POS0536 REFINING THE SEROLOGICAL SCORES OF THE ACR/EULAR 2010 RHEUMATOID ARTHRITIS CLASSIFICATION CRITERIA: AN INTERNATIONAL STUDY

Background

Rheumatoid factor (RF) and anti-cyclic citrullinated protein/peptide antibodies (ACPA) are included in the ACR/EULAR 2010 classification criteria for rheumatoid arthritis (RA)(1). Both markers are given the same weight in the criteria.

Objectives

As the performance characteristics differ significantly between RF and ACPA(2), we set out to refine the serological scores for RA classification.

Methods

Diagnostic samples from 398 RA patients and from 1073 diseased controls were evaluated with five RF assays (two RF IgM isotype-specific assays and three total RF assays) and five ACPA IgG assays from five different manufacturers.

Results

Firstly, we harmonized thresholds between manufacturers based on predefined specificity for low positive (at 92.5% specificity for RF and at 97.5% specificity ACPA) and high positive results (at 97.5% specificity RF and at 99.0% specificity for ACPA). Next, we determined likelihood ratios (LRs) for RF, ACPA, and combinations of both, for negative, low positive, and high positive results. The LR was higher for ACPA than for RF, for high positive results than for low positive results and for double positivity than for single positivity. Based on these data we refined the weights of serological scores for classification (Table 1).

Table 1.

Refined weights of serological scores for RA classification

RF negativeRF low positiveRF high positiveACPA negative011ACPA low positive233ACPA high positive344

Application of such refined serological weights significantly increased the area under the curve of receiver operating characteristics analysis to distinguish RA from controls, significantly reduced the serological scores in the controls as well as the number of RA misclassifications without affecting the diagnostic sensitivity.

Besides, we showed that combining predefined specificity thresholds with the refined serological scoring, reduced manufacturer-dependent variability in RA classification impacting RA classification for controls from 18.0-29.0% by ACR/EULAR to 11.0-13.0% (significantly increasing specificity) and for RA patients from 67.8-74.0% to 67.6-71.5% (without significantly affecting sensitivity).

Conclusion

Serological weight factors for RA classification can be improved by taking into account the antibody type (RF versus ACPA), the antibody level, and single or combined positivity.

References

[1]Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham COr, et al. 2010 rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Ann Rheum Dis 2010; 69: 1580-8.

[2]Bossuyt X. Anticitrullinated protein antibodies: taking into account antibody levels improves interpretation. Ann Rheum Dis 2017; 76: e33.

Acknowledgements

We thank all participating diagnostic companies for the in-kind support of assays, their technical training and the constructive discussions. Furthermore, we are very thankful to the laboratory technicians of all participating laboratories for their most appreciated assistance in the performance of the RF/ACPA analyses.

Disclosure of Interests

Lieve Van Hoovels Speakers bureau: Thermo Fisher, Consultant of: Thermo Fisher, Grant/research support from: Thermo Fisher, Bert Vander Cruyssen: None declared, Daniela Sieghart Speakers bureau: Thermo Fisher, Consultant of: Thermo Fisher, Carolien Bonroy: None declared, Eszter Nagy: None declared, Rille Pullerits: None declared, Saša Čučnik: None declared, Charlotte Dahle: None declared, Ingmar Heijnen Speakers bureau: Thermo Fisher, Luca Bernasconi Speakers bureau: Thermo Fisher, Farid Benkhadra: None declared, Laura Bogaert: None declared, Stefanie Van Den Bremt: None declared, Ann Vanliedekerke: None declared, Geert Vanheule: None declared, Johan Robbrecht: None declared, Lucy Studholme: None declared, Wirth Claudine: None declared, Rüdiger Müller: None declared, Diego Kyburz: None declared, Christopher Sjowall: None declared, Alf Kastbom: None declared, Rok Jese: None declared, Boja Jovancevic: None declared, Emese Virag Kiss: None declared, Peggy Jacques: None declared, Günter Steiner Speakers bureau: Thermo Fisher, Consultant of: Thermo Fisher, Patrick Verschueren: None declared, Xavier Bossuyt Speakers bureau: Thermo Fisher, Consultant of: Thermo Fisher.

