Incidence of Low Seroimmunity to Hepatitis B Virus in Children with Inflammatory Bowel Disease: A Single Center Experience

Purpose

Immunosuppressive therapy is frequently administered to patients with inflammatory bowel disease (IBD), which may make them more susceptible to infections like hepatitis B.

Methods

A cross-sectional study was conducted on patients aged 5-18 years diagnosed with IBD who visited a gastroenterology clinic along with controls who were the same age as the patients with IBD and were healthy overall. A logistic regression analysis using the independent variables of age, sex, race, disease phenotype, surgery, and medications and the dependent variable of adequate hepatitis B surface antibody (HBsAb) titers (>10 mIU/mL) was performed on quantitative serum HBsAb titers.

Results

The study enrolled 62 patients, including 37 males and 25 females. Crohn's disease, ulcerative colitis, and indeterminate colitis were diagnosed in 16, 22, and 24 patients, respectively. Thirty-nine patients were taking corticosteroids at the time of the study, 42 were taking immunomodulators, and four were taking biologics. Compared to 44.7% of the control group, 9.3% of the patients had protective titers. Only 12 out of 62 patients had HBsAb titers greater than 10 million IU/mL. None of the patients who received biologics or corticosteroids and 3.2% of those who received immunomodulators were found to be seroimmuned.

Conclusion

The younger patients had the highest titers. Patient-specific factors that may impact these low titers include the length of the patient's illness and the use of immunosuppressants.

Size Matters! Anti-HBs Titer and HBV Reactivation During Anti-TNF Therapy

BACKGROUND AND AIMS

We and others have previously described that hepatitis B surface antibody (anti-HBs) seems to protect against clinically significant HBV reactivation in cohort studies of patients undergoing anti-tumor necrosis factor (TNF) therapy. However, there were too few cases of HBV reactivation within cohort studies to assess the role of anti-HBs titer on reactivation. The purpose of this study was to systematically review the correlation between anti-HBs titer and the degree of clinically relevant HBV reactivation in patients undergoing anti-TNF therapy.

METHODS AND RESULTS

We systemically reviewed all studies discussing anti-TNF therapy in patients with resolved HBV infection, defined as hepatitis surface antigen (HBsAg) negative and hepatitis B core antibody (anti-HBc) positive. We identified a total of 48 cases of reactivation from 5 cohort studies and 10 case reports or case series; 21 were anti-HBs negative, 7 were only reported as anti-HBs positive, 16 were anti-HBs positive with titer below 100, and 4 were anti-HBs positive with titer above 100. HBsAg sero-reversion was dominantly seen in patients with negative, low and/or declining anti-HBs titers. There was a significant trend toward less clinically relevant form of reactivation with increase in baseline anti-HBs titer (p = 0.022).

CONCLUSION

Anti-HBs titers greater than 100 iU/L protect against clinically relevant HBV reactivation, while patients with low anti-HBs titers or negative anti-HBs had more clinically relevant HBV reactivation and higher rates of HBsAg sero-reversion. This suggests the importance of baseline quantitative anti-HBs prior to starting anti-TNF therapy and consideration vaccination for boosting anti-HBs titers prior to and/or during therapy.

Evaluation of factors associated the expression of anti-HBs in children in Hunan Province, China

BACKGROUND AND OBJECTIVES

Vaccine is the most essential avenue to prevent hepatitis B virus (HBV) infection in infants and preschool children in China, with the largest populations carrying HBV in the world. This study aimed to evaluate the factors associating the response level of anti-HBs in children, providing instructions for HBV prevention clinically.

METHODS

The children taking physical examinations in the Third Xiangya Hospital from January 2013 to April 2020 were recruited. Telephone follow-up were adopted to collect further information. Univariate logistic regression was used to analyse the relationship between age and anti-HBs expression. Grouping by age and anti-HBs expression, we used chi-square test and T test to compare qualitative and quantitative data between positive group and negative group in each age subgroup. The meaningful variables (P < 0.10) in chi-square test or T test were further assessed with collinearity and chosen for univariate and multivariate logistic regression analysis by the stepwise backward maximum likelihood method (α_in = 0.05, α_out = 0.10).

