Review article: hepatitis vaccination in patients with chronic liver disease

Prevalence of Immunity Against Hepatitis A and B in Patients With Steatotic Liver Disease in the U.S Population

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The Multiple Facets and Disorders of B Cell Functions in Hepatitis B Virus Infection

Chronic hepatitis B virus (HBV) infection continues to be a global public health burden. B cells play a pivotal role in mediating HBV clearance and can participate in the development of anti-HBV adaptive immune responses through multiple mechanisms, such as antibody production, antigen presentation, and immune regulation. However, B cell phenotypic and functional disorders are frequently observed during chronic HBV infection, suggesting the necessity of targeting the disordered anti-HBV B cell responses to design and test new immune therapeutic strategies for the treatment of chronic HBV infection. In this review, we provide a comprehensive summary of the multiple roles of B cells in mediating HBV clearance and pathogenesis as well as the latest developments in understanding the immune dysfunction of B cells in chronic HBV infection. Additionally, we discuss novel immune therapeutic strategies that aim to enhance anti-HBV B cell responses for curing chronic HBV infection.

Recent Advances in Protective Vaccines against Hepatitis Viruses: A Narrative Review

Vaccination has been confirmed to be the safest and, sometimes, the only tool of defense against threats from infectious diseases. The successful history of vaccination is evident in the control of serious viral infections, such as smallpox and polio. Viruses that infect human livers are known as hepatitis viruses and are classified into five major types from A to E, alphabetically. Although infection with hepatitis A virus (HAV) is known to be self-resolving after rest and symptomatic treatment, there were 7134 deaths from HAV worldwide in 2016. In 2019, hepatitis B virus (HBV) and hepatitis C virus (HCV) resulted in an estimated 820,000 and 290,000 deaths, respectively. Hepatitis delta virus (HDV) is a satellite virus that depends on HBV for producing its infectious particles in order to spread. The combination of HDV and HBV infection is considered the most severe form of chronic viral hepatitis. Hepatitis E virus (HEV) is another orally transmitted virus, common in low- and middle-income countries. In 2015, it caused 44,000 deaths worldwide. Safe and effective vaccines are already available to prevent hepatitis A and B. Here, we review the recent advances in protective vaccines against the five major hepatitis viruses.

Efficacy of Hepatitis B Virus Vaccines HBVaxpro40© and Fendrix© in Patients with Chronic Liver Disease in Clinical Practice

Chronic liver disease results in a low response rate to the hepatitis B virus vaccine. Information on the efficacy of the double adjuvanted vaccine FENDRIX® (3-O-desacyl-4'-monophosphoryl lipid A and aluminum phosphate) and single adjuvant HBVAXPRO®40 (aluminum hydroxyphosphate sulfate) in chronic liver disease is scarce. The primary aim of this prospective study in clinical practice was to evaluate the effectiveness of HBVAXPRO®40 and FENDRIX® in this setting. Patients received HBVAXPRO® (0, 1 and 6 months) or FENDRIX® (0, 1, 2 and 6 months) depending on availability. Clinical data and anti-HBs levels were collected at 2, 6 and 12 months. A total of 125 patients were included (mean age 61.8 years; 57.6% males; 43.2% liver cirrhosis; 75.9% Child A and 24.1% Child B): 76 were vaccinated with HBVAXPRO® and 49 with FENDRIX®. There were no significant differences between the two vaccines. The overall response rates at 2, 6 and 12 months were 76.8, 72.8 and 59.2%, respectively. In the univariate analysis, active alcohol intake, alcohol etiology, liver cirrhosis and ultrasound signs of portal hypertension were associated with a lower response to vaccination, whereas in the multivariate analysis, liver cirrhosis was the only factor that significantly increased the likelihood of nonresponse (OR 10.5). HBVAXPRO® and FENDRIX® are good options for HBV vaccination in patients with chronic liver disease.

Humoral immunity in hepatitis B virus infection: Rehabilitating the B in HBV

Insights into the immunopathogenesis of chronic HBV infections are fundamental in the quest for novel treatment approaches aimed at a functional cure. While much is known about the ineffective HBV-specific T-cell responses that characterise persistent HBV replication, B cells have been left largely understudied. However, an important role for humoral immunity during the natural history of HBV infections, as well as after functional cure, has been inadvertently revealed by the occurrence of HBV flares following B cell-depleting treatments. Herein, we review our current understanding of the role of the humoral immune response in chronic HBV, both at the level of HBV-specific antibody production and at the phenotypic and broader functional level of B cells. The recent development of fluorescently labelled HBV proteins has given us unprecedented insights into the phenotype and function of HBsAg- and HBcAg-specific B cells. This should fuel novel research into the mechanisms behind dysfunctional HBsAg-specific and fluctuating, possibly pathogenic, HBcAg-specific B-cell responses in chronic HBV. Finally, novel immunomodulatory treatments that partly target B cells are currently in clinical development, but a detailed assessment of their impact on HBV-specific B-cell responses is lacking. We plead for a rehabilitation of B-cell studies related to both the natural history of HBV and treatment development programmes.

Ethnic Minorities and Low Socioeconomic Status Patients With Chronic Liver Disease Are at Greatest Risk of Being Uninsured

Background

Chronic liver disease (CLD) predominantly affects ethnic minorities and socially vulnerable populations, who have high prevalence of risk factors (e.g., suboptimal insurance coverage) predisposing to healthcare disparities. We evaluate prevalence and predictors of uninsured status among CLD adults, and secondarily, how this affects documented immunity or vaccination for hepatitis A virus (HAV) and hepatitis B virus (HBV).

Methods

Using 2011 - 2018 National Health and Nutrition Examination Survey data, self-reported insurance status was determined among adults with CLD. Prevalence of uninsured status was stratified by patient characteristics and evaluated using multivariable logistic regression models. Prevalence of self-reported completion of vaccination as well as laboratory value-based documented immunity to HAV and HBV was stratified by insurance status.

Results

Overall, 19.0% of adults with CLD reported having no insurance, which was highest among individuals of Hispanic ethnicity (33.5%), less than high school education (33.7%), and below poverty status (35.3%). On multivariable analyses, significantly lower odds of having any insurance coverage was observed in men, Hispanics, and individuals with lower education and lower household income. Prevalence of documented immunity or vaccination for HAV was low across all insurance categories, ranging from 46.5% to 54.0%. Prevalence of documented immunity or vaccination for HBV was similarly low across all insurance categories, ranging from 24.3% to 40.8%.

Conclusion

Prevalence of uninsured status among CLD was more than twice the US adult population, and lack of insurance particularly impacted Hispanics and individuals with low education and low household income. Low prevalence of documented immunity or vaccination for HAV and HBV across all insurance categories is concerning.

