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.     

Compliance with hepatitis B vaccination in 1175 heroin users and risk factors associated with lack of vaccine response

Aims To investigate the feasibility of hepatitis B vaccination among heroin users, assessing adherence to the vaccination schedules and identifying factors associated with antibody response. Design and participants A large cohort study in nine public centres for drug users (PCDUs) in north‐eastern Italy, with data collected between January 1989 and December 1998. A total of 1175 heroin users were selected and vaccinated with a recombinant vaccine using two schedules (0–1–6 months and 0–1–2 months). Findings Eighty‐eight per cent of patients completed the vaccination series and a protective antibody response occurred in 77% of subjects. Completion of the vaccination series was not related to the length of the vaccination schedule or whether the patient was still in drug abuse treatment at the end of the series, but was related strongly to the number of patients enrolled at each PCDU (Spearman correlation = – 0.93, P < 0.001). Four variables were significantly associated with lack of seroconversion in response to vaccination: older age (AOR = 0.91 per year, 95% CI 0.88–0.94, P < 0.001), 2‐month vaccination schedule (AOR = 3.10, 95% CI 2.06–4.68, P < 0.001), HCV seropositivity (AOR = 0.69, 95% CI 0.47–0.99, P = 0.04), HIV seropositivity (AOR = 0.27, 95% CI 0.10–0.77, P = 0.01). Conclusions A large‐scale, multi‐site hepatitis B vaccination programme for heroin users proved feasible and effective. The factors associated with a lack of antibody response may be useful in identifying patients who would benefit most from routine post‐vaccination testing, with booster doses for non‐responders. These results suggest that hepatitis B vaccination for drug users should become a routine public health practice.     

Response to hepatitis B vaccination by liver transplant candidates

Liver transplantation (OLTx) is a procedure offered to individuals with advanced liver disease who are expected to live less than a year. Despite improvement in the care of transplant recipients, these patients are exposed to large volumes of blood and, as a result, are at risk to acquire hepatitis. Currently, the only vaccines available for the prevention of hepatitis are those that induce a response to HB_sAg. In this study, 144 patients awaiting OLTx and 15 controls were vaccinated three times, once a month, intramuscularly in the deltoid using the Merck Hepatovax plasma-derived vaccine. This schedule was continued regardless of whether or not OLTx occurred before the series was completed. For the 15 controls, the response rate was 93% and for individuals with end-stage liver disease, it ranged from 44 to 54% (P<0.004). No difference in the percentage of those developing antibody was detected between groups based upon disease indication or whether the vaccination series was completed before or after OLTx. Of the following: WBC, lymphocytes (percent and number), CD3+ cells (percent and number), CD4+ cells (percent and number), CD8+ cells (percent and number), CD4+/CD8+ ratio, and B cells (percent and number), only the absolute WBC (P<0.05) distinguished between those who did and did not develop antibody. These data suggest: (1) those with chronic liver disease respond less well to Hepatovax than do controls; (2) a rapid sequence of vaccinations is capable of producing antibody in normals and those with liver disease; (3) no difference is evident between those who completed their vaccination schedule before or after OLTx; and (4) among patients with chronic advanced liver disease, a higher total WBC is associated with an increased rate of seroconversion.     

Implementation of Vaccination in Patients with Cirrhosis

Vaccination for hepatitis A, hepatitis B, pneumococcus, and influenza in patients with chronic liver disease is recommended. Our purpose was to determine the degree of adherence to these recommendations in cirrhotics presenting for liver transplantation evaluation. Our sample consisted of 105 patients presenting for evaluation for liver transplantation. Data were obtained by medical record review and patient interview. The age of the patients was 52 ± 9 years (mean ± sd) and the Child-Pugh score was 9 ± 2. Twenty-nine patients had natural immunity for hepatitis A. Of the remaining 76, 20 (26.3%) received vaccine. Of the 89 patients without evidence of prior exposure to hepatitis B, 23 (25.8%) received vaccine. Pneumococcal and influenza vaccination was performed in 36 (34%) and 58 (55%) respectively. In conclusion, vaccination for viral hepatitis, pneumococcus, and influenza not being consistently performed. Public health efforts aimed at raising awareness about implementing vaccination in these patients are strongly encouraged.     

