Hepatitis B

A recent study published in Clinical Gastroenterology and Hepatology and led by Dr. Imad Absah, M.D. pediatric gastroenterologist and pediatrician at Mayo Clinic in Rochester, Minnesota, assessed the effectiveness of hepatitis B virus (HBV) vaccination for patients with inflammatory bowel disease (IBD) and celiac disease (CeD).

What did they do?  

The researchers conducted a retrospective cohort study on Olmsted County, Minnesota residents. The study included two groups; the first group consisted of 351 individuals diagnosed with IBD or CeD between Jan. 1, 2000, and Dec. 31, 2019 (the index date). These individuals had received two or more HBV vaccines before their index date and subsequently underwent HBV screening after their index date.
 

What did they find?

People with IBD and CeD respond to HBV vaccination similarly to people without these conditions. Researchers found no evidence of increased HBV risk in patients with IBD or CeD who were fully vaccinated, and the trend in their immunity titers (laboratory tests that measure antibodies in a blood sample) was similar to those found in the general population.
 

What does this mean? What does this change? 

These results suggest that routine testing of anti-HBs titers may not be necessary for all patients with IBD or CeD who are fully vaccinated for HBV. This study shows that low titers in fully vaccinated patients may not indicate that CeD patients lack immunity. Further studies are needed to support these findings.

Celiac disease is an autoimmune disorder that can occur in genetically predisposed people where the ingestion of gluten leads to damage in the small intestine. People with celiac disease are also at an increased risk for other autoimmune diseases. Therefore, it is not unreasonable to wonder if the immune system of celiac patients is different in other ways as well, such as how it responds to vaccinations. For the most part, vaccinations work just as effectively as they do in the general population. There is one notable exception that has been uncovered: hepatitis B.

Hepatitis B is a disease that affects the liver. Caused by the hepatitis B virus (HBV), it can be transmitted through blood and other bodily fluids. Hepatitis B can present either chronically (long-term) or acutely (suddenly), but both can be fatal. The disease is present in less than 1% of North Americans, but is still common in sub-Saharan Africa and East Asia.

The hepatitis B vaccine has been around since the 1980s and is one of the safest vaccines available. The World Health Organization suggests vaccinating infants in their first day of life, as well as later on for the full protective effect. Like all vaccines, there is some percentage of people who simply do not respond, and therefore do not develop immunity to the disease.

There are many factors that are associated with non-responsiveness, such as smoking habits, age, and obesity. It is important for as many people as possible to get vaccinated so these “non-responders” are protected from the disease through “herd immunity.” In the general population, about 4-10% of people are non-responders. When enough people are successfully immunized against a disease, it helps protect people who are still vulnerable by reducing their contact with the disease.

For celiac disease patients, the hepatitis B vaccine is just as safe, but it is far less effective. In a study published back in 2003, Dr. Joseph Murray of the Celiac Disease Foundation Medical Advisory Board, and other researchers, searched through a medical database and found that 13 of 19 people with celiac disease who were also vaccinated against hepatitis B did not show an adequate response to the Hepatitis B vaccine. Many studies have confirmed that celiac patients have a very high rate of non-response to the hepatitis B vaccine.

The exact reason for this phenomenon is most likely genetic, at least in part. Interestingly, a 2008 study out of Hungary found that celiac patients who were already being treated with a gluten-free diet fared much better than those still eating gluten. The study, titled “Gluten Intake Interferes With the Humoral Immune Response to Recombinant Hepatitis B Vaccine in Patients With Celiac Disease,” monitored blood antibody levels in children to keep track of both celiac disease activity (transglutaminase and endomysium antibodies) and hepatitis B immunity (anti-HBs). The study researchers found that not only did the children on a gluten-free diet respond as well as the control group to the hepatitis B vaccine, but children who initially showed no response to the vaccine were able to later develop immunity by going on a gluten-free diet and getting re-vaccinated. The authors also suggest that patients who do not respond to the hepatitis B vaccine be tested for celiac disease.

These results were mirrored by a 2010 study done in Turkey. The group of researchers tested diagnosed celiac patients who had been vaccinated for hepatitis B and found that the rate of non-response was significantly higher in the celiac patients when compared to controls (32.5% versus 14.8% respectively). But in celiac patients who were vaccinated after they were diagnosed and already on a gluten-free diet, the difference in response rate was insignificant. From these studies, it seems that only patients with active and untreated celiac disease are at risk for not responding to the hepatitis B vaccine.