Asociación Mexicana de Hepatología A.C. Clinical guideline on hepatitis B

Hepatitis B virus (HBV) infection continues to be a worldwide public health problem. In Mexico, at least three million adults are estimated to have acquired hepatitis B (total hepatitis B core antibody [anti-HBc]-positive), and of those, 300,000 active carriers (hepatitis B surface antigen [HBsAg]-positive) could require treatment. Because HBV is preventable through vaccination, its universal application should be emphasized. HBV infection is a major risk factor for developing hepatocellular carcinoma. Semi-annual liver ultrasound and serum alpha-fetoprotein testing favor early detection of that cancer and should be carried out in all patients with chronic HBV infection, regardless of the presence of advanced fibrosis or cirrhosis. Currently, nucleoside/nucleotide analogues that have a high barrier to resistance are the first-line therapies.

Asociación Mexicana de Hepatología A.C. Clinical guideline on hepatitis B

Hepatitis B virus (HBV) infection continues to be a worldwide public health problem. In Mexico, at least three million adults are estimated to have acquired hepatitis B (total hepatitis B core antibody [anti-HBc]-positive), and of those, 300,000 active carriers (hepatitis B surface antigen [HBsAg]-positive) could require treatment. Because HBV is preventable through vaccination, its universal application should be emphasized. HBV infection is a major risk factor for developing hepatocellular carcinoma. Semi-annual liver ultrasound and serum alpha-fetoprotein testing favor early detection of that cancer and should be carried out in all patients with chronic HBV infection, regardless of the presence of advanced fibrosis or cirrhosis. Currently, nucleoside/nucleotide analogues that have a high barrier to resistance are the first-line therapies.

Efficacy of an accelerated double-dose hepatitis B vaccine regimen in patients with cirrhosis

The hepatitis B (HBV) vaccine is recommended in unvaccinated adults with cirrhosis, despite its low efficacy. We aimed to evaluate the response to a double-dose/accelerated vaccine schedule in patients with cirrhosis admitted into a hepatology ward. All patients with cirrhosis admitted to the hepatology ward without exclusion criteria were offered the HBV HBVAXPRO 40mcg vaccine at months 0, 1 and 2. Non-responders received a second cycle. We evaluated 468 patients and only 19% were seroprotected against HBV. In 196 patients without exclusion criteria for HBV vaccination, the per protocol response rate (anti-HBs >10 U/ml) was 23% after a first cycle and 59% after a second cycle. The overall response per intention to treat was only 23%. We have not identified predictors of response. Only one patient had a mild adverse event. Most patients with cirrhosis admitted in the hepatology ward are unprotected against HBV. Although a second HBV vaccination cycle increases the response rate, the poor overall response reinforces the implementation of HBV vaccination before the development of cirrhosis.

Transition to decompensation and acute-on-chronic liver failure: Role of predisposing factors and precipitating events

The transition from compensated to decompensated cirrhosis results from a complex interplay of predisposing and precipitating factors and represents an inflection point in the probability of a patient surviving. With the progression of cirrhosis, patients accumulate multiple disorders (e.g. altered liver architecture, portal hypertension, local and systemic inflammation, bacterial translocation, gut dysbiosis, kidney vasoconstriction) that predispose them to decompensation. On the background of these factors, precipitating events (e.g. bacterial infection, alcoholic hepatitis, variceal haemorrhage, drug-induced liver injury, flare of liver disease) lead to acute decompensation (ascites, hepatic encephalopathy, variceal bleeding, jaundice) and/or organ failures, which characterise acute-on-chronic liver failure. In this review paper, we will discuss the current hypotheses and latest evidences regarding predisposing and precipitating factors associated with the transition to decompensated liver disease.

Low Prevalence of Vaccination or Documented Immunity to Hepatitis A and Hepatitis B Viruses Among Individuals with Chronic Liver Disease

BACKGROUND

Despite national guidelines emphasizing the importance of vaccination or documenting immunity to hepatitis A virus and hepatitis B virus for patients with chronic liver disease, the success of adhering to these recommendations is suboptimal. We aim to evaluate the prevalence of vaccination or documented reactivity to hepatitis A antibody and hepatitis B surface antibody among US adults with chronic liver disease.

METHODS

Using 2011-2018 National Health and Nutritional Examination Survey data, adults with nonalcoholic fatty liver disease, alcoholic liver disease, hepatitis B, and hepatitis C were evaluated to determine prevalence of vaccination (self-reported completion) and hepatitis A antibody reactivity or hepatitis B surface antibody reactivity.

RESULTS

Overall prevalence of vaccination or hepatitis A antibody reactivity was lowest among individuals with nonalcoholic fatty liver disease (60.8%; 95% confidence interval [CI], 57.9-63.6) and alcoholic liver disease (61.8%; 95% CI, 59.0-64.6), and highest among individuals with hepatitis B (82.9%; 95% CI, 76.8-89.0). Prevalence of vaccination or hepatitis B surface antibody reactivity was much lower: 38.6% (95% CI, 35.7-41.4) in nonalcoholic fatty liver disease, 40.7% (95% CI, 34.4-47.0) in chronic hepatitis C virus, and 47.1% (95% CI, 44.3-49.9) in alcoholic liver disease.

CONCLUSION

Among US adults with chronic liver disease, prevalence of vaccination or documented reactivity to hepatitis A antibody and hepatitis B surface antibody was alarmingly low. These observations are particularly concerning given that underlying chronic liver disease increases risks of severe liver injury and decompensation from acute hepatitis A or hepatitis B infections.

Low seroprevalence of SARS-CoV-2 antibodies in a liver transplant cohort

Solid organ transplant recipients might be at greater risk for acquisition and mortality because of SARS‐CoV‐2. There are no data regarding SARS‐CoV‐2 seroprevalence among liver transplant (LT) recipients, and whether it is different from that of the general population or other immunosuppressed groups. We evaluated the prevalence of IgG SARS‐CoV‐2 antibodies among LT recipients to estimate the frequency of asymptomatic SARS‐CoV‐2 infection using serological assays in our outpatient clinic. We conducted a cross‐sectional analysis from 10 May to 26 October 2020 of all adult (>18 years) LT recipients that underwent a routine laboratory test for the outpatient clinic follow‐up at the Hospital Universitari Vall d’Hebron (Barcelona) in which we included serological testing for SARS‐CoV‐2. Nine out of 294 LT recipients (3.1%) tested positive for anti‐SARS‐CoV‐2 IgG antibodies. Five of them (55.5%) had suffered clinically symptomatic SARS‐CoV‐2 infection confirmed by RT‐PCR, four (44.4%) had presented compatible symptoms but without microbiological confirmation and only one patient (1/9, 11.1%) tested positive without any previous symptom. SARS‐CoV‐2 seroprevalence among LT recipients in an area highly affected by the pandemic is lower than in the general population in the same area. These results render the possibility of asymptomatic infection in LT recipients very unlikely.

