1. NEW INSIGHT IN HEPATITIS B IN CHILDREN Mei-Hwei Chang, M.D. Department of Pediatrics, National Taiwan University Hospital, Taipei, TAIWAN

2. Chang MH Replication Cycle of HBV

3. Chang MH EPIDEMIOLOGY

4. Prevalence of Chronic Hepatitis B HBsAg Prevalence > 8% - High 2-8% - Intermediate < 2% - Low Immigration numbers summed by continent from 1996-2002 ~ 2 million Asians ~ 400,000 South Americans ~ 350,000 Africans ~ 930, 000 Europeans Centers for Disease Control. Hepatitis B fact sheet. Available at: http://www.cdc.gov/hepatitis. Accessed January 31, 2006. Mahoney FJ. Clin Microbiol Rev. 1999;12:351-366. Hepatitis B Foundation. Hepatitis B statistics. Available at: http://www.hepb.org/hepb/statistics.org. Accessed January 31, 2006.

5. Chang MH NATURAL HISTORY OF HEPATITIS VIRUS INFECTION

6. Chang MH Natural History of Hepatitis B

7. Chang MH FACTORS AFFECTING THE CLINICAL COUSE OF HEPATITIS VIRUS INFECTION FACTORS AFFECTING THE CLINICAL COUSE OF HEPATITIS VIRUS INFECTION Host Host Age of Infection Age of Infection Virus : Virus : Genotype Genotype Mutants / Variants Mutants / Variants Route of Infection Route of Infection Other Factors Other Factors

8. Chang MH - Perinatal Transmission - Perinatal Transmission - Childhood Infection - Childhood Infection - Adolescent/Adult Onset - Adolescent/Adult Onset Disease Disease Age of Infection and Outcome

9. Chang MH HBV GENOTYPE AND HBeAg SEROCONVERSION

10. Chang MH Kao JH, Chen DS. Current Hepatitis Report 2006 (in press). Kao JH, Chen DS. Current Hepatitis Report 2006 Worldwide Distribution of HBV Genotypes. The Size of the Capitals indicates the Relative Prevalence of the Genotypes

11. Chang MH No. of Children with Chronic HBV Infection 160 238 62 26 HBV Genotype Follow-up BBB B C C C C Ni YH, Chang MH, et al. Gastroenterology 2004 ;127:1733-8.

12. Chang MH Age in Years HBeAg Seropositivity Genotype C Genotype B Ni YH, Chang MH, et al. Gastroenterology 2004 ;127:1733-8. Genotype C Genotype B

13. Chang MH HBV Genotype and Clinical Course in Children Genotype C Delays HBeAg Seroconversion in Chronic HBV Infection in Children Genotype C Delays HBeAg Seroconversion in Chronic HBV Infection in Children Genotype Changes : Rare Genotype Changes : Rare Genotype B Dominates in Children with Chronic HBV Infection and HCC in Taiwan Genotype B Dominates in Children with Chronic HBV Infection and HCC in Taiwan Ni YH, Chang MH, et al. Gastroenterology 2004 ;127:1733-8.

14. Chang MH HBV VARIANTS / MUTANTS HBV VARIANTS / MUTANTS

15. Chang MH A Point Mutation at Codon 28 ( Nucleotide 1896) of HBV Precore Gene TGGTGG TAG (Tryptophan) (Stop Codon) Leading to HBeAg Negative Strains

16. Chang MH CHANGES OF HBV PRECORE GENE 1896 IN 80 HBsAg CARIER CHILDREN Chang MH, et al. J Hepatol. 1998 ;28:915-22.

17. Chang MH Peak ALT levels during follow-up in 3 groups with different patterns of HBV precore 1896 Peak ALT Group 1 Group 2 Group 3 Total (IU/l) (n=37) (n=22) (n=21) (n=80) Mean 136 179 209 167 +- SD +- 149 +- 141 +- 195 +-161 Group 1: Wild type throughout the whole course. Group 2: Mutant after HBe seroconversion Group 3: Mutant before HBe seroconversion. ALT levels between groups, p=0.07. ALT levels between groups, p=0.07. Chang MH, et al. J Hepatol 1998; 28: 915-22.

