Update On Prevalence, Diagnosis and Treatment of Hepatitis B Virus

UPDATE ON PREVALENCE, DIAGNOSIS
AND TREATMENT OF HEPATITIS B

VIRUS
ESSAY
Submitted for the partial Fulfillment of the
Master degree in Tropical Medicine
Presented by
Dr. Hesham Noaman Abdel Raheem Mustafa

(M.B., B.Ch.)
Under Supervision of
Dr. Laila Ahmad Mohammad

Professor of Tropical Medicine
Faculty of Medicine
Cairo University
Dr. Ahmad Nabil Lotfy Hassan

Lecturer of Tropical Medicine
Faculty of Medicine
Cairo University
Faculty of Medicine
Cairo University
2005
ACKNOWLEDGEMENT
I would like to start by thanking "God" for
his help during this work as a part of his generous
help through out my life.
I am deeply indebted to Professor. Dr. LAILA
AHMAD MOHAMMAD (Professor of Tropical
Medicine, Faculty of Medicine, Cairo University) for
suggesting, planning and supervising this work and
for her continuous guidance and encouragement .
I would like to express my deepest thanks
and gratitude to DR. AHMAD NABIL LOTFY
HASSAN (Lecturer of Tropical Medicine, Faculty of
Medicine, Cairo University) for his wise guidance,
criticism and valuable suggestions throughout the
present study.
Last, but not least, to all patients who are
suffering, hoping that this work will give them hope
for a better future.
Hesham Noaman Abdel Raheem

(M.B., B.Ch.)
December 2005
II
Table of Contents
Title
Introduction and Aim of the Work
Page No.
1-3
Review of Literature
1
Historical Note.
Morphology of Hepatitis B Virus.
5-20
Epidemiology of HBV.
21-34
Clinical Presentation and Sequelae.
35-44
HBV Status in Egypt.
45-54
Diagnosis of Acute and Chronic Hepatitis B.
55-76
Treatment of Chronic Hepatitis B.
77-112
Prevention of HBV.
113-124
Summary and Conclusions
125-126
Recommendations
References
Arabic Summary
127
128-159
III
List of Figures
Title
Fig. (1): Schematic diagram of hepadnavirus particles.
Fig. (2): Electron microscopic presentation of HBV particles.
Fig. (3): Genome organization of HBV.
Fig. (4): A group of hepatitis B virions (right) and enlargements of the
two exposed cores.
Fig. (5): Hepatitis B Surface Proteins.
Fig. (6): Largest HBs proteins.
Fig. (7): Middle Hepatitis B proteins (MHBs).
Fig. (8): Schematic diagram of two loops of the "a" determinant of HBs
protein.
Fig. (9): Small Hepatitis B proteins (SHBs).
Fig. (10): HBV outer envelope contains high amounts of hepatitis B
surface proteins.
Fig. (11): Diagram showing Purified virions possess the HBc protein.
Fig. (12): HBV has evolved a unique life cycle.
Fig. (13): HBsAg Endemicity.
Fig. (14): Countries with areas with moderate to high risk of infection.
Fig. (15): Geographic pattern of Hepatitis B prevalence.
Fig. (16): Geographic distribution of HBV Genotype.
Fig. (17): Analysis of 1860 acute hepatitis cases.
Fig. (18): Evolution of HBV markers in acute infection.
Fig. (19): Characteristics of progression to chronic HBV infection.
Fig. (20): Mode of action of interferon alpha (INF-).
Fig. (21): Global status of countries using HepB vaccine in their
national infant immunization system.
Page
No.
6
7
9
10
12
13
14
15
16
16
18
20
21
22
23
47
49
61
62
80
118
IV
List of Tables
Title
Table (1): Characteristics of endemic patterns of hepatitis B
virus infection.
Table (2): Geographic Distribution of HBV Genotypes.
Table (3): Prevalence of HCV, HBV and HBsAg in Egypt 1996.
Table (4): Etiology of acute viral hepatitis among 200 patients.
Table (5): The frequency of acute hepatitis B in different age
groups in year 2002 in comparison to year 1983.
Table (6): HBeAg.
Table (7): Interpretations of available serologic test results
for HBV.
Table (8): Serological test findings at different stages of HBV
infection and in convalescence.
Table (9): Hepatitis B tests.
Table (10): Antibody to Hepatitis B Surface Antigen (HBsAg
Assay).
Table (11): Hepatitis B Surface Antigen (Anti-HBs Assay).
Table (12): Hepatitis B Virus Core Antigen (Anti-HBc Assay).
Table (13): Histological Activity Index.
Table (14): Modified HAI grading: necroinflammatory scores.
Table (15): Glossary set by Keeffe et al., 2004 to correlate
clinical terms with laboratory results.
Table (16): The stages of HBV in correlation with the
laboratory results.
Table (17): Interpretation of serological markers.
Table (18): Hepatitis B Therapies and Treatment.
Table (19): Types and Properties of Interferon
Table (20): Determinant of responsive factors to interferon.
Table (21): Comparison of Three Approved Treatments of
Chronic Hepatitis B.
Table (22): Goals of Therapy and Definitions of Response to
Therapy in Chronic Hepatitis B.
Table (23): Available Agents for Treatment of Chronic Hepatitis
B.
Table (24): Recommendations for Treatment of Chronic
Hepatitis B.
Table (25): Post Exposure Prophylaxis and Post Liver
Transplant Therapies & Preventive Vaccines for HBV.
Table (26): Results of Lamivudine Monotherapy Prior to OLT.
Table (27): Effect of Combination Therapy with HBIG and
Lamivudine to Prevent HBV Reinfection after OLT.
Page
No.
27
47
48
48
49
64
65
66
66
67
67
68
72
73
74
75
76
79
81
83
104
105
106
112
119
123
124
List of Graphs
Title
Graph (1): Virological response of chronic hepatitis C patients
with and without past history of HBV.
Graph (2): Age distribution of patients with acute HBV.
Graph (3): Lamivudine: Histologic Improvement at week 52 in
HBeAg-positive patients.
Graph (4): Effect of Lamivudine on HBV DNA Levels.
Graph (5): Response to Lamivudine in HBeAg-negative CHB.
Graph (6): Treatment of Lamivudine Resistance: Prospective
study of Adefovir vs Lamivudine vs Combination Therapy.
Graph (7): HBeAg Seroconversion with Lamivudine: Effect of
treatment Duration and Baseline ALT.
Graph (8): HBeAg-positive patients: Adefovir vs placebo for 48
weeks.
Graph (9): Long-term Adefovir in HBeAg-negative Patients:
Serum ALT.
Graph (10): Long-term Adefovir in HBeAg-negative Patients:
Median Serum HBV DNA.
Graph (11): Adefovir vs Placebo: Change from Baseline in HBV
DNA.
Graph (12): Entecavir Treatment of Lamivudine-resistant
Hepatitis B.
Page
No.
42
50
86
87
88
90
91
94
95
96
96
97
VI
List of Abbreviations
Abbreviation
ADV
Anti-HBc
Anti-HBe
Anti-HBs
ALT
AST
CHB
cccDNA
CTL
ETV
FHF
GMCSF
HBV
HBIG
HBcAg
HBeAg
HBsAg
INF-
LAM
LHBs
MHBs
ORFs
OLT
PCR
Pre-S1, pre-S2
SHBs
ULN
WHO
WT
Term
Adefovir depevoxil
Antibody to HBcAg
Antibody to HBeAg
Antibody to HBsAg
Alanine aminotransferase
Aspartate aminotransferase
Chronic hepatitis B
covalently closed circle DNA
cytotoxic T lymphocyte
Entecavir
Fulminant hepatic failure
granulocyte macrophage colony stimulating factor
Hepatitis B virus
Hepatitis B immune globulin
Hepatitis B core antigen
Hepatitis B e antigen" Envelope "
Hepatitis B surface antigen
Interferon Alfa
Lamivudine
Large HBs protein
Middle HBs protein
Open reading frames
Orthotopic liver transplantation
Polymerase chain reaction
Envelope protein epitopes
Small HBs protein
Upper limit of normal
World health organization
Wild Type
UPDATE ON PREVALENCE, DIAGNOSIS

AND TREATMENT OF HEPATITIS B VIRUS
ESSAY
Submitted for the partial Fulfillment of the
Master degree in Tropical Medicine
Presented by
Dr. Hesham Noaman Abdelraheem Mustafa

(M.B., B.Ch.)
Under Supervision of
Dr. Laila Ahmad Mohammad

Professor of Tropical Medicine
Head of Tropical Medicine Department,
Faculty of Medicine
Cairo University
Dr. Ahmad Nabil Lotfy Hassan

Lecturer of Tropical Medicine
Tropical Medicine Department,
Faculty of Medicine
Cairo University
Faculty of Medicine
Cairo University
2004
INTRODUCTION AND AIM OF THE WORK

Hepatitis B virus (HBV) infection is a serious global health
problem, with 2 billion people infected worldwide, and 350 million
suffering from chronic HBV infection (Lavanchy, 2004).
Being the 10th leading cause of death worldwide, HBV infections
result in 0.5 to 1.2 million deaths per year caused by chronic hepatitis,
cirrhosis, and hepatocellular carcinoma; the last accounts for 320 000
deaths per year In Western countries, the disease is relatively rare and
acquired primarily in adulthood, whereas in Asia and most of Africa,
chronic HBV infection is common and usually acquired perinatally or in
childhood (Alter, 2003; Lavanchy, 2004).
Hepatitis B is a major health problem in Egypt (Attia, 1998). As
for acute HBV infection, the prevalence of HBV in Egypt is not yet
adequately estimated after the use of hepatitis B vaccine (Zakaria et al.,
2000).
However, Orfi (2002) stated that the prevalence of acute HBV
infection was 12% in children 4-14 years old and 50.9% in adults > 14
years old. The most common age group infected by HBV ranged from
21-30 years (42.4%) whereas the least infected age group was from 4-8
years (3%). Sherif et al. (1985) reported that HBV was more prevalent in
Upper Egypt (11.7%) than in Lower Egypt (8.8%).
Initial testing for hepatitis B should include hepatitis B surface
antigen and hepatitis B core antibody, (which is frequently reported as
total core antibody and subsequently fractionated into its IgM and IgG
components) (Russo, 2004). The presence of hepatitis B core IgM
indicates acute infection or, in some cases, reactivation; the presence of
hepatitis B core IgG indicates prior infection (Russo, 2004).
The primary aim of antiviral therapy is durable
suppression of serum HBV DNA to the lowest level possible. The
threshold level of HBV DNA for determination of candidacy for therapy

is >10
copies/ml for patients with (HBeAg) positive chronic hepatitis B
(Keeffe et al, 2004). A lower serum HBV DNA threshold is appropriate

for patients with HBeAg-negative chronic hepatitis B and those with
decompensated cirrhosis, and the scientists recommends thresholds of
10
copies/ml and 10 copies/ml respectively (Keeffe et.al., 2004).

Effective vaccines for hepatitis B virus have been available
since 1982; infant and childhood vaccination programs introduced in the

1990s have resulted in a marked decrease in new infections. Risk factors
for progression to chronic infection include age at the time of infection
and impaired immunity (Lin and Kirchner, 2004). From 15 to 30
percent of patients with acute hepatitis B infection progress to chronic
infection. Medical therapies for chronic hepatitis B include interferon
alfa-2b, lamivudine, and the nucleotide analog adefovir dipivoxil (Lin
and Kirchner, 2004).
Chronic infection with hepatitis B and its sequelae remains a
major
global
health
concern.
Despite
recommendations
and
implementation of vaccination programs, the health and economic

burdens are still significant (Tran and Martin, 2004). People in endemic
areas and immigrants from these areas need to be adequately screened
and treated. HBeAg-negative chronic hepatitis is increasingly recognized
with additional challenges in management. Programs implementing
primary prophylaxis strategies such as vaccination of high-risk adult and
adolescent groups should continue (Tran and Martin, 2004).
The aim of the present work is to reveal of the prevalence of
HBV worldwide and in Egypt and to discuss updated clinical issues in the
diagnosis and modern modalities of treatment.
REFERENCES:
1. Alter M.J. (2003): Epidemiology of hepatitis B in Europe and
worldwide.J Hepatol; 39 Suppl 1:S64-9.
2. Attia M.A. (1998): prevalence of hepatitis B and C in Egypt and
Africa.Antiver ther; 3(supl 3):1-9.
3. Keeffe E. B., Dieterich D.T.,Han S.H., Jacobson I.M. et. al.
(2004): A Treatment Algorithm for the Management of Chronic
Hepatitis B Virus Infection in the United States. Clinical
Gastroenterology and Hepatology; 2: 87-106.
4. Lavanchy D. (2004): Hepatitis B virus epidemiology, disease
burden, treatment, and current and emerging prevention and
control measures. J Viral Hepat ; 11(2):97-107.
5. Lin, K.W. and Kirchner JT. (2004): Hepatitis B. Am Fam
Physician; 69(8):1863.
6. Orfi M. (2002): The role of hepatitis B virus as a cause of acute
viral hepatitis after the wide use of hepatitis B vaccine in Egypt.
M.Sc. Thesis: Tropical Medicine, Cairo University: 63-71.
7. Russo M. W. (2004): Care and Management of Chronic Hepatitis
B: An Overview for Patients and Family Caregivers Hepatitis B.
Emergency Medicine.
8. Sherif M.M., Abou-Atia M.A., Pazzagalia G. et.al. (1985):
Hepatitis B Virus infection in Upper and Lower Egypt. J. Med.
Virol; 15(2); 129-35.
9. Tran, T.T. and Martin, P. (2004): Hepatitis B: epidemiology and
natural history. Clin Liver Dis.; 8(2):255-66.
10.Zakaria S.; Zakaria M. and Fouad R. (2000): Sero-prevalence
of viral hepatitis markers in a rural and semi-rurual Egyptian
district.Antiviral therapy; 5(suppl 1):12.
/

-

2004
Introduction and aim of the work
INTRODUCTION AND AIM OF THE WORK

Hepatitis B virus (HBV) infection is a serious global health
problem, with 2 billion people infected worldwide, and 350 million
suffering from chronic HBV infection (Alter, 2003).
Being the 10th leading cause of death worldwide, HBV infections
result in 0.5 to 1.2 million deaths per year caused by chronic hepatitis,
cirrhosis, and hepatocellular carcinoma; the last accounts for 320 000
deaths per year In Western countries, the disease is relatively rare and
acquired primarily in adulthood, whereas in Asia and most of Africa,
chronic HBV infection is common and usually acquired perinatally or in
childhood (Lavanchy, 2004).
Hepatitis B is a major health problem in Egypt (Abdelhamed et
al., 2002). As for acute HBV infection, the prevalence of HBV in Egypt
is not yet adequately estimated after the use of hepatitis B vaccine
(Zakaria et al., 2000).
Sherlock and Doodley, 2002 stated that chronic hepatitis B is
often a silent disease. The patient may be virtually symptom-free with
only biochemical evidence of continued activity and may simply
complain of fatigue and being generally unwell. The diagnosis is made
after a routine medical check. Lok and McMahon, 2001 reported that
15-40% of HBV carriers would develop serious sequelae during their
lifetime.
Initial testing for hepatitis B should include hepatitis B surface
antigen and hepatitis B core antibody, (which is frequently reported as
total core antibody and subsequently fractionated into its IgM and IgG
components) (Russo, 2004).The presence of hepatitis B core IgM
indicates acute infection or, in some cases, reactivation; the presence of
hepatitis B core IgG indicates prior infection (Russo, 2004).
-1-
Introduction and aim of the work
The primary aim of antiviral therapy is durable suppression of

serum HBV DNA to the lowest level possible. The threshold level of
HBV DNA for determination of candidacy for therapy is >10
copies/ml for patients with (HBeAg) positive chronic hepatitis B (Keeffe
et al, 2004). A lower serum HBV DNA threshold is appropriate for
patients with HBeAg-negative chronic hepatitis B and those with
decompensated cirrhosis, and the scientists recommends thresholds of
10
copies/ml and 10 copies/ml respectively (Keeffe et.al., 2004).

Effective vaccines for hepatitis B virus have been available since
1982; infant and childhood vaccination programs introduced in the 1990s

have resulted in a marked decrease in new infections. Risk factors for
progression to chronic infection include age at the time of infection and
impaired immunity (Lin and Kirchner, 2004). From 15 to 30 percent of
patients with acute hepatitis B infection progress to chronic infection.
Medical therapies for chronic hepatitis B include interferon alfa-2b,
lamivudine, and the nucleotide analog adefovir dipivoxil (Lin and
Kirchner, 2004).
Chronic infection with hepatitis B and its sequelae remains a major
global health concern. Despite recommendations and implementation of
vaccination programs, the health and economic burdens are still
significant (Tran and Martin, 2004). People in endemic areas and
immigrants from these areas need to be adequately screened and treated.
HBeAg-negative chronic hepatitis is increasingly recognized with
additional challenges in management. Programs implementing primary
prophylaxis strategies such as vaccination of high-risk adult and
adolescent groups should continue (Tran and Martin, 2004).
The aim of the present work is to reveal the prevalence of HBV
worldwide and in Egypt and to discuss updated clinical issues in the
diagnosis and modern modalities of treatment.
-2-
Historical Note
HISTORICAL NOTE
The HBV was discovered in 1966 (Blumberg et al., 1967). HBV,
the causative agent of B-type hepatitis in humans, is a Hepatotrophic
DNA-containing virus that replicates via reverse transcription (Shen et
al., 2004). HBV is the only known DNA virus that has hepatocytes
specificity (Lu et al., 2004a).
Hepatitis B virus (HBV) was the first human hepatitis virus from
which the proteins and genome were identified and characterized. Before
discovery of the hepatitis viruses, two types of hepatitis transmission
were differentiated based on epidemiological observations. Type A was
considered to be predominantly transmitted by the fecal-oral route,
whereas type B was transmitted parenterally (Seo et al., 2004).
In 1966, Blumberg, in a research for polymorphic serum proteins,
discovered a previously unknown antigen in the blood of an Australian
Aborigine (Australia antigen). Four years later, it was recognized that the
appearance of this antigen was related to type B hepatitis (Mao et al.,
2004). Using immune electron microscopy, Dane eventually discovered
virus-like particles that carried this antigen on their surface, in the serum
of hepatitis B patients, and these particles were considered the hepatitis B
virus (Lee et al., 2004).
In 1973, the viral nature of the particles discovered by Dane was
confirmed by the detection of an endogenous DNA polymerase activity
within their core (Schiefke et al., 2004).
This enzyme allowed Shen et al. (2004) to detect and characterize
the HBV genome as a small, circular, partially double-stranded DNA
molecule.
-3-
Morphology of hepatitis B virus
CHAPTER I
MORPHOLOGY OF HEPATITIS B VIRUS
The virion of hepatitis B (Dane particle) consists of surface and
core. The core is formed in hepatocyte nucleus and the surface particles
are made in the cytoplasm. The core contains a DNA polymerase. The
structure is double-stranded and circular. It is approximately 3200
nucleotides in length and has a single-stranded gap of 600-2100
nucleotides (Sherlock and Dooley 2002). The DNA-polymerase reaction
appears to repair the gap. The core contains a core antigen and another
antigen called e is a protein subunit of the core (Shindo et al., 2004).
Hepatitis B virus is spherical with a diameter of 42nm. Using
negative staining of virions adsorbed to the electron microscopic grids, a
double-shelled structure of the virions becomes apparent. The outer
protein shell (or envelop) is formed by the HBs proteins (Kumar and
Agrawal, 2004). Surface structure details such as knobs or spikes as
observed on many other enveloped viruses are found on HBV (Sugauchi
et al., 2004).
The inner protein shell is referred to as the core particle or capsid,
having a diameter of 34nm in cryoelectron microscopy (Hanazaki,
2004). It is composed of HBc protein and encloses the viral DNA, which
is often positively stained (Tsitsilonis et al., 2004).
-4-
Fig. (1) Schematic diagram of hepadnavirus particles. Individual subunits

containing SHBs protein only, HBs protein plus pre-S2 (MHBs), and HBs
protein plus pre-S1 and pre-S2 (LHBs) is shown in intact virus, among
filamensts and spheres. The virus particles contain an internal nucleocapsid
(HBc) and viral genome (Lai et al., 2003a).
-5-
Fig. (2): Electron microscopic presentation of HBV particles. The round 42 nm

particles represent infectious virions (Dane particle). The small empty spheres
and the filaments are non-infectious. The preparation was enriched in virus
particles (Guptan et al., 2002).
HBV Genome:
The complete virus comprises a lipoprotein coat, the HBsAg,
enveloping a nucleocapsid core that contains a small, circular DNA
molecule. Four open reading frames (ORFs) have been identified on the
HBV DNA genome. They encode seven proteins, including a HBV DNA
polymerase molecule with reverse transcriptase activity. The replication
of the virus resembles that of retroviruses and occurs predominantly but
not exclusively in hepatocytes. Virus variants involving genomic
mutations have been identified (Michael et al., 2002).
-6-
There are four partially overlapping ORFs encoding the envelope

(pre-S/S), core (precore/core), polymerase (P) and X proteins. The pre
S/S ORF encodes the large (L), middle (M) and small (S) surface
glycoproteins (Peksen et al., 2004). The precore/core ORF is translated
into a precore polypeptide, which is modified into a soluble protein
HBeAg and the nucleocapsid protein HBcAg. The p protein functions as
a reverse transcriptase as well as a DNA polymerase. The X protein is a
potent transactivator and may play a role in hepatocarcinogenesis (Hahne
et al., 2004).
Expression of the viral gene products is regulated by four
promoters directing the synthesis of a set of viral transcripts, which are
heterogeneous at their 5 ends but coterminal at their 3 ends
(Benhamou, 2004).
HBV envelope is composed of three polypeptides of different size
major, middle and large envelope protein (Kirschberg et al., 2004). The
HBsAg contains several antigenic determinants termed ad, y, w and r
while some 10 subtypes combinations are recognized; the most common
are adw, adr, ayr. These have uneven distribution worldwide and
epidemiologically have proved useful in identifying the source of
hepatitis B outbreaks (Huo et al., 2004).
The HBeAg minus strain is associated with more severe disease
(acute and chronic) and a high rate of progression to cirrhosis (Lin and
Kirchner, 2004).
-7-
Fig. (3): Genome organization of HBV. The outer lines represent the different
classes of transcripts; the bold inner circles the DNA genome as present in the
virion. The four major ORFs (preC/C, preS1/preS2/S, P and X) are indicated
in the center (Kawaguchi et al., 2003).
The Virion DNA:

Using electron microscopy, the DNA of HBV was shown to be
circular; partially double-stranded (Marcellin, 2002).
In vivo, HBV particles are obviously secreted from the infected
cell before the double strand is completed. Thus, the incomplete plus
strand has a defined 5 end but a variable 3 end (Perrillo, 2002).
-8-
The complete minus strand has defined 5 and 3 ends, with a

terminal redundancy of 9 bases, in the region in which the genome is
triple-stranded (Robek et al., 2002).
Fig. (4): A group of hepatitis B virions (right) and enlargements of the two
exposed cores (Tong and Tu, 2004).
The viral polymerase is covalently bound at tyrosine 63 via a

phosphodiester bridges to the 5 end of the minus strand (Humphries
and Dixon, 2003). This linkage caused extraction of virion-derived DNA
to the phenol phase during classical DNA extraction (Hadziyannis et al.,
2003). The 5 end of the plus-DNA strand is formed by an 18-base-long
oligoribnucleotide, which is capped in the same manner as a messenger
RNA-mRNA (Lai et al., 2003b). The genome contains two directly
repeated sequences of 10 or 11 bases, DR1 and DR2 (Tong and Tu,
2004).
From the nucleotide sequence of a double-stranded version of the
DNA genome, it is possible to get six different sequences of amino acid
encoding triplets of nucleotides (codons). If a sequence of potential
codons does not encode a protein, one of the three possible stop codons
randomly interrupts it, whereas protein-encoding sequences are usually
-9-
free of stop codons for a distance of at least 50 codons (Carretero and

Herraiz, 2004).
Protein composition of HBV particles:

(1) Surface proteins (HBs proteins):
Virions and large structures such as the HBs proteins are built from
protein subunits that are held together by noncovalent interactions, and, in
the case of HBV proteins, by disulfide bonds between cysteines of
different protein molecules (Honkoop and de Man, 2003).
In HBs proteins, six protein bands are visible ranging from 24000
to 42000 apparent molecular weight. All of these proteins can also be
stained specifically by immune blotting with an antibody against the
smallest component, P24, which demonstrates that at least one epitope of
the smallest protein is present in the larger proteins. Four of the proteins
contain an oligosccharide linked to one or two of their asparagines
residues (N-linked glycan). These glucoproteins migrate as somewhat
larger molecules in electrophoresis than the nonglycosylated forms
(Sakai et al., 2003).
Enzymatic removal of the glycan shows that HBs proteins contain
only three different HBs polypeptides:
(i)
The largest (LHBs) is converted by partial glycosylation in vivo

from p39 to GP42.
(ii)
A middle-sized protein (MHBs) that is either single or double

glycosylated at GP33 or GP36 and.
(iii)
A small protein (SHBs) that may be glycosylated at GP27 or

nonglycosylated at P24 (Trifan and Stanciu, 2003).
- 10 -
Fig. (5): Hepatitis B Surface Proteins (Trifan and Stanciu, 2003).
(I) Largest Hepatitis B proteins (LHBs):

It contains two domains; Pre-S (composed of the pre-S1 and pre-S2
sequence) and S. In the mature virions, the pre-S domains are accessible
for antibodies; receptors and proteases (Saruc et al., 2002). The S
domain and parts of the pre-S1 sequence are hidden by the pre-S2
sequence of LHBs. During biosynthesis, the entire pre-S domain of HBs
seems to stay initially at the cytosol; thus, the asparagine 4 of the pre-S2
sequence is not glycosylated (Liu and Schinazi, 2002).
The amino end of the pre-S domain carries the sequence
methionine-glycine, which, together with other less well-defined
neighboring amino acids, serves as a signal for the replacement of the
methionine by the C14 fatty acid, myristic acid (Zheng et al., 2002).
Myristylation is not essential for virion formation, but is essential for
virion infectivity of HBV (Zhou et al., 2002).
During virion maturation, the pre-S domains reconfigure in about
50% of the LHBs molecules and translocate to the surface of the particle.
- 11 -
The other 50% remain on the cytosolic side. The significance of this dual
topology of LHBs is obvious; most studies on the attachment of HBV to
the target cells showed the necessity of the pre-S domain for binding to
the cellular receptors, implying that externally localized pre-S is essential
for the viral life cycle. The pre-S domain is one of the most variable
regions of the HBV genome (Duseja et al., 2002).
Fig. (6): largest HBs proteins (Duseja et al., 2002).
(II) Middle Hepatitis B proteins (MHBs):

This minor component of the HBV virion is composed of the S
domain and of the 55 amino acid long pre-S2 domain (Wen et al., 2002).
The pre-S2 domain is hydrophilic and does not contain cysteins. It is very
sensitive to proteases and can be removed selectively from HBs particles
without destroying the S domain. Thus, MHBs is virtually absent in HBV
vaccines that contain protease-treated HBs particles from carrier plasma
(Shang et al., 2002). The pre-S2 domain is located at the surface and
partially covers the S domain of MHBs. The central pan of the pre-S2
- 12 -
domain (amino acid 7-20), which also forms the major epitope, binds a
modified form of serum albumin (Li et al., 2003). HBV carriers with
more than 10mg HBsAg/ml have usually free albumin binding sites on
their particles, whereas at lower HbsAg concentrations all binding sites
are occupied (Tang et al., 2003).
Fig. (7): Middle Hepatitis B proteins (MHBs) (Shang et al., 2002).
(III) Small Hepatitis B proteins (SHBs):

The amino acid sequence of SHBs at the amino and carboxy ends
has been determined biochemically. The internal sequence could be only
partially analyzed by this approach (Cho et al., 2002). However, together
with the protein sequence predicted by the nucleotide sequence, it became
clear that the sequence of SHBs begins at the third conserved AUG of
ORFS (Open reading frames), and that it ends at the stop codon of ORFS
(Chen et al., 2002a). SHBs are rich in hydrophobic amino acids. It has
many tryptophans, but few tyrosines, and thus, unlike most proteins
possesses an ultraviolet absorption spectrum similar to tryptophan.
Furthermore, it contains a very high number of 14 cysteines, which are
cross-linked with each other (Chang et al., 2002).
- 13 -
At asparagine 146, there is a signal for addition of an N-linked

glycan, which is present in approximately half of the molecules (Jung et
al., 2002). This glycan has two complex antennas with terminal sialic
acids (Suzuki et al., 2002).
SHBs occur in stable subtypes that were originally defined by
antibodies. Antigen reactivities that were present on all known HBs
isolates were considered as determinant a. The best-known subtypical
determinants are d or y and w or r (Thakur et al., 2002a).
Fig. (8): Schematic diagram of two loops of the "a" determinant of HBs
protein. The major epitope is located in the second loop between amino acids
139 and 147 (Hwang et al., 2003).
- 14 -
Fig. (9): Small Hepatitis B proteins (SHBs) (Hayashi and Furusyo, 2004).
Furthermore, a subdivision of w into w1 and w4 is possible (Wang

et al., 2002a). Subtyping has been done by DNA sequencing of the SHBs
gene (De Gottardi and Negro, 2004). Because all SHBs subtypes are
able to induce cross-protection after immunization, the significance of
serological or other subtyping is mainly of epidemiological and
phylogenetic interest (Hayashi and Furusyo, 2004).
Fig. (10): HBV outer envelope contains high amounts of hepatitis B surface
proteins. The envelope surrounds the inner nucelocapsid which is comprised
of 180 hepatitis B core proteins arranged in an icosahedral arrangement with
T=3 and T=4 symmetry. The nucleocapsid also contains at least one hepatitis
B polymerase protein as well as the HBV genome (Lacarnini, 2004).
- 15 -
(2) Core proteins:

