The evaluation of immune responses to hepatitis B vaccination in diabetic and non-diabetic haemodialysis patients and the use of tetanus toxoid

Current Vaccination Practice in Diabetic (Diabetes I) Patients

The worldwide prevalence of diabetes, an endocrine condition, is rising quickly. The alarming rise of diabetes in recent years has emerged as a major contributor to premature death and illness among persons of working age. The potential use of immunomodulatory drugs to prevent diabetes has been a source of worry in light of recent advances in our understanding of the role of autoimmune responses in the development of diabetes. Vaccines can work in a variety of ways, including by eliminating autoreactive T-cells or by blocking the connections between immune cells. Most diabetes vaccines that have been created so far have only been evaluated in animal models, with just a small number having undergone successful human trials. In this article, the authors also look at the clinical trial research that are currently being conducted to create a prototype diabetes vaccine.

Obesity: A comorbidity-acquired immunodeficiency syndrome (CAIDS)

Accumulating data emphasize a strong link between obesity and the severity of coronavirus disease-2019 (COVID-19), including mortality. Obesity interferes with several components of the immune system including lymphoid tissue's integrity, leukocytes' development and function, complement system's activation, and the coordination of innate and adaptive immune responses. Overall, obesity results in a less efficient immune response to infectious agents. Severe acute respiratory syndrome coronavirus 2 exploits this weakened immune system in people with obesity to precipitate COVID-19, and in some cases death. It is therefore the author's recommendation that obesity should be viewed as another form of acquired immunodeficiency syndrome and be treated with the appropriate seriousness. Unlike the previously described acquired immunodeficiency syndrome (AIDS) that is caused by the Human Immunodeficiency Virus (HIV), obesity is a comorbidity-acquired immunodeficiency syndrome. People with AIDS do not die from HIV, but may die from opportunistic pathogens such as Mycobacterium tuberculosis. However, AIDS is ascribed its due importance in the course of deterioration of the patient. Similarly, obesity should be acknowledged further as a risk factor for mortality from COVID-19. Obesity is a modifiable condition and even in people with a strong genetic predisposition, lifestyle modifications can reverse obesity, and even moderate weight loss can improve the inflammatory milieu. Strong public health actions are warranted to promote lifestyle measures to reduce the burden from overweight and obesity that currently affect more than one-third of the global population, with projections alarming this may reach 55-80% within the next thirty years.

The Nature of Immune Responses to Influenza Vaccination in High-Risk Populations

The current pandemic has brought a renewed appreciation for the critical importance of vaccines for the promotion of both individual and public health. Influenza vaccines have been our primary tool for infection control to prevent seasonal epidemics and pandemics such as the 2009 H1N1 influenza A virus pandemic. Certain high-risk populations, including the elderly, people with obesity, and individuals with comorbidities such as type 2 diabetes mellitus, are more susceptible to increased disease severity and decreased vaccine efficacy. High-risk populations have unique microenvironments and immune responses that contribute to increased vulnerability for influenza infections. This review focuses on these differences as we investigate the variations in immune responses to influenza vaccination. In order to develop better influenza vaccines, it is critical to understand how to improve responses in our ever-growing high-risk populations.

Diabetes mellitus as a vaccine-effect modifier: a review

INTRODUCTION

Diabetes mellitus (DM) is a highly prevalent, chronic condition in adults worldwide. Little is known about the potential role of diabetes as an effect modifier of vaccine protective responses.

AREAS COVERED

We conducted a literature review of the immunogenicity, efficacy and effectiveness of immunization in individuals, in studies that compared subjects with DM (DM+) and without DM (DM-). We found few published studies, which were only for vaccines against hepatitis B, influenza, pneumococcal disease, or varicela zoster. Except for a consistent attenuation of the immune response to hepatitis B vaccine among DM+ individuals, we found little other consistent evidence for DM as an effect modifier of vaccine responses.

EXPERT OPINION

There are substantial gaps in our knowledge of the impact of DM on the immune response to immunization or effect of vaccination.

