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BackgroundHepatitis B virus is hyperendemic in Sudan. Our aim was to molecularly characterize hepatitis B virus from Sudanese individuals, with and without liver disease, because genotypes play an important role in clinical manifestation and treatment management.MethodsNinety-nine patients - 30 asymptomatic, 42 cirrhotic, 15 with hepatocellular carcinoma, 7 with acute hepatitis and 5 with chronic hepatitis- were enrolled. Sequencing of surface and basic core promoter/precore regions and complete genome were performed.ResultsThe mean ± standard deviation, age was 45.7±14.8 years and the male to female ratio 77:22. The median (interquartile range) of hepatitis B virus DNA and alanine aminotransferase levels were 2.8 (2.2-4.2) log IU/ml and 30 (19–49) IU/L, respectively. Using three genotyping methods, 81/99 (82%) could be genotyped. Forty eight percent of the 99 patients were infected with genotype D and 24% with genotype E, 2% with putative D/E recombinants and 7% with genotype A. Patients infected with genotype E had higher frequency of hepatitis B e antigen-positivity and higher viral loads compared to patients infected with genotype D. Basic core promoter/precore region mutations, including the G1896A in 37% of HBeAg-negative individuals, could account for hepatitis B e antigen-negativity. Pre-S deletion mutants were found in genotypes D and E. Three isolates had the vaccine escape mutant sM133T.ConclusionSudanese hepatitis B virus carriers were mainly infected with genotypes D or E, with patients infected with genotype E having higher HBeAg-positivity and higher viral loads. This is the first study to molecularly characterize hepatitis B virus from liver disease patients in Sudan.

Hepatitis virus infections are the most common cause of liver disease worldwide. Sudan is classified among the countries with high hepatitis B virus seroprevalence. Exposure to the virus varied from 47%–78%, with a hepatitis B surface antigen prevalence ranging from 6.8% in central Sudan to 26% in southern Sudan. Studies pointed to infection in early childhood in southern Sudan while there was a trend of increasing infection rate with increasing age in northern Sudan. Hepatitis B virus was the commonest cause of chronic liver disease and hepatocellular carcinoma and was the second commonest cause of acute liver failure in the Sudan. Studies of hepatitis C virus showed a low seroprevalence of 2.2%–4.8% and there was no association with schistosomiasis or with parenteral antischistosomal therapy. Hepatitis E virus was the commonest cause of acute hepatitis among pediatric, adult, and displaced populations. Recent introduction of screening of blood and blood products for hepatitis B virus and hepatitis C virus infections and the introduction of hepatitis B virus vaccine as part of the extended program of immunization is expected to reduce the infection rate of these viruses in the Sudan.

Evidence of HBV infection was detected in 26.8% of HIV patients with HBsAg-negative infection, with viraemia detected in 15.1% of the patients. All HIV-infected patients should be screened carefully for HBV infection with HBsAg and anti-HBc IgG antibodies prior to starting antiretroviral therapy.

In HBV/HIV co-infected Sudanese patients, the ratio of genotype A to non-A was higher than that in mono-infected patients. The genotype E intra-group divergence in HBV/HIV co-infected individuals was significantly higher than that in HBV mono-infected patients.