Prevalence of hepatitis A virus and hepatitis B virus immunity in patients with polymerase chain reaction-confirmed hepatitis C: implications for vaccination strategy

Effectiveness of hepatitis B vaccination in chronic HCV patients after successful generic direct acting antiviral therapy: significance of isolated hepatitis B core antibodies

OBJECTIVE

Previous reports show conflicting results regarding hepatitis B virus (HBV) vaccine efficacy in Hepatitis C virus (HCV) infected individuals and in those with isolated hepatitis B core antibodies (HBcAb). We aimed to evaluate the effectiveness of HBV vaccine and identify possible factors that may contribute to hyporesponsivness in HCV-treated patients, including those with isolated HBcAb.

METHODS

We conducted a prospective study with 118 enrolled chronic HCV patients who followed a 12-week regimen of direct acting antivirals (DAAs) and were evaluated for HBV serological markers. Eventually, 98 received appropriate HBV vaccination and were assessed for response.

RESULTS

A total of 57.1% were vaccine responders although only 5.1% achieved a seroprotective level of HBsAb titre. The response rate was significantly lower among treated HCV patients with isolated HBcAb [2 (5.6%) vs. 40 (64.5%) respectively]. On multivariate analysis, advanced age [OR (95% CI) = 1.09 (1.02-1.17)] and presence of isolated HbcAb [OR (95% CI) = 39.59 (7.98-196.63)] were predictors of vaccine non-response. In our cost-effectiveness models, the cost of HBV serological screening was less than the nationally adopted non-screening approach. A model ratifying reinforced vaccination in non-responder HBcAb seropositive HCV patients would incur extra cost.

CONCLUSION

Hyporesponsiveness to the HBV vaccination is frequent in chronic HCV patients even after achieving SVR following DAAs. Although there is no consensus on the clinical management of patients with isolated HBcAb, our cost-effectiveness options may support decision-making for better clinical benefit and proper health investments.

Fulminant hepatitis B reactivation leading to liver transplantation in a patient with chronic hepatitis C treated with simeprevir and sofosbuvir: a case report

INTRODUCTION

Hepatitis B and C coinfection is commonly seen in clinical practice. In coinfected individuals, high levels of hepatitis C viremia are often associated with low levels of serum hepatitis B DNA. Hepatitis B reactivation in hepatitis C-infected patients treated with pegylated interferon and ribavirin has been reported, but severe or fulminant reactivation is uncommon. Hepatitis C treatment-associated hepatitis B reactivation in patients with chronic hepatitis C and isolated core antibody has not been reported previously.

CASE PRESENTATION

A 59-year-old white woman with chronic hepatitis C genotype 1B and isolated hepatitis B core antibody initiated treatment with simeprevir, sofosbuvir, and ribavirin for treatment of chronic hepatitis C. She responded very well to treatment initially with near normalization of aminotransferases and hepatitis C viral load suppressed to below the level of quantification after 4 weeks of treatment. At week 11 of a planned 12-week course, she developed fulminant hepatic failure due to hepatitis B reactivation and ultimately required liver transplantation. Fortunately, her posttransplant clinical course was unremarkable.

CONCLUSIONS

This is the first report of hepatitis B reactivation in a patient with isolated hepatitis B core antibody leading to fulminant hepatic failure and liver transplantation after initiation of treatment with sofosbuvir, simeprevir, and ribavirin for hepatitis C. This case raises the concern for the risk of severe hepatitis B reactivation in hepatitis B and C-coinfected patients or chronic hepatitis C-infected patients with isolated hepatitis B core antibody treated with direct-acting antiviral drugs for hepatitis C.

Fulminant hepatitis B reactivation leading to liver transplantation in a patient with chronic hepatitis C treated with simeprevir and sofosbuvir: a case report

INTRODUCTION

Hepatitis B and C coinfection is commonly seen in clinical practice. In coinfected individuals, high levels of hepatitis C viremia are often associated with low levels of serum hepatitis B DNA. Hepatitis B reactivation in hepatitis C-infected patients treated with pegylated interferon and ribavirin has been reported, but severe or fulminant reactivation is uncommon. Hepatitis C treatment-associated hepatitis B reactivation in patients with chronic hepatitis C and isolated core antibody has not been reported previously.

CASE PRESENTATION

A 59-year-old white woman with chronic hepatitis C genotype 1B and isolated hepatitis B core antibody initiated treatment with simeprevir, sofosbuvir, and ribavirin for treatment of chronic hepatitis C. She responded very well to treatment initially with near normalization of aminotransferases and hepatitis C viral load suppressed to below the level of quantification after 4 weeks of treatment. At week 11 of a planned 12-week course, she developed fulminant hepatic failure due to hepatitis B reactivation and ultimately required liver transplantation. Fortunately, her posttransplant clinical course was unremarkable.

CONCLUSIONS

This is the first report of hepatitis B reactivation in a patient with isolated hepatitis B core antibody leading to fulminant hepatic failure and liver transplantation after initiation of treatment with sofosbuvir, simeprevir, and ribavirin for hepatitis C. This case raises the concern for the risk of severe hepatitis B reactivation in hepatitis B and C-coinfected patients or chronic hepatitis C-infected patients with isolated hepatitis B core antibody treated with direct-acting antiviral drugs for hepatitis C.

Hepatitis A and B immunity and vaccination in chronic hepatitis B and C patients in a large United States cohort

BACKGROUND

Hepatitis A and B vaccines are effective in preventing superinfection and sequelae in patients with chronic hepatitis B or C. We describe immunity and vaccination against hepatitis A and B in chronic hepatitis patients from the US Chronic Hepatitis Cohort Study.

METHODS

We identified chronic hepatitis B and C patients with healthcare utilization during 2006-2008 and 12 months of enrollment. We used electronic laboratory records to determine immunity and medical and billing records for vaccination history. Immunity against hepatitis A was defined by positive hepatitis A antibody or documented vaccination. Immunity against hepatitis B was defined as hepatitis B surface antibody level ≥10 mIU/mL or core antibody positive, or by documented vaccination.

