Natural history of the HBsAg carrier

Chronic hepatitis B virus infection in the Asia-Pacific region and Africa: review of disease progression

Countries in the the Asia-Pacific region and Africa tend to have the highest prevalence of hepatitis B infection worldwide. Hepatitis B infection progresses from an asymptomatic persistently infected status to chronic hepatitis B, cirrhosis, decompensated liver disease and/or hepatocellular carcinoma. The aim of this review was to summarize rates and risk factors for progression between disease states in the Asia-Pacific region and Africa. A literature search was conducted employing MEDLINE and EMBASE (1975-2003) using the following key words: hepatitis B, natural history, disease progression, cirrhosis, hepatocellular carcinoma, mortality, Africa and the Asia-Pacific region. Bibliographies of articles reviewed were also searched. Ranges for annual progression rates were: (i) asymptomatic persistent infection to chronic hepatitis B, 0.84-2.7%; (ii) chronic hepatitis B to cirrhosis, 1.0-2.4%; and (iii) cirrhosis to hepatocellular carcinoma, 3.0-6.6%. Patients with asymptomatic persistent infection and chronic hepatitis B had relatively low 5-year mortality rates (<4%); rates (>50%) were much higher in patients with decompensated liver disease and hepatocellular carcinoma. No data were found for progression rates in African populations. Hepatitis B e antigen was a risk factor for chronic hepatitis B, and bridging hepatic necrosis in chronic hepatitis B increased the risk of cirrhosis. Risk factors for hepatocellular carcinoma included cirrhosis, co-infection with hepatitis C virus, and genetic and environmental factors. In this review, wide ranges of disease progression estimates are documented, emphasizing the need for further studies, particularly in Africa, where progression rates are largely not available. Summarizing information on factors associated with disease progression should assist in focusing efforts to arrest the disease process in those at most risk.

Epidemiology of precore mutants of hepatitis B in the United Kingdom

A point mutation assay was used to study the codon 28 and codon 1 precore mutant status of 310 chronic hepatitis B carriers (82 HBeAg positive and 228 HBeAg negative). Fourteen of 228 (6%) of HBeAg negative carriers had high levels of serum HBV DNA. Nine of these were explained by precore variants, three by core promoter variants, and two were not explained by recognised precore changes. Nested PCR detected serum HBV DNA in 36% (82/228) of HBeAg negative carriers and 63% (52/82) of these had precore variants. Four of 82 (4%) of the HBeAg positive carriers had precore variants, all as mixed mutant/wild type populations and evidence indicated that these carriers were seroconverting. Overall 23% (52/228) of HBeAg negative carriers had both serum HBV DNA and codon 1 or 28 precore mutations. A sexual transmission event from an HBeAg negative carrier with a relatively low serum HBV DNA level (10(4)-10(6) genome copies/ml) and only core promoter mutations was observed. Despite high rates of variant carriage in the antenatal sub-group perinatal transmission was not observed. The results of direct sequencing on 45 carriers validated the point mutation assay and also showed that codon 28 mutations were only seen in carriers with the genotype CCT at codon 15. For the Caucasian population a higher prevalence of codon 28 mutations (13/25 or 52%) than expected was seen. Liver biopsy data indicated that there was no link between the presence or absence of precore mutants and the severity of liver disease.

The value of quantitative measurement of HBeAg and HBsAg before interferon-alpha treatment of chronic hepatitis B in children

Serum concentrations of HBsAg, HBeAg and hepatitis B virus DNA were measured quantitatively before interferon treatment in 23 children (17 boys, 6 girls) suffering from chronic hepatitis B, and correlated to the outcome of the treatment. Five children remained HBsAg- and HBeAg-positive throughout the treatment and 6 months after the end of the treatment (non-responders), 12 children eliminated HBeAg but not HBsAg (partial responders) and six eliminated HBeAg and HBsAg (complete responders). The five non-responders had significantly higher initial HBsAg and HBeAg concentrations and significantly lower alanine aminotransferase levels than the partial or complete responders. The six complete responders had significantly lower HBsAg concentrations than the partial or non-responders, and seemed to be younger. No significant difference in HBV DNA levels was found in the three response groups. These data suggest that quantitative assays of HBsAg and HBeAg are particularly useful in selecting patients with chronic hepatitis B for interferon therapy.