(I) HBc Protein:
This protein contains many hydrophilic and charged amino acids. It
does not contain lipid or glycan, but if expressed in eukaryotic cells, it
becomes phosphorylated (Carreno et al., 2004). It is synthesized in the
cytosol of the infected cells. As an essential step in the viral life cycle, it
packages its own mRNA and the viral polymerase after formation of the
RNA-polymerase complex and assembles into core particles. A protein
kinase is also packaged. These particles are then enveloped by patches of
the ER membrane, which contains the three HBc proteins (Carretero
and Herraiz, 2004).
Once core particles are assembled and have left the reducing
environment of the cytosol, their structure is stabilized by disulfide
bonds, but the conserved cysteines are not required for assembly or
envelopment (Kondili et al., 2004).
The significance of the HBc protein for the viral life cycle is
evident. After assembly of core particles and encapsidation of the viral
genome, the particles allow envelopment by the HBs proteins and
formation of the virus. Furthermore, some regions within the carboxy
terminal part of the HBc subunits seem to be essential for genome
maturation (Kobak et al., 2004).
Besides being enveloped, the core particle may play an important
role in delivering the mature viral genome into the nucleus of the infected
cell, leading to restoring and amplification of HBV DNA in the nucleus
of the persistently infected hepatocytes (Ding et al., 2004).
- 16 -
Fig. (11): a diagram showing Purified virions possess the HBc protein, which
aggregates to form the core particle (Ding et al., 2004).
(II) HBe Protein:

All hepadnaviruses have evolved to the ability to express a
secretory form of their HBc proteins. They achieve this by the 5 terminal
part of the ORF C called the pre-C sequence. The pre-C sequence
encodes a hydrophobic -helix, which is a secretion signal and allows for
translocation of the HBe protein into the lumen of the Endoplasmic
Reticulum (ER) (Wan et al., 2004). Part of the HBe protein is transported
to the plasma membrane (Tanaka et al., 2004).
Another part of the HBe protein does not reach the ER lumen and
is not cleaved at all. Furthermore, uncleaved HBe precursor protein
accumulates as phosphoprotein (Zhou and Wu, 2004).
HBe protein is not essential for the viral life cycle. Variants
without functional pre-C sequence and HBe protein arise often during
acute or chronic HBV infection, especially during interferon therapy.
High levels of secreted HBe protein are found in low symptomatic highly
- 17 -
viraemic virus carriers. Elimination of HBeAg is usually accompanied by

a flare-up of immune pathogenesis and a decrease of viraemia (Kim and
Sherker, 2004).
These observations suggest that HBe protein may somehow
suppress the immune elimination of HBV producing hepatocytes. It
appears that a functional pre-C sequence inhibits partially HBV
replication (Lai and Terrault, 2004).
The life cycle of the virus:

As with all other viruses, the life cycle of HBV and its relatives in
the animal kingdom can be divided into several steps: Attachment of the
virus to the host cells, Penetration into the cell, Release of the viral
genome, Expression of viral gene products, Replication of the viral
genome, finally, Assembly of virions, and Release of the virus (Zhu et
al., 2004).
HBV have a unique pathway, allowing the entry of newly
synthesized viral DNA from the cytosol into the nucleus (Zhang, 2004).
- 18 -
Fig. (12): HBV has evolved a unique life cycle that results in the production of
enormous viral loads during active replication without actually killing the infected
cell directly (Lacarnini, 2004).
- 19 -
Epidemiology of HBV
CHAPTER II
EPIDEMIOLOGY OF HBV
The world health organization (WHO) estimated that 2 billion
people have been infected by HBV worldwide of these more than 300
millions are chronically infected carriers of whom 25% are at risk of
serious illness and eventually death from cirrhosis or hepatocellular
carcinoma (WHO, 2004). Three quarters of the world population lives in
areas where there are significant levels of infection (Tsai, 2004).
Fig. (13): HBsAg Endemicity (CDC, 2003).
It is estimated that worldwide, more than 50 million new infections

with HBV occur yearly, and as many as 1 million deaths annually can be
attributed to the effects of this infection. Studies of the prevalence of
chronic infections (chronic carriers) have yielded estimates of 250 to 350
million individuals, or about 5% of the earths population. Prevalence of
- 20 -
Epidemiology of HBV
anti-HBs (HBsAb) is much higher than those of chronic carriers (HBsAgpositives) in all populations (Deng et al., 2004).
The annual incidence rate of acute hepatitis B is estimated to be
approximately 7.4 per 100.000 in Western Europe and approximately 3.7
per 100.000 in the U.S.A. (Hahne et al., 2004).
Fig. (14): Countries with areas with moderate to high risk of infection (WHO,
2003).
The prevalence of HBV infection varies markedly throughout

regions of the world (Huo et al., 2004). Hepatitis B is highly endemic in
developing regions with large population such as South East Asia, China,
Sub-Saharan Africa and the Amazon Basin, where at least 8% of the
population are HBV chronic carrier (Wang et al., 2004b). In these areas,
7095% of the population shows past or present serological evidence of
HBV infection. Most infections occur during infancy or childhood. Since
- 21 -
Epidemiology of HBV
most infections in children are asymptomatic, there is little evidence of

acute disease related to HBV, but the rates of chronic liver disease and
liver cancer in adults are high (Yang et al., 2004).
Fig. (15): Geographic pattern of Hepatitis B prevalence (WHO, 2004).
Asia and Africa have previously been classified as areas of high

endemicity for HBV, but in some countries, highly effective vaccination
programmes have shifted this pattern towards intermediate or low
endemicity. Thus, China is now the only country in Asia where HBV
endemicity is high (Cooksley, 2004).
Hepatitis B is moderately endemic in parts of Eastern and Southern
Europe, the Middle East, Japan, India, Korea, the Philippines, Taiwan and
Thailand and part of South America. Between 1060% of the population
have evidence of infection, and 2-7% is chronic carriers. Acute disease
related to HBV is common in these areas because many infections occur
- 22 -
Epidemiology of HBV
in adolescents and adults; however, the high rates of chronic infection are
maintained mostly by infections occurring in infants and children
(Suskind and Rosenthal, 2004). In these areas, mixed patterns of
transmission exist, including infant, early childhood and adult
transmission (Lu et al., 2004b).
The endemicity of HBV is low in most developed areas, such as
North America, Northern and Western Europe and Australia (Song et al.,
2004). In these regions, HBV infects 57% of the population, and only
0.52% of the population is chronic carriers (Flisiak et al., 2004). In
these areas, most HBV infections occur in adolescents and young adults
in relatively well-defined high-risk groups, including injection drug user,
homosexual males, health care workers and patients who require regular
blood transfusion or hemodialysis (Wang et al., 2004b).
Most countries in Africa have high HBV endemicity, with the
exceptions of Tunisia and Morocco, which have intermediate endemicity
(Lada et al., 2004). Zambia has borderline intermediate/high endemicity.
In the Middle East, Bahrain, Iran, Israel and Kuwait are areas of low
endemicity, Egypt, Saudi Arabia, Cyprus, Iraq and the United Arab
Emirates have intermediate endemicity, and Jordan, Oman, Palestine and
Yemen have high endemicity (Zhu et al., 2004).
The outcome of HBV infection is the result of complicated viralhost interactions. As in other infections with non cytopathic viruses, the
immune response is thought to play a crucial role in disease pathogenesis
but there is increasing evidence that a variety of viral mechanisms, some
depending on the function of virally encoded proteins, have a profound
impact on the infected hepatocytes, the liver microenvironment and host
anti-viral responses (Brunetto and Bonino, 2004).
Park et al. (2004) found that chronic hepatitis B is often a silent
disease. The patient may be virtually symptom-free with only
- 23 -
Epidemiology of HBV
biochemical evidence of continued activity and may simply complain of

fatigue and being generally unwell. The diagnosis is made after a routine
medical check. Lin et al. (2004b) reported that 15-40% of HBV carriers
would develop serious sequelae during their lifetime.
The detection and quantification of hepatitis B virus genomes in
molecular biology-based assays appear to be the most reliable methods
for monitoring HBV infection and assessing responses to antiviral
treatment (Akarca et al., 2004).
The endemicity of HBV infection varies greatly worldwide and is
influenced primarily by the predominant age at which infection occurs.
Endemicity of infection is considered high in those parts of the world
where at least 8% of the population is HBsAg-positive. In these areas,
70% to 90% of the population generally has serological evidence of
previous HBV infection. Almost all infections occur either during the
perinatal period or early in childhood, which accounts for the high rates
of chronic HBV infection in these populations (Tong and Tu, 2004).
Occult HBV infection:

Characterized by the presence of HBV infection with undetectable
hepatitis B surface antigen (HBsAg). Serum HBV level is usually less
than 104 copies /ml in these patients. Diagnosis of occult HBV infection
requires sensitive HBV-DNA using the polymerase chain reaction (PCR)
assay. Several possibilities have been hypothesized as the mechanisms of
occult HBV infection. These include:
(i)
Mutations of HBV-DNA sequence;
(ii)
Integration of HBV-DNA into hosts chromosomes;
(iii)
Infection of peripheral blood mononuclear cells by HBV;
(iv)
Formation of HBV- containing immune complex;
(v)
Altered host immune response;

- 24 -
(vi)
Epidemiology of HBV
Interference of HBV by other viruses. The precise prevalence of

occult HBV infection remains to be defined (Wright, 2004).
Loss of HBsAg is associated with marked improvement in clinical
and serum biochemical features of chronic HBV; yet mild degrees of

hepatitis and low levels of viral DNA may persist in the liver (Perrillo,
2004). Occult HBV infection if associated with HCV, increases the
severity of HCV, unfavorable response to IFN therapy and increase risk
for HCC (Allain, 2004).
El-zayadi (2005) described occult HBV infection, as it is the
detection of very low HBV-DNA in individuals who lost all serologic
markers of HBV. May be sero-positive for Anti-HBc +ve, Anti-HBs +ve
or sero-negative for them. It is associated with very low levels of HBV
rather than HBV mutants. No data on the use of antiviral treatment in
patients with occult HBV infection. Its prevalence in high endemic areas
70-90% and in low endemic areas 5-20% but in Intermediate endemic
areas unknown.
No data are available about the amount of hepatitis B virus
genomes in liver of patients with chronic HBV infection. Intrahepatic
HBV DNA was assessed in patients with serological and clinical
evidence of HBV infection with either active or suppressed viral
replication (Lin and Kirchner 2004). Cases with suppressed HBV
activity, despite the very low levels of viraemia, maintain a relatively
high amount of intrahepatic viral genomes. This virus reservoir is likely
involved in HBV reactivation, which is usually observed after stopping
lamivudine treatment (Lacarnini, 2004).
Table (1): Characteristics of endemic patterns of hepatitis B virus
infection (Alter, 2003):
- 25 -
Characteristic
Chronic infection prevalence
Past infection prevalence
Prenatal infection
Early childhood infection
Adolescent/adult infection
Epidemiology of HBV
Endemicity of infection
Low (%)
Intermediate
(%)
0.5-2
2-7
5-7
10-60
Rare
Uncommon
(<10)
(10-60)
Rare
Common
(<10)
(10-60)
Very
Common
common
(70-90)
(20-50)
High (%)
8
70-95
Common
(>20)
Very common
(>60)
Uncommon
(10-20)
There are significant differences in geographic distribution of HBV

genotypes and subtypes (Guillevin et al., 2004). The global prevalence
of chronic HBV infection varies widely, from high ( 8%) to intermediate
(2-7%) and low (< 2%). The predominant routes of transmission vary
according to the endemicity of the HBV infection. In areas of high
endemicity, prenatal transmission is the main route, whereas in areas of
low endemicity, sexual contact amongst high-risk adults is predominant
(Yegane et al., 2004).
Hepatitis B Virus major health problem:

Viral hepatitis with various forms of acute and chronic liver
disease is with potential and ultimately fatal sequelae, causing a public
health problem worldwide (Cui et al., 2002).
Hepatitis B is the most important of several hepatitis viruses of
man because of the number of cases of the disease and the frequent
occurrence of persistent infection that may lead to cirrhosis and cancer of
the liver (Lee et al., 2002). HBV infection is the most common cause of
chronic liver disease worldwide (Kao et al., 2002a).
Roughly, one third of the world population has been infected with
HBV (Liu et al., 2003).
- 26 -
Epidemiology of HBV
Although hepatitis B is an ancient disease, most of our knowledge

of its epidemiology, prevention, pathogenesis, natural history and
treatment were made in the last 30 years (Tibbs and Smith, 2003).
Fulminat HBV infection is an important cause of acute liver failure
and is responsible for approximately 100 to 200 deaths per year in the
United States (Pramoolsinsup, 2002).
1 million persons die each year from HBV-related chronic liver
disease (Akbar et al., 2004). Worldwide HBV infection is one of the ten
leading causes of death (Candotti et al., 2004).
Personal risk factors:

Genetic factors influence disease outcome. Persistent HBV
segregated within families in a manner suggestive of autosomal recessive
trait and the degree of concordance for HBsAg status is significantly
higher in monozygotic twins than in dizygoyic twins. Also, the allele
HLA-DRB1* 1302 was associated with spontaneous elimination of
infection (Zhou et al., 2002).
The prevalence of HBV is closely correlated with age ranging from
2% in those under 12 to 59% in subjects over 39 (Wang et al., 2002a).
However, those aged 15-24 are at the highest risk (Yao et al., 2004).
Lai (2004) found that infection with HBV is found to be inversely
related to the educational level and is directly related to the frequency of
the receipt of parenteral injection for medical purposes. They stated that
risk factors for HBsAg positivity were male sex, age < or = 50 years, and
a family history of HCC.
Risk groups:
- 27 -
Epidemiology of HBV
HBV infection is also more prevalent in certain groups in

developed countries, such as immigrants from endemic areas and persons
with multiple sex partners (Dandri et al., 2002).
Infants under three years of age in areas of hyperendemicity.
The risk is not only of vertical transmission from mother to
infant and intrafamilial contact at home, but also through other
points of close contact, for example, at nurseries (Poynard,
2002).
Health care workers and the staff and inmates of prisons and
residential institutions are recognized as high-risk groups for
hepatitis B because of their exposure to blood and body fluids
(Sherlock and Dooley, 2002).
Drug abusers are very important risk group for HBV and the
risk of HBV infection increased significantly with years of drug
abuse and not associated with age and sex (Agarwal et al.,
2003).
Homosexuals are one of the risk groups and infection among
homosexuals is related to duration of homosexual activity,
number of sexual contacts and anal contact (Stranksy, 2004).
Patients with renal failure, cancer and organ transplant are also
groups at high risk (Aliyu et al., 2004).
Post transfusion populations are at risk in countries where
donors are not screened (Hm et al., 2004).
The prevalence among blood donors in the United States was
found to be less than 0.1% (Peksen et al., 2004). While it is as
high as 15% in some countries such as Taiwan, Singapore and
Hong Kong (Carretero and Herraiz 2004).
- 28 -
Epidemiology of HBV
Transmission of HBV
Percutanous exposure to blood, sexual transmission and peri-natal
transmission account for the majority of cases of HBV infections in
humans (Wang et al., 2002c).
Infection by faeces; urine, tears breast milk, bile or pancreatic juice
has never been demonstrated even though HBsAg or HBV particles been
detected in such fluids (Shang et al., 2002).
1- Peri-natal transmission:
Transmission from mother to neonate may occur through contact
with maternal blood and other infectious fluids during labour, colostrums
and rarely through breast milk or placental transmission (Thakur et al.,
2002b). Between 90-100% of the neonates infected by this route will
themselves go on to become carriers and in turn infect their offsprings
(Saudy et al., 2003). Almost all (HBeAg) positive mothers transmit HBV
to their infants who usually become chronic HBsAg/HBeAg carriers. This
probably because of a tolerogenic effect of HBeAg, this crosses the
placenta inducing immunologic tolerance in utero (Saab et al., 2003).
In high-carriage rate areas, HBV infection is acquired by passage
from the mother to the baby. The infection is usually not via the umbilical
vein, but from the mother at the time of the birth and during close contact
afterward. The risk of transmission increases as term approaches and is
greater in acute than in chronic carriers (Villamil, 2003). The mother is
HBsAg positive, and also, but not always, hepatitis B "e" antigen
(HBeAg) positive.
Antigenaemia develops in the baby within 2 months of birth and
tends to persist (Tamori et al., 2003). There is an inverse relationship
between the risk of chronicity and the age of infection, the risks being
- 29 -
Epidemiology of HBV
80% to 90% for infections before the age of 1 year and 20% to 50% for
infections in early childhood (Tang et al., 2003).
A curious, but yet not fully explained observation is that peri-natal
transmission is much more common in Asia than in Africa (Song et al.,
2004). This finding may be because HBsAg positive women in Asia are
much more likely to be HBeAg positive and to have higher levels of
circulating HBV DNA than women in Africa. However, even when
mothers in Africa are HBeAg positive, their babies do not become
HBsAg positive until 6 moths to one year of age, whereas in Asia,
exposed babies tend to become HBsAg positive by 3 months after birth
(Zhang, 2004).
2- Sexual contact:
HBV-DNA has been detected in seminal fluid, vaginal secretions
and saliva suggesting that these fluids are likely to be infectious. Studies
in patients attending clinics for sexually transmitted diseases have
demonstrated a link between promiscuous sexual activity and the risk of
hepatitis B infection and in terms of population risk, sexual transmission
represents the most important route of transmission in the developed
world (Ferraro et al., 2003). Hepatitis B was previously considered a
sexually transmitted disease predominantly related to homosexual
activity. In recent years, however, changes in sexual practice among the
homosexual community, prompted by health concerns over human
immune deficiency virus, have slowed the spread of HBV among this
population (Giannini et al., 2003).
This decrease of homosexual transmission has high lighted the
relative importance of heterosexual transmission and led to the increased
recognition of HBV infection through heterosexual activity (Trifan and
Stanciu, 2003).
- 30 -
Epidemiology of HBV
In low prevalence areas, such as the United States, most infections

(80% to 85%) occur in adults who are exposed through sexual contact to
a chronically infected person (Papatheodoridis and Hadziyannis,
2004).
The Centers for Disease Control and Prevention CDC (2002)
had a study of acute hepatitis B in sentinel countries (1992-1993) (such as
Asian-Pacific Islanders, Alaskan natives, and Asian-Americans). The
study showed that heterosexual contact with multiple partners or sexual
contact with a person with hepatitis B in the 6 months preceding the acute
case accounted for 41% of cases. History of homosexual contact was
elicited from another 9% of participants. Infection is frequent in
homosexuals and is related to duration of homosexual activity, number of
sexual partners and anal contact (Marcellin et al., 2003). Thus, sexual
contact is the most frequent route of acquisition of hepatitis B in the
United States and probably in other developed countries (Lee et al.,
2004).
3- Blood and blood products:
Post transfusion hepatitis B continues to be the most common
cause of HBV infection; screening of the donor units for HBsAg by
ELISA does not exclude all blood units infectious for HBV. Additional
measures to ensure safety of blood supply should be sought (Mark,
2003).
Blood transfusion continues to cause hepatitis B in countries where
donor blood is not screened for HBsAg. Transmission is more likely with
blood from paid donors than from volunteer blood (Lin and Kirchner,
2004). In the U.S.A and other developed countries, transfusion acquired
hepatitis B is rare because of the testing and elimination of HBVcontaminated donor blood (Park et al., 2004).
- 31 -
Epidemiology of HBV
4- Parentral drug abuse:

Parental drug abusers develop hepatitis from using shared, unsterile
equipments. The mortality may be very high in this group Multiple
attacks are seen and chronicity is frequent (Papatbeodoridis et al.,
2002). Liver biopsy may show, in addition to acute or chronic hepatitis,
foreign material, such as a chalk, injected with the elicited drug (Rivero
et al., 2002).
5- Opportunities for parentral infection:
Opportunities for parenteral infection include the use of unsterile
instruments for dental treatment, ear piercing, subcutaneous injections,
acupuncture and tattooing. Parenteral drug abusers develop hepatitis from
using shared, unsterile equipment (Sherlock and Dooley, 2002).
6- Transmission in high endemic areas:
High endemic areas such as Africa, Greece and the Far East, the
transmission is in the childhood and probably horizontal through kissing,
shared utensils such as toothbrushes and razors and injections
(Vanlandschoot et al., 2002). Blood sucking arthropods such as
mosquitoes or bed bugs may be important vectors, particularly in the
tropics although insecticide spraying of dwellings had no effect on HBV
infection (Wang et al., 2002d).
7- Exposure of unknown origin:
Despite these, apparently obvious routes of transmission, in many
cases the route of transmission cannot be identified (Suskind and
Rosenthal, 2004).
8- Health Care Workers:
Hospital staff and health care workers in contact with patients, and
especially patients blood, usually have a higher carrier rate than the
general population. This applies particularly to staff on renal dialysis or
oncology units. The patients attendant is infected through contact with
- 32 -
Epidemiology of HBV
blood parenterally such as from pricking or through skin abrasions.

Surgeons and dentists are particularly at risk in operating on HBsAgpositive patients with a positive HBeAg. Spread from a surgeon to
patients is rare and usually involves major operation. When standard
cleaning procedures are used, there is no evidence that HBV infection is
spread by endoscopes (Sherlock and Dooley, 2002).
- 33 -
Clinical Presentation and Sequelae
CHAPTER III
CLINICAL PRESENTATION AND SEQUELAE
(a) Acute HBV Infection:
The incubation period ranges from 2 to 20 weeks (average 8-12
weeks). The onset is usually insidious beginning with non-specific
prodromal constitutional and gastrointestinal symptoms including;
malaise, anorexia, nausea and vomiting, and flu-like symptoms of
pharyngitis, cough, coryza, photophobia, headache and myalgias.
Prodromal symptoms abate or disappear with onset of jaundice, although
anorexia, malaise and weakness may persist. These events can be related
to circulating immune complexes (Livezey et al., 2002).
The usual clinical attack diagnosed in the adult tends to be more
severe than for hepatitis A or C, however, the overall picture is similar.
The self-limited, benign icteric disease usually lasts less than 16 weeks,
jaundice rarely exceeds 4 weeks. Occasionally, a prolonged benign
course is marked by increased serum transaminase value for more than 16
weeks, relapses are rare. Cholestatic hepatitis with prolonged deep
jaundice and pruritus is unusual (Craxi and Cooksley, 2003). Physical
examination reveals mild tender hepatomegaly in over 70% of cases.
Mild splenomegaly and posterior cervical lymphadenopathy is found in
15-20% of cases (D. Valla, 2003).
Nevertheless, the clinical course of acute HBV infection may be
anicteric. The high carriage rate of serum markers in those who give no
history of acute HBV infection suggests that subclinical episodes must be
extremely frequent. The non-icteric cases are more liable to become
chronic than the icteric ones (Akarca et al., 2004).
(b) Fulminant Hepatic Failure (FHF):

- 34 -
Based on the centers for Disease Control and Prevention Viral

Hepatitis Surveillance program and sentinel countries study data, the total
number of annual deaths due to fulminant viral hepatitis in the United
States is approximately 2000 of which approximately half are due to
hepatitis B (Desmet, 2003).
In fulminant hepatitis B (FHF), the surface antigen may be in low
titer or undetectable (De Villa et al., 2003). Some cases may be negative
for HBsAg because of infection by mutant strains of the virus that cause
infection and disease, but do not produce HBsAg or HBeAg. It has been
suggested that acute infection with the precore mutant strain of HBV that
is unable to synthesize HBeAg is more frequently associated with a
fulminant presentation than is the acute wild type HBV infection
(Tamori et al., 2003).
The diagnosis may be made by only finding serum IgM anti-HBc
(Ferraro et al., 2003) or by the detection of HBV-DNA by PCR in serum
or liver of patients infected with mutant forms of the virus (Alter, 2003).
The precore mutant has been associated with fulminant disease in Israel
(Barcena et al., 2003) and Japan (Friedman, 2004), but not in France
(Lok et al., 2004) or in North America (Benhamou, 2004).
FHF is characterized by rapidly evolving hepatic dysfunction,
coagulopathy is early fetor hepaticus confusion and drowsiness are
ominous signs. Flapping tremors may only be transient or absent, but
rigidity is usual. Cerebral oedema (usually without papilloedema) is the
most common identifiable cause of death. There is marked elevation of
serum bilirubin and transaminases, but the latter may decline towards
normal despite disease progression. Hypoglycaemia, hyponatraemia,
hypokalaemia and leucocytosis are common laboratory findings. The
development of multi-organ failure worsens the prognosis. Case fatality is
80% without liver tranplantation (Brunetto and Bonino, 2004).
- 35 -
(c) Chronic Hepatitis B:

Chronic HBV hepatitis is found predominantly in males. Males are
six times more likely to become carriers than females. Approximately
10% of patients contracting HBV as adults and 90% of those infected as
neonates will not clear HBsAg from the serum within 6 months
(Goldstein et al., 2002).
Chronicity may follow an unresolved acute attack. The attack is
usually mild. The patient with an explosive onset and deep jaundice
usually recovers completely. Similarly, survivors of fluminant viral
hepatitis seldom, if ever, develop progressive disease. After an attack,
serum transaminase levels fluctuate with intermittent jaundice (Buti et
al., 2002).
The patient may be virtually symptom free with only biochemical
evidence of continued activity, and may simply complain of fatigue and
being generally unwell. Diagnosis may even be made in a symptom-free
patient after a routine medical check or at the time of blood donation
(Candotti et al., 2004).
Chronic hepatitis B is often a silent disease. Symptoms do not
correlate with the severity of liver damage. Apparently, stable patients
with chronic HBV disease may have a clinical relapse. This is marked by
fatigue and rise in serum transaminase values. Relapse may be related to
seroconversion from an HBeAg positive state to an HBeAg and HBVDNA negative one. Serconversion may be spontaneous in 10% to 15% of
patients per annum (Yoshida et al., 2004).
HBV-DNA can remain positive even when anti-HbeAb has
developed (Carreno et al., 2004). Spontaneous reactivation from HBeAg
negative to HBeAg and HBV-DNA positive state has also been
- 36 -
described. The clinical picture ranges from absence of manifestations to

fulminant hepatic failure (Lai et al., 2003a).
(d) Inactive carrier:

Seroconversion from HBeAg to HBe antibody (anti-HBe) is
usually accompanied by marked decrease in serum HBV DNA level (< 5
log 10 copies/ml) and normalization of ALT. Patients who have
undergone seroconversion with suppression of HBV replication and
normalization of ALT are considered to be in an inactive carrier state. It
is now recognized that HBV replication persists during this phase. Using
sensitive PCR assays, HBV DNA can be detected in the sera of most
inactive carriers, but levels rarely exceed 4 log 10 copies/ml (Stephen,
2004).
(e) Extra-hepatic manifestations:

Some extra-hepatic conditions are associated with circulating
immune complexes containing HBsAg. The accompanying chronic liver
disease is usually mild and slowly progressive (Haushofer et al., 2002).
Extra-hepatic manifestations include:
(i)
Joint and neurologic manifestations: Guillain-Barr syndrome,

encephalitis,
aseptic
meningitis,
mononeuritis
multiplex,
arthralgias and arthritis (serum sickness) (Papatheodoridis and

Hadziyannis, 2004).
(ii)
Glomerulonephritis: Membranous GN (MGN), mainly in children

with prevalence rate 11-56.2%. The mechanism is that HBV
antigens (i.e., HBsAg, HBeAg) act as triggering factors eliciting
immunoglobulins and thus forming immune complexes, which are
dense irregular deposits in the glomerular capillary basement
membranes. INF-a therapy has been successful in treating HBV-
- 37 -
related GN. A regimen of 5 million units of IFN-a subcutaneously

daily for 4 months (Song et al., 2004).
(iii)
Polyarteritis nodosa: High prevalence (36-69%) of HBsAg in

patients with polyarteritis nodosa (PAN). Circulating immune
complexes containing HBsAg, immunoglobulins (IgG and IgM),
and complement have been demonstrated in the walls of the
affected vessels. The clinical manifestations of the disease include
cardiovascular (e.g. hypertension, pericarditis, heart failure), renal
(e.g. hematuria, proteinuria, renal insufficiency), gastrointestinal
(e.g. abdominal pain, mesenteric vasculitis), musculoskeletal (e.g.
arthralgias, arthritis), neurological (e.g. mononeuritis), and
dermatological (e.g. rashes) involvement. Small and medium-sized
arteries and arterioles are affected. Adenine arabinoside, an
antiviral drug and IFN-a, an immunomodulator and antiviral
protein, have been used in conjunction with plasmapheresis and
short course of corticosteroids (Lacarnini, 2004).
(iv)
Skin manifestations: Hives and fleeting maculopapular rash.

Women are more affected. Papular acrodermatitis, recognized as
Gianotti-Crosti syndrome, has been associated with hepatitis B in
children (Kumar and Agrawal, 2004).
(v)
Cardiopulmonary
hepatopulmonary,
manifestations:
portopulmonary
Pleural
syndrome,
effusion,
myocarditis,
pericarditis, and arrhythmia (Kobak et al., 2004).

