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INTRODUCTION
By Epidemiology and clinical criteria, two types of viral Hepatitis have been
recognized.
1. Occurring sporadically or as epidemics occurring in children and young
adults and transmitted by fecal-oral route. This is called infectious
Hepatitis later named type A Hepatitis.
2. Transmitted by inoculation originally observed in persons receiving
serum inoculation or blood transfusion. This had been given various
names such as homologous serum jaundice, serum Hepatitis and
transfusion Hepatitis. It was later called type B Hepatitis.
2
Type B Hepatitis is the most widespread and the most important type of
viral Hepatitis. More than a third of the world’s population is estimated to be
having been identified by Hepatitis B virus (HBV). About a quarter of them
became HBV carriers. A quarter of these develop various severe diseases
like2 :-
1. Severe Liver diseases
2. Chronic Hepatitis
3. Cirrhosis
4. Primary hepatic cancer
REVIEW OF LITERATURE
DISCOVERY OF HBV
nature of the disease. It also indicated that two distinct agents lacking cross
immunity were responsible for the military outbreak.
Mc Callum introduced the classic terminology of Hepatitis A virus and
Hepatitis B virus (HBV). It was found that Hepatitis A was induced by oral
route with incubation period of about 15-30 days. The serum was responsible
for inducing the Hepatitis B virus, after several months, when given by
parental route and not by oral route.4
The discovery of Australian antigen by Blumberg and his associates
was a major breakthrough. Prince et al recognized its relation with Hepatitis
B in mid sixties was another milestone in the study of Hepatitis.
The lesson learned from the work on Hepatitis B also helped in
discovery of HAV. Feinstone et al identified HAV in immunocomplexes
from faeces to which serum of a patient convalescent from Hepatitis A had
been added. When test for the Hepatitis A and B was made available, it
became clear that two viruses did not explain all the cause of viral Hepatitis,
as many patients lacked either of the infection.
Thus the concept of a new variant of viral Hepatitis was born. It was
called non A non B Hepatitis and its diagnosis was based on exclusion
criteria. The pre serological era of non A non B Hepatitis came to an end in
the mid eighties. The breakthrough this time resulted after meticulous and
exhaustive research involving the use of sophisticated technological methods.
Thus by the end of 80’s five Hepatitis viruses were identified. They were
HAV, HBV, HCV, HDV and HEV. Recently HGV and HFV have also been
identified.
The research in this field is continuing even today. New forms of
Hepatitis viruses are being discovered now and then.
6
VIROLOGY
CLASSIFICATION 6
STRUCTURE
Under the electron microscope, sera from type B Hepatitis patients show
three types of particles:
• The most abundant form is a ‘spherical particle’ 22 nm in diameter.
• The second type of particle is filamentous or tubular with a diameter of
22 nm and of varying length. The two particles are antigenically
identical and are surface components of HBV (HBsAg) which are
produced in great excess.
• The third particle is a double walled spherical structure 42 nm in
diameter. This particle is the complete Hepatitis B virus, known as
‘Dane particle’.
The envelope proteins expressed on the surface of the virion and the surplus
22 nm diameter spherical and filamentous particle- constitute HBsAg. It
constitute of two major polypeptide, one of which is glycosylated. The
antigen expressed on the core is called HBcAg Hepatitis B core antigen. A
7
C C HBcAg
C+pre-C HBeAg
P DNA polymerase
X HBxAg
The S gene- It codes for the surface antigen. It consists of S region and two
pre S regions, pre S2 and pre S1. When translation begins from pre S2 region,
the M or middle protein is formed. When the entire gene from pre S1 is
translated the L or large protein results. The L protein is present only in the
virion, while the M and S proteins are found in the circulating HBsAg
particle also.
The C gene- It has two regions C and pre C. When C region alone is
translated, the core antigen is formed. HBcAg is assembled as the
nucleocapsid core particles. It is not secreted and does not circulate in blood,
but can be demonstrated in hepatocytes but immunoflorescence. When
translation begins at pre C, the resulting protein is HBeAg, a nonparticulate
antigen processing a single protein which enables it to be secreted, hence
present in circulation. The presence to HBeAg in blood provides a convenient
and readily detectable marker of HBV replication and high infectivity.
The P gene-It is the largest and codes for the DNA polymerase enzyme.
The X gene- It codes for a small nonparticulate protein (HBxAg) which has
transactivating effects on both viral and some gene. HBxAg and its antibody
are present in patients with severe chronic Hepatitis and hepatocellular
carcinoma.