Legacy data sharing to improve drug safety assessment: the eTOX project

The sharing of legacy preclinical safety data among pharmaceutical companies and its integration with other information sources offers unprecedented opportunities to improve the early assessment of drug safety. Here, we discuss the experience of the eTOX project, which was established through the Innovative Medicines Initiative to explore this possibility.

Economic considerations and patients' preferences affect treatment selection for patients with rheumatoid arthritis: a discrete choice experiment among European rheumatologists

OBJECTIVE

To compare the value that rheumatologists across Europe attach to patients' preferences and economic aspects when choosing treatments for patients with rheumatoid arthritis.

METHODS

In a discrete choice experiment, European rheumatologists chose between two hypothetical drug treatments for a patient with moderate disease activity. Treatments differed in five attributes: efficacy (improvement and achieved state on disease activity), safety (probability of serious adverse events), patient's preference (level of agreement), medication costs and cost-effectiveness (incremental cost-effectiveness ratio (ICER)). A Bayesian efficient design defined 14 choice sets, and a random parameter logit model was used to estimate relative preferences for rheumatologists across countries. Cluster analyses and latent class models were applied to understand preference patterns across countries and among individual rheumatologists.

RESULTS

Responses of 559 rheumatologists from 12 European countries were included in the analysis (49% females, mean age 48 years). In all countries, efficacy dominated treatment decisions followed by economic considerations and patients' preferences. Across countries, rheumatologists avoided selecting a treatment that patients disliked. Latent class models revealed four respondent profiles: one traded off all attributes except safety, and the remaining three classes disregarded ICER. Among individual rheumatologists, 57% disregarded ICER and these were more likely from Italy, Romania, Portugal or France, whereas 43% disregarded uncommon/rare side effects and were more likely from Belgium, Germany, Hungary, the Netherlands, Norway, Spain, Sweden or UK.

CONCLUSIONS

Overall, European rheumatologists are willing to trade between treatment efficacy, patients' treatment preferences and economic considerations. However, the degree of trade-off differs between countries and among individuals.

Solvent tuned single molecule dual emission in protic solvents: effect of polarity and H-bonding

Phen-PENMe2 has recently been proposed as a promising new molecule displaying solvent-tuned dual emission, highlighting an original and newly-described charge transfer model. The study of the photophysical behaviour of this molecule was extended to include protic solvents. The effects of polarity and hydrogen bonding lead to an even more evident dual emission associated with a large multi-emission band in some solvents like methanol, highlighting Phen-PENMe2 as a promising candidate for white light emission.

On the interaction of triarylmethane dye crystal violet with LAPONITE® clay: using mineral nanoparticles to control the dye photophysics

The combination of an organic dye with clays leads to very interesting hybrid materials with original properties.

Solvent-tuned dual emission: a structural and electronic interplay highlighting a novel planar ICT (OPICT)

Displaying a dual emission, a Phen-PENMe₂ compound can be foreseen as a new model for fundamental studies.

High plasma levels of vitamin C and E are associated with incident radiographic knee osteoarthritis

BACKGROUND

Previous studies suggest that the antioxidants vitamins C and E may protect against development of knee osteoarthritis (OA). We examined the association of circulating levels of vitamin C and E with incident whole knee radiographic OA (WKROA).

METHODS

We performed a nested case-control study of incident WKROA in MOST, a cohort of 3,026 men and women aged 50-79 years with, or at high risk of, knee OA. Incident cases were knees without either tibiofemoral (TF) or patellofemoral (PF) OA at baseline that developed TF and/or PF OA by 30-month follow-up. Two control knees per case were selected from those eligible for WKROA that did not develop it. Vitamin C and E (alpha-tocopherol) assays were done on baseline supernatant plasma (PCA) and serum samples, respectively. We examined the association of gender-specific tertiles of vitamin C and E with incident WKROA using logistic regression with GEE, adjusting for age, gender, and obesity.

RESULTS

Subjects without WKROA at baseline who were in the highest tertile of vitamin C had a higher incidence of WKROA [adjusted OR = 2.20 (95% CI: 1.12-4.33); P-value = 0.021], with similar results for the highest tertile of vitamin E [adjusted OR = 1.89 (1.02-3.50); P-value = 0.042], compared to those in the lowest tertiles. P-values for the trend of vitamin C and E tertiles and incident WKROA were 0.019 and 0.030, respectively.

