Severe exacerbation of systemic lupus erythematosus after hepatitis B vaccination and importance of pneumococcal vaccination in patients with autosplenectomy: comment on the article by Battafarano et al

Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) 2013: Unveiling the pathogenic, clinical and diagnostic aspects

In 2011 a new syndrome termed 'ASIA Autoimmune/Inflammatory Syndrome Induced by Adjuvants' was defined pointing to summarize for the first time the spectrum of immune-mediated diseases triggered by an adjuvant stimulus such as chronic exposure to silicone, tetramethylpentadecane, pristane, aluminum and other adjuvants, as well as infectious components, that also may have an adjuvant effect. All these environmental factors have been found to induce autoimmunity by themselves both in animal models and in humans: for instance, silicone was associated with siliconosis, aluminum hydroxide with post-vaccination phenomena and macrophagic myofasciitis syndrome. Several mechanisms have been hypothesized to be involved in the onset of adjuvant-induced autoimmunity; a genetic favorable background plays a key role in the appearance on such vaccine-related diseases and also justifies the rarity of these phenomena. This paper will focus on protean facets which are part of ASIA, focusing on the roles and mechanisms of action of different adjuvants which lead to the autoimmune/inflammatory response. The data herein illustrate the critical role of environmental factors in the induction of autoimmunity. Indeed, it is the interplay of genetic susceptibility and environment that is the major player for the initiation of breach of tolerance.

Safety and efficacy of hepatitis B vaccine in systemic lupus erythematosus

Hepatitis B virus (HBV) vaccination has been implicated as a potential trigger for autoimmune diseases but there are no prospective studies in lupus. We therefore assessed prospectively the safety and efficacy of immunization with recombinant DNA HBV vaccine (Euvax B; LG Life Sciences) in systemic lupus erythematosus (SLE) patients. Twenty-eight consecutive inactive SLE patients [Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) <4], age between 18 and 50 years and negative serology for HBV, were selected. Exclusion criteria were prednisone >/=20 mg/day and immunosuppressive drugs. Clinical and laboratorial assessments were obtained at study entry and one month after the three doses. In addition, a previous one year evaluation was performed using a standard electronic protocol. The mean age was 34 +/- 7.7 years and disease duration was 10.4 +/- 6.7 years. An adequate seroconversion was achieved at the end of the study (93%), although a lower frequency after the first (4%) and second dose (54%) was observed. No significant change in mean SLEDAI score was detected after each dose throughout the study (0.14 +/- 0.52 versus 0 versus 0.61 +/- 1.66 versus 0.36 +/- 1.34, P = 0.11). Reinforcing these findings, the 11% flares during vaccination was similar to the 21% observed in the previous year (P = 0.46). Furthermore, the mean prednisone dose at study entry was comparable to the end of the study (2.86 +/- 3.06 versus 4.64 +/- 8.25 mg/day, P = 0.32). In addition, the frequency of immunosuppressive therapy during the vaccination period (11%) was alike to the 14% observed in the previous year before entry (P = 0.66). Hepatitis B vaccination was safe in inactive SLE patients with an adequate vaccine response rate.

Infectious diseases in systemic lupus erythematosus: risk factors, management and prophylaxis

Infections are one of the leading causes of morbidity and mortality in patients with systemic lupus erythematosus (SLE). Therapeutic, disease-related and genetic factors all contribute to a lupus patient's increased susceptibility to infections. Although bacterial pathogens are the most common cause of infections, a wide variety of pathogens have been reported. In high-risk populations, identification and treatment of chronic infections such as tuberculosis, hepatitis B or human immunodeficiency virus, are important prior to the institution of immunosuppression to prevent reactivation or exacerbation of the infection. Judicious use of corticosteroids and cytotoxic drugs is critical in limiting infectious complications. Vaccines against influenza and pneumococcus appear to be safe and immunogenic in SLE patients and their routine administration should be encouraged.

Epidemiology of autoimmune reactions induced by vaccination

In order for vaccinations to 'work', the immune system must be stimulated. The concern that immunizations may lead to the development of autoimmune disease (AID) has been questioned. Since AID occur in the absence of immunizations, it is unlikely that immunizations are a major cause of AID. Epidemiological studies are needed, however, to assess whether immunizations may increase the risk in some susceptible individuals. This paper discusses the evidence for and against vaccination as a risk factor for AID. Evidence for immunizations leading to AID come from several sources including animal studies, single and multiple case reports, and ecologic association. However more rigorous investigation has failed to confirm most of the allegations. Unfortunately the question remains difficult to address because for most AIDs, there is limited knowledge of the etiology, background incidence and other risk factors for their development. This information is necessary, in the absence of experimental evidence derived from controlled studies, for any sort of adequate causality assessment using the limited data that are available. Several illustrative examples are discussed to highlight what is known and what remains to be explored, and the type of epidemiological evidence that would be required to better address the issues. Examples include the possible association of immunization and multiple sclerosis (and other demyelinating diseases), type 1 diabetes mellitus, Guillain-Barre Syndrome, idiopathic thrombocytopenic purpura, and rheumatoid arthritis.

[Systemic lupus erythematosus and risk of hepatitis B vaccination: from level of evidence to prescription]

INTRODUCTION

Case reports focusing on immunological diseases occurring subsequently to vaccination are often described in the literature. Reporting of such cases may influence physicians' perception of risks related to immunization, and thereby immunization practices. The decision to vaccinate a patient with an immunological disease should not rely on such case reports, but on the level of evidence of a causal relationship between vaccination and the occurrence of an adverse event. This article describes the search for available data supporting such causality before taking the decision to introduce vaccination against hepatitis B in a female patient with systemic lupus erythematosus (SLE).

CURRENT KNOWLEDGE AND KEY POINTS

Data extracted from Medline and surveillance system showed that: 1) biologic plausibility of a relationship between the HBs antigen and SLE was unlikely; 2) case reports or case series were seldom and not convincing regarding potential causality; and 3) there were neither controlled observational studies nor controlled clinical trials. The only available clinical study was of poor quality and did not show any adverse event. The level of evidence of a causal relationship between vaccination against hepatitis B and the occurrence of an adverse event in patients with SLE was low, in-between levels 4 and 5 as defined by the Center for evidence-based medicine. The risk-benefit ratio may therefore rely on these results and guide the decision whether or not vaccination should be introduced.

FUTURE PROSPECTS AND PROJECTS

The type of reasoning reported in this paper can be used for other vaccines or other immunological diseases, and have wider applicability in terms of therapeutic risk management when data and evaluation are lacking that could guide decisions.