Vietnamese community screening for hepatitis B virus and hepatitis C virus

Summary. Asian Americans represent an important cohort at high risk for viral hepatitis. To determine the prevalence of Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infection and HBV vaccination in a Vietnamese community, a total of 322 Vietnamese subjects from a local doctor’s office and annual Vietnamese Health Fair were included in this study. Demographic and clinical data were collected. 2.2% of the screened cohort tested positive for anti‐HCV and 9.3% tested positive for HBsAg. Unlike HBV‐positive subjects, HCV‐positive subjects had significantly higher liver enzymes (P = 0.0045 and P = 0.0332, respectively). The HBV‐positive group was more likely to report jaundice (P = 0.0138) and a family history of HBV (P = 0.0115) compared to HBV‐negative subjects. Forty‐eight patients (15.5%) reported a family history of liver disease (HBV, HCV, HCC, cirrhosis, other). Of this 48, 68.8% reported no personal history of HBV vaccination and 77.1% reported no family history of vaccination for HBV. Among the 183 subjects without a family history of liver disease, 156 (85.2%) reported no personal history of vaccination and 168 (91.8%) reported no family history of vaccination. HBV vaccination rates in those reporting a family history of liver disease were significantly higher (P = 0.020). There was a high prevalence of HBV infection in this community screening. Nevertheless, the rate for HBV vaccination was low. The low prevalence of abnormal liver enzymes in HBV‐positive subjects emphasizes the need for screening to be triggered by risk factors and not by abnormal liver enzymes.     

Immunization of liver and renal transplant recipients: a seroepidemiological and sociodemographic survey

Abstract: Several life‐threatening infections, a major risk to adult solid organ transplant (SOT) recipients on immunosuppressive therapy, can be prevented by immunization. We analyzed sociodemographic parameters and the immunization status of adult liver transplant recipients (LTX‐R, n=267) and renal transplant recipients (RTX‐R, n=197) SOT recipients at the Transplantation Center, Berlin, Germany. Date, number, and provider of recommended vaccines were recorded and seroprotection rates determined. The social status in both groups was similar. Most patients (89%) were not adequately informed about immunizations; and if informed, main sources were physicians (47%) and the media (40%). Vaccinations were predominantly provided by family doctors (LTX‐R, 66%; RTX‐R, 31%) or hemodialysis centers (RTX‐R, 37%). Before transplantation, RTX‐R had significantly more often received booster vaccinations against tetanus and diphtheria (P<0.005), and a primary hepatitis B immunization (55%); whereas in LTX‐R, post‐transplant vaccinations against hepatitis A (16%) and pneumococcal disease (13%) were more frequent. Seroprotection rates against tetanus were fairly high in LTX‐R (85.3%) and RTX‐R (86.8%), and considerably lower for diphtheria, hepatitis A, and influenza. Immunization rates are too low in SOT recipients. Improvement will depend on a more active role of health care providers.     

Cases of Rapid Hepatitis B Surface Antigen Reduction after COVID-19 Vaccination

Objective One of the therapeutic goals for chronic infection with hepatitis B virus is the clearance of hepatitis B surface antigen (HBsAg) from the blood, as a high load of HBsAg has been proposed to induce antigen-specific immunotolerance. To achieve HBsAg reduction, Pegylated interferon and nucleos(t)ide analogs are used to treat chronic hepatitis B. Following the coronavirus disease 2019 (COVID-19) outbreak, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has rapidly spread worldwide, and vaccination with mRNA COVID-19 vaccines has been conducted since 2021 in Japan. We experienced three clinical cases in which HBsAg levels rapidly decreased after injection of the COVID-19 vaccine without any incentive. Method To examine whether the vaccine administration was involved in the HBsAg reduction, the number of patients with chronic hepatitis B showing a change in the HBsAg levels during the period before the commencement of the COVID-19 vaccination program in Japan (i.e. until the end of 2020; pre-vaccination-program period) was compared to the number of those who showed a change in HBsAg levels after the initiation of the program (i.e. 2021 onwards; post-vaccination-program period). Results The number of patients whose HBsAg levels was reduced by >50% per year was prominent after the initiation of the vaccination program. Although the involvement of vaccination in HBsAg reduction was not statistically proven (p=0.0532), the result suggests that the administration of COVID-19 vaccines may have been involved in HBsAg reduction in patients with chronic hepatitis B. Conclusion COVID-19 vaccines may be involved in HBsAg reduction.     

