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Hepatitis B vaccine nonresponse and celiac disease
THE AMERICAN JOURNAL OF GASTROENTEROLOGY © 2003 by Am. Coll. of Gastroenterology Published by Elsevier Inc.
Vol. 98, No. 10, 2003 ISSN 0002-9270/03/$30.00 doi:10.1016/S0002-9270(03)00707-X
Hepatitis B Vaccine Nonresponse and Celiac Disease Kyung W. Noh, M.D., Gregory A. Poland, M.D., and Joseph A. Murray, M.D. Department of Internal Medicine, Mayo Vaccine Research Group, and Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
OBJECTIVES: There is a genetic predisposition to hepatitis B vaccine nonresponse. The link between human leukocyte antigen (HLA) genotype and ineffective development of immunity to the hepatitis B vaccine has been characterized in multiple studies. Celiac disease has a strong association with a particular HLA genotype of DQ2; interestingly, this HLA genotype is seen in association with nonresponders to the hepatitis B vaccine. We report a disproportionate number of patients with celiac disease who are nonresponders to the hepatitis B vaccine series. METHODS: We reviewed the hepatitis B vaccine records, serological tests for anti– hepatitis B surface antigen antibody (anti-HBs), and HLA genotypes of celiac disease patients identified as nonresponders to hepatitis B vaccine. Subjects were identified from a database of patients diagnosed with celiac disease at our institution or referred to our center for evaluation and management of celiac disease between November, 2000, and October, 2002. RESULTS: A total of 23 subjects were reviewed. All had a clinical and pathological diagnosis of celiac disease. All subjects reported receiving the full series of hepatitis B vaccinations. Of the subjects, 19 had testing for hepatitis B vaccine response. Of these 19 subjects, 13 did not achieve long-term immunity as seen by the negative qualitative or quantitative anti-HBs antibody titer. All tested subjects were either homozygous or heterozygous for DQ2. CONCLUSIONS: We postulate that celiac disease patients may have a significant predisposition to hepatitis B vaccine nonresponse. Both celiac disease and hepatitis B vaccine nonresponse is genetically mediated. Celiac disease patients may have a failure of induction of humoral immune response needed for development of long term immunity; the mechanism for this is unclear. (Am J Gastroenterol 2003;98: 2289 –2292. © 2003 by Am. Coll. of Gastroenterology)
INTRODUCTION Celiac disease is characterized by a permanent intolerance to ingested gluten, which results in immunologically mediated inflammatory damage to small intestinal mucosa (1). The classic symptoms include steatorrhea, weight loss, flatulence, and bloating. It is estimated that the prevalence of
this disorder is as high as 1 in 200 –300 in the general population (2, 3). Concordance for celiac disease in firstdegree relatives ranges from 8% to 18% and reaches 70% in monozygotic twins (4). It is a disorder with a multifactorial etiology. Human leukocyte antigen (HLA) and non-HLA genes in association with gluten and additional environmental factors are involved in disease pathogenesis (5). Celiac disease is most strongly associated with the extended major histocompatability complex (MHC) haplotype B8, DR3, and DQ2, but most specifically with DQ2, as HLA-DQ2 is found in 90 –95% of patients with celiac disease (6). Acute and chronic hepatitis B poses a considerable public health problem in the United States. Currently, an estimated 1 to 1.25 million persons have chronic hepatitis B virus infection and approximately 4000 –5000 of these individuals subsequently die of chronic liver disease every year (7). Hepatitis B vaccination can prevent the morbidity and occasional mortality associated with acute hepatitis B viral infection and can decrease the occurrence of chronic liver disease and its complications (8). The hepatitis B vaccine was introduced in the early 1980s and is considered to be among the safest vaccines available. Initially, it was recommended for persons at high risk for acquiring hepatitis B virus infection: infants born to HbsAg-positive mothers, sexually active homosexual men, injection drug users, and health care workers exposed to blood products (8). Recently, hepatitis B vaccination has become more widely used. The Occupational Health and Safety Administration has mandated employers to offer vaccination free of charge to all health care workers exposed to blood and blood products (9). Recommendations for hepatitis B vaccination have been extended to all infants, previously unvaccinated children by the age of 11 yr, and unvaccinated adults at high risk (8). In the general population, the rate of nonresponse has been estimated to be 4 –10%, depending upon gender, age, and the presence of various medical conditions (7, 10). Certain populations are more likely to develop a reduced response or nonresponse to the vaccine. These include individuals ⬎40 yr of age and those who are immunocompromised (10). Previous studies have demonstrated a genetic predisposition to hepatitis B vaccine nonresponse (11, 12). Analysis of HLA subtypes in vaccine nonresponders demonstrated an unusually high incidence of a particular ex-
2290
Noh et al.
