Intradermal hepatitis B vaccination for mentally retarded patients

Comparison of intramuscular and intradermal applications of hepatitis B vaccine in hemodialysis patients

This study compared the application of intramuscular recombinant hepatitis B vaccine in hemodialysis patients with the application of accelerated intradermal recombinant hepatitis B vaccine, which can be applied with one-tenth of the standard dose. Sixty seronegative patients for hepatitis B were randomly separated into two groups. Twenty mug of the recombinant hepatitis B vaccine was intramuscularly applied at 0-, 1-, 2-, and 6-month intervals to the first group (32 cases). One more dose was applied at month 12 to those whose anti-HBs titers remained below 100 mIU/mL at month 7. The same vaccine was intradermally applied at 2 microg dose six times with one-month intervals to the second group (28 cases). Vaccine applications were continued in those whose anti-HBs titers remained below 100 mIU/mL at month 7 until antibody titers reached above this value or until the dose number became 12. Measurements of antibody titers were repeated at month 13 in both groups. As a result, in the vaccination of hemodialysis patients against hepatitis B, the accelerated ID application of hepatitis B vaccine with a dose reduced to one-tenth is more cost-effective than the standard dose vaccination schedules. Especially for hemodialysis patients, the time has come for routine application of ID hepatitis B vaccine as an alternative vaccination method.

Hepatitis B and C in institutions for individuals with intellectual disability

People with intellectual disability are a well-known high-risk group for hepatitis B virus (HBV) infection. Hepatitis B virus is a major public health problem, but it is often neglected because of its largely asymptomatic course with long-term complications. Safe and effective vaccines have been available for over 15 years. However, universal vaccination strategies have not or have not completely been implemented to date, even though epidemiological data have indicated the effectiveness and efficacy of vaccination, and economic evaluations have shown that it is cost effective. Hepatitis C virus (HCV), which was discovered in 1989, has similar risk factors and is also a cause of chronic hepatitis. The prevalence of HCV amongst individuals with intellectual disability has not been clearly established. An overview of the literature on the prevalence of HBV and HCV in this population, as well as risk factors, transmission and prevention is presented in the present review. The literature cited in the present article was obtained by searches in MedLine using the following keywords and keyword combinations: hepatitis, hepatitis B virus, hepatitis C virus, mentally retarded, mentally handicapped, developmentally retarded, intellectual disability, institutionalization, Down's syndrome and hepatitis B vaccination. The search was done from 1980 to 1998. Beside this, the older articles found in the references were included if these were considered necessary for completeness.

Intradermal administration of viral vaccines

Intradermal administration maybe useful in lowering the cost of vaccination against hepatitis B significantly, and may also be helpful for the rapid induction of antibodies, reversing non-responsiveness, improving postexposure prophylaxis and immunising immunocompromised people. In addition, delayed type hypersensitivity skin reaction to the vaccine could serve as a useful marker for the acquisition of T helper type 1 immunoreactivity in vivo. However, there are some disadvantages when using intradermal vaccinations, including the requirement for skilful administration, the absence of approval from licensing authorities, the development of local skin reactions and a lower antibody response when 1/10 of the standard vaccine dose is used. This requires that appropriate vaccination regimens, including the correct vaccine dosage, and vaccination schedule are followed. In the future, a similar vaccination strategy might also be applied for the prevention and control of other infectious diseases. Copyright 1998 John Wiley & Sons, Ltd.

Non-efficacy of low-dose intradermal vaccination against hepatitis B in Down's syndrome

Persons with Down's syndrome (DS) constitute a risk group for hepatitis B (HB) and are recommended to be immunized. Of 123 persons with DS in Orebro county screened for markers of HB, 31% had such markers; 16% were potentially contagious. 83 persons without markers participated in a comparative trial of the immunogenicity of a recombinant HB vaccine given either intramuscularly (IM) or in a lower dose intradermally (ID). Immunity developed in 73% after IM vaccination as compared to 29% of those given ID vaccination (p < 0.005). At 3-year follow-up half and two-thirds of the immune persons, respectively, had lost their immunity. Those > 30 years had a poor immunization response compared to the younger ones (p < 0.01). Only 19% of the non-responders developed immunity after an IM booster dose given 10 months after the third injection. Intradermal vaccination is not warranted in persons with DS, especially not in middle aged and older persons. A booster dose of vaccine does not ascertain immunity in those who do not respond with immunity to the ordinary immunization schedule. Post-vaccination immunity should therefore be controlled.

