Immunomodulatory and Antiviral Therapy Improved Functional Cure Rate in CHB Patients with High HBsAg Level Experienced NA

Background and Aims

A functional cure, or hepatitis B virus (HBV) surface antigen (HBsAg) loss, is difficult to achieve in patients with hepatitis B virus e antigen (HBeAg)-positive chronic hepatitis B. The HBV vaccine and granulocyte-macrophage colony-stimulating factor (GM-CSF) have been reported to help reduce HBsAg levels and promote HBsAg loss. In this prospective randomized trial, we evaluated HBsAg loss in patients receiving pegylated interferon-α2b (PEGIFN-α2b) and tenofovir disoproxil fumarate (TDF), with and without GM-CSF and HBV vaccination.

Methods

A total of 287 patients with HBeAg positive chronic hepatitis B and seroconversion after nucleot(s)ide analog treatment were assigned randomly to three treatment groups for 48 weeks, TDF alone (control), PEGIFN-α2b + TDF, and PEGIFN-α2b + TDF + GM-CSF + HBV vaccine. The primary endpoints were the proportions of patients with HBsAg loss and seroconversion at 48 and 72 weeks.

Results

The cumulative HBsAg loss rates in the control, PEGIFN-α2b + TDF, and PEGIFN-α2b + TDF + GM-CSF + HBV vaccine groups at week 48 were 0.0%, 28.3%, and 41.1%, respectively. The cumulative HBsAg seroconversion rates in these groups at week 48 were 0.0%, 21.7%, and 33.9%, respectively. Multivariate regression analysis showed that GM-CSF use plus HBV vaccination was significantly associated with HBsAg loss (p=0.017) and seroconversion (p=0.030).

Conclusions

In patients with HBeAg-positive chronic hepatitis B and seroconversion after nucleot(s)ide analog treatment, immunomodulatory/antiviral treatment regimens effectively improved HBsAg loss, and the regimen including GM-CSF and HBV vaccination was most effective.

Decreased placental TLR3 is associated with hepatitis B virus vaccine responsiveness in infants born to HBsAg-positive mothers

Background

Although hepatitis B vaccination has a significant impact on the reduction hepatitis B virus (HBV) infection, babies born to hepatitis B surface antigen (HBsAg) positive mothers bear a high risk of being poor responsive to the vaccine with unilluminated mechanism. Toll-like receptor 3 (TLR3) plays a vital role in placental immunity, which affects the immune response of these babies. This study investigated the role of placental TLR3 in the immune responses of babies born to HBsAg-positive mothers to the HBV vaccine.

Methods

One hundred pairs of HBsAg-positive mothers and their newborns were recruited. Maternal blood samples were collected before delivery, and placental tissues were collected after delivery. Newborns were administered standard passive and active immunoprophylaxis and followed up until the age of 1. Infant blood samples were collected at 1 year of age. Mothers and infants were tested for HBV serological markers and HBV DNA by electrochemiluminescence immunoassay and fluorescence quantitative polymerase chain reaction. respectively. Placental TLR3 was detected by immunohistochemistry and score in a semi-quantitative fashion, circulating cytokines in infants were detected by enzyme-linked immunosorbent assay. Infants with anti-HBs ≥100 and <100 mIU/mL were classified into the high-responsiveness group and the non- or hypo-responsiveness group.

Results

The TLR3 protein was expressed in all placentas. Compared with the high-responsiveness group, the expression of TLR3 in the non- or hypo-responsiveness group was significantly decreased (χ²=10.39, P=0.001). A non-conditional logistic regression model showed that the increased expression of placental TLR3 protein decreased the odds of HBV vaccine non- or hypo-responsiveness in the babies of HBsAg-positive mothers [OR =0.25 (95% CI: 0.11-0.58)], and this association remained significant after accounting for maternal factors, such as HBeAg and HBV DNA, as well as infant cytokines, including IL-6, IL-12, TNF-α, IFN-α, and IFN-γ [OR =0.15 (95% CI: 0.05-0.44)].

Conclusions

Decreased placental TLR3 expression is associated with impaired responsiveness to HBV vaccination in babies born to HBsAg-positive mothers.

Efficacy and Safety of Revaccination against Tetanus, Diphtheria, Haemophilus influenzae Type b and Hepatitis B Virus in a Prospective Cohort of Adult Recipients of Allogeneic Hematopoietic Stem Cell Transplantation

