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DETECTING OCCULT HEPATITIS B WHEN TESTING DONATED BLOOD
Eremeeva ZhG1 Fazylov VH2
1 Republican Clinical Dermatovenerologic Dispensary, Kazan, Russia
2 Department of Infectius Diseases, Medico-Prophylactic Faculty, Kazan State Medical University, Kazan, Russia
Individuals carrying occult (latent) hepatitis B pose epidemiological threat. Testing donated blood donors for surface antigen HBsAg (hepatitis B virus, HBV) only does not allow to assume the blood safe from the point of view of infections, which can result in post-transfusion transmission of infection. Lack of confidence here is due to the fact that the virus is present in the body even when HBsAg is negative. The study analyzes data of 61,155 blood donors of the Republican Blood Center (Kazan), collected in 2010-2014. The tests applied were those aimed at detecting HBsAg, anti-HBc-total, anti-HBc IgM (enzyme immunoassay), and determining DNA of the virus in the blood by polymerase chain reaction in "real time". It was found that donors with occult hepatitis B are identified each year, but their numbers decrease gradually. To prevent the spread of the virus it is recommended to add the anti-HBc-total test to the standard set of diagnostic tests.
Keywords: occult hepatitis B, latent hepatitis B, HBV infection, donor, blood, enzyme immunoassay, PCR diagnostics, HBsAg, anti-HBc-total, anti-HBc IgM
Acknowledgements: authors thank Ramil Turaev from the Republican Blood Center (Kazan, Russia) for the opportunity to work with donor cards and Center's reports.
CR] Correspondence should be addressed: Zhanna Eremeeva
prospekt Pobedy, d. 39, kv. 91, Kazan, Russia, 420110; fin5zhannik@rambler.ru
Received: 01.02.2017 Accepted: 18.02.2017
ВЫЯВЛЕНИЕ ОККУЛЬТНОГО ГЕПАТИТА B ПРИ ТЕСТИРОВАНИИ ДОНОРСКОЙ КРОВИ
Ж. Г. Еремеева1 В. Х. Фазылов2
1 Республиканский клинический кожно-венерологический диспансер, Казань
2 Кафедра инфекционных болезней, медико-профилактический факультет, Казанский государственный медицинский университет, Казань
Эпидемиологическую опасность представляют лица с оккультным (латентным) гепатитом B. Исследование крови доноров только на поверхностный антиген вируса (hepatitis B virus, HBV) HBsAg не может обеспечить полную инфекционную безопасность крови, следствием чего может быть посттрансфузионная передача инфекции. Это объясняется тем, что вирус присутствует в организме даже при отрицательном HBsAg. В работе проанализированы данные 61 155 доноров Республиканского центра крови (Казань), полученные в 2010-2014 гг. Анализировали результаты тестирования на HBsAg, anti-HBc-total, anti-HBc IgM (методом иммуноферментного анализа) и определения ДНК вируса в крови (методом полимеразной цепной реакции в «реальном времени»). Установлено, что доноры с оккультным гепатитом B выявляются ежегодно, хотя и отмечена тенденция к снижению их числа. Для предотвращения распространения вируса в популяции рекомендуется ввести в стандарт диагностики HBV-инфекции определение маркера anti-HBc-total.
Ключевые слова: оккультный гепатит B, латентный гепатит B, HBV-инфекция, донор, кровь, иммуноферментый анализ, ПЦР-диагностика, HBsAg, anti-HBc-total, anti-HBc IgM
Благодарности: авторы благодарят Рамиля Тураева из Республиканского центра крови (Казань) за возможность работать с картами доноров и отчетными формами учреждения.
[X] Для корреспонденции: Еремеева Жанна Григорьевна
пр-т Победы, д. 39, кв. 91, г Казань, 420110; fin5zhannik@rambler.ru
Статья получена: 01.02.2017 Статья принята в печать: 18.02.2017
To avoid transmission of bloodborne infections from donor to recipient, it is imperative to ensure infectious safety of donated blood. Screening for hepatitis B (hepatitis B virus, HBV) helped to significantly reduce incidence of this infection [1]. However, despite availability of sensitive tests detecting HBV surface antigen (HbsAg), post-transfusion hepatitis B still occurs [2, 3]. This is due to the fact that the virus can lay dormant in liver tissue for a long time, and in some cases even in blood of HBsAg-negative patients [4, 5]. Therefore, occult (latent) hepatitis B is a risk factor in blood donation and organ transplantation [6]. There are documented cases of HBV DNA found in recipients that received Hbs-negative blood from donors who had occult
HBV. Thus, there is a real threat of spread of latent hepatitis B and its further activation in human body when the immunity is suppressed [5].
The goal of our study was detection of latent HBV at the stage of donated blood testing.
METHODS
The study was conducted at the Republican Blood Center (RBC) of the city of Kazan. Data obtained from testing 61,155 donors in 2010-2014 were analyzed, namely: HBsAg tests, anti-HBc-total tests, anti-HBc IgM tests, HBV DNA tests.
HBsAg, anti-HBc-total and anti-HBc IgM were identified by ELISA using commercial reagents made by Vector-Best (Russia), sensitivity of 0,01 ME/ml. HBV DNA was detected by polymerase chain reaction in real time using COBAS S 201 (Roshe, Switzerland) device and a set of Sobas TaqScreen MPX Test reagents, v2.0 and CobasTaqScreen MPX ControlKit, v.2.0 (Roche).
RESULTS
HBsAg is the screening marker for HBV-infection. Detection of this marker when testing donated blood confirms presence of active infection. Individuals with HBsAg are dismissed as donors and receive applicable treatment. In 2010-2014, Kazan's RBC registered 6 to 25 cases of marker detection per year (Fig. 1), the trend is downward.
Anti-HBc-total tests returned positive in 3.5-6.9 % of cases a year, which means that blood from 400 to 900 donors could not be used (Fig. 2). When this marker is detected, the blood is subject to anti-HBc IgM. In 2010-2014, M-class immunoglobulins were detected in 2.5-9.9 % of donated blood samples, with signs of latent HBV in donors' bodies (anti-Hbc-total positive samples) (Fig. 3). Anti-HBc IgM is the viral activity market that signals the need for detailed medical examination of the person.
301
2010
2011
2012 Year
2013
2014
Fig. 1. Positive screening tests (HBsAg) statistics, 2010-2014 14000 n 12000 10000 H
« o
■g 8000
o
® 6000 H
E
ZD
z 4000 2000 0
2010
HBV DNA in blood serum is the main indicator of viral replication. Approximately 20 % of cases require solely DNA diagnostics to reveal latent HBV since no other tests are capable of detecting it [7]. At RBC, PCR is performed in real time to confirm absence of infection in donors that showed negative results for classical markers. This extra blood test also helps to detect active forms of HBV in cases of latent hepatitis B (Fig. 4).
DISCUSSION
In Russia, far from all medical institutions test donated blood for antibodies to hepatitis B (using anti-HBc-total or anti-HBc IgM tests), which hinders timely detection of latent forms of HBV. Our findings allow concluding that absence of HBsAg does not guarantee infectious safety of donated blood, since a positive anti-HBc-total test indicates previous exposure to the virus and a positive anti-HBc IgM test signals an active infection.
HBsAg-negative phase can show low level of virus DNA in the body: it is detected in liver and rarely in serum [8]. That is why this phase does not mean full recovery, since a relapse can occur any moment [9, 10]. Patients with latent HBV were found to maintain effective immunological response (anti-HBc total), which can lead to reactivation of HBV and HBsAg reappearance [11].
The complications of detection of occult hepatitis B arise from non-mandatory character of tests for markers of latent HBV
100 1
80 -
60 -
40 -
20 -
2010
2011
2012 Year
2013
2014
Positive anti-HBc IgM test
Positive anti-HBc-total and/or HBsAG test
Fig. 2. Positive anti-HBc-total tests, 2010-2014
2011
2012 Year
2013
2014
I Number of donors with positive anti- HBc-total test results
Total number of donors
Fig. 3. Share of donors with M-class Immunoglobulin In blood, donors with positive anti-HBc-total and/or HBsAg tests, 2010-2014
0
40 "I
2010 2011 2012 2013 2014
Year
■ Positive anti-HBc-total and/or HBsAG test
■ HBV DNA detected
Fig. 4. Number of HBV DNA detection occurrences, donors with positive HBsAg and/or anti-HBc-total tests, 2010-2014
and further examination of the donor. Disease control center only receives information about donors with positive HBsAg tests. Timely implementation of preventive and anti-epidemic measures requires further medical examination and outpatient observation of individuals with anti-HBc-total and anti-HBc IgM in blood. Otherwise, use of blood from donors with occult hepatitis B increases the risk of transfusion transmission of HBV and its spread in the population [12, 13].
CONCLUSIONS
Donors with positive tests for HBV markers (HBsAg, anti-HBc-total, anti-HBc IgM, HBV DNA) are found every year. Introduction of anti-HBc-total test to the standard set of HBV diagnostic tests will increase the rate of detection of latent HBV [14, 15]. Setting up seamless workflow and cooperation between blood donation centers and other medical institutions will ensure early detection of active forms of infection and prevention of chronic process, and also help prevent infection of others.
References
1. Enticott JC, Kandane-Rathnayake RK. Prevalence versus incidence. Transfusion. 2012 Sep; 52 (9): 1868-70. DOI: 10.1111/j.1537-2995.2012.03687.x.
2. Saraswat S, Banerjee K, Chaudhury N, Mahant T, Khandekar P, Gupta RK, et al. Post-transfusion hepatitis type B following multiple transfusions of HBsAg-negative blood. J Hepatol. 1996 Nov; 25 (5): 639-43.
3. Satake M, Taira R, Yugi H, Hino S, Kanemitsu K, Ikeda H, et al. Infectivity of blood components with low hepatitis B virus DNA levels identified in a lookback program. Transfusion. 2007 Jul; 47 (7): 1197-205.4.
4. Ivashkin VT, Morozova MA, Maevskaya MV, Sokolina IA, German YeN, Bundina MV. [Risk factors of development of hepatocellular carcinoma]. The Russian Journal of Gastroenterology, Hepatology and Coloproctology. 2009; (1): 4-15. Russian.
5. Aleshkin VA, Zubkin ML, Selkova EP, Chervinko VI, Suslov AP, Ovchinnikov YuV, et al. [Epidemiological and clinical significance of "occult" HBV-infection]. Epidemiology and Infectious Diseases. Topical issues. 2015; (4): 55-64. Russian.
6. Fazylov VH. [Etiological and pathogenetic aspects of diagnosis and treatment, of viral hepatitis]. Kazan Medical Journal. 2013; (6): 785-92.
7. Hollinger FB. Hepatitis B virus infection and transfusion medicine: science and the occult. Transfusion. 2008 May; 48 (5): 1001-26. DOI: 10.1111/j.1537-2995.2008.01701.x.
8. Zerbini A, Pilli M, Boni C, Fisicaro P, Penna A, Di Vincenzo P, et
al. The characteristics of the cell-mediated immune response identify different profiles of occult hepatitis B virus infection. Gastroenterology 2008 May;134 (5): 1470-81.
9. World Gastroenterology Organisation. WGO Global Guideline — Hepatitis B. Version 2.0. 2015 Feb. Available from: http://www. worldgastroenterology.org/UserFiles/file/guidelines/hepatitis-b-english-2015.pdf.
10. Nechaev VV, Mukomolov SL, Nazarov VYu, Pozhidaeva LN, Chakharyan VV. [Chronic viral hepatitis: past, present and future]. Epidemiology and Infectious Diseases. 2013; (3): 4-10. Russian.
11. Raimondo G, Allain JP, Brunetto MR, Buendia MA, Chen DS, Colombo M, et al. Statements from the Taormina expert meeting on occult hepatitis B virus infection. J Hepatol. 2008 Oct; 49 (4): 652-7. DOI: 10.1016/j.jhep.2008.07.014.
12. Enaleeva DSh. [Modern aspects of the natural history of chronic hepatitis B-virus wi-B]. Kazan Medical Journal. 2012; 93 (2): 1616. Russian.
13. Enaleeva DSh, Fazylov VH, Sozinov AS. Khronicheskie virusnye gepatity B, C i D. Moscow: MED-press-infrom; 2011. 464 p. Russian.
