To the Editor.—
We red with great interest the article by Nemes E et al about gluten
intake interference with the humoral response to recombinant hepatitis B
vaccine in patients with celiac disease (CD). We think it is very useful
and commendable as, although other factors may contribute to successful
immunization, they consider that human leukocyte antigen DQ alleles do not
seem to have a primary role. However they affirm that nonresponse to
recombinant hepatitis B surface antigen may be a sign of undiagnosed
celiac disease and that there is a good vaccine response in adequately
treated patients. They recommend revaccination for CD patients after
starting a controlled gluten-free diet. In other publications, even more
than 50% of children with CD do not show a response to standard
vaccination regimens for hepatitis B virus (HBV).
Some studies point out that 5-10% of the individuals vaccinated
against HBV do not develop protective immunity. Therefore, many research
laboratories across the world have taken a significant amount of effort to
increase the potency of the vaccine by various innovative means.
As CD is a worldwide disease, this observation suggests that there is
a large HBV-susceptible population despite widespread vaccination.
Immunization strategies need to be reassessed to achieve universal
protection, and revaccination must be reconsidered for these patients as
HBV recombinant vaccine response also seems to be dose-dependent.
We carried out a study with the aim of determining the HBV response
rate (we consider as a responder if anti-HBs antibodies >10 mUI/ml,
measured by microparticle enzyme immunoassay) in CD children and in
healthy ones who were completely vaccinated at birth (”0,2,6 months” or
”2,4,6 months” regimes) and comparing them with a control group. After
initial evaluation, a 10 µg (0.5 ml) single booster dose was administered
to all negative subjects and blood samples were obtained after 4-6 weeks
for anti-HBs detection.
We divided children into three groups. Group 1: out of 38 CD patients
diagnosed early in childhood (mean age at diagnosis 3.4 ± 2.6 y;) under
strict gluten free diet (mean time since diagnosis 12.5±2.1 y); Group 2:
out of 43 recently diagnosed of CD children (mean age 4.0±1.2 y) still
under gluten containing diet and Group 3: out of 26 healthy children
(control group), who tested negative for CD antibodies (mean age 8.3±1.9
y).
Persistence of vaccine response was significantly higher in Group 1
than in Group 2 (68.5% vs 54%, p=0.004) and similar to control group
(68.5% vs 65.4%, p=0.13). Negative anti-HBs was higher in group 2 than in
control group (46% vs 34.6%, p=0.04). After administration of booster
single dose of HBV recombinant vaccine, a positive response was achieved
in all groups in similar percentages (89.5%, 86.1%, 87.2% respectively).
We can conclude that there is a limited duration to the HBV
vaccination response in CD patients especially at diagnosis, while still
exposed to gluten, but in similar proportion to general healthy population
vaccinated at birth According to the practical need for reducing the total
number of childhood vaccinations, we think that a single booster dose may
be enough to achieve and maintain seroprotection in these patients in
similar proportion to healthy children.
Conflict of Interest:
None declared
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