AJG – Vol. 98, No. 10, 2003
Table 1. Characteristics of Study Patients Patient No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (yr) 67 56 58 37 42 47 32 35 49 59 42 65 19 22 67 51 24 31 26
Sex
Year and Age of Hepatitis B Vaccination
Year of Hepatitis B Vaccine Response Testing
Vaccine Response
Time to Testing (yr)
DR
DRw
DQ
F M F F F F F F F F F F F M F F F F F
1995/60 2001/55 1993/49 1993/28 1986/27 1993/38 1994/24 1995/28 2001/48 1994/51 1993/33 1986/49 1997/14 1998/18 1986/51 1991/40 1999/21 1991/20 1998/22
1995 2002 2001 1999 1996 2000 2001 2001 2001 2001 2001 2001 2001 1999 2001 1991 2001 1997 2002
Yes No Yes No No No No No No No No No No No No Yes Yes Yes Yes
0 1 8 6 10 7 7 6 0 7 8 15 4 1 15 0 2 6 4
17,4 17,7 17,7 17,7 17 17,7 13,17 17,7 17 4,7 15,17 17 17,7 17,7 15,17 NT NT NT NT
52,53 52,53 52,53 52,53 52 52,53 52 52,53 52 53 51,52 52 52,53 52,53 51,52 NT NT NT NT
2,8 2 2 2 2 2 6,2 2 2 7,2 6,2 2 2 2 6,2 NT NT NT NT
HLA
F ⫽ female; M ⫽ male; N/A ⫽ not applicable; NT ⫽ not tested.
tended MHC haplotype (11). Homozygotes for HLA-B8, DR3, and DQ2 were found to be exclusively in the nonresponder group and heterozygotes for these alleles were found to be in the nonresponder group significantly more often than in the responder group (12). In this report, we describe our experience with a series of celiac disease patients who are nonresponders to the hepatitis B vaccine. Interestingly, they have a similar or a strongly linked HLA phenotype associated with hepatitis B nonresponse.
MATERIALS AND METHODS Study Subjects Hepatitis B vaccine nonresponders were identified among patients with clinical and pathological diagnoses of celiac disease at the Mayo Clinic, Rochester, MN. Subjects were either diagnosed with celiac disease or were referred for management of previously diagnosed celiac disease from November, 2000, to October, 2002. All patients were asked their hepatitis B vaccination status as a part of their medical evaluation. Those who had been vaccinated were asked specifically about the dates of vaccination. The vaccination dates were verified if records were available. The subjects were all white, were predominantly from southeastern Minnesota and northern Iowa and engaged in occupations thought to place these individuals at risk for hepatitis B; these occupations were predominantly related to health care and special education. The study was approved by the Institutional Review Board of the Mayo Clinic and Foundation. Serological Studies Serological tests for hepatitis B antibody were obtained as a part of their evaluation. Study subjects had either a negative
qualitative or quantitative anti-HBs antibody titer. The qualitative determination of antibody to hepatitis B surface antigen was carried out using the AUSAB EIA enzyme immunoassay kit (Abbott Laboratories, Abbott Park, IL). The cut-off value for a negative qualitative anti-HBs antibody test was 10 mIU/mL. The quantitative determination of anti-HBs was performed using the AUSAB Quantitation Panel (Abbott Laboratories). Tests were performed at the Mayo Medical Laboratories in Rochester, MN. HLA Typing HLA type was obtained through a celiac disease database established for a previous study. HLA class II was typed by the PCR-SSP (One Lambda Inc., Canoga Park, CA) method. This method is a sequence specific primer test to identify DRB1,2,3,4,5 and DQA1 alleles of the HLA class II gene locus by polymerase chain reaction. Typing was performed in the Tissue Typing Laboratory of the Mayo Medical Laboratories