Need for hepatitis A prevention in patients with chronic liver disease in the changing epidemiological setting of India

The burden of chronic liver disease (CLD) in India is high, particularly among middle-aged men, with nearly 220,000 deaths due to cirrhosis in 2017. CLD increases the risk of infection, severe disease (e.g. hepatitis A virus or HAV superinfection, acute-on-chronic liver failure, fulminant hepatic failure), and mortality. Hence, various countries recommend HAV vaccination for CLD patients. While historic Indian studies showed high seroprevalences of protective HAV antibodies among Indian adults with CLD, the most recent ones found that nearly 7% of CLD patients were susceptible to HAV infection. Studies in healthy individuals have shown that HAV infection in childhood is decreasing in India, resulting in an increasing population of adults susceptible to HAV infection. As patients with CLD are at increased risk of severe HAV infection, now may be the time to recommend HAV vaccination among people with CLD in India.

Quality of Care in Patients With Cirrhosis: Trends in Recommended Adult Vaccination Coverage

Objective

To assess the proportion of patients with cirrhosis up to date with vaccinations and associations of vaccination with age, sex, race, ethnicity, marital status, and type of provider follow-up.

Patients and Methods

Patients with cirrhosis diagnosed at Mayo Clinic in Rochester and Mayo Clinic Health System in Minnesota from January 1, 2007, to December 31, 2009, were followed up from diagnosis until May 31, 2015. Data were abstracted from Mayo Clinic and Minnesota State records. Factors determining vaccination coverage were assessed.

Results

At the end of the study period (8 years follow-up), 26.4% (95 of 360), 24.7% (82 of 332), 63.2% (180 of 285), and 25.5% (54 of 212) of patients with cirrhosis were up to date with hepatitis A virus (HAV), hepatitis B virus, pneumococcal pneumonia (PN), and herpes zoster vaccinations, respectively. Influenza (FLU) vaccine coverage increased from 36.1% (57 of 158) in 2007 to 2008 to 65.8% (106 of 161) in 2014 to 2015. Of those unvaccinated for HAV and hepatitis B virus before cirrhosis diagnosis, 18.6% (59 of 318) and 23.4% (71 of 304) completed vaccination. For HAV, more whites than nonwhites (28.3% [91 of 322] vs 10.5% [4 of 38]; odds ratio [OR], 3.35; 95% CI, 1.29 to 11.45; P=.02) and more non-Hispanics than Hispanics (27.4% [95 of 347] vs 0% [0 of 13]; OR, 0.00; 95% CI, 0.00 to 0.43; P=.03) were vaccinated. For PN, more younger than elderly people (66.8% [135 of 202] vs 54.2% [45 of 83]; OR, 1.70; 95% CI, 1.01 to 2.87; P=.04) and married vs single people (56.8% [100 of 176] vs 73.4% [80 of 109]; OR, 2.10; 95% CI, 1.26 to 3.56; P=.005) were vaccinated. For FLU, in 2013 to 2014, more elderly (72.0% [54 of 75] vs 58.0% [69 of 119]; OR, 0.54; 95% CI, 0.28 to 0.99; P=.05); in 2008 to 2009, more Hispanics (100% [4 of 4] vs 41.6% [116 of 279]; OR, ∞; 95% CI, 2.25 to ∞; P=.02); and in 2011 to 2012, more married people (62.4% [101 of 162] vs 50.5% [56 of 111]; OR, 1.63; 95% CI, 0.1.0 to 2.66; P=.05) were vaccinated. For FLU in 2008 to 2009, coverage was higher in the primary care than the specialist setting (55.8% [48 of 86] vs 36.6% [72 of 197]; P=.003).

Conclusion

Except for PN and FLU, vaccination coverage in patients with cirrhosis falls short of Healthy People 2020 target. Specific interventions are needed to improve vaccination coverage in patients with cirrhosis.

Prevention of Hepatitis A Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices, 2020

HEPATITIS A IS A VACCINE-PREVENTABLE, COMMUNICABLE DISEASE OF THE LIVER CAUSED BY THE HEPATITIS A VIRUS (HAV). THE INFECTION IS TRANSMITTED VIA THE FECAL-ORAL ROUTE, USUALLY FROM DIRECT PERSON-TO-PERSON CONTACT OR CONSUMPTION OF CONTAMINATED FOOD OR WATER. HEPATITIS A IS AN ACUTE, SELF-LIMITED DISEASE THAT DOES NOT RESULT IN CHRONIC INFECTION. HAV ANTIBODIES (IMMUNOGLOBULIN G [IGG] ANTI-HAV) PRODUCED IN RESPONSE TO HAV INFECTION PERSIST FOR LIFE AND PROTECT AGAINST REINFECTION; IGG ANTI-HAV PRODUCED AFTER VACCINATION CONFER LONG-TERM IMMUNITY. THIS REPORT SUPPLANTS AND SUMMARIZES PREVIOUSLY PUBLISHED RECOMMENDATIONS FROM THE ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES (ACIP) REGARDING THE PREVENTION OF HAV INFECTION IN THE UNITED STATES. ACIP RECOMMENDS ROUTINE VACCINATION OF CHILDREN AGED 12-23 MONTHS AND CATCH-UP VACCINATION FOR CHILDREN AND ADOLESCENTS AGED 2-18 YEARS WHO HAVE NOT PREVIOUSLY RECEIVED HEPATITIS A (HEPA) VACCINE AT ANY AGE. ACIP RECOMMENDS HEPA VACCINATION FOR ADULTS AT RISK FOR HAV INFECTION OR SEVERE DISEASE FROM HAV INFECTION AND FOR ADULTS REQUESTING PROTECTION AGAINST HAV WITHOUT ACKNOWLEDGMENT OF A RISK FACTOR. THESE RECOMMENDATIONS ALSO PROVIDE GUIDANCE FOR VACCINATION BEFORE TRAVEL, FOR POSTEXPOSURE PROPHYLAXIS, IN SETTINGS PROVIDING SERVICES TO ADULTS, AND DURING OUTBREAKS.

Initial assessment and ongoing monitoring of lysosomal acid lipase deficiency in children and adults: Consensus recommendations from an international collaborative working group

BACKGROUND

Lysosomal acid lipase (LAL) deficiency is an ultra-rare, progressive, autosomal recessive disorder. Functional mutations in LIPA, the gene that encodes LAL, result in accumulation of cholesteryl esters and triglycerides in hepatocytes and in the macrophages of the intestines, vascular endothelial system, and numerous other organs. LAL deficiency has a broad clinical spectrum; children and adults can present with dyslipidemia, liver enzyme elevations, hepatosplenomegaly, hepatic steatosis, liver fibrosis and/or cirrhosis, and vascular disease, which may lead to significant morbidity and premature mortality in some patients. Given the systemic involvement and the wide range of healthcare specialists who manage patients with LAL deficiency, there is a need for guidelines to assess and monitor disease involvement.

