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 Table of Contents  
Year : 2016  |  Volume : 14  |  Issue : 4  |  Page : 149-152

Impact of dual hepatitis B and C infection on disease severity and treatment outcome: updated review

Department of Endemic Hepatogastroenterology, Faculty of Medicine, Cairo University, Giza, Egypt

Date of Submission09-Feb-2016
Date of Acceptance04-Jul-2016
Date of Web Publication23-Jun-2017

Correspondence Address:
Tamer Elbaz
Associate Professor Endemic Hepatogastroenterology, Endemic Hepatogastroenterology Department, Faculty of Medicine, Cairo University
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1687-1693.208929

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Hepatitis B, C are commonly present together. They both share same routes of transmission. Dual infection carries a wide, variable range of virological, clinical profiles. Even in terms of management, large debates arose due to related issues such as priority for treatment, fate of the second virus if the primary one is eradicated.

Keywords: hepatitis B, hepatitis C, dual, dual infection

How to cite this article:
Esmat G, Elbaz T. Impact of dual hepatitis B and C infection on disease severity and treatment outcome: updated review. Al-Azhar Assiut Med J 2016;14:149-52

How to cite this URL:
Esmat G, Elbaz T. Impact of dual hepatitis B and C infection on disease severity and treatment outcome: updated review. Al-Azhar Assiut Med J [serial online] 2016 [cited 2021 Apr 18];14:149-52. Available from: http://www.azmj.eg.net/text.asp?2016/14/4/149/208929

  Introduction Top

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are two hepatotropic viruses that cause chronic liver diseases and consequent serious sequelae. In high endemic areas and among people with a high risk for parenteral infections, combined infection with both viruses is frequent and not uncommon [1]. High-risk populations include intravenous drug users (IDUs), patients undergoing regular hemodialysis, and recipients of organ transplantations [2].

  Epidemiology Top

The WHO announced that more than 500 million individuals are chronically infected with HBV or HCV worldwide [3]. Chronic HCV patients of 2–10% are positive for hepatitis B surface antigen (HBsAg) and 5–7% of HBV patients are positive for HCV antibody (HCV-Ab) [2],[4]. In other words, it is estimated that dual infection is present in 3.5–7 million individuals (among 350 million HBV carriers). True incidence may be higher if occult HBV infection is taken into consideration [5].

In the USA, Tyson et al. [1] conducted a large cohort study and found a prevalence of 1.4% for overt HBV infection in HCV-positive patients, and one-third of the study population showed positivity for antibodies directed to HBV antigens. In Egypt, a study found that occult HBV infection occurred in 3.9% of chronic HCV genotype four patients and tended to be associated with higher baseline HCV viral load as well as younger age patients and less hepatic fibrosis [6].

Focused on certain high-risk groups, eligible reports detected a high prevalence of HCV-Ab among IDUs that can reach even more than 80%. An estimate of 10 million IDUs could be positive for HCV-Ab. As regards HBsAg, reports estimated an incidence ranging from 5 to 10% in certain countries and more than 10% in others with an estimate of 6.4 and 1.2 million IDUs being positive for anti-HB core and HBsAg, respectively [7].

  Virological and clinical spectra of dual infection Top

In clinical practice, coinfection with both viruses is usually identified by the seropositivity for HBsAg and HCV-Ab. Consequent detection of viral genomes (essentially HCV RNA) is important to confirm the current status of coinfection. In cases of acute hepatitis, three different scenarios are proposed: (a) first time exposure to both viruses simultaneously; (b) HCV superinfection for a chronic HBsAg carrier patient; and (c) HBV superinfection for a chronic HCV-positive patient. In these three situations, all subsequent outcomes can occur from complete recovery from one or both viruses up to fulminant liver cell failure and death [3].

Another clinical form is coinfection of HCV with occult HBV. Occult HBV is the presence of HBV DNA in HBsAg-negative individuals and could be either seronegative or seropositive for anti-HBc IgG with a higher predominance of seropositivity. It may need intrahepatic assessment of HBV DNA [8]. Impact of occult HBV on HCV infection is highly variable [9].

As both infections are rather acquired through blood and blood products, this dual infection can be triple if associated with hepatitis D virus or HIV [10]. Quadruple infection is also possible (HBV, HCV, hepatitis D virus, and HIV) [11],[12],[13].

An extremely wide and different spectrum of virological profiles can be detected and were previously documented in cases of dual HBV and HCV infections [14]. Early in-vitro studies declared that HCV core protein strongly inhibits the replication of HBV [15],[16]. As HCV generally suppresses HBV, studies found hepatitis B e antigen seroconversion as well as HBsAg seroclearance in chronic HBV patients who were superinfected with HCV [17],[18].