10
ANTIGEN DIVERSITY
HBsAg exhibits antigenic diversity. It contains two different antigenic
components – the common group reactive antigen ‘a’ and the two pairs of
type specific antigens d-y and w-r only member of each pair being present at
time.
It can be divided into four antigenic subtypes’ adw, adr, ayw, ayr.
These phenotypic variations reflect differences and can be used in
epidemiological studies. There are differences in the geographical
distribution of the types and also to some extent with the means of
transmission.
STABILITY
HBV is relatively heat stable virus. It remains viable at room temperature for
long periods. Heat at 600oC for 10 hours reduces infectivity by hundred to
thousand folds. It is susceptible to chemical agents. Exposure to
hydrochlorite (10,000 ppm available chlorine) or 2 % glutaraldehyde
inactivates infectivity, through HBsAg may not destroy by such treatment.
REPLICATION
Replication of viral nucleic acid starts with the hepatocyte nucleus where
viral DNA can be either free, extra chromosomal or integrated at various sites
within the host chromosome. However, integration is not essential for viral
replication.
To replicate hepadnavirus DNA, a full length RNA copy is enclosed in
core protein in the hepatocyte nucleus, this is copied to DNA by the
polymerase, the RNA is destroyed and the DNA copied, to form double
stranded as the virion matures.
CLINICAL FEATURES
There is a broad range of clinical features associated with HBV infection.
The incubation period is long, about 1-6 months. The clinical picture of
Hepatitis B is similar to that of type A, but it tends to be more severe and
11
PATHOGENESIS8
All types of viral Hepatitis produce similar changes at the histological level.
In the acute stage there are signs of inflammation in the portal triads. The
infiltrate is lymphocytic.
In healthy carriers the inflammatory response is mild and the affected
hepatocyte are pale staining and glassy.
In chronic Hepatitis, damage extends out from the lobular tracts giving
the piecemeal necrosis appearance. Some lobular inflammation is also seen.
As the disease progress fibrosis develops and eventually cirrhosis.
Acute disease- HBV replicates in the hepatocytes, reflected in the detection
of viral DNA and HBcAg in the nucleus and HBcAg in the cytoplasm and at
the hepatocyte membrane. Both B and T cell responses are induced by these
antigens; damage to the hepatocyte could result from both antibody-
dependent NK and cytotoxic T cell action. Expression of MHC class 1
antigens is poor in hepatocytes but can be enhanced as interferons are
produced in response to the infection. This in turn leads to increased antigen
recognition and lysis of the infected hepatocytes.
In asymptomatic carriers there may be no evidence of cell damage,
despite the presence of integrated HBV DNA and HBsAg
in the liver and plasma.
Cell-mediated responses to HBcAg are often detectable in patients with
chronic active Hepatitis. Super infection with delta virus may predispose to
progression to cirrhosis.
12
Persistence of Hepatitis B:
• Is indicated by HBsAg present for more than 6 months.
• Occurs in 5-10% of adults, 30% of childhood and 90% of newborn
infections.
• Is more frequent in males.
• Is more likely in the immunocompromised.
MODE OF TRANSMISSION
HBV is a blood borne virus and the infection is transmitted by-
• Parenteral
• Sexual
• Perinatal modes
• Blood of carriers
• Congenital or vertical
The virus may also be present in other body fluids and secretions such
as saliva, breast milk, semen, vaginal secretions, urine, bile and feces.10
Transfusion of carrier blood, once the most widely known mode of
infection has largely been eliminated whenever donor screening is
strictly enforced. Therapeutic preparations from pooled human blood
and serum have led to Hepatitis but this risk is now minimal with
screening of donors and production techniques ensuring virus
inactivation.
13
HBV is very highly infectious, far more than HIV. Any object or
producer that can contain very minute traces of infected blood or other
material as little as 0.00001 ml can be infectious. These include:
• Shared syringes, needles and other sharp items or endoscopes
• Personal articles such as razors, nail clippers or combs
• Practices such as acupuncture, tattooing, ritual circumcision ear
or nose piercing
Field camps for surgery or disease detection by blood testing where separate
sterile articles may not be available.
Infection by direct contact with open skin lesions such as pyoderma,
eczema, cuts and scratches is very common among young children in
developing countries.
Congenital or vertical transmission is quite common from carrier
mothers. The risk to babies is high if the mother is HBeAg positive. Infection
is acquired during birth by contact of maternal blood with the skin and
mucosa of the fetus or in the immediate post natal period. HBV infected
neonates generally do not suffer from any clinical illness but remain carriers
for life and some of them may develop HCC after many decades.