RESULTS A database of 271 patients with a clinical and pathological diagnosis of celiac disease was reviewed. A total of 178 subjects were newly diagnosed between November, 2000, and October, 2002. The others were referred to our institution with a prior diagnosis during this period. Of the 271 subjects, 23 had verifiable records of vaccination. Among these subjects, 19 were checked for hepatitis B response. The 19 patients had HLA typing performed, and 15 had both hepatitis B response testing and HLA typing performed. The characteristics of the study subjects are shown in Table 1. In all, there were 21 women and two men, with a mean age of
AJG – October, 2003
45 yr (range 19 – 67 yr). The mean age of vaccination was 37 yr (range 14 – 60 yr). The mean time to testing was 5.6 yr (range 0 –15 yr). Among the 19 subjects tested for response, 13 did not respond to vaccination. HLA typing was performed on 15 of these subjects (13 nonresponders and two responders). Four responders did not have HLA typing performed. The analysis of the HLA type is outlined in Table 1. All tested subjects were apparently either homozygous (cases 2– 6, 8, 9, and 12–14) or heterozygous for DQ2 (cases 1, 7, 10, 11, and 15). Of the two responders (cases 1 and 3), case 1 was heterozygous and case 2 was homozygous for DQ2. In our series of celiac patients, there was an excessively high hepatitis B vaccine nonresponse rate of 68%.
DISCUSSION In our database of celiac disease patients, we have identified a large percentage of nonresponders to the hepatitis B vaccination. Previous studies have demonstrated a strong genetic link with nonresponse to hepatitis B vaccination. Analysis of these studies has suggested a very high incidence of a particular extended HLA haplotype. Homozygotes for HLA-B8, DR3, and DQ2 were found to have a significantly higher incidence of hepatitis B vaccine nonresponse (12). The genetic predisposition in celiac disease has also been well characterized in previous studies. Celiac disease has a particularly strong association with the presence of HLADQ2 and is seen in 90 –95% of patients. Furthermore, a DR heterodimer (DR53) in DR7 individuals was suggested to be associated with celiac disease (13). It is thought that the genetic risk is maximal for patients who carry both DQ2 and DR53 heterodimers. The link between celiac disease and hepatitis B vaccine nonresponse seems to be the HLA type of the individual. Approximately 4 –10% of vaccinated individuals fail to produce antibody levels ⬎10 mIU/ml (14). The cause of nonresponse have been attributed to several defects in the normal immune response, which include defects in antigen uptake, processing, and presentation, as well as T cell suppression or lack of type 2 helper T cell response necessary for the production of anti-HbsAg antibodies by B cells (14, 15). Successful vaccination depends on the ability of the vaccine to induce a protective immune response to foreign antigens by producing neutralizing antibodies or cell-mediated immunity (16). This ability to mount a protective immune response to antigenic vaccines has been linked to the HLA haplotype of the individual. Both B cells and T cells work in concert to form antibodies and an immune response. Previous studies have suggested that hepatitis B vaccine nonresponders seem to have a very specific failure in the stimulation of T helper cells needed for long-term immunity (17, 18). The CD4 positive T helper cells are responsible for induction of the immune response. Type 1 helper cells (Th1) secrete inter-
Hepatitis B Vaccine Nonresponse and Celiac Disease
2291