(vi)
Hematologic
and
Pancreatitis,
aplastic
gastrointestinal
anemia,
tract
manifestations:
agranulocytosis
intravascular coagulation (Haushofer et al., 2004).
(e) Post Hepatitis B Cirrhosis:
- 38 -
and
diffuse
Many patients with chronic HBV infection evolving over many

years present with established liver cirrhosis, with jaundice, ascites or
portal hypertension. Encephalopathy is unusual at presentation (Honkoop
and de Man, 2003). In many cases, cirrhosis is clinically silent.
Development of hepatic cirrhosis in a patient with chronic HBV infection
could be suspected if the patient has mild pyrexia, vascular spiders,
palmer erythema, epistaxis or lower limb oedema (Guillevin et al.,
2004).
Firm hepatomegaly is common, but progressive hepatocyte
destruction and fibrosis gradually reduce liver size as the disease
progresses. Jaundice is usually mild when it first appears (Friedman,
2004). With disease progression, easy bruising becomes more common,
endocrine changes are noticed, more readily in men, signs of portal
hypertension including splenomegaly, collateral vessel formation, ascites,
and upper gastrointestinal tract hemorrhage develop. Evidence of hepatic
encephalopathy also becomes increasingly common with advancing
disease (Ding et al., 2004).
(f) The relation with HDV:

The delta agent is a very small RNA particle coated with HBsAg. It
is capable of infection only when activated by the presence of HBV. The
interaction between the two viruses is very complex (Cui et al., 2002).
Hepatitis B and delta infection may be simultaneous (co-infection). Delta
infection is strongly associated with intravenous drug abuse, but can
affect all risk groups for HBV infection (Dandri et al., 2002).
Delta infection is world wide, but is particularly prevalent in
Southern Europe, the Balkans, the Middle East, South India and parts of
Africa (Kato et al., 2002). With co-infection, the acute delta hepatitis is
usually self-limited, as the delta cannot outlive the transient HBV
- 39 -
antigenaemia, the clinical picture is usually indistinguishable from

hepatitis resulting from HBV alone. However, a biphasic rise in ALT
may be noticed, the second rise being due to the acute effects of delta (D.
Valla, 2003).
With super infection, the acute attack may be severe and even
fulminant, or may be marked only be rise in serum transaminases. Delta
infection should always be considered in any HBV carrier, usually
clinically stable, who has a relapse (Fabrega et al., 2003). Co-infection is
more likely to be followed by recovery, with the patient becoming
immune to delta. Superinfection is followed by a complete recovery in
only 10% of patients and there is a high chronicity rate. Both modes of
infection can have a fulminant course (Giannini et al., 2003).
g) HCV and previous HBV infection:

Prevalence of anti-HBc is high among HCV positive
individuals 50-55% (Hu, 2002). Previous HBV infection among
anti-HCV patients is associated with worse disease stage
(Hadziyannis et al., 2004). Hepatitis B virus (HBV) and hepatitis
C virus (HCV) infections account for most of the cases of liver
disease worldwide (Hahne et al., 2004).
- 40 -
Virological response of chronic hepatitis C

patients with and without past history of
HBV
80
60
HBV seronegative (Group I)
40
HBV seropositve (Group II +

III)
20
0
At week 24
At week 48
(EVR)
At week 72
(SVR)
Graph (1): (Esmat, 2005).
Chronic Hepatitis B and Hepatocellualr Carcinoma

The history of HBV is influenced by the age at which the infection
is acquired, integrity of the host's immunity, and exposure to
environmental cofactors. Chronic infection with HBV is more frequent in
men
than
in
women,
in
neonates
than
in
adults,
and
in
immunocompromised patients than in immunocompetent ones (Wen et

al., 2002). The risk of chronicity decline 60% during the second year of
life to 10% by 5 years of age (Wolters et al., 2002).
In the immunocompetent patient, persistence of HBeAg-producing
strains is associated with hepatic inflammation. Seroconversion to antiHBe is paralleled by exacerbation of hepatitis as a result of immunemediated liver cell necrosis and progressive clearance of infected
hepatocytes and serum HBV DNA "healthy carriers" (Leung, 2002). The
condition of healthy carriers is clinically a long-term benign situation. A
prospective cohort study of 92 Italian healthy carriers showed that the
- 41 -
prognosis for these subjects was excellent, with a low risk of developing
cirrhosis or HCC over 10 years (Ohshiro et al., 2002).
Conversely, HBeAg-seropsitive patients with replicating HBV
display various degrees of liver damage, from benign forms of chronic
lobular hepatitis to more severe forms of active cirrhosis and HCC
(Rodriguez et al., 2003). Persistent HBV replication is instrumental in
the progression of the disease to cirrhosis and HCC. Virus heterogenecity
is another important factor in the natural history of HBV infection
(Stephen, 2004).
Hepatocellular carcinoma (HCC) is a frequent sequela of chronic
HBV infection. In endemic areas, the risk of developing HCC among
individuals chronically infected with HBV is up to 100 times that of nonHBV carriers (Tanaka et al., 2004). The risk to carriers, however, varies
substantially from region to region because of factors not clearly
understood (Tsai, 2004).
The classic work of Beasley, 1988 in adult Taiwanese civil service
workers reported an incidence rate of 495 per 100.000 person-years in
HBsAg-positive subjects McMahon et al., 1990 studying a populationbased cohort of Alaskan natives, have found an HCC incidence of 387
per 100.000 person-years in HBV carrier males of all ages. Wright
(2004) have reported HCC incidence rates for a cohort of 1.069 HBV
carriers in Toronto with an average follow up length of 26 months. He
found HCC incidence rates of 657 per 100.000 person-years in males and
122 per 100.000 person-years in females (Zhang, 2004).
In a multicenter European study of 349 patients with compensated
cirrhosis, secondary to chronic HBV infection, HCC developed in 9%
during a mean follow up period of 6 years. The yearly incidence of
cirrhosis among chronic HBV patients is 2.4% to 7%, with approximately
1.5% of cirrhotic developing HCC every year (Yang et al., 2004).
- 42 -
HBV status in Egypt
CHAPTER IV
HBV STATUS IN EGYPT
Hepatitis B is and will for some time be a major health problem in
Egypt (Marzaban, 2003). It is recommended to consolidate the Egyptian
program of infant hepatitis B vaccination, and to extend it to older
children and high-risk adult groups (Sallam, 2000). The prevalence of
HBsAg carriers in Egypt varies widely with age, sex, community (urban
or rural), schistosomiasis and/or chronic liver disease, exposure to certain
risk factor (Marzaban, 2003).
Egypt was reported by Andre (2000) to be an area of high
prevalence for HBV; however, Poynard (2002) reported it to be an
intermediate area. It was also reported that the carrier rate to be 8%
among primary school children (Esmat, 2005).
In the early 90s, carrier rate of 3.25% and 3.6% were reported in
Alexandria and Cairo by Marzaban (2003); and Hasseb (2000) found
that, among school children 5-15 years from a rural village in Dakahlia,
the exposure rate for HBV infection was 22% with frequency of HBsAg
of 4% by counter immune electrophoresis, 16% by reversed passive
haemagglutination and 18% by other tests. The frequency of HBsAb was
4.5%.
Labib et al., 2002 stated that the maximum HBsAg percentage
13.37% was found in the age group 2-5 years, decreasing afterwards to
reach 12.85% in the age group 5-12 years.
In the mild 80s, Abdelaziz (2004) reported higher prevalence as
follows; 8.8% in Lower Egypt and 11.7% in Upper Egypt with more
prevalence in young adults and in males than females in both
communities.
- 43 -
HBV status in Egypt
The overall seroprevalence of HBV when HBsAg and/or HBcAb

were assessed was found to increase progressively with age peaking in
the 40-67 years old group at a rate of 66%, which is an extraordinarily
high seroprevalence rate (Abdelaziz et al., 2000). Abdelhamed et al.
(2002) found it to be 20.7% collectively in all age groups in 1996 and
19.6% in 1997 (Orfi, 2002). There is the impression that HB carriage rate
is decreased from 10% (Marzaban, 2003) to 3.2% (Abdelaziz, 2004).
As for acute HBV infection, the prevalence of HBV in Egypt is not
yet adequately estimated after the use of hepatitis B vaccine (Abdelaziz,
2004). However, Orfi (2002) stated that the prevalence of acute HBV
infection was 12% in children 4-14 years old and 50.9% in adults > 14
years old. The most common age group infected by HBV ranged from
21-30 years (42.4%) whereas the least infected age group was from 4-8
years (3%). The most common risk factor for infection with acute HBV
was accidental puncture in (56.1%), followed by dental procedures in
(48.5%) and surgical intervention in (24.2%).
Saudy et al. (2003) reported that HBV genotype D is the most
prevalent in Egypt. Abdelhamed et al. (2004) found genotype D in more
than 75% of Egyptian patients with positive HBV DNA.
- 44 -
HBV status in Egypt
Fig. (16): Geographic distribution of HBV Genotype (Hayashi and Furusyo,

2004).
Table (2): Geographic Distribution of HBV Genotypes (Hou et al.,

2005):
Genotypes Distributions
A (Aa, Ae) White Caucasians in Europe, Black Americans in US (Ae), Black
Africans, South Africa (Aa), Asia (Aa), India
B (Ba, Bj) Southern China (Ba), Taiwan (Ba), Vietnam (Ba), Asians in the USA,
Japan (Bj)
C
China (Mainland and Taiwan), Japan, Thailand, Asians in the USA
D
White Caucasians (Southern Europe), Arabs (North Africa and the
Middle East), India
E
West Africa
F
Central and South America
G
United States, France
H
Central America
Kamel et al., 1994 described the HBV situation in Egypt as

hyperendemic in egypt, with seroprevelence rates ranging from 24% in
the general population to 66% in persons 40-67 years of age (Darwish et
al., 1996).
- 45 -
HBV status in Egypt
Table (3): Prevalence of HCV, HBV and HBsAg in Egypt 1996

(Mohamed and Aoun, 2002):
Age Adjusted Rates /100
Total Egypt
Rural
Urban
Males
Females
HCV
14.5
18.9
9.1
16.4
12.7
HBcAb
22.5
24.9
19.5
23.9
21
HBsAg
4.5
5.2
3.7
5.0
4.0
Table (4): Etiology of acute viral hepatitis among 200 *patients

presented with acute symptomatic hepatitis to Embaba Fever
Hospital between December 2001 and September 2002 (Zakaria et
al., 2004).
Etiology
Total
N
68
25
63
34
%
34
12.5
31.5
17
Single infection
N
%
34
17
15
7.5
29
14.5
10
5
HAV
HEV
HBV**
HCV
Non A-E hepatitis
CMV
12
6
1
EBV
7
3.5
1
HGV
23
11.5
1
TTV
46
23
9
Undiagnosed
13
6.5
* Infection by more than one virus: 82 (41%)
** HDV in 8 patients (3 co-infection and 5 super infections)
0.5
0.5
0.5
4.5
Abdelhamed et al. (2002) explained this discrepancy about

prevalence rates, by the fact that all the previous studies were performed
on hospitalized patients with moderate to severe illness and not on the
large number of mild and asymptomatic infection that must have occurred
in the community.
- 46 -
HBV status in Egypt
Etiology of Acute Viral Hepatitis in Egypt 1997-2000
21%
25%
16%
HCV
HBV
All-ve
Mixed
HEV
HAV
24%
1%
13%
Fig. (17): Analysis of 1860 acute hepatitis cases (Mohamed and Aoun, 2002).
Table (5): The frequency of acute hepatitis B in different age groups

in year 2002 in comparison to year 1983 (Zakaria et al., 2004):
Age
groups
1983
Total
(235)
< 5ys
6-8ys
9-11ys
12-20ys
21-40ys
41-60ys
>60ys
(36)
(22)
(12)
(48)
(73)
(28)
(16)
Acute HBV
N
%
7
19.4
9
40.9
5
41.7
28
58.3
38
52.1
11
39.3
4
25
2002
Total
(200)
(23)
(35)
(22)
(26)
(73)
(19)
(2)
- 47 -
P
Acute HBV
N
%
0
0
0
0
6
27.3
10
38.5
41
56.2
6
31.6
0
0
NS
NS
NS
NS
HBV status in Egypt
Age distribution of patients with

acute hepatitis B
70
60
50
40
Sedes
1
30
20
10
0
< 14 ys
14-30 ys
31-50 ys
> 50 ys
Graph (2): Age distribution of patients with acute hepatitis B (Zakaria et al.,
2004).
Although HBV vaccination was effective in decreasing the

infection in those below 10 years (Esmat, 2005). HBV is still responsible
about a high percentage of acute viral Hepatitis disease in Egypt
(Abdelaziz, 2004).
HBV Status in Egypt in Various groups:

(1) Among the general population:
Based on HBsAg positivity alone, Esmat (2005) reported 6.7%
carriage rate in two rural villages in the Nile Delta and El-Zayadi (2005)
reported 8% carriage rate among primary school children. Studies which
included the overall seroprevalence of HBV (HBsAg and/or anti-HBc),
gave higher percentage rates of 20.7% (Saudy et al., 2003) and 19.6%
(Hasseb, 2000) among different regions of Egypt.
Hasseb (2000) determined the prevalence of HBV in Egypt by
studying 3186 normal Egyptian born and living in 4 Egyptian
governorates (Kaliobia, Menoufia, Gharbia and Aswan). They
represented both sexes, both urban and rural populations and include all
- 48 -
HBV status in Egypt
age groups (except neonates and infants in their first year of life), thus
permitting a mass evaluation of HBV in Egypt. Serum from each
participant was tested for HBsAg, HBcAb and HBsAb. They found that
the prevalence of HBsAg in the whole population was 6.35% and HBcAb
was 38.68% of those studied (Marzaban, 2003).
Sallam (2000) measured the exposure rate of hepatitis B in Egypt.
Exposure rate depends on both HBsAg and HBcAb where:
No. of cases positive for HBcAb + No. of cases positive for
Exposure rate =
HBsAg alone
Total number of cases studied
He reported that the exposure rate to hepatitis B virus was found to

be 40.3%. This percent was similar to El-Zayadi (2005), who showed
that the exposure rate for HBV in whole population studies was found to
be (40.37%).
Heikal (2005) reported that HBV was more prevalent in Upper
Egypt (11.7%) than in Lower Egypt (8%). Sallam (2000) showed that the
highest prevalence of HBV in Egypt was in Aswan.
The high prevalence of HBsAg together with high exposure rate to
HBV found in Gaffar studies and El-Sahly studies are sufficient to
transfer Egypt from an area of intermedicity for HBV as categorized by
the WHO to an area of high endemicity of this virus (Abdelhamed et al.,
2002).
(2) Among patients with acute hepatitis:
Marzaban (2003) studied the etiology of acute hepatitis in
Egyptian children of both urban and rural areas. Two groups of patients
were studied. Group one consisted of 77 infants and children with acute
hepatitis admitted to pediatric department of Abbasia fever hospital
(urban area), group (2) consisted of 21 infants and children with acute
hepatitis admitted to Banha fever hospital (rural area). The ages of the
- 49 -
HBV status in Egypt
children in both studies ranged between 2 months and 17 years. In urban

group HBV was responsible for (41.8%) of the cases, HDV (whether a
coinfection or as superinfection) was responsible for (26%) of the cases
(Abdelaziz, 2004).
(3) Among Chronic Liver Disease patients:
Abdelaziz (2004) found that 43% of patients with nonschistosomal chronic liver disease and 36% of patients with
hepatocellular carcinoma were HBsAg carriers in their series.
Another study by Aoki et al. (2002) was done on 135 adult patients
living in Alexandria governorate, mostly in rural areas of the Nile Delta,
and who had established chronic liver disease showed a carrier rate of
HBsAg of 16%, and 64% of anti-HBcAb. Similarly, Attia et al. (1998)
found a 21% carrier rate of HBsAg and 54% of anti-HBcAb among
cirrhotic patients in their own study.
(4) Schistosomal infection:
Schistosomiasis contributes to significantly increased HBV
infection (Abdelaziz, 2004).
A study was applied on patients with acute viral hepatitis who were
followed up for 12 months. Patients with concomitant schistosomiasis
had higher mean values for liver function test results and a greater
proportion had abnormal liver function test results during hospitalization
and follow-up than those with acute viral hepatitis only. Concomitant
schistosomiasis increased the prevalence and prolonged splenomegaly
and morbidity due to acute viral hepatitis. Both male sex and concomitant
schistosomiasis prolonged the HBsAg carrier state. Acute viral hepatitis
frequently
converts
uncomplicated
intestinal
schistosomiasis
to
hepatosplenic schistosomiasis (Marzaban, 2003).

High prevalence of chronic HBs antigenaemia (58%) has been
demonstrated in children with schistosomal hepatic fibrosis but only (2%)
- 50 -
HBV status in Egypt
in normal children, this denotes that children with SHF represent a

dangerous reservoir for hepatitis B infection to the community
(Abdelhamed et al., 2002). It is said that, patients suffering from
heaptosplenic schistosomiasis experience 28% higher HBsAg carrier rate.
An important observation is the diminished anti HBs rate in such patients.
This may be due to an immunological defect, resulting in an
unsatisfactory antibody response and chronic hepatitis B antigenemia
(Abdelhamed et al., 2002).
Schistosomiasis does not only increase the severity of HBV
infection but also elevates to risk of HCC over that associated with the
HBV infection alone (Badawi and Michael, 1999).
However, a study by Marzaban (2003) revealed that the primary
residence in the Nile delta and Valley areas where shistosomiasis is
highly endemic was a statistically significant risk factor for HCV, but not
HBV infection.
(5) Drug abusers:
Labib et al. (2002) studied the prevalence of HBV among
Egyptian drug abusers and it was 57.75 and 15.4% in injecting and noninjecting drug abusers respectively. The former group showed
significantly more common signs of liver disease as hepatomegaly,
elevated enzymes, cirrhosis and history of jaundice. These manifestations
correlated positively with the duration of addiction thus all injecting drug
abuses cases > 10 years duration were infected by HBV but this was less
obvious in non-injecting ones.
(6) Children to carrier mothers & peri-natal infection:
17% of newborn infants to HBsAg positive mothers were HBsAg
positive and none of the mother was HBeAg positive (Abdelaziz, 2004).
(7) Among Blood Donors:
- 51 -
HBV status in Egypt
The carrier rate among blood donors was 3.9% for villagers
(Annual report Agouza center, 1982) whereas Abdelaziz (2004) and
Marzaban (2003) in Alexandria and Cairo reported a carrier rate of
3.25% and 3.6% respectively. A more recent study El-Zayadi (2005) on
90 blood donors showed 4.4% HBsAg positivity.
(8) Among the immunocompromised:
Several workers reported an increased susceptibility to hepatitis B
virus in immuncompromised patients. A study done by Sallam (2000) on
137 patients with an immuncomprimising illness (Leprosy, Bronchial
asthma and diabetes mellitus) along with 25 healthy individuals serving
as controls indicated that HBsAg carrier rate was 4% for the control
healthy group, 7% for bronchial asthma, 10% for diabetes and 24% for
leprosy.
(9) Dental field:
The exposure rate of HBV among dentists working or studying at
the Faculty of Oral and Dental Medicine, Cairo University was found to
be 27.1% with a carrier rate of 7.1% (Abdelhamed et al., 2002).
- 52 -
Diagnosis of HBV
CHAPTER V
DIAGNOSIS OF ACUTE AND CHRONIC
HEPATITIS B
(1) Acute Hepatitis:
Newly infected subjects have an incubation period averaging 8-12
weeks after exposure and before clinical symptoms, and the length of
time depends on size of inoculum and host factors (Akahane et al.,
2002). HBsAg appearance accompanies the prodromal phase, the
arthralgia and skin rash that sometimes appear are thought to be related to
formation of HBsAg anti-HBs complexes. All of this occurs before ALT
elevations and other manifestations of liver involvement (Akcam et al.,
2002).
HBsAg concentrations peak at or shortly after an increase in serum
ALT. The duration of HBsAg positivity can be highly variable and
usually has little relationship to recovery, but the ALT and HBsAg
decline and disappear together. HBsAg is cleared from serum early in
10% of patients by the time they present to physicians (Aoki et al., 2002).
Such a serological event can cause diagnosis problems, but in such cases,
the detection of IgM anti-HBc can help to confirm the diagnosis. The
presence of a strong IgM anti-HBc is indicative of acute phase infection
(Arase et al., 2002).
HBeAg and HBV-DNA is detected in sera of patients before
symptoms develop and at about the same time that HBsAg is detected.
Both are considered markers of viral replication. The disappearance of
these markers and the seroconversion to anti-HBe precede clearance of
HBsAg, and such events predict recovery. The best serological indicator
of recovery is the appearance of anti-HBs, but in many cases, it is not
74
Diagnosis of HBV
detected before recovery is already clinically evident (Beckebaum et al.,

2002).
2. Chronic outcomes of HBV infection:

In most adult cases of acute hepatitis B serum HBsAg disappears
within 12 to 16 weeks after exposure, but in about 10% of patients
antigenaemia will be detected for more than 6 months. A 6 months
persistence of HBsAg by convention defines the carrier state because
these patients have a reduced likelihood of recovery. Most remain
chronically infected and experience several possible outcomes; every year
about 1% of adult-onset carriers will spontaneously lose HBsAg and
seroconvert to anti-HBs. In contrast, 90% of babies who have been
infected perinatally of within the first 5 years of life become carriers and
have little chance of spontaneous recovery during their lifetime (D. Valla,
2003).
After the acute phase, a typical marker pattern is evident; IgM antiHBc declines slowly, but markers of viral replication HBeAg and HBVDNA
remain
detectable, with
anti-HBe
and
anti-HBs
usually
undetectable. Elevated ALT values indicate ongoing active hepatitis.

Some carriers will have persistently active hepatitis, and some will
progress to cirrhosis and possibly hepatocellular carcinoma (Craxi and
Cooksley, 2003).
At intervals after the acute phase that are yet unpredictable, many
patients become asymptomatic carriers. That is, while HBsAg and antiHBc persist, ALT levels return to near normal and seroconversion from
HBeAg to anti-HBe occurs. HBV-DNA declines, but patients remain
infectious. This transition from active to asymptomatic chronic infection
can occur directly after the acute phase, or it may happen years later,
often after a flare of symptoms and a brief increase in ALT levels.
74
Diagnosis of HBV
Occasionally, asymptomatic carriers experience a return to active

hepatitis with reappearance of HBeAg and HBV-DNA. A few chronic
carries may have serum levels of HBsAg below detectable limits.
Although asymptomatic carriers appear to be in an inactive state of
hepatitis, they remain at significantly high risk of cirrhosis and
hepatocellular carcinoma (Cooksley, 2004).
Serology and molecular testing:

Because
the
clinical
symptoms
of
HBV
infection
are
indistinguishable from other forms of viral hepatitis, definitive diagnosis

is dependent on serologic testing for HBV infection. Varieties of tests are
available to make the diagnosis of HBV infection (Berger and Preiser,
2002). Acute HBV infection is characterized by the presence of HBsAg in
serum and the development of IgM class antibody (IgM anti-HBc)
(Fabrega et al., 2003).
Both serologic and molecular assays are useful in the diagnosis of
viral hepatitis. They may detect early infections before other sings of
disease appear, differentiate acute from chronic infections, and detect
persistence of viraemia or verify development of immunity (Bienzle et
al., 2003).
(I) HBsAg:
The discovery of the Australia antigen and its association with
hepatitis was a major advance in the laboratory diagnosis of viral hepatitis
(Bonacini et al., 2002). The Australia antigen (HBsAg) could be detected
in most of the patients with acute and chronic disease by simple assay
procedures
as
agar-gel
diffusion
(AGD)
or
counter
immunoelectrophoresis (Goldstein et al., 2002). Following exposure to

HBV, HBsAg can be detected in serum for several weeks before
increased serum amino tansferase levels are observed. HBsAg persists
74
Diagnosis of HBV
during the prodromal phase and is not usually cleared from the serum
until convalescence (Chan et al., 2002).
Hepatitis B surface antigen (HBsAg) subtyping method based on
a commercial enzyme immunoassay (EIA) for detection of HBsAg in
which the procedure was modified to include the use of monoclonal
antibodies with restricted anti-HBs specificities. This method, which was
able to classify HBsAg as: ayw1, ayw2, ayw3, ayw3* (intermediate
between ayw3 and ayw4), ayw4, ayr, adw2, adw4 and adr. This reliable
procedure, derived from commercially available reagents, can be easily
used in several applications such as large epidemiologic studies and as a
substitute for nucleotide sequencing genotyping which is not adapted for
large-scale screening and not applicable on samples from nonviremic
hepatitis B virus (HBV) carriers (Cerenzia et al., 2002).
It was subsequently found that most of the remaining patients with
hepatitis B also had serum HBsAg, but that tests with significantly greater
sensitivity were necessary to detect those (Chan et al., 2002). Ferraro et
al. (2003) develop a modified "sandwich" radio immunoassay (RIA) to
detect HBsAg this diagnostic method has a dilution sensitivity more than
100 times that of AGD and can detect less than 0.5ng HBsAg/ml serum
(Craxi and Cooksley, 2003). In the last decade, enzyme sandwich
immunoassays (EIAs) have largely replaced RIAs. Recent modified EIAs
that use micro-particles, computerized instrumentation produce very rapid
and completely automated micro-particle enzyme immunoassay
(MEIAs) for HBsAg (Conjeevaram and Lok, 2003).
HBsAg is often used as the serological marker to screen for HBV
infection in the investigation of liver cirrhosis (Chang, 2003). HBsAg is
the most important serological marker of acute and chronic hepatitis B
infection. Therefore, sensitivity of the currently used detection system for
74
Diagnosis of HBV
HBsAg is critical to blood screening, diagnosis of HBV infection and

therapy monitoring of HBV infected individuals (Giannini et al., 2003).
The performance of HBsAg screening assays is continuously
improved in order to reduce the residual risk of transfusion-associated
hepatitis B (De Villa et al., 2003). HBV-associated HCC expresses
HBsAg on its cell surface, and this may serve as a tumor-associated
antigen (Desmet, 2003).
The most commonly used definition of the carrier state is presence
of HBsAg in serum for at least 6 months. It is important to recognize that
occasionally it may take a few more months for some individuals to clear
HBsAg, but HBsAg should be undetectable 1 year after acute HBV
infection (Friedman, 2004).
Chronic carriers of HBV usually show HBsAg in their sera.
However, in some individuals this antigen can't be detected by routine
serological assays lack of HBsAg might be mutations in the part of the
molecule recognized by specific antibodies. At least some of the chronic
low-level carriers where HBsAg is not detected could be infected by
diagnostic escape mutants and/or by variants with impaired replication
(Brown, 2005).
(II) HBsAb:
Antibodies are formed against several antigenic sites HBsAg and
are all generally designated as HBsAb. Some of these are unique to
specific viral strains, but all wild strains of HBV contain a common
immunological determinant commonly referred to as "a". HBsAb/a is the
most prominent antibody in convalescent sera or in vaccines (Cui et al.,
2002).
The group specific antibodies directed against the HBsAg prevent
viral infection or reinfection and reduce the virus load in body fluids
(Dandri et al., 2002). Clearance of HBsAg from the sera was observed
74
Diagnosis of HBV
within 6 months after disease onset, and the corresponding antibody

appeared within 12 months (Duseja et al., 2002).
HBsAb or their immune complexes were found in 83% of acute
hepatitis B and in 37% of chronic ones. Their detection in a single serum
sample should not be considered as an evidence of elimination of the
infection (Hu, 2002). Circulating HBsAb secreting B cells were
significantly higher in early acute hepatitis B or early after HBs
vaccination than in chronic hepatitis B and decreased in the follow-up as
a result of compartmentalization to lymphoid tissues (Haushofer et al.,
2004).
HBV replication progressively disappears in most of the patient
after seroconversion of HBsAg to HBsAb (Haushofer et al., 2002). In
patients who recover from acute hepatitis B, seroconversion to anti-HBs
occurs shortly after disappearance of HBsAg. There may be subjects who
have an extended period between loss of antigenaemia and appearance of
anti-HBs, and this period is referred to as the "core window", a time when
antibodies to hepatitis B core proteins are the only serological indicators
of HBV infection (Friedman, 2004). This core window may last for a
few days to several months. In an HBV infection, serum anti-HBs
indicate lifelong immunity to re-infection by hepatitis B. In vaccine
recipients, the immune response is not usually as strong as the immune
response to infection, and vaccine-induced anti-body does not persist as
long, but declines predictably after the final inoculations (Flisiak et al.,
2004). Nonetheless, the efficacy of these vaccines proves that humoral
anti-HBs responses to these surface antigens are protective against HBV
infection (Haushofer et al., 2004).
74
Diagnosis of HBV
Fig. (18): Evolution of HBV markers in acute infection (Guillevin et al., 2004).
Fig. (19): Characteristics of progression to chronic HBV infection (Guillevin et al.,