Sexual transmission of HBV occurs everywhere but is more in the
developed countries, particularly in the promiscuous homosexual. The risk of
transmission by heterosexual and homosexual contact increases with the
number of partners and the duration of such relationships. HBV infection has
occurred after artificial insemination. Semen donor screening is therefore
obligatory.
Certain groups and occupations carry a high risk of infection. These
include medical and paramedical personnel, staff of blood bank, dialysis
units, medical laboratories and mental health institutions, barbers and sex
workers. Dentists and doctors have been responsible for small outbreaks. In
non endemic countries like Britain HBV carriers are barred from invasive
medical practices. Carriers are also not permitted to be medical students.
14
LABORATORY DIAGNOSIS11
Specific diagnosis of HBV rests on the serological demonstration of the viral
markers.
HBsAg- This is the first marker to appear in the blood after infection, being
detectable even before elimination of transaminases and onset of clinical
illness. It remains in circulation throughout the icteric or asymptomatic
course of the start of the diseases. In typical cases it may disappear within 2
months of the start of the clinical disease but may sometimes last for six
months even beyond. When it is no longer detectable antibody, anti HBs
appears and remains for a long period.
HBV DNA level in serum reflects the degree of viral replication in the liver
and so helps to assess the progress of patients with chronic Hepatitis under
anti viral chemotherapy.
EPIDEMIOLOGY
Hepatitis B occurs throughout the world. There is no seasonal distribution.
The infection is usually sporadic, though occasional outbreaks have occurred
in hospitals, orphanages and institution of mentally handicapped.
The prevalence of Hepatitis carriers varies widely in different countries
in relation to their living standards.12
(www)
Map. Prevalence of chronic infection with Hepatitis B virus, 2006
Now that the vaccine is manufactured in India and is available at lower cost
it should be possible to include this in national immunization schedule.
19
PROPHYLAXIS13
General prophylaxis consists in avoiding
• Risky practices like promiscuous sex.
• Injectable drug use.
• Direct or indirect contact with blood, serum or other body fluids of
patients and carriers.
• Health education.
• Use of disposable syringes and needles.
• Screening of blood, semen and organ donors.
Above all have helped to an extent, but alone cannot eliminate the risk
altogether, particularly in the developing countries. The only certain method
appears to be universal immunization. Both passive and active immunizations
are available.
TREATMENT15
No specific antiviral treatment is available for acute HBV infection.
Interferon alpha, alone or in combination with other antiviral agents such as
lamivudine and famcylovir, has been beneficial in some of the chronic
Hepatitis. There is no effective treatment for the carrier state, though
spontaneous resolution takes place in some of them.
• Remove the serum or plasma from the clot of red cell as soon as
possible to avoid hemolysis. Only clear, non-hemolysed specimens
should be used.
ACON HBsAg
INTENDED USE
22
SUMMARY
Viral Hepatitis is a systematic disease primarily involving the liver. Most
cases of acute Hepatitis are caused by Hepatitis A virus, Hepatitis B virus or
Hepatitis C virus. The complex antigen found in the surface of HBV is called
HBsAg; previous designation included the Australian or Au antigen (1). The
presence of HBsAg will be detected 2-4 weeks before the ALT level becomes
abnormal and 3-5 weeks before systems or jaundice develop. HBsAg has four
principle subtypes: adw, ayw, adr, and ayr. Because of antigenic
heterogeneity of the determinant, there are 10 major serotypes of Hepatitis B
virus.
The ACON HBsAg One Step Test is a rapid test to qualitatively detect
the presence of HBsAg in serum or plasma specimens. The test utilizes a
combination of monoclonal and polyclonal antibodies to selectively detect
elevated levels of HBsAg in serum or plasma.
PRINCIPLE
The ACON HBsAg One Step Test is a qualitative, solid phase, two site
sandwich immunoassay for the detection of Hepatitis B surface Antigen
(HBsAg) in serum or plasma. The membrane is pre-coated with anti-HBsAg
antibodies on the test line region and anti-mouse antibodies on the control
region. During testing the serum or plasma samples reacts with dye conjugate
(mouse anti-HBsAg antibody-colloidal gold conjugate) which has pre-coated
in the test strip. The mixture migrated upwards on the membrane
chromatographically by capillary action to react with anti-HBsAg antibodies
on the membrane and generates a red line. Presence of this red line indicates
a positive result, while its absence indicates a negative result. Regardless of
the presence of HBsAg as the mixtures continues to migrate across the
membrane to the immobilized goat anti-mouse region, a red line at the
control region will always appear. The presence of this red line serves as
23
verification for sufficient sample volume and proper flow as a control for the
reagents.