Data on immunogenicity and safety of the recommended revaccination schedule against diphtheria, tetanus, poliomyelitis, pertussis, Haemophilus influenzae type b (Hib), and hepatitis B in adult allogeneic hematopoietic stem cell transplantation (allo-HSCT) recipients are limited. This prospective single-center cohort study (April 2014 to March 2018) included adult allo-HSCT recipients referred to a dedicated vaccinology consultation and vaccinated with the pediatric combined diphtheria, tetanus, acellular pertussis, hepatitis B virus, inactivated poliovirus, and Haemophilus influenzae type b (DTaP(±HB)-IPV-Hib) vaccine (3 doses 1 month apart, booster dose 1 year later). The proportion of responders to tetanus, diphtheria, Hib, and hepatitis B vaccine and geometric mean concentrations (GMCs) of antibodies were assessed before and up to 24 months after vaccination. A total of 106 patients were vaccinated at a median (interquartile range) time of 12.4 (10 to 18.4) months post-transplant. At 5.3 (4.8 to 6.6) and 23.1 (21.1 to 25.1) months after vaccine initiation, high and sustained rates of protective antibody titers were achieved for tetanus (97.8% [95% confidence interval (95% CI), 92.4% to 99.7%], n = 91/93 and 100% [95% CI, 92% to 100%], n = 44/44), diphtheria (94.6% [95% CI, 87.9% to 98.2%], n = 88/93 and 90.9% [95% CI, 78.3% to 97.5%], n = 40/44), Hib (96.6% [95% CI, 90.4% to 99.3%], n = 85/88 and 93% [95% CI, 80.9% to 98.5%], n = 40/43), and hepatitis B (83.5% [95% CI, 73.5% to 90.9%], n = 66/79 and 81.1% [95% CI, 64.8% to 92%], n = 30/37). Underlying disease, stem cell source, chronic graft-versus-host-disease, and extracorporeal photopheresis differentially influenced GMCs of tetanus, diphtheria, and hepatitis B antibodies after 3 doses but not in the long term (24 months). Six (5.7%) patients experienced mild side effects. The pediatric DTaP(±HB)-IPV-Hib vaccine was safe and effective in eliciting a sustained protective humoral response in adult allo-HSCT recipients. Hepatitis B revaccination might be optimized by using higher antigen doses.

Management Approaches to Hepatitis B Virus Vaccination Nonresponse

Background: Despite the availability of hepatitis B virus (HBV) vaccination, HBV remains a cause of significant morbidity and mortality around the world. Immunologic response and the development of immunity to the HBV vaccine vary significantly among patients. Multiple studies have looked at patients who are at risk of nonresponse and have offered their own approaches to patients who do not respond. This article reviews the best approaches to HBV vaccine nonresponse. Methods: We searched the PubMed database for all articles on HBV vaccination response from 1981 to January 2018. Recommended and tested approaches to nonresponse were identified. Results: A total of 71 adequate-quality studies with 2354 patients were identified. Repeat vaccination with the same dose increased immunologic seroconversion in 85.7% of patients who previously reported nonresponse and in over 80% of patients with end-stage renal disease, HIV infection, hepatitis C virus (HCV) infection, advanced age, hypoalbuminemia, liver cirrhosis, and hemodialysis (HD) dependence. Patients with inflammatory bowel disease, celiac disease, and diabetes had a milder response (67.5%). Increasing the vaccination dose to 40 µg improved seroconversion in HIV-infected, HCV-infected, and HD patients of initial nonresponse. The use of a subcutaneous injection route increased response by 12% in patients infected with HIV. Conclusion: Patients not responding to an initial vaccine series and not actively infected with HBV benefited from reimmunization by repeating the vaccine series or receiving a single-dose vaccine booster. Although the overall response rate was approximately 90% of previous nonresponders, the rate varied among the populations studied.

Factors affecting responsiveness to hepatitis B immunization in dialysis patients

BACKGROUND

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are widespread health problems all over the world and have high morbidity and mortality. Hemodialysis patients are more frequently exposed to these viruses as they have poor immune system and frequently undergo parenteral interventions. The vaccination against HBV prevents infection and it has been recommended for the prevention of HBV infection in all susceptible dialysis patients. This study aimed to determine the seroprevalence of HBV and HCV infections and analyzed the factors affecting inadequate response to HBV vaccine in dialysis patients.

METHODS

The data for 584 dialysis patients that were followed up at seven dialysis centers were analyzed. The patients received four doses of 40 μg recombinant hepatitis B vaccine at 0, 1, 2, and 6 months and were tested for anti-HBs titer after one month of completion of vaccination. If patients showed a titer of anti-HBs <10 IU/mL, an additional 40 μg in four vaccine doses was administered immediately and they were retested for the anti-HBs following the same schedule. The patients were divided into two groups: responders and non-responders.

RESULTS

HBsAg and anti-HCV seroprevalence was 3.4% and 10.3%, respectively. After vaccination schedule, 264 (83.5%) patients had antibody response to HBV vaccine and 52 (16.5%) had no response. Hepatitis B vaccine unresponsiveness is more common in the patients with hepatitis C positivity (p = 0.011), BMI >30 (p = 0.019), over the age of 65 years (p = 0.009), and duration of dialysis treatment >5 years (p = 0.001). There was no statistically significant difference between gender, causes of renal disease, erythropoietin treatment, and the type of dialysis.

CONCLUSION

Hepatitis C infection, obesity, being elderly, and having long hemodialysis period reduced the hepatitis B vaccination response in hemodialysis patients.