Evaluation of the Potential for Bloodborne Pathogen Transmission Associated with Diabetes Care Practices in Nursing Homes and Assisted Living Facilities,Pinellas County

OBJECTIVES: To evaluate and characterize routine blood glucose monitoring practices in nursing homes and assisted living facilities (ALFs). DESIGN: Cross‐sectional, self administered survey and facility site visit. SETTING: Two hundred eighty‐nine licensed long‐term care facilities in Pinellas County, Florida. PARTICIPANTS: Stratified random sample of 48 long‐term care facilities (17% overall sample). MEASUREMENTS: Data on facility characteristics, infection control policies, staff practices, and equipment used for blood glucose monitoring. Differences between facilities in each stratum were compared and evaluated using the Pearson chi‐square or Fisher exact test. RESULTS: Fifteen nursing homes and 17 small and 16 large ALFs participated; 53 declined (48% participation rate). Bloodborne pathogen training (P=.02), hepatitis B vaccination (P=.003), and blood glucose monitoring (P<.001) policies were reported less often at ALFs. Staff glove use during blood glucose monitoring was lowest (50%) at small ALFs (P=.02). Reusable fingerstick devices intended for personal use were most often in use at ALFs (P<.001); four of 18 facilities (including 1 nursing home) were inappropriately using them for multiple residents. At 22 facilities (including all nursing homes), multiple residents shared blood glucose meters; only six (27%) reported cleaning them after each use. CONCLUSION: Despite existing recommendations, practices that facilitate bloodborne pathogen transmission during blood glucose monitoring were identified at nursing homes and ALFs. Infection control practices and polices were most often lacking at ALFs. Better training and oversight of blood glucose monitoring in long‐term care is needed to prevent transmission of bloodborne pathogens.     

Wild‐type precore and core promoter sequences in patients with acute self‐limited or chronic hepatitis B

Background: Mutations in the precore region and core promoter were compared between patients with acute and chronic hepatitis B. Methods: There were 69 patients with acute self‐limited hepatitis B and 210 with chronic hepatitis B who had been followed for >15 years. The hepatitis B virus (HBV) of genotypes A, B and C was detected in 14 (23%), 8 (13%) and 28 (45%) of the patients with acute self‐limited hepatitis, respectively, in contrast to 11 (5%), 25 (12%) and 167 (80%) of those with chronic hepatitis. Results: At presentation, hepatitis B e antigen (HBeAg) in serum was the more common (82% versus 65%, P?P?P?15 years. Conclusion: HBV with the wild‐type sequences of the precore region and core promoter prevails in patients with acute self‐limited hepatitis, unlike in patients with chronic hepatitis.     

Increased effective immunogenicity to high-dose and short-interval hepatitis B virus vaccination in individuals with chronic hepatitis without cirrhosis

Hepatitis B virus (HBV) vaccination is recommended for individuals with chronic liver disease. However, the response to standard doses of hepatitis B vaccines in such individuals has been poor. The aim of the present study was to assess the response to high-dose short-interval HBV vaccination in individuals with chronic liver disease of different aetiologies. A total two hundred and 24 subjects with chronic liver disease (138 chronic active hepatitis and 86 cirrhosis) and 26 healthy controls were vaccinated using a high-dose (40 μg) short-interval (monthly for 3 consecutive months) HBV vaccination schedule.
One hundred and thirty-eight of the 224 subjects with chronic liver disease (62%) seroconverted to anti-HBs antibody positivity (>10 mIU/mL) after the third dose of vaccine as compared with 24 of the 26 controls (92%) ( P  < 0.01). The response rate was reduced in individuals with cirrhosis (36/86, 42%), particularly in alcohol-induced cirrhosis (2/17, 12%), as compared with individuals with chronic hepatitis (102/138, 74%) ( P  < 0.001). No significant HBV vaccination-related adverse effects were seen in individuals with or without cirrhosis as well as in the controls.
High-dose short-interval HBV vaccination is safe and efficacious in individuals with chronic liver disease. The response to HBV vaccination is reduced in cirrhotics, particularly those with alcoholic cirrhosis. These data suggest that HBV vaccination should be accomplished early in an individual cause of chronic liver disease prior to the development of cirrhosis.     