RESULTS

Among 1635 chronic hepatitis B patients, 978 (59.8%) were immune or vaccinated against hepatitis A, 122 (7.5%) had negative hepatitis A antibody tests, and 535 (32.7%) had no testing or vaccination record. Among 5328 chronic hepatitis C patients, 2998 (56.3%) were immune or vaccinated against hepatitis A, 659 (12.4%) had negative hepatitis A antibody tests, and 1671 (31.4%) had no testing or vaccination record. Additionally, 3150 (59.1%) chronic hepatitis C patients were immune or vaccinated against hepatitis B, 1003 (18.8%) had a negative test result, and 1175 (22.1%) were neither tested for nor vaccinated against hepatitis B.

CONCLUSIONS

Approximately 40% of chronic hepatitis B and C patients are susceptible to or have no documented immunity or vaccination against hepatitis A or hepatitis B. Clinicians should consider antibody testing and vaccination for this vulnerable population.

Hepatitis B virus and hepatitis C virus dual infection

Hepatitis B virus (HBV) and hepatitis C virus (HCV) share common mode of transmission and both are able to induce a chronic infection. Dual HBV/HCV chronic coinfection is a fairly frequent occurrence, especially in high endemic areas and among individuals at high risk of parenterally transmitted infections. The intracellular interplay between HBV and HCV has not yet been sufficiently clarified, also due to the lack of a proper in vitro cellular model. Longitudinal evaluation of serum HBV DNA and HCV RNA amounts has revealed that complex virological profiles may be present in coinfected patients. Dual HBV/HCV infection has been associated to a severe course of the liver disease and to a high risk of developing hepatocellular carcinoma. Despite the clinical importance, solid evidence and clear guidelines for treatment of this special population are still lacking. This review summarizes the available data on the virological and clinical features as well as the therapeutic options of the dual HBV/HCV infection, and highlights the aspects that need to be better clarified.

Prevalence and predictors of hepatitis B virus coinfection in a United States cohort of hepatitis C virus-infected patients

There are sparse epidemiologic data on coinfection of hepatitis B (HBV) and hepatitis C (HCV) in the United States. Therefore, the aim of this study was to determine the prevalence and predictors of HBV coinfection in a large U.S. population of HCV patients. We used the National Veterans Affairs HCV Clinical Case Registry to identify patients tested for HCV during 1997-2005. Patients were categorized based on HCV exposure (any two +HCV tests or one test with a diagnostic code), HCV infection (+RNA or genotype), HBV exposure (any +HBV test, excluding +HBsAb only), and HBV infection (+HBsAg, HBV DNA, or HBeAg). The prevalence of HBV exposure among patients with HCV exposure and that of HBV infection among patients with HCV infection were determined. Multivariate logistic regression evaluated potential demographic and clinical predictors of HBV coinfection. Among 168,239 patients with HCV exposure, 58,415 patients had HBV exposure for a prevalence of 34.7% (95% confidence interval [CI] 34.5-35.0). Among 102,971 patients with HCV infection, 1,431 patients had HBV coinfection for a prevalence of 1.4% (95% CI 1.3-1.5). Independent associations with HBV coinfection compared with HCV monoinfection were age ≤ 50 years, male sex, positive HIV status, history of hemophilia, sickle cell anemia or thalassemia, history of blood transfusion, cocaine and other drug use; there was decreased risk in patients of Hispanic ethnicity.

CONCLUSION

This is the largest cohort study in the U.S. on the prevalence of HBV coinfection in HCV patients. Among veterans with HCV, exposure to HBV is common (~35%), but HBV coinfection is relatively low (1.4%). Several possible risk factors were identified.

Prevalence of immunity to hepatitis viruses A and B in a large cohort of HIV/HCV-coinfected patients, and factors associated with HAV and HBV vaccination

Hepatitis A (HAV) and B (HBV) vaccination is strongly recommended for HIV-infected patients, especially those with hepatitis C coinfection. The aim of this study was to determine the prevalence of antibodies directed against HAV and HBV in a large cohort of HIV/HCV-coinfected patients, and to identify factors associated with HAV and HBV vaccination.

PATIENTS AND METHODS

We studied 1175 HIV/HCV-coinfected patients enrolled in the ANRS CO13 HEPAVIH cohort, whose HAV and HBV serostatus was known.

RESULTS

1056 patients (89.9%) have been tested for anti-HBc IgG, anti-HBs, and HbsAg. Only 10.9% of patients had received HBV vaccination and 70% of the patients with no HBV immunity (231/265) had never received HBV vaccination. In multivariate analysis, male sex (OR 2.0. 95% CI 1.1-3.8; p=0.02), a higher level of school education (OR 2.5, 95% CI 1.3-4.5; p=0.003), a higher CD4 cell nadir (OR 1.05, 95% CI 1.009-1.103; p=0.018) and no cirrhosis (OR 2.7, 95% CI 1.2-6.4; p=0.02) were associated with HBV vaccination. Only 368 patients (31.3%) were tested for immunity to HAV. Despite a frequent lack of HAV immunity (48.3%), a low rate of HAV vaccination (6%) was observed. In multivariate analysis, a higher level of school education (OR 3.6, 95% CI 1.03-12.4; p=0.045) was the only factor associated with HAV vaccination. HAV screening rates and HAV and HBV vaccination rates were low in this population of HIV/HCV-coinfected patients. The benefits of routine HAV and HBV screening, vaccination and post-vaccination testing should be emphasized.