Factors That Influence the Immune Response to Vaccination

There is substantial variation between individuals in the immune response to vaccination. In this review, we provide an overview of the plethora of studies that have investigated factors that influence humoral and cellular vaccine responses in humans. These include intrinsic host factors (such as age, sex, genetics, and comorbidities), perinatal factors (such as gestational age, birth weight, feeding method, and maternal factors), and extrinsic factors (such as preexisting immunity, microbiota, infections, and antibiotics). Further, environmental factors (such as geographic location, season, family size, and toxins), behavioral factors (such as smoking, alcohol consumption, exercise, and sleep), and nutritional factors (such as body mass index, micronutrients, and enteropathy) also influence how individuals respond to vaccines. Moreover, vaccine factors (such as vaccine type, product, adjuvant, and dose) and administration factors (schedule, site, route, time of vaccination, and coadministered vaccines and other drugs) are also important. An understanding of all these factors and their impacts in the design of vaccine studies and decisions on vaccination schedules offers ways to improve vaccine immunogenicity and efficacy.

Cryptosporidium infection in chronic kidney disease patients undergoing hemodialysis in Egypt

Patients with chronic renal failure are more susceptible to infections due to acquired immunodeficiency caused by uremia. Parasitic infections are one of the significant causes of morbidity and mortality in those patients, So we aimed to assess the prevalence of Cryptosporidium spp. and other protozoan infections in patients undergoing hemodialysis in Qena Governorate, Upper Egypt. The present study took place in Qena University Hospitals, Egypt. Participants were 150 Chronic Kidney Disease (CKD) patients undergoing hemodialysis, and 50 healthy individuals. After questionnaire, three consecutive stool samples from each participant were examined macroscopically and microscopically by different techniques for the presence of different stages of different protozoa. 66% of CKD patients and 26% of the control group were infected with intestinal protozoa. Cryptosporidium spp. were the protozoa with the highest prevalence in cases (40%) and control (6%) with statistical significance (P < 0.05). It was detected only in watery stool samples (P value < 0.05). Residence, age and gender were not significant variables in the prevalence of infection among patients with CKD. In Egypt, few studies had reported the prevalence of Cryptosporidiosis in chronic renal patients. Cryptosporidium infection should be suspected in all cases of prolonged watery diarrhea in CKD patients and stool samples should be examined using special stains as cold modified Ziehl-Neelsen staining for proper diagnosis of Cryptosporidium infections.

Evaluation of Response to Hepatitis B Vaccination in Chronic Hemodialysis Patients

Background:

Hemodialysis (HD) patients are at an increased risk of acquiring hepatitis B virus (HBV) infection. Active HBV immunization in these patients is recommended. A response rate in HD patients is variable but generally lower than healthy individuals.

Objective:

The aim of this study is to assess the response of HD patients to the HBV vaccine and correlate response and long-term immunity to various clinical and biomedical factors.

Patients and Methods:

One hundred and one patients, with a mean age 48.7 ± 18.5 years, received 40 μg of HBV vaccine administered intramuscularly in the deltoid region at 0, 1, 2 and 6 months. The patients' responses to the vaccine were determined by measuring hepatitis B surface antibody (HBsAb) 6 weeks after the last injection and monitored thereafter at 3-month intervals.

Results:

Seventy-one patients (70.3%) mounted a response with HBsAb >10 mIU/ml 6 weeks following the fourth dose of vaccine, and thus were considered considered as adequate responders. Forty-nine (48.5%) patients mounted an excellent response with HBsAb >100 mIU/ml 6 weeks after the fourth dose. Thirty patients (29.7%) were nonresponders. Responders were significantly younger than nonresponders (P = 0.01). Gender, hemoglobin level, serum albumin, ferritin, parathyroid hormone level and hepatitis C virus infection had no effect on the response to the vaccine. Similarly, there was no difference in diabetic state and adequacy of HD between the two groups. Fifty-nine patients (88%) had persistent protective antibodies at 1 year, while eight (12%) lost such protection. Predictors of persistent immunity at 1 year were high HBsAb level at the completion of the vaccination regime and, to a lesser extent, young age.

Conclusion:

A 70% response rate to HBV vaccine was observed in the cohort of this study. Young age predicts a favorable response to HBV vaccine in HD patients. High (>100 mIU/ml) HBsAb levels achieved at vaccine completion predict persistent immunity at 1 year.

Respiratory Burst Process in Diabetic Children

BACKGROUND

Increased rate of infections in diabetes mellitus (DM) is an accepted fact. Pathophysiologically, several tasks of the immune system could be involved including polymorphonuclear (PMN) functions.

OBJECTIVES

The aim of this research was to evaluate the respiratory burst process of PMNs that is an essential part of phagocytosis, in children with DM.