OBJECTIVES

To provide a set of recommendations for the initial assessment and ongoing monitoring of patients with LAL deficiency to help physicians in various disciplines effectively manage the disease based on the observed presentation and progression in each case.

METHODS

A group of internationally recognized healthcare specialists with expertise in clinical genetics, pathology, hepatology, gastroenterology, cardiology, and lipidology convened to develop an evidence-based consensus of best practices for the initial assessment and ongoing monitoring of children and adults with LAL deficiency, regardless of treatment status; infants with LAL deficiency have been excluded from these guidelines because they require specialized care.

RESULTS

The authors present guidance for the assessment and monitoring of patients with LAL deficiency based on age and disease manifestations that include the hepatic, cardiovascular, and gastrointestinal systems. A schedule for ongoing monitoring of disease progression is provided. In addition, the need to establish an interdisciplinary and integrated care team to optimize the approach to managing this systemic disease is highlighted.

CONCLUSIONS

There is currently no published guidance on the assessment and monitoring of patients with LAL deficiency. These consensus recommendations for the initial assessment and ongoing monitoring of children and adults with LAL deficiency are intended to help improve the management of these patients.

Therapeutic Targeting of Hepatic Macrophages for the Treatment of Liver Diseases

Hepatic macrophages play a central role in maintaining homeostasis in the liver, as well as in the initiation and progression of liver diseases. Hepatic macrophages are mainly derived from resident hepatic macrophages called Kupffer cells or circulating bone marrow-derived monocytes. Kupffer cells are self-renewing and typically non-migrating macrophages in the liver and are stationed in the liver sinusoids in contrast to macrophages originating from circulating monocytes. Kupffer cells regulate liver homeostasis by mediating immunity against non-pathogenic blood-borne molecules, while participating in coordinated immune responses leading to pathogen clearance, leukocyte recruitment and antigen presentation to lymphocytes present in the vasculature. Monocyte-derived macrophages infiltrate into the liver tissue when metabolic or toxic damage instigates and are likely dispensable for replenishing the macrophage population in homeostasis. In recent years, different populations of hepatic macrophages have been identified with distinct phenotypes with discrete functions, far beyond the central dogma of M1 and M2 macrophages. Hepatic macrophages play a central role in the pathogenesis of acute and chronic liver failure, liver fibrosis, non-alcoholic fatty liver disease, alcoholic liver disease, viral hepatitis, and hepatocellular carcinoma, as well as in disease resolution. The understanding of the role of hepatic macrophages in liver diseases provides opportunities for the development of targeted therapeutics for respective malignancies. This review will summarize the current knowledge of the hepatic macrophages, their origin, functions, their critical role in maintaining homeostasis and in the progression or resolution of liver diseases. Furthermore, we will provide a comprehensive overview of the therapeutic targeting strategies against hepatic macrophages developed for the treatment of liver diseases.

Hepatitis B Vaccination in Patients with Liver Cirrhosis Evaluated for Liver Transplantation - A Simple Intervention Ensures High Adherence

BACKGROUND There is an unmet need to improve the HBV vaccination status in patients with chronic liver diseases. Primary care physicians and outpatient hepatologists often fail to vaccinate as recommended. Thus, new strategies to improve the HBV vaccination rate are required. MATERIAL AND METHODS This study was performed in a cohort of patients with chronic liver diseases evaluated for liver transplantation. Vaccination status was taken from the patients' vaccination cards. HBsAg-, anti-HBc-, and anti-HBs-negative individuals were vaccinated against HBV at hospital discharge, and subsequent outpatient completion of the standard vaccination protocol was recommended in detail in the discharge letter. At months 2 and 8, titer controls were performed, and completion of vaccination was evaluated. RESULTS We prospectively recruited 37 patients. At baseline, the vaccination rate against HBV was 24% (N=9/37), and 3/9 HBV vaccinated patients presented with an anti-HBs-titer >10 IU/L. Thus, N=34 were vaccinated with Engerix® or Twinrix®. We evaluated 26/34 patients at month 2 and 10/26 again at month 8. The second vaccine dose was obtained by 21/26 (80%) of the patients seen at month 2, and 9/10 (90%) seen at month 8 obtained the third vaccine dose by primary care physicians or ambulant hepatologists. Only 2 patients presented with an anti-HBs-titer >10 IU/L at month 8. CONCLUSIONS Initiation of HBV vaccination during hospitalization and detailed recommendations on subsequent vaccinations in the discharge letter improve previously inadequate vaccination rates in the outpatient setting. Similar measures should be implemented at earlier time points of chronic liver diseases to achieve higher immune response rates.

Gender Impacts on the Disease Severity of Overt Acute Hepatitis A: Different from Overt Acute Hepatitis B

BACKGROUND

Acute hepatitis A (AH-A) and acute hepatitis B (AH-B) were found more severe in males and females, respectively, while impacts from underlying liver disease on severity were not excluded in the AH-A study.

AIM

The precise gender-specific impact on the severity of AH-A was investigated and compared with that of AH-B.

METHODS

A case-control study of overt AH-A (n = 118) and AH-B (n = 118) patients without any underlying liver disease was conducted. Overt hepatitis was defined as serum bilirubin ≥ 2 mg/dL and alanine transaminase (ALT) ≥ 10 × upper limit of normal.

RESULTS

Of the AH-A patients, age (95% confidence interval of odds ratio 1.051-1.147) and ALT (1.001-1.002) were associated with hepatic decompensation. Indifferent rates of hepatic decompensation, hepatic failure, and mortality were found between male and female patients. Compared with the AH-B patients, AH-A patients showed lower bilirubin levels (p < 0.001), hepatic decompensation (p = 0.004), and mortality rates (p = 0.013). Among patients < 40 years, the AH-A patients had higher hepatic decompensation rates than AH-B in the male subgroup (15% vs. 2.8%, p = 0.045), while the situation is reverse in the female subgroup (7.7% vs. 48.1%, p = 0.001).

CONCLUSIONS

Overt AH-A was less severe than overt AH-B and, unlike AH-B, had no difference in severity between males and females. Among subgroups < 40 years, AH-A was more severe than AH-B in males, but the situation was reverse in females in terms of hepatic decompensation rates.

Immunization Against Hepatitis A Virus and Hepatitis B Virus in Patients with Chronic Liver Disease: Are We Doing a Good Job?