Hepatitis B virus infection among American patients with chronic hepatitis C virus infection: prevalence, racial/ethnic differences, and viral interactions

Little is known about hepatitis B virus (HBV) infection among patients with chronic hepatitis C virus (HCV) infection in the United States. We prospectively enrolled 1,257 patients with chronic HCV infection from two medical centers in New York City. A total of 61.5% (95% confidence interval, 58.8%-64.2%) had evidence of prior exposure to HBV (hepatitis B core antibody-positive), whereas 5.8% (95% confidence interval, 4.5%-7.1%) had dual infection with HBV (hepatitis B surface antigen-positive). Multivariable logistic regression analysis identified age <40 years, Asian race, injection drug use, and a greater number of lifetime sexual partners as independent risk factors for HBV-HCV dual infection. Liver biopsy results in 26 HBV-HCV-infected and 658 HCV-monoinfected patients showed that stage 3 or 4 fibrosis was significantly more common in those with HBV-HCV dual infection (84.6% versus 29.9%; P < 0.001). Patients infected with HBV and HCV had significantly lower median HCV RNA levels (1.3 versus 4.5 x 10(6) copies/mL; P < 0.001) and were less likely to have HCV RNA levels > or =5 x 10(6) copies/mL (12.3% versus 45.4%; P < 0.001) than those who had HCV monoinfection. All five patients with HBV-HCV dual infection who had undetectable HBV DNA levels had HCV RNA levels > or =5 x 10(6) copies/mL.

CONCLUSION

American patients with chronic HCV infection should be tested for HBV, especially younger patients, Asians, injection drug users, and those with an increased number of lifetime sexual partners. The presence of severe liver disease and HBV-HCV viral interactions in patients with dual infection necessitates careful but aggressive clinical management, although the optimal strategy remains to be determined.

Cost-effectiveness of hepatitis A vaccination for individuals with chronic hepatitis C

The incidence of hepatitis A infection in the United States has decreased dramatically in recent years because of childhood immunization programs. A decision analysis of the cost-effectiveness of hepatitis A vaccination for adults with hepatitis C was conducted. No vaccination strategy is cost-effective for adults with hepatitis C using the recent lower anticipated hepatitis A incidence, private sector costs, and a cost-effectiveness criterion of $100,000/QALY. Vaccination is cost-effective only for individuals who have cleared the hepatitis C virus when Department of Veterans Affairs costs are used. The recommendation to vaccinate adults with hepatitis C against hepatitis A should be reconsidered.

Response to hepatitis A and B vaccine alone or in combination in patients with chronic hepatitis C virus and advanced fibrosis

Patients with advanced fibrosis are at increased risk of severe outcomes if they develop acute infection with hepatitis A (HAV) or hepatitis B (HBV) viruses. There are no data on the efficacy of combined HAV/HBV vaccination in patients with advanced fibrosis. Our aim was to evaluate the response to the HAV and HBV vaccine alone or in combination for patients with chronic hepatitis C (HCV) and advanced fibrosis and to evaluate the impact of administering the vaccine while patients were receiving peginterferon for treatment of chronic HCV. In this prospective study of patients with advanced fibrosis (Ishak 3-6), those without serologic evidence of prior exposure were vaccinated with either Havrix HAV, Engerix( HBV, or the TWINRIX HAV/HBV combination vaccine as appropriate, and response was defined as the development of anti-HAV or anti-HBV surface antibodies. Of the 162 eligible patients, the prevalence of prior exposure to HAV and HBV was 30 and 18%, respectively. Of the 84 patients vaccinated, 38% received Havrix, 14% Engerix, and 48% TWINRIX. The response to the HAV vaccine was 75% in those receiving Havrix compared to 78% receiving TWINRIX. In contrast, the response to HBV vaccination was 42% in patients receiving Engerix compared to 60% in those vaccinated with TWINRIX (difference 18.3%; OR 0.29; 95% CI: 0.57-7.79). The presence of diabetes was the only risk factor identified for reduced HBV response (P = 0.01). Responses to both HAV and HBV vaccines when administered alone or in combination were lower than expected in patients with HCV and advanced fibrosis, especially in those with diabetes. The observation that the decline in HBV vaccine response was somewhat lower when this was administered alone as opposed to the combination A/B vaccine suggests that the administration of a combination vaccine may enhance the vaccination response to HBV.

Hepatitis C performance measure on hepatitis A and B vaccination: missed opportunities?

OBJECTIVES

Prevention of hepatitis A virus (HAV) and hepatitis B virus (HBV) infection in patients with chronic hepatitis C (CHC) through vaccination is endorsed by all major professional societies. This study was conducted to determine adherence to the recently adopted physician performance measure on HAV and HBV vaccination.

METHODS

This was a retrospective study. Hepatitis A and B serology data and immunization records between 2000 and 2007 from CHC patients with detectable hepatitis C virus (HCV) RNA were analyzed.

RESULTS

A total of 2,968 CHC patients were included in the study. Of these, 2,143 patients (72%) were tested for susceptibility to HAV, of which 53% had immunity. Of the non-immune patients, 746 (74%) were vaccinated as well as an additional 218 without prior testing. For HBV, 2,303 patients (78%) were tested for immunity and 782 (34%) were immune. Of the susceptible patients, 1,086 (71%) were vaccinated as well as an additional 197 patients without prior testing. The overall vaccination performance measure adherence rate was 71% for HAV, 70% for HBV, and 62% for both HAV and HBV. Random review of 176 charts found the major reasons for non-adherence were missed opportunity (41%), change of health care system (31%), and documented vaccination outside our health care system (22%).

CONCLUSIONS

Our study found a high and improved adherence to the recommendations, but missed opportunity was still the main reason of non-adherence. This study also supported the strategy of selective vaccination in the veteran population.

Should Brazilian patients with chronic hepatitis C virus infection be vaccinated against hepatitis A virus?

BACKGROUND AND AIM

Hepatitis A virus (HAV) superinfection is associated with a high risk of liver failure and death in patients with hepatitis C virus (HCV) infection. The aim of this study was to investigate the presence of serological and molecular HAV markers in a population of HCV-infected patients in order to determine a cost-effective strategy to vaccinate against HAV.