18. Chang MH Comparisons of HBV Core Gene Between 31 Chronic Carriers and 12 HCC Children Codon Mutated Cases (No.) in HCC Mutated Cases (No.) in Chronic carrier Mutations P value Precore 2858% (7)52.2% (12) WXWX 0.73 Core 218% (1)21.7% (5) S  P or A 0.32 Core 6533% (4)17.3% (4) L  W or V 0.29 Core 7433% (4)0 SGSG 0.0032 Core 8733% (4)0 SGSG 0.0032 Core 1318% (1)0 ADAD 0.16 Core 14333% (4)4.3% (1) LPLP 0.015 Core 1478% (1)21.6% (5) T  C or S 0.32 Core 15942% (5)0 RSRS 0.0006 Core 18242% (5)4.3% (1) QXQX 0.0035 Ni YH, et al. Gut 2003;52:122-5

19. Chang MH Comparisons of HBV Core Gene Between 31 Chronic Carriers and 12 HCC Children - SUMMARY Core gene codon 21, 65, and 147 were the commonest mutation sites in children with chronic HBV infection. All were located in HBcAg epitopes of CTL. Core gene codon 21, 65, and 147 were the commonest mutation sites in children with chronic HBV infection. All were located in HBcAg epitopes of CTL. Codon 74, 87, and 159 mutations are found in HCC children, but not in the chronic infection group. Codon 74, 87, and 159 mutations are found in HCC children, but not in the chronic infection group. Ni YH, et al. Gut 2003;52:122-5

20. Chang MH DISCUSSION These mutations may help HBV to escape host immune pressure, to expand viral proteins, and finally bring in the cancer development. These mutations may help HBV to escape host immune pressure, to expand viral proteins, and finally bring in the cancer development.

21. Chang MH TREATMENT OF HEPATITIS B CURRENT THERAPY FOR HEPATITIS B IS NOT SATISFACTORY

22. Chang MH CURRENT GOAL OF ANTIVIRAL THERAPY FOR HEAPTITIS B Reduction of Viral Replication Reduction of Viral Replication Amelioration of Hepatic Dysfunction Amelioration of Hepatic Dysfunction

23. Chang MH HBV Antiviral Therapy Is Not Recommended in HBeAg Negative & Normal ALT Subjects : Relatively Stable Course with Low Rate of Progression. HBeAg Negative & Normal ALT Subjects : Relatively Stable Course with Low Rate of Progression. HBeAg Positive & Normal ALT Subjects : May Progress, But No Effective Therapy. HBeAg Positive & Normal ALT Subjects : May Progress, But No Effective Therapy.

24. Chang MH CURRENT APPROVED THERAPY FOR HEPATITIS B Interferon Interferon Interferon –α* Interferon –α* Pegylated Interferon-α Pegylated Interferon-α Nucleoside Analog Nucleoside Analog Lamivudine* Lamivudine* Adefovir Adefovir Entecavir Entecavir * Approved for use in children

25. Chang MH Effects of interferon in childhood hepatitis B Effects of interferon in childhood hepatitis B Place & ALT HBeAg Clearance (%) Authors at Rx Control IFN Rx Barbera no limit 14% (5/37) 26% (10/39) Gregorio > 1.5xN 13% (4/31) 38% (24/64) Lai no limit 0% (0/30) 8% (5/60) Tsai, Hsu > 2xN 38% (5/13) 44% (8/18) Sokal > 2xN 11% (8/74) 26% (18/70) Meta-Ana no limit 11% (12/113) 23%(29/126)

26. Chang MH Efficacy according to baseline ALT 11/88 43/183 9/58 33/97 4/17 8/16 50% 24% 34% 16% 23% 13% % complete virologic response (HBeAg(-), HBV DNA(-) Jonas et al, N Engl J Med 2002; 346: 1706.

27. Chang MH Lamivudine paediatric phase 3 study (NUC30903) Placebo (n=97) Wk 52 Baseline No treatment (n=63) One year placebo controlled study Two year follow-on study Lamivudine 3 mg/kg (n=191) Lamivudine 3mg/kg HBeAg-ve HBeAg+ve Treatment (n=213) 89% Durability of response at month 36 Sokal E et al. Hepatology. 2006; 43: 225-32.

28. Chang MH Long term lamivudine therapy for children with HBeAg+ve CHB (2) Virologic response in the treatment arm Virologic response in the treatment arm 21% after 12 + 24 months of Rx (n=133) 21% after 12 + 24 months of Rx (n=133) 30% after 0 + 24 months Rx (n=77) 30% after 0 + 24 months Rx (n=77) * VR = loss of HBeAg loss and HBV DNA * VR = loss of HBeAg loss and HBV DNA The incidence of YMDD mutations was The incidence of YMDD mutations was 64% (66/103) after 12 + 24 months of lamivudine 64% (66/103) after 12 + 24 months of lamivudine 49% (34/70) after 0 + 24 months of lamivudine 49% (34/70) after 0 + 24 months of lamivudine Sokal E et al. Hepatology. 2006; 43: 225-32.

