A review of the long-term protection after hepatitis A and B vaccination

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Summary

Vaccine-preventable viral hepatitis continues to be a cause of considerable morbidity and mortality: on worldwide basis, approximately 1.4 million cases of hepatitis A are reported every year. The true incidence, however, has been estimated to be 3–10 times higher.

Regarding hepatitis B, more than a third of the world's population has been infected. The World Health Organization has estimated (2000) that there are 367 million chronic carriers of hepatitis B worldwide, and approximately 1 million deaths per year as a consequence of chronic complications and acute fulminant disease.

Hepatitis B vaccines have been licensed since 1982, and hepatitis A vaccines since 1992. In 1996, a combined hepatitis A and B vaccine became available. An update on the long-term protection conferred by hepatitis A and hepatitis B vaccines as well as the combined hepatitis A and B vaccine is offered in this paper.

Long-term efficacy and booster policy for hepatitis B vaccines have often been a topic of discussion. Based on current data and field experience there is, in general, no necessity for booster doses for fully vaccinated immunocompetent individuals. Long-term protection has been demonstrated by the rapid (5–7 days) development of anamnestic antibody responses among vaccinees who no longer have detectable anti-HBs. Anamnestic responses correlate with lymphoproliferative T-cell responses following challenge with hepatitis B vaccine. Furthermore, employing Spot-ELISA techniques, circulating B-cells were shown to be able to produce anti-HBs in vaccinees who lost their detectable antibodies. The accumulated data from a large number of studies indicate that despite antibody decline or loss, immune memory exhibits long-term persistence.

There is somewhat less information available for hepatitis A vaccines, yet an increasing number of studies indicate that the findings for hepatitis B vaccines are also applicable to hepatitis A vaccines. The necessity to provide a booster dose was based on early projections of observed antibody levels. However, recent follow-up studies with up to 12 year observation, as well as studies employing mathematical models predict that following primary vaccination, antibodies will persist for at least 25 years. In addition, experimental studies confirm that vaccination against hepatitis A induces immunological memory. Therefore hepatitis A booster vaccination is presently considered as unnecessary in fully vaccinated individuals.

The above findings are of importance in the context of administering combined hepatitis A and B vaccine for which similar long-term data have been observed.

All available data on monovalent and combined hepatitis A and hepatitis B vaccines indicates that there is no support for a hepatitis A or hepatitis B booster when a complete primary vaccination course is offered to immunocompetent individuals.

Introduction

Viral hepatitis is still a cause of considerable morbidity and mortality in the world. On worldwide basis, approximately 1.4 million cases of hepatitis A are reported every year. The true incidence, however, has been estimated to be 3–10 times higher.

Regarding hepatitis B, more than a third of the world's population has been infected. The World Health Organization has estimated (2000) that there are 367 million chronic carriers of hepatitis B worldwide, and approximately 1 million deaths per year as a consequence of chronic complications and acute fulminant disease.

Hepatitis B vaccines have been licensed since 1982, the recombinant ones since 1986, hepatitis A vaccine since 1992. In 1996, a combined hepatitis A and B vaccine became available. An update on the long-term protection conferred by hepatitis A and hepatitis B vaccines is given in the following paragraphs.

Section snippets

Hepatitis B vaccine and long-term protection

Hepatitis B vaccines have been shown safe and very effective in protecting against hepatitis B. Early data from the Taiwan vaccination programme (started in 1984) showed good efficacy in reducing chronic HBV infection, decrease in hepatocellular carcinoma and fulminant hepatitis in Children.1

The primary course of a hepatitis B vaccination can consist of three or four doses, administered according to a 0, 1 and 6 months schedule or a 0, 1, 2 and 12 months schedule. A booster dose of vaccine,

Hepatitis A vaccine and long-term protection

Several inactivated and live attenuated vaccines against hepatitis A were developed in the 1980s and licensed for use in the early 1990s. These vaccines are safe and well-tolerated, they are highly immunogenic, and they provide long-lasting protection against hepatitis A disease in children and adults.18 High anti-HAV antibody levels and seroconversion rates have been observed in long-term follow-up studies in adults following the administration of a primary vaccination course (0–6, 0–12, or

Combined hepatitis A and B vaccine

Available data shows that the immunogenicity of a combined hepatitis A and B vaccine (Twinrix), administered according to the regular 0, 1, and 6 months schedule, is comparable to that of the monovalent vaccines.33, 34, 35, 36, 37 The decline in anti-HAV and anti-HBs antibody titers after combined hepatitis A and B vaccination is similar to that observed with monovalent vaccines, suggesting that this combined vaccine also provides long-term protection, as is the case for the monovalent

Frequently asked questions

In the final part of this manuscript the authors would like to answer, based on the above-mentioned evidence, some frequently asked questions related to booster administration, serology and schedules.

If a young child received a two-dose schedule of children's hepatitis A monodose vaccine, is a hepatitis A booster recommended or needed to guarantee long-term protection?

Let us summarise that the hepatitis A consensus statement holds also for infants and children, and is valid for all hepatitis A

Conclusion

Immunocompetent vaccinees, in particular travellers, can be reassured that following the correct administration (intramuscularly, in the Deltoid muscle) of a complete primary course of hepatitis A or hepatitis B vaccines (monovalent or combined), they will be afforded a long-term protection without requiring booster doses. Currently available data do not support the need for a booster vaccination.

By abandoning the administration of hepatitis A and hepatitis B booster doses among immunocompetent

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