HEPATITIS B

“Life is not the way it’s supposed to be...

It’s the way it is…
The way we cope with it ,
is what makes the difference”
 A SCENARIO

A baby is born to a mother who is a patient of Hepatitis B.

The parents are concerned about the baby getting the
disease. What preventive measures are likely to be helpful?
 HEPATITIS B GLOSSARY

• Acute hepatitis = less than 6 months

• Chronic hepatitis = longer than 6 months
• Perinatal = acquired around the time of birth (also called
vertical transmission)

• Horizontal transmission = person to person within a

household or community
 CONTD.

• HBs Ag: Surface antigen, indicates current infection

• HBs Ab: Surface antibody, indicates immunity
• Hbe Ag: e antigen, indicates active viral replication
• Hbe Ab: e antibody, indicates cessation of viral replication
 THE CULPRIT

• Member of the Hepadnaviridae family

• The surface of the virus includes particles designated
hepatitis B surface antigen (HBsAg)
• The inner portion of the virion contains hepatitis B core
antigen (HBcAg), the nucleocapsid that encodes the viral
DNA, and a nonstructural antigen called hepatitis B e
antigen (HBeAg)
• HBeAg serves as a marker of active viral replication and
usually correlates with HBV DNA levels
 EPIDEMIOLOGY

• HBV has a worldwide spread

• Estimated 400 million persons chronically infected
• In the United States, since 1982 when the 1st vaccine for
HBV was introduced, the overall incidence of HBV
infection has been reduced by more than half.
 EPIDEMIOLOGY
(CONTD.)
High concentration of the Hepatitis B virus is present in:
 Blood
 Serum
 Wound secretions (exudates)

N.B.: The higher the concentration = the easier to get

infected
 EPIDEMIOLOGY
(CONTD.)

Moderate concentration of Hepatitis B virus is present in

 Semen
 Vaginal fluid
 Saliva
 EPIDEMIOLOGY
(CONTD.)

Low or Absent concentration of Hepatitis B virus is present in:

 Urine
 Feces
 Sweat
 Tears
 Breast Milk
 TRANSMISSION

MTCT (Mother To Child Transmission):

• Perinatal Period:
From 28 weeks of gestation till 28 days after delivery. Does not
actually include infections that occur before or after this time
period

• MTCT takes account of all HBV infections contracted before

birth, during birth and in early childhood
Theoretically, there are three possible routes for transmission of
HBV from an infected mother to her infant: 13
• Transplacental transmission of HBV in utero
• Natal transmission during delivery
• Postnatal transmission during care or through breast milk
 TRANSMISSION

Percutaneous = virus enters through the skin

Contaminated needle stick [ I/V drug use/occupational
exposure]
Hemodialysis
Human bite
Transplantation / Transfusion
Acupuncture, Tattooing, Body piercing
 OUTCOME OF HBV INFECTION

Infection

Symptomatic Acute
Asymptomatic
Hepatitis B

Resolved Resolved
Chronic infection Chronic infection
Immune Immune

Cirrhosis / Cirrhosis /
Asymptomatic Asymptomatic
Liver cancer Liver cancer
CONTD.
 RISK OF CHRONIC
HEP. B

100
90
80
70
60
% 50
40
30
20
10
0
Neonates Infants Children Adults
 PATHOGENESIS

• Predominantly a non-cytopathogenic virus

• Causes injury mainly by immune-mediated processes
• Infection of hepatocytes by HBV Expression of viral
antigens on the cell surface
• These antigens make the cell a target for cytotoxic T-cell
lysis leading to ‘Acute Hepatitis’
 CONTD.

• If ‘Tolerance’ against these antigens develops, ‘Chronic

Hepatitis’ results
• In case of ‘zero tolerance’, massive hepatocyte
destruction leading to ALF (Acute Liver Failure)
• Circulating immune complexes containing HBsAg cause
the extrahepatic conditions associated with HBV
infections
 CLINICAL FEATURES

• Majority remains asymptomatic

• Lethargy, anorexia, and malaise occur about 6–7 wks after
exposure
• Jaundice in 25%, appears ~8 wks after exposure &
remains for ~4 wks
• In case of resolving HBV infection, symptoms are
present for 6–8 wks
 CONTD.

• ‘Carrier State’ develops in 10% infections acquired in

adulthood & in 90% of perinatally acquired cases !!
• Chronic hepatitis cirrhosis and hepatocellular carcinoma
are seen with chronic infection.
• On physical examination in acute cases: Icteric skin and
mucous membranes
• Tender Hepatomegaly
• Splenomegaly and lymphadenopathy are also common
 INVESTIGATIONS

• LFTs: (S. Bil., ALT, AST, Alk Phos, GGT, Albumin, PT)
• Viral Markers: HBsAg, HBsAb, HBcAb (IgG, IgM),
HBeAg, HBeAb, HBV DNA (By PCR)
• Liver Biopsy
INTERPRETATION
 COMPLICATIONS

• ALF with coagulopathy, encephalopathy, and cerebral

edema
• Risk of ALF increased in co-infection or super-infection
with HDV
• Mortality due to ALF is >30%
• Chronic hepatitis, which can lead to cirrhosis & end-
stage liver disease
• Hepatocellular carcinoma
 TREATMENT

Goals of Treatment in Children:

• Suppression of viral replication
• Seroconversion from e Ag to e Ab

• Reduction in long-term sequelae of HBV-associated liver

disease
 HBsAg positive at least 6 months Age at
least 2 years

Evidence for active viral replication?

HBeAg negative HBeAg positive

HBV DNA undetectable HBV DNA measurable

No indication for treatment

Check ALT on several occasions
 AGENTS FOR CHB

• Approved Antiviral Agents

– Lamivudine*

– Adefovir dipivoxil

– Interferon alfa*

– Entecavir

– Pegylated interferon

– Telbivudine
 CONTD.

• Further Experimental Agents

– Tenofovir

– Clevudine

– Emtricitabine

• Combination therapy
– Experimental
 PREVENTION

 Screen pregnant women and vaccinate all exposed infants

Routine early childhood vaccination – 1991
Vaccinate active IDU’s, non-monogamous adults, healthcare
workers, & household contacts
Standard precautions used to prevent exposure to blood –
healthcare workers, tattoo artists, body piercing. Wear
protective gear such as gloves, goggles, etc
Don’t use an infected person’s toothbrush, razor, or
anything else that could have blood on it
 CONTD.

• Hepatitis B vaccine and hepatitis B immunoglobulin

(HBIG) are available for prevention of HBV infection
• All newborns should be vaccinated. (part of our EPI)
• Household, sexual, and needle-sharing contacts should
be identified and vaccinated if they are susceptible to
HBV infection
 CONTD.

• All neonates of HBV infected mothers MUST receive HB

Vaccine AND Immunoglobulin within 12 hrs of birth.
 PROGNOSIS

• In general, the outcome after acute HBV infection is

favorable, despite a risk of ALF
• The risk of developing chronic infection brings the risks
of liver cirrhosis and hepatocellular carcinoma to the
forefront
• Perinatal transmission leading to chronicity is responsible
for the high incidence of hepatocellular carcinoma in
young adults in the endemic areas