Immunogenicity of recombinant hepatitis B virus vaccine in patients with and without chronic hepatitis C virus infection: A case-control study

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.

Eliminating viral hepatitis in children after liver transplants: How to reach the goal by 2030

Viral hepatitis infections are a great burden in children who have received liver transplant. Hepatotropic viruses can cause liver inflammation that can develop into liver graft fibrosis and cirrhosis over the long term. Immunological reactions due to viral hepatitis infections are associated with or can mimic graft rejection, rendering the condition difficult to manage. Prevention strategies using vaccinations are agreeable to patients, safe, cost-effective and practical. Hence, strategies to eliminate viral hepatitis A and B focus mainly on immunization programmes for children who have received a liver transplant. Although a vaccine has been developed to prevent hepatitis C and E viruses, its use is not licensed worldwide. Consequently, eliminating hepatitis C and E viruses mainly involves early detection in children with suspected cases and effective treatment with antiviral therapy. Good hygiene and sanitation are also important to prevent hepatitis A and E infections. Donor blood products and liver grafts should be screened for hepatitis B, C and E in children who are undergoing liver transplantation. Future research on early detection of viral hepatitis infections should include molecular techniques for detecting hepatitis B and E. Moreover, novel antiviral drugs for eradicating viral hepatitis that are highly effective and safe are needed for children who have undergone liver transplantation.

NEW IMMUNIZATION SCHEDULE EFFECTIVENESS AGAINST HEPATITIS B IN LIVER TRANSPLANTATION PATIENTS

BACKGROUND

Although liver transplantation is considered to be a high-risk procedure, it is well-established as a treatment option for the cure and quality of life enhancement for individuals who suffer from diseases. Preventing an infection by hepatitis B virus through immunization schedules has been the most effective way to reduce complications, since it decreases the number of people who suffer from chronic hepatitis caused by the hepatitis B virus and eradicates its transmission.

OBJECTIVE

1. Analyzing evidence in the literature on various schedules employed for immunization against hepatitis B in patients who have received a liver transplantation. 2. Suggesting potential immunization schedules against hepatitis B in patients who suffer from liver cirrhosis, without previous verifying documentation, using the Child-Turcotte Pugh score, according to evidences found in the literature.

METHODS

Systematic review of the literature, conducted on the data bases MedLine, PubMed, and Lilacs, between September, 2017 and January, 2018, by using the following keywords: "Liver Transplantation, "Immunization Schedule", "Hepatitis B Vaccines". In order to analyze the articles, a summary figure was especially designed and both the results and discussion were presented in a descriptive way.

RESULTS

We included 24 studies; among them, eight had accelerated immunization schedules, 13 followed the conventional schedules, and three had super accelerated schedules. Regarding immunization, 21 studies were conducted with patients in the pre-transplant period, one with a transplanted patient, one with a pre-transplant group, and one with a post-transplant group. Found articles suggest that, disregarding the chosen immunization schedule, seroconversion rates tended to be lower as the liver disease advanced, compared to the healthy population.

CONCLUSION

The studies did not find seroconversion superiority between the different immunization schedules (conventional and unconventional). However, since candidates to liver transplantation are usually very vulnerable, results show that super accelerated immunization schedules are possibly recommended for such group of patients; serologic test results will be higher when the immunization schedule is completed in the pre-transplant period.

Immune response to hepatitis B vaccine in patients with chronic hepatitis C infection: A systematic review and meta-analysis