Sci-B-VacTM Vs ENGERIX-B Vaccines for Hepatitis B Virus in Patients with Inflammatory Bowel Diseases: A Randomised Controlled Trial

BACKGROUND AND AIMS

Response rate to second-generation hepatitis B virus vaccines is relatively low in patients with inflammatory bowel diseases compared with the general healthy population. We compared the efficacy and safety of a third- vs a second-generation hepatitis B virus vaccine in a group of patients with inflammatory bowel diseases treated with immunosuppressive medications.

METHODS

Prospective, randomised, single-blind, controlled study. Eligible patients were randomly assigned to receive one of two vaccines, ENGERIX-B or Sci-B-Vac. The vaccines were administered in three doses at 0, 1, and 6 months. The primary endpoint was defined as the titre of anti-hepatitis B S [HBs] antibodies following the standard three-dose hepatitis B virus vaccination schedule.

RESULTS

A total of 72 patients complied with study protocol [37 and 35 patients in the ENGERIX-B and Sci-B-Vac groups, respectively]. Overall, 75% of the cohort seroconverted. The primary endpoint was met in 81.1% in the ENGERIX-B group and 68.6% in the Sci-B-Vac group [p = 0.22]. Patients in the Sci-B-Vac group showed a statistically significant decreased seroconversion rate compared with the ENGERIX-B group, with use of tumour necrosis factor [TNF] alpha inhibitors [p = 0.03], and higher degree of disease activity [p = 0.03].

CONCLUSIONS

Overall seroconversion rate in our cohort was higher than in previous reports in the literature, possibly due to a low disease activity state in the majority of participants. Third-generation hepatitis B virus vaccines showed no apparent advantage over standard of care vaccine in this patient group.

Chronic hepatitis B infection in pregnancy

There are no standard guidelines to follow when a patient with chronic hepatitis B infection becomes pregnant or desires pregnancy. Topics to consider include which patients to treat, when to start treatment, what treatment to use and when to stop treatment. Without any prophylaxis or antiviral therapy, a hepatitis B surface antigen and E antigen positive mother has up to a 90% likelihood of vertical transmission of hepatitis B virus (HBV) to child. Standard of care in the United States to prevent perinatal transmission consists of administration of hepatitis B immune globulin and HBV vaccination to the infant. The two strongest risk factors of mother to child transmission (MTCT) of HBV infection despite immunoprophylaxis are high maternal HBV viral load and high activity of viral replication. The goal is to prevent transmission of HBV at birth by decreasing viral load and/or decreasing activity of the virus. Although it is still somewhat controversial, most evidence shows that starting antivirals in the third trimester is effective in decreasing MTCT without affecting fetal development. There is a growing body of literature supporting the safety and efficacy of antiviral therapies to reduce MTCT of hepatitis B. There are no formal recommendations regarding which agent to choose. Tenofovir, lamivudine and telbivudine have all been proven efficacious in decreasing viral load at birth without known birth defects, but final decision of which antiviral medication to use will have to be determined by physician and patient. The antivirals may be discontinued immediately if patient is breastfeeding, or within first four weeks if infant is being formula fed.

Factors affecting effectiveness of vaccination against hepatitis B virus in hemodialysis patients

Hepatitis B virus (HBV) is a major global health problem. Despite the success of the general measures against blood transmitted infections in hemodialysis (HD) units, the prevalence of HBV infection among the HD patients is still high. Thus vaccination against HBV is indicating in this population. However, compared with the general population the seroprotection achieved in HD patients remains relatively low, at about 70%. In this review patient, HD procedure and vaccine-associated factors that affect the efficacy of HBV vaccination are analyzed. Also alternative routes of HBV vaccine administration as well as new and more immunogenic vaccine formulations are discussed. However, besides scientific progress, vigilance of HD physicians and staff regarding the general measures against the transmission of blood borne infections and the vaccination against HBV is also required for reducing the prevalence of this viral infection.

Antibody to Hepatitis B Surface Antigen in Vaccinated Health Care Workers

BACKGROUND

Health care workers (HCWs) in Armed Forces are immunised against Hepatitis B virus (HBV), however they are not subjected to anti-HBs (antibody to Hepatitis B surface antigen) assessment after primary vaccination. The present study was undertaken to determine the protection offered by HBV vaccine in HCW.

METHODS

Cross-sectional study was carried out at tertiary care hospital. A total 146 HBV vaccine compliant HCW were evaluated for quantitative anti-HBs by enzyme immune assay.

RESULT

129 (88.4%) subjects had protective levels of anti-HBs. Higher age at vaccination was an important risk factor in low vaccine response. Decline in anti-HBs with time was evident. Anti-HBs levels were more than 10mIU/ml in subjects even after 11 years of primary vaccination. There was no difference in protection in booster and non booster groups.

CONCLUSION

Age is the most important factor in HBV vaccine response. Booster dose of HBV vaccine is not necessary in healthy HCW for atleast ten years after primary vaccination. The study recommends early primary vaccination of HCW and 'initial' anti-HBs assay for confirmation of vaccine response.