However, other studies reported that HCV RNA levels significantly decreased in some dually infected patients when HBV DNA in serum was detected compared with PCR-negative patients for HBV [19]. A dominant effect of HBV even led to higher rates of HCV RNA clearance [20]. Recent in-vitro studies used full-length HBV genomes and HCV replicons detected possible dual replications of both viruses in same hepatocytes without any evidence of overt interference, either in cases of simultaneous coinfection or superinfection [21],[22]. Specific inhibition of one virus has not led to affection of replication or gene expression of second virus [22]. From previous evidence of extremely variable virological profiles, it is truly possible that dominance of one of the two viruses may alternate and change at different periods during the infection. Even more, suppression of the dominant virus can lead to reactivation of the other virus [23].

In terms of clinical outcomes of dual infection, studies were similarly debatable. Many studies studied the increased severity of liver disease compared with infection by a single virus. A higher prevalence of liver cirrhosis and hepatic decompensation dominated in dual rather than monoinfection [17],[19],[24],[25],[26],[27],[28],[29]. A study found increased prevalence of HCV-Ab with severity of chronic HBV infection. HCV-Ab was detected in 8% of chronic HBV infection; it was detected in 10 and 17% of patients who suffered from HBV-related cirrhosis and HBV-related hepatocellular carcinoma (HCC), respectively [30]. Studies also reported that serum alanine aminotransferase and histological activity as well as liver cirrhosis were more common in chronic HCV patients associated with occult HBV infection with a documented synergistic action of both viruses together in progression of liver disease [31],[32],[33].

In contrast, Sagnelli et al. [34] reported the absence of association between occult HBV and degree of liver necro inflammation and fibrosis in chronic HCV patients. Similar conclusions were similarly reported by other studies [8],[35],[36],[37],[38],[39].

Different studies debated the issue of impact of dual infection on the development of HCC. The Hepatitis Antiviral Long-Term Treatment against Cirrhosis (HALT-C) prospective trial followed up chronic HCV patients and advanced liver fibrosis patients for different clinical outcomes. They found no significant difference in the prevalence of serum anti-HBcore or HBV DNA between patients who developed HCC and those who did not develop it. They highlighted that neither previous nor occult HBV infection is related to HCC development among chronic advanced HCV patients [40]. In contrast, another study evaluated the development of HCC in patients who suffered from dual infection versus patients who suffered from HBV or HCV monoinfection. HCC was more frequently documented in dually infected patients (14%) as compared with 2 and 4% of patients who developed malignancy on top of chronic HBV and HCV infections, respectively [41]. A meta-analysis study reported a statistically significantly higher relative risk for HCC in cases of dual infections [odds ratio (OR)=165] compared with HBV (OR=22.5) and HCV (OR=17.3) monoinfected patients. Moreover, another study found that some dually infected patients still develop HCC after achieving HCV-sustained virologic response (SVR) and even HBsAg seroclearance after treatment [42].

Another form of clinical interference is the impact of chronic HCV infection on response to HBV vaccination. Generally, studies declared a poor response rate to vaccination in HCV-infected patients compared with normal healthy individuals and those who were spontaneously resolved from HCV infection [43],[44],[45].

Finally, it looks that single-point evaluation of viral genomes of both viruses does not provide a reliable and definite conclusion about the impact of each virus. As such, repeated evaluation is necessary for proper assessment before specific treatments, during their therapies, and thereafter follow-up after treatments [3],[46].

  Treatment response Top

Treatment of dual infection is a real challenge. Many studies tried to answer many pending questions such as priority of treatment and fate of second virus after treatment of the primary one.

Treatment priority can be addressed through determination of the relative viral activity of both hepatitis viruses. In addition, response to antiviral therapy is an important factor. Active hepatitis C can be successfully managed and is documented as the dominant affecting virus in 70% of dually infected patients [14]. This is the reason for the priority to treat HCV in the majority of cases.

Several studies reported a good response rate of HCV in dually infected patients that was comparable to rates in monoinfected patients treated for HCV. A large multicenteric study that was conducted in Taiwan documented 72.2% SVR in dually infected patients with genotype 1 HCV versus 77.3% in monoinfected HCV patients. Moreover, they reported 82.8% SVR in genotypes 2/3 infections versus 84%. They used pegylated interferon and ribavirin [26]. Similar findings were reported when treating HCV in occult HBV-infected patients [35],[47],[48],[49], whereas some studies reported contradictory results [50],[51],[52]. This difference in findings may be attributed to the type of treatment, different protocols, HBV status, and types of HCV genotypes treated.

Fate of HBV in dually infected patients who are successfully managed for HCV is an important concern. Reactivation of HBV and its replication is a common observation [53],[54],[55]. However, a study reported HBV virologic response with same HCV treatment using pegylated interferon-based therapy in 56% of dually infected patients. HBsAg clearance was seen in 11.2% of patients, whereas other patients suffered from reappearance of HBV DNA and elevation of ALT levels [5]. However, certain studies concluded a maintenance of HBV status independent of HCV response to treatment [23],[56].

  Conclusion Top

Dual infection carries many debatable issues either in virological and clinical patterns, treatment responsiveness or prioritization to treatment. Mostly, the behavior of each virus looks to be independent with somewhat points of interactions. Serial evaluation at different times for the virological status of both viruses is crucial.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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