CONCLUSIONS

Higher levels of circulating vitamin C and E did not provide protection against incident radiographic knee OA, and may be associated with an increased risk of knee OA.

Effect of pps disruption and constitutive expression of srfA on surfactin productivity, spreading and antagonistic properties of Bacillus subtilis 168 derivatives

AIMS

To analyse the effects of plipastatin operon disruption and constitutive expression of surfactin operon in Bacillus subtilis 168 on surfactin productivity, in vitro invasive growth and antagonism against fungi.

METHODS AND RESULTS

The srfA native promoter was replaced by the constitutive promoter P(repU) in B. subtilis 168 after integration of a functional sfp gene. Moreover, the plipastatin synthesis was further disrupted in the B. subtilis 168 derivatives. In liquid media, an earlier and higher expression of P(repU), than that found with P(srfA), led to a specific surfactin production fivefold higher after 6 h of culture. On solid media, not only the invasive growth and the haemolytic activity but also the antifungal activity of the constitutive strains were improved when compared to the parental strain BBG111. As expected, the disruption of the plipastatin operon strongly reduced in vitro antifungal properties but, interestingly, enhanced specific surfactin production (1.47 g g(-1) of biomass), spreading behaviour and haemolytic activity of the strains.

CONCLUSIONS

This work demonstrates for the first time the interdependency of surfactin and plipastatin regarding their biosynthesis as well as their influence on the biological activities of the producing strain.

SIGNIFICANCE AND IMPACT OF THE STUDY

The constitutive overproduction of surfactin enhances the invasive growth and the in vitro antagonistic activity of the mutant strain. Both properties are known to play an important role in the biocontrol of plant diseases. Plipastatin operon disruption increases the surfactin productivity of mutant strains. These mutants are interesting for use in continuous bioprocesses for surfactin production or in bioremediation.

Reversible changes in serum immunoglobulin galactosylation during the immune response and treatment of inflammatory autoimmune arthritis

OBJECTIVES

Improved DNA sequencer-aided fluorophore-assisted carbohydrate electrophoresis (DSA-FACE) technology was used to monitor the changes in the galactosylation status of serum immunoglobulins during the immune response and therapy of autoimmune arthritis.

METHODS

Collagen-induced arthritis (CIA) was induced in susceptible DBA/1 mice and the undergalactosylation status (UGS) of serum immunoglobulins was determined using the improved DSA-FACE technology. Prophylactic intravenous tolerisation with type II collagen as well as semitherapeutic treatment with dexamethasone (DEX) were performed and UGS was analysed. Next, the serum immunoglobulin glycosylation profiles of patients with rheumatoid arthritis (RA) and spondyloarthropathy (SpA) were studied and changes in the UGS scores during anti-tumour necrosis factor (TNF)alpha therapy followed.

RESULTS

In the longitudinal CIA study, the undergalactosylation state of immunoglobulins was found to be significantly correlated with the clinical arthritis scores. Upon collagen-specific tolerisation as well as glucocorticoid semitherapeutic treatment, improvement of the clinical arthritis scores correlated with decreased levels of UGS. It was also demonstrated that withdrawal of DEX was associated with an increased UGS score. Interestingly, reversibility in the UGS was also shown during treatment of patients with RA and SpA with anti-TNFalpha.

CONCLUSIONS

These findings demonstrate that the UGS of serum immunoglobulins changes during the disease course of CIA and that this UGS is inhibited by antigen-specific and antigen-independent treatment procedures. The observation that Ig galactosylation is a reversible process is also documented during treatment of patients with RA and SpA with anti-TNFalpha.

Setting up and modelling of overflowing fed-batch cultures of Bacillus subtilis for the production and continuous removal of lipopeptides

This work is related to the set-up of overflowing exponential fed-batch cultures (O-EFBC) derived from carbon limited EFBC dedicated to the production of mycosubtilin, an antifungal lipopeptide belonging to the iturin family. O-EFBC permits the continuous removal of the product from the bioreactor achieving a complete extraction of mycosubtilin. This paper also provides a dynamical Monod-based growth model of this process that is accurate enough to simulate the evolution of the specific growth rate and to correlate it to the mycosubtilin specific productivity. Two particular and dependant phenomena related to the foam overflow are taken into account by the model: the outgoing flow rate of a broth volume and the loss of biomass. Interestingly, the biomass concentration in the foam was found to be lower than the biomass concentration in the bioreactor relating this process to a recycling one. Parameters of this model are the growth yield on substrate and the maximal specific growth rate estimated from experiments led at feed rates of 0.062, 0.071 and 0.086h(-1). The model was extrapolated to five additional experiments carried out at feed rates of 0.008, 0.022, 0.040, 0.042 and 0.062h(-1) enabling the correlation of the mean specific growth rates with productivity results. Finally, a feed rate of 0.086h(-1) corresponding to a mean specific growth rate of 0.070h(-1) allowed a specific productivity of 1.27mg of mycosubtiling(-1) of dried biomassh(-1).

