{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T10:18:39Z","timestamp":1783419519650,"version":"3.54.6"},"reference-count":49,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T00:00:00Z","timestamp":1782777600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Maria Em\u00edlia Foundation\/Bahian Infectious Diseases Foundation","award":["FBaI002\/2023"],"award-info":[{"award-number":["FBaI002\/2023"]}]},{"name":"Rond\u00f4nia Foundation to Support the Development of Scientific and Technological Actions and Research in the State of Rond\u00f4nia\u2014FAPERO","award":["VPPIS-003-FIO-20-2-75\/2023"],"award-info":[{"award-number":["VPPIS-003-FIO-20-2-75\/2023"]}]},{"name":"state health department\u2014SESACRE"},{"name":"Governor Flaviano Melo Foundation"},{"name":"M\u00e9rieux Foundation"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Viruses"],"abstract":"<jats:p>Background: Hepatitis delta (HDV) is the most severe form of chronic viral hepatitis, with rapid progression to cirrhosis and hepatocellular carcinoma, and remains neglected in the Amazon Basin. The state of Acre, in the Western Brazilian Amazon, is endemic for HDV, with a high prevalence of genotype 3 (HDV-3). This study aimed to analyze epidemiological data, quantify HDV RNA, identify genotypes, and describe the phylogeny and phylogeography of HDV in Acre. Methods: This cross-sectional study included patients positive for HBsAg and anti-HDV under follow-up at the Specialized Assistance Service (SAE) in Rio Branco, Acre, between March and November 2023. Blood samples were collected for HDV RNA quantification using one-step RT-qPCR. Samples with detectable viremia (Ct \u2264 30) underwent Nested-PCR, Sanger sequencing, phylogenetic analysis (Maximum Likelihood), temporal signal evaluation, and Bayesian phylogeographic reconstruction. Results: Among 108 patients (median age 43; 55.6% female), HDV RNA was detected in 48.1%, with viral loads ranging from 140 to 24,000,000 copies\/mL. Of these, 55.8% had &gt;100,000 copies\/mL. Genotyping (n = 41) identified exclusively HDV-3. Phylogenetic analysis revealed genetic heterogeneity among HDV-3 isolates, with the formation of two major phylogenetic clades. Bayesian analysis estimated tMRCA around 1818 and suggested dispersion from Amazonas to Acre and neighboring regions. Conclusion: HDV-3 predominates in Acre with high genetic diversity, indicating sustained viral circulation in the Western Amazon and reinforcing the need for improved surveillance and diagnosis.<\/jats:p>","DOI":"10.3390\/v18070730","type":"journal-article","created":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T03:06:34Z","timestamp":1782875194000},"page":"730","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Molecular Characterization of Hepatitis Delta Virus in the Western Amazon, Acre, Brazil"],"prefix":"10.3390","volume":"18","author":[{"given":"Rutilene Barbosa","family":"Souza","sequence":"first","affiliation":[{"name":"Programa de P\u00f3s-Gradua\u00e7\u00e3o em Medicina e Sa\u00fade, Universidade Federal da Bahia, Salvador 40110-040, Brazil"},{"name":"Laborat\u00f3rio Rodolphe M\u00e9rieux, Centro de Infectologia Charles M\u00e9rieux, Rio Branco 69917-672, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thor Oliveira","family":"Dantas","sequence":"additional","affiliation":[{"name":"Funda\u00e7\u00e3o Hospitalar Governador Flaviano Melo, Rio Branco 69917-672, Brazil"},{"name":"Centro de Ci\u00eancias da Sa\u00fade e Desporto, Universidade Federal do Acre, Rio Branco 69920-900, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luiz Fellype Alves","family":"de Souza","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio Rodolphe M\u00e9rieux, Centro de Infectologia Charles M\u00e9rieux, Rio Branco 69917-672, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"T\u00e1rcio P.","family":"Roca","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio de Virologia Molecular, Funda\u00e7\u00e3o Oswaldo Cruz Rond\u00f4nia\u2014FIOCRUZ\/RO, Porto Velho 76812-245, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adrhyan","family":"Ara\u00fajo","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio de Virologia Molecular, Funda\u00e7\u00e3o Oswaldo Cruz Rond\u00f4nia\u2014FIOCRUZ\/RO, Porto Velho 76812-245, Brazil"},{"name":"Programa de P\u00f3s-Gradua\u00e7\u00e3o em Biologia Experimental, Universidade Federal de Rond\u00f4nia e Funda\u00e7\u00e3o Oswaldo Cruz Rond\u00f4nia\u2014UNIR\/FIOCRUZ\/RO, Porto