Clinical features of hepatitis B virus genotype A in Japanese patients

Background. Hepatitis B virus (HBV) genotype A is predominant in northern Europe and central Africa. In the present study, we examined the clinical features associated with HBV genotype A disease in the Tokyo metropolitan area. Methods. We investigated 53 cases of HBV surface antigen (HBsAg)-positive Japanese patients with HBV genotype A. The 53 cases were further classified as to their serum alanine aminotransferase (ALT) status being within the normal range (asymptomatic carriers, n = 17), chronic hepatitis (n = 15), liver cirrhosis (n = 4), and acute hepatitis (n = 17). Results. Chronic hepatitis patients had significantly higher HBV DNA levels (P = 0.003) and hepatitis B e antigen (HBeAg) positivity rates at the initial visit than did asymptomatic carriers or patients with liver cirrhosis (P = 0.003 and P = 0.054, respectively). The efficacy of treatment (HBeAg seroconversion rate) was 75% in 12 chronic hepatitis patients, which was excellent. A family history of HBsAg positivity was identified in eight (15%) families (five asymptomatic carriers, three with chronic hepatitis). However, none of the mothers in the study was positive for HBV genotype A. Conclusions. Maternal transmission of HBV has often been reported in Japan, but our present findings suggest that horizontal infection of HBV genotype A is more prevalent in the Tokyo metropolitan area. Our data indicate that HBV genotype A exhibits a mode of infection different from that of conventional HBV previously seen in Japan.     

Antibodies to Hepatitis E and A Viruses among Patients with Non-Alcoholic Chronic Liver Disease in Taiwan

Tsai J-F, Jeng J-E, Chang W-Y, Lin Z-Y, Tsai J-H. Antibodies to hepatitis E and A viruses among patients with non-alcoholic chronic liver disease in Taiwan. Scand J Gastroenterol 1994;29:651-654

Background: The prevalence of hepatitis E virus (HEV) and hepatitis A virus (HAV) infection in patients with non-alcoholic chronic liver disease (CLD) was assessed.

Methods: Antibody levels to HEV (anti-HEV) and HAV (anti-HAV) were evaluated in 100 pairs of CLD patients and healthy controls.

Results: The prevalence of anti-HEV was higher in patients (10.0%) than in controls (0%; p = 0.0001). There was no difference in anti-HAV positivity between patients (95%) and controls (93%). The patient group with anti-HEV was older (p equals; 0.024) and had more smokers (p equals; 0.03), having a higher prevalence of antibodies to hepatitis C virus (p equals; 0.02). Patients with anti-HAV were older than patients without (p equals; 0.0001). The prevalence of anti-HAV in patients more than 30 years old was higher than younger patients (95.1% versus 73.6%, p equals; 0.011). Conclusion: HEV may superinfect on chronic liver disease in an area hyperendemic for hepatitis A and B.     

Cold activation of complement in sera from patients with persistent hepatitis C virus infection on interferon therapy