Evaluation of the microtensile bond strength of composite resin restoration in dentin prepared with different sizes of aluminum oxide particles, using the air abrasion system

AIM

The purpose of this in vitro study was to evaluate the influence of the abrasive technique on the microtensile bond strength of composite resin restorations. In addition, any differences in the microtensile bond strength were observed when different aluminum oxide particle sizes were used.

METHODS

Flat coronal dentin surfaces were randomly distributed into 3 groups, according to surface treatment: Group A27 Air-abraded dentin with 27 microm aluminum oxide particles; Group A50-Air-abraded dentin with 50 microm aluminum oxide particles; Group HS cut dentin with a #1013 diamond bur in high-speed rotary instrument. After the bonding procedure (Single Bond/Z100), the teeth were stored in distilled water at 37 masculineC for 48 h prior to sectioning. Then, each bonded tooth was longitudinally sectioned producing sticks with a cross-sectional area of 0.81 mm2. The tensile load was applied at a crosshead speed of 0.5 mm/min, until the stick fractured. The data were analyzed by one-way ANOVA and post hoc multiple comparisons using Tukey's test.

RESULTS

No difference was observed in composite bond strength when 27 and 50 microm aluminum oxide particles were used for dentin surface preparation using an air abrasion system. However, air-abraded dentin, using 27 microm aluminum oxide particles, demonstrated a higher bond strength when compared to dentin prepared by the conventional method (bur in high-speed).

CONCLUSIONS

The air-abraded dentin, using 27 microm alumina powder, demonstrated higher composite bond strength when compared to bur-cut dentin, raising the possibility that this method may increase restoration longevity.

NKT cells: manipulable managers of joint inflammation

The importance of T cell participation in the aetiology and pathogenesis of rheumatoid arthritis (RA) is now widely appreciated. The disease is mediated by activated pro-inflammatory, self-reactive T helper cells, instigating the chronic autoimmune response characteristic of rheumatoid inflammation. Natural killer T (NKT) cells are a distinctive population of T cells thought to protect self-tissues from damaging inflammatory immune responses, and are often recognized as a regulatory T cell subtype, regulating the magnitude or class of the immune response. Recently, a number of studies have provided insight concerning the role of NKT cells in different models of autoimmune joint inflammation, suggesting the involvement of this specialized T cell subset in controlling initiation and perpetuation of arthritic disease. The aim of this review is to provide rheumatologists with an introduction of the principal features of NKT cells, to give an overview of the data obtained in animal models of arthritis and to discuss the hypothesized mechanisms. Finally, we will speculate on future prospects with regard to NKT cell-targeted treatment of arthritic disease by use of glycolipids.

Studies on bone enzymes. The assay of acid hydrolases and other enzymes in bone tissue

1. Nine acid hydrolases, cytochrome oxidase, alkaline phenylphosphatase and catalase were demonstrated in 0.25m-sucrose homogenates of newborn-rat calvaria. The acid hydrolases were: acid phenylphosphatase, acid beta-glycerophosphatase, beta-glucuronidase, beta-N-acetylglucosaminidase (beta-N-acetylaminodeoxyglucosidase), acid ribonuclease and acid deoxyribonuclease, showing optimum activity at about pH5; cathepsin, beta-galactosidase and hyaluronidase, with optimum activity at about pH3.6. 2. The main kinetic characters of these enzymes have been studied and methods for their quantitative assay have been worked out. The activities present in bone are given and compared with those found in liver. 3. Acid-phosphatase activity was assayed with phenyl phosphate and beta-glycerophosphate as substrates: activities with these two substrates appeared to be due to two different enzymes. Acid phenylphosphatase is particularly labile and is readily inactivated by various physical or chemical agents.