Methotrexate for rheumatoid arthritis. Suggested guidelines for monitoring liver toxicity. American College of Rheumatology

Methotrexate (MTX) has become an important drug in the treatment of rheumatoid arthritis (RA). The American College of Rheumatology convened a committee to assess the risks of development of clinically significant liver disease (CSLD) during MTX treatment, to evaluate the risk and role of surveillance liver biopsies, and to provide recommendations about monitoring patients for liver toxicity. The committee recommends obtaining liver blood tests (alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase, albumin, bilirubin), hepatitis B and C serologic studies, and other standard tests including complete blood cell count and serum creatinine tests prior to starting treatment with MTX. A pretreatment liver biopsy should be considered only for patients with a history of prior excessive alcohol consumption, persistently abnormal baseline AST values, or chronic hepatitis B or C infection. At intervals of every 4-8 weeks the AST, ALT, and albumin levels should be monitored. Routine surveillance liver biopsies are not recommended for RA patients receiving traditional doses of MTX. However, a biopsy should be performed if a patient develops persistent abnormalities on liver blood tests. These are defined as elevations (above the upper limit of laboratory normal) in the AST in 5 of 9 determinations within a given 12-month interval (6 of 12 if tests are performed monthly) or a decrease in serum albumin below the normal range. The recommendations for monitoring and selection of patients for liver biopsy identify patients at potential risk for CSLD, and thus significantly reduce the number or patients who would be exposed to this procedure. Close monitoring is essential to reduce the risk of unrecognized serious liver disease. These recommendations should be revised as necessary to reflect new and compelling information.

Persistence of hepatitis B virus DNA after reduction of viral replication in serum and liver

Liver and serum samples from 67 children with hepatitis B chronic infection, whether or not treated with recombinant interferon, were analyzed for the presence of hepatitis B virus DNA. After follow-up, 44/67 (66%) still had serum and liver viral DNA; 23/67 (34%) were negative for serum hepatitis B virus DNA. Of the 23 children in the latter group, liver biopsy was available in 21 and viral DNA was not detected by Southern-blot in 20. In the remaining patient, viral DNA was in an episomal nonreplicative form. Polymerase chain reaction was performed in the 21 serum samples negative for viral DNA by conventional techniques and in the 21 liver samples (20 negative for hepatitis B virus DNA and 1 with episomal nonreplicative form). All liver samples resulted in a positive reaction to viral DNA by this technique. Serum viral DNA by polymerase chain reaction was detected in 15/21 (71%) of these patients. The mean of alanine aminotransferase values was similar in patients with or without hepatitis B virus DNA in serum by polymerase chain reaction. In summary, in the majority of the patients who respond to the therapy, there is a persistence of viral replication detected by polymerase chain reaction. This fact explains the persistence of serum HBsAg in these patients. However, more studies are necessary to determine the meaning of the presence of hepatitis B virus DNA that is only detectable by polymerase chain reaction.

Occupational exposure to human immunodeficiency virus and hepatitis B virus: a comparative analysis of risk

OBJECTIVE

To estimate the occupational risk from infection with the human immunodeficiency virus (HIV) in terms of loss of (quality-adjusted) life expectancy, and to compare that risk to those posed by other hazards faced by health care workers.

DESIGN

Decision-analytic model.

RESULTS

For a 30-year-old female health care worker (unvaccinated for hepatitis B virus [HBV]), the loss of life expectancy from a needlestick from a symptomatic HIV-positive (HIV+) patient is 39 days (range, 17 to 93 days), as compared with a loss of 17 days from a needlestick from a patient who is hepatitis-B-surface-antigen-positive (HBsAg+), and 38 days from a needlestick from a patient who is hepatitis-B-e-antigen-positive (HBeAg+). When morbidity is included in the analysis of risk (through calculation of the quality-adjusted loss of life expectancy), the risk from both HBV and HIV increases. The quality-adjusted loss of life expectancy due to a needlestick exposure from a symptomatic HIV+ patient is 45 days (range, 20 to 108 days), as compared with a quality-adjusted loss of life expectancy of 48 days from a needlestick from an HBsAg+ patient, and 109 days from a needlestick from a patient who is known to be HBeAg+. By comparison, a cross-country automobile trip is associated with a loss of life expectancy of approximately 1 day. The 45- to 50-day loss of quality-adjusted life expectancy from percutaneous exposures to HIV and HBV is approximately the same magnitude as the gain in life expectancy from 10 years of annual screening for breast cancer with mammography and physical examination.

