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Understanding Hepatitis-B<br />Prof Arif M. Siddiqui<br />MBBS(KE);MRCP(UK);FRCP(London)<br />FRCP(Edin);FRCP(Glasg)<br />...
Prologue<br />There has been an explosion of information on Hepatits B in the last few years and this many doctors have no...
PAKISTAN<br />151 millionpopulation<br />35% Urban<br />65% Rural<br />22 millionchildren under 5 years<br />6.6 million c...
HBV worldwide distribution, 2000sWHO2003<br />WHO 2003<br />
HBV by age at infection<br />
Global distribution of HBV genotypes (A to H)<br />A, D<br />B,C<br />G<br />A, C, B, D, G<br />B, C<br />A,D<br />F, H<br...
Hepatitis B<br />Source: Centers for Disease Control and Prevention, USA<br />Revised December 2003<br />
Hepatitis B - diagnostic tools<br />Antibodies to the virus<br /><ul><li>Anti-HBc
Anti-HBe
Anti-HBs</li></ul>Severity of liver damage<br /><ul><li>Bilirubin
Albumin
Prothrombin time</li></ul>Markers of the virus<br /><ul><li>HBV DNA
HBeAg
HBsAg</li></ul>Markers of liver damage<br /><ul><li>ALT
AST
Bilirubin</li></ul>HBV<br />
Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />HBe<br />Anti-HBe<br />HBc (does not appear in blood)<br />Anti-HBc IgG & IgM<...
Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />HBe-Ag<br />Anti-Hbe (Hbe-Ab)<br />HBc (does not appear in blood)<br />Anti-HB...
Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />Hbe-Ag<br />Anti-HBe<br />HBc (does not appear in blood)<br />Anti-HBcIgG & Ig...
Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />HBe-Ag<br />Anti-HBe<br />HBc (does not appear in blood)<br />Anti-HBcIgG & Ig...
Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />HBe<br />Anti-HBe<br />HBc (does not appear in blood)<br />Anti-HBc IgG & IgM<...
Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />Hbe<br />Anti-Hbe<br />HBc (does not appear in blood)<br />Anti-HBc IgG & IgM<...
Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />Hbe<br />Anti-Hbe<br />HBc (does not appear in blood)<br />Anti-HBc IgG & IgM<...
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  1. 1. Understanding Hepatitis-B<br />Prof Arif M. Siddiqui<br />MBBS(KE);MRCP(UK);FRCP(London)<br />FRCP(Edin);FRCP(Glasg)<br />AllamaIqbal Medical College/Jinnah Hospital Lahore<br />
  2. 2. Prologue<br />There has been an explosion of information on Hepatits B in the last few years and this many doctors have not been able to grasp fully.<br />New management guidelines have emerged.<br />I will, in this short time, try to explain few basic important facts on which the understanding and management of this disease is based.<br />
  3. 3. PAKISTAN<br />151 millionpopulation<br />35% Urban<br />65% Rural<br />22 millionchildren under 5 years<br />6.6 million childreninfected by HBV before the age of 5 years go on to develop Chronic Hepatitis B infection.<br />Hepatitis<br />2.6% prevalence among general public<br />3.8% prevalence among pregnant women<br />Ref: WHO/MDG<br />
  4. 4. HBV worldwide distribution, 2000sWHO2003<br />WHO 2003<br />
  5. 5. HBV by age at infection<br />
  6. 6. Global distribution of HBV genotypes (A to H)<br />A, D<br />B,C<br />G<br />A, C, B, D, G<br />B, C<br />A,D<br />F, H<br />E<br />F<br />A<br />* Defined by divergence in the entire genome sequence > 8%.<br />
  7. 7. Hepatitis B<br />Source: Centers for Disease Control and Prevention, USA<br />Revised December 2003<br />
  8. 8. Hepatitis B - diagnostic tools<br />Antibodies to the virus<br /><ul><li>Anti-HBc
  9. 9. Anti-HBe
  10. 10. Anti-HBs</li></ul>Severity of liver damage<br /><ul><li>Bilirubin