2004).
74
Diagnosis of HBV
(III) HBcAg:
Hepatitis B core antigen (HBcAg) is not directly detectable in
serum because of the HBsAg envelope that surrounds it. Furthermore,
any exposed HBcAg reacts with circulating antibody, thus blocking its
detection. However, HBcAg can be identified in liver biopsies by
immunofluorescent techniques, and the histochemical detection of this
antigen is occasionally used as a marker of viral replication (Gheit et al.,
2002). HBcAg does not circulate in serum (Hbscher and Potmann,
2002).
(IV) HBcAb:
Detection of IgM HBcAb is a useful marker for HBV acute
infection (Goldstein et al., 2002). IgA HBcAb is a sensitive marker for
HBV replication, and its absence may exclude HBV replication (Kao et
al., 2002b).
Anti-HBc (antibody to HBcAg), is perhaps the most serological
prominent marker of HBV exposure. HBcAg is very immunogenic and
consequently high anti-HBc titers early in an infection suggest a period of
active viral replication. The antibody is detectable in serum shortly after
the appearance of HBcAg, but usually before elevations in ALT, and it
persists in serum throughout disease and recovery (Kao and Clsen,
2002). The earliest anti-HBc in acute disease is predominantly. IgM antibody, with lower activities of IgG and IgA anti-HBc also present
concurrently. There is no evidence; however, that serum anti-HBc offers
any immune protection (Mao et al., 2004).
(V) HBeAg / Anti-HBe:
HBeAg in serum can be detected by a sandwich immunoassay
format similar to that for HBsAg. The antigen is captured by antibody
affixed to a solid phase and is then detected with a second labeled
antibody (Gotsman et al., 2002). The HBeAg positive chronic hepatitis
74
Diagnosis of HBV
patients displayed significantly higher transaminase levels than those

negative for HBeAg (Guptan et al., 2002).
Before the introduction of DNA testing, HBeAg was used as a
marker for active HBV replication and infectivity and as a criterion for
treatment (Brunetto and Bonino, 2004). Its role as a marker of active
viral replication is associated with the increased risk of HCC. The risk of
HCC was increased by a factor of 10 among the men who were HBsAg
positive only and by a factor of 60 among those who were HBsAg and
HBeAg positive. The striking increase in cases of HCC in men who were
HBeAg+ve might suggest an oncogenic role of HBeAg (Guillevin et al.,
2004).
Table (6): HBeAg (Liang and Ghany, 2002).
Analysis of 505 cases history of patients among men with viral

hepatitis demonstrates that the frequency of HBsAg detection by Enzyme
Immune Assay (EIA) in saliva of patients in acute period was found to
correlate with the frequency of its detection in serum. In early
74
Diagnosis of HBV
convalescence the frequency of detection of that antigen in serum (59.5%

of patients) was significantly higher than in saliva (23.8%).The
frequencies of HBeAg detection by EIA in saliva samples was
significantly higher than that in serum samples in both acute phase
(84.3% and 28.1% of patients, respectively) and in early convalescence
(56.2% and 3.1% of patients, respectively). HBeAg became undetectable
in blood whereas HBs-antigenemia was still pronounced, and a month
after the beginning of the disease it was not found in serum specimens. In
saliva, HBeAg was detected in 95.8% of patients observed directly after
admission. A month after the beginning of the disease it was detected in
saliva of 66.7% of patients and, by the end of observation period, in
12.5% of patients recovered from viral hepatitis. HBV DNA revealed by
PCR in saliva and serum of HBV-infected patients was detected in acute
period not only in serum (84.6% of cases) but also in saliva (46.2% of
cases) (Hakozaki et al., 2002).
Persistence of HBeAg has been associated with progression to
chronicity; persistence of HBeAg for more than 12 weeks indicates
chronicity, whereas early seroconversion to anti-HBe signals recovery
(Hayashi and Furusyo, 2004). A competitive assay procedure is used to
detect anti-HBe, using the same kit reagent provided for HBeAg. Serum
concentrations of HBeAg and anti-HBe are typically low and, unlike antiHBc or anti-HBs, when a patient develops anti-HBe in recovery, the
antibody will probably disappear within 12 months (Hadziyannis et al.,
2003).
74
Diagnosis of HBV
Table (7) Interpretations of available serologic test results for HBV

(Lacarnini, 2004):
HBsAg IGM
ANTIHBC
+
-
TOTAL
ANTIHBC
-
ANTIHBS
INTERPRETATION
-or +
Early HBV infection before anti-HBc

response.
Early HBV infection. Because IgM antiHBc is positive, the onset is within
6 months. IgG antibody usually appears
shortly after IgM; therefore, both are
usually posi-tive when IgM is positive.
Recent acute HBV infection (within 4-6
months) with resolution; i.e., HBsAg has
already disappeared. Anti-HBs usually
appear within a few weeks or months of
HBsAg disappearance.
HBV infection, onset at least 6 months
earlier because IgM anti-HBc has
disappeared. Prob-able chronic HBV
infection.
Response to hepatitis B vaccine. No
evidence of infection.
Past HBV infection, recovered.
Table (8): Serological test findings at different stages of HBV

infection and in convalescence (Honkoop and de Man, 2003).
Stage of infection
HBsAg AntiHBs
Late incubation period
+
Acute hepatitis B or +
persistent carrier state
HBsAg
ve
acute hepatitis
Recovery with loss of anti-HBs
Healthy HBsAg carrier
++
+
Chronic
hepatitis
B, +
persistent carrier state
HBV infection in recent ++
past, convalescence
HBV infection in distant + or past, recovery
Recent HBV vaccination, ++
repeated
exposure
to
antigen without infection,
74
ANTI-HBC
IGG IGM
HBeAg
AntiHbe
+ or +
++
+
++
+
++
+ or -
+ or
+ or -
+ or -
Diagnosis of HBV
or recovery from infection

with loss of detectable antiHBc
Table (9): Hepatitis B tests (Perillo, 2004).

Hepatitis B Hepatitis B (HBV) antibodies and/or antigens are detected. Additional
(HBV)
tests may be needed to determine whether you have an acute or chronic
HBV infection.
Hepatitis B surface antigen (HBsAg) indicates an active
infection. If levels remain high, this indicates a chronic carrier. You
can infect others with HBV.
Hepatitis B surface antibody (HBsAb) indicates end of active
infection and protection against HBV for life. It can also indicate
protection from receiving the HBV vaccine.
Hepatitis B core antibody (HBcAb) indicates that you have been
infected with HBV. It does not distinguish between a past or
present infection.
Hepatitis B e-antigen (HBeAg) indicates an active contagious
state.
Hepatitis B e-antibody (HBeAb) indicates the end of an HBV
infection. You are less contagious but can still infect others.
HBV DNA testing detects genetic material (DNA) from the
hepatitis B virus.
FDA- Approved Tests for Hepatitis B

Table (10): Antibody to Hepatitis B Surface Antigen (HBsAg Assay)
(Lok et al., 2004).
Tradename(s) Format Sample
Approval
Date
Serum /
Donor
Abbott Laboratories 4/1/1985
Plasma
Screen & Abbott Park, IL
Conf. Kit US License 0043
Serum /
Donor
Bio-Rad
12/28/1999
Plasma /
Screen & Laboratories Blood
Cadaveric Conf. Kit Virus Division
Serum
Redmond, WA
US License 1109
Serum /
Donor
Ortho-Clinical
7/23/1971
Plasma
Screen & Diagnostics, Inc.
Conf. Kit Raritan, NJ
US License 1236
Auszyme
Monoclonal
EIA
Genetic
Systems
HBsAg
EIA 2.0
EIA
Ortho
Antibody to
HBsAg
ELISA Test
System 2
AUK-3
EIA
RIA
Serum /
Plasma
ETI-MAK-2
EIA
Serum /
Plasma
Use
Manufacturer
Donor
Screen &
Conf. Kit
Donor
Screen &
Conf. Kit
DiaSorin s.r.l.
Saluggia, Italy
US License 1257
DiaSorin s.r.l.
74
5/9/1986
4/18/1995
Diagnosis of HBV
Table (11): Hepatitis B Surface Antigen (Anti-HBs Assay) (Lok et al.,

2004).
Tradename(s) Format Sample Use
Manufacturer
Ausab
RIA
Serum / Anti-HBs
Plasma
Ausab EIA
EIA
AB-AUK-3
RIA
Serum / Anti-HBs
Plasma
Serum / Anti-HBs
Plasma
ETI-AB-AUK
EIA
Serum / Anti-HBs
Plasma
Approval
Date
Abbott Park, IL
US License 0043
DiaSorin s.r.l.
Saluggia, Italy
US License 1257
DiaSorin s.r.l.
6/27/1989
4/18/1995
Table (12): Hepatitis B Virus Core Antigen (Anti-HBc Assay) (Lok et

al., 2004).
Trade
name(s)
Corzyme
Format
Sample Use
Manufacturer
EIA
Serum / Donor Screen

Plasma
Ortho HBc EIA

ELISA Test
System

Plasma
ABCOREK
RIA

Plasma
ETI-ABCOREK
EIA

Plasma
Approval
Date
Abbott
Park,
IL
US License 0043
Ortho-Clinical
4/18/1991
Diagnostics,
Inc.
Raritan,
NJ
US License 1236
DiaSorin
s.r.l. 3/19/1991
Saluggia,
Italy
US License 1257
DiaSorin s.r.l.
3/19/1991
(VI) HBV DNA:

HBV DNA is regarded to be the most sensitive marker of viral
replication and infectivity, which was previously related to the presence
of HBsAg in serum and HBcAg in liver cells. In liver tissue, different
molecular patterns can be recognized as free viral DNA and integrated
sequences. Introduction of the PCR allows the detection of very small
amounts of viral DNA and has markedly improved diagnostic sensitivity.
The study of HBV DNA has become a valuable part of the routine
74
Diagnosis of HBV
diagnosis in chronic hepatitis B facilitating more precise statements about

the course and prognosis of the disease (Chu and Lok, 2002).
Immunoaffinity capture of intact HBV with biotinylated pre-S1
antibodies coupled to streptavidin-coated magnetic beads is apparently an
optimal method of sample preparation for amplification of HBV DNA in
patients in the pre-HBsAg window period, and for detecting low-level
viraemia persistent in several individuals who were former chronic HBV
carriers who had seroconverted i.e. developed anti-HBs (Kao and Clsen,
2002).
The principle of the polymerase chain reaction (PCR) is the
amplification of DNA using a heat stable polymerase. It has been used to
detect extremely small quantities (i.e. organisms) of HBV DNA in serum
(Berger and Preiser, 2002). This principle of target amplification
techniques is to synthesize a large number of copies of the viral genome
(amplicons) in a cyclic enzymatic reaction then, they can be detected by
various methods, and the amount of viral genomes in the clinical sample
can be quantified. The PCR method uses several temperatures and one
enzyme, a thermostable DNA polymerase. The amplicons are double
stranded DNA. PCR can be applied to HBV DNA directly after extraction
of nucleic acids or lysis of the viral envelope. Each complete PCR cycle
doubles the number of DNA copies; after n cycles, 2 n copies of each
number of DNA molecules present at the beginning of the reaction are
therapeutically synthesized. In fact, the reaction is saturable and reaches a
plateau generally after 35 to 45 cycles (Pawlotsky, 2002).
Real-time PCR techniques have been developed. The principle is to
detect amplicon synthesis and to deduce the amount of viral genomes in
the starting clinical sample during rather than at the end of the PCR
reaction. These methods are theoretically more sensitive than classical
74
Diagnosis of HBV
target amplification techniques and are not prone to carryover

contamination (Kakimi et al., 2002b).
Viral genome sequence analysis is aimed at identifying signature
sequences and/or amino acid substitutions specific positions. Signature
sequences are used to classify viral strains into phylogenetic groups,
called genotypes. This method can be applied to the detection of known
clinically relevant motifs or mutations (Kakimi et al., 2002a).
PCR-ISH is a technique that combines the sensitivity of PCR with
the localizing ability of in situ hybridization (ISH). PCR-ISH is a
sensitive technique for localizing HBV in tissue sections and the low
level of HBV replication persists in HCC cells (Kajiya et al., 2002).
HBV DNA can be detected on average 21 days before the
appearance of HBsAg, even when HBsAg is assayed with the most
sensitive test (Jiang et al., 2002). HBV DNA continued to be detectable
1-3 weeks after the production of the HBsAg (Jung and Pape, 2002).
PCR is an extremely sensitive technique that has been used for
detection of DNA sequences in formalin-fixed paraffin embedded tissues.
Freezing of fresh tissue yields quantitatively more HBV DNA, formalin
fixation qualitatively preserves the viral DNA sequences adequately for
detection by PCR. Therefore formalin-fixed paraffin embedded tissues
may be used for the detection of viral DNA sequences by PCR (lsikawa
et al., 2002).
PCR assay was developed for the direct detection of HBV in
paraffin embedded liver tissue and applied this assay to determine
whether HBV DNA exists in livers. The limit of detection of HBV DNA
by these methods was estimated to be one genomic copy of HBV DNA
per cell (Liaw et al., 2002).
Detection of HBV DNA is a reliable evidence of the presence of
the viral agent and its replication. With the PCR, it became possible to
74
Diagnosis of HBV
extend the sensitivity by amplification of viral sequences. A study was

done to test whether viral sequences could be found in liver tissue
specimens negative for HBV DNA by conventional hybridization
techniques and confirmed PCR to be more sensitive method to detect
HBV DNA in the liver compared with the conventional hybridization
technique (Irshad et al., 2002).
PCR is a highly sensitive technique for the detection of HBV-DNA
in serum, liver tissue and peripheral mononuclear blood cells. In chronic
HBV, it is particularly useful for identification of the infectious subjects
who are HBsAg positive and anti HBeAg antibody positive and for the
follow up of HBV infections in liver transplantation programs (Sherlock
and Dooley, 2002). Hwang et al. (2003) stated that HBV DNA in serum
detected by PCR is a good marker of the level of viraemia. It can be
correlated with serum transaminase levels and parallels the presence of
HBsAg in serum. It can be found in serum and liver after the loss of
HBsAg.
PCR was used to detect HBV DNA in the sera and livers of
patients with chronic HBV after treatment-induced or spontaneous loss of
serum HBsAg. HBV DNA may be detectable by PCR in liver tissue years
after the disappearance of HBsAg even in the absence of detectable HBV
DNA in serum (Humphries and Dixon, 2003).
Serum HBV DNA level is strongly correlated with liver HBV
DNA levels in chronic HBV with cirrhosis. Liver free HBV DNA can
still be detected in about half of the cirrhotic patients with undetectable
serum HBV DNA. Serum HBeAg is not a good predictor of serum or
liver HBV DNA levels in cirrhotic patients (Hou et al., 2005).
(VII) Liver biopsy:
Histologic examination of liver biopsy material is still the best way
of assessing the severity of chronic hepatitis B and establishing the
74
Diagnosis of HBV
prognosis (Pawlotsky, 2002). The purpose of a liver biopsy is to assess

the liver damage and to rule out other causes of liver disease. The
histologic diagnosis of chronic hepatitis should include the etiology,
grade of necroinflammatory activity and stage/extent of fibrosis (Liu et
al., 2003).
Histological Activity Index by Knodell (Kao et al., 2002a):

The Knodell system was the first formal numerical scoring system
to be proposed. It involves assessment of four main histological features,
as summarized in Table (13). Scores for the individual categories can be
added to produce an overall "histological activity index' ranging from 022. The knodell system has been widely used in many studies throughout
the world.
Table (13): Histological Activity Index by Knodell (Kao et al., 2002a):
PERIPORTAL BRIDGING NECROSIS.
0 = NONE.
1 = MILD PIECEMEAL NECROSIS.
3 = MODERATE PIECEMEAL NECROSIS (<50% OF CIRCUMFERENCE OF
MOST TRACTS).
4 = MARKED PIECEMEAL NECROSIS ({50% OF CIRCUMFERENCE OF MOST
TRACTS).
5 = MODERATE PIECEMEAL NECROSIS AND BRIDGING NECROSIS.
6 = MARKED PIECEMEAL NECROSIS AND BRIDGING NECROSIS.
10 = MULTILOBULAR NECROSIS.
INTRALOBULAR DEGENERATION AND FOCAL NECROSIS
0 = NONE 1 = MILD (ACIDOPHILIC BODIES, BALLOONING DEGENERATION
AND/OR SCATTERED FOCI OF NECROSIS IN < 1/3 OF LOBULES OR
NODULES.
3 = MODERATE (INVOLVEMENT OF 1/2-2/3 LOBULES OR NODULES)
4 = MARKED (INVOLVEMENT OF > 2/3 OF LOBULES OR NODULES).
PORTAL INFLAMMATION
0 = NONE.
1 = MILD (FEW INFLAMMATORY CELLS IN < 1/3 OF TRACTS).
3 = MODERATE (INCREASED INFLAMMATORY CELLS IN 1/3-2/3 OF
TRACTS).
4 = MARKED (NUMEROUS INFLAMMATORY CELL IF > 2/3 OF TRACTS).
FIBROSIS
0 = NO FIBROSIS
1 = FIBROSIS PORTAL EXPANSION.
3 = BRIDGING FIBROSIS (PORTAL-PORTAL OR PORTAL-CENTRAL).
4= CIRRHOSIS.
74
Diagnosis of HBV
Histological Grading and Staging of Chronic Hepatitis

(Kawaguchi et al., 2003):
This scheme represents an extension of the original knodell system,
with a number of minor modifications. Firstly, a continuous scale is used
for scoring of each of the features assessed. Secondly, necroinflammatory
activity and fibrosis are considered as separate categories. Thirdly,
confluent necrosis is separated from periportal hepatitis and is included as
a separate category of necoinflamamtory activity.
Table (14): Modified Hai Grading: Necroinflammatory Scores
(Kawaguchi et al., 2003):
SCORE
A. Periportal or periseptal interface hepatitis (Piecemeal necrosis)
Absent
Mild (focal, few portal areas)
Mild/moderate (focal most portal areas)
Moderate (continuous around < 50% of tracts or septa).
Severe (continuous around > 505 of tracts of septa)
B. Confluent necrosis
Absent
Focal confluent necrosis
Zone 3 necrosis in some areas
Zone 3 necrosis in most areas
Zone 3 necrosis + occasional portal-central (P-C) bridging.
Zone 3 necrosis + multiple P-C bridging.
Panacinar or multiacinar necrosis.
C. Focal (spotty) Iytic necosis, apoptosis and focal inflamamtion
Absent
One focus or less per 10 x objective.
Two to four foci per 10 x objective.
Five to ten foci per 10 x objective.
More than ten foci per 10 x objective.
D. Portal inflammation
None
Mild, some or all protal areas.
Moderate, some or all protl areas.
Moderate/marked, all protal areas
Marked, all portal areas.
Maximum possible score
0
1
2
3
4
0
1
2
3
4
5
6
0
1
2
3
4
0
1
2
3
4
18
Table (15) a glossary set by Keeffe et al., 2004 to correlate clinical

terms with laboratory results as follows:
74
Diagnosis of HBV
Definitions:
- Chronic hepatitis B:
Chronic necroinflammatory disease of the liver caused by persistent infection
with HBV.
Chronic hepatitis B can be subdivided into HBeAg-positive and HBeAg-negative
chronic hepatitis B.
- Inactive HBsAg carriers state:
Persistent HBV infection of the liver without significant, ongoing
necroinflamamtory disease.
- Resolved hepatitis B:
Previous HBV infection without further virolgoic, biochemical, or histologic
evidence of active virus infection or disease.
- Acute exacerbation or flare of hepatitis B:
Intermittent elevations of aminotransferase activity to more than 10 times the
upper limit of normal and more than twice the baseline value.
- Reactivation of hepatitis B:
Reappearance of active necroinflammatory disease of the liver in a person known
to have the inactive HBsAg carrier state or resolved hepatitis B.
- HBeAg clearance:
Loss of HBeAg in a person who was previously HBeAg positive.
- HBeAg seroconversion:
Loss of HBeAg and detection of HBeAb in a person who was previously HBeAg
positive and HBeAb negative, associated with decrease in serum HBV DNA to <
10 copies/mL.
- HBeAg reversion :
Reappearance of HBeAg in a person who was previously HBeAg negative and
HBeAb positive.
Diagnostic criteria :
a) Chronic hepatitis B:
1. HBsAg positive > 6 months.
2. Serum HBV DNA > 10 copies/ml.
3. Persistent or intermittent elevation in ALT/AST levels.
4. Liver biopsy showing chronic hepatitis (necroinflammatory score 4)
b) Inactive HBsAg carrier state :
1. HBsAg positive > 6 months.
2. HBeAg negative, HBeAb positive.
3. Serum HBV DNA < 10 copies/ml.
4 Persistently normal ALT/ AST levels.
5. Liver biopsy confirms absence of significant hepatitis (necroinflammatory
score <4).
c) Resolved hepatitis :
1. Previous known history of acute or chronic hepatitis B or the presence of
HBcAb HBsAb.
2. HBsAg negative.
3. Undetectable serum HBV DNA.
4. Normal ALT level.
74
Diagnosis of HBV
Table (16): The stages of HBV in correlation with the laboratory

results (Kim and Sherker 2004):
DISEASE
MARKER
HBsAb
HBsAb
HBV DNA
HBeAg
HBeAb
HBcAb
AST/ALT
REPLICATIVE PHASE
INTEGARATIVE PHASE
Stage 1
+
+(strongly)
+
+
Normal
Stage 3
+
+
Normal
Stage 2
+
+
+
+
elevated
74
Stage 4
+
+
+
Normal
Diagnosis of HBV
Diagnosis of HBV
Table (17): Interpretation of serological markers according to symptoms, transaminases and histological features
(Poynard, 2002).
Acute
HBSAG HBSAB HBEAG HBEAB HBCAB HBCAB HBVIGG

IGM
DNA
+
+
+/+
+
+
SYMPTOMS ALT HAI

AND
FIBROSIS
+/+/+
+
Chronic carrier wild type
+/-
+/-
Chronic carrier pre-core +

mutant
-/+
+/-
+/-
'Healthy carrier"
"Immune tolerance"
++
Recovery/Immunity
from -
+/-
+/-
+/-
+/-
+/-
+/-
Immunity
vaccination
Occult infection
74
Treatment of Chronic Hepatitis B
CHAPTER VI
TREATMENT OF CHRONIC HEPATITIS B
Effective treatment of chronic hepatitis B is defined as sustained
clearance of circulating HBeAg and HBV-DNA with production of
HBeAb and improvement in liver disease as determined by normalization
of serum ALT level and reduction of necro-inflammation on liver
biopsies. The most widely available agents for the treatment of chronic
hepatitis B are interferon and Lamivudine (Pramoolsinsup, 2002).
Definitive treatment:
The kinetics of HBV clearance during anti-viral therapy is slow
requiring long-term therapy to control viral replication. Emergence of
resistant mutants is accelerated by high HBV replication and hepatocyte
turnover, which are common features in patients with chronic HBV
infection. These mutants have a decreased priming and elongation
activity, and remain sensitive to novel nucleoside analogues (Kiss et al.,
2002).
Decision to treat: it must be taken individually, based on
precisely weighted parameters. Elevated ALT activity, a liver biopsy
showing chronic hepatitis with or without cirrhosis and the presence of
significant levels of HBV DNA are strong arguments about initiating
antiviral therapy. The precise HBV DNA cutoff that discriminates
between low and high pretreatment replication needs to be determined,
using standardized quantification units (De Gottardi and Negro, 2004).
Treatment monitoring: HBV DNA quantification with repeated
ALT determinations and HBeAg/HBeAb assessment in HBeAg positive
patients are critical in monitoring treatment (Kirschberg et al., 2004).
Aims of treatment: are to achieve sustained suppression of HBV
- 75 -
replication and remission of liver disease. The end points used to assess
treatment response include normalization in serum ALT level,
undetectable serum HBV, loss of HBeAg with or without detection of
HBeAb and improvement in liver histology (Kobak et al., 2004).
Inconsistencies
in
the
definition
of
response,
lack
of
standardization of HBV DNA assays, and heterogeneity in patient

populations make it difficult to compare response rates in clinical trials of
treatment of chronic hepatitis B. Responses to antiviral therapy of chronic
hepatitis B are categorized as biochemical, virologic or histologic and as
on-therapy or sustained off therapy (Kondili et al., 2004). ALT level and
HAI, rather than low HBV DNA level were found to be important
predictors for response (Kumar and Agrawal, 2004).
Established treatment: treatments as studied by Kuo et al. (2004)
including the developed therapeutic modalities are based either on antiviral drugs or focus on attempts to augment anti viral immune response.
Their results have been largely disappointing. The treatment of chronic
hepatitis B is based on IFN- administration at a dose of 5-10 million
units 3 times a week subcutaneously for 16-32 weeks or lamivudine at a
dose of 100 mg /day orally for 48 weeks or longer. Which of these two
drugs should be chosen for first line treatment for chronic hepatitis B is
controversial. Patients with a low HBV DNA are more likely than the
others who are not to have a sustained response to IFN- i.e. HBe
seroconversion (Lacarnini, 2004).
- 76 -
Table (18): Hepatitis B Therapies and Treatment (Lok et al., 2004).

Drug Name
Intron A
(interferon alfa-2b)
Hepsera
(adefovir dipivoxil)
Epivir-HBV
(lamivudine; 3TC)
Drug Class
Manufacturer
interferon
Schering-Plough
Baraclude
(entecavir)
nucleoside
analogue
Bristol-Myers Squibb
interferon
Roche Labs
Pegasys
(peginterferon alfa-2a)
Emtricitabine
(FTC)
Telbivudine
(LdT)
Clevudine
(L-FMAU)
Elvucitabine
(ACH 126, 443)
Valtorcitabine
Racivir
BAM 205
HepX-B
nucleotide
analogue
nucleoside
analogue
Gilead Sciences
GlaxoSmithKline
nucleoside
analogue
nucleoside
analogue
nucleoside
analogue
nucleoside
analogue
nucleoside
analogue
nucleoside
analogue
small molecule
monoclonal
antibody
Gilead Sciences
FDA Status
FDAapproved
FDAapproved
FDAapproved
about to
got FDAapproval
FDAapproved
Phase III
NDA filed
Idenix
Phase III
Gilead Sciences
Phase II
Achillon Pharmaceuticals
Phase II
Idenix
PhaseII
Pharmasset
Phase II
Novelos
Phase II/III
XTLBiopharm
Phase II
Phase II
Phase II in combo
with Epivir-HBV
AND Orphan drug
for liver cancer in
US
Phase II
Phase II
Phase I
Phase I
Phase I
Phase I
HE 2000
immune stimulant
Hollis-Eden
Zadaxin
(thymosin-alpha)
immune stimulant
SciClone
Theradigm
EHT 899
MCC 478
MIV 210
Hepavir B
HBV DNA vaccine
immune stimulant
viral protein
nucleoside analogue
nucleoside analogue
nucleoside analogue
immune stimulant
Epimmune
Enzo Biochem
Eli Lily
Medivir
Ribapharm
PowderJect
Prednisone priming:
The rationale for administering a tapering course of steroids prior
to antiviral therapy (prednisone priming) is that recovery of immune
function following steroid withdrawal may be beneficial particularly if
- 77 -
this is timed with the initiation of IFN- therapy (Lada et al., 2004).
Although a small subset of patients may benefit from prednisone
priming, there is a risk of fatal exacerbations in patients with underlying
cirrhosis. Therefore, prednisone priming is not recommended as a
primary treatment of chronic hepatitis B (Lai, 2004).
(1) Immunomodulating agents and chronic hepatitis B:

Interferon therapy:
IFN- has direct effect on the immune system, including enhanced
expression of HLA-class 1 molecules and stimulation of CD8+ cytotoxic
T-cell activity, and treatment-induced alanine transaminase (ALT) flares
are a surrogate marker of these properties (Lai and Terrault, 2004).
Interferon is cytokine with Immunomodulatory; antiproliferative
and antiviral properties. Interferon alpha (INF-) was licensed in 1992
and it is the first approved treatment for chronic hepatitis B in most
countries (Waked, 2005).
Fig. (20): Mode of action of interferon alpha (INF-) (Cooksley, 2004).
- 78 -
Natural interferon is a protein produced by the body's cells in

response to viral infections. There are three types: IFN-alfa (also known
as leukocyte interferon), IFN-beta (also known as fibroblast interferon)
and IFN-gamma (also known as immune interferon). IFN-alpha and
IFN-beta are also referred to as Type I interferon and IFN-gamma as
Type II. There are approximately 20 subtypes of IFN-alpha but only one
IFN-beta and IFN-gamma (Cooksley, 2004).
Commercially produced (genetically engineered) interferon alfa
mimics the activity of naturally-occurring interferon alfa produced by the
body, although the mechanism of action of the drug is not well
understood (Lin and Kirchner, 2004).
Table (19): Types and Properties of Interferon (Lin and Kirchner,

2004).
Property
Previous
designations
Genes
pH2 stability
Inducers
Principal source
Alpha
Leukocyte IFN
Type I
>20
Stable
Viruses
(RNA>DNA)
dsRNA
Leukocytes,
Epithelium
Interferon
Beta
Fibroblast IFN
Type I
1
Stable
Viruses(RNA>DNA)
dsRNA
Gamma
Immune IFN
Type II
1
Labile
Antigens,
Mitogens
Fibroblasts
Lymphocytes
Intron a (interferon alfa-2b) is one commercial form of interferon

approved by the US Food and Drug Administration for the treatment of
Hepatitis B (Leung, 2002).
Multiple studies of interferon therapy in chronic HB have
demonstrated beneficial effects. A 4-month course of interferon alfa-2b
treatment results in virological response in 30-40% of patients with
significant reduction of serum HBV-DNA expression, normalization of
ALT level and loss of HBeAg. Seroconversion from HBeAg to Anti-HBe
- 79 -
occurs in 15-20% of interferon treated patients (Lai et al., 2003b).