METHODS

The presence of total and immunoglobulin (Ig)M anti-HAV antibodies was investigated in 399 patients (median age, 50 years; range, 4-81) referred to the Public Health Central Laboratory of Pernambuco State who tested positive for anti-HCV antibodies and HCV RNA. HAV RNA was investigated by reverse transcription-nested polymerase chain reaction in these patients.

RESULTS

Three hundred and eighty-four (96%) patients were positive for anti-HAV total and negative for IgM anti-HAV antibodies (immune patients). Three patients had IgM (and total) anti-HAV antibodies, showing an acute infection, and two of them had HAV RNA detected in serum samples. HAV RNA was also found in another patient in the absence of detectable anti-HAV antibodies. By nucleotide sequencing, it was demonstrated that the HAV isolates infecting these patients belonged to subgenotype 1B.

CONCLUSION

This study provides valuable new data on anti-HAV prevalence among HCV carriers in Brazil. In the present study, we found a high proportion of patients with anti-HAV positivity, indicating that anti-HAV testing of HCV-infected patients is a cost-effective strategy and should be carried out before vaccination against HAV in these patients, particularly in regions such as our geographical area with high total anti-HAV prevalence.

Descriptive epidemiology of chronic hepatitis B by using data from a hepatitis registry in Central Greece

BACKGROUND

In Greece, there are few data on the epidemiological characteristics of HBV. Our aim was to study the epidemiological patterns of HBV in Central Greece and identify the possible differences in HBV prevalence (clusters) among areas inside this region using data from the hepatitis registry.

METHODS

The study was performed in Thessaly, one out of the thirteen regions of Greece and covers most of the part of Central Greece. A total of 921 HBV patients were registered in the hepatitis registry during the period 1999-2004 while 303 were randomly selected to be studied further using a detailed questionnaire on several epidemiological factors.

RESULTS

187/303 patients (61.7%) classified as chronic inactive HBV carriers, 78/303 (25.7%) had chronic hepatitis B, 29/303 (9.6%) had HBV-related cirrhosis and 9/303 (3%) HBV-related hepatocellular carcinoma (HCC). The route of HBV transmission was vertical in 103 (34%), sexual in 46 (15.1%) and intrafamilial in 98 (32.4%). Folk remedies were identified as the predisposing risk factor for contracting HBV infection in 38 (12.5%), previous transfusion in 9 (3%) and unknown mode of transmission in 9 patients (3%). Alcohol abuse was the only independent factor (OR: 2.5; p=0.01) associated with the progression to cirrhosis-HCC. There were specific areas (clusters) inside Thessaly region with increased ratio of HBV infection; Vertical and sexual modes of transmission were more prominent in some of these areas.

CONCLUSIONS

Vertical, intrafamilial and sexual modes of HBV transmission identified as the major routes of HBV infection in our study. We also identified cluster areas of HBV infection in Central Greece. Alcohol abuse is frequent among HBV patients and is acting as an effect modificator risk factor for the development of HBV-related cirrhosis and HCC. Extended population studies in Greece are needed to assess in detail the epidemiological patterns of HBV and evaluate control programmes.

[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.

Demographics of a large cohort of urban chronic hepatitis C patients

Purpose

Recent studies suggest that African Americans (AA) with chronic hepatitis C (CHC) differ from non-Hispanic whites (NHW) with respect to the natural history and mortality resulting from the complications of chronic liver disease. The aim of this study was to examine the demographics of a large cohort of CHC patients and identify potential differences between AA and NHW.

Methods

This is a retrospective analysis, consisting of 2,739 hepatitis C antibody-positive patients seen at Wayne State University between 1995 and 2005. Patient demographics, risk factors, comorbidities, alanine aminotransferase (ALT), aspartate aminotransferase (AST), serum hepatitis C (HCV) RNA levels, genotype, and liver biopsy results were recorded.

Results

AA constituted 75.4%, NHW 22.5%, and Asians or Hispanics 2.1% of the patients. Males predominated (58%), and the mean age of AA and NHW was 50.0 and 45.3 years, respectively (P ≤ 0.001). The most common risk factor was injection drug use in 55.3% (AA 57.1% vs. NHW 49.7%; P ≤ 0.002). HCV RNA by PCR obtained in 2,407 patients was positive in 94.8%, with a high viral load in 61%. Genotype 1 was significantly more frequent in AA (92.6%) than in NHW (70.6%, P ≤ 0.001). AA had lower median ALT levels (P ≤ 0.001). In those patients who were biopsied, there was no significant difference in fibrosis between the two groups. Aspartate to platelet index calculated in those patients who were not biopsied showed significantly lower fibrosis scores in AA.

Conclusions

In this large cohort of CHC patients from a single institution, AA were older at presentation, had a higher prevalence of genotype 1, but significantly lower ALT levels than NHW.

Incidence of HAV and HBV infections and vaccination rates in patients with autoimmune liver diseases

OBJECTIVES

Hepatitis A virus (HAV) or hepatitis B virus (HBV) superinfection is associated with an increased mortality in patients with chronic liver diseases (CLD). Despite official recommendations, it was reported that the vaccination rate against HAV is low in patients with chronic hepatitis C infection. To evaluate the situation in patients with autoimmune liver diseases, we conducted a retrospective cohort study.

METHODS

Susceptibility to HAV and HBV infections, course of HAV and HBV infections, vaccination rates against HAV and HBV, and efficacy of hepatitis A/B vaccines were evaluated by antibody testing in 225 patients with autoimmune liver diseases during 1,677 person-years.

RESULTS

Susceptibility to HAV/HBV infection was 51/86%. Incidence of HAV/HBV infection was 1.3/1.4 per 1,000 person-years. One HAV infection occurred, but the patient recovered spontaneously. Two patients were HBV-infected after receiving an anti-HBc-positive (antibody to hepatitis B core antigen) donor graft during orthotopic liver transplantation, and one of them developed chronic HBV infection. Vaccination rates were 11% (HBV) and 13% (HAV), respectively. Seventy-six percent of the vaccinated patients (HBV vaccine) developed anti-HBs (antibody to hepatitis surface antigen) >or=10 UI/L. Ten out of 13 vaccinated patients, showing a low or nonresponse to hepatitis B vaccine, had concomitant immunosuppressive therapy. Anti-HAV was detectable in all patients after administration of HAV vaccine.

