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Regrine B.

PH 201 Take Home Exam on Hepatitis

1. If a patient showed the following results:
(-) HBsAg
(-) anti- HBs
(+) anti-HBc,
would you recommend changing the recent algorithm in the laboratory?

The current algorithm for screening we use HBsAg to screen patients to Hepatitis B. If I
were part of the committee that recommends the algorithm for Hepatitis B screening and
diagnosis, I would recommend that the screening test would be anti-HBc instead. The
reason is that Hepatitis B core antigen persists lifelong that is why HBV infection can be
detected in the acute and chronic carrier stage of Hepatitis B even when negative for
hepatitis B surface antigen (HBsAg) and HBV-DNA . And in some patients with chronic
Hepatitis B, only the anti-HBc and not the HBsAg or anti-HBs can be detected. (World
Health Organization, 2013). When detectable, the amount of HBV-DNA in the serum is
usually very low (<200 IU/ml) (Raimondo, et al., 2008). In some countries, such as in
Argentina, Brazil, France, Germany, Japan, Paraguay, Peru Uruguay, USA and Venezuela,
they have utilized anti-HBc as a mandatory screening test to improve blood safety. (World
Health Organization, 2013)

In a study by Firnhaber, et. al in 2008 showed that of the 502 participants in the study, 24
(4.8%) were HBsAg-positive and 53 (10.6%) were positive for anti-HBc alone. Of these 53,
screening for occult disease was carried out in 43, of whom 38 (88.4%) were positive.

Since Hepatitis B is highly infective with low viral load needed to cause virulence, it is very
important that occult Hepatitis B among donors be identified in order to prevent the
spread of the disease.

2. Can vaccination against Hepatitis B virus prevent:
a. Co-infection with Hepatitis D

Hepatitis D infection can occur as a co-infection, which means it occurs at the same time as
hepatitis B infection. People who are co-infected with hepatitis B and hepatitis D may
experience a more seriously acute illness and have a higher risk (2%–20%) of developing
acute liver failure compared to people infected with hepatitis B alone. (Centers for Disease
Control and Prevention, 2013). Since the outer envelope of HDV is the HBsAg, and there has
been no proof that the HBV derived envelope is modified or antigenically different from the
HBsAg present in HBV, vaccination against the HBsAg can provide protection against HDV.
(World Health Organization, 2001) (Chibber & Shah, 2005) The preformed antibodies will
attack the HBsAg expressed by HBV, therefore will kill HBV and prevent encapsulation of
HDV since the HBsAg that it needs is already destroyed.

b. Superinfection with Hepatitis D

Superinfection happens when HDV infects of a chronically infected HBV carrier.
Superinfection is associated with the fulminant form of viral hepatitis. (World Health
Organization, 2001) (Chibber & Shah, 2005) (Chibber & Shah, 2005) Since HBsAg needed
for the encapsulation of HDV to prevent its denaturation and promote replication is already
present in the host, vaccination cannot prevent superinfection. The only way of preventing
superinfection is to educate chronic HBV carriers about transmission and risky behaviors.
HDV can be transmitted via blood exchange, sexual contact, sharing needles, and from
mother-to-child. (Centers for Disease Control and Prevention, 2013) (World Health
Organization, 2001)

Raimondo, G., Allain, J.-P., Brunetto, M., Buendia, M.-A., Chen, D.-S., Colombo, M., et al. (2008,
October 4). Journal of Hepatology. Statements from the Taormina expert meeting on occult
hepatitis B virus infection . USA.

Firnharber, C., Viana, R., Schultze, D., Maskew, M., Di Bisceglie, A., MacPhail, P., et al. (2008,
August 15). ccult hepatitis B virus infection in patients with isolated core antibody and HIV
co-infection in an urban clinic in Johannesburg, South Africa. International Journal of
Infectious Disease . (W. Cameron, Ed.) Johannesburg, South Africa.

World Health Organization. (2013, April 15). First International Standard for anti-Hepatitis
B core antigen. Retrieved September 7, 2014, from National Institute for Biological
Standards and Control:

Centers for Disease Control and Prevention. (2013, September 20). Hepatitis D Fact Sheet.
Retrieved September 7, 2014, from Centers for Disease Control and Prevention:

World Health Organization. (2001). Hepatitis D. Retrieved September 7, 2014, from Global
Alert and Response- World Health Organization:

Chibber, A., & Shah, M. (2005, November 25). Hepatitis D Virus. Retrieved September 7,
2014, from Hepatitis D Virus: