Hepatitis B virus (HBV) infection is very common, with over 350 million chronically infected people worldwide. This review plans to answer some key questions regarding hepatitis B infection during pregnancy, in order to provide healthcare professionals with updated information on the current knowledge in this field. The focus is on the following topics: the main risk factors associated with vertical transmission of HBV in pregnant women who are chronically infected, the influence of pregnancy on HBV viral load, and the effect of pregnancy on the clinical course of chronic hepatitis B. Some recommendations have also been made that may be effective in decreasing the vertical transmission rates of chronic viral hepatitis.

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Background: Hepatitis B is a major health problem in India. To prevent transmission and progression of the disease in the community, proper community awareness about the disease, including prevention, is necessary. Our objective was to study the awareness amongst the general population about hepatitis B virus, including knowledge regarding vaccine. Materials and Methods: The study was conducted in Department of Gastroenterology of SCB Medical College. The patients attending the OPD and their attendants were subjected to a questionnaire about different aspects of hepatitis B. Binary logistic regression analysis (SPSS 16) was employed to assess the statistical importance of the observations. Results: In all, 682 individuals (65% patients, 35% non-patients) were studied; 78% were males while 22% were females. Majority were in the age group of 31-40 years. 65% hailed from rural area; 65% were poor. About half of the subjects attended state run medical centers for medical attention; only 17% preferred medical colleges. Awareness about the disease and the vaccine among the subjects was 38% and 32%, respectively. 50% of those who were aware had no knowledge about route of transmission, infectivity, or importance of vaccination. Educated individuals were more aware about hepatitis B vaccine (P < 0.05). Those who read newspaper and listened to radio were more aware about hepatitis B (P < 0.05), and its vaccine (P < 0.05). The percentage of vaccination was 20% among study subjects, but in 30%, their children were vaccinated. The common reason for non-vaccination was lack of awareness (50%); of them, 60% blamed government/doctors/media for their ignorance. Majority (56%) received the vaccine from government hospitals or health centers. Only (10%) obtained vaccination from private centers. Reasons cited for non-vaccination included ignorance (50%), carelessness (12%), high cost (10%), and nonavailability (6%). Source of information regarding hepatitis B included television (75%), newspapers (55%), and radio (26%). Conclusions: Only about one-third of the population in coastal Eastern India are aware about hepatitis B and its vaccine. Less than a third of the population are vaccinated for hepatitis B. The educated, especially those who read newspapers and listened to radio, were more aware about the disease/vaccine. The government health agencies and physicians should work together to educate the masses about hepatitis B and its vaccine.

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About two billion people worldwide have been infected with the hepatitis B virus and about 350 million live with chronic infection. Besides, an estimated 600 000 persons die each year due to the acute or chronic consequences of hepatitis B. The course of HBV infection is a dynamic process and is influenced by many factors including viral, host, and exogenous factors. Clinical suspicion of acute viral hepatitis usually does not necessitate biopsy; however, persistence of clinical symptoms or biochemical evidence of hepatotrophic viral infection for more than six months duration necessitates a liver biopsy - in several instances to primarily establish the histopathological diagnosis, to grade and stage the hepatic changes (determine management and prognosis), to document the severity and extent of the hepatic inflammation, as a guide to therapy or to monitor the changes of liver histology while on treatment. Moreover, improvement in liver histology can be used as an endpoint in clinical trials for new forms of therapy. Additionally, in some cases there is considerable clinical overlap between the states of exacerbation of chronic hepatitis and acute hepatitis. Biopsy is helpful in these cases too. Nevertheless, it must be mentioned that with the current trends and various guidelines, the indications for liver biopsy in chronic hepatitis B are somewhat reduced. It is hoped that with non-invasive markers the number of liver biopsies will reduce further. This article provides an overview of the histopathology of chronic hepatitis B virus infection.

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Hepatitis B virus (HBV) infects approximately more than 350 million people worldwide, especially in Asia, Africa, southern Europe and Latin America. Except for interferon-α, most anti-HBV drugs are derived from the anti-herpes and anti-HIV drugs. Because of the high cost of hepatitis B medications, herbs-also called 'complementary and alternative therapies' in modern Western science-are widely used for treatment of chronic hepatitis B in developing countries. Herbals confer their activities not only by inhibiting HBV secretion but also by building up immunity against viruses. After studying the anti-HBV mechanism of herbs, scientists were encouraged to find that novel anti-HBV drugs target viral secretion, whereas nucleoside analogues target viral polymerase. The complementary and alternative anti-HBV therapies published in scientific peer-reviewed journals are reviewed and discussed in this article.

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Healthcare personnel, especially medical students, represent a high risk population for Hepatitis B Virus (HBV) infection. Hepatitis B is the most important infectious occupational hazard which Indian medical students and healthcare workers (HCWs) encounter. The medical students and HCWs all over the world do not practice universal precautions on a routine basis and there exists the widely prevalent problem of under reporting of percutaneous and mucocutaneous exposures and a lack of awareness about the disease transmission, its consequences and the importance of adhering to universal precautions at all times. This further compounds the issue of safety of student HCWs. This article highlights the dismal scenario vis-ΰ-vis awareness about these risks and HBV prophylaxis amongst medical students from a student's perspective and suggests how to tackle the situation to protect the unfortunate medical students from an unwarranted predicament.

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Hepatitis B virus is a microorganism formed in the excess of surface antigen which is devoid of nucleic acid. Surface antigen of HBV was from the beginning the natural candidate for the vaccine which was thus produced by isolation of plasma HBsAg and later substituted by recombinant protein(s). The Extended Program of Immunization was beneficial for the reduction of HBV incidence in the populations of many participating countries. It is further postulated that HCC incidence in the world was also reduced at least in the portion caused by hepatitis B virus. Persistence of anti-HBV immunity was first measured by quantitative anti-HBs assay determined at 1 month post vaccination cycle, and then at different time points, even up to 12-15 years. The frontier of 10 IU/L (mIU/ml) is a mark of sustained immunity. However, cellular immunity studies revealed that this kind of response is very important in the defense against the virus and may last longer than the detectable antibodies. It was shown that 'full' surface vaccines, i.e. preS+S, may give stronger immunity and are good even for neonates. The next generation vaccines are DNA-based and plant-based HBV vaccines. This last category raises many hopes and with sufficient immunogenicity could ensure the most comfortable route of administration.

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Background and Aim: Hepatitis B virus (HBV)-related liver disease is not an uncommon problem in India. There are very few reports on pattern of chronic HBV infection from South India. The aim of the present study was to determine the spectrum of chronic HBV infection among patients attending the liver clinic in a tertiary referral center. Materials and Methods: Hepatitis B surface antigen (HBsAg) positive patients registered in the liver clinic between July 2010 and March 2011 were included in the study. All patients had baseline liver function tests, serological markers for HBV infection (hepatitis B e antigen [HBeAg], anti-HBe, anti-HBc total, and anti-HBc IgG, and HBV DNA quantification), serum alpha-fetoprotein, and ultrasound. Based on the viral profile and transaminase levels and ultrasound findings, patients were categorized as immunotolerant, inactive carriers, immune clearance and reactivation phase, and chronic liver disease with or without hepatocellular carcinoma. Results: Majority of the patients were asymptomatic and incidentally detected during blood donation camps, master health checkup (MHC), or during initial screening. Almost 40% of patients were either in immune inactive phase or had features of chronic liver disease. In the immunotolerant phase (24 patients), women were a decade younger than their male counterparts. Alanine aminotransferase (ALT) levels were similar in both HBeAg-positive and negative patients. The mean HBV DNA values were significantly high in HBeAg-positive men and women. In the immune inactive phase (58 patients), there were only three patients who were HBeAg positive. The ALT levels were in the normal range. HBV DNA values were low or not detectable. Among patients with elevated ALT and HBV DNA levels (immune clearance/immune reactive) (fifty patients), the mean ALT levels were higher in HBeAg-negative patients. HBV DNA quantity was significantly high in patients who were HBeAg positive. Conclusion: A significant proportion of HBsAg-positive patients is in inactive or in immunotolerant phase and do not require treatment. Patients with elevated ALT and HBV DNA levels need further evaluation to categorize them into immune clearance or immune reactive phase.

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Aim: To evaluate the occurrence of Hepatitis B surface antigen positivity in family members of HBsAg-positive patients, to assess the profile of HBV infection in them, to identify possible risk factors in a close family environment, and to evaluate the burden of liver disease in these family members. Materials and Methods: All Hepatitis B surface antigen-positive patients who attended the Liver Clinic of the Gastroenterology Department of the Calicut Medical College, from January 2009 to December 2010, were studied. The index case was evaluated with HBeAg, anti HBeAb, HBV DNA, liver function tests (LFTs), ultrasonogram of the abdomen, and alpha fetoprotein, as also liver biopsy in indicated cases. The index patient was interviewed and a detailed history with special emphasis on probable risk factors was taken. All first-degree relatives and relatives staying in the same house of the index case were screened for HBsAg. The relatives who tested negative for the infection were advised HBV vaccination, while the relatives who tested positive were evaluated for disease activity using LFTs, HBeAg, anti-HBeAb, HBV DNA, ultrasonogram of abdomen, alpha fetoprotein, and biopsy as per indication. Results: There were 376 index cases available for the study, 230 males (61.17%) and 146 females (38.83%). Male : Female ratio was 1.57 : 1. Mean age was 32.8 years (range 6-76). Seventy-six persons (20.21%) were detected to be HBsAg-positive during various preprocedural screenings, 42 (11.17%) were detected during medical checkup for jobs in gulf countries, and 30 (7.98%) were detected during screening for blood donation. Among the female patients, 88 (60.27%) were detected during antenatal screening. Ninety-six patients (25.53%) did not turn up after the initial visit. Among the remaining 280 patients, 48 (17.14%) were HBeAg positive. LFT abnormalities were seen in 153 (54.64%) cases. Out of 280 patients, 46 (16.43%) had established cirrhosis and 10 (3.57%) had HCC. Twenty-one cases (7.5%) presented as acute hepatitis. Complete family screening was done for 173 (61.78%) index cases. Out of the 280 index cases, 47 (16.79%) patients were reluctant for family screening. Among the 173 cases whose family members were screened, 95 (54.91%) had at least one family member who was HBsAg positive. Among the 95 index cases with at least one family member affected, 25 (26.31%) were HBeAg positive . On HBsAg screening of the relatives, it was found that brothers were affected in 45 (26.01%), sisters in 33 (19.08%), mothers in 18 (10.40%), fathers in 19 (10.98%), sons in nine (6.08%), and daughters in two (1.35%) cases. Ten (5.78%) index cases had second-degree relatives affected. Among a total of 173 index cases screened, 148 were married and among them 4.72% of the spouses were found to be HBsAg positive on screening. A total of 1115 family members of the 173 index cases were screened, of whom 162 (14.53%) were HBsAg positive. Of the 162 family members who were HBsAg positive, complete evaluation to find the stage of liver disease was performed in 43 family members. Among them 31 (72.09%) had LFT abnormality, four (9.3%) had underlying cirrhosis, and one had HCC. Twelve cases (27.9%) were HBeAg positive. Even though HBV screening was advised for all family contacts of the index cases, there was not much enthusiasm among the patients to get their relatives screened. Conclusion: The occurrence of hepatitis B positivity among family members of HBsAg-positive patients was 14.53% in our study. This prevalence was twenty-eight times more than the community prevalence of HBV infection in our population, which was earlier found to be 0.52% by our group. Brothers and sisters were the most commonly affected group, as against mothers who were positive for HBsAg, only 11.3%. Hence, the infection among siblings and parents may also be due to horizontal transmission. Index cases of 16.79% were totally reluctant for family screening due to various reasons like social stigma, high cost of the investigations, and reluctance to believe that they were having a problem, because they were asymptomatic. In view of the very high occurrence of HBV infection in family members, there is an urgent need for better counseling and vigorous screening of family members, to identify asymptomatic cases in the community and target this pool for curative as well as preventive measures.

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HBV infection is a major public health problem. Acute viral hepatitis B is successfully cleared in more than 95% of immunocompetent patients. HBV infection can cause severe acute hepatitis which can progress to acute liver failure. The purpose of this review is to discuss the immune response in acute hepatitis B and the possible role of HBV genotypes in development of severe acute HBV related hepatitis, define severe acute hepatitis B and to look at the role of the available antivirals in this clinical setting.

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Hepatitis B is a global healthcare problem. An estimated one third of the global population have been infected with the hepatitis B virus (HBV). Various guidelines have been proposed for management of chronic hepatitis B. These guidelines have similarities and differences and are changed from time to time. Here, we have reviewed the management guidelines of chronic hepatitis B published after 2007 and highlighted the similarities and differences between their different recommendations.

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There is a high global prevalence of hepatitis B. Perinatal transmission of hepatitis B is the predominant mode of transmission in high prevalence areas. The risk of progression to chronic liver disease and development of hepatocellular carcinoma in individuals who acquire the infection at birth is high. Perinatal transmission of hepatitis B can be reduced by early identification of hepatitis B virus (HBV) carrier mothers. High maternal viral loads and maternal serum HBeAg positivity increase the risk of perinatal transmission of hepatitis B. Passive and active immunoprophylaxis at birth reduces the risk of perinatal transmission of hepatitis B in approximately 95%. Failure of immunoprophylaxis has been related to possible in utero transmission of HBV. Reducing maternal HBV DNA levels by treatment with lamivudine in the last trimester of pregnancy in high viremic mothers may help reduce the risk of perinatal transmission of hepatitis B.

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Hepatitis B is a well-recognized global public health problem. It is estimated that nearly 2 billion people around the world have serologic evidence of past or present hepatitis B virus (HBV) infection, while 350 million people are chronically infected. This worldwide burden of hepatitis B mandates accurate and timely diagnosis of patients infected with HBV and the use of treatment strategies derived from evidence-based guidelines. HBV is a DNA virus that produces a series of viral protein products. Serologic and nucleic acid testing are critical to disease prevention and treatment objectives. Information from such testing helps determine patients' infectivity and immune status, appropriate monitoring strategies, and the efficacy of treatment, as well as providing data that contributes to a better understanding of the natural history and epidemiology of the disease. This article reviews the clinical use of serologic and nucleic acid tests as markers of disease activity.

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Hepatitis B vaccine can induce transient hepatitis B surface antigen positivity not only in adult hemodialysis patients but also in normal adults and children. Hence hepatitis B vaccinees may be mistaken for confirmed hepatitis B surface antigen-positive carrier. Hence blood donors should not donate blood in this early post-vaccination period and renal dialysis patients should not be screened for hepatitis B surface antigen for at least 21 to 28 days after hepatitis B vaccination. These guidelines could prevent individuals in the early post-inoculation period from being erroneously labeled as having hepatitis B viral infection.

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In the nineties, lamivudine (LMV) was the first nucleoside analog to be marketed for the treatment of patients with chronic hepatitis B virus (HBV). Following the advent of LMV, the management of patients with chronic hepatitis B, particularly those with advanced liver disease was markedly improved, with a substantial reduction in the rates of liver-related complications and mortality. In the face of excellent safety profile records of the drug, hepatologists had to face for the first time the issue of high rates of HBV resistance to therapy as the result of years of treatment of large cohorts of patients in the West and East. Initially considered no more than a virological problem, LMV resistance was later recognized to be a relevant clinical issue whose management requires specific therapeutic strategies. New, more active oral analogs have been marketed since, and new agents are to appear in the market scenario in the near future; however, LMV is still the number one prescribed anti-HBV agent worldwide for the treatment of chronic HBV patients, due to its limited cost, excellent safety and well predicted resistance profile.

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Delta hepatitis or hepatitis D leads to acute and chronic liver disease in humans. The causative agent, the hepatitis delta virus (HDV), is a defective virus which leads to hepatitis in humans in the presence of the hepatitis B virus. This helper function of HBV is required for transmission and propagation of HDV infection but not for replication. HDV RNA replication occurs through the double-rolling circle model and does not possess a reverse transcription step. Hepatitis D-induced liver disease is immune-mediated and occurs either as co-infection of both viruses or as superinfection of a hepatitis B carrier with hepatitis D. Based on a sequence variation of 19-38%, to date seven genotypes of HDV have been described. HDV infection has declined significantly in many endemic areas in the last decades, however, due to migration to industrialized countries, this decline appears to have reached a plateau in western countries. The clinical course of delta hepatitis in general is associated with rapid progression. Delta hepatitis may be an additional risk factor for the development of hepatocellular carcinoma. The only established management for delta hepatitis consists of treatment with interferon for a period of at least one year. For those unresponsive to interferon treatment and patients with advanced disease new therapies are an urgent need. Such therapies may be on the horizon but translation of bench work to clinical practice is required.

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Hepatitis B virus (HBV) cross-infection during endoscopy is rare. Most of the reported cases have occurred when the endoscope reprocessing was inadequate. Standard reprocessing of endoscopes and accessories is sufficient to prevent HBV transmission.

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Malnutrition is prevalent in all forms of liver diseases. A number of factors contribute to malnutrition in patients with hepatic failure. Early diagnosis of malnutrition is essential to allow appropriate treatment, since malnutrition is an important predictor of complications of liver disease and mortality. Disease-specific nutritional therapy should be considered for acute liver failure, sepsis, transplantation, and encephalopathy. This article provides an overview of the nutritional management of acute and chronic liver disease and discusses the need for further intervention studies before appropriate rational treatment guidelines can be formulated.

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Approximately 400 million people worldwide are chronically infected with the hepatitis B virus (HBV). Chronic infection with HBV can lead to progressive liver diseases including cirrhosis, liver failure, and hepatocellular carcinoma. During treatment of chronic hepatitis B (CHB) patients, flares of inflammatory activity are a well known phenomenon. Flares can be life threatening but have also been associated with virological response. While, interferon induced flares have been attributed to the stimulatory effect of IFN, and may precede HBeAg seroconversion, Lamivudine related flares are seen during treatment and after withdrawal of lamivudine, which are probably caused by reoccurrence of HBV replication, and have been associated with decompensation of liver disease. These flares play an important role in the treatment with Peg-IFN α-2b alone or in combination with lamivudine, and patients with pre-existing cirrhosis are at greater risk for experiencing a flare. Furthermore, host induced flares but not virus induced flares may herald a response to therapy. For optimisation of treatment, it is necessary to understand the virological and immunological mechanisms which induce the specific flare patterns. This article reviews the pathogenesis, significance and management of flares encountered during and after cessation of treatment of patients with chronic HBV infection.

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The literature on hepatitis B virus (HBV) in immunocompromised patients is heterogeneous and refers mainly to the pre-antivirals era. Today a rational approach to the problem of hepatitis B in these patients provides for: a) the evaluation of HBV markers and of liver condition in all subjects starting immunosuppressive therapies (baseline), b) the treatment with antivirals (therapy) of active carriers, c) the pre-emptive use of antivirals (prophylaxis) in inactive carriers, especially if they are undergoing immunosuppressive therapies judged to be at high risk, d) the biochemical and HBsAg monitoring (or universal prophylaxis, in case of high risk immunosuppression) in subjects with markers of previous contact with HBV (HBsAg-negative and antiHBc-positive), in order to prevent reverse seroconversion. Moreover it is suggested a strict adherence to the criteria of allocation based on the virological characteristics of both recipients and donors in the general setting of transplants, and in liver transplantation the universal prophylaxis with nucleos(t)ides analogues (frequently combined with specific anti-HBV immunoglobulins) in HBsAg-positive candidates and in HBsAg-negative recipients of antiHBc-positive grafts should be adopted.

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Nonalcoholic fatty liver disease [NAFLD] has rapidly emerged as the most common liver disorder not only in developed countries, but also in the developing countries. This entity encompasses a wide variety of liver abnormalities ranging from plain hepatic steatosis through nonalcoholic steatohepatitis [NASH] to cirrhosis of the liver and hepatocellular carcinoma [HCC]. NAFLD is now recognized as the hepatic manifestation of insulin resistance [IR], and an important marker of the metabolic syndrome [MS]. Although a number of advances have been made in elucidating the pathogenetic mechanisms involved in the causation and perpetuation of NAFLD, a great many unanswered questions remain unresolved yet. In view of the involvement of so many different pathways in the pathogenesis, there has always been a speculation regarding the interaction between NAFLD and other liver diseases especially chronic hepatitis C [CHC] and chronic hepatitis B [CHB], because of theubiquitous distribution of NAFLD and its common association with other liver diseases.

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