INF- therapy has been accepted as an effective therapy with a
good response rate for patients with chronic hepatitis B who were
HBeAg-positive, had high serum ALT levels and low HBV-DNA levels
(Lee et al., 2004).
Selection of patients and indications for interferon therapy:

a) Patients with compensated chronic hepatitis with active viral
replication that is elevated serum ALT levels, detectable HBeAg
and/or HBV DNA and histology of active hepatitis (Chan et al.,
2002b).
b) Patients who are HBeAg-negative but HBV DNA positive and with
elevated ALT levels, usually respond temporary to interferon therapy
with decreases in serum levels of both HBV-DNA and ALT. These
patients are commonly seen in Mediterranean region and Asia, and
have a low sustained response and common relapse but requiring
longer course of interferon treatment (Leung, 2002).
c) Patients in the immune-tolerant phase of chronic hepatitis B infection,
with circulating HBeAg and HBV-DNA but have normal or near
normal ALT values, have very low response rates to interferon
therapy, they are commonly seen in Asia among perinatally infected
children, the response rate is less than 10% so they are not treated in
most of the authorities (Li et al., 2003).
d) Patients with decompensated cirrhosis may benefit from interferon
therapy by inhibiting viral replication but it may produce significant
adverse events such as serious infection and hepatic failure (Lin et al.,
2004b).
Dosage regimen:
The recommended regimen of interferon alfa-2b 5 MU or 10 MU
- 80 -
three times per week for 4-months course subcutaneously. In case of

HBeAg +ve for 16 weeks while in case of HBeAg ve for 12 months
(Perrillo et al., 2002).
Long term twice weekly INF- therapy could be a worldwide
strategy for HBeAg positive patients with serum HBV-DNA level of less
than 200 Meq/ml and patients with transient acute exacerbation of ALT
during or after INF- therapy could often respond well after exacerbation
of ALT (Arase et al., 2002).
The FDA-approved dose of standard interferon alfa for treatment
of hepatitis. FDA-approved treatment for hepatitis B is five million units
daily for 16 weeks (Liaw, 2002).
Patients with lower ALT, higher HBV-DNA, and immunosuppressed patients have a poorer response to IFN- and can be
dangerous in cirrhosis (De Gottardi and Negro, 2004).
Table (20): Determinant of responsive factors to interferon (Lin and
Kirchner, 2004).
Favorable outcome
HBeAg positive
Low serum HBV-DNA level
High serum ALT
Active liver histology
Female-western adult
Acquired or recent HBV infection
Unfavorable outcome
HBeAg negative
High serum HBV-DNA level
Normal serum ALT
Inactive liver histology
Male Asian
Long standing HBV infection
Non-cirrhotic
Anti-HIV negative
HDV negative
Cirrhotic patients
Anti-HIV positive
HDV positive
Side effects of interferon:

Common side effects include:
Flu like symptoms, including headaches, Extreme weariness
(fatigue), Muscle aches, Fever, Hair loss, Depression and other mood
- 81 -
disorders, Decreased number of platelets and Decreased white blood cell

count (Pramoolsinsaip, 2002).
Rare side effects include:
Thyroid problems, Confusion, Excessive amounts of protein in the
urine, indicating poor kidney function and Heart problems (Perillo,
2004).
Peters et al. (2004) found that Pegylated Interferon-Alfa has
primary role in treatment of Chronic hepatitis B whether HBeAg-positive
or HBeAg-negative. Its concept is the production of a molecule which
maintains prolonged biologic effect, thus reducing the opportunity for the
virus to escape. There are 2 Pegylated interferons alfa-2a (40 KD)
and alfa-2b (12 KD).
Cooksley (2004) added that pegylated interferon-Alfa was more
effective than conventional interferon. Its dose is 1.5 mcg/kg body weight
interferon alfa-2b for the first 24 weeks and 1 mcg/kg for the second 24
weeks. At follow-up 6 months after the end of therapy.
(2) Antiviral nucleoside analogues:

Nucleoside analogues suppress HBV-DNA replication mainly by
inhibiting the viral polymerase. The lower side effect profile of the
nucleoside analogues has made them preferred agents for first-line
therapy, although concerns about resistance developing during
monotherapy has tempered enthusiasm somewhat (Pfeifer et al., 2002).
Nucleoside analogues have been introduced in the management of
chronic HBV infection. They mainly act by inhibition of HBV
polymerase activity resulting in decrease of viral replication. They are
administered orally and most of them have excellent tolerance and safety
profile (Kidd et al., 2002).
Lamivudine is the only nucleoside analogue licensed for chronic
- 82 -
hepatitis B. It has potent activity against HBV and 12 month course

achieves clearance of HBeAg in 20-30% of HBeAg positive patients and
both biochemical and virological remission in more than 65-70% of
HBeAg-negative chronic hepatitis B patients (Lagget and Rizzetto,
2002).
Prolonged effective antiviral therapy is required for eradication of
chronic HBV infection, but long-term treatment with nucleoside
analogues has been found to be associated with progressively increasing
rates of viral resistance because of emergence of resistant HBV mutant
strains (Lalekha et al., 2002).
Virological breakthroughs usually develop after the first 6 months
of lamivudine monotherapy and their rate ranges between 15% and 30%
at 12 months and exceeds 50% after 3 years of therapy. Resistant HBV
mutant strains harbor point mutations in the HBV polymerase gene and
predominantly in the well-conserved tyrosine methionine aspartate
aspartate (YMDD) motif. Although resistant HBV strains may have
impaired replication capacity compared with the wild HBV, their clinical
significance has not been completely clarified yet. No significant
biochemical breakthroughs with or without deterioration of liver function
may develop in others. There is no proven effective therapy for the
resistant HBV mutant strains, although adefovir and entecavir seem to be
interesting candidates (Le Pogam and Shih, 2002).
(a) Lamivudine
Lamivudine is a cytosine analogue with potent inhibitory effect in
the RNA-dependant DNA polymerase of HBV, HIV and it is approved
for the treatment of chronic hepatitis B (Liaw, 2002).
- 83 -
Graph (3): (Schiff et al., 2003b).
Lamivudine may also reverse the T-cell hypo responsiveness to

hepatitis B viral antigens observed in patients who have chronic hepatitis
B virus infection (Rodriguez et al., 2003).
Graph (4): (Roque et al., 2002).
- 84 -
Efficacy and tolerability:

Worldwide studies of lamivudine in patients with HBeAg-positive
chronic hepatitis B have demonstrated good efficacy based on improved
hepatic histology, HBeAg seroconversion, suppression of serum HBVDNA and normalization of ALT levels (Roque et al., 2002).
Lamivudine monotherapy is also effective in suppressing HBV
replication and ameliorating disease in patients who are HBeAg negative
(Sakai et al., 2002).
Graph (5): (Saab et al., 2003).
Studies in Asian and Western patients with elevated ALT

activity and markers of HBV replication (HBeAg and HBV-DNApositive) have responses to lamivudine with HBeAg seroconversion 1618%, HBeAg loss in 30-33%, sustained normalization of ALT in 41-49%
and histology improvement and reduction in histologic activity index of
more than 2 points in 50-60% of treated patients (Sakai et al., 2002).
Reductions of HBV-DNA serum levels were detected after 2 weeks
of lamivudine therapy in 97% of patients and eventually became
undetectable in all patients (Spijkerman et al., 2002). However, after
- 85 -
cessation therapy, serum HBV-DNA in these patients always reappeared,

this may be attributed to the persistence of HBV covalently closed
circular DNA in the nuclei of hepatocytes (Squadrito et al., 2002).
This competitor of cytidine is 80% bioavailable and devoid of side
effects at the oral dose of 100mg daily; tolerance continues for therapies
up to 3 years. It induces a rapid decline of ALT accompanied by
improvement of histology; however, there is a delayed accumulating
seroconversion to HBeAb and the switch to HBsAb is rare (Sobao et al.,
2002).
Over the long term, its activity is abolished by the emergence of
specific viral mutations YMDD mutants that rekindle the disease. The
indication to lamivudine therapy in HBeAg negative chronic hepatitis B
is currently under investigation. Lamivudine is highly efficacious in
preventing HBV reinfection in liver transplants (Sakugawa et al., 2002).
It is well tolerated after 1 year of treatment, HBeAg seroconversion
rate increased with higher pretherapy ALT levels, suggesting that patients
with stronger endogenous antiviral defenses to kill hepatocytes harboring
viral DNA. In addition, it is beneficial in HBeAg negative chronic
hepatitis B, and patients with decompensated cirrhosis and HBV
replication. However, genotypic resistant YMDD mutations start to
emerge after 9-10 months of lamivudine therapy, and their incidence
increases more quickly than the HBeAg seroconversion rate durating
prolonged therapy (Tedder et al., 2002).
Thus, the benefits of long-term lamivudine must be balanced
against concern about YMDD mutations and the durability of treatment
response. There are encouraging preliminary results for adefovir
dipivoxial, entecavir, emtricitabine, clevudine and other nucleoside
analogues in the early stages of appraisal; entecavir and adefovir
dipivoxil appear effective in patients with YMDD mutants (Tamori et
- 86 -
al., 2003).
Treatment of patients with lamivudine results in loss of detectable
levels of HBV DNA from serum; however, the relapse rate, with regard
to both reappearance of virus in the bloodstream and hepatic
inflammation, is high when therapy is terminated (Abdelhamed et al.,
2002).
Samuel (2004) concluded the following results; 1) Lamivudine
resistant mutants are likely to be cross resistant to other L-cytidine
analogues; 2) antiviral therapy using a single reverse transcriptase (RT)
inhibitor is likely to fail to eradicate viral DNA and 3) new nucleoside
analogues with unique mode of action (inhibition of priming or
elongation of RT, or DNA polymerase activity) and activity against
lamivudine resistant strains are emerging. Combination of these new anti
HBV agents with DNA based immunization may prove useful to
eradicate viral infection.
Graph (6): (Peters et al., 2004).
- 87 -
Long-term efficacy of Lamivudine:

Studies in Asia have shown that the frequency of HBeAg
seroconversion increases with longer duration of treatment from 22% at 1
year to 27% at 2 years and to 40% at 3 years (Schiff et al., 2003a). The
role of indefinite maintenance treatment with lamivudine after HBe
seroconversion is unclear during a maintenance therapy; lamivudine
resistant mutants increased from 14-40% of treated patients and in other
study 66% of patients developed YMDD mutation after 4 years of
lamivudine therapy (Schiff et al., 2003b).
Graph (7): (Schiefke et al., 2004).
Predictors of Response to Lamivudine Therapy:

The pretreatment factors that predict the response of patients with
HBeAg-positive chronic hepatitis to lamivudine are the high baseline
ALT and high baseline HAI; they are very similar to those for IFN except
that baseline HBV DNA may not be as important a predictor for
lamivudine efficacy (Perrillo et al., 2002).
Sekiya et al. (2002) clearly showed that baseline ALT is highly
- 88 -
predictive of lamivudine efficacy but high ALT is also predictive of

spontaneous HBeAg seroconversion.
Lamivudine Resistance:
The likelihood of developing drug resistance increases with
duration of therapy. After 1 year of lamivudine therapy, 14 to 32% of
individuals have genotypic resistant mutations. This figure increases with
each year of extended Lamivudine therapy (Selimo et al., 2002).
Lamivudine resistance is more likely to develop in individuals with
high baseline HBV DNA and/or high baseline ALT (Seo et al., 2004),
high HAI score, and high body mass index (31) (Wright, 2004).
Consequences of Drug Resistance:

It remains possible for individuals who have developed drug
resistance to seroconvert and to have an improvement in liver histology
(Wong et al., 2002). The presence of lamivudine-resistant mutations may
not cause major adverse effects during short-term follow-up, especially in
immunocompetent
patients
with
mild
disease.
However,
in
immunocompromised patients, (particularly those co-infected with HIV)

and in immunocompetent patients with cirrhosis; hepatic decompensation
and even death have been described (Shiao et al., 2002).
Thus, consequences of drug resistance may be:
Exacerbation of hepatitis.
Decreased rate of seroconversion.
Rapid re-infection of liver graft.
Rapid disease progression (after liver transplantation).
Severe hepatitis HBV/HIV co-infection.
Transmission of drug resistance (Tanaka et al., 2004).
Possible Actions to Take When Lamivudine Resistance

Develops:
- 89 -
1) Continue lamivudine monotherapy if serum ALT levels remain normal

despite reactivation of HBV DNA (Yang et al., 2002).
2) Stop Lamivudine. If Lamivudine treatment is stopped in those who
have developed drug resistance, viral replication returns to wild type.
The cessation of treatment in this situation has been discouraged by
the relevant pharmaceutical company, but there have been two reports
which suggest that cessation of therapy in individuals whose ALT and
HBV DNA have become elevated once again is safe (Sinturk et al.,
2002).
3) Add another drug effective against the drug-resistant mutant. The
alternative to stopping lamivudine if ALT and HBV DNA levels
become elevated once more is to add an antiviral agent effective
against
lamivudine-resistant
mutations
(Yano
et al.,
2002),
particularly if the patient has cirrhosis, it is probably safest to take this

action. None is currently licensed but several are known to be
effective, and adefovir dipivoxil {approved by the Food and Drug
Administration (FDA)} has already been shown in vivo to be very
effective after liver transplantation (Zhang et al., 2002). Yano et al.
(2003) suggest from preliminary results of an ongoing study that
adefovir dipivoxil alone may be as effective as adefovir dipivoxil and
lamivudine in this setting.
(b) Other Nucleoside Analogues:
A number of other agents are either approved by the Food and
Drug Administration (FDA) like (adefovir dipivoxil, entecavir) or in the
process of phase III evaluation (clevudine, emtricitabine) (Yao et al.,
2002).
Adefovir Dipivoxil
Adefovir dipivoxil is a nucleotide analogue of adenosine
- 90 -
monophosphate that inhibits both HBV reverse transcriptase and DNA

polymerase activity. Adefovir has been shown to be effective in
suppressing not only wild-type HBV but also lamivudine-resistant HBV
mutants (Sakai et al., 2002). It does not lead to the emergence of resistant
virus after up to 60 weeks of therapy but it is unclear whether resistance
mutations will emerge after longer therapy or not (Xu et al., 2002).
Graph (8): (Brabin et al., 2002).
It received approval by the FDA in September 2002. A 1-year

randomized, controlled study involving 515 individuals with HBeAgpositive hepatitis indicated that the rate of HBeAg seroconversion in
individuals receiving a 10-mg dose (12%) was significantly greater than
that observed in the placebo group (6%), P <0.05 (Pasquetto et al.,
2002).
The number of individuals whose serum ALT fell within the
normal range was also higher in those randomly assigned to treatment (10
or 30 mg), 48% and 55%, respectively (compared with 16% in the control
group). Serum HBV DNA levels fell to less than 400 copies/ml in 21% of
those who received 10 mg/day and in 39% of those who received 30
mg/day and this effect was not observed in any of those who received
placebo (Chang et al., 2003).
- 91 -
Graph (9): (Dahmen et al., 2004).
At the 10 mg/day dose, a significant improvement in both the

necro-inflammatory and the fibrosis scores on liver biopsy was observed
after 1 year of therapy The major advantages of adefovir dipivoxil appear
to be the apparent lack of development of drug resistant mutations (Chu
et al., 2002) and its antiviral efficacy in the presence of lamivudineresistant mutations (Danalioglu et al., 2004).
Graph (10): (Dando et al., 2003).

- 92 -
Graph (11): (Fattovich, 2003).
Entecavir:
On March 29, 2005, FDA approved Baraclude (entecavir) for the
treatment of chronic hepatitis B virus infection in adults with evidence of
active viral replication, and either evidence of persistent elevations in
serum aminotransferases (ALT or AST), or histologically active disease
(Gish et al., 2005a).
Entecavir is a guanosine nucleoside analogue, which is a potent
selective inhibitor of hepatitis B virus, and is undergoing phase III
development worldwide (Gish et al., 2005b). In the woodchuck model,
it is highly active, and importantly has shown reduction in CCC DNA
(covalently closed circular DNA) levels and reduction in development of
HCC with prolonged survival (Brown, 2005).
- 93 -
Graph (12): (He et al., 2002).
Famciclovir:
It is the oral pro-drug of penciclovir, an acyclic deoxyguanosine
analogue. Penciclovir triphosphate competes with dGTP for incorporation
into the nascent HBV DNA chains and for the priming of reverse
transcription. Given the low virological response rates, potential risk of
drug resistance and the need for thrice daily administration, the role of
famciclovir in the management of chronic HBC is limited (Kao, 2002).
Emtricitabine/ coviracil:
It is a cytosine nucleoside analogue with potent anti viral activity
against HBV. Because of the structural similarity with lamivudine, longterm therapy with emtricitabine may select the same resistant mutants
(Kim et al., 2004).
Others:
- 94 -
Three simple related nucleosides -L-2 deoxycytidine, -Lthymidine and -L 2 deoxyadenosine; have been discovered to be
potent, specific and selective inhibitors of the replication of HBV. The
nucleosides are efficiently converted intracellularly into active
triphosphate metabolites that have a long half-life. These compounds
have the potential for use in combination therapy with goal of achieving
superior viral suppression and diminishing the onset of resistance (Lohr
et al., 2002).
BAY 41-4109 is a member of a class of heteroaiyl-pyimidines that
was identified as potent inhibitors of human HBV replication and antiHBV drug candidate (Manesis et al., 2002). Pharmacokinetic studies in
mice have shown rapid absorption, a bioavailability of 30% and dose
proportional plasma concentrations (Manesis et al., 2002).
Oligodeoxynucleotide TGO20 can be transfected into cells by
packing with liposme and can be combined with HBV DNA. TGO20 can
effectively inhibit replication of HBV (Moola et al., 2002).
Novel 2-amino-6 arylthio-9-2 {(phosphonomethoxy) ethyl}
purine bis (2, 2, 2-trifluoroethyl) esters (PMEA) showed considerably
high anti- HBV activity, and exhibited low cytotoxicity (Gotsman et al.,
2002). It is a lipophilic prodrug of 9-(2-phosphonylmethOxyethyl)
adenine (PMEA), designated PMEALO, and incorporated it into
reconstituted lactosylated high-density lipoprotein (LacNeoHDL) was
internalized by the asialogycoprotein receptor on parenchymal liver cells
and converted into its active diphosphorylated metabolite. Asialofetuin,
an established ligand for the asialoglycoprotein receptor, inhibited the
association by > 75%, which confirms the role of the asialoglycoprotein
receptor. Association of the prodrug-loaded particles to HepG2 cells was
coupled to degradation. LacNeoHDL-associated PMEALO effectively
- 95 -
inhibited HBV DNA synthesis (Lo et al., 2003).

Effective antiviral agents are thought to inhibit HBV DNA
synthesis irreversibly by chain determination because RT lack an
exonucleolytic activity that can remove incorporated nucleotides. The
HBV-RT pyrophosphorolytic activity may be a determinant of antiviral
drug efficacy and could serve as a target for antiviral drug therapy. The
strong inhibitory effect of cytoplasmic pyrophosphate concentration on
viral DNA synthesis may also partly account for the apparent slow rate of
HBV genome replication (Myers et al., 2003).
(3) Combination therapy:

A number of subsequent investigator-initiated trials of combination
IFN and lamivudine therapy also suggest that this combination is more
efficacious than either therapy given alone. In the study reported by
Hakozaki et al. (2002), 150 patients were randomly assigned to
interferon alfa-2b 9 MU 3 times a week and lamivudine 100 mg daily for
24 weeks or to lamivudine 100 mg daily as monotherapy for 52 weeks.
Follow-up was conducted for a further 48 weeks. The rate of HBeAg
seroconversion was 35% with combination therapy and 19% with
monotherapy. A repeat liver biopsy was performed. At the end of
treatment, improvement in inflammation (2 points fall in the HAI score
from baseline) was seen in 46% of those assigned to combination and in
27% of those assigned to lamivudine monotherapy. An improvement in
fibrosis was reported in 42% with the combination and in 24% of those
with monotherapy (Ogawa et al., 2002).
The combination of IFN and lamivudine is associated with an
enhanced rate of virologic response when compared with either agent
alone. From a theoretical perspective, the combination of lFN with one
or more nucleoside analogues may be the most effective way to treat
- 96 -
HBV infection in many clinical situations (Fattovich, 2003).

The combination of large dosage IFN- 2b and lamivudine
therapy in children was compared at the end of therapy and 6 monthsafter therapy, normalization of ALT and the clearances of HbeAg and
HbsAg in both groups were directly proportional to the duration of
treatment. However, the higher complete response rate at 12 months of
combination therapy was not statistically different from that at 6 months
(Hanazaki, 2004). However, Hadziyannis et al. (2004) in their study
found that the response rate of IFN- and lamivudine combination
therapy in children with chronic hepatitis B was similar to that of IFN-
monotherapy.
Combination IFN- 2b and thymosin-1 treatment may provide
a safe and effective therapeutic approach for the difficult to treat HbeAb
positive chronic hepatitis B patients (Haushofer et al., 2004).
Combination of IFN- plus GMCSF (granulocyte macrophage
colony stimulating factor) was effective in non-responders (Hayashi and
Furusyo, 2004).
Combination or sequential therapy of nucleoside analogues may
help to better achieve the goals of treatment for chronic hepatitis B in the
new century (Hm et al., 2004).
(4) Therapeutic vaccine:

HBcAg based therapeutic vaccine was found to induce T cell
proliferative responses in chronically infected hepatitis B patients to the T
helper epitope. The induction of a T helper 0/T helper 2 CD4+ T cell
response rather than T helper 1 response. Thus, its combination with
IFN- or IL-12, which might reverse the CD4+ cell response, should be
considered. It is likely that different types of combination therapy may
have to be tailor made for chronic HBV infection with different
- 97 -
virological and immunological profiles and different degrees of liver

damage (Gheit et al., 2002).
PreS2/S vaccination of chronic HBV carriers led to a reduction in
HBV replication or clearance of virus in 30% of treated patients
(Gotsman et al., 2002). Combination of IFN- with Pre S2 containing
vaccine (Genhevac-B) is effective for the vaccine failures and may
increase sustained response compared to IFN- alone (Hou et al., 2005).
(5) Gene therapy:

A hammerhead ribosome, RzC was designed to target the sequence
encoding the tail region of the HBV core protein suggesting the
possibility of hammerhead ribosome mediated gene therapy for the
treatment of HBV infections (Hbscher and Potmann, 2002). As an
alternative to ribozymes, the use of DNA containing, phosphorothioatemodified minimized hammerhead ribozymes (minizymes) to inhibit
HBsAg expression and viral replication. Minizymes can inhibit HBV
gene expression and may potentially be useful for clinical therapy against
chronic HBV infection (Humphries and Dixon, 2003).
(6) Immunotherapy:
Administration of monoclonal antibodies against HBsAg to HBVTrimera mice, a system that provides a mouse model for human hepatitis
B infection, reduced the viral load and the percentage of HBV-DNA
positive mice in a dose dependent manner. They were more effective than
a polyclonal antibody preparation in both inhibitions of HBV liver
infection and reduction of viral load (Hunter, 2002).
CTL (cytotoxic T lymphocyte) reactivity is stimulated following
treatment with certain cytokines, but is dependent on the time of
administration (Rapicetta et al., 2002). IL-12 plays a central role in
mounting an effective cellular immune response directed towards
- 98 -
elimination of intracellular pathogens. Subcutaneously administered

recombinant human IL-12 treated for 12 and 10 consecutive weeks was
generally well tolerated, but was associated with temporary decrease in
neutrophils and lymphocyte counts, and with elevation in serum
transaminases and bilirubin. Serum IL-12 levels do not appear to be
advantageous in comparison to other currently available treatment
(Sakugawa et al., 2002).
(7) Other modalities under trial:

Peptide aptamers are molecules, which can block viral replication
by interfering with capsid formation. Specifically bound to be HBV core
protein under intracellular conditions. One of them, named CL-I,
efficiently inhibited viral capsid formation and consequently, HBV
replication and virion production (Tsamandas et al., 2002).
Hepatocyte nuclear factor (HNF 3) inhibits nuclear hormone
receptor-mediated viral replication. Inhibition of HBV replication by
Hepatocyte nuclear factor (HNF-) is associated with the preferential
reduction in the level of the pregenornic RNA compared with that of
precore RNA. HBeAg encoded by the precore RNA mediates part of the
inhibition of viral replication by Hepatocyte nuclear factor (HNF 3- )
(Torbenson and Thomas, 2002).
The amino terminal transcriptional activation domain of
Hepatocyte nuclear factor (HNF 3- ) is essential for the inhibition of
HBV replication. The activation of transcription by (HNF3) from HBV
promoters downstream from the nucleocapsid promoter appears to
contribute indirectly to the reduction in the steady state level of 3.5-Kb
HBV RNA, possibly by interfering with the elongation rate of these
transcripts.
Therefore,
transcriptional
interference
mediated
by
Hepatocyte nuclear factor (HNF-) may also regulate HBV RNA

- 99 -
synthesis and viral replication (Tang and Mclachlan, 2002).

Higher doses of bifendate (Bethanechol chloride) taken for a long
term has remarkable anti- HBV efficacy in treatment of chronic hepatitis
B (Saruc et al., 2002).
All patients receiving indomethacin 75 mg daily for 6 months
exhibited a total HBeAb immunoglobulin response. The prostaglandin
pathway is involved in the pathogenesis of the immune response against
HBV, and that the suppression of viral replication is achieved as indicated
by the disappearance HBeAg and HBV DNA in healthy chronic HBV
carriers (Tibbs and Smith, 2003).
Capsid-targeted viral inactivation is a conceptually powerful
approach that exploits virion structural proteins to target a degradative
enzyme specifically into viral particles. C proximal fusion to the HBV
capsid protein of the Ca 2+ dependent nuclease SN from staphylococcus
aureus yields a chimeric protein, core SN. The antiviral effect depends on
both an enzymatically active SN and on the core domain. Core SN does
not block assembly of RNA containing nucleocapsids but interferes with
proper synthesis of viral DNA inside the capsid or leads to rapid DNA
degradation. An intracellular nuclease activation that owing to the
characteristics of HBV morphogenesis, is nonetheless highly virus
specific (Saudy et al., 2003).
- 100 -
Table (21): Comparison of Three Approved Treatments of Chronic

Hepatitis B (Shen et al., 2004).
Indications
IFN-
HBeAg+, normal ALT
Not indicated
HBeAg+ chronic
Indicated
hepatitis
HBeAg- chronic hepatitis
Indicated
Duration of Treatment
HBeAg+ chronic
4-6 months
hepatitis
HBeAg- chronic hepatitis
1 year
Route
Subcutaneous
Side Effects
Drug Resistance
Lamivudine
Not
indicated
Not indicated
Indicated
Indicated
Indicated
Indicated
1 year
1 year
>1 year
Oral
>1 year
Oral
Potential
nephrotoxicity
None, year 1
3%, year 2
Intermediate
Many
Negligible
0%, year 1
70%, year 5
Low
Cost*
High
*
Based on treatment duration of 1 year.
Adefovir
Kawaguchi et al. (2003) reported that even after resolution of

hepatitis B and recovery, there is persistence of very small amounts of HBV
DNA. Some of organs or tissues, for instance, the renal tubular epithelium
and the choroids plexus, are not readily accessible to T cells due to a closed
basal membrane and could represent immunoprivileged sites.
Table (22): Goals of Therapy and Definitions of Response to Therapy
in Chronic Hepatitis B (Papatheodoridis and Hadziyannis, 2004):
Goals of therapy
Ideal: HBV eradication (clearance HBsAg)

Realistic: Sustained suppression of HBV
HBeAg-positive CHB: sustained seroconversion of HBeAg to
anti-HBe
HBeAg-negative CHB: sustained biochemical and virological
response
Types of response Biochemical: normalization of serum ALT/AST activity

Virological:
HBeAg-positive CHB: loss of HBeAg (and development of
anti-HBe) and decrease in serum HBV-DNA to low levels*
HBeAg-negative CHB: undetectable serum HBV-DNA by PCR
assays (or perhaps decrease in serum HBV-DNA from initially
- 101 -
high to low levels*)

Complete: Both biochemical and virological response as well as
loss of serum HBsAg
Histological: Decrease in necroinflammatory activity by >/= 2
points without worsening in fibrosis (compared with pre-treatment
histological findings)
Time of
assessment of
response
On-therapy response: response during therapy

Initial response: response achieved at any time within the first 12
months of therapy
Maintained on-therapy response: response that persists throughout
therapy
End-of-therapy response: response at the end of a defined course
of therapy
Off-therapy or sustained response: maintenance of response for
>/= 12 months after discontinuation of therapy
High and low serum HBV-DNA levels are considered as >/= and < 105 copies/ml.
Table (23): Available Agents for Treatment of Chronic Hepatitis B

(Papatheodoridis and Hadziyannis, 2004).
Interferon-alpha
Lamivudine
Adefovir
dipivoxil
Anti-viral activity
++
++
Immunomodulatory activity
++
Frequent and
potentially severe
Minimal
Minimal
High
Low
High
None
25%, 40%,
>50%
at 1, 2 and 3
years
Minimal
(< 2% at 2
years)
17-32%
(controls: 611%)
24%
(controls:
11%)
Side-effects
Cost
Efficacy of courses of finite
duration*
In HBeAg-positive CHB
HBeAg loss
HBeAg seroconversion
33%
(controls: 12%)
18%
(more than controls)
16-17%
12%
(controls: 4(controls: 6%)
6%)
In HBeAg-negative CHB
End-of-therapy response
46-54%
- 102 -
65-90%
70-75%
Sustained off-therapy response
22-30%
< 10-15%
Unknown
Efficacy of long-term therapy

