1. Hepatitis B Hepatitis B : A management Update

2. HBV Virus Member of the family Hepadnaviridae Partially double-stranded DNA, also known as relaxed-circular DNA (RC-DNA); it is 3.2 kb in length (smallest DNA virus) It is not cytopathic Although HBV is a DNA virus, it replicates through reverse transcription (lack of proof reading confers survival advantage) ccc DNA – Episomal intranuclear existence – confers invincibility

3. HBsAg Prevalence  8% - High 2-7% - Intermediate <2% - Low Geographic Distribution of Chronic HBV Infection http://www.who.int/vaccines-documents/DocsPDF01/www613.pdf

4. Global Impact of HBV infection WHO and CDC fact sheets, available at www.who.int and www.cdc.gov Almost half of the world ’ s population lives in an area with high HBV prevalence World population 6 billion (400 million carriers) 40 million with chronic HBV 25–40% die of cirrhosis or HCC (>1 Lac deaths / yr)

5. Child-to-child Contaminated needles Sexual contacts Healthcare worker Blood transfusion 6% of people infected over the age of 5 become chronically infected Perinatal 90% of infected infants become chronically infected Perinatal transmission(High) Horizontal transmission Transmission of HBV CDC. Viral hepatitis B fact sheet. Available at: http://www.cdc.gov/ncidod/diseases/hepatitis/b/fact.htm. Accessed January 22, 2008. Lee WM. N Engl J Med. 1997;337:1733-1745. Lavanchy D. J Viral Hepat. 2004;11:97-107. Host Mother Infant Recipient

6. Natural History of Chronic HBV Infection Ref-Ganem and Prince 350 (11): 1118

7. Approach to Incidentally detected HBsAg + person

8. First time detection Screening – Health Check ups - Blood banks - Jobs - Pre surgery

9. Shall we confirm a card test No Sensitivity and specificity 98.07% and 99.56% respectively. With an HBV prevalence of 5%, PPV and NPV were predicted to be 92.14% and 99.90%, respectively. Meta-analysis for the pooled sensitivity and specificity of hepatitis B surface antigen rapid tests. Hwang SH et al Korean J Lab Med 2008

11. Counselling HBs Ag – Going to stay for long Chances of loss 40% at 20 yrs HBs Ag titers available routinely are semiquantitative and have no proven significance Treatment decision is based on status of Liver Inflammation NOT only on HBsAg

12. AASLD Guideline Recommendations for Counseling Lok AS, McMahon BJ. Hepatology. 2009;50:661-662. Chronic Hepatitis B: Update 2009, Lok ASF, McMahon BJ, www.aasld.org. Copyright@2009. American Association for the Study of Liver Diseases, Reproduced with permission of the American Association for the Study of Liver Diseases. Recommendations Regarding Prevention of Transmission of HBV to Others Persons who are HBsAg positive should:  Have contacts vaccinated (Check HBsAg /Anti HBs before vaccination)  Use barrier protection during sexual intercourse if partner not vaccinated or naturally immune  Not share toothbrushes or razors  Cover open cuts and scratches  Clean blood spills with detergent or bleach  Not donate blood, organs, or sperm Children and adults who are HBsAg positive:  Can participate in all activities including contact sports  Should not be excluded from daycare or school participation and should not be isolated from other children  Can share food, utensils

13. Vaccination Inj Engerix B / Recombivax 20 mcg im in deltoid Schedule – 0, 1 mo, 6 mo 0, 1 mo, 2 mo, 12 mo Check for seroconversion after 1- 2 mo of last dose Seroconversion rates > 90% 60 – 70% in elderly, HD, diabetics Pregnancy not a contraindication

15. Initial Evaluation of Chronic HBV–Infected Patients Initial Evaluation History and physical examination Family history of liver disease, HCC Laboratory tests to assess liver disease: CBC with platelets, hepatic panel, and prothrombin time Tests for HBV replication: HBeAg/anti-HBe, HBV DNA Tests to rule out viral coinfections: anti-HCV, anti-HDV (in persons from countries where HDV infection is common and in those with history of injection drug use), and anti-HIV in those at risk Tests to screen for HCC: AFP and ultrasound as appropriate Consider liver biopsy to grade and stage liver disease: for patients who meet criteria for chronic hepatitis Lok AS, McMahon BJ. Hepatology. 2009;50:661-662. Chronic Hepatitis B: Update 2009, Lok ASF, McMahon BJ, www.aasld.org. Copyright@2009. American Association for the Study of Liver Diseases, Reproduced with permission of the American Association for the Study of Liver Diseases.

