a randomized clinical trial of immunization with combined hepatitis a and b versus hepatitis b alone...
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A Randomized Clinical Trial of Immunization With Combined Hepatitis A and B Versus Hepatitis B Alone for
Hepatitis B Seroprotection inHemodialysis Patients
Jennifer Tung et al.
Preceptor-Dr.WahidSpeaker- Basavaraj.Utagi
American Journal of Kidney Diseases, Vol 56, No 4 (October), 2010: pp 713-719
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INTRODUCTION
350million people are chronically infected worldwide(WHO)
with hepatitis B
About 20 million new cases reported annually
First large-scale outbreaks of Hepatitis B in dialysis centers
in the 1970s
The prevalence and incidence of the hepatitis B infections
are very high about 7.6% and 3.2 % respectively among
dialysis patients in India
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INTRODUCTION(CONTD)
CDC recomends immunisation of dialysis patients with
Hepatitis B vaccine
After a primary series of hepatitis B vaccination, 90%-95%
of healthy immunocompetent adults develop protective
anti–hepatitis B surface antigen(HBsAg) antibodies
Protective antibody titer defined as 10 mIU/mL
1.MMWR Recomm Rep. 2001;50(RR-5):1-43.
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INTRODUCTION(CONTD)
However, the efficacy of the vaccine in hemodialysis patients
is much lower,with a median of 64%1(range, 34%-88%)
Various approaches to increase the immunogenicity vaccine
variations in dose and frequency
use of novel adjuvants
coadministration of immunomodulators (IL2,IFN,levamisole)
However all these approaches had varying results
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Background
Mean of anti-HBsAg titers at month 6, patients receiving the
combined Hepatitis A and Hepatitis B vaccine showed a
statistically significant higher response than with
monovalent vaccines in healthy adults
Ambrosch et al. J Med Virol. 1994;44(4):452-456.
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Background
Combined vaccination of hepB and hep A improves
immunogenicity to hepatitis B in healthy individuals
Knoll A et al.Vaccine. 2000;18(19):2029-2032.
Czeschinski PA et al. Vaccine. 2000;18(11-12):1074-1080
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Need for this Study?
Effect of combined vaccination on anti-HBsAg antibody
response in hemodialysis patients is unknown
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Methods
Randomized controlled trial in outpatient hemodialysis
patients St. Joseph’s Healthcare
Inclusion criteria
Receiving hemodialysis treatment
18 years or older
Undetectable antibody to HBsAg
Able and willing to give informed consent
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Methods(contd..)
Exclusion criteria
Presence of HBsAg and antibody to hepatitis B core antigen
Treatment with intravenous immune globulin within the last 6
months
Hypersensitivity to components of either vaccine
Contraindication to intramuscular injectionsPatients were not excluded based on pre-existing antibodies
to hepatitis A
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Methods(contd..)
Patients were randomly assigned starting in February
2005
Vaccination began in March 2005, and the vaccination
schedules were completed by November 2005
Ethics approval was obtained from the St. Joseph’s
Healthcare Research Ethics Board
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Study Design
Patients were given 4 doses at 0, 1, 2, and 6 months
according to the vaccine schedule
Randomly assigned to receive one of the following
regimens
Engerix-B, 20 mcg (1 mL), and Twinrix (720 ELISA units
of inactivated hepatitis A virus and 20 mcg of recombinant
HBsAg protein) at 0, 1, and 6 months plus Engerix-B, 40
mcg,at month 2 or
Engerix-B, 40 mcg (2 mL), at 0, 1, 2, and 6
months
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Both groups received a total dose of 160 mcg of hepatitis
B vaccine
The route of administration was intramuscular
injection
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Methods(contd..)
The primary outcome was the difference in proportion of
patients achieving seroprotection against hepatitis B
virus between the 2 arms
Seroprotection defined as an anti-HBsAg antibody titer
10 mIU/mL at month 7
The secondary end point was the frequency of adverse
events associated with vaccine administration
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Methods(contd..)
Blood samples were drawn at baseline and months 3
and 7 to determine antibodies to HBsAg
Neither patients nor clinical study personnel were blinded
with respect to the vaccine administered
The laboratory personnel performing tests for antibody
levels and the independent statistician assessing clinical
outcomes were blinded
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Adverse events were recorded after each dose
Patients were interviewed to obtain ratings for pain and
swelling, which were evaluated using a visual analogue
scale
Temperatures were measured 1 hour after vaccination
and on days 2and 4
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Engerix 40Engerix
20+Twintrix
96 patients randomised
Month 3 blood work
Month 3 blood work
Engerix 40Engerix 40
Engerix 40Engerix
20+Twintrix
Month 7 blood work
Month 7 blood work
Engerix 40
Engerix 20+Twintri
x
TwintrixEngerix
Month 0
Month 1
Month 2
Month 6
Month 7
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Statistical Analysis
Descriptive statistics are expressed in terms of mean
standard deviation for continuous variables and
percentages for categorical variables
Standard statistical tests for comparing mean values,
unpaired t test, and unpaired proportion tests were used
to assess treatment differences
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RESULTS
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Results
Overall,mean age was 67 years (range, 34-91 years),
and 63% were men
Duration of dialysis therapy ranged from 10 days to 9
years, with a mean of 3 years
At Month-3 there was no statistically significant
difference in seroprotection rates for hepatitis B between
the 2 groups(25% vs 27%) (P =0.4)
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Results
At Month-7 there was a statistically significant difference in anti-
HBsAg antibody response between the groups using either per-
protocol or ITT analyses
At month 7, using per-protocol analysis, 68% and 49% of patients
had experienced seroconversion in the treatment and control
groups, respectively(P 0.05; RR, 1.4; absolute abatement, 19%).
Using ITT analysis, 58% and 38% of patients had experienced
seroconversion in the treatment and control groups, respectively(P
0.02; RR, 1.5; absolute abatement,20%).
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Results
There were no significant differences between groups in adverse events(pain scores or swelling scores)
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DISCUSSION
The study’s main outcome,hepatitis B seroconversion at 7
months,showed a statistically significant and clinically
important improvement in the combined-vaccination arm
In comparison to healthy persons, who have a reported
89% seroprotection rate at month 3 and 90%-95% at month
7 with standard dosing, seroprotection rates in this study
population were much lower
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The seroprotection rate in control group also was lower
compared with previous studies of hemodialysis patients, in
which median seroprotection rates of 64%-86% were
reported
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Limitations
Small sample size
Study had a power of 80%
The short study period
The duration of a patient’s seroprotection status couldn’t
be assessed
The need for future booster shots or revaccination
couldnot de determined
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Mean age of patients was 67yrs,so efficacy of vaccine in
young dialysis patients could not be assessed
Study was done in mainly western population
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Conclusion
Vaccination of hemodialysis patients with a combined
hepatitis A and hepatitis B regimen may be more
effective than hepatitis B monovalent vaccine in
providing seroprotection against hepatitis B virus
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THANK YOUThank you