In HBeAg-positive CHB
HBeAg seroconversion at 24
months
Unknown
27%
21%
months
Unknown
33%
Unknown
months
Unknown
47%
Unknown
In HBeAg-negative CHB
On-therapy 24-month response
46%
55-65%
71-73%
Unknown
40-50%
Unknown
Unknown
35-40%
Unknown
* Duration of interferon therapy: 4-6 months in HBeAg-positive CHB and 12-24

months in HBeAg-negative CHB. Duration of lamivudine and adefovir dipivoxil
therapy: 12 months in all cases.
Anti-HBc is more prevalent in chronic hepatitis C patients than

previously reported in the general population. The seropositivity of antiHBc is often associated with severe liver fibrosis. Pegylated interferon based
therapy was more effective than standard interferon in HCV patients with
previous exposure to HBV (Hwang et al., 2003).
HBV specific antibodies and T cells, in turn, may prevent viral spread
and reinfection and therefore control remaining virus. Activation or
transmission has been reported during immunosuppression and after
transplantation of organs from recovered (anti-HBs positive) donors into
immunosuppressed recipients (Keeffe et al., 2004). Post exposures to HBV
affect the severity & the response to the treatment in patients with chronic
HCV (Esmat, 2005).
Treatment strategies for HBV

Antiviral therapies are able to inhibit replication of-hepatitis B with
varying efficiency. Introduction of treatment activates the hosts immune
- 103 -
response to the virus either directly (IFN) or indirectly, secondary to a fall

in viral load (lamivudine) (Vanlandschoot et al., 2002).
IFN is contraindicated in the treatment of occult HBV, poorly
tolerated and ineffective. The more suitable is Lamivudine 100 mg/day or
Adefovir 10 mg/day (Allain, 2004).
The likelihood of success can be predicted by:

1) Baseline levels of ALT:
Patients who are HBeAg positive with normal or nearly normal
ALT levels will not respond to either IFN or lamivudine. Such
individuals are generally in the immune tolerant phase of their disease;
less often, they may be just at the turning point of spontaneous
seroconversion. (The level of serum HBV DNA will determine which
situation is more likely, HBV DNA levels being very high in the former
and relatively low in the latter) (Wang et al., 2002d).
The higher the baseline ALT, the more likely the individual is to
seroconvert upon introduction of antiviral therapy (and the more likely
they are to seroconvert spontaneously); Thus, prior to initiating treatment
the patient should be monitored for at least 3 months to assess whether or
not the process of spontaneous seroconversion is about to occur. In one
study, 37% of individuals with HBcAg-positive chronic hepatitis
observed for 3 months prior to recruitment to a therapeutic trial were
noted to seroconvert spontaneously (Weber et al., 2002).
2) High baseline HBV DNA
Generally (but not always) predicts poor response to IFN (Wolters
et al., 2002), this is not necessarily the case for lamivudine, although it is
predictive of the development of drug resistance. Rate of fall of HBV
DNA after introduction of therapy may be helpful in predicting
subsequent seroconversion (Xu et al., 2002).
- 104 -
Antiviral therapy can prevent or reduce fibrosis progression. Thus,

even when baseline ALT is not high, if the liver biopsy results indicate
severe disease, treatment is appropriate (Yang et al., 2002).
The following strategies are recommended for patients with

(I) HBeAg-positive moderate or severe chronic hepatitis without
cirrhosis:
A 4-6 months course of interferon alpha (5 MU daily or 9-10 MU
thrice weekly, or 6 MU/m2 thrice weekly for children may be used as an
initial therapy. If interferon is contraindicated, ineffective or poorly
tolerated, lamivudine should be given at a dose 100 mg daily for at least 1
year. Adefovir should be given in a dose 10 mg daily for at least 1 year.
Treatment with lamivudine or Adefovir should be continued for 4-6
months after virological response is achieved. If a virological response is
not achieved after 1 year, decision to continue treatment should weigh
likelihood of a sustained response against the risk of development of drug
resistance particularly with lamivudine (D. Valla et al., 2003).
(II) For patients with HBeAg-negative moderate or severe chronic
hepatitis
without
cirrhosis,
the
following
strategies
are
recommended:
A 12-24 month course of interferon alpha, 5-6 MIU thrice weekly
may be considered as an initial therapy. If interferon is contraindicated,
ineffective or poorly tolerated, lamivudine or Adefovir should be
considered. Because HBeAg is already undetectable, the end point of
treatment is not established. Sustained suppression of HBV replication is
associated with histological improvement and therefore appears a realistic
goal of treatment. The optimal duration of treatment is not known. Most
patients will require more than one year of therapy, decision to continue
treatment should weigh the likelihood of a sustained response against the
- 105 -
risk of development of drug resistance or drug toxicity (Liu et al., 2003).

Hepatitis relapses on stopping Lamivudine therapy, whether
HBeAg positive or negative, reintroduction of the drug as a maintenance
therapy if the patient has not developed drug resistance (Haushofer et
al., 2004).
(III) If a breakthrough on lamivudine therapy (for HBeAg positive or
negative chronic hepatitis B) is thought to be due to emergence of
lamivudine-resistant mutants, treatment options include:
a. Continue lamivudine if serum HBV DNA and
aminotransferases levels are lower than they were pretreatment.
b. Discontinue lamivudine in patients without underlying cirrhosis
and who are not immunosuppressed and
c. Change to or add adefovir if available (Giannini et al., 2003).
Patients with cirrhosis, but without clinical or laboratory signs of
decompensation can be managed like non-cirrhotic patients. Particular
care should be paid to these as flares due to antiviral response, antiviral
resistance or after cessation of treatment can lead to severe
decompensation.
(IV) Decompensated cirrhotic patients should be evaluated for liver
transplantation. If they show active viral replication, they should receive
antiviral therapy. Several options are available:
a. Start lamivudine early, in the hope that a successful virological
response may delay or obviate the need for liver transplantation.
Adefovir can be added or substitute lamivudine when lamivudine
resistance develops.
b. Start lamivudine only when transplant is imminent (within the next 6
months).
c. Use adefovir as first line therapy with close monitoring for the renal
function (Aliyu et al., 2004).
- 106 -
(V) Post transplant patients with recurrent hepatitis B who have not
previously received lamivudine should be treated with lamivudine or
adefovir. Breakthrough during lamivudine therapy should be treated with
adefovir and careful monitoring of the renal function is required (Hm et
al., 2004).
(VI) In HBV infected patients requiring immunosuppressive therapy
Lamivudine is generally preferable to interferon as antiviral therapy.
Treatment can be started 2-4 weeks before immunosuppression or at the
first sign of an exacerbation of the hepatitis. (Yao et al. 2004).
Table (24): Recommendations for treatment of Chronic Hepatitis B
(Lok et al., 2004):
HBeAg
+
HBV
DNA*
+
ALT
Treatment Strategy
2
ULN
>2
ULN
Low efficacy with current treatment. Observe;

consider treatment when ALT becomes elevated
IFN- , LAM, or ADV may be used as initial therapy
>2
ULN
End point of treatment - seroconversion from

HBeAg to anti-HBe
Duration of therapy
IFN- : 16 weeks
Lamivudine: minimum 1 year, continue for 3-6
months after HBeAg seroconversion
Adefovir: minimum 1 year
IFN nonresponders/contraindications to IFN-
LAM or ADV
LAM resistance ADV
IFN , LAM or ADV may be used as initial therapy,
IFN- or ADV is preferred because of the need for
long-term therapy
End point of treatment - sustained normalization of
ALT and undetectable HBV DNA by PCR assay
Duration of therapy
IFN- : 1 year
Lamivudine: >1 year
Adefovir: >1 year
IFN nonresponders/contraindications to IFN LAM
or ADV
LAM resistance ADV
No treatment required
- 107 -
ULN
Cirrhosis Compensated: LAM or ADV
Decompensated: LAM (or ADV); coordinate
treatment with transplant center. Refer for liver
transplant. IFN- contraindicated
Cirrhosis Compensated: Observe

Decompensated: Refer for liver transplant
5
N.B: DNA > 10 copies/ml; this value is arbitrarily chosen.
- 108 -
Prevention of HBV
CHAPTER VII
PREVENTION OF HBV
Risk personnel:
Persons who should be screened for HBV infection: persons born
in hyperendemic areas, men who have sex with men, injecting drug users,
dialysis patients, HIV-infected individuals, pregnant women, family
members, household members, and sexual contacts of HBV infected
persons (Chang et al., 2002).
(A) Passive Immunization:

(1) Hepatitis B immunoglobulin (HBIG):
HBIG is administered to prevent hepatitis B infection after
exposure of HBV-contaminated body fluids and in infants born to
HBsAg-positive mothers (Yang et al., 2004).
Polyclonal HBIG has been shown to reduce HBV recurrence after
liver transplantation and to decrease the possibility of graft loss by
rejection (Wang et al., 2004b).
(2) Passive immunization in adults:
Hepatitis B immunoglobulin is prepared from pooled plasma with a
high titer of hepatitis B surface antibody and may confer temporary
passive immunity under certain defined conditions. The major indication
for the administration of hepatitis B immunoglobulin is a single acute
exposure to hepatitis B virus, such as occurs when blood containing
surface antigen is inoculated or splashed onto mucous membranes and the
conjunctiva. The optimal dose has not been established, but doses in the
range of 250 to 500 IU have been used effectively. It should be
administered as early as possible after exposure and preferably within 48
hours, usually 3 ml (containing 200 IU of anti-HBs per milliliter) in
- 109 -
Prevention of HBV
adults. It should not be administered more than 7 days after exposure. It is

generally recommended that two doses of hepatitis B immunoglobulin
should be given 30 days apart (Tsai, 2004).
(3) Passive immunization in babies:
Results with the use of hepatitis B immunoglobulin for prophylaxis
in babies at risk of infection with hepatitis B virus are encouraging if the
immunoglobulin is given as soon as possible after birth or within 12
hours of birth, and the chance of the baby developing the persistent
carrier state is reduced by about 70%. More recent studies using
combined passive and active immunization indicate an efficacy
approaching 90%. The dose of hepatitis B immunoglobulin recommended
in the newborn is 1 to 2 ml (200 IU of anti-HBs per milliliter) (Vierling,
2005).
(B) Active immunization:

Vaccination:
HB vaccine (HBsAg vaccine) was started soon after its
identification in 1970. The first plasma-derived vaccine was licensed in
the United States in 1981 (Heptavax B, Merck Sharp and Dohme,
USA). It was derived from the plasma of patient with chronic HBV
infections. Despite its excellent efficacy and safety profile in millions of
individuals worldwide, acceptance of the vaccine was low because of
illegitimate fears of transmission of live HBV and other blood borne
pathogens (Tong and Tu, 2004). Clinical trials with the yeast-derived
recombinant hepatitis B vaccine started in 1984 and in 1986 EngerixTMB (SmithKline Beecham Biologicals, Rixensart, Belgium) became the
first human vaccine manufactured using recombinant DNA technology to
be marketed. A second similar vaccine, Recombivax HB, (Merck Sharp
and Dohme, USA) was licensed in the U.S. in 1989. These second- 110 -
Prevention of HBV
generation recombinant hepatitis B vaccines rendered plasma derived

vaccines obsolete and they progressively disappeared in the course of the
1990s. Meanwhile hundreds of millions of vaccines doses have been
administered. The different vaccines turned out to be safe and
immunogenic (Wang et al., 2004a).
The International strategy to eliminate hepatitis B virus (HBV)
transmission is based on:
1) Screening all pregnant women for hepatitis B surface antigen and
post-exposure vaccination of infants of infected mothers.
2) Vaccinating all infants as part of the childhood vaccination schedule.
3) Vaccinating children and adolescents not vaccinated previously.
4) Vaccinating adolescents and adults in groups at increased risk for
infection (Yano et al., 2003).
In areas of high endemicity, where mothers may not always be
screened for hepatitis B infection, routine vaccination of infants at birth
with a course of hepatitis B vaccine alone should be highly protective
even for very high-risk infants of HBeAg-positive mothers (Lacarnini,
2004).
Needle stick injuries and non-reporting of needle stick injuries
were highly prevalent in nursing students. More intensive education
programs should be directed at students to increase their awareness of and
compliance with universal precautions before commencing their practical
work experience. Students need to practice prompt post-exposure
evaluation so that the need for early intervention can be assessed. Any
public health and infection control strategy should include a universal
catch-up
HBV
vaccination
program
among
students
before
commencement of internship (Toniutto et al., 2004).

The WHO recommended that by the end of the 20 th century
hepatitis B vaccine be incorporated into routine infant and childhood
- 111 -
Prevention of HBV
immunization programmes for all countries. The efficacy of universal

immunization has been shown in different countries with striking
reductions of the prevalence of HBV carriage in children. Most
important, hepatitis B vaccination can protect children against HCC and
fulminant hepatitis (Yegane et al., 2004).
Infection with HBV has become a vaccine preventable disease. In
order for recombinant HBV vaccines to eradicate HBV, a universal
vaccination of neonates and or children needs to be implemented
however; there are major obstacles on the road to global hepatitis B
vaccination i.e. poverty and scarcity of human resources in those parts of
the world who are most badly in need of these vaccines. Despite their
proven immunogenicity, hepatitis B vaccines are unable to induce an
adequate immune response in 5-10% of healthy adults. The nonresponsiveness of these subjects is a selective phenomenon and not the
expression of a general immune deficiency (Akbar et al., 2004).
Immunization against hepatitis B is required for groups that are at
an increased risk of acquiring this infection. These groups include
individuals requiring repeated transfusions of blood or blood products,
prolonged in-patient treatment, patients who require frequent tissue
penetration or need repeated access to the circulation, patients with
natural or acquired immune deficiency, and patients with malignant
disease (Candotti et al., 2004). Viral hepatitis is an occupational hazard
among health care personal. High rates of infection with hepatitis B occur
in narcotic drug addicts and drug abusers, homosexuals and prostitutes.
Individuals working in high endemic areas are also at increased risk of
infection. Young infants, children and susceptible persons living in
certain tropical and subtropical areas where present socioeconomic
conditions are poor and the prevalence of hepatitis B is high should also
be immunized (Lai, 2004).
- 112 -
Prevention of HBV
Many countries, including the United States, introduced universal

immunization for infants in 1992. More than 85 countries have
introduced hepatitis B vaccine into their national immunization programs
(Yao et al., 2004).
Available vaccines are highly effective in inducing long-term
seroprotection and are considered of equivalent immunogenicity for most
purposes. Immunologic memory maintains seroprotection in the absence
of measurable HBsAb. Innovations have included the 2-dose, 10mg
Recombivax HB regimen for those 11-15 years old and Twinrix, a
combination hepatitis A and B vaccine. The immunocompromised are at
increased risk for hypo or non-response to HBV vaccine and loss of
immunologic memory. These patients should have post vaccination
testing for HBsAb titers as well as periodic testing thereafter. If their titer
decreases to less than 10 MIU/, they should receive a booster dose (Hm
et al., 2004).
Types of vaccines:
1- Human plasma derived vaccines:
The first active protective vaccines were introduced in 1981 (Schiff
et al., 2003a).
2- Recombinant DNA vaccine:
The first human vaccine produced with molecular biologic
techniques (Kakimi et al., 2002b).
3- Hybrid virus vaccine:
Potential live vaccines using recombinant vaccine viruses to HB,
rabies and herpes simplex (Chen et al., 2002b).
Immune response to HB vaccines in special groups:
Vaccination of special groups who are at increased risk of infection
shows lower immune response to the vaccines. For example, only 60% of
- 113 -
Prevention of HBV
haemodialysis patients develop anti HBs after vaccination (Keeffe et al.,

2004) and mentally retarded patients who have significantly lower
response rates (Perillo, 2004).
Hepatitis B vaccines are effective in producing protection against
HBV infection in hemodialysis patients but antibody response is variable
(Yoshida et al., 2004). Non-responders have higher morbidity and
mortality. Thus can be considered as a risk factor in the Haemodialysis
populations (Zhang, 2004).
Fig. (21): Global status of countries using HepB vaccine in their national
infant immunization system (WHO, 2003).
I.D. administration of recombinant HB vaccine in repeated small
injections is absolutely effective in Haemodialysis patients (gave higher
antibody titers in at least 50% of the follow-up measurements) (Zhou
and Wu, 2004).
Zhu et al. (2004) investigated the immune response of liver
transplantation to HB vaccines they stated that the total response rate to
- 114 -
Prevention of HBV
HB vaccine in liver transplant patients, is much lower than in general

population and there is a rapid decline of antibody titers probably due to
immune suppression. The role of booster in these patients should be
clarified (Wright, 2004).
Table (25): Post Exposure Prophylaxis and Post Liver Transplant
Therapies & Preventive Vaccines for HBV (Lok et al., 2004):
Post Exposure Prophylaxis and Post Liver Transplant Therapies
Brand Name
Activity
Manufacturer
FDA Status
HBV immune Bayer (US)

Globulin
HBV immune Nabi
Nabi-HB
Globulin
HBV immune Cangene (Canada)
VariZIG
Globulin
Preventive Vaccines for HBV
FDAapproved
FDAapproved
BLA filed with
FDA
Brand Name
Activity
Manufacturer
FDA Status
Recombivax HB
Hepatitis B
Merck & Co.
BayHepB
FDAapproved
Hepatitis B
GlaxoSmithKline
Energix-B
FDAapproved
Hepatitis
A GlaxoSmithKline
Twinrix
FDAand B
approved
Hepatitis
B GlaxoSmithKline
Pediarix*
FDAand other
approved
Pediarix: a new combination vaccine that protects infants against diphtheria, tetanus,
pertussis (whooping cough), polio, and disease due to the hepatitis B virus.
Prophylaxis against hepatitis B recurrence following liver

transplantation:
Innovations in the management of HBV infection before and after
orthotopic liver transplantation (OLT) have revolutionized outcomes
for hepatitis B virus (HBV)-infected recipients. In the absence of
preventative therapies, OLT for patients with acute or chronic
replicating HBV infections resulted in universal reinfection of the
allograft, progressive graft failure and excessive mortality, even with
retransplantation (Weber et al., 2002). Thus, HBV-related liver disease
- 115 -
Prevention of HBV
was initially regarded as a contraindication to OLT (Tan et al., 2002)

and was excluded as an indication by Medicare in the U.S.A. (Tai et al.,
2002).
Over the past 15 years, sequential application of therapeutic
strategies to prevent recurrent HBV infection after OLT and to inhibit
HBV replication before and after OLT has steadily improved outcomes
(Shang
et
al.,
2002).
Indefinite
administration
of
passive
immunoprophylaxis with hepatitis B immune globulin (HBIG, a source

of high titer, polyvalent anti-HBs antibodies) resulted in a significant
reduction in recurrent hepatitis B, especially among recipients without
active HBV replication at the time of OLT (Sobao et al., 2002).
Pre-OLT inhibition of HBV replication using lamivudine (LAM)
rendered patients with active replication eligible for transplantation,
prevented recurrence post-OLT (unless LAM-resistant escape mutations
developed) and improved the outcome of patients who became
reinfected (Squadrito et al., 2002). The combination of HBIG and
lamivudine enhanced prevention of HBV reinfection (Lalekha et al.,
2002) and the advent of adefovir dipoxil (ADV) provided a safe and
efficacious therapeutic option for patients with LAM-resistant infection
(Lai and Terrault, 2004). As a result of this progress in prevention and
treatment of HBV reinfection, acute or chronic hepatitis B is now
universally accepted as an excellent indication for OLT (Squadrito et
al., 2002).
Transplantation of livers from donors with isolated anti-HBcpositivity (i.e. negative for HBsAg and anti-HBs) has resulted in
additional challenges, since isolated anti-HBc-positive livers are
capable of transferring HBV infection to 50-78% of HBV-nave
recipients in the absence of preventative therapy (Thakur et al., 2002).
In addition, HBV-nave recipients who have not been vaccinated to
- 116 -
Prevention of HBV
prevent hepatitis B prior to OLT have an ongoing risk of acquiring

parenterally transmitted HBV infections that require prompt diagnosis
and treatment (Torbenson and Thomas, 2002). Mandatory hepatitis B
vaccination for all HBV-naive patients with diseases that could require
OLT could significantly reduce this risk (Tsamandas et al., 2002).
Two mechanisms have been implicated in allograft reinfection: 1)
rapid reinfection by HBV in the circulation of the recipient and/or 2)
reinfection from HBV replicating in extrahepatic sites (Vanlandschoot
et al., 2002). Since the former mechanism predominates in recipients
with high HBV viral loads at the time of OLT, patients with active
replication detected by insensitive molecular hybridization assays were
considered as inferior candidates (Wen et al., 2002).
LAM has been extensively studied in OLT candidates, is well
tolerated in decompensated cirrhosis and results in undetectable HBV
DNA using molecular hybridization in 63-100% of patients within 2-3
months (Ohshiro et al., 2002). LAM is effective for both wild type
(WT) and precore mutant (HBeAg-negative) strains (Gotsman et al.,
2002). Uninterrupted therapy is required prior to OLT, since premature
cessation results in recurrent HBV replication (Wolters et al., 2002).
Unfortunately, prolonged therapy, which is necessary for clinical
benefit, increases the risk of developing LAM-resistant mutations as a
result of amino acid substitutions in the YMDD motif encoded by the
HBV RNA-dependent DNA polymerase gene (Wong et al., 2002).
The incidence of such mutations was 15-20% per year in the
studies summarized in the Table (26), and development of mutations
can worsen liver failure (Brabin et al., 2002). Results of OLT in
patients with YMDD mutations before transplantation have been
reported for only a few patients and were conflicting (Pramoolsinsup,
2002).
- 117 -
Prevention of HBV
Combination HBIG and LAM prevented recurrence in some (Buti

et al., 2002), but not all recipients (Chan et al., 2002). Since ADV and
tenofovir have excellent efficacy against LAM-resistant HBV mutants
(Perrillo, 2002), they should be used to treat patients with LAM
resistance prior to OLT (Dando and Plosker, 2003).
Adefovir Monotherapy is an excellent therapy for pre-OLT patients
with LAM-resistant infections (Schiff et al., 2003b).
Entecavir Monotherapy is a potent antiviral agent for both WT
(Wild type) and LAM-resistant forms of HBV (Honkoop and de Man,
2003) that reduces HBV DNA levels to a greater degree than LAM
(Barcena et al., 2003).
ETV (Entecavir) is currently in phase III
clinical trials in non-transplant patients (Toniutto et al., 2004).

The combination of LAM therapy pre- and post-OLT with HBIG
post-OLT has become the standard of care for most liver transplant
programs (Samuel, 2004).
Table (26): Results of Lamivudine Monotherapy Prior to OLT
(*Mean or Median. NR; not reported) (Dahmen et al., 2004).
Authors
N=
Grellier et al.,
Markowitz et al.,
Villeneuve et al.,
Lo et al.,
Perrillo et al.,
Yao et al.,
Seehofer et al.,
Rosenau et al.,
Marzano et al.,
Fontana et al.,
Andreone et al.,
Fontana et al.,
17
10
35
31
30
23
17
19
33
162
25
154
Duration of
Therapy*(months)
>1
2.7
19
3.2
29
13
7.2
12
16
16
4.5
5.7
- 118 -
Negative HBV
DNA (%)
100
100
100
63
74
100
88
NR
73
67
92
>80
Resistant
Mutants (%)
NR
NR
25
NR
22
10
18
10.5
3
11
8
27
Prevention of HBV
Adoptive Transfer of HBV Immunity from Donor Livers

Effective adoptive transfer of humoral immunity to hepatitis B was
first demonstrated in recipients of bone marrow transplants from immune
donors (Chang, 2003). Transplantation of livers from HBV vaccinated
woodchucks into HBV-infected recipients also has been shown to reduce
or delay severity of reinfection, presumably due to the effects of HBVspecific memory cells among passenger leukocytes (Dahmen et al.,
2004). An initially low recurrence rate in a Chinese cohort receiving
LAM monotherapy was hypothesized to be due to transplantation of
passenger leukocytes in HBV-immune donors that produced anti-HBs in
the recipients (Papatheodoridis and Hadziyannis, 2004). A recent
report ascribed the successful elimination of a de novo HBV infection
post-OLT with development of anti-HBs to the fact that the liver donor
had been immunized against hepatitis B (Toniutto et al., 2004).
Table (27): Effect of Combination Therapy with HBIG and
Lamivudine to Prevent HBV Reinfection after OLT. (IV,
intravenous; IM, intramuscular, NR, not reported) (Toniutto et al.,
2004).
Authors
N=
HBV
DNANegative
at OLT (%)
HBIGRoute of
Administration
HBV
Reinfection
(%)
14
Pre-OLT
Duration*
of
LAM(mos)
3
Markowitz et
al.,
Yao et al.,
Yoshida et al.,
Angus, et al.
Marzano et
al.,
McCaughan et
al.,
Rosenau et al.,
Roche et al.,
Han et al.,
Seehofer et al.,
93
IV
10
7
37
33
8.6
NR
3.2
4.6
80
100
NR
100
IV then IM
IM
IM
IV
10
0
3
4
NR
IM
21
15
59
17
4.6
4.6
NR
10.6
77
73
NR
71
IV
IV
IV
IV
10
7
0
18
- 119 -
Prevention of HBV
Vaccination after Transplantation

The prospect of generating active immunity against HBsAg
epitopes remains an intriguing strategy that could obviate the need for
passive immunoprophylaxis (Ohshiro et al., 2002).
Because of the shortage of deceased donor organs, livers from
isolated anti-HBc-positive donors (negative for HBsAg and anti-HBs) are
being routinely transplanted into HBV-nave recipients (Moola et al.,
2002). In the absence of preventative measures, HBV infection occurred
in 50% to 78% of such recipients in Spain (Arase et al., 2002) and the
U.S.A. (Chang et al., 2003), respectively. However, livers from antiHBc-positive donors can be successfully used without reinfection if
recipients receive prophylactic therapy with a combination of HBIG and
LAM (Fabrega et al., 2003) or LAM monotherapy (Saab et al., 2003).
Recent reports also indicate that anti-HBc positivity in the donor is not a
contraindication for live donor liver transplantation when effective
prophylaxis is given (Hwang et al., 2003).
- 120 -
Summary
SUMMARY & CONCLUSION