leukin-2 (IL-2), interferon-␥ (IFN␥), tumor necrosis factor–, and others that activate cell-mediated reactions. Type 2 helper cells (Th2) cytokines IL-3, IL-4, IL-5, IL-10, and others are responsible for mucosal immunity (18). In addition, IFN-␥ secreted by Th1 cells inhibits Th2 effector functions, and Il-4, IL-10, and IL-13 secreted by Th2 cells inhibit Th1 functions (15, 18). Therefore, the Th2 response is important in the downregulation of the inflammatory process, which leads to repair and healing (19). In celiac disease, cell-mediated inflammatory reactions seem to play the major role in intestinal mucosal damage. Cytokine profiles of HLA-DQ2-restricted T cell clones obtained from gluten-stimulated intestinal mucosa of celiac disease patients revealed a Th1 pattern of secretion (19). When stimulated in vitro with gluten, the IFN-␥ mRNA level of intestinal biopsy samples from patients on glutenfree diets has been demonstrated to reach levels comparable to those of untreated patients. These results are consistent with the concept that gluten reactive T cells in the lamina propria have a cytokine profile dominated by the production of IFN-␥ (5). The high production of IFN-␥ would produce the classic pathological features of celiac disease and inhibit the Th2 response leading to impaired downregulation of the inflammatory process. We postulate that patients with celiac disease have a genetic predisposition for ineffective development of immunity after hepatitis B vaccination. Hepatitis B nonresponders may have a failure of induction of the Th2 response needed for B cell differentiation and formation of memory B cells needed for immunization. The same lack of Th2 response needed to regulate the cell-mediated inflammatory reaction modulated by the Th1 response is seen in the development of celiac disease. This lack of Th2 response is thought to be a result of the particular HLA genotype of the individual. This report draws attention to the possible lack of response to hepatitis B vaccination in patients with celiac disease. This may have implications for management of risk exposures and strategies for vaccination in celiac disease patients. It may be worthwhile considering the possibility of covert celiac disease in hepatitis B vaccine nonresponders. The association of celiac disease and hepatitis B vaccine nonresponse provides insight into the possible pathogenesis of both processes. Limitations of this case series include small sample size, delayed time of serological testing for hepatitis B response, and the older age of our subjects. It is not entirely clear whether the nonresponse is caused by celiac disease, the underlying HLA genotype, or the tendency of older individuals to have a weaker response to the vaccine or to the waning of immunity. Larger systematic analysis of celiac patients will be needed to confirm this association and to develop recommendations regarding vaccination in this population.
2292
Noh et al.
ACKNOWLEDGMENTS We thank Cindy Kroning and S. Breanndan Moore, M.D., for the data on HLA typing. This study was supported in part by research grant DK 57982 from the National Institutes of Health, United States Public Health Service. Reprint requests and correspondence: Joseph A. Murray, M.D., Mayo Clinic, 200 1st Street, SW, Rochester, MN 55905. Received Aug. 22, 2002; accepted Mar. 26, 2003.
REFERENCES 1. Murray JA. The widening spectrum of celiac disease. Am J Clin Nutr 1999;69:354 –65. 2. Pena AS, Garrote JA, Crusius JBA. Advances in the immunogenetics of coeliac disease. Clues for understanding the pathogenesis and disease heterogeneity. Scand J Gastroenterol 1998;225(suppl):56 –8. 3. Volta U, Bellentani S, Bianchi FB, et al. High prevalence of celiac disease in Italian general population. Dig Dis Sci 2001; 46:1500 –5. 4. Schuppan D. Current concepts of celiac disease pathogenesis. Gastroenterology 2000;119:234 –42. 5. Sollid LM. Molecular basis of celiac disease. Annu Rev Immunol 2000;18:53–81. 6. Lundin KEA, Gjertsen HA, Scott H, et al. Function of DQ2 and DQ8 as HLA susceptibility molecules in celiac disease. Hum Immunol 1994;41:24 –7. 7. Reid KC, Grizzard TA, Poland GA. Adult Immunizations: Recommendations for practice. Mayo Clin Proc 1999;74:377– 84.