Introduction: In the era of highly effective vaccines for Hepatitis A Virus (HAV) and Hepatitis B Virus (HBV), acute viral hepatitis in patients with a chronic liver disease remains a public health concern. Vaccination for HAV and HBV is endorsed by all liver society guidelines. The aim of our study was to determine the rates of immunization in an internal medicine resident clinic.

Methods: We identified patients with a chronic liver disease seen at the University of Oklahoma Internal Medicine resident clinic between June 2014 and May 2015. ICD-9 code 571 was used to identify patients with a chronic liver disease. Vaccination records and patient data were reviewed.

Results: A total of 141 patients with a chronic liver disease (mean age 54.1 years, 56% males) were identified. Almost half of the patients (47.5%) were also being seen in the gastroenterology clinic. During the internal medicine resident clinic visit, vaccination against HAV and HBV was addressed for 50% and 46% of the patients, respectively. Patients being seen by senior residents were more likely to be immunized against HAV (OR 2.7, p=0.009) and HBV (OR 2.1, p=0.03). Patients followed in the GI clinic were more likely to be immunized against HAV (OR 2.1, p= 0.02) and HBV (OR 2.0, p=0.02). The gender of the treating physician and etiology had no impact on vaccination rates.

Discussion: Immunization rates for HAV and HBV remain subpar despite clear guidelines for patients with a chronic liver disease. This provides an important avenue for improvement. Different strategies, including resident education, developing vaccination protocols, and referral to the gastroenterology clinic, are likely to improve vaccination status for patients with chronic liver diseases.

Hepatitis A and hepatitis B vaccination coverage among adults with chronic liver disease

BACKGROUND

Infection with hepatitis A and hepatitis B virus can increase the risk of morbidity and mortality in persons with chronic liver disease (CLD). The Advisory Committee on Immunization Practices recommends hepatitis A (HepA) and hepatitis B (HepB) vaccination for persons with CLD.

METHODS

Data from the 2014 and 2015 National Health Interview Surveys (NHIS), nationally representative, in-person interview surveys of the non-institutionalized US civilian population, were used to assess self-reported HepA (≥1 and ≥2 doses) and HepB vaccination (≥1 and ≥3 doses) coverage among adults who reported a chronic or long-term liver condition. Multivariable logistic regression was used to identify factors independently associated with HepA and HepB vaccination among adults with CLD.

RESULTS

Overall, 19.4% and 11.5% of adults aged ≥ 18 years with CLD reported receiving ≥1 dose and ≥2 doses of HepA vaccine, respectively, compared with 14.7% and 9.1% of adults without CLD (p < .05 comparing those with and without CLD, ≥1dose). Age, education, geographic region, and international travel were associated with receipt of ≥2 doses HepA vaccine among adults with CLD. Overall, 35.7% and 29.1% of adults with CLD reported receiving ≥1 dose and ≥3 doses of HepB vaccine, respectively, compared with 30.2% and 24.7% of adults without CLD (p < .05 comparing those with and without CLD, ≥1 dose). Age, education, and receipt of influenza vaccination in the past 12 months were associated with receipt of ≥3 doses HepB vaccine among adults with CLD. Among adults with CLD and ≥10 provider visits, only 13.8% and 35.3% had received ≥2 doses HepA and ≥3 doses HepB vaccine, respectively.

CONCLUSIONS

HepA and HepB vaccination among adults with CLD is suboptimal and missed opportunities to vaccinate occurred. Providers should adhere to recommendations to vaccinate persons with CLD to increase vaccination among this population.

Hepatitis B and C in Children

The diagnosis and treatment of infection with hepatitis B and C has undergone a paradigm shift in the past decade. Although children with these infections are usually asymptomatic with normal liver function, their evaluation and management can often involve complex issues and require specialized expertise. Here the authors review the common clinical scenarios which might be encountered by a general pediatrician, explain the various tests available for diagnosis, and provide practical guidelines for managing these children.

Vaccinating Adult Patients with Cirrhosis: Trends over a Decade in the United States

Introduction. The progression of chronic liver disease to cirrhosis involves both innate and adaptive immune system dysfunction resulting in increased risk of infectious complications. Vaccinations against pneumococcus, hepatitis A virus (HAV), and hepatitis B virus (HBV) are well tolerated and effective in disease prevention and reduction in morbidity and mortality. Prior studies assessing vaccination rates in patients with cirrhosis have specific limitations and to date no study has provided a comprehensive evaluation of vaccination rates in patients with cirrhosis in the United States. Aim. This study assessed vaccination rates for pneumococcus, HAV, and HBV in patients with cirrhosis. Results. Overall 59.7% of patients with cirrhosis received at least 1 vaccination during the study period. Vaccination rates within the same or following year of cirrhosis diagnosis were 19.9%, 7.7%, and 11.0% against pneumococcus, HAV, and HBV, respectively. Trend analysis revealed significant increases in vaccination rates for pneumococcus in all patients with cirrhosis and within subgroups based on age, gender, and presence of concomitant diabetes. Conclusion. The study demonstrated that vaccination rates in patients with cirrhosis remain suboptimal. Ultimately, the use of electronic medical record (EMR) reminders improved communication between healthcare professionals and public health programs to increase awareness are fundamental to reducing morbidity, mortality, and health-care related costs of vaccine preventable diseases in patients with cirrhosis.

Management options in decompensated cirrhosis

Chronic injury to the liver from a variety of different sources can result in irreversible scarring of the liver, known as cirrhosis. Cirrhosis is a major cause of morbidity and mortality in the USA, and according to the Centers for Disease Control and Prevention was responsible for 31,903 deaths in 2010 alone. It is thus of the utmost importance to appropriately manage these patients in the inpatient and outpatient setting to improve morbidity and mortality. In this review, we address four major areas of cirrhosis management: outpatient management of portal hypertension with decompensation, hepatic encephalopathy, hepatorenal syndrome, and bleeding/coagulation issues. Outpatient management covers recommendations for health care maintenance and screening. Hepatic encephalopathy encompasses a brief review of pathophysiology, treatment in the acute setting, and long-term prevention. Hepatorenal syndrome is discussed in regards to pathophysiology and treatment in the hospital setting. Finally, a discussion of the assessment of coagulation profiles in cirrhosis and recommendations for bleeding and thrombosis complications is included. These topics are not all encompassing with regard to this complicated population, but rather an overview of a few medical problems that are commonly encountered in their care.

Need for immunization against hepatotropic viruses in children with chronic liver disease

OBJECTIVES

Infection with hepatotropic viruses is a common cause of acute deterioration and adverse outcome in children with chronic liver disease (CLD). Such superimposed infections may be preventable through vaccination. The present study aimed to evaluate the exposure rates of hepatitis A, B, and E viruses in children with CLD and suggest an optimal vaccination strategy.