HBV is a Hepatotropic DNA-containing virus, discovered in 1966
by Blumberg. The virion of hepatitis B (Dane particle) consists of
surface and core with a diameter of 42 nm (Kumar and Agrawal, 2004).
The protein composition of HBV particles; either surface protein (HBs
proteins) composed of LHBs (largest Hepatitis B proteins), MHBs
(middle Hepatitis B proteins), SHBs (small Hepatitis B proteins) or core
proteins; composed of HBc protein and HBe protein.
The world health organization (WHO, 2004) estimated that 2
billion people have been infected by HBV worldwide; of these more than
300 millions are chronically infected carriers of whom 25% are at risk of
serious illness and eventually death from cirrhosis or hepatocellular
carcinoma. The prevalence of HBV infection varies markedly throughout
regions of the world; highly endemic in South East Asia, moderately
endemic in Eastern and Southern Europe and low endemic areas as in
North America (Tsai, 2004).
Concerning transmission of HBV; there is peri-natal transmission,
sexual contact, blood and blood products, parentral drug abuse,
opportunities for parentral infection, transmission in high endemic areas,
exposure of unknown origin is still present.
As regards clinical presentation and sequelae; HBV can present as
acute infection, fulminant hepatic failure (FHF), chronic hepatitis, extrahepatic manifestations, post hepatitis B cirrhosis or combinations with
HDV or HCV. Occult HBV infection is characterized by the presence of
HBV infection with undetectable hepatitis B surface antigen (HBsAg).
Concerning the diagnosis of acute and chronic hepatitis B; the
advances in molecular biology techniques led to the development of
hybridization and polymerase chain reaction (PCR) assays for direct
- 121 -
Summary
determination of HBV DNA. The diagnosis of HBV infection can also be

made by the detection of HBsAg or HBcAg in liver tissues by
immunohistochemical staining and of HBV DNA by Southern
hybridization, in-situ hybridization, or PCR.
Treatment of chronic hepatitis B include Interferon therapy,
nucleoside analogues such as Lamivudine, Adefovir Dipivoxil, Entecavir,
Famciclovir, Emtricitabine/ coviracil, Combination therapy, Therapeutic
vaccine, Gene therapy and Immunotherapy.
Prophylaxis against viral B infection is highly recommended using
vaccination alone or combined with hepatitis B immunoglobulin for
infants and individuals at risk of exposure.
- 122 -
Recommendations
RECOMMENDATIONS
Hepatitis B vaccination is the best protection as it provides protection
against hepatitis B for 15 years and possibly much longer. It is
recommended that all infants, health care workers and persons at risk
of exposure e.g. sexual partners of chronically infected persons;
should be vaccinated.
Hepatitis B Immune globulin is recommended for accidentally
exposed persons, ideally within 24 hours of exposure and no later than
7 days. A repeated dose is necessary 28 - 30 days later.
Newborns of HBV infected mother should receive HBIG plus the
hepatitis B vaccine within l2 hours of birth and two additional doses
of vaccine at one and six to twelve months of age.
Strict governmental instructions for hygiene and sterilization should
be followed particularly in risky procedures e.g. surgical intervention,
dental procedures, endoscopies and blood or body fluids sampling.
Strict observation of blood donors, the presence of normal ALT, AST
are not sufficient. Evaluation for occult HBV infection by
determination of HBV DNA in serum or tissues should be considered
in the context of the prevalence of HBV infection in this geographical
area and the type of population.
In order to prevent HBV reinfection after liver transplantation, it is
recommended to combine Lamivudine therapy pre- and posttransplantation with HBIG post-transplantation. This regimen has
become the standard of care for most liver transplant programs.
- 123 -
References
REFERENCES
Abdelaziz, M.S. (2004): Interrelation between HCV related chronic
liver disease and various serelogical status of HBV infection. M.D.
thesis, Tropical Medicine, Cairo University; 73-99.
Abdelaziz, F., Habib, M., Mohamed, M.K. et al. (2000): Hepatitis C
virus (HCV) infection in a community in the Nile Delta: Population
description and HCV prevalence. Hepatology, 32: 111-115.
Abdelhamed, A.M., Kelley, C.M., Miller, T.G. et al. (2002):
Rebound of hepatitis B virus replication in HepG2 cells after cessation
of antiviral treatment. J Virol; 76 (16): 8148-60.
Abdelhamed et al. (2004): sited by Esmat, G. (2005): Hepatitis B
virus (HBV): the Egyptian situation. The first Egyptian HBV day;
Sheraton Heliopolis, Cairo-Egypt; Jan.13.2005 (Conference Book):
17-25.
Agarwal, N., Naik, S., Aggarwal, R. et al. (2003): Occult hepatitis B
virus infection as a cause of cirrhosis of liver in a region with
intermediate endemicity. Indian J Gastroenterol. Jul-Aug; 22 (44):
127-31.
Akahane, Y., Okada, S., Sakamoto, M. et al. (2002): Persistence of
hepatitis B viraemia after recovery from acute hepatitis B: correlation
between anti HBc titer and HBV DNA in serum. Hepatol Res; 24 (1):
8.
Akarca, U.S., Ersoz, G., Gunsar, F. et al. (2004): Interferonlamivudine combination is no better than lamivudine alone in antiHBe-positive chronic hepatitis B. Antivir Ther. June; 9 (3): 325-34.
Akbar, S.M., Furukawa, S., Horiike, N. and Onji, M. (2004):
Vaccine therapy for hepatitis B virus carrier. Curr. Drug Targets Infect
Disord. Jun; 4 (2): 93-101.
Akcam, Z., Sunbul, M., Durupinar, B. et al. (2002): Tissue types as
prognostic risk factor in hepatitis B virus infection. Indian J
Gastroenterology; 21 (4): 139-41.
Aliyu, S.H., Aliyu, M.H., Salihu, H.M. et al. (2004): Rapid detection
and quantitation of hepatitis B virus DNA by real-time PCR using a
new fluorescent (FRET) detection system. J. Clin Virol. Jun; 30 (2):
191-5.
Allain, J.P. (2004): Occult hepatitis B virus infection. Transfus Clin
Biol. Feb; 11 (1): 18-25.
Alter, M.J. (2003): Epidemiology and prevention of hepatitis B.
Seminars in Liver Disease. Hepatitis B. Editors: Paul D Berk and
Anna SF Lok. Thieme Medical Publishers; 23 (1): 39-46.
Andre, F. (2000): HBV epidemiology in Asia, the Middle East and
Africa. Vaccine; 18 Suppl 1: S 20-2.
- 124 -
References
Annual Report, Agouza Center of the Egyptian Organization for

Biological Products and Vaccines, Agouza, Giza (1982).
Aoki, M., Saito, T., Watanabe, H. et al. (2002): Clinical significance
of a highly sensitive enzyme immunoassay of hepatitis B surface
antigen using a novel electronic spin resonance technique. J Med
Virol; 66 (2): 166-70.
Arase, Y., Tsubota, A., Saitoh, S. et al. (2002): Randomized
controlled trial of natural interferon alpha therapy for e Ag positive
chronic hepatitis B patients. Hepatol ; Res ; 28(2):98-104
Attia, M.A. (1998): prevalecne of hepatitis B and C in Egypt and
Africa. Antivir. Ther; 3(suppl 3): 1-9.
Badawi, A.F. and Michael, M.S. (1999): Risk factors of HCC in
Egypt: the role of hepatitis B viral infection and scistosomiasis.
Anticancer Res; 19; 5: 456-459.
Barcena, M.R., Cid, G.L. and Lopez, S.P. (2003): Use of adefovir in
the treatment of the chronic hepatitis B virus infection with resistance
to lamivudine. 35 (5):1841-1843.
Beckebaum, S., Cicinnati, V., Dworacki, G. et al. (2002): Reduction
in the circulating pDC1/pDC2 ratio and impaired function of Ex. vivo
generated DCJ in chronic hepatitis B infection. Clin Immunol; 104
(2):138.
Benhamou, Y. (2004): Antiretroviral therapy and HIV/hepatitis B
virus coinfection. Clin infect Dis. Mar 1; 38 Suppl. 2: 98-103.
Berger, A. and Preiser, W. (2002): Viral genome quantification as a
tool for improving patient management: the example of HIV, HBV,
HCV and CMV. J. Antimicrob Chemotherapy; 49(5):713 -21.
Bienzle, U., Gunther, M., Neuhaus, R. et al. (2003): Immunization
with an adjuvant hepatitis B vaccine after liver transplantation for
hepatitis B-related disease. Hepatology. 38 (4):811-819.
Blumberg, B.S., Gerstley, B.J.S., Hungerford, D.A. et al. (1967): A
serum antigen (Australia antigen) in Down's syndrome, leukemia and
hepatitis. Ann. Internal Med. 66:924-931.
Bonacini, M., Kurz, A., Lacarnini, S. et al. (2002): Fulminant
hepatitis B due to a lamivudineresistant mutant of HBV in a patient
coinfected with HIV, Gastroenterology; 122: 244-250.
Brabin, B., Beeching, N.J., Bunn, J.G. et al. (2002): Hepatitis B
prevalence among Somali households in Liverpool. Arch Dis Child;
86: 67-68.
Brown, R.S. (2005): Entecavir demonstrates consistent responses
among baseline subgroups in the treatment of nucleoside-nave,
HBeAg (+) and HBeAg (-) patients with chronic hepatitis B. Abstract
M913. Digestive Disease Week. Chicago, IL; 348(9):808-16.
- 125 -
References
Brunetto, M.R. and Bonino, F. (2004): Treatment of chronic

hepatitis B: from research to clinical practice via the consensus
conferences. Curr Pharm Des; 10 (17): 2063-75.
Buti, M., Costa, X., Valdes, A. et al. (2002): Study of hepatitis B
virus replication and infection by other hepatitis viruses in patients
with chronic hepatitis B virus infection. Gastroenterol Hepatol May;
25 (5): 295-8.
Candotti, D., Temple, J., Owusu, O.S. and Allain, J.P. (2004):
Multiplex real-time quantitative RT-PCR assay for hepatitis B virus,
hepatitis C virus, and human immunodeficiency virus type 1. J. Virol
Methods. June 1; 118 (1): 39-47.
Carreno, N., Mareno, D. and Sangro, B. (2004): Treatment of
chronic Hepatitis B virus infection. An. Sist. Sanit. Navar; 27 Suppl 2:
33-9.
Carretero, C. and Herraiz, M. (2004): Chronic Hepatitis B virus
infection. An. Sist. Sanit. Navar; 27 Suppl 2: 27-32.
Center for Disease Control and prevention (2002): Incidence of
acute hepatitis B- United States, (1990-2002). MMRR Morb Mortal
Wkly Rep. Jan 2; 52 951-52: 1252-4.
Center for Disease Control and prevention (2003): Epidemiology
and prevention of viral hepatitis A to E: an overview- United States,
(1998-2003). MMWR; 54: 649-752-783.
Cerenzia, G., Pollicino, T., Chang, M. et al. (2002): Genomic
heterogeneity of hepatitis B virus (HBV) and outcome of perinatal
HBV infection. J Hepatol; 3 6(3): 426-32.
Chan, H.L., Tsand, S.W., Leung, N.W. et al. (2002): Occult HBV
infection in cryptogenic liver cirrhosis in area with high prevalence of
HBV infection. Am J Gastroenterol. May; 97 (5): 121-5.
Chang, K.M. (2003): Immuno-pathogenesis of hepatitis C virus
infection. Clin Liver Dis Feb; 7 (1): 89-105.
Chang, S.H., Suh, K.S., Yi, N.J. et al. (2003): Active immunization
against de novo hepatitis B virus infection in pediatric patients after
liver transplantation. Hepatology J. 37 (6):1329-1334.
Chang Y.J., Yim J.Y., Cho N.Y. et al. (2002): Viral breakthrough in
HBeAg-negative chronic hepatitis B patients receiving lamivudine
therapy. Taehan Kan Hakhoe Chi. Dec; 8 (4): 397-404.
Chen, M.L., Shieh, Y.S., Shim, K.S. et al. (2002a): Comparative
studies on the detection of hepatitis B virus DNA in frozen and
paraffin sections by the polymerase chain reaction. Med Pathol; 4(5):
555-8.
Chen, Y.X., Mao, B.Y. and Jiang, J.H. (2002b): Relationship
between serum load of HBV-DNA and therapeutic effect of
- 126 -
References
oxymatrine in patients with chronic hepatitis B. Zhongguo Zhong Xi

Yi Jie He Za Zhi. May; 22 (5): 335-6.
Cho, S.C., Lee, S.H., Shinn, J.J. et al. (2002): HBV DNA levels,
aminotransferase and histological activity in young male patients with
HBeAg positive chronic hepatitis B. Taehan Kan Hakhoe Chi, Mar; 8
(1): 44-51.
Chu, C.J., Hussain, M. and Lok, A.S. (2002): hepatitis B virus
genotype B is associated with carrier HBsAg seroconversion
compared with hepatitis B virus genotype C. Gastroenterol; 122(7):
1756-62.
Chu, C.J. and Lok, A.S. (2002): Clinical utility in quantifying serum
HBV DNA levels using PCR assays. J Hepatol; 36 (4): 549-51.
Conjeevaram, H.S. and Lok, A.S. (2003): Management of chronic
hepatitis B. J of Hepatol; 38:90-103.
Cooksley, W.G. (2004): Treatment with interferon (including
pegylated interferon) in patients with hepatitis B. Semin Liver Dis; 24
Suppl 1: 45-53.
Craxi, A. and Cooksley, W.G. (2003): Pegylated interferons for
chronic hepatitis B. Antiviral Res. Oct; 60 (2): 87-9.
Cui, S., Wang, M. and Fan, G. (2002): Anti HBV efficacy of
bifendate in treatment of chronic hepatitis B: a primary study.
Zhonghua Yi Xue Za Zhi 82(8): 538-40.
Dahmen, U., Dirsch, O., Li, J. et al. (2004): Adoptive transfer of
immunity: a new strategy to interfere with severe hepatitis virus
reinfection after woodchuck liver transplantation. 77 (7):965-972.
Danalioglu, A., Kaymakoglu, S., Cakaloglu, Y. et al. (2004):
Efficacy of alpha interferon therapy for lamivudine resistance in
chronic hepatitis B. Int. J. Clin Pract. Jul; 58 (7): 659-61.
Dando, T. and Plosker, G. (2003): Adefovir dipivoxil: a review of its
use in chronic hepatitis B. Drugs. 63 (20):2215-2234.
Dandri, M., Bunda, MR., Bunkle, A. et al. (2002): Increase in de
novo HBV DNA integration in response to oxidative DNA danger or
inhibition of poly ADP-ribosylation. Hepatology; 35(1): 217-23.
Darwish, M.A., Faris, R., Clemens, J.D. et al. (1996): High
seroprevalence of hepatitis A, B, C and E viruses in residents in an
Egyptian village in the Nile Delta; a pilot study. A. J. trop. Med. Hyg.:
54(6): 554-8.
D. Valla (2003): EASL International consensus conference on
hepatitis B. Special article. J. Hepatology 38: 533-540.
De Gottardi, A. and Negro, F. (2004): Management of hepatitis B.
Ther Umsch. Aug; 61 (8): 487-91.
- 127 -
References
De Villa, Chen, Y.S. and Chen, C.L. (2003): Hepatitis B core

antibody = positive grafts: Recipients risk. Transplantation Vol.
75S49-S53, No. 3, February 15.
Deng, H., LV, Y. and Fu, J. (2004): Efficacy changes of short-term
lamivudine therapy for chronic hepatitis B with emergence of YMDD
mutation. Zhonghua Gan Zang Bing Za Zhi. Jun; 12 (6): 368-9.
Desmet, V.J. (2003): Liver tissue examination. J Hepatol; 39 Suppl 1:
S43-9.
Ding, J.J., Zhang, W.S. and Zhang, L.S. (2004): A study on
detection method of lamivudine related mutations in hepatitis B virus
polymerase gene. Zhonghua Shi Yan He Lin Chuang Bing Du Xue Za
Zhi. Mar; 18 (1): 24-7.
Duseja, A., Arora, L., Masih, B. et al. (2002): Hepatitis B and C
virus -prevalence and prevention in health care workers. Trop
Gastroenterol. Jul-Sep; 23 (3): 125-6.
El-Zayadi, A. (2005): Hepatitis B virus (HBV): clinical presentations
of an evasive disease. The first Egyptian HBV day; Sheraton
Heliopolis, Cairo-Egypt; Jan.13.2005 (Conference Book): 1-11.
Esmat, G. (2005): Hepatitis B virus (HBV): the Egyptian situation.
The first Egyptian HBV day; Sheraton Heliopolis, Cairo-Egypt;
Jan.13.2005 (Conference Book): 17-25.
Fabrega, E., Garcia, S.C., Guerra, A. et al. (2003): Liver
transplantation with allografts from hepatitis B core antibody-positive
donors: a new approach. Liver Transpl. 9 (9):916-920.
Fattovich, G. (2003): Natural history and prognosis of hepatitis B.
Seminars in Liver Disease. Hepatitis B. Editors: Paul D Berk and
Anna S F Lok. Published by Gilead Sciences. 23; 1: 47-58.
Ferraro, D., Bonura, C., Giglio, M. et al. (2003): Occult HBV
infection and suppression of HCV replication in early phase of
combination therapy for chronic hepatitis C. J. Biol Regul Homeost
Agents; 17 (2): 172-5.
Flisiak, R., Al-Kadasi, H., Jaroszewicz, J. et al. (2004): Effect of
lamivudine treatment on plasma levels of transforming growth factor
beta (1), tissue inhibitor of metalloproteinases-1 and
metalloproteinase-1 in patients with chronic hepatitis B. World J.
Gastroenterol. Sep 15; 10 (18): 2661-5.
Friedman, L.S. (2004): Controversies in liver biopsy: who, where,
when, how, why? Curr Gastroenterol Rep. Feb; 6 (1): 30-6.
Gheit, T., Sekkat, S., Cova, L. et al. (2002): Experimental
transfection of Macaca Sylvanus with cloned human hepatitis B virus.
J Gen Virol; 83 (pt7):1645-9.
Giannini, E., Ceppa, P., Botta, F. et al. (2003): Previous hepatitis B
virus infection is associated with worse disease stage and occult
- 128 -
References
hepatitis B virus infection has low prevalence and pathogenicity in

hepatitis C virus-positive patients. Liver Int. Feb; 23 (1): 12-8.
Gish et al. (2005a): Entecavir leads to sustained response offtreatment in nucleoside-nave HBeAg+ patients who met on-treatment
response endpoints at 48 weeks of therapy in phase 3 studies ETV022. Digestive Disease Week. Chicago, IL. 119 (5):1382-1384.
Gish et al. (2005b): Entecavir is well tolerated for the treatment of
nucleoside nave and lamivudine-refractory chronic hepatitis B: phase
2/3 safety results. Abstract 323 (oral). Digestive Disease Week.
Chicago, IL. 35(5):679-681.
Goldstein, S.T., Alter, M.J., Williams, I.T. et al. (2002): Incidence
and risk factors for acute hepatitis B in the United States, 1982-1998:
implications for vaccination programs. J Infect Dis; 185: 713-719.
Gotsman, I., Alper, R., Klein, R.E. et al. (2002): inducing oral
immune regulation of hepatitis B virus envelope protein suppresses
the growth of hepatocellular carcinoma in mice. Cancer; 94(2); 40612.
Guillevin, L., Mahr, A., Cohen, P. et al. (2004): French Vasculitis
Study Group. Short-term corticosteroids then lamivudine and plasma
exchanges to treat hepatitis B virus-related polyarteritis nodosa.
Arthritis Rheum; 5 (3): 482-7.
Guptan, R.C., Thakur, V., Kazim, S.N. et al. (2002): Efficacy of a
granulocyte macrophage colony-stimulating factor on lamivudine
combination with recombinant interferon in non-responders to
interferon in hepatitis B virus- related chronic liver disease. J
Gastroenterol Hepatol; 17 (7): 765-71.
Hadziyannis, S.J., Papatheodoridis, G.V. and Vassilopoulos, D.
(2003): Treatment of HBeAg-negative chronic hepatitis B. Semin
Liver Dis. Feb; 23 (1): 81-8.
Hadziyannis, S., Tassopoulos, N., Chang, T. et al. (2004): Threeyear study of adefovir dipivoxil (ADV) demonstrates sustained
efficacy in presumed precore mutant chronic hepatitis B (CHB)
patients in long-term safety and efficacy study (LTES). Presented at
the 39th Annual Meeting of the European Association for the Study of
the Liver (EASL); Berlin, Germany. 119 (5):1382-1384.
Hahne, S., Ramsay, M., Balogun, K. et al. (2004): Incidence an
routes of transmission of hepatitis B virus in England and Wales,
1995-2000: implications for immunization policy. J. Clin virol. Apr;
29 (4): 211-20.
Hakozaki, Y., Yoshiba, M., Sekiyama, K. et al. (2002): Mannosebinding lectin and the prognosis of fulminant hepatic failure caused by
HBV infection. Liver; 22(1): 29-34.
- 129 -
References
Han, L., Sun, W., Ma, C. et al. (2002): The influence of HBV
infection on a TRAIL induced apoptosis and its mechanism.
Zhonghua Yi Xue Za Zhi; 82 (9): 597-600.
Hanazaki, K. (2004): Antiviral therapy for chronic hepatitis B: a
review. Curr Drug Targets inflamm. Allergy J. Mar; 3 (1): 63-70.
Hasseb, A.F. (2000): A study on the relation between hepatocellular
carcinoma, HBV, HCV and aflatoxins among Egyptian. M.Sc. thesis,
Tropical Medicine, Cairo University; 70-75.
Haushofer, A.C., Hauer, R., Brunner, H. et al. (2002): HCV, HBV
genotypes and age distribution in patients of Vienna and surrounding
areas. J Clin Virol Dec: 25 Suppl 3: s99-102.
Haushofer, A.C., Hauer, R., Brunner, H. et al. (2004): No evidence
of hepatitis B virus activity in patients with anti-HBc antibody
positivity with or without anti-hepatitis C virus antibody positivity.
Journal of Clinical Virology 29; 221-223.
Hayashi, J. and Furusyo, N. (2004): The epidemiology of HBV: the
trend from 1970 to present. Nippon Rinsho. Aug; 62 Suppl 8: 180-5.
He, M.L., Wu, J., Chen, Y. et al. (2002): Quantification of HBV ccc
DNA by real-time PCR. Biochem Biophys Res Commun; 295 (5):
1102-7.
Heikal, O. (2005): Chronic Hepatitis B virus (HBV): Update points
and management. The first Egyptian HBV day; Sheraton Heliopolis,
Cairo-Egypt; Jan.13.2005 (Conference Book): 53-55.
Hm, X., Little, N.R., Gardner, S.D. and Jonas, M.M. (2004):
Predictors of virologic response to Lamivudine treatment in children
with chronic hepatitis B infection. Pediatr. Infect Dis. J. May; 23 (5):
441-5.
Honkoop, P. and de Man, R.A. (2003): Entecavir: a potent new
antiviral drug for hepatitis B. Expert Opin Investig Drugs. 12 (4):683688.
Hou, J., Liu, Z. and Gu, F. (2005): Epidemiology and Prevention of
Hepatitis B Virus Infection. Int. J. Med. Sci; 2:50-57.
Hu, K.Q. (2002): Occult hepatitis B virus infection and its clinical
implications. J Viral Hepatol. Jul; 9 (4) 243-57.
Hbscher, S.G. and Potmann, B.C. (2002): Transplantation
pathology. In: MacSween RNM, Burt AD, Portman BC, Ishak KG,
Scheuer PJ, Anthony PP, eds. Pathology of the Liver. 4 th ed. London:
Churchill Livingstone; 228-941.
Humphries, J.C. and Dixon, J.S. (2003): Antiviral for the treatment
of chronic hepatitis B: current and future options. Intervirology. 2003;
46 (6): 413-20.
- 130 -
References
Hunter, S.S. (2002): Ultrasonography of hepato-duodenal lymph

nodes in patients with chronic hepatitis C with or without cirrhosis.
M.D. thesis, Tropical Med. Dept. Kasr A1-Aini Faculty of Medicine.
75-83.
Huo, T.I., Wu, J.C., Wu, S.I. et al. (2004): Changing
seroepidemiology of hepatitis B, C, and D virus infections in high-risk
populations. J. Med Virol. Jan; 72 91): 41-5.
Hwang, S., Moon, D.B., Lee, S.G. et al. (2003): Safety of antihepatitis B core antibody-positive donors for living-donor liver
transplantation; 75 (3 Suppl):S45-S48.
Irshad, M., Chaudhuri, P.S. and Joashi, Y.K. (2002): Superoxidc
dismutase and total antioxidant levels in various forms of liver
diseases. Hepatol Res; 23(3): 178-184.
Isikawa, K., Koyama, L. and Masuda, T. (2002): Prevalence of
HBV genotype in asymptomatic carrier residents and their clinical
characteristics during long-term follow-up: the relevance to changes in
the HBsAg / antilHBe system. Hepatol; 24 (1): 1.
Jiang, R., Feng, X., Guo, Y. et al. (2002): T helper cells in patients
with chronic hepatitis B virus infection. Chin med J I 15(3):4224-4.
Jung, S., Suh, D.J., Park, H.J. et al. (2002): Therapeutic efficacy of
lamivudine in patients with hepatitis B virus-related decompensated
cirrhosis in Korea. Taehan Kan Hakhoe Chi. 2002 Dec; 8 (4): 418-27.
Jung, M.C. and Pape, G.R. (2002): immunology of hepatitis B
infection. Lancet infection disease; 2(1): 43-50.
Kajiya, Y., Harnasaki, K., Nakata, K. et al. (2002): Full length
sequence and functional analysis of hepatitis B virus genome in a
virus carrier: a case report suggesting the impact of pre-S and core
promotor mutations on the progression of the disease. Virol Hepatol;
9(2): 149-56.
Kakimi, K., Isogawa, M., Chung, J. et al. (2002a): Immunogenicity
and tolerogenicity of hepatitis B virus structural and non-structural
proteins: implications for immunotherapy of persistent viral infection.
J virology sept; 76(17): 8609-20.
Kakimi, K., Lane, T.G., Chisari, F.V. et al. (2002b): Cutting edge:
inhibition of hepatitis B virus replication by activated NKT cells does
not require inflammatory cell recruitment to the liver. Immunology
15; 167(2): 6701-5.
Kamel, M.A., Miller, F.D., El-Masry, A.G. et al. (1994): the
epidemiology of schistosoma mansoni hepatitis B and hepatitis C
infection in Egypt. Amm. trop. med. parasitol. ; 88(5):501-9.
- 131 -
References
Kao, J.H. (2002): Hepatitis B viral genotypes: clinical relevance and

molecular characteristics. J Gastroenterol Hepatol; 17(6): 643-50.
Kao, J.H. and Clsen, D.S. (2002): Global control of hepatitis B virus
infection. Lancet Infect Dis; 2(7): 395-403.
Kao, J.H., Chen, P.J., Lai, M.Y. et al. (2002a): Occult hepatitis B
virus infection and clinical outcomes of patients with chronic hepatitis
C. J Clin Microbiol; 40(11): 4068-4071.
Kao, J.L., Chen, P.J., Lai, M.Y. et al. (2002b): Genotypes and
clinical phenotypes of hepatitis B virus in patients with chronic
hepatitis B virus infection. J Clin Microbiol; 40(4): 1207-9.
Kato, J., Kato, N., Yoshida, H. et al. (2002): Hepatitis C virus NS4A
and NS4B proteins suppress translation in vivo. J Med Virol. Feb; 66
(2): 187-99.
Kawaguchi, K., Kaneko, S., Honda, M. et al. (2003): Detection of
Hepatitis B Virus DNA in Sera from Patients with Chronic Hepatitis B
Virus Infection by DNA Microarray Method. J. Clin. Microbiol. 41:
1701-1704.
Keeffe, E.B., Douglas, T.D., Steve, H.B. et al. (2004): A Treatment
Algorithm for the Management of Chronic Hepatitis B Infection in the
United States. Clinical Gastroenterology and Hepatology; S117-S121.
Kidd, L.K., Miyakawa, K. and Kidd, A.H. (2002): Genetic
variability in hepatitis B viruses. J Gen Virol; 83(pt6): 1267-80.
Kim, J.D. and Sherker, A.H. (2004): Antiviral therapy: role in the
management of extrahepatic disease. Gastroenterol Clin North Am.
Sep; 33 (3): 693-708, xi.
Kim, W.R., Poterucha, J.J., Kremers, W.K. et al. (2004): Outcome
of liver transplantation for hepatitis B in the United States. Liver
Transpl; 10 (8):968-976.
Kirschberg, O., Schuttler, C., Repp, R. and Schaefer, S. (2004): A
multiplex-PCR to identify hepatitis b virus-genotypes A-F. J. Clin.
Virol. Jan; 29 (1): 39-43.
Kiss, A., Lotz, G., Kaposi, N.P. and Schaff, Z. (2002): Hepatitis
viruses and hepatocarcinogenesis. Orv. Hetil; 143(2): 83-6.
Kobak, G.E., Mackenzie, T., Sokol, R.J. and Narkewicz, M.R.
(2004): Interferon treatment for chronic hepatitis B: enhanced
response in children 5 years old or younger. J. Pediatr; 145 (3): 340-5.
Kondili, L.A., Osman, H. and Mutimer, D. (2004): The use of
lamivudine for patients with acute hepatitis B (a series of cases). J.
Viral Hepat. Sep; 11 (5): 427-31.
Kumar, R. and Agrawal, B. (2004): Novel treatment options for
hepatitis B virus infection. Curr Opin Investig Drugs; 5 (2): 171-8.
- 132 -
References
Kuo, A., Dienstag, J.L. and Chung, R.T. (2004): Tenofovir

disoproxil fumarate for the treatment of lamivudine-resistant hepatitis
B. Clin Gastroenterol Hepatol; 2 (3):266-272.
Labib, S., Medhat, I., al-Boraey, Y. and Abulmagd, S. (2002):
Hepatitis B & C and human immunodeficiency virus infection in
Egyptian chronic drug abusers: assessment of relevant knowledge
prevalence of infection and resultant morbidity. Kasr el-Aini Med J;
8(4):39-52
Lacarnini, S. (2004): Molecular virology of hepatitis B virus. Semin
Liver Dis. 24 Suppl. 1: 3-10.
Lada, O., Benhamou, Y., Cahour, A. et al. (2004): In vitro
susceptibility of lamivudine-resistant hepatitis B virus to adefovir and
tenofovir. Antivir Ther. June; 9 (3): 353-63.
Lagget, M. and Rizzetto, M. (2002): Treatment of chronic hepatitis
B. Curr Pharm Des; 8(11): 953-8.
Lai, C.L. (2004): Therapeutic advances in chornic hepatitis B. J.
Gastroenterol Hepatol. Mar; 19 Suppl: S5-9.
Lai, C.L., Liaw, G. and Schiff, E.R. (2003b): Treatment of hepatitis
B: Presented at the AIDS International Training and Research
Program (AITRP) US-Georgia Symposium at Tbilisi, Georgia, Russia.
(5):307-12.
Lai, C.L., Ratziu, V., Yuen, M.F. and Poynard, T. (2003a): Viral
hepatitis B. Lancet. Dec 20; 362 (9401): 2089-94.
Lai, C.L. and Terrault, N.A. (2004): Antiviral therapy in patients
with chronic hepatitis B and cirrhosis. Gastroenterol Clin. North Am.
Sep; 33 (3): 629-54.
Lalekha, S., Warach, B., Hirunyachoe, A. et al. (2002): Protective
efficacy of hepatitis B vaccine without HBIg in infant of HBsAgpositive carrier mother in Thailand. Vaccine; 20(31-32): 3732-43.
Lavanchy, D. (2004): Hepatitis B virus epidemiology, disease
burden, treatment, and current and emerging prevention and control
measures. J. Viral Hepat. Mar; 11 (2): 97-107.
Le Pogam, S. and Shih, C. (2002): Influence of a putative
intermolecular interaction between core and the pre-S1 domain of the
large envelop protein on hepatitis B virus secretion. J Virol; 76 (13):
6510-7.
Lee, C.K., Suh, J.H., Cho, Y.S. et al. (2004): Adequacy of
immediate lamivudine trial for chronic hepatitis B patients with acute
exacerbation. Korean J. Hepatol. Mar; 10 (1): 22-30.
Lee, C.Z., Huang, G.T., Yang, P.M. et al. (2002): Correlation of
HBV DNA levels in serum and liver of chronic hepatitis B patients
with cirrhosis. Liver; 22(2): 130-5.
- 133 -
References
Leung, N.W. (2002): Management of viral hepatitis C. J