Studies on bone enzymes. Distribution of acid hydrolases, alkaline phenylphosphatase, cytochrome oxidase and catalase in subcellular fraction of bone tissue homogenates

1. When bone homogenates were fractionated according to the scheme developed for liver by de Duve, Pressman, Gianetto, Wattiaux & Appelmans (1955), all the enzymes assayed except cytochrome oxidase were found to occur partly in soluble and partly in particulate fractions. Among the particle-bound enzymes, the highest specific activity was found in the heavy-mitochondrial fraction for cytochrome oxidase, in the microsomal fraction for alkaline phenylphosphatase and in the light-mitochondrial fraction for eight acid hydrolases and for catalase. 2. Combined heavy-mitochondrial and light-mitochondrial fractions were subfractionated by isopycnic centrifugation in density gradients of sucrose or glycogen. In the various systems tried, cytochrome oxidase showed a relatively narrow distribution range with a sharp peak; the acid hydrolases and catalase showed flat and irregular distribution patterns, differing slightly in shape from one enzyme to the other. However, it was not possible to achieve a marked separation between the various enzymes under study. 3. It is concluded from these results that the acid hydrolases belong to special cytoplasmic particles, probably lysosomes, and that these particles are physically and enzymically heterogeneous. Catalase appears to be non-mitochondrial and could also belong to the lysosomes; but the possibility of an association with another type of particle must be kept in mind in view of what is known of liver catalase. Alkaline phenylphosphatase is largely attached to microsomal elements.

Direct measurements of Ab and Ac using vertex and kaon charge tags at the SLAC detector

Exploiting the manipulation of the SLAC Linear Collider electron-beam polarization, we present precise direct measurements of the parity-violation parameters A(c) and A(b) in the Z-boson-c-quark and Z-boson-b-quark coupling. Quark-antiquark discrimination is accomplished via a unique algorithm that takes advantage of the precise SLAC Large Detector charge coupled device vertex detector, employing the net charge of displaced vertices as well as the charge of kaons that emanate from those vertices. From the 1996-1998 sample of 400 000 Z decays, produced with an average beam polarization of 73.4%, we find A(c)=0.673+/-0.029(stat)+/-0.023(syst) and A(b)=0.919+/-0.018(stat)+/-0.017(syst).

Hepatitis B Vaccination Coverage in Belgian Health Care Workers

BACKGROUND

The hepatitis B virus (HBV) vaccination policy for health care workers (HCW) started in Belgium in 1983. An update of vaccination coverage and rates of seroconversion and seroprotection among HCW can give an insight into the actual status and encourage further development of vaccination programs.

PATIENTS AND METHODS

5,064 HCW were tested for anti-HBs. We considered those who had a positive anti-HBs test as seroconverted (SC) and those who had an anti-HBs titer > 10 IU/l as seroprotected (SP).

RESULTS

4,771 HCW were eligible for vaccination; 84.9% of them were effectively vaccinated. Among high-risk professions (nurses, care and laboratory workers), 94.79% were vaccinated; for other professions the vaccination coverage was 69.26%. Of the 1,015 non-vaccinated persons, 293 were anti-HBs positive. Among these 54.95% declared they had had a previous hepatitis infection that was serologicaLly proven to be HBV (anti-HBc positive). Of the remaining 132 positives, 70.45% had previously undergone surgery and/or transfusion. Among these 1,015 non-vaccinated HCW, 59.03% were anti-HBs positive. Of these, 373 were nurses, care or laboratory workers. This contrasts with the results for HCW in other sectors, where 11.49% were anti-HBs positive.

CONCLUSION

In our sample, high vaccination, seroconversion and seroprotection rates were achieved, at least for higher risk HCW. The same conclusion can be drawn if we consider hospital departments which carry a higher risk of blood-borne infections.

Role of lipopeptides produced by Bacillus subtilis GA1 in the reduction of grey mould disease caused by Botrytis cinerea on apple

AIM

Test of Bacillus subtilis strain GA1 for its potential to control grey mould disease of apple caused by Botrytis cinerea.