Hepatitis B virus and hepatitis C virus (HCV) co-infection can add to the severity of hepatitis and the risks of liver cirrhosis and hepatocellular carcinoma. Whether chronic HCV infection decreases antibody response to hepatitis B vaccination is still controversial. We evaluate the influence of HCV infection on antibody response to hepatitis B vaccination by a systematic review of published works with a meta-analysis of clinical trials. The random-effects model of DerSimonian and Laird with heterogeneity and sensitivity analyses were used in this study. The end-point of interest was the rate of patients showing seroconversion of antibody responses at completion of hepatitis B vaccination schedule among patients with chronic HCV infection versus healthy controls. We identified 11 studies involving 704 patients with HCV and 812 controls. Our results show a significant decrease in antibody seroconversion rates among patients with HCV versus healthy controls (pooled odds ratio = 0.17 [95% confidence interval, 0.11-0.28]). The P-value was 0.21 for our test of study heterogeneity. Stratified analysis in subgroups of interest and sensitivity analysis did not meaningfully change our results. Our meta-analysis showed patients with hepatitis C infection have a statistically significant lower rate of seroconversion in comparison to healthy controls, both in cirrhotic and non-cirrhotic patients. Chronic HCV infection can decrease the immune response to a standard schedule of hepatitis B vaccination. Further studies are needed to investigate the optimum vaccination schedule for patients with chronic HCV infection.

Robust Antibody and Cytokine Response to Hepatitis B Vaccine Among Not-in-Treatment Patients With Chronic Hepatitis C: An Open-Label Control Study in China

Background

Hepatitis B vaccine is an effective measure to prevent hepatitis B virus infection. Whether chronic hepatitis C virus (HCV) infection decreases humoral and cell-mediated immunity responses to hepatitis B vaccination is still controversial.

Methods

Patients with chronic HCV infection who were not in treatment and healthy controls, matched at a 1:2 ratio for community, sex, and age (within 5 years), were identified from a community-based screening. All participants received 3 doses of hepatitis B vaccine. Antibody to hepatitis B surface antigen was tested 1 month after the third vaccine dose and was compared between 2 groups. Spot-forming cells (SFCs) of interferon γ and interleukin 2, 4, 5, and 6 were counted by means of enzyme-linked immunospot, and SFC counts were compared between the 2 groups.

Results

The rates of nonresponse and low, normal, and high response were 3.80%, 10.13%, 45.57%, and 40.50% respectively, in the HCV group, and the corresponding rates in the healthy control group were 1.26%, 10.13%, 39.24%, and 49.37% (all P > .05). There were no significant differences in SFC counts between the 2 groups for interferon γ or interleukin 2, 4, or 5 (all P > .05).

Conclusions

This study provided preliminary evidence of the good immunogenicity and safety of hepatitis B vaccination among patients in China with chronic hepatitis C who are not in treatment.

Clinical Trials Registration

NCT 02898922.

Old and new adjuvants for hepatitis B vaccines

The safety and immunogenicity profiles of currently available recombinant hepatitis B vaccines are excellent. However, it remains a real challenge to induce protective immunity in the target groups that respond poorly or not at all to conventional vaccines. Ideally, a hepatitis B vaccine can be developed that conveys lifelong protection against infection rapidly after the injection of a single dose. Although this goal is far from being reached, important improvements have been made. Novel vaccine adjuvants have been developed that enhance the immunogenicity of recombinant hepatitis B vaccines while maintaining a good safety profile. The different adjuvants and adjuvant systems that are discussed herein have all been thoroughly evaluated in clinical trials and some have reached or are close to reach the market.

Surface protein mutations in chronic hepatitis B patients who received hepatitis B vaccine therapy

OBJECTIVE S

The aim of this study was to determine the correlation between vaccine therapy and appearance of mutations in hepatitis B surface antigen (HBsAg)-positive chronic hepatitis B virus (HBV) patients.

MATERIALS AND METHODS

16 patients received the HBV vaccine and another 16 individuals from the control group did not. The surface gene was amplified and directly sequenced from samples prior to vaccination and six months after the third dose.

RESULTS

Only one patient lost HBsAg. 48 and 44 amino acid mutations were found before and after vaccine therapy in the vaccine group respectively, 51 of which (55.4%) occurred in immune epitopes: 5 were in B cell, 21 in T helper (Th), and 25 in cytotoxic T-lymphocyte (CTL) epitopes. In the control group, 35 and 41 amino acid substitutions were found before and after therapy, respectively. 32 (42%) of 76 amino acid changes occurred within immune epitopes. There were no differences in age, gender, and duration of chronicity in both patient and control groups in terms of the frequency and the patterns of mutations.

