and COVID-19.

The spatio-temporal trends and determinants of liver cancer attributable to specific etiologies: a systematic analysis from the Global Burden of Disease Study 2021

BACKGROUND

Although liver cancer has varied causes, its evolving epidemiology and causal drivers remain underexplored. This study quantifies the trends and drivers of liver cancer burden attributable to specific causes from 1990 to 2021.

METHODS

Using data from the Global Burden of Disease Study, we extracted prevalence, mortality, and disability-adjusted life years (DALYs) associated with specific causes of liver cancer. We assessed spatio-temporal trends across the sociodemographic index (SDI) and quantified the contributions of epidemiological shifts, population growth, and ageing to DALYs.

RESULTS

In 2021, liver cancer accounted for 0.74 million cases, 0.48 million deaths, and 12.89 million DALYs globally. Average annual percentage changes (AAPCs) in prevalence, mortality, and DALY rates from 1990 to 2021 were 1.17%, 1.04%, and 0.48%, respectively. HBV, HCV, and alcohol use were major contributors to DALYs, accounting for 1.92 million (36.00%), 1.53 million (28.62%), and 1.27 million (23.88%) of the increase, respectively. High-income North America and Western Europe experienced rapid growth in liver cancer prevalence from 1990 to 2021, while High-income North America and Southern Latin America had rapid growth in mortality. Global DALY increases were mainly driven by population growth (3.91 million, 73.29%) and population ageing (3.03 million, 56.86%).

CONCLUSIONS

The study revealed that hepatitis B, hepatitis C, and alcohol consumption were the primary contributors to the increasing DALYs from liver cancer, with population growth and ageing as key drivers of these changes. These findings underscore the importance of considering the major factors and demographic dynamics in addressing the burden of liver cancer when formulating prevention and intervention strategies.

Performance of the AASLD, EASL, and APASL Clinical Practice Guidelines in"grey zone"stages of Chinese patients with chronic hepatitis B

BACKGROUND/OBJECTIVE

Chronic hepatitis B (CHB) patients who do not meet any immunostaging criteria are categorized as the "grey zone" (GZ). However, there are discrepancies in the definition of the GZ in different areas.

AIM

To investigate the prevalence and clinical characteristics of Chinese GZ patients and to validate the application value of three international guidelines.

METHODS

Data from 807 naïve CHB patients with liver biopsies from seven Chinese centres were retrospectively collected. GZ patients were defined and compared across four guidelines: the Chinese guidelines, the American Association for the Study of Liver Diseases (AASLD) guidelines, the European Association for the Study of the Liver (EASL) guidelines, and the Asian Pacific Association for the Study of the Liver (APASL) guidelines.

RESULTS

When the Chinese guidelines were used, 38.79% of patients were categorized into the GZ, 78.91% of whom were indicated for antiviral therapy. The EASL guidelines yielded a greater proportion of GZ patients (50.56%) than did the APSAL (36.68%) and AASLD guidelines (33.21%). The APASL guidelines yielded a lower proportion of GZ patients who were indicated for antiviral therapy (42.57%) than did the AASLD (47.76%) and EASL guidelines (60.54%). According to the AASLD, EASL, APASL and Chinese guidelines, if liver biopsy was not performed, 13.06%, 31.86%, 0% and 64.54% of GZ patients were indicated for antiviral therapy, respectively.

CONCLUSIONS

GZ patients account for a significant proportion of CHB patients, with approximately half of them requiring antiviral therapy.

CLINICAL TRIAL REGISTRATION

NCT06041022.

A review of the progress and challenges of developing dendritic-based vaccines against hepatitis B virus (HBV)

Hepatitis B virus (HBV) infections that last a long time are a significant public health problem worldwide. About 254 million people around the world are chronically sick with HBV. Each year, 1.2 million new cases occur, and in 2022, 1.1 million people will die from the disease. So, it has been essential to work on finding ways to treat and avoid HBV. The process of therapeutic vaccination involves giving people a non-infectious form of a virus to start or improve immune reactions specific to HBV. This helps keep HBV infections under control. Dendritic cells (DCs) play a significant part in beginning the adaptive immune response, which could decide how well an HBV infection is treated. DC-based treatment has been looked into for people with chronic HBV (CHB) infection and has shown some sound effects. Vaccines for CHB that use DCs boost antiviral immunity by improving T cells and breaking the immune system's resistance against HBV. In these vaccines, DCs are loaded with HBV antigens (like HBsAg, HBcAg, or peptides) outside of the body and then put back into the patient to make the immune system work better. In conclusion, this DC treatment is a biological therapy method with a good chance of being used. This study examined the different DC-based medicines that can treat and prevent HBV. Finally, we've talked about clinical studies, the current problems, how to fix them, and the future of this vaccine for treating and preventing HBV.

The insight to history and trends of transient elastography for assessing liver fibrosis-a bibliometric analysis

Background

Transient elastography (TE) has become a prominent technique for the detection of fibrosis, owing to its non-invasive nature, rapid execution, safety, and ease of repetition. This study aims to conduct a bibliometric analysis of the historical development and trends in the application of TE for the assessment of liver fibrosis.

Methods

In the Web of Science (Core Collection database), we selected the Science Citation Index Expanded database to search for relevant literature from 1 January 1983 to 20 November 2023. We performed a search using the following topic words: transient elastography, liver fibrosis. After screening according to the title, abstract and keyword and removing the repetition, the literature included in the study was finally determined, and full records were downloaded. Bibliometric analysis was performed using VOSviewer and CiteSpace.

Results

Through the bibliometric visualization analysis of 577 articles, it was found that since TE was first reported for the measurement of liver fibrosis in 2003, the number of publications in this field has generally shown an upward trend, and the distribution of publications has shown a bimodal distribution, with peaks in 2010 and 2019. France and China have shown a high contribution in this field with a high number of publications. In terms of contributions from individual research centers, Yonsei University stands out prominently. Throughout the history of research in this field, early studies focused on chronic viral hepatitis, by comparing TE and Fibrosis-4, aspartate aminotransferase to platelet ratio index, FibroTest, liver biopsy and other liver fibrosis detection indicators to verify its diagnostic efficacy. Subsequently, the focus of research gradually shifted to non-alcoholic fatty liver disease and other liver diseases, and the scope of research extended to the establishment of prediction models and efficacy evaluation through TE.

Conclusions

The application scope of TE is gradually expanding, and its safety, simplicity, rapidity, high accuracy, quantitative results, repeatability and good tolerance make it popular in clinical practice. Nowadays, the application of TE is not limited to the diagnosis of liver fibrosis, but has been extended to the establishment of prognostic models and efficacy evaluation of various liver diseases. To explore the deeper value of TE through new research methods such as machine learning models, radiate the advantages of TE to more liver diseases, and combine TE with a variety of non-invasive detection indicators to improve its application value, may be the future development and application prospect of TE in the field of liver fibrosis.

Detection of substantial numbers of latent tuberculosis and positive hepatitis B serology results in rheumatology patients preparing to receive intensified immunosuppressive therapy in a low-prevalence country: why screening still matters

INTRODUCTION /OBJECTIVES

International guidelines recommend screening for latent tuberculosis infection (LTBI) and chronic viral hepatitis infections before initiating intensified immunosuppressive therapy. We assessed the prevalence of positive screening tests for LTBI, hepatitis B virus (HBV), and hepatitis C virus (HCV) in patients screened at a large rheumatology outpatient center in Germany.

METHOD

This retrospective cohort study used electronic health records from adult rheumatology patients. The presence of LTBI was evaluated by chest X-rays, patient medical history/self-report, and QuantiFERON®-TB Gold Plus (QFT) interferon-gamma release assays. Antibodies to HBV core antigen (anti-HBc) and HCV were used to assess HBV and HCV, respectively. Statistically significant associations were evaluated by Fisher exact tests.

RESULTS

Of 697 screened patients with a rheumatological condition (61.3% female, mean age 60.0 years), 132 (18.9%) patients were positive for LTBI (99 [14.2%]), anti-HBc (39 [5.6%]), or anti-HCV (3 [0.4%]). Nine patients had more than one positive result; different infections were not significantly associated. QFT detected the most LTBI cases (59.5%) followed by patient report/history (42.4%) and chest X-rays (17.2%). Although most patients (83.8%) were positive on only one test, associations among LTBI tests were statistically significant. Biologic disease-modifying antirheumatic drug (bDMARD) use was lower in patients with a positive LTBI screening result compared with all screened patients (73.7% vs 86.4%) and targeted synthetic DMARD (tsDMARD) use was higher (10.1% vs 5.9%).

CONCLUSIONS

Almost one-fifth of rheumatology patients preparing to initiate intensified immunosuppressive therapy have positive results on screening tests for LTBI or show evidence of exposure to HBV or HCV. These findings support the need for careful screening, even in "low-prevalence" countries.

Hepatitis E Virus Infection in Vietnamese Pregnant Women with Hepatitis B: Prevalence and Clinical Outcomes

Background

Hepatitis E virus (HEV) infection during pregnancy is associated with obstetric complications and adverse maternal and neonatal outcomes. This study aimed to determine the seroprevalence of HEV and RNA positivity in both healthy pregnant women and women coinfected with hepatitis B virus (HBV).