RESULTS

A total of 5838 samples (3362 males, 57.6%) were enrolled. In total, the incidence of negative anti-HBs increased with age[OR = 1.037(1.022-1.051)]. Multivariate logistic regression analysis illustrated that anemia[OR = 0.392(0.185-0.835)], age[OR = 2.542(1.961-3.295)] and Vit D[OR = 0.977(0.969-0.984)] in 0.5-2.99 years subgroup, Zinc deficiency[OR = 0.713(0.551-0.923] and age[OR = 1.151(1.028-1.289)] in 3-5.99 years subgroup, Vit D[OR = 0.983(0.971-0.995)] in 12-18 years subgroup had significant association with anti-HBs.

CONCLUSIONS

This retrospective study illustrated that age, anemia status, zinc deficiency and vitamin D were associated with anti-HBs expression in specific age groups of children, which could serve as a reference for the prevention of HBV.

Chronic hepatitis B: New potential therapeutic drugs target

Chronic hepatitis B (CHB) infection remains the most causative agent of liver-related morbidity and mortality worldwide. It impacts nearly 300 million people. The current treatment for chronic infection with the hepatitis B virus (HBV) is complex and lacks a durable treatment response, especially hepatitis B surface antigen (HBsAg) loss, necessitating indefinite treatment in most CHB patients due to the persistence of HBV covalently closed circular DNA (cccDNA). New drugs that target distinct steps of the HBV life cycle have been investigated, which comprise inhibiting the entry of HBV into hepatocytes, disrupting or silencing HBV cccDNA, modulating nucleocapsid assembly, interfering HBV transcription, and inhibiting HBsAg release. The achievement of a functional cure or sustained HBsAg loss in CHB patients represents the following approach towards HBV eradication. This review will explore the up-to-date advances in the development of new direct-acting anti-HBV drugs. Hopefully, with the combination of the current antiviral drugs and the newly developed direct-acting antiviral drugs targeting the different steps of the HBV life cycle, the ultimate eradication of CHB infection will soon be achieved.

Extremely high titer of hepatitis B surface antigen antibodies in a primary hepatocellular carcinoma patient: A case report

BACKGROUND

Hepatocellular carcinoma (HCC) may be caused by hepatitis B virus (HBV) infection. Post-infection recovery-associated changes of HBV indicators include decreased hepatitis B surface antigen (HBsAg) level and increased anti-HBsAg antibody titer. Testing to detect HBV DNA is conducted rarely but could detect latent HBV infection persisting after acute infection and prompt administration of treatments to clear HBV and prevent subsequent HBV-induced HCC development. Here, we present an HCC case with an extremely high anti-HBsAg antibody titer and latent HBV infection.

CASE SUMMARY

A 57-year-old male patient with abdominal pain who was diagnosed with primary HCC presented with an extremely high level (over 2000 ng/mL) of serum alpha-fetoprotein. Abdominal B-ultrasonography and computed tomography scan results indicated focal liver lesion and mild splenomegaly. Assessments of serological markers revealed a high titer of antibodies against hepatitis B core antigen (anti-HBcAg antibodies), an extremely high titer (1000 mIU/mL) of hepatitis B surface antibodies (anti-HBsAg antibodies, anti-HBs) and absence of detectible HBsAg. Medical records indicated that the patient had reported no history of HBV vaccination, infection or hepatitis. Therefore, to rule out latent HBV infection in this patient, a serum sample was collected then tested to detect HBV DNA, yielding a positive result. Based on the aforementioned information, the final diagnosis was HCC associated with hepatitis B in a compensated stage of liver dysfunction and the patient was hospitalized for surgical treatment.

CONCLUSION

A rare HCC case with high serum anti-HBsAg antibody titer and detectable HBV DNA resulted from untreated latent HBV infection.