METHODS

Children with CLD were prospectively evaluated with a demographic, clinical, and investigative proforma. Hepatitis B surface antigen positive cases were labeled as hepatitis B virus-CLD, and all other etiologies as non-HBV-related CLD. Patients were tested for exposure to hepatitis A (total anti-hepatitis A virus [HAV], immunoglobulin M anti-HAV), hepatitis B (hepatitis B surface antigen, total anti-hepatitis B core, anti-hepatitis B surface), and hepatitis E (IgG anti-hepatitis E virus).

RESULTS

A total of 142 children with CLD (age 9.1 ± 3.7 years, 83 [58.5%] boys) were enrolled. A total of 3.5% (5/142) and 38.7% (55/142) had received HAV and HBV vaccines, respectively. A total of 134 (94.4%) were total anti-HAV positive including 5 postimmunization patients, with higher positivity in those older than 5 years (19/25 vs 115/117; P = 0.001). Of the 115 patients with non-HBV-related CLD, 45 (39.1%) had exposure to HBV (40 total anti-hepatitis B core positive and 5 anti-HBs positive without immunization). Only 28 of 142 (19.7%) patients were IgG anti-HEV positive, with no difference across age.

CONCLUSIONS

A total of 90.8%, 39.1%, and 19.7% of children with CLD from the developing world are exposed to hepatitis A, B, and E infections, respectively. Selective hepatitis A vaccination (patients younger than 5 years of age) and universal hepatitis B vaccination are required to protect children with CLD. Sanitation improvement and HEV vaccine trial are needed for prevention against HEV.

Hepatitis A infection in patients with chronic viral liver disease: a cross-sectional study in Jahrom, Iran

Infection with hepatitis A virus (HAV) in patient with chronic liver disease (CLD; due to hepatitis B or hepatitis C) may cause severe disease and fulminant liver failure. This study aimed to determine the seroprevalence of HAV antibodies in patients infected with HCV or HBV in Iran (Jahrom city). A total of 159 patients with underlying CLD were recruited between September 2012 and February 2013. Serum samples were collected from each patient and tested for anti-HAV using enzyme-linked immunosorbent assay (ELISA). The overall seroprevalence of total anti-HAV was 79·2%. Patients aged 20-30 years had the lowest (28·3%) anti-HAV seropositivity and those aged >50 years had the highest (95%) seropositivity. The overall prevalence of anti-HAV in patients with chronic HCV and HBV infection was 93·7% and 77·1%, respectively. The anti-HAV seropositivity in liver cirrhosis patients was 100% compared to CLD patients. Because of low HAV immunity in younger CLD patients, vaccination against HAV should be considered.

Vaccination of the immunocompromised child

The development of vaccination is a major achievement in modern medicine. However, children treated with immunosuppression may not at all, or only in part, receive routine immunization due to uncertainty of its risks and effect. There is a substantial lack of pediatric studies concerning the efficacy and safety of vaccination in this patient group. Experience from similar adult groups and children with HIV infection can be used as a model for other disease categories. With increasing knowledge of the immunologic basis of vaccination and how immunosuppressive drugs interfere with the immune system, improved vaccines could be tailored, and adequate, individualized guidelines issued.

Safety and efficacy of hepatitis B vaccination in cirrhosis of liver

Introduction. Patients with chronic liver disease (CLD) are more likely to have severe morbidity and fatality rate due to superimposed acute or chronic hepatitis B (HBV) infection. The literature has shown that hepatitis B vaccines are safe and effective in patients with CLD, but the data in cirrhosis liver is lacking. We assessed the safety and immunogenicity of HBV vaccine in patients with cirrhosis liver. Methods. CTP classes A and B CLD patients negative for hepatitis B surface antigen and antibody to hepatitis B core antigen were included. All patients received three doses of hepatitis B vaccine 20 mcg intramuscularly at 0, 30, and 60 days. Anti-HBs antibody was measured after 120 days. Results. 52 patients with mean age 47.48 ± 9.37 years were studied. Response rates in CTP classes A and B were 88% and 33.3%. We observed that the alcoholic chronic liver disease had less antibody response (44%) than other causes of chronic liver disease such as cryptogenic 69% and HCV 75%. Conclusions. Patients with cirrhosis liver will have low antibody hepatitis B titers compared to general population. As the age and liver disease progress, the response rate for hepatitis B vaccination will still remain to be weaker.

Response to vaccination against hepatitis B virus with a schedule of four 40-μg doses in cirrhotic patients evaluated for liver transplantation: factors associated with a response

We performed a retrospective study to evaluate the rate of and factors associated with a response to recombinant hepatitis B virus (HBV) vaccination using 4 intramuscular doses (40 μg) administered at 0, 1, 2, and 6 months among 278 cirrhotic patients being evaluated for orthotopic liver transplantation (OLT). We re-vaccinated 57 non-responders with the same schedule. The 39.2% overall response rate to vaccination included 36% after three and 40.7% after four doses, namely, a median anti-HBs level of 100 IU/mL (range, 10 to 1000 IU/mL). The 51% revaccination response rate achieved a median hepatitis B surface antibody (anti-HBs) level of 99 IU/mL (range, 11 to >1000 IU/mL). Upon univariate analysis, variables associated with a higher response were: better liver function (Child-Pugh class [A, 53.8% B, 33.3%, C, 30.1%; P = .002), Model for End-stage Liver-Disease (MELD) score (11.4 versus 13.6; P = .001]), absence of diabetes (43.6% versus 20.8%; P = .002), presence of isolated hepatitis B core antibody (anti-HBc) positivity (80% versus 37.7%; P = .007), and younger age (< 45 years, 52.2%; range, 45 to 55 years, 40.4%; > 55 years, 34.1%; P = .031). Upon multivariate logistic regression analysis, lower MELD score (odds ratio [OR]: 0.922; P = .046), absence of diabetes (OR:0.359; P = .008) and isolated anti-HBc positivity (OR:5.826; P = .034) were associated with a higher response. No differences were observed to be associated with gender, weight, body mass index, etiology or tobacco consumption. Among the same patient cohort (n = 79), the responses after the third and fourth doses were 36.7% and 51.9% respectively. In conclusion, the response rate to HBV vaccination in cirrhotic patients evaluated for OLT reached more than 35% among those who received at least 3 doses. It was higher among patients who showed isolated anti-HBc positivity, better liver function, younger age, and non-diabetic status. The fourth dose only increased the response rate by 24% over that obtained after the first three doses, whereas a revaccination achieved a 50% response rate, which probably accounts for revaccination after no response to 3 doses. Vaccination should be introduced against HBV in the early stages of the disease.

