Immune Response of Hepatitis B Vaccine Among Persons with Diabetes a Systematic Review of the Literature
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SYSTEMATIC REVIEW Immune Response of Hepatitis B Vaccine Among Persons With Diabetes A systematic review of the literature 1 SARAH F. SCHILLIE, MD among persons with diabetes show some 2 PHILIP R. SPRADLING, MD 1 heterogeneity compared with adults without TRUDY V. MURPHY, MD diabetes. Differences in diabetes type, man- agement, and glycemic control, as well as vaccine, dosage, administration route, or schedule, may underlie this heterogeneity. n October 2011, the Advisory Com- and other comorbid conditions (6–12). The 2011 ACIP recommendation for hepa- Imittee on Immunization Practices Results of studies of the hepatitis B vac- titis B vaccination for adults with diabetes, an (ACIP) recommended hepatitis B vac- cine among persons with diabetes gener- increasing incidence of diabetes, and the cination for adults with diabetes in the ally follow these patterns (13,14). high prevalence of diabetes among certain United States (1). Serosurvey data from Primary hepatitis B vaccination usu- groups recommended for hepatitis B vacci- the 1999–2010 National Health and Nu- ally consists of 3 (or 4) doses of 10 or nation (e.g., persons with end-stage renal trition Examination Survey found that 20 mg of recombinant hepatitis B surface disease) suggests that a review of vaccine ef- noninstitutionalized adults aged $18 antigen (HBsAg) protein administered in- ficacy among persons with diabetes may be years with diabetes have an increased se- tramuscularly into the deltoid muscle timely. We therefore performed a systematic roprevalence of past or current hepatitis B on a 0-, 1-, and 6-month schedule review of the literatureandsummarizedthe virus (HBV) infection (1). Outbreaks of (Table 1). Alternative schedules are U.S.- evidence for seroprotection after hepatitis B hepatitis B in elderly persons with diabe- approved for routine vaccination for spe- vaccination among persons with diabetes. tes in long-term care facilities have been cific ages and vaccine formulations, and fi fi linked to diabetes care procedures (in- they elicit dose-speci cand nal rates of RESEARCH DESIGN AND cluding blood glucose monitoring), with seroprotection similar to those obtained METHODS likely vehicles for transmission including on a 0-, 1-, and 6-month schedule (4). fi spring-loaded nger-stick devices used Two single-antigen recombinant vac- Search strategy on multiple patients and blood glucose cines, Recombivax HB (Merck & Co, Electronic searches of MEDLINE (via testing meters that were not cleaned be- Inc., Whitehouse Station, NJ) and PubMed), EMBASE (via Ovid), Cochrane tween uses on different patients. Engerix-B (GlaxoSmithKline Biologicals, Library, and Web of Knowledge databases In the U.S., hepatitis B vaccination is Rixensart, Belgium), and one combi- were performed. The search terms con- routinely recommended for infants, chil- nation hepatitis A/hepatitis B vaccine, sisted of (hepatitis b vaccin* OR hbv vac- dren, and adolescents. It also is recom- Twinrix (GlaxoSmithKline Biologicals), cin* OR hepatitis b immuni* OR hbv mended for adults at increased risk of are approved for use in adults in the U.S. immuni*) AND (immunogeni* OR im- HBV infection, including persons with (15). Hepatitis B vaccines are safe for all mune response OR antibody) AND (dia- end-stage renal disease or chronic liver age groups. Administration of additional betes). The search terms also were used as disease, health care personnel, injection- vaccine doses for nonresponders is not Medical Subject Heading terms (MEDLINE) drug users, and men who have sex with associated with an increase in adverse – or key words (EMBASE), as applicable. men (2 4). A hepatitis B vaccination se- events (16). Vaccination is not contrain- Where possible, limits included publica- ries results in protection in a high propor- dicated in persons with autoimmune or . tion date from 1986 through 30 April tion ( 95%) of infants, children, and chronic diseases, or in those who are 2012, English language, and study of hu- young adults (5). As with other vaccines, pregnant (4). mans. The MEDLINE and EMBASE the efficacy of the hepatitis B vaccine pro- No review has been published of the fi searches were limited to items containing gressively declines with advancing age, ef cacy of the hepatitis B vaccine among abstracts. Studies conducted in the U.S. and as well as with the presence of obesity persons with diabetes; results of studies other countries were eligible for inclusion. ccccccccccccccccccccccccccccccccccccccccccccccccc Inclusion criteria From the 1Division of Viral Hepatitis, Vaccine Research and Policy Team; National Center for HIV/AIDS, Viral Peer-reviewed, published randomized Hepatitis, STD, and