Paradoxical HBsAg and anti-HBs coexistence among Chronic HBV Infections: Causes and Consequences

Hepatitis B surface antigen (HBsAg) and Hepatitis B surface antibody (anti-HBs) were reported simultaneously among Hepatitis B virus (HBV) infections. HBsAg is a specific indicator of acute or chronic HBV infections, while anti-HBs is a protective antibody reflecting the recovery and immunity of hosts. HBsAg and anti-HBs coexist during seroconversion and then form immune complex, which is rare detected in clinical cases. However, with the promotion of vaccination and the application of various antiviral drugs, along with the rapid development of medical technology, the coexistence of HBsAg and anti-HBs has become more prevalent. Mutations in the viral genomes, immune status and genetic factors of hosts may contribute to the coexistence. Novel HBsAg assays, with higher sensitivity and ability to detect mutations or immune complexes, can also yield HBsAg/anti-HBs coexistence. The discovery of coexistence has shattered the idea of traditional serological patterns and raised questions about the effectiveness of vaccines. Worth noting is that HBsAg/anti-HBs double positivity is strongly associated with progressive liver diseases, especially hepatocellular carcinoma. In conclusion, viral mutations, host factors, and methodology impacts can all lead to the coexistence of HBsAg and anti-HBs. This coexistence is not an indicator of improvement, as an increased risk of adverse clinical outcomes still exists.

A comparison of post vaccination hepatitis B surface antibody level on the large and appropriate for gestational age infants

Purpose

The aim of this study was to compare the hepatitis B surface antibody (HBs Ab) titer 1 month after the 4th dose of hepatitis B vaccine administration on the large and appropriate for gestational age infants.

Materials and Methods

This cross-sectional study was conducted on 7-month-old cases (n=132) divided into two groups of 2-4 kg (group 1: appropriate for gestational age, 63 cases) and >4 kg (group 2: large for gestational age, 69 cases), whom were vaccinated with a four-dose schedule of hepatitis B vaccine in 2016, Tehran, Iran.

Results

Mean birth weight of the groups was 2.98±0.528 and 4.19±0.190 kg, respectively. Hepatitis B surface antigen and hepatitis B core antibody were negative in all cases. HBs Ab level in group 1 and 2 was 13,701.00±11,744.439 and 8,997.15±2,827.191, respectively (95% confidence interval of difference, -7,607.44 to -1,800.25). There was a significant difference between the two groups in antibody titration and antibody logarithm level (p=0.002, p=0.0001).

Conclusion

Birth weight may affect the response to the hepatitis B virus vaccine administration.

Risk factors for de novo hepatitis B during solid cancer treatment

BACKGROUND

Reactivation of hepatitis B virus (HBV) during anticancer treatment is a critical issue. When treating patients with solid tumors, it is unclear whether specific cancer types or treatments affect HBV reactivation in hepatitis B surface antigen (HBsAg)-negative and hepatitis B core antibody (HBcAb)-positive patients, so-called de novo hepatitis B patients. The risk of de novo hepatitis B may vary based on different background factors.

AIM

To determine the frequency and risk factors for de novo hepatitis B during solid tumor treatment.

METHODS

This retrospective cohort study comprised 1040 patients without HBsAgs and with HBcAbs and/or hepatitis B surface antibodies (HBsAbs). The patients were treated for solid cancer from 2008 to 2018 at the National Kyushu Cancer Center and underwent HBV DNA measurements. Patient characteristics and disease and treatment information were investigated. HBV DNA measurements were performed using TaqMan polymerase chain reaction (PCR). To identify the risk factors associated with HBV DNA expression, the age, sex, original disease, pathology, treatment method, presence or absence of hepatitis C virus (HCV), and HBsAb and/or HBcAb titers of all subjects were investigated. In patients with HBV DNA, the time of appearance, presence of HBsAgs and HBsAbs at the time of appearance, and course of the subsequent fluctuations in virus levels were also investigated.