Methods

A cross-sectional study was conducted involving 528 pregnant women (278 with and 250 without hepatitis B surface antigen [HBsAg]) in their third trimester. Anti-HEV specific immunoglobulin (Ig) G and IgM antibodies were tested for using enzyme-linked immunosorbent assay, while HEV RNA was detected by means of nested polymerase chain reaction. The status of anti-HEV antibodies was analyzed regarding pregnancy outcomes and the risks of obstetric complications.

Results

The results indicated that 24% of participants (127 of 528) tested positive for anti-HEV IgG, while 2.5% (13 of 528) showed detectable anti-HEV IgM. Among HBV-positive women, 26% (55 of 250) had anti-HEV IgG, comparable to 22% (61 of 278) in HBV-negative controls. Notably, 28% (140 of 501) of cord blood samples were positive for anti-HEV IgG. No cases of HEV RNA were detected. The prevalence of anti-HEV IgG increased with maternal age and was associated with higher infant birth weights. Anti-HEV IgM positivity was associated with an increased risk of neonatal infections (odds ratio, 20.6; P = .05). Among HBsAg-positive women, those with anti-HEV IgG (26%) had higher gestational age at delivery and higher infant birth weights but lower platelet counts and prothrombin times (P < .05).

Conclusions

These findings highlight the endemic nature of HEV in Vietnam and underscore the potential risks of coinfection with HBV during pregnancy, which may lead to adverse obstetric outcomes.

Prevalence of hepatitis B virus infection and associated factors among adults intrafamilial household contacts attending antenatal care clinics in the Central Ethiopian region: from pregnant women index cases

BACKGROUND

In Ethiopia, hepatitis B virus infections are prevalent and highly endemic. Additionally, there has been a significant increase in hospital admissions, morbidity, and mortality associated with hepatitis B virus infections. This study aimed to assess the prevalence of hepatitis B virus infection and associated factors among adult intrafamilial household contacts of pregnant women index cases attending antenatal care clinics in the central Ethiopian region.

METHODS

A community-based cross-sectional study was conducted between October 1, 2023, and March 1, 2024. Three hundred eighty-five adult intrafamilial household contacts were randomly selected via lottery methods. A 3 ml venous blood sample was taken from adult intrafamilial household contacts and checked for hepatitis B virus infection through hepatitis B surface antigen. An interviewer-administered questionnaire was used to collect the data. A logistic regression model predicted the relationship between predictor and outcome variables. A p-value of < 0.05 indicated statistical significance.

RESULTS

The overall response rate was 96.1%. Two-thirds of the adults of intrafamilial household contacts (n = 229; 61.9%) were aged between 18 and 28 years, with a mean age of 28 years. The prevalence rate of hepatitis B virus infection among adults of intrafamilial household contacts with pregnant women as the index case was 11.6% (95% CI, 8.6 to 15.1). Being male (AOR: 0.09; 95% CI: 0.03, 0.37) and a duration of stay with the index case of less than six months (AOR: 0.30; 95% CI: 0.11, 0.81) were associated with a reduced risk of hepatitis B virus infection. Meanwhile, large family sizes (≥ 7) (AOR: 4.32; 95% CI: 1.34, 13.98), genital discharge (AOR: 3.14; 95% CI: 1.60, 6.15), engagement in unsafe sex (AOR: 2.37; 95% CI: 1.13, 4.97), and a history of mortality due to hepatitis in the family (AOR: 3.03; 95% CI: 1.09, 8.42) were associated with an increased risk of hepatitis B virus infection.

CONCLUSION

This study found that hepatitis B surface antigen seropositivity among adult intrafamilial household contacts with pregnant women index cases in the central Ethiopia region was high at 11.6%. These findings suggest that interventions to prevent HBV infection should prioritize educational campaigns targeting adult intrafamilial household contacts of HBV-positive index cases, focusing on risk factors associated with HBV transmission, prevention, counselling, testing, and vaccination.

Correlation of IL-10 and IL18 with the development of liver cirrhosis associated with hepatitis B virus infection: A systematic review

BACKGROUND

Patients who have been infected with the Hepatitis B virus (HBV) are susceptible to developing liver cirrhosis (LC) and hepatocellular carcinoma (HCC). The objective of this systematic review was to comprehensively scrutinize the existing evidence concerning the association between host genetic polymorphisms and HBV-associated LC.

METHODS

We searched databases of PubMed, Scopus, and Web of Science for relevant articles published from building databases to 25 October 2023.

RESULT

We detected 104 relevant articles, relating to 84 individuals genes. Nine genes had the strong evidence of correlation, including IL-10, IL-18, IL-1B, TGF- β, TLR3, STAT4, IL-1RN, Tim3, and IFN receptors. A positive correlation was found for 33 genes but this data had not yet been replicated, 11 genes had limited or mixed evidence of a correlation, and 34 genes indicated no correlation. IL-10 and IL-18 had the most evidence of correlation. There was a notable amount of diversity in both the design and method of studies and data quality.

CONCLUSION

IL-10 and IL-18 had the most evidence of correlation. There was a notable amount of diversity in both the design and method of studies and data quality. It is of necessary to take into account the fundamental mechanism behind these associations and discern those that are confounded by the coexistence of other LC/HCC risk factors and response to therapy. These results are expected to guide future studies on the genetic susceptibility of HBV-related LC/HCC.

Knowledge, attitudes and practices to hepatitis B among South African primary healthcare staff

BACKGROUND

 Hepatitis B virus (HBV), a significant cause of liver disease globally, is recognised as a 2030 elimination target by the World Health Organization (WHO). Healthcare workers (HCWs) require appropriate HBV knowledge to identify, manage and prevent HBV.

AIM

 We investigated the knowledge, attitude and practices (KAP) pertaining to HBV among HCWs to establish insights into awareness and inform the delivery of training.

SETTING

 The study was conducted among HCWs of 18 primary healthcare facilities in Bloemfontein, Free State province, South Africa.

METHODS

 Data were collected via anonymous, self-applied, 28-question-questionnaires in English. Data were captured on a Microsoft Excel spreadsheet and analysed by a biostatistician, using Statistical Analyses Software (SAS 9.4).

RESULTS

 The response rate was 88% (88/100), and median participant age was 44 years. Participants were mostly female (83%), professional nurses (65%) with more than 8 years of experience (60%). Median scores were 83% for epidemiology and transmission, 50% for clinical picture, 44% for laboratory diagnosis, 40% for management and 40% for prevention. No difference was noted based on number of years of experience.

CONCLUSION

 Considerable gaps in KAP to HBV were noted among primary HCWs in Bloemfontein. Larger studies are needed to ascertain the KAP towards HBV among South African HCWs, to identify areas for enhanced training.Contribution: Hepatitis B virus, an important cause of liver disease in Africa, is poorly identified and managed. Our study highlights the need to strengthen HCW education to ensure individuals are appropriately diagnosed, managed and educated on preventative measures, to reduce the burden of disease.

A New Approach in the Early Electrochemical Diagnosis of Hepatitis B Virus Infection using Carbon-based Nanomaterials

The importance of early diagnosis of hepatitis B virus infection to treat and follow up this disease has led to many advances in diagnostic techniques and materials. Conventional diagnostic tests are not very useful, especially in the early stages of infection; it is therefore suggested that nanomaterials can enhance them by changing and strengthening their performance for a more accurate and rapid diagnosis. Electrochemical immunosensors with unique features such as miniaturization, low cost, specificity and simplicity have become a suitable and vital tool in the rapid diagnosis of hepatitis B since the patent. Different strategies have been presented, such as graphene oxide and gold nanorods (GO-GNRs), graphene oxide (GO), copper metal-organic framework/ electrochemically reduced graphene oxide (Cu-MOF/ErGO) composite, Label-free graphene oxide/ Fe3O4/Prussian Blue (GO/Fe3O4/PB) immunosensor, and graphene oxide-ferrocene-CS/Au (GOFc- CS/Au) nanoparticle layered electrochemical immunosensor. In this review, we discuss a group of the most widely used nanostructures, such as graphene and carbon nanotubes, which are used to develop electrochemical immunosensors for the early diagnosis of the hepatitis B virus.

Hepatitis B Virus-Related Cirrhosis and Hepatocellular Carcinoma Hospital Discharge Rates from 2005 to 2021 in Spain: Impact of Universal Vaccination

Background: The main consequences of chronic hepatitis B virus (HBV) infections are cirrhosis and hepatocellular carcinoma (HCC), both associated with frequent hospitalization. The aim of this study was to analyze the impact of universal HBV vaccination in Spain on chronic HBV-related hospital discharges from 2005 to 2021. Methods: Using data from the Minimum Basic Data Set of the Spanish National Health System, we calculated the hospital discharge rate ratio (HDRR) and 95% confidence interval (CI) values for chronic HBV-related discharges between 2005 and 2021. For comparative purposes, we calculated the HDRR and 95% confidence interval (CI) values for the early (2005-2013) and later (2014-2021) periods and the vaccinated compared with unvaccinated cohorts for the 20-39 age group. Results: The hospital discharge rate per 1,000,000 people was 3.08 in 2005 and 4.50 in 2021 for HCC, and 4.81 in 2005 and 1.92 in 2021 for cirrhosis. Comparing the early and later periods, values were higher for HCC (HDRR 1.13; 95% CI: 1.06-1.20) and lower for cirrhosis (HDRR 0.56; 95% CI: 0.51-0.60). The rate for the 20-39 age group was lower for the vaccinated compared with the unvaccinated cohorts overall (HDRR 0.53; 95% CI: 0.45-0.62), for HCC (HDRR 0.66; 95% CI: 0.53-0.82), and for cirrhosis (HDRR 0.41; 95% CI: 0.33-0.53). Conclusions: This study describes the important impact, after 25 years, of universal HBV vaccination in Spain: cirrhosis hospital discharge rate was reduced, and the vaccinated cohorts, compared with the unvaccinated cohorts in the 20-39 age group, had a lower hospital discharge rate of both HCC and cirrhosis.