CONCLUSIONS

The risk associated with percutaneous exposures to symptomatic HIV+ patients is comparable to other risks that health care workers have faced knowingly and have accepted in the recent past. However, the loss of quality-adjusted life expectancy associated with a needlestick exposure is significant. Identification of cost-effective methods that increase the safety of medical personnel but also ensure full access to high-quality care for HIV+ patients should be a high priority.

Effect of duration of hepatitis B virus infection on the association between human immunodeficiency virus type-1 and hepatitis B viral replication

This study examined the effect of duration of hepatitis B virus infection on the association between human immunodeficiency virus type-1 infection and hepatitis B viral replication. Twenty-five chronic HBsAg carriers were studied. Presence of hepatitis B virus DNA and expression of HBeAg were more frequent among 20 chronic HBsAg carriers positive for human immunodeficiency virus type-1 antibody compared with five chronic HBsAg carriers negative for human immunodeficiency virus type-1 antibody, but the associations were not statistically significant. Hepatitis B virus DNA and HBeAg were inversely related to duration of hepatitis B virus infection (p less than 0.001). Stratifying for duration of hepatitis B virus infection, the presence of viral replication was similar among patients negative and positive for antibody to human immunodeficiency virus type-1. Hepatitis B virus DNA levels did not increase with the decline of cellular immunity over time. In conclusion, hepatitis B virus replication among chronic carriers may be a function of duration of hepatitis B virus infection rather than of an effect of human immunodeficiency virus type-1.

Diminished response to recombinant hepatitis B vaccine in homosexual men with HIV antibody: an indicator of poor prognosis

Three doses of a recombinant DNA HBV vaccine (MSD) were given to healthy male homosexuals. Seventy-eight out of 104 (77.6%) participants had detectable antibody (anti-HBs) two months after the third dose. Seroconversion occurred in only 9 out of 27 subjects (33.3%) who were anti-HIV positive compared with 69 out of 77 (89.6%) who were negative (chi 2 = 30.8; P less than .001). Fifteen of the 18 anti-HIV positive who did not mount an antibody response to the hepatitis B vaccine (anti-HBs) later progressed to persistent generalised lymphadenopathy syndrome (5), AIDS-related complex (5), and AIDS (5). Only one of the nine anti-HIV positive anti-HBs responders developed PGL (chi 2 = 10.14; P less than .005). Our results show that anti-HIV positive homosexuals are poor responders to the recombinant hepatitis B vaccine and anti-HIV positive non-responders are more likely to develop clinically apparent HIV infection.

Factors affecting clearance of hepatitis B e antigen in hepatitis B surface antigen carrier children

To understand the natural history of chronic hepatitis B virus infection in children, we studied factors affecting the clearance of hepatitis B e antigen (HBeAg). One hundred sixty-nine apparently healthy children whose sera were positive for HBeAg and hepatitis B surface antigen (HBsAg) and who were recruited by screening were followed prospectively to delineate the HBeAg clearance rate. Another 59 carrier children visiting the outpatient clinic because of symptoms or abnormal liver function were studied for comparison. The annual HBeAg clearance rate was low (less than 2%) during the first 3 years of life but increased with age. The HBeAg clearance rate in children older than 6 years of age was lower in those whose mothers had HBsAg positivity (14.3%) than in those whose mothers had no detectable HBsAg (35.3%). Children who were brought for medical care had higher HBeAg clearance rates (42.4%) than those who were recruited by screening (14.6%) because immune clearance of hepatitis B virus and hence HBeAg often led to hepatocellular damage manifested by abnormal liver function profiles or by symptoms that had caused the parents to seek medical care for their children. We conclude that age, source of subject recruitment, and maternal HBsAg status are important factors affecting HBeAg clearance rate in HBsAg carriers.

HBeAg/anti-HBe circulating immune complexes in patients chronically infected with hepatitis B virus

An enzyme-linked immunosorbent assay based on the ability of polyethylene-glycol (PEG) fixed on a solid support to adsorb circulating macromolecules (PEG-solid phase test) was developed in order to provide evidence for the existence of immune complexes of HBeAg/anti-HBe (HBeAg/anti-HBe complex) in sera of HBsAg chronic carriers. The method can detect HBeAg in immune complexes whether antigen or antibody is in excess. In the chronic phase of HBV infection, HBeAg/anti-HBe complexes are formed transiently in the course of the disease, unrelated to the phases of virus replication or peaks of hepatocytolysis, or to the histologic picture of liver disease. Our study indicates that this method offers a new approach to the understanding of biological and clinical problems of the HBeAg/anti-HBe antigenic system in chronic HBV infection.

