Hepatitis B virus vaccination of recipients and donors of allogeneic peripheral blood stem cell transplantation

Infectious diseases in allogeneic haematopoietic stem cell transplantation: prevention and prophylaxis strategy guidelines 2016

Infectious complications after allogeneic haematopoietic stem cell transplantation (allo-HCT) remain a clinical challenge. This is a guideline provided by the AGIHO (Infectious Diseases Working Group) of the DGHO (German Society for Hematology and Medical Oncology). A core group of experts prepared a preliminary guideline, which was discussed, reviewed, and approved by the entire working group. The guideline provides clinical recommendations for the preventive management including prophylactic treatment of viral, bacterial, parasitic, and fungal diseases. The guideline focuses on antimicrobial agents but includes recommendations on the use of vaccinations. This is the updated version of the AGHIO guideline in the field of allogeneic haematopoietic stem cell transplantation utilizing methods according to evidence-based medicine criteria.

Reactivation of hepatitis B virus in hematopoietic stem cell transplant recipients in Japan: efficacy of nucleos(t)ide analogues for prevention and treatment

We retrospectively reviewed 413 recipients with hematologic malignancies who underwent hematopoietic stem cell transplantation (HSCT) between June 1986 and March 2013. Recipients with antibody to hepatitis B core antigen (anti-HBc) and/or to hepatitis B surface antigen (anti-HBs) were regarded as experiencing previous hepatitis B virus (HBV) infection. Clinical data of these recipients were reviewed from medical records. We defined ≥1 log IU/mL increase in serum HBV DNA from nadir as HBV reactivation in hepatitis B surface antigen (HBsAg)-positive recipients, and also defined ≥1 log IU/mL increase or re-appearance of HBV DNA and/or HBsAg as HBV reactivation in HBsAg-negative recipients. In 5 HBsAg-positive recipients, 2 recipients initially not administered with nucleos(t)ide analogues (NUCs) experienced HBV reactivation, but finally all 5 were successfully controlled with NUCs. HBV reactivation was observed in 11 (2.7%) of 408 HBsAg-negative recipients; 8 of these were treated with NUCs, and fortunately none developed acute liver failure. In 5 (6.0%) of 83 anti-HBc and/or anti-HBs-positive recipients, HBV reactivation occurred. None of 157 (0%) recipients without HBsAg, anti-HBs or anti-HBc experienced HBV reactivation. In HSCT recipients, HBV reactivation is a common event in HBsAg-positive recipients, or in HBsAg-negative recipients with anti-HBc and/or anti-HBs. Further attention should be paid to HSCT recipients with previous exposure to HBV.

Vaccination of hematopoietic stem cell transplantation recipients: perspective in Korea

Antibody titers to vaccine-preventable diseases such as tetanus, polio, measles, mumps, and rubella decline within 1-10 years after allogeneic or autologous hematopoietic stem cell transplantation (SCT) if the recipient is not vaccinated. Vaccine-preventable diseases such as pneumococcal diseases, Haemophilus influenzae type b infections, influenza, measles, and varicella can pose an increased risk for SCT recipients. Therefore, after SCT, the recipients should be routinely revaccinated. Vaccination recommendations have previously been developed and published by the European Group of Blood and Marrow Transplantation and the Centers for Disease Control, by the Infectious Diseases Society of America, and by the American Society for Blood and Marrow Transplantation in 2009. Different epidemiologies and strategies have existed in Korea. In 2012, the Korean Society of Infectious Diseases published "Vaccination for Adult" describing the guidelines for vaccination, one of the chapters assigned for vaccination of SCT recipients. The present article reviews the current available vaccination strategies for SCT recipients, their family members, and healthcare workers, with the focus on recent Korean perspectives.

Evaluation and management of hepatitis B virus infection in hematopoietic stem cell transplantation: before and after transplantation

HBV infection remains a major global health problem and continues to be a common cause of liver-related morbidity and mortality in both immunocompetent and immunosuppressed individuals. Reactivation of HBV is a serious complication of chemotherapy/immunosuppressive therapy in patients with HBV infection. In this article, we aim to describe the diagnosis, prevention and management of HBV infection in allogeneic hematopoietic stem cell transplant candidates, from the pre- to post-transplant period. The data currently available suggest that all individuals with hemato-/onco-logical malignancies who undergo chemotherapy/immunosuppressive therapy should be screened for hepatotropic viruses such as HBV and HCV. HBV surface antigen-positive individuals who receive chemotherapy/immunosuppressive therapy are at considerable risk of HBV reactivation. Antiviral prophylaxis prevents HBV reactivation, decreases reactivation-related morbidity and mortality, and prevents interruptions in chemotherapy/immunosuppressive therapy in such individuals. The optimal duration of antiviral prophylaxis remains to be elucidated. The vaccination of HBV-naive recipients and their donors against HBV infection prior to transplantation plays an important role in preventing acquired HBV infection. The presence of hepatitis B surface antigen positivity is not an absolute contraindication for allogeneic hematopoietic stem cell transplantation.