The Efficacy of Post-Exposure Prophylaxis in Infants Born to HBsAg-Positive Mothers: A Single Center Experience in Saudi Arabia

Objectives. Post exposure prophylaxis (PEP) with the hepatitis B vaccine (HBVac) in combination with HBV immunoglobulins (HBIG) significantly minimizes the odds of vertical transmission of HBV to newborn infants. In this retrospective study, we aimed to evaluate the compliance and efficacy of PEP in a tertiary care center in Saudi Arabia. Methods. Infants were tested with HBV serological markers at 7 months of age to assess their PEP protection rate. Results. Out of 13,125 mothers who delivered in KAMC, 105 (0.8%) mothers were found to have HBsAg positive, with a prevalence of 8 per 1000 live births. All infants (n = 100) completed their PEP as per protocol before discharge from the hospital (2 days after delivery). Among infants (n = 59; 56.2%) who were tested at 7 months of age, all (100%) were found to be negative for HBV. Conclusion. PEP achieved 100% efficacy among infants who complied with the study protocol at 7 months of follow-up. The prevalence of hepatitis B among pregnant women was 8 per 1000 live births.

Evolution and diversity of the hepatitis B virus genome: Clinical implications

Hepatitis B virus (HBV) infection remains a significant global health burden. The genetic variation of HBV is complex. HBV can be divided into nine genotypes, which show significant differences in geographical distribution, clinical manifestations, transmission routes and treatment response. In recent years, substantial progress has been made through various research methods in understanding the development, pathogenesis, and antiviral treatment response of clinical disease associated with HBV genetic variants. This progress provides important theoretical support for a deeper understanding of the natural history of HBV infection, virus detection, drug treatment, vaccine development, mother-to-child transmission, and surveillance management. This review summarizes the mechanisms of HBV diversity, discusses methods used to detect viral diversity in current studies, and the impact of viral genome variation during infection on the development of clinical disease.

Role of viral hepatitis in pregnancy and its triggering mechanism

Hepatitis viral infection can cause severe complications, even mortality in pregnant women and their offspring. Multiple studies have shown that vertical transmission can cause viral hepatitis infections in newborns, especially in hepatitis B, C, and E. Screening for hepatitis viral infection in pregnant women is essential. Once infected, pregnant women should be given timely antiviral treatments, which could effectively alleviate the disease progression and reduce adverse outcomes. Besides, the mechanism of viral hepatitis mediating adverse pregnancy outcomes has been a hot topic. Hepatitis B virus has been found to mediate both mother- to-child and parent-child transmission. Liver injury in hepatitis C virus infection is associated with immune-mediated mechanisms, which can be regulated by hormonal factors as well. The mediating mechanism of adverse maternal and infant outcomes caused by hepatitis E virus infection is mainly related to viral replication in the placenta and changes in cytokine and estrogen. Nevertheless, the specific mechanisms related to hepatitis A virus and hepatitis D virus remain unclear, and more research is needed. This review shows that the existence of viral hepatitis during pregnancy can pose certain risks for pregnant women and infants, and different interventions have been used to treat pregnant women infected with viral hepatitis. It may provide deep insight into adverse pregnancy outcomes caused by viral hepatitis and give guidance on treatment.

The epidemiology of laboratory-confirmed Hepatitis B Virus infection in the general population of South Africa, 2016-2018

Introduction

despite the introduction of the Hepatitis B Virus (HBV) vaccine in South Africa in 1995, HBV remains endemic. South Africa's HBV vaccine coverage for the third dose was 71% in 2015. Information on the HBV prevalence in South Africa in recent years is limited, therefore, we estimated HBV prevalence and described annual trends.

Methods

we conducted a retrospective descriptive study of data extracted from the Notifiable Medical Conditions Surveillance System, and estimated HBV prevalence per 100,000 population using the mid-year population estimates obtained from Statistics South Africa, for the 2016-2018 period.

Results

in total, 105 308 laboratory-confirmed HBV cases were analysed, of which 50.2% (53 895/105 308), 95% CI (49.9-50.5) were males. HBV prevalence for males was 34.1 in 2016, 84.1 in 2017, and 72.3 per 100,000 population in 2018. The age group with the highest HBV cases and prevalence were ages 15-49 years having 80.5% (n=84 718), with 52.2 in 2016, 123.3 in 2017, and 99.6 per 100 000 population in 2018. Between 2016 and 2018, South Africa had an overall HBV prevalence of 33.8, 82.6, and 68.8 per 100,000 population, respectively. KwaZulu-Natal province had the highest number of HBV cases with 37.8% (n=39 851) however, Mpumalanga province had the highest HBV prevalence with 73.2 in 2016, 188.8 in 2017, and 126.5 per 100,000 population in 2018.

Conclusion

our results indicated a high HBV prevalence is reflective of the group prior to the HBV vaccine introduction in South Africa.

Association of hepatitis B virus treatment with all-cause and liver-related mortality among individuals with HBV and cirrhosis: a population-based cohort study

Background

We evaluated the association of hepatitis B virus (HBV) treatment with all-cause, and liver-related mortality among individuals with HBV and cirrhosis in British Columbia (BC), Canada.

Methods

This analysis included people diagnosed with HBV and had cirrhosis in the BC Hepatitis Testers Cohort, including data on all individuals diagnosed with HBV from 1990 to 2015 in BC and integrated with healthcare administrative data. We followed people with cirrhosis from the first cirrhosis diagnosis date until death or December 31, 2020. We compared all-cause and liver related mortality between those who received treatment and those who did not. HBV treatment was considered a time-varying variable. We performed multivariable Cox proportional hazards model and competing risk regression models to assess the association of HBV treatment with all causes, and liver-related mortality respectively using inverse probability of treatment weighted population.

Findings

Among 4962 individuals with HBV and cirrhosis, 48.1% received HBV treatment. Treated individuals had a median follow-up of 2.97 years, compared to 2.87 years for untreated individuals. The treated group was older (median age 57 vs 54 years), had higher proportion of treated of males [1802 (75.50%) vs 1766 (68.8%)], from urban area [2318 (97.2%) vs 2355 (91.8%)], and from East and South Asian ethnicity [1506 (63.1%) vs 709 (27.5%)] compared to untreated group. Untreated people experienced higher all-cause mortality (115.47 vs. 35.72 per 1000 person-years) and liver-related mortality (49.86 vs. 11.39 per 1000 person-years). Multivariable models showed that HBV treatment significantly lowered the risk of all-cause mortality (adjusted hazard ratio (aHR) 0.74; 95% CI: 0.65, 0.84) and liver-related mortality (adjusted subdistribution hazard ratio (asHR) 0.72; 95% CI: 0.58, 0.89) compared to untreated individuals. Among untreated individuals with HBV, those with HCV coinfection had a higher risk of both all-cause and liver-related mortality (aHR 1.57; 95% CI: 1.22, 2.04, and asHR 1.60; 95% CI: 1.25, 2.05, respectively).

Interpretation

HBV treatment was associated with a significant reduction in all-cause and liver-related mortality among individuals with cirrhosis. The findings highlight the need for treatment among individuals with HBV related cirrhosis especially those with coinfection with hepatitis C virus.

Funding

This work was supported by the BC Centre for Disease Control and the Canadian Institutes of Health Research (CIHR) [Grant # NHC-142832, PJT-156066, and SC1 -178736]. JDM has received doctoral fellowship from the Canadian Network on Hepatitis C (CanHepC). DJ has received Doctoral Research Award (#201910DF1-435705-64343) from the Canadian Institutes of Health Research (CIHR) and doctoral fellowship from the CanHepC. CanHepC is funded by a joint initiative of the Canadian Institutes of Health Research (CIHR) (NHC-142832) and the Public Health Agency of Canada (PHAC).

Comparison of Clinical Features of HBV and HDV Coinfection with HBV Monoinfection: A Study from the Developing World

Hepatitis B infection remains a significant global health concern, with hepatitis D co-infection observed in approximately 5% of the patients. Treatment options for hepatitis D are currently limited, with most therapies awaiting approval by the FDA. However, there is a lack of comprehensive data on the prevalence and clinical presentation of patients with hepatitis B and D coinfection, particularly in Pakistan. In this study, we aimed to compare demographic characteristics, clinical presentations, laboratory, and endoscopic parameters along with the different treatment options between patients with hepatitis B monoinfection and those with hepatitis B and D coinfection.