Treatment of protracted acute type B hepatitis with recombinant alpha-A-interferon. A pilot study

Six individuals with protracted acute type B hepatitis were treated with recombinant alpha-A-interferon for 12 weeks. Two females eliminated the HBV completely, while 4 males did not respond. Response was preceded by a flare-up of the liver disease. It appears that responses to interferon are not higher in protracted acute type B hepatitis than in progressed chronic active hepatitis B. This assumption has to be proven in larger studies on a statistical basis.

An acupuncture-associated outbreak of hepatitis B in Jerusalem

Two clusters of between five and eleven cases of hepatitis B associated with acupuncture treatment by a physician occurred in Jerusalem in late 1986. The origin of the outbreak is believed to have been an Ethiopian immigrant surgical patient, a known HBsAg carrier, who infected an operating room nurse during a surgical procedure. This is the first recorded instance of transmission of HBV from an Ethiopian immigrant to the local Israeli population. We reiterate the need for the enforcement of correct sterilization techniques in all skin-piercing settings, a step which in many countries will require the licensing of a variety of occupations not presently covered by health regulations.

Chronic hepatitis: pathogenesis and treatment

Current therapies for chronic viral hepatitis, autoimmune "lupoid" chronic active hepatitis, and drug-induced chronic hepatitis are discussed in the context of recent advances in our understanding of the pathophysiology of chronic active liver disease. Accurate diagnosis is the cornerstone of proper treatment; the limitations and pitfalls of conventional techniques are discussed. Current theories of the pathogenesis of chronic hepatitis B are reviewed to provide a framework for the use of antiviral drugs. Data from the early results of therapy with adenine arabinoside, acyclovir, and immunomodulatory agents are reviewed, and the theoretical basis for the use of alpha-interferon as well as preliminary data supporting its efficacy is presented. Strategies for the treatment of chronic delta hepatitis and chronic non-A, non-B viral hepatitis are discussed as well. The immunological changes associated with autoimmune chronic active hepatitis are described to help define those patients with chronic active hepatitis who are likely to respond to immunosuppressive therapy. The recognized hazards of long-term corticosteroid therapy are indicated and guidelines for the management of these patients are suggested. Chronic drug-induced liver disease will usually improve with cessation of the offending agent. An approach to the patient with suspected drug-induced chronic hepatitis is indicated. Finally, the role of liver transplantation is mentioned as the ultimate treatment modality available for endstage liver disease.

Identification of different degrees of hepatitis B virus (HBV) replication by serological (HBV-DNAp, HBcAg and HBV-DNA) and histological (HBcAg) methods

The incidence of HBV-DNA polymerase, HBV-DNA and serum and liver HBcAg in 104 chronic HBsAg carriers was studied. HBV-DNA was the most frequently detected marker, followed by HBcAg and HBV-DNAp. According to their individual or combined presence, four different serological patterns of viral replication were discerned: 53 patients had all these markers, 30 had HBV-DNA but lacked HBV-DNAp (15 with and 15 without HBcAg) and 21 had no such markers detectable. The simultaneous positivity for all of those markers was observed only in HBeAg-positive patients. HBV-DNA alone or along with HBcAg was found in a similar incidence irrespective of the HBe system. Liver HBcAg was found in all but four patients with and in four without HBV-DNA. Viral DNA concentration was significantly (p less than 0.001) higher when HBV-DNAp tested positive. Indeed, HBeAg rather than anti-HBe patients had higher (p less than 0.005) levels of HBV-DNA. In HBeAg-positive patients, the nuclear HBcAg staining was significantly (p less than 0.05) higher when HBV-DNAp tested positive. In DNA polymerase-negative patients, but positive for HBV-DNA, those with or without HBcAg had a similar percentage of core antigen staining. The same distribution was seen in anti-HBe, HBV-DNA-positive patients. However, the mean percentage of hepatocytes displaying cytoplasmic HBcAg did not differ significantly among patients with HBV-DNA, irrespective of the HBe system and the HBV-DNAp status. Such patients had significantly (p less than 0.001) higher ALT levels than those without viral DNA.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomised controlled trial of lymphoblastoid interferon for chronic active hepatitis B