AJG – Vol. 98, No. 10, 2003
8. Lemon SM, Thomas DL. Vaccines to prevent viral hepatitis. N Engl J Med 1997;336:196 –204. 9. Bonanni P, Bonaccorsi G. Vaccination against hepatitis B in health care workers. Vaccine 2001;2001:2389 –94. 10. Poland GA. Hepatitis B immunization in health care workers. Dealing with vaccine nonresponse. Am J Prev Med 1998;15: 73–7. 11. Apler CA, Kruskall MS, Marcus-Bagley D, et al. Genetic prediction of nonresponse to hepatitis B vaccine. N Engl J Med 1989;321:708 –12. 12. Stachowski J, Kramer J, Fust G, et al. Relationship between the reactivity to hepatitis B virus vaccination and the frequency of MHC class I, II and III alleles in haemodialysis patients. Scand J Immunol 1995;42:60 –5. 13. Clot F, Babron MC. Genetics of celiac disease. Mol Genet Metab 2000;71:76 –80. 14. Schuenke KW, Cook RG, Rich RR. Binding specificity of a class II-restricted hepatitis B epitope by DR molecules from responder and nonresponder vaccine recipients. Hum Immunol 1998;59:183–93. 15. Ada G. Vaccines and vaccination. N Engl J Med 2001;345: 1042–53. 16. Poland GA. Immunogenetic mechanisms of antibody response to measles vaccine: The role of the HLA genes. Vaccine 1999;17:1719 –25. 17. Egea E, Iglesias A, Salazar M, et al. The cellular basis of lack of antibody response to hepatitis B vaccine in humans. J Exp Med 1991;173:531–8. 18. Sell S. Immunology, immunopathology, and immunity. Washington, DC: ASM Press, 2001. 19. Nilsen EM, Lundin KEA, Scott PK, et al. Gluten specific, HLA-DQ restricted T cells from coeliac mucosa produce cytokines with Th1 or Th0 profile dominated by interferon ␥. Gut 1995;37:766 –76.
Vol. 98, No. 10, 2003 ISSN 0002-9270/03/$30.00 doi:10.1016/S0002-9270(03)00707-X
Hepatitis B Vaccine Nonresponse and Celiac Disease Kyung W. Noh, M.D., Gregory A. Poland, M.D., and Joseph A. Murray, M.D. Department of Internal Medicine, Mayo Vaccine Research Group, and Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
OBJECTIVES: There is a genetic predisposition to hepatitis B vaccine nonresponse. The link between human leukocyte antigen (HLA) genotype and ineffective development of immunity to the hepatitis B vaccine has been characterized in multiple studies. Celiac disease has a strong association with a particular HLA genotype of DQ2; interestingly, this HLA genotype is seen in association with nonresponders to the hepatitis B vaccine. We report a disproportionate number of patients with celiac disease who are nonresponders to the hepatitis B vaccine series. METHODS: We reviewed the hepatitis B vaccine records, serological tests for anti– hepatitis B surface antigen antibody (anti-HBs), and HLA genotypes of celiac disease patients identified as nonresponders to hepatitis B vaccine. Subjects were identified from a database of patients diagnosed with celiac disease at our institution or referred to our center for evaluation and management of celiac disease between November, 2000, and October, 2002. RESULTS: A total of 23 subjects were reviewed. All had a clinical and pathological diagnosis of celiac disease. All subjects reported receiving the full series of hepatitis B vaccinations. Of the subjects, 19 had testing for hepatitis B vaccine response. Of these 19 subjects, 13 did not achieve long-term immunity as seen by the negative qualitative or quantitative anti-HBs antibody titer. All tested subjects were either homozygous or heterozygous for DQ2. CONCLUSIONS: We postulate that celiac disease patients may have a significant predisposition to hepatitis B vaccine nonresponse. Both celiac disease and hepatitis B vaccine nonresponse is genetically mediated. Celiac disease patients may have a failure of induction of humoral immune response needed for development of long term immunity; the mechanism for this is unclear. (Am J Gastroenterol 2003;98: 2289 –2292. © 2003 by Am. Coll. of Gastroenterology)
INTRODUCTION Celiac disease is characterized by a permanent intolerance to ingested gluten, which results in immunologically mediated inflammatory damage to small intestinal mucosa (1). The classic symptoms include steatorrhea, weight loss, flatulence, and bloating. It is estimated that the prevalence of