TB Prevention; Centers for Disease Control and Prevention, Atlanta, Georgia; and the 2 clinical trials or observational studies (all Division of Viral Hepatitis, Epidemiology and Surveillance Branch; National Center for HIV/AIDS, Viral types) assessing response to hepatitis B Hepatitis, STD, and TB Prevention; Centers for Disease Control and Prevention, Atlanta, Georgia. Corresponding author: Sarah Schillie, [email protected]. vaccine among persons with type 1 or Received 13 February 2012 and accepted 6 June 2012. type 2 diabetes were included. Studies DOI: 10.2337/dc12-0312 among both children and adults were in- The findings and conclusions in this report are those of the author(s) and do not necessarily represent the cluded to ascertain the effect of age upon official position of the Centers for Disease Control and Prevention. © 2012 by the American Diabetes Association. Readers may use this article as long as the work is properly vaccine response among persons with cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/ diabetes. Reports had to specify the pro- licenses/by-nc-nd/3.0/ for details. portion (numerator and denominator) of 2690 DIABETES CARE, VOLUME 35, DECEMBER 2012 care.diabetesjournals.org Schillie, Spradling, and Murphy Table 1dRecommended dosages of hepatitis B vaccine for adults aged >20 years* (4) 85 duplicates were identified. Abstracts from the remaining 140 studies (62.2%) Single-antigen vaccine Combination vaccine were reviewed, and 94 (67.1%) were deemed not relevant. Forty-six (32.9%) Recombivax HB Engerix-B Twinrix full-text studies were retrieved and re- Dosage Volume Dosage Volume Dosage Volume viewed, and one additional duplicate was (mg) (mL) (mg) (mL) (mg) (mL) identified (Fig. 1). Fifteen studies did not fulfill inclusion criteria, and 13 met at Adults 10 1 20 1 20 1 least one criterion for exclusion (Table 2 Adult hemodialysis patients and other and Fig. 1), leaving 17 studies. † ‡ immunocompromised adults 40 140 2NANA The 17 studies included 2 random- NA, not applicable. *Please refer to package insert. †Dialysis formulation administered on a 3-dose schedule ized clinical trials, 12 prospective, and 3 at 0, 1, and 6 months. ‡Two 1-mL doses administered in 1 or 2 injections on a 4-dose schedule at 0, 1, 2, and 6 retrospective studies published between months. 1989 and 2012 (Table 3). The 17 studies included 16,310 unique subjects, of which approximately 9,286 had diabetes. subjects seroprotected by diabetes status publication year, country); subject charac- The subject categories consisted of adults (or data available that allowed for calcula- teristics (e.g., age, diabetes type); vaccine for 4 studies (285 subjects, of whom 152 tion of the proportions), or available odds characteristics (e.g., vaccine, dosage, had diabetes); children for 4 studies (472 ratios from a multivariate analysis, which route, schedule); and the proportion of subjects, of whom 206 had diabetes); and included diabetes as a predictor variable. subjects attaining seroprotection, includ- hemodialysis/chronic kidney disease pa- Studies of specific subject populations of ing the time interval (in months) from the tients for 9 studies (15,553 subjects, of which persons with diabetes represented a last dose at which immune response was whom approximately 8,928 had diabe- subset were included. measured. When vaccine or route of ad- tes). Subjects in the studies among adults ministration differed by study arm, extrac- and children generally lacked comorbid- Exclusion criteria tion elements were recorded for each arm ities (including kidney disease) other than Studies were excluded when immune when possible. diabetes. One study among hemodialysis/ response using an antibody to hepatitis An anti-HBs threshold of 10 mIU/mL chronic kidney disease patients included B surface antigen (anti-HBs) threshold of after series completion (an accepted only subjects with chronic kidney disease 10 mIU/mL was not reported; immune marker of immune protection) defined (i.e., no hemodialysis patients) (32), and response was not measured between seroprotection (4). When multiple im- three studies included both hemodialysis 0 and 6 months after the last vaccine mune response measurements were re- and chronic kidney disease patients dose (because anti-HBs titers wane over ported reflecting seroprotection at different (36,42,44), one of which also included time); 10 or fewer subjects with diabetes intervals during the primary vaccine se- peritoneal dialysis patients (44). The re- were included; vaccine was administered ries, the result after the final dose was re- mainder were comprised entirely of he- intradermally; or subjects were not naïve corded. When immune response was modialysis patients. Seroprotection to the vaccine or had positive serology for measured more than once after