Velho 76801-974, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jackson A. S.","family":"Queiroz","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio de Virologia Molecular, Funda\u00e7\u00e3o Oswaldo Cruz Rond\u00f4nia\u2014FIOCRUZ\/RO, Porto Velho 76812-245, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ana M.","family":"Passos-Silva","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio de Virologia Molecular, Funda\u00e7\u00e3o Oswaldo Cruz Rond\u00f4nia\u2014FIOCRUZ\/RO, Porto Velho 76812-245, Brazil"},{"name":"Programa de P\u00f3s-Gradua\u00e7\u00e3o em Biologia Experimental, Universidade Federal de Rond\u00f4nia e Funda\u00e7\u00e3o Oswaldo Cruz Rond\u00f4nia\u2014UNIR\/FIOCRUZ\/RO, Porto Velho 76801-974, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariana Ara\u00fajo","family":"Costa","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio Central de Sa\u00fade Publica do Acre, Rio Branco 69918-504, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edna Maria Gomes","family":"Gon\u00e7alves","sequence":"additional","affiliation":[{"name":"Funda\u00e7\u00e3o Hospitalar Governador Flaviano Melo, Rio Branco 69917-672, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luis Edgardo Riveros","family":"Aguilar","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio Rodolphe M\u00e9rieux, Centro de Infectologia Charles M\u00e9rieux, Rio Branco 69917-672, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3374-5418","authenticated-orcid":false,"given":"Ana Alice Maia","family":"Gon\u00e7alves","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio de Biotecnologia de Microrganismos, Universidade Federal de S\u00e3o Jo\u00e3o Del Rei, Campus Centro Oeste, Divin\u00f3polis 36307-352, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8890-3030","authenticated-orcid":false,"given":"Alexsandro Sobreira","family":"Galdino","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio de Biotecnologia de Microrganismos, Universidade Federal de S\u00e3o Jo\u00e3o Del Rei, Campus Centro Oeste, Divin\u00f3polis 36307-352, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9273-7285","authenticated-orcid":false,"given":"Daniel Archimedes","family":"da Matta","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio Rodolphe M\u00e9rieux, Centro de Infectologia Charles M\u00e9rieux, Rio Branco 69917-672, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deusilene","family":"Vieira","sequence":"additional","affiliation":[{"name":"Laborat\u00f3rio de Virologia Molecular, Funda\u00e7\u00e3o Oswaldo Cruz Rond\u00f4nia\u2014FIOCRUZ\/RO, Porto Velho 76812-245, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4673-6991","authenticated-orcid":false,"given":"Carlos","family":"Brites","sequence":"additional","affiliation":[{"name":"Programa de P\u00f3s-Gradua\u00e7\u00e3o em Medicina e Sa\u00fade, Universidade Federal da Bahia, Salvador 40110-040, Brazil"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,6,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"433","DOI":"10.1016\/j.jhep.2023.05.001","article-title":"EASL Clinical Practice Guidelines on Hepatitis Delta Virus","volume":"79","author":"Brunetto","year":"2023","journal-title":"J. Hepatol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1016\/j.coph.2021.03.008","article-title":"Current Status of Hepatitis Delta","volume":"58","author":"Papatheodoridi","year":"2021","journal-title":"Curr. Opin. Pharmacol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"001963","DOI":"10.1099\/jgv.0.001963","article-title":"ICTV Virus Taxonomy Profile: Kolmioviridae 2024","volume":"105","author":"Kuhn","year":"2024","journal-title":"J. Gen. Virol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1565","DOI":"10.1099\/jgv.0.001150","article-title":"ICTV Report Consortium ICTV Virus Taxonomy Profile: Deltavirus","volume":"99","author":"Magnius","year":"2018","journal-title":"J. Gen. Virol."