16. Investigations Don’t use panels HBeAg or Anti Hbe No Anti HBs if HBsAg + If Acute hepatitis wait till remission for doing HBeAg or Anti HBe HBV DNA – before starting treatment or if needed for classification Close Follow up with serial ALTs – a useful surrogate

17. Immune Tolerance Immune Active/ HBeAg-Positive CHB Nonreplicative (Inactive Carrier) HBeAg-Negative CHB Typical HBV DNA, IU/mL > 200,000 and often > 10 7-8 200,000 - 2 x 10 9 < 2000 2000 - 2 x 10 7 HBeAgPositive Negative ALT (M <30u/l) (F<19 u/l) NormalElevated (>2X) or fluctuating (over 1mo) NormalElevated or fluctuating > 2X over 1 mo Other observations Liver biopsy typically normal or minimal findings Active inflammation on liver biopsy HBsAg may become undetectable Active inflammation on liver biopsy Observe HBV DNA, ALT & HBeAg 3-6 mo Treat ALT every 3mo Then 6 – 12mo HCC Screening AFP & USG 6 monthly Treat Stratify the risk.

19. Goals No Cure of HBV available at present HBsAg loss or seroconversion is ideal but rarely achieved Treatment outcome: suppression of viral activity ie, - Normalization of ALT, - loss of HbeAg, Appearance of Anti HBe - Loss of HBV DNA associated with a lower risk of cirrhosis, hepatocellular carcinoma, and death [Iloeje 2006; Chen 2006; Yang 2002]Iloeje 2006Chen 2006Yang 2002

20. Drugs available for Treatment of CHB DrugsAdvantagesDisadvantages Interferons (IFN) Peg IFN Absence of resistance Immune mediated containment of infection Off treatment response HBsAg Clearance Finite Duration Frequent side effects Subcutaneous injection Contraindicated in depression and psychotic cases, Autoimmune disease Adefovir (ADV) Less efficacious Telbivudine (LdT) Potent inhibitor of HBV Low genetic barrier to resistance Lamivudine (LAM) Affordable High rates of resistance with monotherapy Entecavir (ETV) & Tenofovir (TDF) Potent HBV inhibitors High genetic barrier to resistance European Association for Study of Liver. J Hepatol 2009; 50. 227-242

21. On-treatment monitoring - Efficacy Both IFN or Nucs LFT monthly – 3 months then 3 monthly HBV DNA 3 monthly for 6 mo then 6 monthly HBeAg/ Anti HBe – 6 monthly and HBsAg yearly IFN HBsAg Titres at week 12 > 20000 iu/ml with no decline – less chances of response <2000 at wk 12 good responder

22. On-treatment monitoring – S/E Peg IFN  CBC weekly in first month then every 4 wks  TSH every 12 wks Duration – 48 weeks Response at 1 yr 25-30%

23. On-treatment monitoring Nucs - Muscle weakness should be monitored, especially if LdT is used - TDF or ADV - renal monitoring every 3 months during the first year and every 6 months thereafter - Duration – Indefinite, as per response Ideal End point – HBsAg seroconversion Practical - HBeAg seroconversion with HBV DNA loss (PCR) for at least 12 months. e- at least 2 years of treatment with undetectable HBV DNA documented on three separate occasions 6 months apart. Response at 5 yrs – 70-80%

24. Patterns of response - Nucs Primary non response – Check compliance Add/switch Partial Response – Add at wk48 Complete Response – continue Break Through – Check compliance Resistance Testing Add a drug

25. Monitoring post treatment Post treatment - ALT and HBV DNA monthly for the first 3 months to detect early relapse every 3 months in the first year. If uneventful, monitor every 3 months (for cirrhotic patients) to 6 months (for responders) thereafter (IIA). Monitoring for HCC

26. Potential Pitfalls Failure to Screen all under going chem0/immunosuppressive therapy Consider HBV DNA a major factor before classifying Asymptomatic carrier To realize that Lab normal for ALT is not Healthy ALT To aggressively screen HCC To consider resistance in long term treatment

27. Take Home Messages Never drop guards even after treatment – lifelong risk Only comfortable time to stop t/t Appearance of Anti HBs. Still monitor and screen for HCC Test for mutation in virological breakthrough on t/t Do not use Entecavir in Lamivudine treated patients Treatment is not curative Vaccine Holds the key

28. Hepatitis B Flare on Immunosuppression Screen – HBsAg, Anti HBc T, Anti HBs If All Negative – Vaccinate If Any + - Strong IS (Retuximab, Cyclophsphamide) – Prophylaxis - Steroids, Mtx - HBV DNA – If +ve – Prophylaxis If –ve – monitor Prophylaxis – Tenof/ Enteca- 2 wk before to 6-12 mo after stopping Monitring – ALT, HBsAg, HBV DNA at 1 month then 3 monthly Treat if worsens or HBV DNA appears