Changes of hepatitis B virus serologic status after allogeneic hematopoietic stem cell transplantation and impact of donor immunity on hepatitis B virus

Reverse seroconversion (RS) of Hepatitis B virus (HBV) has been reported after allogeneic transplantation with an incidence of 14% to 86%. However, most prior studies on HBV RS were performed in HBV nonendemic areas. In this study, the frequency of HBV RS at a single center in Korea, endemic for HBV, was evaluated. Also, the influence of the donor's immunity for HBV on posttransplantation HBV serologic changes in recipients was also investigated. A total of 288 patients underwent allogeneic transplantation between February 1996 and June 2008. We retrospectively reviewed the medical records of 288 patients and their paired donors. Among the 268 HBsAg(-) patients, 205 were assessed for posttransplantation HBsAg, and 114 (55.6%) of 205 had HBcAb before transplantation. With a median follow-up of 77.9 months, 3 of 114 patients experienced HBV RS (2.6%). With regard to donor immunity, significantly more patients with anti-HBs(-) donors experienced anti-HBs loss (P = .006), and the donor anti-HBs showed significant protective effects against the anti-HBs loss with an HR of 0.4. HBV RS after allogeneic transplantation may not be as common in HBV endemic areas. Also, donor anti-HBs showed a significant favorable effect on maintaining HBV immunity in recipients.

Viruses

Viral infections are an important and often unrecognized component of disease in immunocompromised patients. The diagnosis and management of viral infections have expanded largely because of new quantitative molecular diagnostic assays. Well-recognized pathogens such as herpes simplex virus (HSV), cytomegalovirus (CMV), and respiratory viruses have been joined by newly recognized pathogens such as BK virus, human herpesvirus-6 (HHV-6), and human metapneumovirus in this highly susceptible patient population. The role of Epstein-Barr virus (EBV) and Human herpesvirus-8 (HHV-8) in lymphoproliferative diseases also continue to be clarified. As a result, the management of viral infections in patients with hematologic malignancies continues to be a growing challenge for the clinician.

Allografted Recipients Immunized Against Hepatitis B Virus are at High Risk of Gradual Surface Antibody (HbsAb) Disappearance Post Transplant, Regardless of Adoptive Immunity Transfer

Immunized against hepatitis B virus (HBV) recipients are at risk of developing HBV postallogeneic stem cell transplantation because of the potential loss of their HBV immunity. The aim of the study was to evaluate: (1) the HbsAb eradication incidence posttransplant and potential risk factors, (2) the impact of donor's immunity on HbsAb loss, (3) the incidence of hepatitis B in patients with HbsAb disappearance. We studied, retrospectively, in 26 vaccinated and 56 naturally immunized recipients, the posttransplant HbsAb titers for a median period of 36 (6-132) months. The probability of HbsAb loss and HBV-related hepatitis was determined in all recipients. The impact of donor's immunity origin in the HBsAb disappearance was evaluated in the subgroup of, actively or naturally, immunized recipients/donors pairs. The 5-year probability of HbsAb disappearance was 90% for all patients with 18% probability of developing hepatitis at 12 years, for those who lost HbsAb. Marrow graft, antithymocyte globulin administration, age<30 years and chronic graft-versus-host disease were significant risk factors for HbsAb loss. In the subgroup of immunized recipients/donors, the donor's active immunization significantly affected this loss. Allotransplanted patients are at high risk of losing protection against HBV. The adoptive transfer of active HBV immunity does not seem to offer sustained protection posttransplant.

Risk assessment in haematopoietic stem cell transplantation: The liver as a risk factor

Patients with liver dysfunction have an increased risk of developing early and late complications after haematopoietic stem-cell transplantation (HSCT). That's why it is mandatory to evaluate liver status before transplantation in all cases. This evaluation should allow us to decide whether HSCT can be performed or whether we should adopt measures focused on preventing these complications. The evaluation of the liver in an HSCT candidate requires the collection of information by history-taking, physical examination, liver-function tests and, occasionally, imaging tests and liver biopsy. Additionally, as infection by hepatitis B or C viruses represents the most relevant cause of hepatic dysfunction after HSCT, the serological status of the patient should be carefully evaluated. This chapter tries to analyse and systematise the most important aspects in the patient's evaluation. Finally, as some liver dysfunctions in the stem-cell donor can have a negative impact for the donor during the harvest and/or for the recipient during HSCT, the methodology to evaluate the donors will also be analysed.