Acute hepatitis B in a patient with OLT during treatment with peg-interferon and ribavirin for hepatitis C recurrence

The course and outcome of acute viral hepatitis in liver transplanted patients with hepatitis C recurrence are unknown. Here we describe a patient who presented with acute hepatitis B infection while on treatment with peg-interferon and ribavirin for hepatitis C recurrence after liver transplantation. A nucleoside analogue was added (entecavir) and the patient cleared hepatitis C virus (HCV) infection and seroconverted to anti-HBs. In this case, the acute hepatitis B virus (HBV) infection might have contributed to the clearance of HCV, the concomitant immunosuppression might have lead to the slow clearance of HBV infection, and the combined antiviral therapy has helped in the resolution of both infections. Hepatitis B vaccination should be recommended in susceptible patients waiting for liver transplantation.

Seroprevalence of hepatitis A immunity among brazilian adult patients with liver cirrhosis: is HAV vaccination necessary?

BACKGROUND

Patients with chronic liver disease have a higher risk of fulminant hepatitis when infected with hepatitis A virus, and vaccination of these patients against such infection is recommended. In Brazil, mainly in the South and Southeast regions, the epidemiology of hepatitis A (HA) has shifted from high to intermediate endemicity, which would have implication on policy of HA vaccination for these populations.

OBJECTIVE

To verify the prevalence of HA immunity in adult patients with liver cirrhosis (LC), in Uberlândia MG, a city of Southeastern Brazil.

METHODS

Between December 2005 and December 2006, 106 patients with LC were consecutively evaluated. In addition, 75 individuals without LC or alcoholism were evaluated (control group - CG).

RESULTS

Total anti-HAV (ELISA methods) was positive in 104 (98.1%) patients with LC (82 men, 24 women; mean age, 53.3 ± 11.9 years) and in 74 (98.7%) individuals of the CG (55 men, 20 women; mean age, 47 ± 11.6 years), p > 0.05.

CONCLUSIONS

For patients with chronic liver disease, in the geographic regions and age groups evaluated, routine vaccination against hepatitis A is not recommended. Moreover, the serum determination of total anti-HAV, used to assess immunity, is five times cheaper than vaccination against hepatitis A and, for this reason, should precede vaccination.

Hepatitis B virus and hepatitis C virus services offered by substance abuse treatment programs in the United States

Although substance abuse treatment programs are important contact points for providing health services for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, availability of services in these programs has not been well characterized. This study evaluated the spectrum of HBV and HCV services offered by substance abuse treatment programs within the National Drug Abuse Treatment Clinical Trials Network. Our survey of substance abuse treatment program administrators covered availability of testing for HBV and HCV; hepatitis A virus (HAV) and HBV immunization; and HCV medical and nonmedical services. There were also questions covering clarity of guidelines for HBV and HCV testing and HAV and HBV immunization. Differences between methadone and nonmethadone programs were examined. Despite the importance of substance abuse in sustaining the hepatitis epidemics, few programs offer comprehensive HBV and HCV testing or HCV health care services. Interventions to improve access to hepatitis services for substance-abusing patients are needed.

Anti-hepatitis A seroprevalence among chronic viral hepatitis patients in Kelantan, Malaysia

AIM: To determine the seroprevalence of anti-hepatitis A virus (HAV) antibodies in patients with chronic liver disease (CLD) and to justify the need for hepatitis A vaccination.

METHODS: Patients (n = 119) were enrolled between July and September 2009. The diagnosis of CLD was based on the presence of viral markers for more than 6 mo. The diagnosis of liver cirrhosis was based on clinical, biochemical and radiological profiles. Patient serum was tested for anti-HAV IgG.

RESULTS: The overall anti-HAV seroprevalence was 88.2%. The aetiology of CLD was hepatitis B in 96 patients (80.7%) and hepatitis C in 23 patients (19.3%). Mean age was 44.4 ± 14 years. Patients were grouped according to age as follows: 24 (20.2%) patients in the 21-30 years age group, 22 (18.5%) in the 31-40 years age group, 31 (26.1%) in the 41-50 years age group, 23 (19.3%) in the 51-60 years age group and 19 (16.0%) patients aged greater than 60 years, with reported seroprevalences of 66.7%, 95.5%, 93.5%, 91.3% and 94.7%, respectively. There was a marked increase of seroprevalence in subjects older than 30 years (P = 0.001).

CONCLUSION: Our study demonstrated that patients aged greater than 30 years of age were likely to have natural immunity to hepatitis A. Therefore, hepatitis A vaccination may not be routinely required in this age group.

Predicting implementation from organizational readiness for change: a study protocol

Background

There is widespread interest in measuring organizational readiness to implement evidence-based practices in clinical care. However, there are a number of challenges to validating organizational measures, including inferential bias arising from the halo effect and method bias - two threats to validity that, while well-documented by organizational scholars, are often ignored in health services research. We describe a protocol to comprehensively assess the psychometric properties of a previously developed survey, the Organizational Readiness to Change Assessment.

Objectives

Our objective is to conduct a comprehensive assessment of the psychometric properties of the Organizational Readiness to Change Assessment incorporating methods specifically to address threats from halo effect and method bias.

Methods and Design

We will conduct three sets of analyses using longitudinal, secondary data from four partner projects, each testing interventions to improve the implementation of an evidence-based clinical practice. Partner projects field the Organizational Readiness to Change Assessment at baseline (n = 208 respondents; 53 facilities), and prospectively assesses the degree to which the evidence-based practice is implemented. We will conduct predictive and concurrent validities using hierarchical linear modeling and multivariate regression, respectively. For predictive validity, the outcome is the change from baseline to follow-up in the use of the evidence-based practice. We will use intra-class correlations derived from hierarchical linear models to assess inter-rater reliability. Two partner projects will also field measures of job satisfaction for convergent and discriminant validity analyses, and will field Organizational Readiness to Change Assessment measures at follow-up for concurrent validity (n = 158 respondents; 33 facilities). Convergent and discriminant validities will test associations between organizational readiness and different aspects of job satisfaction: satisfaction with leadership, which should be highly correlated with readiness, versus satisfaction with salary, which should be less correlated with readiness. Content validity will be assessed using an expert panel and modified Delphi technique.

Discussion

We propose a comprehensive protocol for validating a survey instrument for assessing organizational readiness to change that specifically addresses key threats of bias related to halo effect, method bias and questions of construct validity that often go unexplored in research using measures of organizational constructs.

Hepatitis A and hepatitis B vaccination responses in persons with chronic hepatitis C infections: A review of the evidence and current recommendations

In persons with chronic hepatitis C virus (HCV) infections, superinfection by hepatitis A virus (HAV) or hepatitis B virus (HBV) can cause serious complications, including fulminating hepatitis or increased severity of hepatitis. Therefore, it is important to adequately protect persons with chronic HCV infections by immunization. Suboptimal response to vaccines has been reported in patients with chronic liver disease. The present article reviews HAV and HBV vaccine responses reported in the literature when administered to individuals with chronic HCV infection, and reviews current national and international recommendations.