29. Revised ALT Males – 30 u/l Females – 19 u/l AASLD 2009 PNALT – Persistantly normal ALT in first 3 years FU – Good prognosis High normal Serum ALT - 0.5 – 1 x ULN minimally raised Serum ALT - 1 - 2 x ULN APASL 2012 Liver Biopsy or non invasive assessment of fibrosis if patient > 40 yrs if high normal or minimally raised ALT If higher grade of Inflammation or Fibrosis – Treat If No or mild inflammation or fibrosis – Observe 1-3 months ALT

30. Recommendations for Treatment of Pts With HBV Cirrhosis HBeAgHBV DNA (PCR), IU/mL ALTTreatment Strategy +/-DetectableCirrhosisCompensated  Treat irrespective of ALT and DNA levels  EASL 2012 Decompensated  Coordinate treatment with transplant center; refer for liver transplant +/-UndetectableCirrhosisCompensated: observe Decompensated: refer for liver transplant. Lok AS, McMahon BJ. Hepatology. 2009;50:661-662. Chronic Hepatitis B: Update 2009, Lok ASF, McMahon BJ, www.aasld.org. Copyright@2009. American Association for the Study of Liver Diseases, Reproduced with permission of the American Association for the Study of Liver Diseases.

31. Non invasive Markers of Liver fibrosis ECM components and enzymes - Serological – Direct – ECM components and enzymes - HA, PIIINP, Collagen IV, Collagen VI, TIMP-1, Laminin, YKL-40, Tenascin, Undulin, MMP-2 Measures of liver function - Indirect – Measures of liver function - AST, ALT,  GT, Apolipoprotein A1, bilirubin,  2-macroglobulin, haptoglobin, cholesterol, HOMA-IR, Platelets, PT Radiological Liver stiffness measurement – TE or Fibroscan Best performance in diagnosing advanced fibrosis (METAVIR C 3) than any other serum test formulae < 6.0 kPa normal ALT and < 7.5 kPa for elevated ALT –no fibrosis > 9 kPa with normal ALT and > 12 kPa for patients with elevated ALT – Advanced Fibrosis Overall Status – should be used as complimentary data not a replacement for Biopsy

32. HBsAg quantification Correlates with ccc DNA level HBsAg <1,000 IU/mL and HBV DNA <2,000 IU/mL identified inactive carriers with high accuracy HBeAg-negative subjects HBsAg level<200 IU/mL may predict HBsAg seroclearance in 3 years esp with a > 1 log10 IU/mL decline in the preceeding 2 years At present has role in monitoring IFN treatment HBsAg levels at 12 weeks < below 1500 IU/ ml - strong predictor of anti-HBe seroconversion >20,000 IU/ml or no decline - very low probability of subsequent anti- HBe seroconversion

33. PhaseImmune TolerantImmune ClearanceInactive Carrier State Reactivation Liver Minimal inflammation and fibrosis Chronic active inflammation Mild hepatitis and minimal fibrosis Active inflammation Yim HJ, et al. Hepatology. 2006;43:S173-S181. Optimal treatment times Anti-HBeAg HBV DNA ALT activity Current Understanding of HBV Infection 4 Phases of Chronic HBV Infection HBeAg

34. HCC Screening Asian Men > 40yr, Women > 50 yrs esp with Persistently raised ALT / High viral load Family History of HCC Vertically transmitted Infection Cirrhosis AFP and USG Abd every 6 months

35. How to choose?

36. Young Patients needing finite duration of T/t or Planning pregnancy in future – Peg IFN

37. SettingAnti-HBV Agent Decompensated cirrhosis  Entecavir preferred Entecavir  Tenofovir may be apropriate Tenofovir Renal insufficiency  Entecavir preferred (with dose modification) Entecavir Pregnancy, woman of child-bearing age planning pregnancy in the near term  Tenofovir preferred Tenofovir Woman of child-bearing age wishing to eradicate virus prior to pregnancy Younger patients  Peginterferon alfa-2a or peginterferon alfa-2b Peginterferon alfa-2apeginterferon alfa-2b HIV coinfection  Tenofovir plus emtricitabine or lamivudine Tenofoviremtricitabinelamivudine Factors Associated With Choosing Interferons or Nucleos(t)ides as Initial Therapy Patient Preference & Affordability

