1. Hepatitis B virus (HBV) is a serious disease that can cause lifelong infection, liver cirrhosis, liver cancer, liver failure, and death. It is 100 times more infectious than HIV. 2. HBV is transmitted through contact with infectious blood or body fluids and can lead to either an acute or chronic infection. Chronic infections may progress to complications like cirrhosis or liver cancer. 3. Treatment options for chronic HBV infection include nucleoside/nucleotide analogues like entecavir and tenofovir, as well as interferon-alpha. Vaccination and immunoglobulin can prevent HBV infection in high-risk groups or following exposure.

1. Hepatitis B virus
Dr. K. G. Maharjan
Liver unit, Bir hospital

2. Introduction
• Hepatitis is an inflammation of the liver.
• It is usually caused by viral & non viral infections also
due to toxins (alcohol) & drugs (mostly ATT)
• In our setup it maybe due to bacterial infection but
may be an autoimmune response as well.
• It is characterized by anorexia , jaundice, abdominal
pain, liver enlargement and sometimes fever.
• Others , usually bacterial infections leading to HV&IVC
thrombophlebitis, metabolic cause (Wilson disease)
• Congestive causes like ( HVOO,IVC disease , CHF)
• HBV can lead to cirrhosis and liver cancer.

3. Introduction
• Hepatitis is an inflammation of the liver.
• It is usually caused by viral & non viral infections also
due to toxins (alcohol) & drugs (mostly ATT)
• In our setup it maybe due to bacterial infection but
may be an autoimmune response as well.
• It is characterized by anorexia , jaundice, abdominal
pain, liver enlargement and sometimes fever.
• Others , usually bacterial infections leading to HV&IVC
thrombophlebitis, metabolic cause (Wilson disease)
• Congestive causes like ( HVOO,IVC disease , CHF)
• HBV can lead to cirrhosis and liver cancer.

4. Viral hepatitis
• The different types of viral hepatitis A,E,(virus
transmitted through the faces of an infected
person.
• Hepatitis B,C,D are serum hepatitis
• Hepatitis F,G, cryptogenic ( caused by a virus
as not identified)
• More hepatitis viruses are less common
yellow fever, epstien barr virus(EBV),
cytomegalovirus(CMV),

5. Hepatitis B virus
• HBV is a serious disease ,can cause lifelong
infection , liver cirrhosis ,liver cancer , and
liver failure ,death.
• HBV is 100 times more infectious than HIV and
10 times more infectious than HCV.
• HBV is a blood borne transmitted ( body fluids
, semen, saliva,vaginal fluid (high titers in the
blood and lower titer in body fluids)

6. Hepatitis B virus introductions
• HBV is a 42 nm,double-shelled DNA virus of
the class Hepadnaviridae.
• The outer surface membrane contains HBV
surface antigen (HBsAg) which also circulates
in blood as 22 nm spherical and tubular
particles.

7. HBV virus

8. Continu…
• The inner core of the virus contains HBV core
antigen (HBcAg) (HBeAg)
• HBV is a single molecule of partially double –
stranded DNA, and DNA- dependent DNA
polymerase.

9. Continu…

10. Risk groups
• 1, I/V drug users Health workers
• 2, Multiple sex partners
• 3,Homosexuals
• 4,Infant born to HBV infected mothers
• 5,Hemodialysis patients
• 6, Areas with high rates of HBV infections
• 7,Tatooing

11. HBV transmitted
• HBV is transmitted by the exchange of blood
& body fluids ,eg . Blood, semen, breast milk
,saliva and vaginal secretor fluids , tears.

13. Epidemiology
• Globally
• 50 million new cases per year
• 350-400 million chronic carriers 75% in Asia
• 520,000 deaths per year

14. Epidemiology in Nepal
• One epidemiology study in done in nepal
• Group;1, Population No. HBsAg
• a, Soldiers 922 20 (2.2%)
• b, healthy people 232 2 (0.8%)
from districts
• c, pregnant women 81 1 (1.2%)
• d, blood donors 624 5 (0.8%)
• blood donors 168 1 (0.6%)

15. Continu…….
• Group 2,
• Hospital staff 792 7 (0.8%)
• Student nurses 122 0
• Relatives of CLD 388 12 (3.1%)
• Patients
• Group 3,
• Hemophilia 4 1 (25%)
• Drug addicts 72 2(3%)
• Hemodialysis 41 1(2%)
• HBV carriers 49 49(100%)

16. Continu…
• Group 4,
• Chronic liver disease 145 57 (39%)
• Acute hepatitis 150 14 (9.3%)

18. Clinical course of hepatitis B infection
Death Recovery
1% 99%
Transient
Acute 100%
Subclinical
hepatitis
infection
25% 65%
Acute HBV
infection
10%
10-30% Chronic HBV 70-90%
Infection
Chronic Healthy
Hepatitis ?
HBsAg
Carrier
Cirrhosis
Hepatocellular
Carcinoma ?