How to cite this article

Majid Z, Abrar G, Ahsam S, et al. Comparison of Clinical Features of HBV and HDV Coinfection with HBV Mono-Infection: A Study from the Developing World. Euroasian J Hepato-Gastroenterol 2024;14(2):151-155.

Shifting paradigm in electrochemical biosensing matrices comprising metal organic frameworks and their composites in disease diagnosis

Metal Organic Frameworks (MOFs) are an evolving category of crystalline microporous materials that have grabbed the research interest for quite some time due to their admirable physio-chemical properties and easy fabrication methods. Their enormous surface area can be a working ground for innumerable molecular adhesions and site for potential sensor matrices. They have been explored in the last decade for incorporation in electrochemical sensor matrices as diagnostic solutions for a plethora of diseases. This review emphasizes on some of the recent advancements in the area of MOF-based electrochemical biosensors with focus on various important diseases and their significance in upgrading the sensor performance. It summarizes MOF-based biosensors for monitoring biomarkers relevant to diabetes, viral and bacterial sepsis infections, neurological disorders, cardiovascular diseases, and cancer in a wide range of real matrices. The discussion has been supplemented with extensive tables elaborating recent trends in the field of MOF-composite probe fabrication strategies with their respective sensing parameters. The article sums up the future scope of these materials in the field of biosensors and enlightens the reader with recent trends for future research scope. This article is categorized under: Diagnostic Tools > Biosensing Diagnostic Tools > Diagnostic Nanodevices.

Pharmacovigilance in Vaccines: Importance, Main Aspects, Perspectives, and Challenges-A Narrative Review

Pharmacovigilance plays a central role in safeguarding public health by continuously monitoring the safety of vaccines, being critical in a climate of vaccine hesitancy, where public trust is paramount. Pharmacovigilance strategies employed to gather information on adverse events following immunization (AEFIs) include pre-registration data, media reports, clinical trials, and societal reporting. Early detection of AEFIs during clinical trials is crucial for thorough safety analysis and preventing serious reactions once vaccines are deployed. This review highlights the importance of societal reporting, encompassing contributions from community members, healthcare workers, and pharmaceutical companies. Technological advancements such as quick response (QR) codes can facilitate prompt AEFI reporting. While vaccines are demonstrably safe, the possibility of adverse events necessitates continuous post-marketing surveillance. However, underreporting remains a challenge, underscoring the critical role of public engagement in pharmacovigilance. This narrative review comprehensively examines and synthesizes key aspects of virus vaccine pharmacovigilance, with special considerations for specific population groups. We explore applicable legislation, the spectrum of AEFIs associated with major vaccines, and the unique challenges and perspectives surrounding pharmacovigilance in this domain.

Exploring the potential of drug repurposing for liver diseases: A comprehensive study

Drug repurposing involves the investigation of existing drugs for new indications. It offers a great opportunity to quickly identify a new drug candidate at a lower cost than novel discovery and development. Despite the importance and potential role of drug repurposing, there is no specific definition that healthcare providers and the World Health Organization credit. Unfortunately, many similar and interchangeable concepts are being used in the literature, making it difficult to collect and analyze uniform data on repurposed drugs. This research was conducted based on understanding general criteria for drug repurposing, concentrating on liver diseases. Many drugs have been investigated for their effect on liver diseases even though they were originally approved (or on their way to being approved) for other diseases. Some of the hypotheses for drug repurposing were first captured from the literature and then processed further to test the hypothesis. Recently, with the revolution in bioinformatics techniques, scientists have started to use drug libraries and computer systems that can analyze hundreds of drugs to give a short list of candidates to be analyzed pharmacologically. However, this study revealed that drug repurposing is a potential aid that may help deal with liver diseases. It provides available or under-investigated drugs that could help treat hepatitis, liver cirrhosis, Wilson disease, liver cancer, and fatty liver. However, many further studies are needed to ensure the efficacy of these drugs on a large scale.

Evaluation of PAGE-B Score for Hepatocellular Carcinoma Development in Chronic Hepatitis B Patients: Reliability, Validity, and Responsiveness

Chronic hepatitis B (CHB) constitutes a major global public health issue, affecting millions of individuals. Despite the implementation of robust vaccination programs, the hepatitis B virus (HBV) significantly influences morbidity and mortality rates. CHB emerges as one of the leading causes of hepatocellular carcinoma (HCC), introducing a major challenge in the effective management of CHB patients. Therefore, it is of utmost clinical importance to diligently monitor individuals with CHB who are at high risk of HCC development. While various prognostic scores have been developed for surveillance and screening purposes, their accuracy in predicting HCC risk may be limited, particularly in patients under treatment with nucleos(t)ide analogues. The PAGE-B model, incorporating age, gender, and platelet count, has exhibited remarkable accuracy, validity, and reliability in predicting HCC occurrence among CHB patients receiving HBV treatment. Its predictive performance stands out, whether considered independently or in comparison to alternative HCC risk scoring systems. Furthermore, the introduction of targeted adjustments to the calculation of the PAGE-B score might have the potential to further improve its predictive accuracy. This review aims to evaluate the efficacy of the PAGE-B score as a dependable tool for accurate prediction of the development of HCC in CHB patients. The evidence discussed aims to provide valuable insights for guiding recommendations on HCC surveillance within this specific population.

Beyond schistosomiasis: unraveling co-infections and altered immunity

Schistosomiasis is a neglected tropical disease caused by the helminth Schistosoma spp. and has the second highest global impact of all parasites. Schistosoma are transmitted through contact with contaminated fresh water predominantly in Africa, Asia, the Middle East, and South America. Due to the widespread prevalence of Schistosoma, co-infection with other infectious agents is common but often poorly described. Herein, we review recent literature describing the impact of Schistosoma co-infection between species and Schistosoma co-infection with blood-borne protozoa, soil-transmitted helminths, various intestinal protozoa, Mycobacterium, Salmonella, various urinary tract infection-causing agents, and viral pathogens. In each case, disease severity and, of particular interest, the immune landscape, are altered as a consequence of co-infection. Understanding the impact of schistosomiasis co-infections will be important when considering treatment strategies and vaccine development moving forward.

Review of Related Factors for Persistent Risk of Hepatitis B Virus-Associated Hepatocellular Carcinoma

Chronic hepatitis B virus (HBV) infection is the largest global cause of hepatocellular carcinoma (HCC). Current HBV treatment options include pegylated interferon-alpha and nucleos(t)ide analogues (NAs), which have been shown to be effective in reducing HBV DNA levels to become undetectable. However, the literature has shown that some patients have persistent risk of developing HCC. The mechanism in which this occurs has not been fully elucidated. However, it has been discovered that HBV's covalently closed circular DNA (cccDNA) integrates into the critical HCC driver genes in hepatocytes upon initial infection; additionally, these are not targets of current NA therapies. Some studies suggest that HBV undergoes compartmentalization in peripheral blood mononuclear cells that serve as a sanctuary for replication during antiviral therapy. The aim of this review is to expand on how patients with HBV may develop HCC despite years of HBV viral suppression and carry worse prognosis than treatment-naive HBV patients who develop HCC. Furthermore, HCC recurrence after initial surgical or locoregional treatment in this setting may cause carcinogenic cells to behave more aggressively during treatment. Curative novel therapies which target the life cycle of HBV, modulate host immune response, and inhibit HBV RNA translation are being investigated.

Prevalence of hepatitis B virus infection among general population of Armenia in 2021 and factors associated with it: a cross-sectional study

OBJECTIVES

This study sought to determine the prevalence and associated factors of hepatitis B virus (HBV) infection ever in life and chronic HBV infection in Armenia.

DESIGN

A population-based cross-sectional seroprevalence study combined with a phone survey of tested individuals.

SETTING

All administrative units of Armenia including 10 provinces and capital city Yerevan.

PARTICIPANTS

The study frame was the general adult population of Armenia aged ≥18 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

The participants were tested for anti-HBV core antibodies (anti-HBc) and HBV surface antigen (HBsAg) using third-generation enzyme immunoassays. In case of HBsAg positivity, HBV DNA and hepatitis D virus (HDV) RNA PCR tests were performed. Risk factors of HBV infection ever in life (anti-HBc positivity) and chronic HBV infection (HBsAg positivity) were identified through fitting logistic regression models.

RESULTS

The seroprevalence study included 3838 individuals 18 years and older. Of them, 90.7% (3476 individuals) responded to the phone survey. The prevalence of anti-HBc positivity was 14.1% (95% CI 13.1% to 15.2%) and HBsAg positivity 0.8% (95% CI 0.5% to 1.1%). The viral load was over 10 000 IU/mL for 7.9% of HBsAg-positive individuals. None of the participants was positive for HDV. Risk factors for HBsAg positivity included less than secondary education (aOR=6.44; 95% CI 2.2 to 19.1), current smoking (aOR=2.56; 95% CI 1.2 to 5.6), and chronic liver disease (aOR=8.44; 95% CI 3.0 to 23.7). In addition to these, risk factors for anti-HBc positivity included age (aOR=1.04; 95% CI 1.04 to 1.05), imprisonment ever in life (aOR=2.53; 95% CI 1.41 to 4.56), and poor knowledge on infectious diseases (aOR=1.32; 95% CI 1.05 to 1.67), while living in Yerevan (vs provinces) was protective (aOR=0.74; 95% CI 0.59 to 0.93).