38. On-treatment monitoring Primary Treatment failure – Adherent – Add more potent drug from other class Virological response - > 1 log decline at 12 wks HBV DNA at 24 wks Complete Response Partial (>60-2000IU) Inadequate >2000IU DNA – Neg Add more potent drug 3 monthly monitor 6 monthly monitor

39. On-treatment monitoring Partial response Monitor 3 monthly continue beyond 48 weeks Tenofovir, Entecavir If incomplete at 48 wks– add a second drug with different mutation profile

40. Hepatitis B: Disease Progression Acute Infection Chronic Infection Cirrhosis Death Torresi J et al. Gastroenterology. 2000;118(2 Suppl 1):S83-S103. Fattovich G et al. Hepatology. 1995;21(1):77-82. Moyer LA et al. Am J Prev Med. 1994;10(Suppl):45-55. Perrillo RP et al. Hepatology. 2001;32(2):424-432. 5%-10% 10%-30% 23% within 5 years Liver Cancer (HCC) Liver Failure (Decompensation) 2%-6%

41. Screening Ideally everybody should be screened if Prevalence > 2% CDC 2008 Esp- pts needing Immunosuppressants – Chemotherapy, Post tx, treatment for GI or rheumatic diseases Donors of blood, plasma, organs, semen Screening – HBsAg, Anti HBs and Anti HBc

42. Problem - India India has over 40 million HBV carriers and accounts for 10–15% of the entire pool of HBV carriers of the world. Every year over 100,000 Indians die due to illnesses related to HBV infection. Predominant Genotype A followed by D World Health Organization (2012). Introducing Hepatitis B Vaccine in UIP in India.

43. e-negativity: Community 90% - 97%, CH/CLD 24% - 75% Pooled Prevalence 2% - 4% ALT elevation: HBeAg negative 17% - 45%, HBeAg positive 47% - 94%. Chowdhury A. J Gastroenterol Hepatol. 2005;20:1712-20. HBV Scenario in India

44. Patients for Immunosuppression

47. When to stop therapy? IFN-based therapy – PEG IFN – 12 month both e+ and e -

48. When to stop therapy - NUCs Ideal – HBsAg seroconversion Practical - HBeAg seroconversion with HBV DNA loss (PCR) for at least 12 months. e- at least 2 years of treatment with undetectable HBV DNA documented on three separate occasions 6 months apart.

50. Peginterferon alfa  Liver chemistry and CBC every 4 wks  HBV DNA and TSH every 12 wks  HBeAg/anti-HBe every 24 wks  HBsAg every 6 mos 48 wks HBeAg + HBeAg loss or seroconversion with concomitant HBV DNA < 2000 IU/mL, HBsAg loss HBeAg Neg Undetectable HBV DNA, HBsAg loss

51. Factors Associated With Choosing Interferons or Nucleos(t)ides as Initial Therapy NUCLEOS(T)IDES Specific patient demographics: Older people, pregnency, immunosuppression, decompensation Concomitant HIV infection INTERFERONS Favorable predictors of response Genotype A or B > C or D Specific patient demographics: Younger people/Young woman wanting future pregnancy Concomitant HCV infection Patient Preference & Affordability Keeffe EB, et al. Clin Gastroenterol Hepatol. 2008;6:1315-1341. EASL HBV Guidelines. J Hepatol. 2009;50:227-242

54. Normal ALT & Liver Disease 37% pts with chronic HBV infection and persistently normal ALT had evidence of significant fibrosis (stage 2-4) or inflammation (grade 2-3) by liver biopsy Lai M, et al. J Hepatol. 2007;47:760-767.

55. Definitions Primary non-response - < 1 log decrease in HBV DNA level from baseline at 3 months of therapy. Partial virological response - decrease in HBV DNA > 1 log10 IU/ml but detectable HBV DNA after at least 6 months of therapy in compliant patients. Virological breakthrough - increase in HBV DNA level of more than 1 log10 IU/ml compared to the nadir (lowest value) HBV DNA level on therapy

56. Genotypes A & D are predominant C reported from Eastern India like Arunachal Pradesh Significance A – Less Aggressive, early seroconversion, better IFN response C – Vertical Transmission more aggressive

57. Indian Adaptations In HBeAg positive patients with raised ALT being planned for NA therapy, frequent or even initial HBV DNA monitoring could be avoided There is some evidence that in among Asian patients (genotype B and C HBV infected patients), an HBsAg level of less than 100 IU/mL might predict lower risk of relapse and stopping treatment can be considered. There needs to be a concerted effort from the medical fraternity to provide universal immunization against HBV. Decompensating Hepatitis B (Acute / Reactivation) HBV DNA may be done after 4-6 weeks ie, after assuring survival Anand AC : Indian Guidelines and protocold: Hepatitis B API Update 2013