The loss of haemolytic activity in sera during storage at low temperature (the cold activation of complement) was observed in 136 of 184 (74%) patients with chronic liver disease associated with hepatitis C virus (HCV) infection. This was more frequent than observed in the three of 40 (8%) patients with chronic hepatitis B (P < 0.001) or none in 43 normal controls (P < 0.001). Of 103 patients with chronic hepatitis C who had completed a full course of recombinant interferon-α2a therapy (total dose: 516×10⁶U), 40 responded completely and 21 responded partially, as judged by the normalization or decrease of alanine aminotransferase levels 6 months after the completion of therapy; 42 patients did not respond at all. The cold activation of complement persisted in five (13%) complete responders, less often than in 33 (79%) non-responders (P < 0.001). At the completion of interferon therapy, the cold activation of complement persisted in 12 of 54 patients despite the normalization of alanine aminotransferase. Spontaneous exacerbation of hepatitis occurred in seven of 12 (58%) patients with cold activation, which was more frequent than in the four of 42 patients (10%) without it (P < 0.01). The cold activation of complement disappeared along with the loss of HCV-RNA in five of six responders during the 6 month period after the completion of interferon therapy, while both cold activation and HCV-RNA persisted in all eight non-responders. These results indicate that the cold activation of complement may be useful as a marker of HCV viraemia for monitoring the response to interferon in patients with HCV infection.     

Hepatitis E virus as an etiology of acute exacerbation of previously unrecognized asymptomatic patients with hepatitis B virus-related chronic liver disease

Background and Aim: Hepatitis E virus (HEV) has recently been implicated in episodes of acute decompensation in patients having underlying chronic liver disease (CLD) of varying etiology. However, HEV as a cause of acute exacerbation of previously asymptomatic and unrecognized hepatitis B virus (HBV)‐infected patients is less well described. The aim of the present study was to investigate the etiology of acute exacerbation of previously asymptomatic and unrecognized HBV‐infected patients and to evaluate the relative role of HEV. We also investigated the effect of superinfection on the clinical spectrum of underlying HBV infection. Methods: Forty‐three patients presented with the following were retrospectively analyzed: (i) clinical features suggestive of acute hepatitis; (ii) with hepatitis B surface antigen (HBsAg) (+); (iii) IgM hepatitis B core antibody (IgM anti‐HBc) (?); (iv) no previous history of liver disease; (v) no features suggestive of CLD at presentation; (vi) HBsAg remaining (+) for at least 12 months on follow up; and (vii) having a follow‐up biopsy during the convalescent phase showing evidence of chronic hepatitis B. Results: Of the 43 patients, 21 were hepatitis e antigen (HBeAg) (+) (Gr.1) and 22 HBeAg (?) (Gr.2) at presentation. In Gr.1, only two (9.5%) had superinfection (both with hepatitis A virus), whereas in Gr.2, 11 (50%) had superinfection (27.3% hepatitis E, 13.6% hepatitis A and 9.1% both) (P = 0.007). In Gr.1, the remaining 19 (90.5%) patients had spontaneous exacerbation (immune clearance with spontaneous seroconversion) whereas in Gr.2, the remaining 11 (50%) had spontaneous exacerbation (due to reactivation). Overall, HEV superinfection contributed to 20% of acute exacerbation episodes and, in particular, 36% of episodes in initially HBeAg (?) patients. Time to alanine aminotransferase normalization was longer in patients with superinfection (n = 13) as compared to spontaneous exacerbation (n = 30) (median [range] 36 [8–48]vs 16 [6–36] weeks, P = 0.001). During convalescence, there was no significant difference between histological activity index score (median [range] 8 [4–11]vs 8 [4–16] weeks, P = 0.629) and fibrosis scores (median [range] 3.5 [1–4]vs 2 [1–4] weeks, P = 0.099] on liver biopsy after recovery among patients with acute exacerbation due to superinfection and spontaneous exacerbation. Conclusions: Acute exacerbations in HBeAg (+) patients are most often due to spontaneous viral activation, while in HBeAg (?) patients, superinfection with non‐B hepatitis viruses and spontaneous viral activation are equally common. HEV is an important cause of acute exacerbation in previously asymptomatic and unrecognized patients with HBV‐related CLD.     

