Molecular genesis of drug-resistant and vaccine-escape HBV mutants.

A high rate of viral turnover, combined with an error-prone polymerase, results in a very high frequency of mutational events during HBV replication. Not surprisingly, particular selection pressures, both endogenous (host immune clearance) and exogenous (vaccines and antivirals), readily select out new 'escape' mutants. The introduction of nucleoside/nucleotide analogue (NA) therapy for chronic hepatitis B has witnessed the emergence of antiviral drug resistance as the major factor limiting drug efficacy. Furthermore, because of the overlap of the viral polymerase and envelope reading frames in the HBV DNA genome, NA resistance-associated mutations selected in the catalytic domains of the polymerase frequently result in important changes to the neutralizing antibody-binding domains of the hepatitis B surface antigen, including the emergence of antiviral drug-associated potential vaccine escape mutants (ADAPVEMs). The public health significance of ADAPVEMs is considerable in terms of the global programme for control of hepatitis B via universal infant immunization. Thus, prevention of resistance requires the adoption of strategies that not only effectively control HBV replication, but also prevent the emergence of ADAPVEMs.