REAGENTS
Test strip contains mouse anti-HBsAg antibody-colloidal gold conjugate and
polyclonal anti-HBsAg antibodies coated on the membrane.
PRECAUTIONS
1. For professional in vitro diagnostic use only. Does not use after the
expiration date?
2. Do not eat, drink and smoke in the area where the specimen and kits are
handled.
PROCEDURE17
24
Materials Provided:
• Test strip contains mouse Anti-HBsAg antibody-colloidal gold
conjugate and Polyclonal Anti-HBsAg antibodies coated on the
membrane.
• Instruction for use
1. Remove the ACON HBsAg test strip from the foil pouch (bring the test
to room temperature before opening the pouch). Use strip as soon as
possible but within 1 hour after removal from the pouch especially if
the room temperature is more than environment.
2. Immerse the test strip in the serum samples with arrows pointing
toward the serum or plasma.
3. Wait for red lines to appear. The test should be read in approximately
15 minutes. It is significant that the background is clear before reading
the test, and only a weak line appears in the test region (T). Do not
interpret results after 20 minutes.
INTREPRETATIONS OF RESULT
25
POSITIVE: Two distinct red lines will appear, one in the test region (T) and
other in the control region (C).
NEGATIVE: Only a single red line appears in the control region (C). No
apparent red or pink line appears in the test region (T).
NOTES: The shades of red in the test line region (T) will vary depending on
the concentration of HBsAg present. However, neither the quantitative value
nor the rate of increase in HBsAg can be determined by this qualitative test.
QUALITY CONTROL
26
LIMITATIONS
• ACON HBsAg test is for in vitro diagnostic use only .This test should
be used for the detection of Hepatitis B surface Antigen in serum or
plasma sample.
• This test will only indicate the presence of Hepatitis B surface antigen
in the specimen and should not be used as the sole criteria for the
diagnosis of Hepatitis B viral infection.
• As with all diagnosis tests, all results must be considered with other
clinical information available to the physician.
• ACON HBsAg test cannot detect extremely low concentration of
HBsAg in specimen. If the test result is negative and clinical symptoms
persist, additional follow-up testing using other clinical method is
required. A negative result at any time does not preclude the possibility
of Hepatitis B
PRINCIPLE
Same as in ACON HBsAg one step test since both are immune
chromatographic method for test for detecting HBsAg.
TEST PROCEDURE
1. Bring the required number of Hepacard pouches and specimen to room
temperature prior to testing.
27
2. Take out Hepacard device from the foil pouches. Zip seals the pouch
containing balance device so that they are protected from moisture.
Ensure the zip seal is perfectly locked; otherwise the devise will not
work properly.
3. Label the device with patient’s name or identification number.
4. Add 2 drops (10ul) of serum /plasma specimen into the sample well
using the dropper provided (use separate dropper/ microtip for each
Specimen)
5. Allow reaction to occur during the next 20 minutes.
6. Read reaction at 20 minutes.
7. Discard immediately after reading the result at 20 minutes ,considering
it to be potentially infectious
Fig 5
A total of 350 blood samples were collected and tested for HBsAg using
immune chromatographic test like ACON HBsAg one step test and hepacard
strip test. Out of these 200 samples were collected from Normal Healthy
persons who were all healthy adult males and females of age group 20-45. 50
Blood sample were healthy females of the reproductive age group attending
ante-natal clinics. The remaining 100 samples were from patients with viral
Hepatitis.
Table 3:
TOTAL 350
29
200
150
Normal Healthy
Pesrons
100
Women attending
ante-natal clinic
50
Patient with viral
Hepatitis
0
No. %Positivity
Screened
HBsAg %
Sr.No Study group No. Screened
Positivity Positivity
Normal Healthy
1. 200 1 0.5
Persons
Women attending
2. 50 0 0
ante-natal clinics
DISCUSSION
In the present study ACON HBsAg One step test and Hepacard test kit are
used .one out of 200 cases was found to be positive for HBsAg among
Normal Healthy Persons showing a prevalence of 0.5%.
Prevalence rate among women attending ante-natal clinic was found to be nil.
HBsAg is the first marker to appear in blood after infection, being detectable
even before elevation of transaminases and onset of clinical symptoms in the
typical case it did appears with in about two months of the start of clinical
disease but may sometimes last for 6 month or even beyond.
31
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