},{"key":"ref_5","doi-asserted-by":"crossref","unstructured":"Taylor, J.M. (2020). Infection by Hepatitis Delta Virus. Viruses, 12.","DOI":"10.3390\/v12060648"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2376","DOI":"10.1001\/jama.2023.23242","article-title":"Hepatitis D: A Review","volume":"330","author":"Negro","year":"2023","journal-title":"JAMA"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"997","DOI":"10.1136\/gut.18.12.997","article-title":"Immunofluorescence Detection of New Antigen-Antibody System (Delta\/Anti-Delta) Associated to Hepatitis B Virus in Liver and in Serum of HBsAg Carriers","volume":"18","author":"Rizzetto","year":"1977","journal-title":"Gut"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"637","DOI":"10.1097\/HEP.0000000000000584","article-title":"HDV RNA Assays: Performance Characteristics, Clinical Utility, and Challenges","volume":"81","author":"Wedemeyer","year":"2023","journal-title":"Hepatology"},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Zakh, R., Churkin, A., Totzeck, F., Parr, M., Tuller, T., Etzion, O., Dahari, H., Roggendorf, M., Frishman, D., and Barash, D. (2021). A Mathematical Analysis of HDV Genotypes: From Molecules to Cells. Mathematics, 9.","DOI":"10.3390\/math9060585"},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"Nogueira-Lima, F.S., Botelho-Souza, L.F., Roca, T.P., Santos, A.O.D., Oliveira, S.D.C., Queiroz, J.A.D.S., Santos-Alves, F.A.G.D., Salcedo, J.M.V., and Vieira, D.S. (2019). Phylodynamic and Phylogeographic Analysis of Hepatitis Delta Virus Genotype 3 Isolated in South America. Viruses, 11.","DOI":"10.3390\/v11110995"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e03965-22","DOI":"10.1128\/spectrum.03965-22","article-title":"Circulation of HDV Genotypes in Brazil: Identification of a Putative Novel HDV-8 Subgenotype","volume":"11","author":"Mello","year":"2023","journal-title":"Microbiol. Spectr."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"8047","DOI":"10.1038\/s41598-018-26446-w","article-title":"HDV Infection Rates in Northern Vietnam","volume":"8","author":"Binh","year":"2018","journal-title":"Sci. Rep."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"177","DOI":"10.1186\/s12985-017-0845-y","article-title":"Hepatitis Delta: Virological and Clinical Aspects","volume":"14","author":"Vasconcelos","year":"2017","journal-title":"Virol. J."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1205","DOI":"10.1016\/j.jhep.2014.05.041","article-title":"Chronic HDV\/HBV Co-Infection: Predictors of Disease Stage\u2014A Case Series of HDV-3 Patients","volume":"61","author":"Braga","year":"2014","journal-title":"J. Hepatol."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Crispim, M.A.E., Fraiji, N.A., Campello, S.C., Schriefer, N.A., Stefani, M.M.A., and Kiesslich, D. (2014). Molecular Epidemiology of Hepatitis B and Hepatitis Delta Viruses Circulating in the Western Amazon Region, North Brazil. BMC Infect. Dis., 14.","DOI":"10.1186\/1471-2334-14-94"},{"key":"ref_16","unstructured":"Minist\u00e9rio da Sa\u00fade (2024). Boletim Epidemiol\u00f3gico_Hepatites Virais_2024."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"920","DOI":"10.1093\/infdis\/174.5.920","article-title":"Hepatitis B Virus (HBV)\/Hepatitis D Virus (HDV) Coinfection in Outbreaks of Acute Hepatitis in the Peruvian Amazon Basin: The Roles of HDV Genotype III and HBV Genotype F","volume":"174","author":"Casey","year":"1996","journal-title":"J. Infect. Dis."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"2183","DOI":"10.1099\/0022-1317-82-9-2183","article-title":"Characterization of Hepatitis D Virus Genotype III among Yucpa Indians in Venezuela","volume":"82","author":"Nakano","year":"2001","journal-title":"J. Gen. Virol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1186\/s12985-015-0402-5","article-title":"Hepatitis D Virus and Hepatitis B Virus Infection in Amerindian Communities of the Amazonas State, Colombia","volume":"12","author":"Payares","year":"2015","journal-title":"Virol. J."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2054487","DOI":"10.1155\/ijh\/2054487","article-title":"Clinical Evaluation of the Progression of Liver Disease in Patients Coinfected With HBV and HDV in the Western Amazon Region of Brazil","volume":"2025","author":"Ton","year":"2025","journal-title":"Int. J. Hepatol."