CONCLUSION

In chronic carriers who already had HBsAg variants selected by the host-immune response, any immune stimulation by the vaccine had no effect on the chronic state of these patients or selected any remarkable escape mutants. Newer strategies should be considered based on third generation or the use of DNA vaccines or new adjuvants.

Response to hepatitis A and B vaccination in patients with chronic hepatitis C: 8-year follow-up

BACKGROUND

In patients with chronic hepatitis C (CHC), superinfection with hepatitis A (HAV) or B (HAB) viruses is associated with increased morbidity and mortality. The seroconversion rate of these patients following vaccination is considered to be lower than in healthy subjects.

AIM

To evaluate the response to HAV and HBV vaccination in children with CHC.

METHODS

Thirty patients with CHC aged from 7.3 to 18 years were compared with 50 healthy age-, gender- and body-mass-index-matched controls. Post-vaccination serological evaluation was performed 1 month after the last dose of primary vaccination, 1 month after the booster dose and once a year during follow-up.

RESULTS

Twenty-two patients received hepatitis A vaccine and response rate was 95.4%. Thirty patients received hepatitis B vaccine and 80% responded (hepatitis Bs titres ≥10 mIU/ml). Thirty-five controls received hepatitis A vaccine and protective anti-HAV antibodies developed in all. All of the controls were vaccinated against hepatitis B virus and 90% responded. After the whole vaccination series, overall seroprotection rates were 86% in patients and 96% in controls. No significant reduction in antibody response was observed in patients or controls during 8-years follow-up.

CONCLUSIONS

The rate of seroconversion to the HBV vaccine is lower in patients with CHC than in healthy controls but response to HAV is adequate.

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 A Virus among Drug Users and the Role of Vaccination: A Review

In countries with advanced economies better health and hygiene conditions, along with the introduction, in some cases, of global vaccination, have relegated most viral hepatitis to marginal social groups and, in particular, drug users (DUs). The availability of safe and effective vaccines for hepatitis A virus (HAV) and B (HBV) may play a major role in combating this phenomenon. Despite the availability of a safe and effective vaccine for over a decade and the recommendations of international health organizations, vaccinations against HAV among DUs are not as widely known and available as are HBV vaccinations. The purpose of this review article is to present the most significant data in the literature on the prevalence of HAV among DUs and the role of targeted vaccination. To our knowledge, the present article is the first to solely deal with vaccination against HAV in DUs. Immunization after the administration of anti-HAV vaccine has been demonstrated in DUs even if they have responded significantly less than either the general population or carriers of chronic liver disease. All the vaccines were well tolerated and adherence to the vaccine schedule was good. Further studies are needed to optimize the timing and doses of vaccine to be administered to DUs, especially to assess adherence and antibody persistence. Vaccination campaigns are feasible among DUs and have proven to be highly cost-effective.

Development of up-converting phosphor technology-based lateral-flow assay for rapidly quantitative detection of hepatitis B surface antibody

An up-converting phosphor technology-based lateral-flow (UPT-LF) assay system was developed for rapid and quantitative detection of hepatitis B surface antibody (HBsAb). To evaluate its performance, we compared it with the Abbott Axsym AUSAB (ABBOTT Diagnostics Division, Wiesbaden, Germany) assay and conventional ELISA (Wantai Biological Pharmacy Enterprise, Beijing, China) using 13 standard positive sera and 306 clinical sera. In both laboratory evaluation and clinical application, UPT-LF assay showed the best sensitivity (99.19%) and detection agreement (97.43% for the adjusted agreement) with true results. The concordance rate between UPT-LF and ELISA, as shown by correlative regression analysis, was the highest (R(2)=0.6389), whereas that between UPT-LF and AUSAB was the lowest (R(2)=0.5702). In conclusion, UPT-LF assay for quantitative detection of HBsAb is sensitive and rapid, promising this new assay a bright future.

[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.