CONCLUSION

This study provided robust estimates of HBV markers among general population of Armenia. Its findings delineated the need to revise HBV testing and treatment strategies considering higher risk population groups, and improve population knowledge on HBV prevention.

Effects of Citrus depressa Hayata juice on high-fat diet-induced obesity in HBV transgenic mice

The present study investigated the potential anti-obesity properties of Citrus depressa Hayata (CDH) juice in HBV transgenic mice, as well as the impact of fermentation on the effectiveness of the juice. The results revealed that fermentation increased the levels of polyphenols and hesperidin in CDH juice. The animal study demonstrated that both juices were effective in mitigating the weight gain induced by a high-fat diet by correcting metabolic parameter imbalances, reducing hepatic lipid accumulation, and reversing hepatic immune suppression. Furthermore, fermented juice exhibited superior efficacy in managing body weight and inhibiting the expansion of white adipose tissue (WAT). Fermented juice significantly enhanced adiponectin production and PPARγ expression in WAT, while also reducing hypertrophy. This study offers valuable insights into the potential role of CDH juices in combating obesity associated with high fat consumption and underscores the promise of CDH juice as a functional beverage.

Seroprevalence of hepatitis B, C, and D and associated factors in the semi-isolated Yanomami Amazonian indigenous community

BACKGROUND

Viral hepatitis is a significant health concern among indigenous population in the Americas. In Brazil, reports find high endemicity of HBV and HDV infections has been reported in several indigenous groups. However, few studies have documented the prevalence of HBV, HCV and HDV in the Yanomami. In this study, the prevalence of hepatitis B, C, and D serological markers and potential risk factors were investigated to provide guidance for the development of strategies aimed at reducing viral transmission in the Yanomami indigenous villages.

METHODS

This cross-sectional study was carried out in March 2015 and included 430 individuals from four Yanomami villages: Alapusi (n = 78), Castanha/Ahima (n = 126), Gasolina (n = 105), and Taibrapa (n = 121). A rapid test was used for detection of HBsAg and anti-HCV and chemiluminescent immunoassay for anti-HBs, anti-HBc, and anti-HDV antibodies.

RESULTS

HBsAg, anti-HBc, and anti-HBs were detected in 8.8, 45.5, and 49.4% of the participants, respectively. The estimated HBV status: current infection 9.6% (38/395); resolved infection 43.3% (171/395); vaccine immunity 20.5% (81/395), and susceptible to HBV 26.6% (105/395). Gasolina presented the lowest prevalence of HBV infection (6.5%) and the highest prevalence of vaccine immunity (26.9%). Children < 15 years old were highly susceptible to infection, as 53.1% did not have antibodies to HBV, while more than 80% of individuals over 45 years of age had been exposed to HBV. The markers for HDV were founded among 12.5% (4/32) of the HBsAg carriers. Anti-HCV was identified in all villages, with the highest prevalence in Alapusi (5.1%). Possible risk factors such as the use of piercings, tattoos, and contact with prospectors showed no statistical difference between the groups.

CONCLUSIONS

Viral hepatitis B and serological markers for HCV and HDV were found to be widely distributed among the Yanomami indigenous community, while the prevalence of vaccine immunity to HBV was low. This finding reinforces the importance of promoting systematized diagnostic and vaccination strategies in indigenous communities. Our data confirm that isolated and difficult-to-reach indigenous communities lack appropriate access to diagnosis, treatment, and vaccination.

Interleukin-34 is more suitable than macrophage colony-stimulating factor for predicting liver significant fibrosis in patients with chronic hepatitis B

AIMS

Interleukin-34 (IL-34) and macrophage colony-stimulating factor (CSF-1) have similar functions, such as promoting the formation of liver fibrosis. This study aimed to evaluate and compare the diagnostic value of serum IL-34 and CSF-1 for significant liver fibrosis in patients with chronic hepatitis B (CHB).

METHODS

A total of 369 CHB patients, consisting of 208 HBeAg-negative patients and 161 HBeAg-positive patients, were enrolled in this study. Additionally, 72 healthy individuals served as healthy controls (HCs). Serum levels of IL-34 and CSF-1 were measured using the enzyme-linked immunosorbent assay method. Liver fibrosis grades were assessed using the modified Scheuer scoring system.

RESULTS

Serum IL-34 and CSF-1 levels exhibited significant elevation in both HBeAg-negative and HBeAg-positive patients in comparison to HCs (p < 0.001). IL-34 emerged as an independent factor linked to significant liver fibrosis, whereas CSF-1 did not exhibit such an association. Receiver operating characteristic (ROC) analysis indicated higher areas under the curves (AUCs) for IL-34 (0.814, p < 0.001 and 0.673, p < 0.001) when diagnosing significant liver fibrosis in HBeAg-negative and HBeAg-positive patients, respectively, as opposed to CSF-1 (0.602, p < 0.001; 0.619, p = 0.385). Within the HBeAg-negative patient subgroup, the AUC for IL-34 surpassed that of FIB-4 (p = 0.009) and APRI (p = 0.045).

CONCLUSION

Serum IL-34 has the potential to be a straightforward and practical biomarker that demonstrates superior performance to serum CSF-1 in the diagnosis of significant liver fibrosis in CHB patients, especially within the HBeAg-negative patients.

HBV prevalence in Sub-continental countries: A systematic review and meta-analysis

BACKGROUND

Hepatitis B virus (HBV) is a major source of disease burden worldwide, with an estimated 296 million individuals living with infections worldwide. Although vaccine programs exist to control infections, certain sub-populations around the world continue to have very high prevalence of HBV infection.

METHODS

A systematic search of studies of HBV published after 2010 was conducted for India, Pakistan, Bangladesh, Nepal, Sri Lanka and Bhutan. Each paper was independently screened for risk of bias and inclusion. Data were extracted from included studies before being analysed to estimate pooled prevalence, and to conduct sub-group analyses. Random-effects models were used for estimating summary prevalence due to a high level of heterogeneity between studies, and funnel plots were combined with Egger's test to assess publication bias. Meta-regression was conducted to investigate sources of between-study heterogeneity.

RESULTS

The pooled prevalence of HBV across all studies was 3% (95% CI 0.02, 0.05). For countries with multiple studies, the pooled prevalence in India was 3% (95% CI 0.02, 0.04), in Pakistan 6% (95% CI 0.03, 0.09), in Bangladesh 5% (95% CI of 0.02, 0.12), and in Nepal 1% (95% CI 0.00, 0.08). There was some evidence of publication bias, and a high level of heterogeneity across studies. Risk of bias analysis found most studies to be of fair or moderate quality.

CONCLUSIONS

The prevalence of HBV among countries in the sub-continent was higher than the global average, but was not as high as some other regions. Countries with greater numbers of displaced persons had higher prevalence of HBV, with a wide range of prevalence between subpopulations likely reflecting differential uptake, and implementation, of vaccination programs.

In vitro evaluation of tropolone absorption, metabolism, and clearance

Tropolone compounds can inhibit hepatitis B virus (HBV) replication at sub-micromolar levels and are synergistic upon co-treatment with nucleos(t)ide analog drugs. However, only a few compounds within this chemotype have been screened for their pharmacological properties. Here, we chose 36 structurally diverse tropolones from six subclasses to characterize their in vitro pharmacological parameters. All compounds were more soluble in pHs that reflect the gastrointestinal tract (pH 5 and 6.5) than plasma (pH 7.4). Those compounds that had solubility limits >100 μM were tested in a passive permeability assay, and there was no general trend in the compounds' passive permeability at any pH. Twenty-nine compounds with the best absorption parameters were tested in HEK293 cells to assess potential cytotoxicity; measured toxicities were similar to those in the hepatic HepDES19 cells used for screening (R2 = 0.55). Sixteen representative compounds were tested against five major CYP450 isoforms and there was no substantial inhibition by any compound against any of the enzymes tested (<50%). The t1/2 values of 15 compounds were determined in the microsome stability assay and 12 compounds were evaluated in plasma protein binding assays to assess factors affecting their rate of clearance. All compounds with detectable analyte peaks had t1/2 > 30 min, and while 4 of 12 had statistically significant decreased potency in conditions with increased albumin concentrations, only one compound's potency was biologically significant. These data indicate that the tropolones have pharmacological characteristics that reflect approved drugs and inform future structure activity relationships during drug design.

Patient Preferences and Their Influence on Chronic Hepatitis B-A Review

Chronic hepatitis B (CHB) is a common chronic viral infectious disease that requires long-term treatment to control the condition and prevent complications. To standardize treatment regimens for CHB, professional associations have established relevant guidelines, but they have often overlooked patient preferences. Historically, in the treatment process, medical decisions were predominantly made by physicians or health care administrators, with limited patient involvement, leading to the neglect of patient preferences. Patient attitudes, expectations, and needs are all influenced by their preferences, and patient preferences have a direct impact on treatment adherence. Understanding and respecting patient preferences are crucial to ensuring treatment effectiveness. This article will explore patient preferences in the treatment of CHB and elucidate the influence of patient preferences on treatment adherence, aiming to provide insights for the development of a more personalized and effective health care process.