19. HBsAg
True Positive Negative
ALT Search for other virus
Raised Normal
Anti-HbcIgM Positive HbcAb
Negative F/u after 6 months Positive Negative
F/U
HBeAg HBvDNA F/U
Positive Negative >105ml <105ml
Liver biopsy HBcAb
Rx F/U
HBvDNA Negative Positive
Rx Liver biopsy HBvDNA
HBvDNA
Absent Raised
Search for other causes
of
ALT

20. Infection
• Acute hepatitis B develops in approximately 30% to
50% of adults at the time of initial infection and is
characterized by anorexia, nausea , vomiting and
jaundice.
• SGPT raises 2 ½ times
• The risk of progression to chronic infection varies
with age , being highest among young children and
infants (30%-90%) and lowest among adolescents
and adults (2%-6%).
• Rates of progression to cirrhosis and HCC vary
according to age at acquisition of chronic
infections ,HBeAg status , co infection with
HGV,HIV,HCV, and alcohol abuse.

21. Clinical features
• The first serologic marker to appear following
acute infection is HBsAg, which can be
detected as early as 1 or 2 weeks and as late
as 11 or 12 weeks (mode 30-60 days) after
exposure to HBV
• HBeAg is generally detectable in patients with
acute infections, the presence of HBeAg in
serum correlates with higher titers of HBV and
greater infectivity.

22. Continu….
• A diagnosis of acute HBV infection can be
made on the basis of the detection of IgM
class antibody to HBV core antigen (IgM ,anti-
HBc) in serum ,It is generally detectable at the
time of clinical onset.

23. Serological markers ; HBV
• HBsAg: Marker of infection,presence
>6months=chronic
• HBeAg: active viral replication,
• Anti-HBsAg: indicates recovery and /or
immunity (after vaccine)
• Anti-Hbe: inactive viral replication
• Anti-HBc: infection or immunity

25. HBV genotypes
• HBV classified into 7 genotypes (A-G)
• -a: north america and western europe
• B&C: asia
• D: southern europe and india
• E:&G: africa
• F:central and south america and alaska
• H: central america
• B associated with less HCC, less active and more slowly
progressive liver disease than C
• A&B respond better to Interferon than C&D
• Genotype does not predict response to oral agents

26. HBV infection
• Chronic HBV: chronic necroinflammatory liver
disease >6month,ALT^,HBeAg-postive or –
negative, HBV DNA> 10 x4-5
• Inactive HBsAg carrier : Persistent infection
without necroinflammatory disease, ALT
normal , HBeAg -negative HBV DNA<10 x 4-5
• Resolved HBV: previous infection without
virological ,biochemicalor histological
evidence of active disease.

27. Continu…
• Acute exacerbation HBV: elevated ALT>10 x
ULN or >2 x baseline
• Reactivation of HBV: reappearance of
necroinflammatory disease in person known
to be inactive carrier or resolved HBV

28. Liver histology ≥
Phases of chronic HBV
• Immunotolerant phase: HBeAg- postive; HBV
DNA high (10 x 5-10) ALT normal
-candidates for therapy.
Immunoactive phase: HBeAg-postive or HBeAg –
negative,HBV DNA high (10 x4-10) ,ALT
elevated, symptoms +/-
Non replicative phase :(inactive HBV carrier)
HBeAg –negative HBV DNA low(<10 x4 ) ALT
normal, HBsAg may later become undectable.

29. Routine HBV carriers exam
• Follow-up interval 6 months : Tests : ALT and
AST; AFP. USG,
• Inactive HBsAg carrier: If ALT/AST increase , re
evaluate
• Chronic hepatitis B: CBC,LFT,HBeAg, anti-HBe

30. HBV infected mothers
• Hepatitis B immunoglobulin (HBIG 0.5 ml ,
I/M to new born.
• Hepatitis B vaccination should have been
given 12 hours of birth.

31. Post exposure prophylaxis
• 1, HBIG is required
• 2,the first dose of hepatitis B vaccine
immediately, 0 – 1 – 6 months.

32. Hepatitis B vaccine
• The standard regimen for adult is 10-20mcg
initially ( depending on the formulations ) .
• Schedules; 0 -1 -6 months.
• Alternative schedules have been approved
• 0 -1 -2 -12 months
• 0- 7 and 21 days ,plus 12 months
• Preferred site vaccine deltoid muscles

33. Treatment of chronic HBV
• Nucleoside/nucleotide analogues:
- Entecavir : 0.5-1.0 mg/d
• -Lamivudine : 100 mg/d
• -Adefovir dipivoxil :10mg/d
• -Tenoforvir : 300mg/d
• Interferon: interferon alfa-2b 5MU/d or 10MU tiw x 4
months.
• Peginterferon alfa-2a (Pegasys) 180 mcg/week x 24-48
weeks.
• Liver transplantation ( decompensated chronic HBV
with cirrhosis.

34. Reference
• Davidson principal and practice of medicine
• C.M.D.T
• Oxford hand book of medicine
• Liver unit, Bir hospital

35. Thank you
Thank you