CONCLUSIONS

Patients with autoimmune liver diseases have a high susceptibility to HAV and HBV infections. Vaccination rates are low in this patient cohort and efficacy of hepatitis B vaccine is reduced due to immunosuppressive therapy. Improving adherence to vaccine recommendations is essential to prevent HAV and HBV infections in patients with autoimmune liver diseases.

Hepatitis and human immunodeficiency virus co-infection among injection drug users in Los Angeles County, California

This study examined the prevalence of hepatitis A (HAV), B (HBV), C (HCV), and Human Immunodeficiency Virus (HIV) co-infection among Injection Drug Users (IDUs) in Los Angeles County, California, and predictors of multiple infections in this population. Six hundred seventy-nine IDUs were recruited from October 2002 through June 2004. Participants completed questionnaires to elicit demographic, drug and sex risk information, and were tested for hepatitis A, B, C and HIV.A linear regression model predicting the total number of infections (0 to 4 possible) was constructed. Significant associations were found between HAV and HBV infection, HAV and HCV infection, and HBV and HCV infection. Predictors of total co-infections included age of first injection, lifetime years in jail, and Hispanic ethnicity. Latinos had the highest proportion of HAV and HBV co-infection with HCV. The total number of co-infections, especially those co-infected with all three of the hepatitis infections, was unexpectedly high.

Safety and efficacy of hepatitis A vaccine in children with chronic liver disease

AIM: To study the safety and efficacy of hepatitis A vaccine (HAV) in children with chronic liver disease of various etiologies.

METHODS: Eleven children with chronic liver disease and thirteen age- and sex-matched controls negative for HAV antibodies were vaccinated against hepatitis A after they gave their informed consent. Children with uncontrolled coagulopathy or signs of hepatic decompensation were excluded. The vaccine (Havrix: 720 ELISA units in 0.5 mL, from GlaxoSmithKline Biologicals) was given intramuscularly in the deltoid in 2 doses 6 mo apart. Children were tested for HAV antibodies one and six months after the 1^st dose and one month after the 2^nd dose. Total serum bilirubin, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were determined immediately before and after one month of the 1st dose of the vaccine.

RESULTS: Only 7 out of the 11 patients were positive for HAV antibodies after the 1^st dose of the vaccine, as compared to 100% of the controls. One month after the 2^nd dose, all patients tested were positive for HAV antibodies. No deterioration in liver functions of patients was noted after vaccination. No adverse events, immediate or late, were reported by the mothers after each dose of the vaccine.

CONCLUSION: Hepatitis A vaccine is both safe and effective in this small studied group of children with chronic liver disease. Given the high seroconversion rate, post-vaccination testing for HAV antibodies is not needed.

Overcoming barriers to prevention, care, and treatment of hepatitis C in illicit drug users

Injection drug use accounts for most of the incident infections with hepatitis C virus (HCV) in the United States and other developed countries. HCV infection is a complex and challenging medical condition in injection drug users (IDUs). Elements of care for hepatitis C in illicit drug users include prevention counseling and education; screening for transmission risk behavior; testing for HCV and human immunodeficiency virus infection; vaccination against hepatitis A and B viruses; evaluation for comorbidities; coordination of substance-abuse treatment services, psychiatric care, and social support; evaluation of liver disease; and interferon-based treatment for HCV infection. Caring for patients who use illicit drugs presents challenges to the health-care team that require patience, experience, and an understanding of the dynamics of substance use and addiction. Nonetheless, programs are successfully integrating hepatitis C care for IDUs into health-care settings, including primary care, methadone treatment and other substance-abuse treatment programs, infectious disease clinics, and clinics in correctional facilities.

Immunogenicity of recombinant hepatitis B vaccine in treatment-naive and treatment-experienced chronic hepatitis C patients: the effect of pegylated interferon plus ribavirin treatment

AIM

To retrospectively evaluate the vaccination-induced anti-HBs seroconversion rates in treatment-naive and treatment-experienced chronic hepatitis C (CHC) patients. Also to prospectively evaluate the seroconversion rates in CHC patients during pegylated interferon (PEG) plus ribavirin (RIB) treatment.

METHODS

Seventy treatment-naive CHC patients (group A), 22 sustained virological responders-SVR following interferon (IFN) plus RIB treatment CHC patients (group B) and 121 healthy subjects (group C) had been participated in the same HBV vaccination schedule (20 microg, 0-1-6 mo). Seroconversion was considered if anti-HBs levels were above 10 mIU/mL within 3 mo following the third dose of the vaccine. Moreover, we prospectively selected 30 non-cirrhotic CHC patients and evaluated them for the efficacy of the same vaccine schedule randomizing them in two groups: Group-1, 15 CHC patients received the first dose of the vaccine in parallel with the initiation of PEG plus RIB treatment and Group-2, 15 patients received the same vaccination schedule without concomitant treatment. Determination of anti-HBs was performed at mo 1, 2, and 7. Statistical analysis of data was based on ANOVA student's t-test and chi-square analysis (P < 0.05).

RESULTS

Fifty-eight of 70 group A patients (82.85%), 20/22 group B (90.9%) and 112/121 healthy subjects (92.56%) had been seroconverted. The seroconversion rates were significantly higher in the control group than in treatment-naive CHC patients (P = 0.04). The corresponding rates were comparable between group A and group B CHC patients (P = 0.38). The vast majority of non-responders (10/14, 71.43%) had been infected by genotype-1 of HCV. The seroconversion rates were comparable between group 1 and 2 CHC patients at mo 1 (20% versus 26.7%, P = 0.67), mo 2 (46.7% vs 60%, P = 0.46) and mo 7 (86.7% versus 93.3%, P = 0.54) of follow-up.