29. Chang MH PREVENTION OF VIRAL HEPATITIS PREVENTION OF VIRAL HEPATITIS

30. Chang MH

31. IMPORTANT TRANSMISSION ROUTE IN HYPERENDEMIC AREAS : MOTHER TO CHILD IMPORTANT TRANSMISSION ROUTE IN HYPERENDEMIC AREAS : MOTHER TO CHILD EFFECTIVE PREVENTION EFFECTIVE PREVENTION OF HEPATITIS B : OF HEPATITIS B : VACCINATION IN INFANCY

32. Chang MH HEPATITIS B VACCINATION AND CONTROL OF HEPATITIS B RELATED LIVER DISEASES Acute /Fulminant Hepatitis Acute /Fulminant Hepatitis Chronic Hepatitis Chronic Hepatitis Liver Cirrhosis ? Liver Cirrhosis ? Hepatocellular Carcinoma Hepatocellular Carcinoma

33. Chang MH Universal HBV Vaccination and Decreased Mortality from Fulminant Hepatitis in Infants in Taiwan Universal HBV Vaccination July 1984 Kao JH, Hsu HM, Shau WY, Chang MH, Chen DS. J Pediatr. 2001;139:349-52. *The average mortality rate per 10 5 infants Mortality Ratio: 3.2 (p <0.001) 1974-1984: 5.36* 1985-1998: 1.71*

34. Chang MH Incidence Rate Ratios (IRR) of HBV-Positive v.s. -Negative FHF in 15 Years of the Universal Vaccination Program (Chen et al. Hepatology 2004 ;39:58-63) Year 1985~99,Case No. (Incidence per 10 5 ) P-Value HBV(+) FHF 43 <1 Yr33 (0.74) 54.2 [26.1, 123.2 ] <0.01 1-15 Yr10 (0.014) 1-15 Yr <0.01 IRR(1 v.s. 1- 15Y)[95% C.I.] HBV (-) FHF < 1 Yr 52 25 (0.56) 72 (0.039) 15.2 [8.5, 27.2]

35. Chang MH Childhood HCC 1.Male Predominance : M/F = 3-4 : 1. HBV, But Not HCV, Related 2. HBV, But Not HCV, Related >90% HBsAg Positive, 86% HBeAg Negative, HBV Genome Integration into Host Genome, 94% Maternal HBsAg Positive >90% HBsAg Positive, 86% HBeAg Negative, HBV Genome Integration into Host Genome, 94% Maternal HBsAg Positive Chang MH et al. Hepatology 1991;13:316-20 Chang MH et al. Cancer 1989; 64: 2377-80

36. Chang MH EFFECT OF UNIVERSAL HEPATITIS B VACCINATION ON HCC IN TAIWANESE CHILDREN, 6-9 YEARS Birth HCC Incidence Year in Children 1974-84 0.52/10 5 1974-84 0.52/10 5 1984-86 0.13/10 5 1984-86 0.13/10 5 Chang MH, et al. N Engl Med 1997; 336:1855-9. Chang MH, et al. N Engl Med 1997; 336:1855-9.

37. Chang MH Incidence of HCC in Children Diagnosed at Aged 6 to 14 Years from July 1981 to June 2000 According to Birth Year Birth Population No. of Incidence R.R. 95% Year* Cases (per 10 5 ) CI 1966-84 48,764,799 263 0.54 1 1984-94 17,817,510 35 0.20 0.36 0.26-0.52 __________________________________________________ * Birth Year was counted from July of one year to June of the next year. R.R.: risk ratio; CI: confidence interval. Chang MH, et al. Clin Cancer Res 2005;11: 7953-7.

38. Chang MH Chang MH et al. JAMA2000;284:3040-42

39. Chang MH Problems that remain to be solved for the control of Hepatitis & related Diseases Chang MH. Liver International 2003; 23: 309-14. 1.Inadequate Resources 2. Poor Compliance 3. Vaccine Failure Intrauterine Infection Genetic Hyporesponsiveness Vaccine Escape Mutants / Variants

40. Chang MH ACKNOWLEDGEMENT 1.Hepatitis B Study : Hong-Yuan Hsu, Yen-Hsuan Ni, Huey-Ling Chen, Chien-Jen Chen, Ding-Shinn Chen 2.Hepatoma Study : Tony Chen, Hsu-Mei Hsu, Tzee-Chung Wu, Man- Shan Kong, Der-Cherng Liang, Tai-Tsung Chang, Jiann-Shiuh Chen, Chieh-Chung Lin, Fu-Chen Huang, Ming-Tzong Cheng, Chia-Hsian Chu, Su-Fen Wu, Pei-Shin Chang

41. Chang MH Thank You Thank You Very Much Very Much