What's my status?

I had chronic active hep-B in 1988 (age 27).  I was treated with the alpha-interferon protocol at Mayo in Oct 89.  Went HBVDNA negative and HBeAG negative in Jun 90.  In 10/91 I was still HBsAG positive, but became positive for Anti-HBe and Anti-HBs.  In 10/92 (or before--who knows?) I became HBsAg negative AND Anti-HBs negative.  My doctor, a hepatic specialist, said I was "cured."  Follow-up for the next 3 yrs showed same results.  I was Anti-HBc positive the entire time.

The only testing I've had done since 1/95 has been routine liver enzyme profiling, which has all been normal.  I recently was accepted into RN school and needed a physical and either hep-B immunization or titers showing Anti-HBs positive.  The Anti-HBs was negative (<3.0 mIU/mL).  This corresponds to the above, when I only had Anti-HBs just before clearing the HBsAg.  I am still Anti-HBc positive.  I'm confused because the nursing college wants either immunization or anti-HBs titers; the county health dept says I don't need immunization because I'm Anti-HBc positive and have documented proof of the illness.

Questions:
1.  Am I immune from another HBV infection due to Anti-HBc?
2.  Why did I not retain the Anti-HBs I had in 10/91?  Could it be because I cleared HBsAg with interferon instead of naturally?
3.  Could my Anti-HBs have fallen to undetectable levels?
4.  Should I be immunized or rely on the Anti-HBc positive result if the nursing college will accept it?
5.  Is Anti-HBc positive and Anti-HBs negative a normal serology of one having had chronic Hep-B?
6.  Am I still considered as being a "carrier" or HAVING (as opposed to HAD) chronic hepatitis B?
7.  Is there a chance that I could become HBsAg positive again from the remnants of the same old condition?

I should see my hapatology doctor again and get some additional tests and advice, but having lost my job and insurance while returning to school full-time to start a new career, this would be extremely difficult for me to do.

Looking forward to your response.  Thank you.

[Kevin Pho, MD]

To answer your questions:
1) Isolated detection of anti-HBc can occur in three settings: during the window period of acute hepatitis B when the anti-HBc is predominantly IgM class; many years after recovery from acute hepatitis B when anti-HBs has fallen to undetectable levels; and after many years of chronic HBV infection when the HBsAg titer has decreased below the cut-off level for detection.  Whether you are immune to hepatitis B depends on which of these settings you fall into.

2) In most patients, anti-HBs persists for life, thereby conferring long-term immunity.  I do not have a good explanation why the anti-HBs cleared - it may be possibly affected by the interferon.

3) It is possible that the anti-HBs had fallen - you may want to repeat this test.

4) You may want to confirm that the anti-HBc is of the IgG variety - suggesting chronic infection.  I cannot comment on the policy of your nursing school.

5)  In acute hepatitis, HBsAg can be detected soon after infection; falling levels of this marker and the appearance of hepatitis B surface antibodies (HBsAb) signal recovery. In chronic hepatitis, HBsAg can be detected for many years, and HBsAb may never appear.

6) In chronic hepatitis, levels of DNA often remain high for many years and then decrease as the immune system gains control over the virus.  You may want to obtain this level to see if you are currently having chronic hepatitis B.

7) It is possible that the anti-HBs may turn positive in the future.  

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Kevin, M.D.
Medical Weblog:
kevinmd_b

Bibliography:
Lok.  Serologic diagnosis of hepatitis B virus infection.  UptoDate, 2004.

[nurse2b]

Thank you for the response.  Not sure if you reply to comments after your first answer, but here goes:  re. #4, it is IgG antibody-HBc, which would suggest chronic infection.  But even on an acute infection doesn't anti-HBc remain forever?  Does anti-HBc protect against another infection?  I guess my main question is: should I be vaccinated or does anti-HBc protect?