CONCLUSION

The immunogenicity of HBV vaccine seems to be lower in CHC patients compared to healthy subjects. SVR following IFN plus RIB treatment does not affect the antibody response to HBV vaccine. Infection by genotype-1 seems to negatively influence the seroconversion rates. Vaccination against HBV during PEG plus RIB combination treatment is not beneficial in terms of anti-HBs seroconversion rates.

Exposure to HAV infection in patients with chronic liver disease in Italy, a multicentre study

We carried out a multicentre study on 2830 patients with chronic liver disease from 79 liver units (25 in northern, 24 in central and 30 in southern Italy) to evaluate naturally acquired immunity against hepatitis A virus (HAV) in relation to age, sex, geographical area of origin and entity of liver disease, and to define the strategy for specific vaccination. Antibody to HAV (anti-HAV) was detected in 1514 (53.5%) of the 2830 patients tested; the prevalence was 50.4% in males and 59.1% in females. Both in central and southern Italy the prevalence of anti-HAV positive subjects increased with increasing age from 43.3 and 44.7%, respectively, in the 0-30-year-old subjects to 80.1 and 68.3%, respectively, in those aged over 60 years. The overall prevalence was much lower in northern Italy, as were the variations from one age group to another, from 28.4% in the 0-30-year-old subjects to 38% in those aged over 60 years. 40.6% of patients with cirrhosis lacked naturally acquired protection against HAV; this percentage was higher in northern (60.5%) than in central (34.9%, P < 0.0001) and southern Italy (27.6%, P < 0.0001). The high prevalence of patients in Italy with chronic hepatitis or cirrhosis who lack naturally acquired immunity to HAV warrants the implementation of vaccination programmes against hepatitis A in such patients.

Hepatitis A and B immunizations of individuals infected with human immunodeficiency virus

All persons at risk for infection with human immunodeficiency virus (HIV) types 1 and 2, including men who have sex with men, those with multiple heterosexual contacts, abusers of illegal injection drugs, and persons frequently exposed to blood and blood products, are also at high risk for hepatitis A virus (HAV) and acute and chronic hepatitis B virus (HBV) infections. HIV can prolong the duration and increase the level of HAV viremia and augment HAV-related liver abnormalities. HIV also magnifies HBV viremia and the risk of HBV reactivation, chronic active HBV infection, cirrhosis, and death. Because of these concerns, hepatitis A vaccination is recommended for all HIV-positive/HAV seronegative persons, with 2 standard doses given 6 to 12 months apart. Immune response to hepatitis A vaccines is excellent, even in moderately immune-suppressed individuals. Hepatitis B vaccination is also recommended for all HIV-positive persons lacking prior immunity. However, immune reactivity to hepatitis B vaccines is frequently suboptimal in terms of patients' rate of response, antibody titer, and durability. Relatively high CD4+ T-cell counts (> or =500/mm3) and low levels of HIV viremia (<1,000 RNA genome copies/mL plasma) are necessary to ensure adequate hepatitis B vaccine response. Higher hepatitis B vaccine doses, prolongation of the vaccination schedule, or both, as prescribed for many patients with non-HIV-related immune deficiencies, may be considered initially. Revaccination should be instituted if postvaccination titers of antibodies to hepatitis B surface antigen are <10 mIU/mL (<10 IU/L). Nonresponders may also react to a subsequent vaccine course if CD4+ T-cell counts rise to 500/mm3 following institution of highly active antiretroviral therapy; vaccine adjuvant trials are under way. Universal, age-based immunization of all young and middle-aged adults appears to be the most comprehensive way of protecting all populations who are at high risk.

Screening for hepatitis A and B antibodies in patients with chronic liver disease

Chronic liver disease (CLD) is highly prevalent, and hepatitis C is one of the leading causes. Acute hepatitis A or B in patients with chronic hepatitis C can lead to more severe hepatic injury and a higher fatality rate than in patients without hepatitis C. Thus, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention and the World Health Organization recommend that persons with CLD be vaccinated against hepatitis A virus (HAV), and the ACIP and the National Institutes of Health recommend vaccination against both HAV and hepatitis B virus (HBV) in patients with chronic hepatitis C. Because coinfection with HAV or HBV in patients with chronic hepatitis C or CLD is common, antibody screening prior to hepatitis A or B vaccination can identify patients who are already immune to these viruses and thus do not need to be vaccinated. Selective hepatitis A vaccination (i.e., vaccination of patients who test negative for either HAV antibody immunoglobulin G or total antibodies to HAV) is most cost-effective in areas where the local prevalence of hepatitis A is higher than the national prevalence and in populations with higher background rates of HAV exposure compared with the general population, such as older adults, foreign-born patients, African Americans, and persons with CLD or hepatitis C. Although not usually recommended for healthy adults or those with compensated CLD because of virtually 100% postvaccination seroconversion, serologic testing after hepatitis A vaccination is recommended in patients with decompensated or advanced end-stage liver disease because of the much lower seroconversion rates in these patients. Selective vaccination against HBV in patients with CLD or hepatitis C is also recommended. Testing for hepatitis B surface antigen (HBsAg) and antibodies to HBsAg (anti-HBs) is considered the most efficient and reasonably cost-effective method to screen for hepatitis B serologic markers because HBsAg identifies individuals with both acute and chronic HBV infection, and anti-HBs identify those who are immune secondary to vaccination or past infection. Testing for antibodies to hepatitis B core antigen is needed to further distinguish between immunity due to vaccination and immunity due to past infection, but it is not recommended as the only screening test for HBV immunity. Postvaccination testing for hepatitis B seroconversion is recommended in all patients with CLD, especially in those with more advanced disease, because the rate of seroconversion is generally lower than in healthy adults. If patients with CLD are not adequately protected after a standard course of hepatitis B vaccination, a repeat course of vaccination using the standard schedule or an accelerated schedule (days 0, 7, and 21) should be considered.