RESULTS

Among the 1040 patients, 938 were HBcAb positive, and 102 were HBcAb negative and HBsAb positive. HBV DNA expression was observed before the onset of treatment in nine patients (0.9%) and after treatment in 35 patients (3.7%), all of whom were HBcAb positive. The HBV reactivation group showed significantly higher median HBcAb values [9.00 (8.12-9.89) vs 7.22 (7.02-7.43), P = 0.0001] and significantly lower HBsAb values (14 vs 46, P = 0.0342) than the group without reactivation. Notably, the reactivated group showed a significantly higher proportion of cancers in organs related to digestion and absorption (79.0% vs 58.7%, P = 0.0051). A high HBcAb titer and cancers in organs involved in digestion and absorption were identified as independent factors for HBV reactivation (multivariate analysis, P = 0.0002 and P = 0.0095). The group without HBsAbs tended to have a shorter time to reactivation (day 43 vs day 193), and the frequency of reactivation within 6 mo was significantly higher in this group (P = 0.0459) than in the other group.

CONCLUSION

A high HBcAb titer and cancers in organs involved in digestion and absorption are independent factors that contribute to HBV reactivation during solid tumor treatment.

Hepatitis B virus infection and diabetes mellitus: the Kailuan prospective cohort study in China

BACKGROUND AND AIMS

The effect of hepatitis B virus (HBV) infection on diabetes has remained unclear. We thus conducted a prospective cohort study to investigate the association between different HBV infection status and new-onset diabetes in a Chinese population.

METHODS

We enrolled 55,520 participants with HBV serological markers and diabetes free in 2010 in Kailuan cohort. Cox regression models were used to analyze the relationship between different HBV infection status and incidence of diabetes after adjusting different confounders.

RESULTS

During an average follow-up of 5.6 years, we identified 6008 incident patients with diabetes. Compared to the participants with hepatitis B surface antigen (HBsAg) negative/hepatitis B surface antibody (anti-HBs) negative/hepatitis B core antibody (anti-HBc) negative, those with chronic HBV infection or with HBsAg negative/anti-HBc positive had a higher risk to occur diabetes. The hazard ratios were 1.18 (95% CI 0.99-1.40, p = 0.0588) and 1.22 (95% CI 1.08-1.36, p = 0.0009), respectively. The association between chronic HBV infection, anti-HBc positive and diabetes was different between those with different levels of high density lipoprotein cholesterol, blood pressure, body mass index, and age.

CONCLUSION

The individuals with chronic HBV infection or anti-HBc positive may have an increased risk of diabetes, and the association may be modified by the different status of metabolism related variables and age. Effective management of HBV infection may contribute to the reduction of the burden of both hepatitis B and diabetes.

Effect of hepatitis B surface antibody in patients with core antibody-positive liver transplantation: a systematic review and meta-analysis

BACKGROUND AND AIM

There is an increased awareness of de novo hepatitis B virus (HBV) infection (DNH) in hepatitis B surface antigen (HBsAg)-negative recipients receiving hepatitis B core antibody (HBcAb)-positive liver organ. Whether hepatitis B surface antibody (HBsAb) has positive result on preventing the occurrence of DNH in HBcAb-positive liver graft recipients remains unknown. A meta-analysis was conducted to evaluate the effect of HBsAb on DNH in these patients.

METHODS

We sought published studies through August 29, 2019, in Medline and other sources that examined DNH in liver transplantation receptors with HBcAb-positive grafts. The rate of DNH was established in random-effects model meta-analyses.

RESULTS

In 36 studies involving 950 patients, the pooled incidence rate of DNH was 5% in patients with HBsAb positive versus 28.0% HBsAb negative. Prophylactic treatment has a significant impact on the occurrence of DNH in HBsAb-negative patients, no difference in hepatitis B immunoglobulin-combined and nucleos(t)ide analogues (NAs)-alone immunoprophylaxis. Unprotected HBV-naïve patients had the highest risk with DNH.

CONCLUSION

Immunoprophylaxis may need more consideration for HBsAb-positive patients receiving HBcAb-positive liver grafts. Active vaccination and mono-prophylaxis with NAs could be recommended in HBsAb-negative recipients against DNH. Further studies should examine the higher genetic barrier drugs for preventing DNH, and the association between DNH and HBV DNA-positive liver graft in this patient population.