  11. 11. Albumin
  12. 12. Prothrombin time</li></ul>Markers of the virus<br /><ul><li>HBV DNA
  13. 13. HBeAg
  14. 14. HBsAg</li></ul>Markers of liver damage<br /><ul><li>ALT
  15. 15. AST
  16. 16. Bilirubin</li></ul>HBV<br />
  17. 17. Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />HBe<br />Anti-HBe<br />HBc (does not appear in blood)<br />Anti-HBc IgG & IgM<br />HBV-DNA by PCR<br />
  18. 18. Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />HBe-Ag<br />Anti-Hbe (Hbe-Ab)<br />HBc (does not appear in blood)<br />Anti-HBcIgG & IgM<br />HBV-DNA by PCR<br />
  19. 19. Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />Hbe-Ag<br />Anti-HBe<br />HBc (does not appear in blood)<br />Anti-HBcIgG & IgM<br />HBV-DNA by PCR<br />
  20. 20. Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />HBe-Ag<br />Anti-HBe<br />HBc (does not appear in blood)<br />Anti-HBcIgG & IgM<br />HBV-DNA by PCR<br />
  21. 21. Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />HBe<br />Anti-HBe<br />HBc (does not appear in blood)<br />Anti-HBc IgG & IgM<br />HBV-DNA by PCR<br />
  22. 22. Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />Hbe<br />Anti-Hbe<br />HBc (does not appear in blood)<br />Anti-HBc IgG & IgM<br />HBV-DNA by PCR<br />
  23. 23. Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />Hbe<br />Anti-Hbe<br />HBc (does not appear in blood)<br />Anti-HBc IgG & IgM<br />HBV-DNA by PCR<br />
  24. 24. Hepatitis-B<br />HBsAg<br />Anti-HBsAg<br />Hbe<br />Anti-Hbe<br />HBc (does not appear in blood)<br />Anti-HBc IgG & IgM<br />HBV-DNA by PCR<br />
  25. 25. Acute HBV Infection: Appearanceand Disappearance of Viral Markers<br />viraemia<br />(HBV-DNA, DNA-polymerase)<br />ALT<br />HBeAg<br />HBsAg<br />anti-HBc<br />anti-HBs<br />ALT<br />anti-HBe<br />8<br />10<br />12<br />2<br />4<br />6<br />2<br />4<br />6<br />Months<br />Years<br />HBV<br />
  26. 26. Acute Hepatitis B Virus Infection with Recovery Typical Serologic Course<br />Symptoms<br />anti-HBe<br />HBeAg<br />Total anti-HBc<br />Titer<br />anti-HBs<br />IgM anti-HBc<br />HBsAg<br />0<br />4<br />8<br />12<br />16<br />24<br />28<br />32<br />52<br />100<br />20<br />36<br />Weeks after exposure<br />
  27. 27. Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course<br />Acute<br />(6 months)<br />Chronic<br />(years)<br />HBeAg<br />anti-HBe<br />HBsAg<br />Total anti-HBc<br />Titer<br />IgM anti-HBc<br />0<br />4<br />8<br />16<br />20<br />24<br />28<br />36<br />12<br />32<br />52<br />Years<br />Weeks after exposure<br />
  28. 28. Progression to Chronic Hepatitis B Virus Infection Typical Serologic Course<br />Acute<br />(6 months)<br />Chronic<br />(years)<br />HBeAg<br />anti-HBe<br />HBsAg<br />Total anti-HBc<br />Titer<br />IgM anti-HBc<br />0<br />4<br />8<br />16<br />20<br />24<br />28<br />36<br />12<br />32<br />52<br />Years<br />Weeks after exposure<br />
  29. 29. Natural Course of CHB<br />Immune<br />Tolerance<br />Immune<br />Clearance<br />Phase<br />Late/Residual<br />Pre-C mutant<br />Reactivation<br />HBV-DNA<br />anti-HBe(+)<br />HBeAg(+)<br />HBsAg<br />Clearance<br />Cirrhosis<br />HCC<br />ALT/Grading<br />HBeAg Nuclear Cytoplasm (++ ~) (-)<br /> (+++) Membrane (++ ~)<br />HBsAg/preS Membrane Cytoplasm (++ ~) Cytoplasm (+++)<br /> (+++) Membrane (++ ~)<br />HLA-1 (-) (++) (++)<br />20<br />40<br />60<br />Age<br />
  30. 30. Treatment<br />When to treat<br />With what to treat<br />How to monitor<br />How long to treat<br />

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