Susceptibility to hepatitis A in patients with chronic liver disease due to hepatitis C virus infection: missed opportunities for vaccination

Hepatitis A virus (HAV) superinfection is associated with a high risk of liver failure and death in patients with underlying chronic liver disease. Although HAV vaccination is recommended for all patients with chronic hepatitis C virus (HCV) infection, little is known about adherence to these recommendations in clinical practice. The aims of this study were to determine the frequency of HAV testing and vaccination among patients with chronic HCV infection. We conducted a retrospective cohort study of 1,193 patients diagnosed with chronic HCV infection over a 1-year period. During 1,646 person-years of follow-up, patients were seen by their primary care provider a median of 10.0 times (interquartile range, 4.0-20.0). HAV antibody testing was performed in 640 subjects (53.6%), and 317 (49.5%) of those tested were susceptible (HAV antibody negative). Only 94 of the 1,193 patients (7.9%) received the HAV vaccine, including 26.8% of the 317 susceptible patients, 0.9% of the 323 patients who were already immune to HAV, and 1.1% of the 553 subjects who were never tested. Among the 94 vaccinated patients, 45 received only one dose of the vaccine. Three of the unvaccinated patients developed acute HAV infection during follow-up, and 1 of them died of acute liver failure. In conclusion, despite published recommendations to vaccinate against HAV in patients with chronic HCV infection, we found that HAV testing and vaccination rates were low in clinical practice. Public health programs to increase awareness about HAV vaccination in patients with chronic liver disease are needed.

Immunization needs of chronic liver disease patients seen in primary care versus specialist settings

Chronic liver disease patients may benefit from certain vaccines, but their immunization coverage levels have not been widely studied. We examined the serologic and vaccination status of 693 chronic liver disease patients from 37 primary care and specialist centers. Patients in primary care had more often received influenza (47 versus 32%; P < .001) and pneumococcal (39 versus 19%; P < .001) vaccines. Among patients without documented prior exposure, those seeing specialists had more often completed hepatitis A (28 versus 5%; P < .001) and hepatitis B (29 versus 14%; P < .001) vaccination. Coverage was higher in centers with a policy of vaccinating on-site, among non-Hispanic whites, and among patients with hepatitis C and cirrhosis. In summary, most patients were unprotected against one or more vaccine preventable diseases. The higher coverage rates evident in centers vaccinating on-site suggests a breakdown may occur when patients are referred to alternative vaccination venues.

Séroprévalence de l'hépatite A chez des patients infectés par le VIH

OBJECTIVE

The authors had for aim to prospectively study the hepatitis A seroprevalence of an HIV-infected population, followed-up in an outpatient clinic (CISIH Strasbourg).

DESIGN

Blood tests were performed on all patients from September 2003 to March 2004 to screen for hepatitis A (total antibodies with Elisa).

RESULTS

The overall seroprevalence was 219/514 (56.6%), similar in male and female patients. It increased with age, especially in European patients (P = 0.003). The seroprevalence was lower in European subjects: 46.3% (while it reached 100% in sub-Saharan Africans), the prevalence was similar whatever the HIV risk group (46% in homosexual as well as in heterosexual patients, 44% in intravenous drug users). Hepatitis B or C co-infection did not increase the seroprevalence of hepatitis A. The hepatitis A seroprevalence was similar in various CD4 T cell count categories.

CONCLUSIONS

Our results stress the utility of hepatitis A serology in HIV-infected patients (more than 50% of European patients are non immune), and the importance of assessing hepatitis A vaccination.

Hepatitis B vaccine efficacy in patients with chronic liver disease by hepatitis C virus

BACKGROUND

Considering the immunosuppression of patients with chronic liver disease, their response to vaccination is discussed in literature.

AIMS

To evaluate the response of hepatitis B vaccine in patients with chronic hepatitis C virus infection.

METHODS

This is a prospective study in which 85 patients with chronic hepatitis C virus infection (46.8 +/- 9.4 years, 44.7% males) and 46 healthy adults (36.7 +/- 11.1 years; 39.1% males) were evaluated. Confirmation of hepatitis C virus was obtained by the technique of polymerase chain reaction. Viral load was determined by the branched DNA method in 74 patients, and genotype was determined by sequencing in 73 patients. All patients and healthy adults received three doses of Engerix B vaccine IM (at 0, 30 and 180 days). Serological responses to the vaccine were divided into three categories: seroprotection, when anti-HBs was > or =100 mUI/mL; seroconversion, when anti-HBs was 10-99 mUI/mL, and non-reagent, when anti-HBs was <10 mUI/mL.

RESULTS

The response of hepatitis B vaccine as determined 1 month following dose 3 was seroprotection in 37.7%, seroconversion in 17.6% and non-reagent in 44.7% among patients and 84.8%, 13.0%, 2.2%, respectively in healthy adults. The number of non-reagent responses was significantly higher among those patients with chronic liver disease. Sixty-five patients with chronic hepatitis were compared to 20 compensated cirrhotic patients in concern to the response to vaccine, but no difference was found. The response to vaccine in patients with genotypes 2 or 3 (n = 40) was better than in those with genotype 1 (n = 33). Response was not related to serum HCV-RNA concentration.

CONCLUSION

The number of non-responders was higher in patients with chronic hepatitis C virus infection, irrespective of histological status and viral load. It is suggested that such patients should receive a double dose of vaccine, particularly the ones with genotype 1.