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Vasconcelos, M.P.A., S\u00e1nchez-Arcila, J.C., Peres, L., De Sousa, P.S.F., Castro-Alves, J., Albuquerque, H.G., Mendes-Correa, M.C., Maia-Herzog, M., Lewis-Ximenez, L.L., and Villar, L.M. (2024). Seroprevalence of Hepatitis B, C, and D and Associated Factors in the Semi-Isolated Yanomami Amazonian Indigenous Community. BMC Infect. Dis., 24.","DOI":"10.1186\/s12879-023-08928-z"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e2020867","DOI":"10.1590\/s1679-49742021000400014","article-title":"Tend\u00eancias e Distribui\u00e7\u00e3o Espacial Da Hepatite D No Norte Do Brasil, 2009-2018: Um Estudo Ecol\u00f3gico","volume":"30","author":"Yamada","year":"2021","journal-title":"Epidemiol. Serv. Sa\u00fade"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Cabezas, C., Trujillo, O., Balbuena, J., Peceros, F.D.M., Terrazas, M., Su\u00e1rez, M., Marin, L., Apac, J., and Ram\u00edrez-Soto, M.C. (2020). Decrease in the Prevalence of Hepatitis B and D Virus Infections in an Endemic Area in Peru 23 Years after the Introduction of the First Pilot Vaccination Program against Hepatitis B. PLoS ONE, 15.","DOI":"10.1371\/journal.pone.0236993"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1002\/hep.1840050225","article-title":"Viral Hepatitis in Colombia: A Study of the \u201cHepatitis of the Sierra Nevada De Santa Marta.\u201d","volume":"5","author":"Ljunggren","year":"1985","journal-title":"Hepatology"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1285","DOI":"10.1002\/hep.1840060610","article-title":"Specific Histologic Features of Santa Marta Hepatitis: A Severe Form of Hepatitis \u03b4-Virus Infection in Northern South America","volume":"6","author":"Buitrago","year":"1986","journal-title":"Hepatology"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1590\/S0037-86821986000200015","article-title":"Estudo dos marcadores sorol\u00f3gicos do v\u00edrus da hepatite B (VHB) em \u00e1rea de ocorr\u00eancia da hepatite de l\u00e1brea (febre negra), Codaj\u00e1s, AM, Brasil","volume":"19","author":"Fonseca","year":"1986","journal-title":"Rev. Soc. Bras. Med. Trop."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"322","DOI":"10.1590\/S0037-86822010000300022","article-title":"Hist\u00f3rico das hepatites virais","volume":"43","author":"Fonseca","year":"2010","journal-title":"Rev. Soc. Bras. Med. Trop."},{"key":"ref_28","first-page":"182","article-title":"Hepatite de L\u00e1brea (febre negra de L\u00e1brea) e outras hepatites fulminantes em Sena Madureirs, Acre e Boca do Acre, Amazonas, Brasil","volume":"25","author":"Bensabath","year":"1983","journal-title":"Hepat. De L\u00e1brea (Febre Negra De L\u00e1brea) E Outras Hepat. Fulminantes Em Sena Madureirs Acre E Boca Do Acre Amazon. Bras."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2638","DOI":"10.1099\/vir.0.013615-0","article-title":"Hepatitis B Virus and Hepatitis Delta Virus Genotypes in Outbreaks of Fulminant Hepatitis (Labrea Black Fever) in the Western Brazilian Amazon Region","volume":"90","author":"Soares","year":"2009","journal-title":"J. Gen. Virol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"349","DOI":"10.1590\/S0037-86822001000400007","article-title":"Ocorr\u00eancia da infec\u00e7\u00e3o pelo v\u00edrus da hepatite B (VHB) e delta (VHD) em sete grupos ind\u00edgenas do Estado do Amazonas","volume":"34","author":"Braga","year":"2001","journal-title":"Rev. Soc. Bras. Med. Trop."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1462","DOI":"10.1016\/j.meegid.2011.05.020","article-title":"Dynamics of Hepatitis D (Delta) Virus Genotype 3 in the Amazon Region of South America","volume":"11","author":"Romano","year":"2011","journal-title":"Infect. Genet. Evol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"12073","DOI":"10.1038\/s41598-023-37756-z","article-title":"Development of Quantitative Multiplex RT-qPCR One Step Assay for Detection of Hepatitis Delta Virus","volume":"13","author":"Roca","year":"2023","journal-title":"Sci. Rep."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"105671","DOI":"10.1016\/j.meegid.2024.105671","article-title":"Exploring Genetic Diversity of Hepatitis D Virus Full-Length Genome in Brazil: Discovery of a Novel HDV-8 Subgenotype beyond African Borders","volume":"125","author":"Angelice","year":"2024","journal-title":"Infect. Genet. Evol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"3022","DOI":"10.1093\/molbev\/msab120","article-title":"MEGA11: Molecular Evolutionary Genetics Analysis Version 11","volume":"38","author":"Tamura","year":"2021","journal-title":"Mol. Biol. Evol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1160","DOI":"10.1093\/bib\/bbx108","article-title":"MAFFT Online Service: Multiple Sequence Alignment, Interactive Sequence Choice and Visualization","volume":"20","author":"Katoh","year":"2019","journal-title":"Brief. Bioinform."