Knowledge, Attitudes, and Practices Toward the Prevention of Hepatitis B Virus Infection Among Medical Students in Medina City, Kingdom of Saudi Arabia

INTRODUCTION

This study focuses on assessing the knowledge, attitudes, and practices related to Hepatitis B virus (HBV) prevention among medical students in Medina, Saudi Arabia. HBV is a significant global health concern, with a high prevalence in Saudi Arabia. Medical students due to their field, are at higher risk of exposure. Prior studies in Saudi Arabia show varied levels of awareness. This research aims to provide insights that can inform educational initiatives for this specific population.

METHODS

This was a cross-sectional study conducted from June 2023 to September 2023 by using a pre-designed online questionnaire that was distributed among medical students in Medina. Data was analyzed using IBM Corp. Released 2020. IBM SPSS Statistics for Windows, Version 27.0. Armonk, NY: IBM Corp.

RESULTS

This study included 307 participants. 67.8% of the participants correctly identified the link between HBV and liver cancer, and 77.5% recognized the transmission risk from carriers. 91.9% acknowledged the transmission via contaminated blood and fluids, and 88.9% recognized the risk from unsterilized instruments. Positive attitudes were observed, with 92.2% agreeing that following infection control guidelines would protect them at work. Practice scores were generally positive, including high rates of screening (57.3%) and adherence to infection control measures (90.2%). Knowledge scores correlated positively with attitude (rho = 0.204) and practice scores (rho = 0.390).

CONCLUSION

A significant proportion of participants had a strong understanding of HBV transmission and the importance of infection control measures. Positive attitudes towards infection control were prevalent, although some reluctance to provide care to HBV-infected individuals was noted.

The Epidemiology, Transmission, Genotypes, Replication, Serologic and Nucleic Acid Testing, Immunotolerance, and Reactivation of Hepatitis B Virus

The epidemiology of Hepatitis B virus (HBV) has drastically changed in recent decades due to public health initiatives, including universal infant vaccination programs,urbanization driving global travel, and migration patterns. Despite screening of pregnant women and newborns significantly reducing the rate of perinatal transmission in certain parts of the world, other, perhaps more uncommon, routes (e.g., parenteral) have led to outbreaks in specific areas affected by the opioid epidemic and injection drug use. Although our current understanding of the effect of genetic variants of HBV is lacking, we review current knowledge and patterns of genetic variants with geographical predominance, pathophysiology, and clinical manifestations. Serologic and molecular markers are used to screen, identify phase and activity of infection, and monitor response to antivirals and/or reactivation. This review will provide the most up-to-date summary of the epidemiology, transmission, genotype, replication, and current methods of screening to follow the various phases of HBV, including immunotolerance and reactivation.

The effect of hepatitis B virus on the risk of pregnancy outcomes: a systematic review and meta-analysis of cohort studies

BACKGROUND

The effect of HBV on neonatal and maternal outcomes can create a basis for more accurate clinical decision-making. So, the aim of this meta-analysis is to detrmine the effect of chronic hepatitis B virus on the risk of pregnancy outcomes by combining cohort studies.

METHODS

International databases in this meta-analysis included the Cumulated Index to Nursing and Allied Health Literature (CINAHL), SPORT Discuss via the EBSCO interface, PubMed (Medline), Scopus, Web of Science, Embase, which were searched up to April 2023. All cohort studies reporting the risk ratio (RR) with a 95% confidence interval (CI) were included in the study. The quality assessment was done based on the Newcastle-Ottawa Scale (NOS).

RESULTS

Finally, thirty-five cohort studies were selected for meta-analysis. Outcomes of interest included pre-eclampsia, gestational diabetes, abortion, preterm birth, infant death, and other related outcomes. Results showed that the pooled RR for incident gestational diabetes in pregnant women with choronic hepatitis B infection was 1.16 (RR: 1.16; 95% CI 1.13-1.18; I-square: 92.89%; P value: 0.00). Similarly, the association between the presence of hepatitis B infection in pregnant women and the occurrence of pre-eclampsia was 1.10 (RR: 1.10; 95% CI 1.04-1.16; I-square: 92.06%; P value: 0.00). The risk of preterm delivery in pregnant women with hepatitis B infection was 1.17 times that of pregnant women without hepatitis B infection (RR: 1.17; 95% CI 1.14-1.20; I-squared: 94.32%; P value: 0.00).

CONCLUSION

This meta-analysis found that hepatitis B infection during pregnancy may be associated with an increased risk of gestational diabetes, preterm delivery, pre-eclampsia, and eclampsia. However, confirmation of this association, as well as the specific biological pathways involved in the association between HBV infection and pregnancy outcomes, requires further investigation.

Hepatitis B eradication: vaccine as a key player

OBJECTIVE

Despite the availability of a highly effective and safe vaccine against hepatitis B virus (HBV) infection for 40 years, still almost 300 million persons are estimated to be chronically infected by this virus worldwide. The World Health Organization (WHO) has proposed a plan for hepatitis elimination by 2030. However, several factors, such as the reduction and limitation in vaccination campaigns or vaccine hesitancy (VH) in some regions of the World, might have played a role in limiting the worldwide coverage of hepatitis B prophylaxis. This review aims to describe which factors, such as VH, may be hampering the WHO 2030 goal for hepatitis B eradication.

METHODS

The review describes the development and characteristics of the HBV vaccine, from the first plasma-derived to the recombinant one. Eventual limitations in its effectiveness and particularly VH were reviewed.

RESULTS

The apparent pitfalls of the HBV vaccine, such as long-term effectiveness, vaccine-escape mutants, and adverse effects, were proven not to be a concern for this vaccine. However, VH persists and was even intensified by the COVID-19 pandemic.

CONCLUSIONS

Many barriers still exist, such as vaccine availability, lack of awareness of the benefits of HBV vaccination, and VH. HBV VH seems to be eventually overcome in many settings with active education campaigns and information, stressing the importance of developing these strategies to achieve the 2030 goal of the WHO.

The Hepatitis B Virus Genotypes E to J: The Overlooked Genotypes

Hepatitis B virus (HBV) genotypes E to J are understudied genotypes. Genotype E is found almost exclusively in West Africa. Genotypes F and H are found in America and are rare in other parts of the world. The distribution of genotype G is not completely known. Genotypes I and J are found in Asia and probably result from recombination events with other genotypes. The number of reported sequences for HBV genotypes E to J is small compared to other genotypes, which could impact phylogenetic and pairwise distance analyses. Genotype F is the most divergent of the HBV genotypes and is subdivided into six subgenotypes F1 to F6. Genotype E may be a recent genotype circulating almost exclusively in sub-Saharan Africa. Genotype J is a putative genotype originating from a single Japanese patient. The paucity of data from sub-Saharan Africa and Latin America is due to the under-representation of these regions in clinical and research cohorts. The purpose of this review is to highlight the need for further research on HBV genotypes E to J, which appear to be overlooked genotypes.

Cross-Reactivity of HBe Antigen-Specific Polyclonal Antibody with HBc Antigen

Hepatitis B virus (HBV) infection is a major health problem worldwide and causes almost one million deaths annually. The HBV core gene codes for two related antigens, known as core antigen (HBcAg) and e-antigen (HBeAg), sharing 149 residues but having different amino- and carboxy-terminals. HBeAg is a soluble variant of HBcAg and a clinical marker for determining the disease severity and patients' screening. Currently available HBeAg assays have a shortcoming of showing cross-reactivity with HBcAg. In this study, for the first time, we evaluated whether HBcAg-adsorbed anti-HBe polyclonal antibodies could specifically recognize HBeAg or still show cross-reactivity with HBcAg. Recombinant HBeAg was cloned in pCold1 vector and successfully expressed in Escherichia coli and after purification by Ni-NTA resin was used to generate polyclonal anti-HBe antibodies in rabbit. Purified HBeAg was further characterized by assessing its reactivity with anti-HBe in the sera of chronically infected patients and HBeAg-immunized rabbit. Sera from patients with chronic HBV infection, containing anti-HBe, specifically reacted with recombinant HBeAg, implying antigenic similarity between the prokaryotic and native HBeAg in the serum of HBV-infected patients. In addition, the designed enzyme-linked immunosorbent assay (ELISA) with rabbit anti-HBe polyclonal antibodies could detect recombinant HBeAg with high sensitivity, while high cross-reactivity with HBcAg was observed. It is noteworthy that HBcAg-adsorbed anti-HBe polyclonal antibodies still showed high cross-reactivity with HBcAg, implying that due to the presence of highly similar epitopes in both antigens, HBcAg-adsorbed polyclonal antibodies cannot differentiate between the two antigens.

World Hepatitis day 2021 -screening and vaccination against Hepatitis B virus in Accra, Ghana

BACKGROUND

In Ghana, Hepatitis B virus (HBV) infection remains a major public health threat as in many parts of the world. Even with an effective vaccine, there are shortfalls with low vaccine coverage among adults. To create awareness and encourage vaccination, community engagement and public-private partnerships are needed in endemic settings to help fund campaigns and offer screening and vaccinations at no cost to under privileged people.

OBJECTIVES

An awareness and screening exercise was scheduled by University of Ghana-based Hepatitis-Malaria (HEPMAL) project team to coincide with the World Hepatitis Day (WHD) 2021. It was to engage the community in creating awareness of the menace and offer diagnostic services to ascertain prevalence levels and provide needed clinical support.