14. Morozov IA, Ilchenko LYu, Fedorov IG, Gordeychuk IV, Gordeychuk IN, Knyazhentseva AK, et al [Hidden Hepatitis B: Clinical significance and problems of diagnostics]. Archive of Internal Medicine. 2012; (4): 39-45. Russian.
15. Gordeychuk IV, Malinnikova EYu, Popova OE. [The latent hepatitis B in patients with HIV infection]. World of Viral Hepatitis. 2008; (6): 3-7. Russian.
Литература
1. Enticott JC, Kandane-Rathnayake RK. Prevalence versus incidence. Transfusion. 2012 Sep; 52 (9): 1868-70. DOI: 10.1111/j.1537-2995.2012.03687.x.
2. Saraswat S, Banerjee K, Chaudhury N, Mahant T, Khandekar P, Gupta RK, et al. Post-transfusion hepatitis type B following multiple transfusions of HBsAg-negative blood. J Hepatol. 1996 Nov; 25 (5): 639-43.
3. Satake M, Taira R, Yugi H, Hino S, Kanemitsu K, Ikeda H, et al. Infectivity of blood components with low hepatitis B virus DNA levels identified in a lookback program. Transfusion. 2007 Jul; 47 (7): 1197-205.
4. Ивашкин В. Т., Морозова М. А., Маевская М. В., Соколи-на И. А, Герман Е. Н. Бундина М. В. Факторы риска развития
гепатоцеллюлярной карциномы. Российский журнал гастроэнтерологии, гепатологии и колопроктологии. 2009; (1): 4-15.
б. Алешкин В. А., Зубкин М. Л., Селькова Е. П., Червинко В. И., Суслов А. П., Овчинников Ю. В. и др. Эпидемиологическое и клиническое значение «оккультной» HBV-инфекции. Эпидемиология и инфекционные болезни. Актуальные вопросы. 2015; (4): 55-64.
6. Фазылов В. Х. Этиологические и патогенетические аспекты диагностики и лечения вирусных гепатитов. Казанский медицинский журнал. 2013; ( 6): 785-92.
J. Hollinger FB. Hepatitis B virus infection and transfusion medicine: science and the occult. Transfusion. 2008 May; 48 (5): 1001-26. DOI: 10.1111/j.1537-2995.2008.01701.x.
8. Zerbini A, Pilli M, Boni C, Fisicaro P, Penna A, Di Vincenzo P, et al. The characteristics of the cell-mediated immune response identify different profiles of occult hepatitis B virus infection. Gastroenterology 2008 May;134 (5): 1470-81.
9. World Gastroenterology Organisation. WGO Global Guideline — Hepatitis B. Version 2.0. 2015 Feb. Available from: http://www. worldgastroenterology.org/UserFiles/file/guidelines/hepatitis-b-english-2015.pdf.
10. Нечаев В. В. Мукомолов С. Л., Назаров В. Ю., Пожидае-ва Л. Н., Чахарьян В. В. Хронические вирусные гепатиты: прошлое, настоящее, будущее. Эпидемиология и инфекционные болезни. 2013; (3): 4-10.
11. Raimondo G, Allain JP, Brunetto MR, Buendia MA, Chen DS, Colombo M, et al. Statements from the Taormina expert meeting on occult hepatitis B virus infection. J Hepatol. 2008 Oct; 49 (4):
652-7. Р01: 10.1016Zj.jhep.2008.07.014.
12. Еналеева Д. Ш. Современные аспекты естественного течения хронического вирусного гепатита В. Казанский медицинский журнал. 2012; 93 (2): 161-6.
13. Еналеева Д. Ш., Фазылов В. Х., Созинов А. С. Хронические вирусные гепатиты В, С и Р. М.: МЕДпресс-информ; 2011. 464 с.
14. Морозов И. А., Ильченко Л. Ю., Федоров И. Г., Гордей-чук И. В., Гордейчук И. Н., Княженцева А. К. и др. Скрытый гепатит В: клиническое значение и проблемы диагностики. Архив внутренней медицины. 2012; (4): 39-45.
15. Гордейчук И. В., Малинникова Е. Ю., Попова О. Е. Латентный гепатит В у пациентов с ВИЧ-инфекцией. Мир вирусных гепатитов. 2008; (6): 3-7.