Seroepidemiology of hepatitis A in patients with chronic liver disease

Hepatitis A virus (HAV) rarely causes fulminant hepatic failure in the general population. Yet it is a cause of significant morbidity and mortality in patients with chronic liver disease (CLD), in whom routine HAV vaccination is recommended. However, studies of HAV seroprevalence and exposure predictors in populations with CLD are scarce. We have studied a cohort of 473 patients with various causes of CLD between July 2000 and June 2002. Patients were stratified on the basis of age, gender, ethnicity and aetiology of liver disease. The HAV seroprevalence in patients with CLD was compared with that in the general population. We used a logistic regression analysis to identify independent predictors of HAV exposure. Of the 473 patients studied, HAV seroprevalence was available for 454 individuals. HCV, HBV, alcohol, and HCV and alcohol were the causes of CLD in 337, 72, 37 and eight patients, respectively. The overall HAV seroprevalence was 55% in the studied cohort. The age-stratified HAV prevalence for ages 21-30, 31-40, 41-50, 51-60, 61-70 and greater than 70 years was 44, 51, 44, 63, 65 and 64%, respectively. Hispanic ethnicity, Asian ethnicity, alcohol use and ages of 51-70 years were found to be independent predictive variables of prior exposure to HAV. HAV infection in patients with CLD causes considerable morbidity and mortality. We demonstrated that age-stratified seroprevalence of HAV in patients with CLD of various aetiologies is significantly higher than that of the general population, and identified several independent predictors of HAV prior exposure.

Hepatitis A and B vaccination practices for ambulatory patients infected with HIV

Few studies exist of adherence to guidelines for vaccination of persons infected with human immunodeficiency virus (HIV), especially in the era of highly active antiretroviral therapy (HAART). In a retrospective, cross-sectional analysis in the HIV Outpatient Study sites, 198 (32.4%) of 612 patients eligible for hepatitis B vaccine received at least 1 dose. In multivariate analysis, hepatitis B vaccination was associated with HIV risk category, education level, and number of visits to the HIV clinic per year. Among 716 patients eligible for hepatitis A vaccine, 167 (23.3%) received > or =1 dose. Response to hepatitis B vaccination was associated with higher nadir CD4+ cell counts (P=.008) and HIV RNA levels less than the level of detection (P=.04), although some response was documented at all CD4+ levels. Although there were low rates of complete hepatitis vaccination in this cohort of ambulatory patients, prompt efforts to vaccinate patients entering care, receipt of antiretroviral therapy, and practice reminder systems may enhance vaccination practices.

Review article: hepatitis vaccination in patients with chronic liver disease

Evidence regarding the outcomes of viral super-infection in patients with chronic liver disease and practical strategies for hepatitis A and B vaccination of these individuals are reviewed. Patients with acute hepatitis A and chronic hepatitis B have a more severe clinical course and a higher death rate compared with otherwise healthy individuals with hepatitis A, and these differences are most pronounced in older patients and those with histological evidence of chronic hepatitis or cirrhosis, rather than in asymptomatic hepatitis B carriers. Patients with acute hepatitis A super-infection and chronic hepatitis C have an increased risk of fulminant hepatitis and death. In addition, patients with other chronic liver diseases also appear to be at increased risk for more severe disease with superimposed hepatitis A. Patients with chronic hepatitis B and hepatitis C virus co-infection have more severe laboratory abnormalities, more severe histological disease, a greater frequency of cirrhosis and complications of cirrhosis, and a higher incidence of hepatocellular carcinoma. Vaccines for both hepatitis A and B are safe and effective if used early in the course of chronic liver disease. Hepatitis A and B vaccination should be part of the routine management of patients with chronic liver disease, preferably as early as possible in the natural course of their disease.

Retrospective detection of a subclinical hepatitis A virus (HAV) epidemic affecting juvenile cohorts of the Hungarian population

Sero-epidemiological surveys of serum samples taken in 1982, 1987, 1994 and 1999 have been performed with hepatitis A virus-specific (HAV-specific) serological tests. Results obtained during these surveys show that the proportion of seropositive blood donors decreased from 69% to 18% within 17 years. The authors have recognised a (mainly subclinical) epidemic, affecting about 115000 teenagers in 1992-1994 in Hungary, is a threatening phenomenon. It was calculated that only about 3600 clinical diseases were associated with the epidemic, recognised retrospectively from the findings of the four sero-epidemiological surveys. Epidemiological data indicated that the excess clinical diseases caused by HAV concentrated in the southern counties of Hungary, which have been affected by the social and military activities between 1992 and 1994. Due to the decrease of subjects seropositive for HAV, sera from preselected or actively immunised donors will be required in the future and vaccination against HAV with killed virus is likely to be recommended for risk groups. Furthermore, health authorities might promote active immunisation of young children against HAV infection; for that, promotion of manufacturing combination vaccines of HAV/HBV/DPT or, for certain countries, HAV/DPT would be desirable.

Hepatitis A virus infection in hepatitis C Brazilian patients

OBJECTIVE

HAV infection in patients with pre-existing chronic liver disease has been associated with increased rate of fulminant hepatitis and mortality. The aim of this study was to investigate the presence of serological and molecular HAV markers in a population of HCV infected patients.

PATIENTS AND METHODS

The presence of total and IgM anti-HAV antibodies was investigated in 197 patients (mean age 44.8+/-12.5 years) referred to the Brazilian Reference Center for Viral Hepatitis and who tested positive for anti-HCV antibodies and HCV RNA. HAV RNA was investigated by reverse transcription-nested PCR in these patients.Results. One hundred seventy patients (86%) had total, but not IgM anti-HAV antibodies, being therefore, immune to hepatitis A, while 27 (14%) were not. A high proportion (6/27, 22%) of the susceptible patients presented markers of recent HAV infection: One patient was IgM anti-HAV positive, three were HAV RNA positive, and two presented both markers. By nucleotide sequencing, it was demonstrated that the HAV isolates infecting these patients belonged to subgenotypes 1A and 1B.

CONCLUSIONS

Superinfection with HAV was a common event in the group of HCV infected patients under study. Implementation of hepatitis A vaccination should be considered for this population.

HAV infection in chronic liver disease: a rationale for vaccination

We report the conduct and results of a systematic search of the literature to assess whether exposure to HAV could induce a fatal deterioration of liver diseases. We assessed 30 studies and found evidence of progressive decrease of natural immunity against HAV in Italy. HAV vaccine seems as safe in chronic liver diseases than in general population. On the basis of the evidence we recommend that subjects with chronic liver disease should be vaccinated against HAV, especially if younger than 40 years.