this disorder is as high as 1 in 200 –300 in the general population (2, 3). Concordance for celiac disease in firstdegree relatives ranges from 8% to 18% and reaches 70% in monozygotic twins (4). It is a disorder with a multifactorial etiology. Human leukocyte antigen (HLA) and non-HLA genes in association with gluten and additional environmental factors are involved in disease pathogenesis (5). Celiac disease is most strongly associated with the extended major histocompatability complex (MHC) haplotype B8, DR3, and DQ2, but most specifically with DQ2, as HLA-DQ2 is found in 90 –95% of patients with celiac disease (6). Acute and chronic hepatitis B poses a considerable public health problem in the United States. Currently, an estimated 1 to 1.25 million persons have chronic hepatitis B virus infection and approximately 4000 –5000 of these individuals subsequently die of chronic liver disease every year (7). Hepatitis B vaccination can prevent the morbidity and occasional mortality associated with acute hepatitis B viral infection and can decrease the occurrence of chronic liver disease and its complications (8). The hepatitis B vaccine was introduced in the early 1980s and is considered to be among the safest vaccines available. Initially, it was recommended for persons at high risk for acquiring hepatitis B virus infection: infants born to HbsAg-positive mothers, sexually active homosexual men, injection drug users, and health care workers exposed to blood products (8). Recently, hepatitis B vaccination has become more widely used. The Occupational Health and Safety Administration has mandated employers to offer vaccination free of charge to all health care workers exposed to blood and blood products (9). Recommendations for hepatitis B vaccination have been extended to all infants, previously unvaccinated children by the age of 11 yr, and unvaccinated adults at high risk (8). In the general population, the rate of nonresponse has been estimated to be 4 –10%, depending upon gender, age, and the presence of various medical conditions (7, 10). Certain populations are more likely to develop a reduced response or nonresponse to the vaccine. These include individuals ⬎40 yr of age and those who are immunocompromised (10). Previous studies have demonstrated a genetic predisposition to hepatitis B vaccine nonresponse (11, 12). Analysis of HLA subtypes in vaccine nonresponders demonstrated an unusually high incidence of a particular ex-
2290
Noh et al.
AJG – Vol. 98, No. 10, 2003
Table 1. Characteristics of Study Patients Patient No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Age (yr) 67 56 58 37 42 47 32 35 49 59 42 65 19 22 67 51 24 31 26
Sex
Year and Age of Hepatitis B Vaccination
Year of Hepatitis B Vaccine Response Testing
Vaccine Response
Time to Testing (yr)
DR
DRw
DQ
F M F F F F F F F F F F F M F F F F F
1995/60 2001/55 1993/49 1993/28 1986/27 1993/38 1994/24 1995/28 2001/48 1994/51 1993/33 1986/49 1997/14 1998/18 1986/51 1991/40 1999/21 1991/20 1998/22
1995 2002 2001 1999 1996 2000 2001 2001 2001 2001 2001 2001 2001 1999 2001 1991 2001 1997 2002
Yes No Yes No No No No No No No No No No No No Yes Yes Yes Yes
0 1 8 6 10 7 7 6 0 7 8 15 4 1 15 0 2 6 4
17,4 17,7 17,7 17,7 17 17,7 13,17 17,7 17 4,7 15,17 17 17,7 17,7 15,17 NT NT NT NT
52,53 52,53 52,53 52,53 52 52,53 52 52,53 52 53 51,52 52 52,53 52,53 51,52 NT NT NT NT
2,8 2 2 2 2 2 6,2 2 2 7,2 6,2 2 2 2 6,2 NT NT NT NT
HLA
F ⫽ female; M ⫽ male; N/A ⫽ not applicable; NT ⫽ not tested.
tended MHC haplotype (11). Homozygotes for HLA-B8, DR3, and DQ2 were found to be exclusively in the nonresponder group and heterozygotes for these alleles were found to be in the nonresponder group significantly more often than in the responder group (12). In this report, we describe our experience with a series of celiac disease patients who are nonresponders to the hepatitis B vaccine. Interestingly, they have a similar or a strongly linked HLA phenotype associated with hepatitis B nonresponse.