COVID-19 vaccination and liver disease

Various vaccines against severe acute respiratory syndrome coronavirus 2 have been developed in response to the coronavirus disease 2019 (COVID-19) global pandemic, several of which are highly effective in preventing COVID-19 in the general population. Patients with chronic liver diseases (CLDs), particularly those with liver cirrhosis, are considered to be at a high risk for severe COVID-19 and death. Given the increased rates of disease severity and mortality in patients with liver disease, there is an urgent need to understand the efficacy of vaccination in this population. However, the data regarding efficacy and safety of COVID-19 vaccination in patients with CLDs is limited. Indeed, several organ-specific or systemic immune-mediated side effects following COVID-19 vaccination, including liver injury similar to autoimmune hepatitis, have been recently reported. Although the number of cases of vaccine-related liver injury is increasing, its frequency, clinical course, and mechanism remain unclear. Here, we review the current findings on COVID-19 vaccination and liver disease, focusing on: (1) The impact of COVID-19 in patients with CLD; (2) The efficacy, safety, and risk-benefit profiles of COVID-19 vaccines in patients with CLD; and (3) Liver injury following COVID-19 vaccination.     

Hepatitis B vaccination

Alcoholics are at risk to develop hepatitis B infections, chronic active hepatitis, and even hepatoma. Hence, immunization with hepatitis B vaccine is recommended. However, immune abnormalities may coexist which alter their responsiveness to vaccination. This study compares the immune response to this vaccine in controls (group I), alcoholics without overt liver disease (group II), and alcoholics with clinical liver disease (group III). By the seventh month after the initial vaccination, 89% in group I, 70% in group II, and 18% in group III had a response >36 RIA units. The magnitude of the response was significantly different in groups I, II, and III (19,456 vs 8,326 vs 153 RIA units, respectively; P <0.05, group I vs III). In those who did not respond, a significant (P < 0.02) lower helper/inducer (T ₄)class of lymphocytes was observed as compared to patients who exhibited an adequate response. These observations suggest: (1) that the response to hepatitis B vaccine is a T-cell-dependent event and (2) that in this population, using the existing vaccine, postvaccination evaluations of antibody concentrations are needed before protection against hepatitis B infection can be assumed.This research was funded by the Veterans Administration, Cincinnati, Ohio; and Merck, Sharp and Dohme Laboratories.     

Intradermal hepatitis B vaccination in a 300-bed primary care hospital: Experience with a recombinant vaccine in a four-dose schedule

Background: All hepatitis B vaccination programs, regardless of route, must address such factors as primary response rate, additional booster injections for primary nonresponders, antibody persistence, the need for and timing of additional booster injections for primary responders, overall costs, and medical efficacy. A voluntary intradermal hepatitis B vaccination program with postvaccination testing was implemented in a 300-bed primary care hospital with a recombinant vaccine packaged in a concentration of 20 μg/ml (Engerix B; SmithKline and French Laboratories, Philadelphia, Pa.).Methods: After informed consent was obtained, 460 employees were vaccinated intradermally over the deltoid muscle by a single employee health nurse at months 0 (initial), 1, 2, and 6, followed by testing for serologic response 1 to 2 months after the final dose.Results: Of 411 employees who completed the entire protocol, 90.5% had seroconversion, as determined by enzyme immunoassay. Twelve of 29 primary nonresponders (41%) had seroconversion after an additional (fifth) intradermal booster injection. Of the primary responders, 84.5% remained seropositive when tested 18 months after the initial vaccination injection. These results are comparable to those of intramuscular vaccination and to the original studies of intradermal vaccination with plasma-derived vaccines that had shown excellent immunogenicity.Conclusions: Intradermal and intramuscular hepatitis B vaccination programs must be implemented in somewhat different ways, but both can provide excellent protection against hepatitis B viral infection. Even allowing for the additional expense of postvaccination testing and more frequent booster injections, intradermal vaccination greatly reduces the overall costs of hepatitis B vaccination and may therefore increase compliance in many different settings.     