PATIENTS AND METHODS

Fifty two children with insulin dependent diabetes and 29 non-diabetic children were enrolled in this cross sectional study from 2010 to 2011. Nitroblue tetrazolium (NBT) test was done on PMNs taken from their heparinized blood. The resultant data was analyzed by SPSS version 16. P values were considered significant when it was under 0.05.

RESULTS

Mean NBTs were 72.1 ± 15.84 and 94.68 ± 5.31 in diabetics and non-diabetics, respectively (P < 0.001). Using Pearson correlation, there was no significant correlation between the NBT level and age, gender, duration of diabetes, daily insulin usage and blood HbA1C level.

CONCLUSIONS

Compared to non-diabetics, respiratory burst process of polymorphonuclears is obviously decreased in diabetic children. This can explain one of the mechanisms involved in the increased rate of infections in DM.

Effect of tetanus-diphtheria (Td) vaccine on immune response to hepatitis B vaccine in healthy individuals with insufficient immune response

Background:

Hepatitis B virus (HBV) fails to produce appropriate immune responses in some healthy individuals; thus, different strategies have been adopted to promote immune responses. The current study aimed at evaluating the efficacy of HBV vaccine coadministered with tetanus-diphtheria (Td) vaccine compared with HBV vaccine in healthy individuals through measuring hepatitis B surface antibody (HBsAb) levels.

Materials and Methods:

This was a randomized controlled clinical trial, which was implemented in Isfahan, Isfahan Province (Iran) in 2013. One hundred and forty healthy individuals, whose HBsAb titers were less than 10 IU/L were recruited. The subjects were randomly assigned to either in intervention or control trials. The control group received 40 μg of recombinant HBV vaccines intramuscularly injected at 0, 1, and 6 months; however, the intervention group was simultaneously vaccinated by Td with the first dose of HBV vaccine. HBV antibody levels (titer) were measured before the vaccination and 6 months after the last vaccination.

Results:

Antibody titers of the subjects in the intervention and control groups increased from 5.07 ± 2.9 IU/L to 744.45 ± 353.07 IU/L and from 4.45 ± 3.4 IU/L to 589.94 ± 353 IU/L, respectively (both P < 0.001). Also, the mean difference of antibody titer was significantly different between the two groups (P = 0.011).

Conclusion:

Td vaccination can be applied as a feasible approach to promote efficient and persistent immunity in healthy individuals with insufficient HBsAb titers.

Sex bias in response to hepatitis B vaccination in end-stage renal disease patients: Meta-analysis

AIM: To systematically review the literature for studies investigating the potential effect of gender of dialysis patients on the immunogenicity of hepatitis B virus vaccines.

METHODS: Literature searches were conducted by the MEDLINE and Google Scholar. The key words used included “hepatitis B (HB)”, “vaccine”, “dialysis”, “hemodialysis”, “sex”, “male” and “female”. Data of seroresponse to HB vaccine in clinical trials regarding sex of the recipients have been achieved and analyzed. Finally data from 19 clinical trials have been pooled and analyzed.

RESULTS: Analysis of response to HB vaccination in our dialysis population showed males significantly respond less to hepatitis B vaccination (P = 0.002, Z = 3.08) with no significant heterogeneity detected [P = 0.766; heterogeneity χ² = 14.30 (df = 19); I² = 0%]. A reanalysis of the pooled data was conducted regarding the dialysis mode to evaluate potential differential impact of sex on HB vaccine response. Hemodialysis was the only subgroup that showed a significant difference regarding dialysis mode in response to HB vaccination regarding sex (P = 0.042, Z = 2.03).

CONCLUSION: This Meta-analysis showed significant effect for the sex of chronic kidney disease and dialysis patients on the immunogenicity of HB vaccine. This sex discrimination was most prominent among hemodialysis patients.

Impact of Obesity and Metabolic Syndrome on Immunity

Obesity is associated with metabolic disturbances that cause tissue stress and dysfunction. Obese individuals are at a greater risk for chronic disease and often present with clinical parameters of metabolic syndrome (MetS), insulin resistance, and systemic markers of chronic low-grade inflammation. It has been well established that cells of the immune system play an important role in the pathogenesis of obesity- and MetS-related chronic diseases, as evidenced by leukocyte activation and dysfunction in metabolic tissues such as adipose tissue, liver, pancreas, and the vasculature. However, recent findings have highlighted the substantial impact that obesity and MetS parameters have on immunity and pathogen defense, including the disruption of lymphoid tissue integrity; alterations in leukocyte development, phenotypes, and activity; and the coordination of innate and adaptive immune responses. These changes are associated with an overall negative impact on chronic disease progression, immunity from infection, and vaccine efficacy. This review presents an overview of the impact that obesity and MetS parameters have on immune system function.