MATERIALS AND METHODS Study Subjects Hepatitis B vaccine nonresponders were identified among patients with clinical and pathological diagnoses of celiac disease at the Mayo Clinic, Rochester, MN. Subjects were either diagnosed with celiac disease or were referred for management of previously diagnosed celiac disease from November, 2000, to October, 2002. All patients were asked their hepatitis B vaccination status as a part of their medical evaluation. Those who had been vaccinated were asked specifically about the dates of vaccination. The vaccination dates were verified if records were available. The subjects were all white, were predominantly from southeastern Minnesota and northern Iowa and engaged in occupations thought to place these individuals at risk for hepatitis B; these occupations were predominantly related to health care and special education. The study was approved by the Institutional Review Board of the Mayo Clinic and Foundation. Serological Studies Serological tests for hepatitis B antibody were obtained as a part of their evaluation. Study subjects had either a negative
qualitative or quantitative anti-HBs antibody titer. The qualitative determination of antibody to hepatitis B surface antigen was carried out using the AUSAB EIA enzyme immunoassay kit (Abbott Laboratories, Abbott Park, IL). The cut-off value for a negative qualitative anti-HBs antibody test was 10 mIU/mL. The quantitative determination of anti-HBs was performed using the AUSAB Quantitation Panel (Abbott Laboratories). Tests were performed at the Mayo Medical Laboratories in Rochester, MN. HLA Typing HLA type was obtained through a celiac disease database established for a previous study. HLA class II was typed by the PCR-SSP (One Lambda Inc., Canoga Park, CA) method. This method is a sequence specific primer test to identify DRB1,2,3,4,5 and DQA1 alleles of the HLA class II gene locus by polymerase chain reaction. Typing was performed in the Tissue Typing Laboratory of the Mayo Medical Laboratories
RESULTS A database of 271 patients with a clinical and pathological diagnosis of celiac disease was reviewed. A total of 178 subjects were newly diagnosed between November, 2000, and October, 2002. The others were referred to our institution with a prior diagnosis during this period. Of the 271 subjects, 23 had verifiable records of vaccination. Among these subjects, 19 were checked for hepatitis B response. The 19 patients had HLA typing performed, and 15 had both hepatitis B response testing and HLA typing performed. The characteristics of the study subjects are shown in Table 1. In all, there were 21 women and two men, with a mean age of
AJG – October, 2003
45 yr (range 19 – 67 yr). The mean age of vaccination was 37 yr (range 14 – 60 yr). The mean time to testing was 5.6 yr (range 0 –15 yr). Among the 19 subjects tested for response, 13 did not respond to vaccination. HLA typing was performed on 15 of these subjects (13 nonresponders and two responders). Four responders did not have HLA typing performed. The analysis of the HLA type is outlined in Table 1. All tested subjects were apparently either homozygous (cases 2– 6, 8, 9, and 12–14) or heterozygous for DQ2 (cases 1, 7, 10, 11, and 15). Of the two responders (cases 1 and 3), case 1 was heterozygous and case 2 was homozygous for DQ2. In our series of celiac patients, there was an excessively high hepatitis B vaccine nonresponse rate of 68%.
DISCUSSION In our database of celiac disease patients, we have identified a large percentage of nonresponders to the hepatitis B vaccination. Previous studies have demonstrated a strong genetic link with nonresponse to hepatitis B vaccination. Analysis of these studies has suggested a very high incidence of a particular extended HLA haplotype. Homozygotes for HLA-B8, DR3, and DQ2 were found to have a significantly higher incidence of hepatitis B vaccine nonresponse (12). The genetic predisposition in celiac disease has also been well characterized in previous studies. Celiac disease has a particularly strong association with the presence of HLADQ2 and is seen in 90 –95% of patients. Furthermore, a DR heterodimer (DR53) in DR7 individuals was suggested to be associated with celiac disease (13). It is thought that the genetic risk is maximal for patients who carry both DQ2 and DR53 heterodimers. The link between celiac disease and hepatitis B vaccine nonresponse seems to be the HLA type of the individual. Approximately 4 –10% of vaccinated individuals fail to produce antibody levels ⬎10 mIU/ml (14). The cause of nonresponse have been attributed to several defects in the normal immune response, which include defects in antigen uptake, processing, and presentation, as well as T cell suppression or lack of type 2 helper T cell response necessary for the production of anti-HbsAg antibodies by B cells (14, 15). Successful vaccination depends on the ability of the vaccine to induce a protective immune response to foreign antigens by producing neutralizing antibodies or cell-mediated immunity (16). This ability to mount a protective immune response to antigenic vaccines has been linked to the HLA haplotype of the individual. Both B cells and T cells work in concert to form antibodies and an immune response. Previous studies have suggested that hepatitis B vaccine nonresponders seem to have a very specific failure in the stimulation of T helper cells needed for long-term immunity (17, 18). The CD4 positive T helper cells are responsible for induction of the immune response. Type 1 helper cells (Th1) secrete inter-