Thirty male patients (27 homosexual) with biopsy proven chronic active hepatitis B were randomised to receive lymphoblastoid interferon (Wellferon) or no treatment. All patients were HBeAg positive and had continuing viral replication. Patients receiving treatment were given a single daily intramuscular injection of interferon for 28 days at a starting dose of 2.5 MU/m2 increasing to a maximum of 7.5 MU/m2/day. Transient side effects of malaise and influenza like symptoms occurred in all patients and resolved rapidly after treatment. Hepatitis B viral replication was suppressed during interferon treatment in all patients but the effect was limited to the period of therapy. After one year there was no appreciable difference in viral markers between the two groups of patients and this treatment schedule appears less effective than the thrice weekly, three month regimes recently reported from other centres.

Long-term follow-up study of asymptomatic HBsAg-positive voluntary blood donors in Austria: a clinical and histologic evaluation of 242 cases

Two hundred forty-two voluntary blood donors, referred after detection of HBsAg positivity, underwent clinical evaluation and liver biopsy and were prospectively followed for an average of 3.5 years. At initial testing, 65% of HBsAg carriers had normal laboratory findings; during follow-up, 26% of these carriers developed abnormal test results, at least transiently. Liver histology was normal in 31.4%, revealed nonaggressive liver disease in 63.6% and chronic active hepatitis or cirrhosis in 5%, only. All except one case of chronic active hepatitis or cirrhosis were associated with abnormal blood biochemical tests. Sequential liver biopsies obtained in 56 HBsAg carriers after a minimal interval of 4 years showed mitigation of inflammatory changes in 5.4% and developing chronic active hepatitis in three cases (5.4%). One carrier died of primary hepatocellular carcinoma. Upon follow-up, HBsAg persisted in 98%. Anti-HBe was found in 90% of all carriers already at the initial testing. HBeAg positivity (7.5%) was associated with chronic active hepatitis as well as nonaggressive liver disease; clearance of HBeAg occurred in 40% after 2 to 8 years. Because of the subclinical progression of liver disease and the increased risk for developing primary hepatocellular carcinoma in asymptomatic HBsAg carriers, routine blood testing, including alpha-fetoprotein screening, as well as abdominal ultrasound surveillance are indicated. Liver biopsy, however, should be restricted to carriers with abnormal biochemical findings.

Changes of hepatitis B virus (HBV) markers during prolonged recombinant interferon alpha-2A treatment of chronic HBV infection

Eleven HBsAg chronic carriers were treated with recombinant-interferon (rIFN)-alpha-2A with either 20 X 10(6) (n = 6) or 10 X 10(6) IU/m2 body surface (n = 5), i.m. twice weekly for 6 months. HBV-markers were tested monthly for 15 months. Throughout the follow-up, 6 patients (54%) became HBeAg, HBV-DNAp and HBV-DNA negative (responders). In addition, 8 were HBcAg-negative, 10 anti-HBc-IgM-negative and 2 HBsAg/IgM complexes negative. All patients gave polymerized human serum albumin receptors and HBsAg-positive results. The low rIFN dose seems to be more efficient for clearing HBV-markers than the high dose. Responder patients already showed lower (P less than 0.05) HBsAg concentration and HBsAg/IgM complexes levels in their basal samples as compared to non-responders, and exhibited under rIFN treatment significant decreases (P less than 0.05) in all HBV-markers studied. In conclusion, the most reliable HBV-markers to be assayed in the evaluation of antiviral therapy are HBV-DNA, HBV-DNAp or HBcAg. The testing of pHSA-R, HBsAg/IgM complexes and anti-HBc-IgM does not seem to be very useful.

Randomised controlled trial of lymphoblastoid interferon for chronic active hepatitis B

Thirty male patients (28 homosexual or bisexual) with biopsy proven chronic active hepatitis B were randomised to receive lymphoblastoid interferon (Wellferon) or no treatment. All patients were HBeAg-positive and had continuing viral replication. Interferon was given as a single daily i.m. injection for 28 days at a starting dose of 2.5 megaunits/m2 increasing to a maximum of 7.5 megaunits/m2/day. Transient side-effects occurred in all patients. Hepatitis B viral replication was suppressed during interferon treatment in all patients but the effect was limited to the period of therapy. After 1 year there was no appreciable difference in viral markers between the two groups of patients and this treatment schedule appears less effective than the thrice weekly, 3-month regimes reported from other centres.