1

Diagnostyka
serologiczna zakażeń
wywołanych przez
wirusy pierwotnie
hepatotropowe

Maciej Jabłkowski
Katedra i Kilinika Chorób

Zakaźnych Uniwersytetu

Medycznego

w Łodzi

Polskie Towarzystwo Diagnostyki

Laboratoryjnej
Łódź 14.12.2006r.

A

A

“

“

I

I

n

n

fectious”

fectious”

“

“

Serum”

Serum”

Viral

Viral

hepatitis

hepatitis

Enterically

Enterically

transmitted

transmitted

Parenterally

Parenterally

transmitted

transmitted

other

other

?

?

E

E

“

“

NANB”

NANB”

B

B

D

D

C

C

VIRAL HEPATITIS

HISTORICAL PERSPECTIVE

Treatment Landscape

Serology

HBV DNA

(PCR)

HBV DNA

(hybridization)

• Progress has been made in laboratory assessment

tools

Hepatitis B Virus

Phases of HBV Infection:

1981

Yim JY, Lok AS-F. Hepatology. 2006;43:S173-S181.

Symptoms

HBeAg

anti-HBe

Total anti-HBc

IgM anti-HBc

anti-HBs

HBsAg

0

4

8 12 16 20 24 28 32 36

52

100

Acute Hepatitis B Virus Infection with
Recovery

Typical Serologic
Course

Weeks after
Exposure

Titr
e

IgM anti-
HBc

Total anti-HBc

HBsAg

Acute

(6 months)

HBeAg

Chronic

(Years)

anti-HBe

0 4 8 1

2

1
6

2
0

2
4

2
8

3
2

3
6

5
2

Year

s

Weeks after Exposure

Titr
e

Progression to Chronic Hepatitis B
Virus Infection

Typical Serologic
Course

Screening Tests

• HBsAg

– If positive, indicates infection

• Anti-HBc

– If positive, indicates HBV

exposure

• Anti-HBs

– If positive, indicates immunity

Further Testing

for HBsAg+ Patients

• HCV antibody in at-risk individuals
• HIV antibody or RNA quantification in

at-risk individuals

• Consider screening for hepatitis

delta virus (HDV)
if adult-acquired HBV

–

Anti-HDV

–

Delta antigen

–

Delta RNA if any HDV testing is available

2nd-Phase Testing

in HBsAg+ Patients

• Anti-HBc

– IgG: if positive, indicates HBV exposure

– IgM: if positive, indicates acute HBV

• HBeAg

– If positive, indicates active HBV replication

– If negative

• If HBV DNA negative, suggests HBV replication is

suppressed

• If HBV DNA positive, most likely has precore mutation

• Anti-HBe

• HBV DNA quantification

– Quantitative level correlates with level of HBV

replication

2nd-Phase Testing

in HBsAg+ Patients

• HBeAg

– Positive, indicates active HBV replication
– Negative

• If HBV DNA negative, suggests HBV replication is

suppressed

• If HBV DNA positive, most likely has precore mutation

• Anti-HBe

• HBV DNA quantification

– Quantitative level correlates with level of HBV replication

• Anti-HDV

– Detects coinfection with delta agent

Phases of HBV Infection:

2005

Yim JY, Lok AS-F. Hepatology. 2006;43:S173-S181.

HBV Serologic and

Molecular Tests in Serum

Category

Test

Significance

Viral antigens

HBsAg*

Acute or chronic

infection; infectivity

HBeAg

Acute or chronic

infection; infectivity

Viral antibodies

Anti-HBc*

Anti-HBe

Anti-HBs*

Marker of infection

Low infectivity

Marker of immunity

Molecular tests

HBV DNA

Acute or chronic

infection; infectivity

*Test recommended for initial screening

*Test recommended for initial screening

Phases of Chronic HBV

Infection

*Precore mutant

†

Expert opinions vary as to this value

1IU = ~5 copies/mL

Lai CL, et al. Lancet. 2003:362:2089. Lok AS, et al. Gastroenterology. 2001;120:1828.

Immune Inactive HBeAg

HBeAg

Tolerant

HBsAg Positive

Negative

Phase

Carrier

CHB

CHB*

HBsAg

+

+

+

+

HBeAg

+

–

+

–

Anti-HBe

–

+

–

+

ALT

Normal

Normal





HBV DNA

>10

5

>10

4

<10

5

>10

4†

copies/mL

copies/mL copies/mL

copies/mL

Histology Normal/Mild

Inactive

Active

Active

Treatment Algorithm

Patients With Compensated

Disease

•No treatment
•Monitor every 6–12 months

•Monitor every

3–12 months

(immune

tolerant)

•Consider

biopsy, if age

>35–40, and

treat if

significant

disease

Keeffe EB et al. Clin Gastroenterol Hepatol. 2006.