RESULTS

Persons with chronic HCV respond well to HAV vaccine, but studies exploring HBV vaccine efficacy in this population have equivocal results. Vaccine schedules and participant characteristics differ among studies, and most do not adjust for confounders. Some studies found no difference in HBV vaccine response between patients with chronic HCV and controls. However, HBV vaccine response was generally reduced in those with cirrhosis and HCV genotype 1. Organizations recommend HAV and HBV vaccines for persons with chronic HCV, but do not suggest alterations in schedule or dose.

RECOMMENDATIONS

Because HAV vaccine response is good and routine laboratory testing may not detect lower levels of vaccine-induced anti-HAV, the standard HAV vaccine schedule is recommended without postimmunization testing. HBV vaccine should be administered early in the course of chronic HCV infection because response may be lower in patients with cirrhosis. Reflex testing of anti-HCV reactive sera for anti-HAV and hepatitis B surface antibody can facilitate appropriate follow-up and timely immunization. Determination of postimmunization hepatitis B surface antibody, especially in patients with cirrhosis or genotype 1, will allow HBV vaccine boosters to be offered.

[Hepatitis B vaccination: a major player in the control of primary liver cancer]

In worst cases, chronic hepatitis B ultimately leads to primary liver cancer. Populations the more at risk to develop hepatocellular carcinoma (HCC), i.e. patients infected perinatally, reside essentially in Asia. A quarter of century after its introduction in medical practice, data coming from Eastern Asia demonstrate a strong impact of the vaccine on HCC incidence. Strikingly, universal immunization of Taiwanese newborns reduced fourfold pediatric HCC incidence. However, residual cases still appear though among children infected at birth by HBe antigen-carrying mothers. Epidemiologic models indicate that the continuation of universal vaccination policy will reduce chronic hepatitis B endemicity 50-fold in three generations. Recently, mutant forms of HBV potentially escaping to vaccine appeared as a potential consequence of large-scale vaccination. Finally, lack of early immunization of newborns in developing countries still represents a major limitation to the progresses against liver cancer.

[Efficacy and safety of vaccination against hepatitis A and B in patients with chronic liver disease]

Vaccination to protect against hepatitis A and B should be part of the routine management of patients with chronic liver disease (CLD).

OBJECTIVES

To evaluate the efficacy and safety of hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination in a group of patients with CLD and to assess the presence of factors predictive of response.

PATIENTS AND METHODS

We performed a prospective, single-center study in 194 patients (123 men, 71 women; mean age, 48.9+/-10.7 years) with CLD: 107 with chronic hepatitis (CH) and 87 with hepatic cirrhosis (HC), all Child-Pugh class A. The most frequent causes of CLD were HCV infection and alcohol. Patients negative for anti-HAV IgG received the HAV vaccination (1440 ELISA units in two doses) and those with negative HBV serology received the HBV vaccination ( three 20 microg doses). Patients with inadequate response to the latter vaccine received an additional double dose. Thirty patients received a combination vaccine (three doses).

RESULTS

Sixty patients (31%) received the HAV vaccine and 150 (77%) patients received the HBV vaccine. Seroconversion was achieved by 91.6% of patients for HAV and by 57% of the patients for HBV. After the additional dose, the response increased to 74%. Efficacy was similar between CH and HC. HBV vaccination was less effective in HC than in CH and the seroconversion rate was significantly lower in patients with HC and previous decompensation. The combination vaccine (30 patients) was highly immunogenic. No adverse effects were registered.

CONCLUSIONS

HAV vaccination has high efficacy in patients with CLD. Patients with HC respond weakly to HBV vaccination compared with those with CH and especially if there is prior decompensation. The combination vaccine seems particularly effective in patients with CLD. The three vaccines are safe.

Hepatitis vaccination and prophylaxis

The three most commonly identified causes of viral hepatitis in the United States are hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Hundreds of millions of people worldwide are infected by these viruses; many experience illness as a result. This article discusses current recommendations for vaccination and other forms of prophylaxis aimed at minimizing the clinical effects of these viruses.

Hepatitis vaccination in patients with hepatitis C: practice and validation of codes at a large Veterans Administration Medical Centre

BACKGROUND

Hepatitis vaccination is recommended in patients with chronic liver disease.

AIM

To validate Current Procedural Terminology (CPT) codes and drug codes for hepatitis vaccination in administrative databases and determine vaccination rates in hepatitis C virus (HCV)-infected patients in a single large Veterans Administration Medical Center.

METHODS

We calculated predictive values for hepatitis vaccination codes in a validation set of 168 patients. We then conducted a retrospective cohort study of 243 HCV-infected patients to determine rates of hepatitis vaccination and serological testing.

RESULTS

The presence of CPT or drug codes for hepatitis A vaccine yielded a positive predictive value (PPV) and negative predictive value (NPV) of 93.2% and 94.0%. The presence of hepatitis B vaccine codes yielded a PPV of 98.0% and an NPV of 94.0%. Among patients diagnosed with HCV between 2000 and 2005, receipt of hepatitis vaccination was documented in approximately 8% overall and 7% in patients with cirrhosis. Half of the patients without hepatitis vaccinations were either not tested for immunity or had negative serology.

CONCLUSIONS

Current Procedural Terminology or drug codes for hepatitis vaccinations in administrative data are highly predictive of the presence of vaccinations in medical records. Our data suggest that there is significant under-utilization of vaccination in patients with HCV.

[Immunity against hepatitis A virus in patients with chronic hepatitis C]

BACKGROUND AND OBJECTIVE

Because of high fatality rate associated with acute infection by hepatitis A virus (HAV) in chronic hepatitis C patients, it is of interest to know the prevalence of immunization against HAV in these patients.

PATIENTS AND METHOD

Immunoglobulin G (IgG) IgG HAV antibodies (IgG anti-HAV) were determined in 313 hepatitis C virus antibodies (anti-HCV) positive patients and in 313 anti-HCV negative subjects (control group). Several epidemiological factors were recorded (age, sex, rural vs urban precedence, tattoos, parenteral drugs use, alcohol consumption and surgery).

RESULTS

The prevalence of IgG anti-HAV was identical in both groups: 81.2%. However, in those younger than 41 years, this prevalence was greater in those anti-HCV positive than in the control group. Parenteral drugs use and tattoos were more frequent in the first group. The presence of IgG anti-HAV was associated with age and the rural origin in both groups.

CONCLUSIONS

The prevalence of IgG anti-HAV increases with age, and is more frequent in individuals with rural origin. It was also greater in young anti-HCV positive patients, when compared with controls of the same age. This finding can be due to the poor standards of hygiene probably associated with some practices more common in this population, such as parenteral drugs use, tattoos and others.