Bloodborne viral hepatitis infections among drug users: the role of vaccination

Drug use is a prevalent world-wide phenomenon and hepatitis virus infections are traditionally a major health problem among drug users (DUs). HBV and HCV, and to a lesser extent HAV, are easily transmitted through exposure to infected blood and body fluids. Viral hepatitis is not inevitable for DUs. Licensed vaccines are available for hepatitis A and hepatitis B. The purpose of this overview is to show some epidemiological data about HBV and the other blood-borne viral hepatitis among DUs and to summarize and discuss use of hepatitis vaccinations in this population. Successful vaccination campaigns among DUs are feasible and well described. We try to focus on the most significant results achieved in successful vaccination programs as reported in scientific literature. Vaccination campaigns among DUs represent a highly effective form of health education and they are cost-saving.

Engineering enhancement of the immune response to HBV DNA vaccine in mice by the use of LIGHT gene adjuvant

DNA vaccines could induce protective immune responses in several animal models. Many strategies have been employed to improve the effect of nucleic acid vaccines. LIGHT is a member of the TNF superfamily and functions as a co-stimulatory molecule for T cell proliferation. In the study, the immunogenicity in the induction of humoral and cellular immune responses by HBV DNA vaccine and the adjuvant effect of LIGHT were studied in a murine model. The eukaryotic expression plasmid pcDNA-L was constructed by inserting mouse LIGHT gene into the vector pcDNA3.1(+). In vitro expression of LIGHT was detected by RT-PCR and indirect immunofluorescence assay in transfected HeLa cells. MLR assay showed that LIGHT-transfected DCs induced markedly higher allogeneic lymphocyte proliferation than pcDNA-transfected DCs and untreated DCs at all dilutions. After BALB/c mice were immunized by three intramuscular injections of the HBV DNA vaccine plasmids alone or in combination with LIGHT expression plasmids, the different levels of anti-HBV immune responses were measured comparable to the control groups immunized with parent plasmid pcDNA or PBS. The HBsAg-specific splenocytes proliferation and specific cytotoxic activities of splenic CTLs in the coinoculation group were both significantly higher than those in the HBV DNA single inoculation group, and an enhancement of antibody response was also observed in the coinoculation group compared with the single inoculation group. Taken together, coimmunization of HBV DNA vaccine plasmids and LIGHT expression plasmids can elicit stronger humoral and cellular immune responses in mice than HBV DNA vaccine plasmids alone, and LIGHT may be an effective immunological adjuvant in HBV DNA vaccination.

Targeting hepatitis B virus antigens to dendritic cells by heat shock protein to improve DNA vaccine potency

AIM: To investigate a novel DNA vaccination based upon expression of the HBV e antigen fused to a heat shock protein (HSP) as a strategy to enhance DNA vaccine potency.

METHODS: A pCMV-HBeAg-HSP DNA vaccine and a control DNA vaccine were generated. Mice were immunized with these different construct. Immune responses were measured 2 wk after a second immunization by a T cell response assay, CTL cytotoxicity assay, and an antibody assay in C57BL/6 and BALB/c mice. CT26-HBeAg tumor cell challenge test in vivo was performed in BALB/c mice to monitor anti-tumor immune responses.

RESULTS: In the mice immunized with pCMV-HBe-HSP DNA, superior CTL activity to target HBV-positive target cells was observed in comparison with mice immunized with pCMV-HBeAg (44% ± 5% vs 30% ± 6% in E: T > 50:1, P < 0.05). ELISPOT assays showed a stronger T-cell response from mice immunized with pCMV-HBe-HSP than that from pCMV-HBeAg immunized animals when stimulated either with MHC classIor class II epitopes derived from HBeAg (74% ± 9% vs 31% ± 6%, P < 0.01). ELISA assays revealed an enhanced HBeAg antibody response from mice immunized with pCMV-HBe-HSP than from those immunized with pCMV-HBeAg. The lowest tumor incidence and the slowest tumor growth were observed in mice immunized with pCMV-HBe-HSP when challenged with CT26-HBeAg.

CONCLUSION: The results of this study demonstrate a broad enhancement of antigen-specific CD4⁺ helper, CD8⁺ cytotoxic T-cell, and B-cell responses by a novel DNA vaccination strategy. They also proved a stronger antigen-specific immune memory, which may be superior to currently described HBV DNA vaccination strategies for the treatment of chronic HBV infection.