Immunization in end-stage renal disease: opportunity to improve outcomes

Infection is the second most common cause of death in patients with end-stage renal disease (ESRD), following cardiovascular causes. Immunization is a fairly simple, but underutilized, strategy for prevention of infectious morbidity and mortality in patients with kidney failure. It is imperative for nephrologists and primary care providers to have an understanding of immunization as an essential component of preventive healthcare measures in this high-risk population. Patients with ESRD represent a unique population due to their immunosuppressed state, dialysis-related exposures and suboptimal response to routine vaccines. While the Advisory Committee on Immunization Practices (ACIP) provides guidelines for vaccination of patients with renal disease against Hepatitis B, influenza and pneumococcal disease, the data on immunization against other commonly preventable infectious diseases are lacking. This article reviews the recent evidence on immunization in the ESRD population and synthesizes the related implications for maximizing prevention of infectious diseases in this high-risk population.

A prospective study of hepatitis B vaccination - a comparison of responders versus nonresponders

Herein we present one of the largest single-center reports of the response of hemodialysis patients to a two-vaccine hepatitis B virus vaccination protocol in a European dialysis population. A hepatitis B recombinant DNA vaccine, HBvaxPRO, was given at a dose of 40 µg intramuscularly using a four-dose schedule at 0, 1, 2, and 12 months. Responses were (1) a titer >100 mIU/mL = patient immune, (2) a titer level 10-99 mIU/mL = give a booster dose and recheck level 2 months later, and (3) 0 ≤ 10 mIU/mL = repeat vaccination course using a different vaccine, Engerix-B. We compared responder groups in terms of titer levels for each vaccine and variables including age, gender, serum albumin, parathyroid hormone (PTH), calcium, phosphate, hemoglobin, years on dialysis, and type of dialysis access. Of the 176 patients who received the first vaccine course, 71 patients achieved immunity, that is, 40% uptake for the first vaccine. Of the 105 who failed, 72 received the second vaccine with 46 responders, that is, 64% uptake for the second vaccine. Overall, 143 of the 176 patients who entered the vaccination program completed the protocol with 117 achieving immunity, representing an 82% success rate. The only variable overall to show significance in achieving seroconversion was serum albumin (p = 0.03). Using a two-vaccine protocol, hepatitis B vaccination response was high in our population of end-stage renal disease patients.

Meta-analysis: the impact of diabetes mellitus on the immunological response to hepatitis B virus vaccine in dialysis patients

BACKGROUND

Patients on maintenance dialysis typically show a suboptimal immune response to hepatitis B virus vaccine compared with the non-uraemic population. A variety of inherited or acquired factors have been implicated in this diminished response. It is well known that patients with diabetes mellitus have a compromised immune system, and diabetic nephropathy is an important cause of chronic kidney disease. However, the impact of diabetes mellitus on the immune response to HBV vaccine in patients receiving long-term dialysis remains unclear.

AIM

To evaluate the influence of diabetes mellitus on the immune response to HBV vaccine in dialysis population by performing a systematic review of the literature with a meta-analysis of clinical studies.

METHODS

We used the random effects model of DerSimonian and Laird with heterogeneity and sensitivity analyses. The end-point of interest was the rate of patients showing seroprotective antibody against hepatitis B surface antigen at completion of vaccine schedule in the diabetic vs. the nondiabetic dialysis individuals.

RESULTS

We identified 12 studies involving 1002 unique patients on long-term dialysis. Aggregation of study results showed a significant decrease in response rates among the diabetic vs. the nondiabetic patients [pooled odds ratio=0.52 (95% CI 0.38-0.71)]. The P-value was 0.29 for our test of study heterogeneity. Stratified analysis in various subgroups of interest did not meaningfully change our results.

CONCLUSIONS

Our meta-analysis showed a clear association between diabetes mellitus and impaired response to hepatitis B virus vaccine in individuals on long-term dialysis. Such a relationship is biologically plausible. Vaccination schedules with adapted vaccine doses and frequent serum testing for loss of immunity against hepatitis B virus should be considered in patients on maintenance dialysis with diabetes mellitus.