METHODS

Participants from the University of Ghana community and its immediate environs were registered, taken through pre-counselling sessions where they were educated on hepatitis transmission and prevention before consenting. Eligible participants were screened for HBV markers (HBsAg, HBeAg, HBsAb, HBcAb,HbcAg) with a rapid test kit. All HBsAb-negative participants were recommended for initial vaccination at the event, whilst the subsequent shots were administered at the University Hospital Public Health Department. Hepatitis B surface Antigen-positive participants were counselled and referred for appropriate care.

RESULTS

/ Outcomes: A total of 297 people, comprising of 126 (42%) males and 171 (58%) females aged between 17 and 67 years were screened during the exercise. Amongst these, 246 (82.8%) showed no detectable protective antibodies against HBV and all of them agreed to and were given the first dose HBV vaccine. Additionally, 19 (6.4%) individuals tested positive for HBsAg and were counselled and referred to specialists from the University Hospital for further assessment and management. We found that 59 (19.9%) of our participants had previously initiated HBV vaccination and had taken at least one dose of the vaccine more than 6 months prior to this screening, 3 of whom tested positive for HBsAg. For the three-dose HBV vaccines deployed, a little over 20% (50/246) and a further 17% (33/196) did not return for the second and the third doses respectively, resulting in an overall 66% (163/246) of persons who completed all three vaccinations.

CONCLUSIONS

/ Lessons learnt: Our medical campaign exercise established an active case prevalence rate of 6.4% and achieved a full vaccination success rate of 66% which is critical in the induction of long-term immunity in the participants. Aside these achievements, we would like to reiterate the importance of the use of different approaches including educational events and WHD activities to target groups and communities to raise awareness. Additionally, home and school vaccination programmes may be adopted to enhance vaccine uptake and adherence to the vaccination schedule. We plan to extend this screening exercise to deprived and/or rural communities where HBV incidence may be higher than in urban communities.

Prevalence of hepatitis B and C, and syphilis among aspirant migrant workers of Bangladesh

Background

In Bangladesh, labour migration is a source of employment and workers' remittances are critical to poverty mitigation. The aim of this study was to assess the prevalence of hepatitis B, C, HIV, tuberculosis, syphilis, kidney and liver diseases along with presence of infections among aspirant migrant workers of Bangladesh.

Method

This study was carried out from September-December 2019. We analysed data collected on screening tests of specific diseases of aspirant workers. For each test, the prevalence was computed with 95% confidence interval. Association between categorical data was determined by the Chi-square test.

Results

A total of 2385 aspirants, 1988 (83.35%) males, aged between 18 and 65 years (29.76±6.578) were studied. Positive results for screening tests of HBsAg were 38 (1.6%,), anti-HCV were 2 (0.08%), TPHA were 25 (1.05%) and VDRL were 5 (0.21%) though no individual was positive for HIV and TB. Elevated level of SGOT (n=99, 4.2%), SGPT (n=322, 13.5%), RBS (n=57, 2.4%), bilirubin (n=46, 1.92%), creatinine (n=7, 0.3%) and ESR (n=19, 0.8%) were found in the workers.

Conclusion

Diagnosis of diseases of workers is obligatory before going abroad to safeguard the health of the workers and residents of destination country. Consequently, it will contribute to reducing the global burden of infectious diseases.

Maximize Donor Cornea Use in a Hepatitis B Endemic Area via Serology Matching

BACKGROUND

This study aims to investigate the rationality of the allocation guidelines in a hepatitis B endemic area that uses corneas from hepatitis B donors.

METHODS

Under Taiwan's current guidelines, corneas donated from hepatitis B surface antigen (HBsAg)(+) donors can be allocated to HBsAg(+) or hepatitis B surface antibody recipients. From January 1, 2015, to December 31, 2019, corneas donated to National Taiwan University Hospital were divided into HBsAg(+), HBsAg(-)/hepatitis B core antibody (anti-HBc)(+), and HBsAg(-)/anti-HBc(-) groups. Hepatitis B virus (HBV) DNA extracted from corneoscleral rims was quantified by polymerase chain reaction and correlated with donor serum HBsAg, anti-HBc, and HBV DNA. Recipients of HBV DNA(+) grafts were called back for serology and serum HBV DNA tests.

RESULTS

The corneoscleral HBV DNA of 170 corneas (113 donors) was quantified, of which 45 corneas were from 28 HBsAg(+) donors, 87 were from 57 HBsAg(-)/anti-HBc(+) donors, and 38 were from 28 HBsAg(-)/anti-HBc(-) donors, and HBV DNA was detected in 80.0%, 9.2%, and 0% of the corneoscleral rims in each group. Donor anti-HBc(+) provided the highest sensitivity (1.00) and negative predictive value (1.00) for corneoscleral HBV DNA. Twenty-eight of 40 recipients (70%) using HBV DNA(+) grafts were called back, and none developed hepatitis in follow-up periods ranging from 6 to 55.5 mo.

CONCLUSIONS

Donor anti-HBc should be tested routinely with HBsAg. Allocating corneas from HBsAg(+) or anti-HBc(+) donors to HBsAg(+) or hepatitis B surface antibody recipients maximizes cornea usage from hepatitis B donors without compromising transplant safety in a hepatitis B endemic setting.

Unravelling the mechanisms by which chronic hepatitis B infection is associated with an increased risk of gestational diabetes

An independent association between chronic hepatitis B virus (HBV) and the development of gestational diabetes (GDM) has been reported in the literature. Ethnic background and regional influences have been demonstrated to play a role in the reporting of incidence rates of GDM among women with chronic HBV. The mechanisms behind this association are poorly understood, but evidence suggests an inflammatory basis. Viral factors such as chronic HBV replication, quantifiable by HBV viral load, have been proposed to contribute to the increasing risk of insulin resistance in pregnancy. More research is needed to better characterise the association and determine if any interventions early in pregnancy for women infected with chronic HBV would mitigate the development of GDM.

Virus-like Particle Vaccines and Platforms for Vaccine Development

Virus-like particles (VLPs) have gained a lot of interest within the past two decades. The use of VLP-based vaccines to protect against three infectious agents-hepatitis B virus, human papillomavirus, and hepatitis E virus-has been approved; they are very efficacious and offer long-lasting immune responses. Besides these, VLPs from other viral infectious agents (that infect humans, animals, plants, and bacteria) are under development. These VLPs, especially those from human and animal viruses, serve as stand-alone vaccines to protect against viruses from which the VLPs were derived. Additionally, VLPs, including those derived from plant and bacterial viruses, serve as platforms upon which to display foreign peptide antigens from other infectious agents or metabolic diseases such as cancer, i.e., they can be used to develop chimeric VLPs. The goal of chimeric VLPs is to enhance the immunogenicity of foreign peptides displayed on VLPs and not necessarily the platforms. This review provides a summary of VLP vaccines for human and veterinary use that have been approved and those that are under development. Furthermore, this review summarizes chimeric VLP vaccines that have been developed and tested in pre-clinical studies. Finally, the review concludes with a snapshot of the advantages of VLP-based vaccines such as hybrid/mosaic VLPs over conventional vaccine approaches such as live-attenuated and inactivated vaccines.

Global burden of primary liver cancer and its association with underlying aetiologies, sociodemographic status, and sex differences from 1990-2019: A DALY-based analysis of the Global Burden of Disease 2019 study

BACKGROUND/AIMS

Global distribution of dominant liver cancer aetiologies has significantly changed over the past decades. This study analyzed the updated temporal trends of liver cancer aetiologies and sociodemographic status in 204 countries and territories from 1990 to 2019.

METHODS

The Global Burden of Disease 2019 report was used for statistical analysis. In addition, we performed stratification analysis to five quintiles using sociodemographic index and 21 geographic regions.

RESULTS

The crude numbers of liver cancer disease-adjusted life years (DALYs) and deaths significantly increased during the study period (DALYs; 11,278,630 in 1990 and 12,528,422 in 2019, deaths; 365,215 in 1990 and 484,577 in 2019). However, the Age-standardized DALY and mortality rates decreased. Hepatitis B virus (HBV) remains the leading cause of liver cancer DALYs and mortality, followed by hepatitis C virus (HCV), alcohol consumption, and non-alcoholic steatohepatitis/non-alcoholic fatty liver disease (NASH/NAFLD). Although Age-standardized DALY and mortality rates of liver cancer due to HBV and HCV have decreased, the rates due to alcohol consumption and NASH/NAFLD have increased. In 2019, the population of the East Asia region had the highest Age-standardized DALY and mortality rates, followed by high-income Asia-Pacific and Central Asia populations. Although East Asia and high-income Asia-Pacific regions showed a decrease during the study period, Age-standardized DALY rates increased in Central Asia. High-income North American and Australasian populations also showed a significant increase in Age-standardized DALY.

CONCLUSION

Liver cancer remains an ongoing global threat. The burden of liver cancer associated with alcohol consumption and NASH/NAFLD is markedly increasing and projected to continuously increase.