58. Vaccination Whom to screen – everybody (Intermediate prevalence zone)

60. Mode of actionSpecific cccDNA degradationKilling of infected hepatocytes NAInhibition of HBV polymeraseNo IFN- α Immune modulation Yes (in a high dose)Yes (indirectly in some patients) Inhibition of HBV replication Epigenetic regulation of the transcriptional activity of cccDNA Upregulation of APOBEC activity for cccDNA hypermutation and degradation LTβR agonist Upregulation of APOBEC3B activity for cccDNA hypermutation and degradation YesNo Adoptive T-cell therapy (T cells expressing chimeric antigen receptor) T cell immune response against HBV-infected hepatocytes NoYes Genome editing tools (ZFNs, TALENs, CRISPR/Cas9) Site-specific cleavage of HBV cccDNAYesNo.

61. ccc DNA – Covalently closed circular DNA the transcriptional template of hepatitis B virus (HBV) NA has no direct effect on viral transcription or cccDNA stability. Therefore, the long half-life of hepatocytes leads to a very slow decline in cccDNA in patients under antiviral therapy The phase – Invincible weapon

62. Occult HBV Infection HBV DNA detection in serum or in the liver by sensitive diagnostic tests in HBsAg-negative patients with or without serologic markers of previous viral exposure OBI can be both a source of virus contamination in blood and organ donations and the reservoir for full blown hepatitis after reactivation More than 20 percent of patients had no serologic markers because the antibody titer may become undetectable over time, leaving HBV DNA as the only marker of the infection. Thus depending on the HBV antibodies (anti-HBc and/or anti-HBs), OBI may be seropositive or seronegative The risk of HBV reactivation in the HBsAg-negative patients was 2.7% versus 48% in HBsAg-positive patients

63. If highly sensitive HBV DNA testing is not feasible, anti-HBc should be used as a less than ideal surrogate marker for identifying potential seropositive OBI individuals in cases of blood, tissue, or organ donation, and when immune suppressive therapy has to be administered not all anti-HBc-positive individuals are found to be HBV DNA positive OBI must be differentiated from S-escape mutants infection, in which undetectable HBsAg is present in spite of the episomal, free HBV genomes at intrahepatic level as in overt infection. These cases (so-called false occult HBV) result from HBV strains with key mutations in pre-S region which is not recognized by commercially available kits, even when the most sensitive ones are used

64. False OBI has been reported in up to 40% of patients with OBI [3, 11–13]. In the HBsAg assays, the use of multivalent anti-HBs antibodies is recommended for detection of false OBI [3].311133 clinical contexts as follows: reactivation of the infection and consequent development of the HBV- related liver disease; transmission of the “occult” virus mainly through blood transfusion and orthotopic liver transplantation (OLT) with consequent hepatitis B in the recipient; the effect on occurrence and progression of the CLD; and the role in hepatocarcinogenesis The prevalence of OBI is estimated to be 4–25% in anti-HBc-positive patients

65. Because of the low risk of HBV reactivation in patients with resolved infection with anti-HBs titer >10 IU/L, close followup of LFTs was thought to be sufficient in immunosuppressive treatment groups [49, 50]; although serial HBV-DNA monitoring is a reasonable strategy4950 Antiviral prophylaxis should be continued for ≥6 months after stopping chemotherapy and for certain immunosuppressive therapies, such as rituximab; it may be better to maintain the prophylaxis until restoration of host immunity All patients who receive chemotherapy and immunotherapy should be tested for serologic markers of HBV infection, including HBsAg, anti-HBc, and anti-HBs before any chemotherapy or immunosuppressive therapy, and monitored for several months or years after stopping treatment because antibody titers may be reduced by the immunosuppressive therapy

66. Current data are insufficient to recommend routine prophylaxis and antiviral therapy to prevent HBV reactivation for HBVDNA and HBsAg- negative but anti-HBc and/or anti-HBs positive patients, except in intense chemotherapy like rituximab Serial HBV-DNA monitoring (monthly during and after chemotherapy for at least 1 year) is a reasonable strategy recommended by the latest Japanese guidelines; in this regard multicenter clinical trial in Japan is now continued All patients receiving chemo- and immunotherapy should be tested at least once for anti-HBc antibodies before starting therapy and monitored periodically for ALT elevations. If ALT elevations occurred, the diagnosis of HBV reactivation must be established with further testing before initiation of antiviral prophylaxis. Optimal duration of prophylaxis in different risk populations should be clarified or even individualized in the future.

67. Vaccine escape mutants

68. Thank You