METHODS AND RESULTS

GA1 was first tested for its ability to antagonize in vitro the growth of a wide variety of plant pathogenic fungi responsible for diseases of economical importance. The potential of strain GA1 to reduce post-harvest infection caused by B. cinerea was tested on apples by treating artificially wounded fruits with endospore suspensions. Strain GA1 was very effective at reducing disease incidence during the first 5 days following pathogen inoculation and a 80% protection level was maintained over the next 10 days. Treatment of fruits with an extract of GA1 culture supernatant also exerted a strong preventive effect on the development of grey mould. Further analysis of this extract revealed that strain GA1 produces a wide variety of antifungal lipopeptide isomers from the iturin, fengycin and surfactin families. A strong evidence for the involvement of such compounds in disease reduction arose from the recovery of fengycins from protected fruit sites colonized by bacterial cells.

CONCLUSIONS

The results presented here demonstrate that, despite unfavourable pH, B. subtilis endospores inoculated on apple pulp can readily germinate allowing significant cell populations to establish and efficient in vivo synthesis of lipopeptides which could be related to grey mould reduction.

SIGNIFICANCE AND IMPACT OF THE STUDY

This work enables for the first time to correlate the strong protective effect of a particular B. subtilis strain against grey mould with in situ production of fengycins in infected sites of apple fruits.

Fluorescent Pseudomonas mainly produce the dihydro form of pyoverdine at low specific growth rate

AIMS

To analyse the influence of cell growth rate and iron concentration on the production of pyoverdines (PVDs) and of their reduced dihydro forms by three fluorescent Pseudomonas strains (P. putida BTP16, P. fluorescens BTP7 and P. aeruginosa 7NSK2).

METHODS

PVD and dihydropyoverdine (DHPVD) productions were determined by LC ESI-MS and spectrophotometry during batch and chemostat culture at different dilution rates.

SIGNIFICANCE

The relatively high PVD-to-DHPVD ratio (0.57) observed in pH-controlled batch cultures suggested that a base-catalysed chemical oxidation of the dihydroform is not the prime mechanism involved in generating PVDs. Interestingly, in chemostat cultures the PVD-to-DHPVD ratio was significantly reduced at low specific growth rate. Our results suggest that the oxidation of DHPVD to PVD is catalysed by an iron-dependent enzymatic reaction rather than a chemical oxidation.

Improved direct measurement of the parity-violation parameter Ab using a mass tag and momentum-weighted track charge

We present an improved direct measurement of the parity-violation parameter A(b) in the Z boson-b-quark coupling using a self-calibrating track-charge technique applied to a sample enriched in Z-->bb events via the topological reconstruction of the B hadron mass. Manipulation of the Stanford Linear Collider electron-beam polarization permits the measurement of A(b) to be made independently of other Z-pole coupling parameters. From the 1996-1998 sample of 400,000 hadronic Z decays, produced with an average beam polarization of 73.4%, we find A(b)=0.906+/-0.022(stat)+/-0.023(syst).

The immunogenicity and reactogenicity profile of a candidate hepatitis B vaccine in an adult vaccine non-responder population

Approximately 5% of vaccinees display an inadequate response after the administration of the standard three dose hepatitis B vaccine. A new hepatitis B vaccine (HBsAg/AS04) formulated with the adjuvant AS04 which contains 3'-deacylated monophosphoryl lipid A (3D-MPL) and alum has been developed. AS04 enhances the immune response which may be beneficial to non-responders. In a single-blind, randomised study, we tested the immunogenicity and reactogenicity of the new vaccine with that of commercially established hepatitis B vaccine, both on a 0, 1, 6 months schedule in 20-60 years old non-responders (titre <10 m IU/ml after four doses of hepatitis B vaccine). One month after the first dose the seroprotection rate was 44% for group 1 (58 subjects) receiving the established vaccine versus 66% for group 2 receiving HBsAg/AS04 (57 subjects) (P=0.03). One month after the second dose this was 58 and 81%, respectively (P<0.005) and 1 month after the third dose this was 68 and 98%, respectively (P<0.001). One month after each dose, GMTs were 34, 56 and 111 mIU/ml for group 1 versus 123222 and 1937 mIU/ml for the HBsAg/AS04 group (P<0.05, <0.01 and 0.0001, respectively). Pain at the injection site was the most commonly reported local symptom and very few symptoms were scored as severe. In this group of adult non-responders to previous hepatitis vaccination, the HBsAg/AS04 vaccine was well tolerated and induced, at all time-points, a superior immune response compared to the licensed hepatitis B vaccine.