Persistence of antibody to hepatitis B surface antigen after low-dose, intradermal hepatitis B immunization and response to a booster dose

To determine the duration of antibody after low-dose, intradermal (i.d.), plasma-derived hepatitis B vaccination and the response to a booster dose, we studied two classes of medical students who were immunized with 2 micrograms doses i.d. In one class, 73/88 (85%) who had been immunized by skilled personnel at 0, 1 and 6 months, had protective concentrations (greater than or equal to 10 mIU ml-1) of anti-HBs at 20 months after the first dose. Twelve (92%) out of 13 students who received only two doses at 0 and 1 months also had protective concentrations at month 20. At month 27, 11/16 (69%) with antibody less than or equal to 10 mIU ml-1 responded to a fourth dose of 2 micrograms i.d. with protective concentrations of anti-HBs. In the second class, after three doses of vaccine at 0, 1, and 6 months, protective concentrations of anti-HBs were present in 90/93 (97%) at 14 months and in 71/80 (89%) at 25 months. In those who received only two doses, protective concentrations were found in 24/31 (74%) at 14 months and 9/16 (56%) at 25 months. After a booster dose of 2 micrograms i.d. at month 25, anti-HBs concentrations rose from a geometric mean of 78 to 1198 mIU ml-1 in 60 subjects previously immunized with three doses and from 18 to 1054 mIU ml-1 in 16 students previously immunized with only two doses. Overall, 73/76 (96%) of students in the second group had protective concentrations of antibody after the booster dose.(ABSTRACT TRUNCATED AT 250 WORDS)

Long term observation of the effect of intradermal hepatitis B vaccination on mentally retarded patients

Sixty-two patients of two institutions for mentally retarded patients were immunized intradermally with 4 micrograms doses of plasma-derived hepatitis B vaccine made in Japan, initially at month 0.1 and 6. The three vaccinations induced antibodies in 93.5% (90.9% in those with Down's syndrome (DS), 94.1% in other forms of mental retardation (OMR) of the vaccinees within 9 months after the first injection, and the percentage of geometric mean titers of antibody above 10 mIU/ml was 89.3% (81.8% DS, 84.3% OMR) within 9 months. Within 2 years, the seroconversion rate showed a significantly higher decrease in subjects with DS (54.5%) than in OMR (86.3%), and the percentage of vaccines with above 10 mIU/ml also showed a significantly higher decrease in subjects with DS (36.4%) than in those with OMR (74.5%) (p less than 0.05). In the OMR patients, the antibody response persisted for 2 years, decreased remarkably in the DS patients.

Cost effectiveness of intradermal vs. subcutaneous hepatitis B vaccination for the mentally handicapped

The currently available hepatitis B vaccine is being under utilized for reasons of cost and availability. To address this problem, we performed a recombinant hepatitis B vaccine trial comparing the currently recommended regimen of 10 micrograms subcutaneously (sc) in months 0, 1 and 6 with a more economical regimen of 2 micrograms intradermally (ID) in months 0, 1, 6. This trial assessed the immunogenicity of both regimens in 95 seronegative mentally handicapped patients. Forty four patients (aged 19-55 years, mean age 29.1 years) were vaccinated subcutaneously with recombinant vaccine and 51 (aged 19-52 years, mean age 28.3 years) were given intradermally. We found no significant difference in seroconversion between the subcutaneous group (93.2%) and the intradermal group (96.1%) 12 months after the first vaccination, but the antibody titres were lower in the intradermal group. We feel therefore that the dose should be increased slightly or further injections should be given. As the cost of intradermal vaccination is considerably lower than when using the subcutaneous route, underprivileged patients in institutions could the more readily be immunized against hepatitis B infection.

Intradermal hepatitis B vaccination

The availability of vaccine since 1982 for immunization against hepatitis B virus (HBV) has had minimal impact on the disease; mass immunization has been suggested. Intradermal vaccination, which has precedent in prophylaxis of other infectious diseases, has been investigated as a low-cost alternative to traditional intramuscular HBV vaccination. Results of open and comparative trials indicate similar seroconversion rates for intradermal and intramuscular HBV vaccination routes in healthy adults. However, antibody titers and, presumably, duration of antibody protection appear to be decreased with intradermal HBV vaccination. Limited data suggest that demographic factors such as age and gender may affect vaccine responsiveness to intradermal HBV vaccine. Adverse skin reactions are common but do not represent a deterrent to continued intradermal HBV vaccination. There is a need for large-scale prospective comparative trials to substantiate the value of intradermal HBV vaccination. Nevertheless, the potential economic and epidemiologic benefit of intradermal vaccination justifies continued investigation for prevention of HBV infection.