•Treat
•Adefovir,

entecavir, and

PEG-IFN are

first-line options

HBeAg-positive

ALT

Elevated

ALT

Normal

HBV DNA

≥10

5

c/mL

HBV DNA

<10

5

c/mL

Treatment Algorithm

Patients With Compensated

Disease

Keeffe EB et al. Clin Gastroenterol Hepatol. 2006.

•No treatment
•Monitor every 6–12 months

•Monitor ALT, or

•Consider biopsy,

since ALT often

fluctuates, and

treat if

significant

disease

•Long-term

treatment

required

•Treat

•Adefovir,

entecavir, and

PEG-IFN are first-

line options

•Long-term

treatment

required (oral

agents

)

HBeAg-negative

ALT

Elevated

ALT

Normal

HBV DNA

≥10

4

c/mL

HBV DNA

<10

4

c/mL

•May choose to treat or observe

•If treat: adefovir or entecavir, or

combination Rx

•May be a role for combination therapy

•Treat with adefovir or entecavir

•May be a role for combination therapy

•Significant clinical consequences

associated with lamivudine resistance in
this population

Keeffe EB et al. Clin Gastroenterol Hepatol. 2006.

Treatment Algorithm

Patients With Compensated

Cirrhosis

HBV DNA

(PCR)

HBV DNA

<10

4

c/mL

HBV DNA

≥10

4

c/mL



Observe



Wait list for

transplant



Treat



Wait list for

transplant

HBV DNA

Detectable by PCR?

No

Ye

s

Treatment Algorithm

Decompensated Cirrhosis

Keeffe EB, et al. Clin Gastroenterol Hepatol. 2006;4:936.

Zapadalność na 100 tys. mieszkańców WZW

typu B

w województwie łódzkim przed i po

wprowadzeniu szczepień ochronnych

0,00

10,00

20,00

30,00

40,00

50,00

60,00

70,00

80,00

90,00

19

79

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

Lata

Z

ap

ad

al

no

ść

okres przed
wprowadzeniem
szczepień
ochronnych

intensyfikacja szczepień

stopniowe
wprowadzanie
szczepien

Hepatitis D (Delta) Virus

Hepatitis D (Delta) Virus

HBsAg

RNA

 antigen

HBV - HDV Coinfection

HBV - HDV Coinfection

Typical Serologic Course

Typical Serologic Course

Time after Exposure

Time after Exposure

T

it

e

r

T

it

e

r

anti-

HBs

Symptom

s

ALT

Elevated

Total anti-

HDV

IgM anti-

HDV

HDV RNA

HBsAg

HBV - HDV Superinfection

HBV - HDV Superinfection

Typical Serologic Course

Typical Serologic Course

Time after

Exposure

Time after

Exposure

T

it

e

r

T

it

e

r

Jaundic

e

Symptoms

ALT

Total anti-HDV

IgM anti-HDV

HDV RNA

HBsAg

Hepatitis C

Serologic Pattern of Acute HCV

Infection with Progression to

Chronic Infection

Symptoms

+/-

Time after Exposure

T

it

e

r

anti-

HCV

ALT

Norma

l

0

1

2

3

4

5

6

1

2

3

4

Years

Month

s

HCV RNA

Serologic Pattern of Acute HCV

Infection

with Recovery

Symptoms

+/-

Time after Exposure

T

it

e

r

anti-

HCV

ALT

Norma

l

0

1

2

3

4

5

6

1

2

3

4

Years

Month

s

HCV RNA

Hepatitis A
Virus

Fecal

HAV

Symptom

s

0

1

2

3

4

5

6

1

2

2

4

Hepatitis A
Infection

Total anti-
HAV

Titr
e

ALT

IgM anti-HAV

Months after
exposure

Typical Serological
Course

Epidemiological shift in

Epidemiological shift in

seroprevalence of

seroprevalence of

anti-HAV

anti-HAV

Age (years)

Age (years)

S

e

ro

p

re

v

a

le

n

c

e

S

e

ro

p

re

v

a

le

n

c

e

o

f

a

n

ti

-H

A

V

(

%

)

o

f

a

n

ti

-H

A

V

(

%

)

Improvement

Improvement

in hygiene

in hygiene

0

0

20

20

40

40

60

60

80

80

100

100

10 20 30 40

10 20 30 40

50

50

Van Damme P et al. 1994.

Hepatitis A in Poland

Hepatitis A in Poland

Cianciara J. Vaccine 2000;18:S68–S70.

Cianciara J. Vaccine 2000;18:S68–S70.

Shift

Shift

Hepatitis E Virus

Hepatitis E Virus

Hepatitis E Virus Infection

Hepatitis E Virus Infection

Typical Serologic Course

Typical Serologic Course

Weeks after Exposure

Weeks after Exposure

T

it

e

r

T

it

e

r

Symptom

s

ALT

IgG anti-HEV

IgM anti-HEV

Virus in stool

0

1

2

3

4

5

6

7

8

9 1

0

1

1

1

2

1

3