Global epidemiology of HBV infection among hemodialysis patients: A systematic review and meta-analysis

BACKGROUND & AIMS

Hemodialysis (HD) is a life-saving procedure that purifies the blood in patients with end-stage renal disease (ESRD). Among all major complications, blood-borne diseases like hepatitis B virus (HBV) may be exposed as serious side effects of hemodialysis. A comprehensive review of the global burden of HBV among HD patients has not been written so far. The aim of the current systematic review and meta-analysis was to determine the globally epidemiology of HBV infection among HD patients.

METHODS

Based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, articles that investigated the prevalence of HBV among HD patients were searched from the major databases such as EMBASE, PubMed, Web of Science collection, and Scopus. Pooled prevalence with 95% CI and identification of heterogeneity were obtained using the random effects model and Cochran's Q-test, respectively, and quantification was evaluated using the I2 statistics. All statistical analyses were performed by STATA 14.1 statistical software.

RESULTS

among 322 datasets (795,623 cases) that included in this study, the pooled prevalence of HBV infection among HD patients was 7.32% (95% CI: 6.53-8.15%; I2 = 97.91%), including 7.57% (95% CI: 6.69-8.48%) for HBsAg and 6.09% (95% CI: 4.05-8.49%) for DNA, respectively. In addition, based on geographic area, the prevalence was 7.44% (95% CI: 6.35-8.61%) in Asia, 4.32% (95% CI: 2.21-7.04%) in North America, 7.07% (95% CI: 6.35-8.61%) in Europe, 5.52% (95% CI: 3.60-7.78%) in Africa, 8.45% (95% CI: 5.81-11.78%) in Oceania, and 9.73% (95% CI: 7.11-12.70%) in South America.

CONCLUSIONS

Our analysis indicates a relatively high prevalence of HBV infection in HD patients, even in some developed countries. Considering that ESRD patients are not able to properly respond to the vaccination strategies in order to develop an acceptable immunity, vaccination of healthy individuals is highly recommended to arm their bodies for possible immunocompromise conditions in the future. Moreover, donated blood in blood transfusion centers should be checked for possible hepatitis B virus infection using sensitive molecular tests.

Liver fibrosis in children: a comprehensive review of mechanisms, diagnosis, and therapy

Chronic liver disease incidence is increasing among children worldwide due to a multitude of epidemiological changes. Most of these chronic insults to the pediatric liver progress to fibrosis and cirrhosis to different degrees. Liver and immune physiology differs significantly in children from adults. Because most of pediatric liver diseases have no definitive therapy, a better understanding of population and disease-specific fibrogenesis is mandatory. Furthermore, fibrosis development has prognostic significance and often guide treatment. Evaluation of liver fibrosis continues to rely on the gold-standard liver biopsy. However, many high-quality studies put forward the high diagnostic accuracy of numerous diagnostic modalities in this setting. Herein, we summarize and discuss the recent literature on fibrogenesis with an emphasis on pediatric physiology along with a detailed outline of disease-specific signatures, noninvasive diagnostic modalities, and the potential for antifibrotic therapies.

Associations between the prevalence of chronic hepatitis B among people who inject drugs and country-level characteristics: An ecological analysis

INTRODUCTION

Globally, hepatitis B virus (HBV) is a leading cause of liver disease. People who inject drugs (PWID) are at greater risk than the general population of contracting HBV. This risk could depend on societal factors in different countries. We investigated the associations between country-level chronic HBV prevalence in PWID with national indicators of development and prevalence of HIV and hepatitis C virus (HCV).

METHODS

We used global systematic review data on chronic HBV prevalence (hepatitis B surface antigen-positive) among PWID and country-level sociodemographic characteristics from online databases. National random-effects meta-analysis estimates of HBV prevalence were the outcome in linear regression models testing for associations with country-level characteristics.

RESULTS

The study included 131,710 PWID from 304 estimates in 55 countries: the pooled HBV prevalence among PWID in the countries analysed was 4.5% (95% CI 3.9-5.1), the highest regional pooled prevalence was in East and Southeast Asia (17.6% [13.3-22.3]), and the lowest was in Western Europe (1.7% [1.4-2.1]). In multivariable models, no indicators of development were associated with HBV prevalence, but there was evidence of positive associations between HBV prevalence in the general population and among PWID, and evidence of HIV and HCV prevalence in PWID being associated with HBV prevalence in PWID: multivariable coefficients 0.03 (95% CI 0.01-0.04); p < 0.001, and 0.01 (95% CI 0.00-0.03); p = 0.01, respectively.

DISCUSSION AND CONCLUSIONS

HBV prevalence among PWID was associated with HIV and HCV prevalence among PWID and background HBV prevalence in the general population, highlighting the need for improving harm reduction in PWID and implementation of HBV vaccination, especially where HBV is endemic.

Prevalence of hepatitis B infection and its associated factors among pregnant mothers attending antenatal care at public hospitals at Hararghe, Eastern Ethiopia

Background

Hepatitis B infection is one of the world's most serious public health problems, causing significant morbidity and mortality. More than 2 billion individuals around the world have been infected with the hepatitis B virus (HBV), and approximately 400 million people are chronically infected with the virus, with more than a million dying each year from hepatitis B virus-related liver disease. A newborn infant whose mother is positive for both HBsAg and HBeAg has a 90% chance of developing chronic infection by the age of 6. Its infectivity is a 100 times that of the human immunodeficiency virus, but it receives little attention in public health. Therefore, this study was conducted to assess the prevalence of hepatitis B infection and its associated factors among pregnant mothers attending antenatal care at public hospitals in west Hararghe, eastern Ethiopia 2020.

Method

This institution-based cross-sectional study was conducted on 300 pregnant mothers selected by systematic random sampling from September to December 2020. Data were collected by face-to-face interview using a pretested structured questionnaire. A blood sample was collected and tested for hepatitis B surface antigen using the enzyme-linked immunosorbent assay test method. Data were entered into EpiData version 3.1 and exported to Statistical Package for the Social Science version 22 for analysis. Bivariate and multivariable logistic regressions were used to assess the association between outcome and predictor variables. P-value <0.05 was considered to be statistically significant.

Results

The overall seroprevalence of hepatitis B virus infection was 8% [95% confidence interval (CI): 5.3-11.0] among pregnant mothers. History of tonsillectomy [adjusted odd ratio (AOR) = 5.7; 95% CI: 1.3-23.9], tattoo (AOR = 4.3; 95% CI: 1.1, 17.0), having multiple sexual partners (AOR = 10.8; 95% CI: 2.5, 45.9), and history of contact with jaundiced patients (AOR = 5.6; 95% CI: 1.2, 25.7) were factors associated with the seroprevalence of hepatitis B virus infection among pregnant mothers.

Conclusion

The hepatitis B virus was highly prevalent. A history of tonsillectomy, tattooing, having multiple partners, and contact with jaundiced patients were factors associated with hepatitis B virus infection. To reduce HBV transmissions, the government should increase HBV vaccination coverage. All newborns should receive the hepatitis B vaccine as soon as possible after birth. It is also recommended that all pregnant women have HBsAg testing and antiviral prophylaxis to reduce the risk of transmission from mother to child. Hospitals, districts, regional health bureaus, and medical professionals should also educate pregnant women about hepatitis B virus transmission and prevention, both in the hospital and in the community, with a focus on modifiable risk factors.

Role of bioactive compounds in the treatment of hepatitis: A review

Hepatitis causes liver infection leading to inflammation that is swelling of the liver. They are of various types and detrimental to human beings. Natural products have recently been used to develop antiviral drugs against severe viral infections like viral hepatitis. They are usually extracted from herbs or plants and animals. The naturally derived compounds have demonstrated significant antiviral effects against the hepatitis virus and they interfere with different stages of the life cycle of the virus, viral release, replication, and its host-specific interactions. Antiviral activities have been demonstrated by natural products such as phenylpropanoids, flavonoids, xanthones, anthraquinones, terpenoids, alkaloids, aromatics, etc., against hepatitis B and hepatitis C viruses. The recent studies conducted to understand the viral hepatitis life cycle, more effective naturally derived drugs are being produced with a promising future for the treatment of the infection. This review emphasizes the current strategies for treating hepatitis, their shortcomings, the properties of natural products and their numerous types, clinical trials, and future prospects as potential drugs.

Hepatitis B and Hepatitis D Viruses: A Comprehensive Update with an Immunological Focus

Hepatitis B virus (HBV) and hepatitis delta virus (HDV) are highly prevalent viruses estimated to infect approximately 300 million people and 12-72 million people worldwide, respectively. HDV requires the HBV envelope to establish a successful infection. Concurrent infection with HBV and HDV can result in more severe disease outcomes than infection with HBV alone. These viruses can cause significant hepatic disease, including cirrhosis, fulminant hepatitis, and hepatocellular carcinoma, and represent a significant cause of global mortality. Therefore, a thorough understanding of these viruses and the immune response they generate is essential to enhance disease management. This review includes an overview of the HBV and HDV viruses, including life cycle, structure, natural course of infection, and histopathology. A discussion of the interplay between HDV RNA and HBV DNA during chronic infection is also included. It then discusses characteristics of the immune response with a focus on reactions to the antigenic hepatitis B surface antigen, including small, middle, and large surface antigens. This paper also reviews characteristics of the immune response to the hepatitis D antigen (including small and large antigens), the only protein expressed by hepatitis D. Lastly, we conclude with a discussion of recent therapeutic advances pertaining to these viruses.