Hepatitis B Vaccine Nonresponse and Celiac Disease
2291
leukin-2 (IL-2), interferon-␥ (IFN␥), tumor necrosis factor–, and others that activate cell-mediated reactions. Type 2 helper cells (Th2) cytokines IL-3, IL-4, IL-5, IL-10, and others are responsible for mucosal immunity (18). In addition, IFN-␥ secreted by Th1 cells inhibits Th2 effector functions, and Il-4, IL-10, and IL-13 secreted by Th2 cells inhibit Th1 functions (15, 18). Therefore, the Th2 response is important in the downregulation of the inflammatory process, which leads to repair and healing (19). In celiac disease, cell-mediated inflammatory reactions seem to play the major role in intestinal mucosal damage. Cytokine profiles of HLA-DQ2-restricted T cell clones obtained from gluten-stimulated intestinal mucosa of celiac disease patients revealed a Th1 pattern of secretion (19). When stimulated in vitro with gluten, the IFN-␥ mRNA level of intestinal biopsy samples from patients on glutenfree diets has been demonstrated to reach levels comparable to those of untreated patients. These results are consistent with the concept that gluten reactive T cells in the lamina propria have a cytokine profile dominated by the production of IFN-␥ (5). The high production of IFN-␥ would produce the classic pathological features of celiac disease and inhibit the Th2 response leading to impaired downregulation of the inflammatory process. We postulate that patients with celiac disease have a genetic predisposition for ineffective development of immunity after hepatitis B vaccination. Hepatitis B nonresponders may have a failure of induction of the Th2 response needed for B cell differentiation and formation of memory B cells needed for immunization. The same lack of Th2 response needed to regulate the cell-mediated inflammatory reaction modulated by the Th1 response is seen in the development of celiac disease. This lack of Th2 response is thought to be a result of the particular HLA genotype of the individual. This report draws attention to the possible lack of response to hepatitis B vaccination in patients with celiac disease. This may have implications for management of risk exposures and strategies for vaccination in celiac disease patients. It may be worthwhile considering the possibility of covert celiac disease in hepatitis B vaccine nonresponders. The association of celiac disease and hepatitis B vaccine nonresponse provides insight into the possible pathogenesis of both processes. Limitations of this case series include small sample size, delayed time of serological testing for hepatitis B response, and the older age of our subjects. It is not entirely clear whether the nonresponse is caused by celiac disease, the underlying HLA genotype, or the tendency of older individuals to have a weaker response to the vaccine or to the waning of immunity. Larger systematic analysis of celiac patients will be needed to confirm this association and to develop recommendations regarding vaccination in this population.
2292
Noh et al.
ACKNOWLEDGMENTS We thank Cindy Kroning and S. Breanndan Moore, M.D., for the data on HLA typing. This study was supported in part by research grant DK 57982 from the National Institutes of Health, United States Public Health Service. Reprint requests and correspondence: Joseph A. Murray, M.D., Mayo Clinic, 200 1st Street, SW, Rochester, MN 55905. Received Aug. 22, 2002; accepted Mar. 26, 2003.
REFERENCES 1. Murray JA. The widening spectrum of celiac disease. Am J Clin Nutr 1999;69:354 –65. 2. Pena AS, Garrote JA, Crusius JBA. Advances in the immunogenetics of coeliac disease. Clues for understanding the pathogenesis and disease heterogeneity. Scand J Gastroenterol 1998;225(suppl):56 –8. 3. Volta U, Bellentani S, Bianchi FB, et al. High prevalence of celiac disease in Italian general population. Dig Dis Sci 2001; 46:1500 –5. 4. Schuppan D. Current concepts of celiac disease pathogenesis. Gastroenterology 2000;119:234 –42. 5. Sollid LM. Molecular basis of celiac disease. Annu Rev Immunol 2000;18:53–81. 6. Lundin KEA, Gjertsen HA, Scott H, et al. Function of DQ2 and DQ8 as HLA susceptibility molecules in celiac disease. Hum Immunol 1994;41:24 –7. 7. Reid KC, Grizzard TA, Poland GA. Adult Immunizations: Recommendations for practice. Mayo Clin Proc 1999;74:377– 84.
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