Determining Whether Prophylactic Antiviral Treatment Is Necessary in HBsAg-Negative/HBcAb-Positive Patients Receiving Allogeneic Hematopoietic Stem Cell Transplantation

The incidence of hepatitis B virus (HBV) infection is high in the Asian population. Increasing attention is being given to the risk of HBV reactivation in hepatitis B core antibody-positive [HBcAb(+)] patients during immunosuppressive therapy. Knowledge of HBV reactivation in hematopoietic stem cell transplantation (HSCT) is limited. Moreover, the effect of hepatitis B surface antibody (HBsAb) on HBV reactivation in HBcAb(+) patients during HSCT remains uncertain. We sought to investigate the role of HBsAb and the need for prophylactic antiviral treatment in hepatitis B surface antigen-negative [HBsAg(-)]/HBcAb(+) patients during HSCT. We classified 665 HBsAg(-) HSCT recipients into 4 groups: HBcAb(-)HBsAb(-) (n = 189), HBcAb(-)HBsAb(+) (n = 176), HBcAb(+)HBsAb(-) (n = 49), and HBcAb(+)HBsAb(+) (n = 251). HBV reactivation was identified in 16 patients after HSCT. The median time to HBV reactivation was 645 days (range, 455 to 1957 days) after transplantation. The cumulative HBV reactivation rate was significantly higher in the HBcAb(+)HBsAb(-) group compared with the HBcAb(+)HBsAb(+), HBcAb(-)HBsAb(-), and HBcAb(-)HBsAb(+) groups, respectively (P< .001). Notably, the risk of HBV reactivation was significantly higher in the HBcAb(+)HBsAb(-) group compared with the HBcAb(+)HBsAb(+) group (P= .007; hazard ratio, 4.750; 95% confidence interval, 1.531 to 14.737). Our results point to a protective role of HBsAb in HBV-resolved patients undergoing HSCT and indicate that prophylactic anti-HBV treatment might not be mandatory for HBsAg(-), HBcAb(+)HBsAb(+) patients following HSCT. The surveillance protocol of intense follow-up early (HBV DNA and HBsAg monthly) might not be necessary.

Strong influence of human leukocyte antigen-DP variants on response to hepatitis B vaccine in a Japanese population

Genome-wide association studies (GWASs) have reported that human leukocyte antigen (HLA) variants are associated with chronic hepatitis B, spontaneous hepatitis B virus (HBV) clearance, and response to hepatitis B vaccine. Single nucleotide polymorphisms (SNPs) in HLA-DP (rs9277535 and rs3077) and HLA-DQ (rs2856718 and rs7453920) have been repeatedly associated with chronic hepatitis B and spontaneous HBV clearance. However, the data on the SNPs associated with response to hepatitis B vaccine are inconclusive. The objective of this study was to determine whether these four HLA SNPs that have been identified as risk loci for chronic HBV infection are associated with response to hepatitis B vaccine in a Japanese population. We enrolled 278 medical students who received hepatitis B vaccination and measured anti-hepatitis B surface (HBs) antibody titers 1month after a three-dose vaccination series. We found that rs9277535 and rs3077 in HLA-DP were strongly associated with response to hepatitis B vaccine (odds ratio [OR]=0.31 and 0.32, P=0.004 and 0.010, respectively). These two SNPs were significantly associated with anti-HBs titers in an allele-dependent manner. On the other hand, rs2856718 and rs7453920 in HLA-DQ were not associated with response to hepatitis B vaccine. These results indicate that rs9277535 and rs3077 in HLA-DP are the major determinants of response to hepatitis B vaccine, whereas rs2856718 and rs7453920 in HLA-DQ have little effect on the immune response to hepatitis B vaccine.

Changes in hepatitis B virus antibody titers over time among children: a single center study from 2012 to 2015 in an urban of South Korea

Background

Hepatitis B virus (HBV) infection is the most common cause of liver disease in endemic areas such as South Korea. After HBV vaccination, hepatitis B surface antibody (HBsAb) titers gradually decrease. Trends in HBsAb titers have not been evaluated among children in South Korea over the past decade.