Differentiating Acute Hepatitis B from the First Episode of Symptomatic Exacerbation of Chronic Hepatitis B

In countries with intermediate or high endemicity for chronic hepatitis B virus (HBV) infection, exacerbations of chronic hepatitis B (CHB) are common. We studied the clinical, biochemical, and virologic characteristics of patients first presenting clinically with features of acute icteric hepatitis B, to identify features that might differentiate between acute viral hepatitis B (AVHB) from first episode of exacerbation of chronic hepatitis (ECHB). We retrospectively analyzed 79 patients (mean age 35.4 ± 14 years; M:F = 60:19) who first presented clinically as AVHB, within 4 weeks of onset of symptoms. Patients who on follow-up cleared HBsAg and/or did not develop any clinical, radiologic, or histologic evidence of chronic liver disease (CLD) were categorized as AVHB (group 1). Patients who had persistence of HBsAg and developed clinical, biochemical, radiologic, or histologic evidence of chronic liver disease were categorized as ECHB (group 2). Forty-nine patients were in group 1 and 30 in group 2. The 2 groups were comparable with respect to prodrome, onset of jaundice, serum bilirubin, ALT, prothrombin time prolongation, serum albumin, and A/G ratio. Among group 1 patients, 78% had IgM anti-HBc positive in titers > 1:1000; in group 2, there were negative or positive in titers < 1:1000 in 70% patients (P < .001). Forty-seven of 49 (95.9%) patients in group 1 had HBV-DNA levels < 0.5 pg/mL, whereas 26 of 30 (86.73%) patients in group 2 had levels > 0.5 pg/mL (P ≤ .001). Quantitative HBV DNA and IgM anti-HBc titers at initial presentation can differentiate patients with a true episode of acute hepatitis B from patients with first episode of symptomatic exacerbation of chronic hepatitis B. Clinical and biochemical features do not help in differentiating the two.     

Raising adult vaccination rates over 4 years among racially diverse patients at inner-city health centers

OBJECTIVES: To increase adult immunizations at inner-city health centers serving primarily minority patients.
DESIGN: A before–after trial with a concurrent control.
SETTING: Five inner-city health centers.
PARTICIPANTS: All adult patients at the health centers eligible for influenza and pneumococcal vaccines.
INTERVENTION: Four intervention sites chose from a menu of culturally appropriate interventions based on the unique features of their respective health centers.
MEASUREMENTS: Immunization and demographic data from medical records of a random sample of 568 patients aged 50 and older who had been patients at their health centers since 2000.
RESULTS: The preintervention influenza vaccination rate of 27.1% increased to 48.9% ( P <.001) in intervention sites in Year 4, whereas the concurrent control rate remained low (19.7%). The pneumococcal polysaccharide vaccine (PPV) rate in subjects aged 65 and older increased from 48.3% to 81.3% ( P <.001) in intervention sites in Year 4. Increase in PPV in the concurrent control was not significant. In logistic regression analysis, the likelihood of influenza vaccination was significantly associated with the intervention (odds ratio (OR)=2.07, 95% confidence interval (CI)=1.77–2.41) and with age of 65 and older (OR=2.0, 95% CI=1.62–2.48) but not with race. Likelihood of receiving the pneumococcal vaccination was also associated with older age and, to a lesser degree, with intervention.
CONCLUSION: Culturally appropriate, evidence-based interventions selected by intervention sites resulted in increased adult vaccinations in disadvantaged, racially diverse, inner-city populations over 2 to 4 years.     

Hepatitis B virus markers and antibodies to hepatitis C virus in Japanese patients with hepatocellular carcinoma

Sera from Japanese patients with chronic liver disease were tested for hepatitis B virus (HBV) markers and antibodies to hepatitis C virus (anti-HCV), and the results were correlated to the presence of hepatocellular carcinoma. In chronic non-A, non-B liver disease, anti-HCV prevalence was high both in patients with hepatocellular carcinoma (78/89, 88%) and without it (66/84, 79%), while previous HBV infection was more common in patients with hepatocellular carcinoma (65/89, 73%) than in those without it (46/84, 55%) (P<0.05). Coexistence of anti-HCV and antibodies to HBV was observed frequently in patients with hepatocellular carcinoma (56/89, 63%) compared with patients without it (39/84, 46%) (P<0.05). In chronic HBV carriers, anti-HCV was more common in patients with hepatocellular carcinoma (12/38, 32%) than in those without it (3/62, 5%) (P<0.01). These results suggest that infection with the two viruses may be a risk factor for more serious liver disease.This work was supported by a Grant-in-Aid from the Ministry of Education, Science and Culture, Japan.