Gastroenterol Hepatol. Feb; 17 Suppl: S146-54.
Li, L., Shao, Q., Zhang, J. and Ji, D. (2003): Famciclovir treatment
of patients with chronic hepatitis B virus infection. Zhonghua Shi Yan
He Lin Chuang Bing Du Xue Za Zhi. Sep 1; 37 (17): 4020.
Liang, T.J. and Ghany, M. (2002): HBeAg the dangerous endgame
of hepatitis B. N Eng J Med 347(3): 208-l0.
Liaw, Y.F. (2002): Management of patients with chronic hepatitis B.
J Gastroenterol Hepatol; 17 (4):406-8.
Liaw, Y.F., Chien, R.N., Yeh, C.T. et al. (2002): To continue or not
continue lamivudine therapy after emergence of YMDD mutations.
Gastroenterology; 122: 7-88.
Lin, K.W. and Kirchner, J.T. (2004): Hepatitis B. Am Fam.
Physician. Jan 1; 69 (1): 75-82.
Lin, C.L., Liao, L.Y., Wang, C.S. et al. (2004a): Evolution of
hepatitis B virus precore/basal core promoter gene in HBeAg-positive
chronic hepatitis B patients receiving lamivudine therapy. Liver Int.
Feb; 24 (1): 9-15.
Lin, S.M., Tai, D.I., Chien, R.N. et al. (2004b): Comparison of longterm effects of lymphoblastoid interferon alpha and recombinant
interferon alpha-2a therapy in patients with chronic hepatitis B. J Viral
Hepat. Jul; 11 (4): 349-57.
Liu, C.J., Chen, P.J., Lai, M, Y. et al. (2003): Ribavrin and
interferon is effective for hepatitis C virus clearance in hepatitis B and
C dually infected patients. Hepatology 37: 568-576.
Liu, X. and Schinazi, R.F. (2002): Hepatitis B virus resistance to
lamivudine and its clinical implications. Antivir Chem Chemother.
May; 13 (3): 143-55.
Livezey, K., Negorev, D. and Simon, D. (2002): Increased
chromosomal alteration and micronuclei formation in human
hepatoma Hep G2 cells transfected with the hepatitis B virus HBx
gene. Mutat Res; 505 (1-2): 63.
Lo, C.M., Fan, S.T., Liu, C.L. et al. (2003): Safety and outcome of
hepatitis B core antibody-positive donors in right-lobe living donor
liver transplantation. Liver Transpl. 9 (8):827-832.
Lohr, H.F., Pingel, S., Bocher, W.O. et al. (2002): Reduced virus
specific T helper cell induction by autologous dendritic cells in
patients with chronic hepatitis B - restoration by exogenous
interleukin - 12 Clin Exp Immunology; 130 (1): 10714.
Lok, A.S., and McMahon, B.J. (2001): chronic hepatitis B.
Hepatology; 34(6) 1225-1241.
- 134 -
References
Lok, A.S., Brian, J. and McMahon, B.J. (2004): Hepatitis B: Update

of Recommendations. Published in Hepatology 39(3): 857-861.
Lok, A.S., Heathcote, E.J. and Hoofnagle, J.H. (2004):
Management of hepatitis B: 2000 summary of a workshop.
Gastroenterology; 120: 1828-53.
Lu, W.L., Xie, D.Y., Yao, J.L. et al. (2004a): Efficacy and safety in
chronic hepatitis B adolescent patients with lamivudine therapy.
Zhonghua Gan Zang Bing Za Zhi. Jul; 12 (7): 429-31.
Lu, X., Weis P. and Block, T. (2004b): A phage with high affinity
for hepatitis B surface antigen for the detection of HBsAg. J. Virol
Methods. Jul; 119 (1): 51-4.
Manesis, E.K., Papatheodoridis, G.V. and Hedziyannis, S.J.
(2002): Serum l-IBV DNA levels in inactive hepatitis B virus carriers.
Gastroenterol; 122(7): 2092-3.
Mao, Q.G., Lo, K.X., Liu, D.L. et al. (2004): Clinical significance of
neutralizing anti-interferon antibodies in chronic hepatitis B patients
treated with recombinant interferon-alpha. Zhonghua Gan Zang Bing
Za Zhi. Apr; 12 (4): 205-7.
Marcellin, P. (2002): Advances in therapy for chronic hepatitis B.
Semin Liver Dis. (22) Suppl 1: 33-6.
Marcellin, P., Chang, T.T., Lim, S.G. et al. (2003): Adefovir
dipivoxil for the treatment of hepatitis B e antigen- positive chronic
hepatitis B. N Engl J Med.; 348(9):808-16.
Mark, N. (2003): Entecavir; a Potent Inhibitor of Hepatitis B Virus.
Kauai, Hawaii. 39(8): 769-75.
Marzaban, R. (2003): Evaluation of liver tissue polymerase chain for
HBV in patients with negative viraemia. M.Sc. thesis, Tropical
Medicine, Cairo University; 5-13.
Michael, W., Fried, M., Mittchell, L. et al. (2002): Peginterferon
alfa-2a plu ribavirin for chronic hepatitis C virus infection. N ENGL J
Med, vol. 347, NO. 13: 34-67.
Mohamed, M.K. and Aoun, E. A. (2002): Epidemiology ,
Prevention and Control programs of Hepatitis C in Egypt; Public
health challenges for controlling HCV infection meeting (WHO
Informal Consultation with VHPB);Geneva -Switzerland.
Moola, N., Kew, M. and Arbuthnot, P. (2002): Regulatory elements
of hepatitis B virus transcription. .1 Viral Hepat; 9(5): 323-31.
Myers, R.P., Thibault, V. and Poynard, T. (2003): The impact of
prior hepatitis B virus infection on liver histology and the response to
interferon therapy in chronic hepatitis C. J. Viral Hepat; 1(2): 103-10.
Ogawa, M., Hasegawa, K., Naritomi, T. et al. (2002): Clinical
features and viral sequences of various genotypes of hepatitis B virus
- 135 -
References
compared among patients with acute hepatitis B. Hepatol Res ; 23(3):

167-77.
Ohshiro, M., Taira, R., Kainiya, K et al. (2002): Laboratory - based
evaluation of a newly developed immunochromatographic test by
using synthesized oligonucleotide - bound protein probes for
simultaneous detection of hepatitis B surface antigen (HBsAg) and
specific antibody to Treponema pallidum. Rinsho Biseibntshu Jinsoku
Shindan Kenkyukai Shi; 12(2): 97-104.
Orfi, M. (2002): The role of hepatitis B virus as a cause of acute viral
hepatitis after the wide use of hepatitis B vaccine in Egypt. MSc.
Thesis: Tropical Medicine, Cairo University; 103-6.
Papatbeodoridis, G.V., Dimou, E. and Papadimitropoulous, V.
(2002): Nucleoside analogues for chronic hepatitis B: antiviral
efficacy and viral resistance. Am J Gastroenterol; 97(7): 1618-28.
Papatheodoridis, G.V. and Hadziyannis, S.J. (2004): Current
management of chronic hepatitis B. Alimentary Pharmacology &
Therapeutics J. Volume 19 Issue 1; 13(4):619-626.
Park, C.B., Lim, H.J., Yun, B.C. et al. (2004): The clinical meaning
of the emergence of viral breakthrough during lamivudine treatment in
patients with hepatitis B virus related chronic liver disease. Korean J.
Hepatol. Jun; 10 (2): 108-16.
Pasquetto, V., Wieland, S.F., Uprichard, S.L. et al. (2002):
Cytokine-sensitive replication of HBV in immunortalised mouse
hepatocyte cultures. I virology 76(11): 5646-53.
Pawlotsky, J.M. (2002): Molecular diagnosis of viral hepatitis.
Gastroenterology; 122 (6): 1554-68.
Peksen, Y., Canbaz, S., Leblebicioglu, H. et al. (2004): Primary care
physicians' approach to diagnosis and treatment of hepatitis B and
hepatitis C patients. BMC Gastroenterol. Feb 06; 4 (1): 3.
Perrillo, R.P. (2002): How will we use the new antiviral agents for
hepatitis B, Curr Gastroenterol Rep; 4(l):63-71.
Perrillo, R.P. (2004): Overview of treatment of hepatitis B: key
approaches and clinical challenges. Semin Liver Dis; 24 Suppl 1: 239.
Perrillo, R.P., Lai, C.L., Liaw, Y.F. et al. (2002): Predictors of
HBeAg loss after lamivudine treatment for chronic hepatitis B.
Hepatology: 36: 186-194.
Peters, M., Hann, W.H., Marin, P. et al. (2004): Adefovir dipivoxil
alone or in combination with lamivudine in patients with Lamresistant chronic hepatitis B virus. J Heaptol; 36: 6- 13.
Pfeifer, K., Dobson, C., Hwan, A. and Kapprell, H.P. (2002):
Performance characteristics of an improved version of the ABBOTT
Mx HBsAg (V2) MEIA. Clin Lab; 48(7-8):359-64.
- 136 -
References
Poynard, T. (2002): Hepatitis B and C: management and treatment.

1st edition. Hepatitis B 1:63.
Pramoolsinsup, C. (2002): Management of viral hepatitis B. J.
Gastroenterol Hepatol. Feb; 17 Suppl: S125-45.
Rapicetta, M., Ferrari, C. and Levero, M. (2002): Viral
determinants and host immune responses in the Pathogenesis of HBV
infection. J. med virology Jul; 67 (3): 454-7.
Rivero, M., Crespo, J., Fabriga, E. et al. (2002): Apoptosis
mediated by the Fas system in the fulminant hepatitis by HBV. J virol
hepatol; 9 (2): 107-13.
Robek, M.D., Wieland, S.F. and Chisari, F.V. (2002): Inhibition of
hepatitis B virus replication by interferon requires proteasome activity.
J. virol; 76 (7): 3570-4.
Rodriguez, E., Mariscal, L., Bartolome, J. et al. (2003):
Distribution of hepatitis B virus in the liver of chronic hepatitis C
patients with occult hepatitis B virus infection. J of Medical Virology
Aug; 70 (4): 571-80.
Roque, A.C., Feray, D., Samuel, S. et al. (2002): Antibodies to
hepatitis B surface antigen prevent viral reactivation in recipients of
liver grafts from anti-HBc positive donors. Gut; 50: 95-99.
Russo, M. W. (2004): Care and Management of Chronic Hepatitis B:
An Overview for Patients and Family Caregivers Hepatitis B.
Emergency Medicine.
Saab, S., Chang, J., Comulada, S. et al. (2003): Outcomes of
hepatitis C- and hepatitis B core antibody-positive grafts in orthotopic
liver transplantation. Liver Transpl. 9 (10):1053-1061.
Sakai, T., Shiraki, K., Inoue, H. et al. (2002): HBV subtype as a
marker of the clinical course of HBV infection in Japanese patients. J
Med Virol; 68(2): 175-81.
Sakai, A., Claire, M. S., Emerson, S.U. et al. (2003): The hepatitis C
virus P7 protein, a new target for drug development, is critical for
infectivity and contains sequences with genotype specific function.
Hepatol Vol. 38, No. 4, Suppl. 1 Oct.43-89.
Sakugawa, H., Nakazone, H., Nakayosld, T. et al. (2002):
Preponderance of hepatitis B virus genotype B contributes to a better
prognosis of a chronic HBV infection in Okinawa, Japan. J Med Virol;
67(4): 484-9.
Sallam, T. (2000): Prevalence of HCV, HBV and HIV infections in
chronic drug abusers. M.Sc. thesis, Tropical Medicine, Cairo
University; 39-42.
Samuel, D. (2004): Management of hepatitis B in liver transplantation
patients. Semin Liver Dis. 24 (Suppl 1):55-62.
- 137 -
References
Saruc, M., Yuceyar, H., Kucukrnetin, N. et al. (2002): Combination

thymosin-Alpha 1 and interferon- Alpha 2b in the treatment of anti
HBe positive chronic hepatitis B in Turkey. Hepatogastroenterol;
49(45):798-802.
Saudy, N., Sugauchi, F., Tanaka, Y. et al. (2003): Genotypes and
phylogenic characterization of hepatitis B and Delta virus in Egypt. J
Med Virol; 70(4): 529-536.
Schiefke, I., Klecker, C., Maier, M. et al. (2004): Sequential
combination therapy of HBe antigen-negative/virus-DNA-positive
chronic hepatitis B with famciclovir or lamivudine and interferonalpha-2a. Liver Int. Apr; 24 (2): 98-104.
Schiff, E.R., Dienstag, J., Karayalcin, S. et al. (2003a): Lamivudine
and 24 weeks of lamivudine/interferon combination therapy for
hepatitis B e antigen-positive chronic hepatitis B in interferon
nonresponders. J Hepatol; 38(6):853-5.
Schiff, E.R., Lai, C.L., Hadziyannis, S. et al. (2003b): Adefovir
dipivoxil therapy for lamivudine-resistant hepatitis B in pre- and postliver transplantation patients. Hepatology; 38 (6):1419-1427.
Sekiya, K., Takashima, H., Ueda, N. et al. (2002): 2-Amino-6
arylthio - 9 - [2-(phosphonomethoxy) ethyl 1] purine bis (2, 2, 2
trifluoroethyl) esters as novel HBV specific antiviral reagents. J Med
Chem; 45(14): 3138-4.
Selimo, G.M., Audo, G.S., Unal, F. et al. (2002): Alpha interferon
and lamivudine combination therapy for chronic hepatitis B in
children. Pediatr Int; 44(4): 404-8.
Seo, Y., Yoon, S., Hamano, K. et al. (2004): Response to interferonalpha in chronic hepatitis B with and without precore mutant detected
by mutation site-specific assay. J. Clin Gastroenterol; 38 (5): 460-4.
Shang, Q., Yu, J., Zhuo, H. et al. (2002): Relationship between
amount of HBV DNA in serum/liver tissue and hepatitis G Virus
(HGV) infection in patients with chronic hepatitis B. Zhonghua Shi
Yan He Lin Chuang Bing Du Xue Za Zhi. Dec; 16 (4): 326-8.
Shen, H., Alsatie, M., Eckert, G. et al. (2004): Combination therapy
with lamivudine and famciclovir for chronic hepatitis B infection. Clin
Gastroenterol Hepatol. Apr; 2 (4): 330-6.
Sherlock, S. and Dooley, J. (2002): Diseases of the liver and biliary
system: 11th edition. Hepatitis B virus Hepatitis and Delta virus. 285303.
Shiao, J.S., Mclaws, M.L., Huang, K.Y. et al. (2002): Student
nurses in Taiwan at high risk for needle stick injuries. Ann Epidemiol;
12 (3): 197-201.
- 138 -
References
Shindo, M., Hamada, K., Nishioji, K. et al. (2004): The predictive

value of liver fibrosis in determining the effectiveness of interferon
and lamivudine therapies for chronic hepatitis B. J. Gastroenterol;
2004; 39 (3): 260-7.
Sinturk, H., Tabak, F., Akdogan, M. et al. (2002): Therapeutic
vaccination, in chronic hepatitis B. I Gastroenterol Hepatol; 17(1):726.
Sobao, Y., Toittiyaina, H., Sugi, K. et al. (2002): The role of
hepatitis B virus specific memory CD8T cells in the control of viral
replication. J hepatology; 36 (1): 105-15.
Song, J.W., Lin, J.S., Kong, X.J. and Liang, K.H. (2004): The
inhibitory effects on hepatitis B virus replication by stable expression
of DN mutants of hepatitis B virus X gene pRev X-GFP. Zhonghua
Gan Zang Bing Za Zhi. Jul; 12 (7): 392-4.
Spijkerman, J.B., Van Doorn, L.J., Janssen, H.W. et al. (2002):
Transmission of hepatitis B virus from a surgeon to his patients during
high-risk low-risk surgical procedures during 4 years. Infect Control
Hosp Epidemiol; 23: 306-312.
Squadrito, G., Orlando M.E., Pollicino, T. et al. (2002): Virological
profiles in patients with chronic hepatitis C and overt or occult HBV
infection. Am. J. Gastroenterol 2002: 97: 1518-1523.
Stephen, L. (2004): Molecular Virology of Hepatitis B Virus. Semin
Liver Dis; 24: 3-10.
Stranksy, J. (2004): Adefovir dipivoxil is a new drug for treatment of
chronic hepatitis B. Vnitr Lek. Mar; 50 (3): 177-80.
Sugauchi F., Kumada H., Acharya S.A. et al. (2004):
Epidemiological and sequence differences between two subtypes (Ae
and Aa) of hepatitis B virus genotype A. J. Gen Virol. Apr; 85 (pt 4)
811-20.
Suskind, D.L. and Rosenthal, P. (2004): Chronic viral hepatitis.
Adoles Med Clin. Feb; 15 (1): 145-58, x-xi.
Suzuki, F., Tsubota, A., Akuta, N. et al. (2002): Interferon for
treatment of breakthrough infection with hepatitis B virus mutants
developing during long-term lamivudine therapy. J. Gastroenterol; 37
(11): 922-7.
Tai, D.I., Lo, S.K., Kuo, C.H. et al. (2002): Replication of hepatitis
B in HBsAg positive siblings. J virol hepat; 9(4): 272-279.
Tamori, A., Nishiguchi, S., Kubo, S. et al. (2003): Sequencing of
human viral DNA junctions in hepatocellular carcinoma from patients
with HCV and occult HBV infection. J Med Virol Apr; 69 (4): 47581.
- 139 -
References
Tan, T.M., Zhou, L., Houssais, S. et al. (2002): Intracellular

inhibition of hepatitis B virus genome expression by chimeric DNARNA phosphorothioate minimized ribozyme. Antisense Nucleic acid
drug Dev; 12(4): 257-64.
Tanaka, Y., Yeo, A.E., Orito, E. et al. (2004): Prognostic indicators
of breakthrough hepatitis during lamivudine monotherapy for chronic
hepatitis B virus infection. J. Gastroenterol, Aug; 39 (8): 769-75.
Tang, H. and Mclachlan, A. (2002): Mechanisms of inhibition of
nuclear hormone receptor dependent hepatitis B virus rep1ication by
hepatocyte nuclear factor 3 beta. I Virol; 76(17): 8572-81.
Tang, S., Shi, W. and Zhang, W. (2003): Therapeutic effects of
Lamivudine in combination with Thymopentin on chronic hepatitis B.
Zhonghua Shi Yan He Lin Chuang Bing Du Xue Za Zhi. Dec; 16 (4):
385-7.
Tedder, R.S., Iiaz, S., Gilbert, N. et al. (2002): Evidence for a
dynamic host-parasite relationship in e-negative hepatitis B carriers. J
Med Virol; 68: 505-512.
Thakur, V., Guptan, R.C., Malhotra, V. et al. (2002a): Prevalence
of hepatitis B infection within family contacts of chronic liver disease
patients does HBeAg passivity really matter? J. Assoc Physicians
India. Nov; 50: 1386-94.
Thakur, V., Gruptan, R.C., Kazim, S.N. et al. (2002b): Profile,
spectrum and significance of HBV genotypes in chronic liver disease
patients in the Indian subcontinent. J gastroenterol Hepatol: 17 (2): 1
65-70.
Tibbs, C.J. and Smith, H.M. (2003): The natural history and
prognosis of viral hepatitis. Clinicians guide to viral hepatitis. Press
Inc-USA 43-59.
Tong, M.J. and Tu, S.S. (2004): Treatment of patients with chronic
hepatitis B with adefovir dipivoxil. Semin Liver Dis; 24 Suppl 1: 3744.
Toniutto, P., Fumo, E., Caldato, M. et al. (2004): Favourable
outcome of adefovir-dipivoxil treatment in acute de novo hepatitis B
after liver transplantation. Transplantation; 77 (3):472-473.
Torbenson, M. and Thomas, D.L. (2002): Occult hepatitis B. Lancet
infection Dis; 2(8): 479-86.
Tran, T.T. and Martin, P. (2004): Hepatitis B: epidemiology and
natural history. Clin Liver Dis.; 8(2):255-66.
Trifan, A. and Stanciu, C. (2003): Chronic hepatitis B virus
infection. Rev Med Chir Soc Med Nat Lasi. Jan-Mar; 107 (1): 19-27.
Tsai, N.C. (2004): Practical management of chronic hepatitis B
infection. Semin Liver Dis; 24 Suppl. 1: 71-6.
- 140 -
References
Tsamandas, A.C., Thomopoulos, K., Gogos, C. et al. (2002):

Expression of locl-2 oncoprotein in cases of acute and chronic viral
hepatitis type B and type C: a clinicopathologic study. Dig Dis Sci; 47
(7): 1618-24.
Tsitsilonis, O.E., Thrasyvoulides, A., Balafas, A. et al. (2004):
Serological detection of hepatitis B viral infection by a panel of solidphase enzyme-linked immunosorbent assays (ELISA). J. Pharm
Biomed Anal. Mar. 1: 34 (4): 811-22.
Vanlandschoot, P., Van Houite, F., Roubrouck, A. et al. (2002):
HBsAg suppresses the activation of monocytes through interaction
with serum protein and monocyte-specific receptors. J gen virol;
83(pt6): 128 1-9.
Vierling, J.M. (2005): Management of HBV Infection in Liver
Transplantation Patients. Int J Med Sci; 2:41-49.
Villamil, F.G. (2003): Prophylaxis with anti-HBs immune globulins
and nucleoside analogues after liver transplantation for HBV
infection. J. Hepatol. 39 (4):466-474.
Waked, I. (2005): Treatment of Hepatitis B virus (HBV): Pros and
Cons of available therapies. The first Egyptian HBV day; Sheraton
Wan, B.M., Liu, S.J., Liu, X.J. et al. (2004): Significance of
detecting HBV-DNA by the fluorescence quantitative PCR. Zhonghua
Shi Yan He Lin Chuang Bing Du Xue Za Zhi. Jun; 18 (2): 162-4.
Wang, C.S., Chang, T.T., Yao, W.J. and Chou, P. (2002a):
Comparison of HBV and HCV prevalence and risk factors in a
community-based study. Am I Trop Med Hyg; 66(4):389-93.
Wang, J.T., Lee, C.Z., Chen, P.J. et al. (2002b): Transfusiontransmitted HBV infection in an endemic area: the necessity of more
scientific screening for HBV carriers. Transfusion; 42(12): 1592-7.
Wang, J.T., Zhu, Q., Zhang, T. and Yu, H. (2002c): A pilot study
on the combined therapy of granulocyte macrophage colonstimulating factor and hepatitis B vaccine on chronic hepatitis B virus
carrier children. Chin Med J. (Engl). Dec; 115 (12): 1824-8.
Wang, L., Kaneko, S., Honda, M. and Kobayashi, K. (2002d):
Approach to establishing a liver targeting gene therapeutic vector
using naturally occurring defective hepatitis viruses devoid of
immunogenic T cell epitope. Virus res; 85(2): 187-97.
Wang, N., Gao, X.Q. and Han, J.X. (2004a): simultaneous detection
of HBV and HCV by multiplex PCR normalization. World J.
Gastroenterol. Aug 15; 10 (16): 2439-43.
Wang, N., Lin, S.J., Tsai, J.H. et al. (2004b): Anti-hepatitis B
surface antigen IgG1 subclass is predominant in individuals who have
- 141 -
References
recovered from hepatitis B virus infection, chronic carriers and

vaccines. Med Microbiol Immunol (Berl). Jul 27.
Weber, B., Schlemmer, K.H., Hartmann, E. et al. (2002): Inhibition
of human hepatitis B virus (HBV) by a novel non-nucleosidic
compound in a transgenic mouse model. Antiviral Res; 54(2): 69-78.
Wen, X., Li, X., Xie, H. et al. (2002): Observation on the therapeutic
effect of Lamivudine on chronic hepatitis B. Zhonghua Shi Yan He
Lin Chuang Bing Du Xue Za Zhi. Dec; 16 (4): 395-7.
WHO (2002): Global distribution of chronic hepatitis B infection; 35:
211-9.
312-9.
420-8.
Wolters, L.M., Hansen, R.E., Niesters, H. et al. (2002): Viral
dynamics during and after entecavir therapy in patients with hepatitis
B. J Hepatol; 37(1): 137-44.
Wong, V.S., Chan, H., Wong, M. et al. (2002): Is it safe to stop
lamivudine after the emergence of YMDD mutants during lamivudine
therapy for chronic hepatitis B? J Hepatol: 36: 177.
Wright, T.L. (2004): Clinical trial results and treatment resistance
with lamivudine in hepatitis B. Semin Liver Dis; 24 Suppl 1: 31-6.
Xu, Z., Yen, T.S., Wu, L. et al. (2002): Enhancement of hepatitis B
virus replication by its x protein in transgenic mice. J vitrol; 76 (5):
2579-84.
Yang, C., Xiao, Y.H., Guan, X.Q. and Yuan, Z. (2004): A study on
the clinical and pathological efficacy of lamivudine in the treatment of
chronic hepatitis B. Zhonghua Gan Zang Bin Za Zhi. June; 12 (6):
364-7.
Yang, H., Westland, C.E., Delaney, W.E. et al. (2002): Resistance
surveillance in chronic hepatitis B patients treated with adefovir
dipivoxil for up to 60 weeks. Hepatology; 36: 464-473.
Yano, Y., Fumihiko, Y., Shuji, S. et al. (2003): Significance of
antibody against hepatitis B virus core antigen in patients with
hepatitis C virus related hepatocellular carcinoma. Liver Int 23 (4):
227-223.
Yano, Y., Yamashita, F., Sumie, S. et al. (2002): Clinical features of

hepatocellular carcinoma seronegative for both HBsAg and anti-HCV
antibody but positive for anti-HBc antibody in Japan. AJG-Vol. 97.
No. 1: 67-85.
- 142 -
References
Yao, Y., Huang, A., Tang, N. et al. (2002): Replication and

transfection of hepatitis B virus DNA into primary duck hepatocytes.
Zhonghua Gan Zang Bing Za Zhi; l0 (1): 34-6.
Yao, G.B., Gui, Z.Y., Wang, B.E. et al. (2004): A 3-year clinical
trial of lamivudine in treatment of patients with chronic hepatitis B.
Hepatobiliary Pancreat Di. Int. May; 3 (2): 188-93.
Yegane, S., Revanli, M. and Taneli, F. (2004): The role of beta 2
microglobulin levels in monitoring chronic hepatitis B. Tohoku J. Exp
Med. May; 203 (1): 53-7.
Yoshida, E.M., Ramji, A., Chatur, N. et al. (2004): Regression of
cirrhosis associated with hepatitis B e (HBe) antigen-negative chronic
hepatitis B infection with prolonged lamivudine therapy. European J.
of Gastroenterology & Hepatology. 16(3):355-358.
Zakaria, S., Zakaria, M. and Fouad, R. et al. (2000): Seroprevalence of hepatitis markers in a rural and semi-rural Egyptian
district. Antiviral therapy; 5(Suppl 1):12.
Zakaria et al., 2004: sited by Esmat, G. (2005): Hepatitis B virus
(HBV): the Egyptian situation. The first Egyptian HBV day; Sheraton
Zhang, F.K. (2004): Interferon-alfa in the treatment of chronic
hepatitis B. Heaptolbiliary Pancreat Dis Int. Aug; 3 (3): 337-40.
Zhang, L., Zhu, L., Ma, Y. et al. (2002): Nucleic Acid quantifying
assay of hepatitis B virus. Zhongua Can Zang Bing Za Zhi Zhi; 10(1):
49-51.
Zhang, X.N., Xiong, W., Wang, J.D. et al. (2004): SiRNA-mediated
inhibition of HBV replication and expression. World J. Gastroenterol.
Oct 15; 10 (20): 2967-71.
Zheng, S.S., Wu, J., Liang, T.B. et al. (2002): Prophylaxis and
treatment of hepatitis B virus reinfection following liver
transplantation. Hepatobiliary Pancreat Dis Int. Aug; 1 (3): 327-9.
Zhou, D.Y., Cao, Y.J., Lin, L.Y. et al. (2002): HBV resistant to
lamivudine: experimental and clinical studies. Hepatobiliary Pancreat
Dis Int. Nov; 1 (4): 519-22.
Zhou, J.L. and Wu, S.P. (2004): Effects comparison of lamivudine
therapy for heaptits B virus genotypes B and C. Zhonghua Gan Zang
Bing Za Zhi. Aug; 12 (8): 489-90.
Zhu, X.D., Zhang, W.H., Li, C.L. et al. (2004): New serum
biomarkers for detection of HBV-induced liver cirrhosis using SELDI
protein chip technology. World J. Gastroenterol. Aug 15; 10 (16):
2327-9.
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Update On Prevalence, Diagnosis and Treatment of Hepatitis B Virus

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UPDATE ON PREVALENCE, DIAGNOSIS

AND TREATMENT OF HEPATITIS B

Dr. Hesham Noaman Abdel Raheem Mustafa

Dr. Laila Ahmad Mohammad

Dr. Ahmad Nabil Lotfy Hassan

Hesham Noaman Abdel Raheem

Morphology of Hepatitis B Virus.

Clinical Presentation and Sequelae.

HBV Status in Egypt.

Diagnosis of Acute and Chronic Hepatitis B.

Treatment of Chronic Hepatitis B.

Summary and Conclusions