Methods

We screened 6155 patients (aged 7 months to 17 years) who underwent HBV antigen/antibody testing at Chung-Ang University Hospital from May 2012 to April 2015. Titer criteria were defined as follows: positive, titer ≥100 IU/L; weakly positive, titer 10–99 IU/L; and negative, titer <10 IU/L. We also compared titers before and 1 month after a single booster vaccination.

Results

Of the 5655 patients included, 3016 were male and 5 (0.09%) tested positive for HBV surface antigen. A marked reduction in antibody titer was observed until 4 years of age. Thereafter, the titers showed fluctuating decreases. HBsAb titers reached their lowest levels by 14 years of age. After 7 years of age, 50% of patients tested negative for HBsAb. Simple linear analysis showed that the titer reached levels of <10 IU/L and zero at 12.9 and 13.4 years of age, respectively. 1 month after a single booster vaccination was administered to those who were HBsAb-negative (n = 72), 69 children (96%) had developed antibodies while 3 (4%) remained HBsAb-negative.

Conclusions

In conclusion, the continuous reduction in HBsAb titers over time and in each age group was confirmed. The titer level was shown significant decline until age 4. More than half of the sample had negative titers after age 7 years. After booster vaccination, most of child significantly increase titer level.

Decreased blood hepatitis B surface antibody levels linked to e-waste lead exposure in preschool children

Lead (Pb) is a widespread environmental contaminant that can profoundly affect the immune system in vaccinated children. To explore the association between blood Pb and HBsAb levels in children chronically exposed to Pb, we measured hepatitis B surface antibody (HBsAb) titers, to reflect the immune response in the children of Guiyu, an electronic and electrical waste (e-waste) recycling area well known for environmental Pb contamination. We performed secondary exploratory analyses of blood Pb levels and plasma HBsAb titers in samples, taken in two phases between 2011 and 2012, from 590 children from Guiyu (exposed group) and Haojiang (reference group). Children living in the exposed area had higher blood Pb levels and lower HBsAb titers compared with children from the reference area. At each phase, generalized linear mixed models (GLMMs) showed that HBsAb titers were significantly negatively associated with child blood Pb levels. This work shows that a decreased immune response to hepatitis B vaccine and immune system might have potential harm to children with chronic Pb exposure. Importantly, nearly 50% of chronically exposed children failed to develop sufficient immunity to hepatitis in response to vaccination. Thus different vaccination strategies are needed for children living under conditions of chronic Pb exposure.

Evaluation of commercialized rapid diagnostic testing for some Hepatitis B biomarkers in an area of intermediate endemicity

Hepatitis B virus (HBV) is a major public health threat. Enzyme immune assay (EIA) of HBsAg is the screening method used in most settings, including in blood banks. Other markers are used to evaluate the HBV replication, immunity and the infectious level of the patient. Testing negative for HBsAg, however, does not always mean the absence of infection, and testing other markers using EIA is costly. This study evaluated the diagnostic reliability of commercially available non-HBsAg HBV biomarkers to detect their usefulness to screen for HBV infection. INTEC rapid tests for HBV markers were evaluated in 508 HBsAg negative blood donors and were compared to EIA as a reference method. Only anti-HBs, anti-HBc and anti-HBe could be evaluated. Sensitivities of all tests (64.2, 85.48, and 82.78 respectively) were much lower than those claimed by the manufacturer. The specificities and negative predictive values for all tests exceeded 95% and 93% respectively and were lowest for anti-HBs. Anti-HBe had the highest accuracy (99.02%), while anti-HBs had the lowest (90.16%). It was concluded that the rapid test performance was lower than the manufacturer's reports. They are reliable tools to prove negativity, but less efficient to confirm reactivity. The best performance was for anti-HBe. The positive results of anti-HBs was significantly associated with higher ELISA titer levels, which is therefore recommended to be used for screening of immunity.