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1530","DOI":"10.1093\/molbev\/msaa015","article-title":"IQ-TREE 2: New Models and Efficient Methods for Phylogenetic Inference in the Genomic Era","volume":"37","author":"Minh","year":"2020","journal-title":"Mol. Biol. Evol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"166","DOI":"10.1159\/000431040","article-title":"Characterization of the Genotypic Profile of Hepatitis Delta Virus: Isolation of HDV Genotype-1 in the Western Amazon Region of Brazil","volume":"58","year":"2015","journal-title":"Intervirology"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"9016","DOI":"10.1073\/pnas.90.19.9016","article-title":"A Genotype of Hepatitis D Virus That Occurs in Northern South America","volume":"90","author":"Casey","year":"1993","journal-title":"Proc. Natl. Acad. Sci. USA"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"924","DOI":"10.1111\/j.1365-3156.2010.02560.x","article-title":"A Comparative Epidemiological Study of Hepatitis B and Hepatitis D Virus Infections in Yanomami and Piaroa Amerindians of Amazonas State, Venezuela: Hepatitis B and Hepatitis D Virus Infections in Yanomani and Piaroa Amerindians","volume":"15","author":"Duarte","year":"2010","journal-title":"Trop. Med. Int. Health"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"66","DOI":"10.1186\/s13099-021-00462-0","article-title":"Hepatitis D: Challenges in the Estimation of True Prevalence and Laboratory Diagnosis","volume":"13","author":"Chen","year":"2021","journal-title":"Gut Pathog."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1358","DOI":"10.1002\/jmv.25196","article-title":"Hepatitis D Infection in Brazil: Prevalence and Geographical Distribution of anti-Delta Antibody","volume":"90","author":"Lago","year":"2018","journal-title":"J. Med. Virol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1081","DOI":"10.1002\/jmv.25411","article-title":"Non-F HBV\/HDV-3 Coinfection Is Associated with Severe Liver Disease in Western Brazilian Amazon","volume":"91","author":"Kay","year":"2019","journal-title":"J. Med. Virol."},{"key":"ref_43","unstructured":"da Sa\u00fade, M. (2024). Clinical Protocol and Therapeutic Guidelines for Hepatitis B and Coinfections."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"148","DOI":"10.1111\/liv.15746","article-title":"Anti-HDVReflex Testing in HBsAg -positive Subjects: An Efficacious Strategy to Identify HDV Infection","volume":"44","author":"Cossiga","year":"2024","journal-title":"Liver Int."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"100547","DOI":"10.1016\/j.jhepr.2022.100547","article-title":"Implementation of Anti-HDV Reflex Testing among HBsAg-Positive Individuals Increases Testing for Hepatitis D","volume":"4","author":"Palom","year":"2022","journal-title":"JHEP Rep."},{"key":"ref_46","doi-asserted-by":"crossref","unstructured":"Silva, R.J.S., Do Nascimento, R.S., Oliveira-Neto, J.A.J., Silva, F.Q., Piauiense, J.N.F., Gomes, C.M., Pinheiro, L.M.L., Resque, R.L., Pinho, J.R.R., and Kupek, E. (2021). Detection and Genetic Characterization of Hepatitis B and D Viruses: A Multi-Site Cross-Sectional Study of People Who Use Illicit Drugs in the Amazon Region. Viruses, 13.","DOI":"10.3390\/v13071380"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"4433","DOI":"10.1007\/s00018-016-2299-6","article-title":"Mechanisms of Viral Mutation","volume":"73","year":"2016","journal-title":"Cell. Mol. Life Sci."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"100","DOI":"10.1016\/j.coviro.2018.10.003","article-title":"HDV Evolution\u2014Will Viral Resistance Be an Issue in HDV Infection?","volume":"32","author":"Tabernero","year":"2018","journal-title":"Curr. Opin. Virol."},{"key":"ref_49","doi-asserted-by":"crossref","unstructured":"Roca, T.P., Queiroz, J.A.S., Passos-Silva, A.M., Ara\u00fajo, A., Lago, B.V., Mello, F.C.A., Salcedo, J.M.V., Vieira, D., and Villar, L.M. (2024). Genetic Spatio-Temporal Analysis of Hepatitis D Virus Infection in Western Brazilian Amazon. Viruses, 16.","DOI":"10.3390\/v16111690"}],"container-title":["Viruses"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1999-4915\/18\/7\/730\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T10:07:08Z","timestamp":1783418828000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1999-4915\/18\/7\/730"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,6,30]]},"references-count":49,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["v18070730"],"URL":"https:\/\/doi.org\/10.3390\/v18070730","relation":{},"ISSN":["1999-4915"],"issn-type":[{"value":"1999-4915","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,6,30]]}}}