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Comparison of antibody response to hepatitis B vaccination in infants with positive or negative maternal hepatitis B e antigen (HBeAg) in cord blood: implication for the role of HBeAg as an immunotolerogen

Comparison of antibody response to hepatitis B vaccination in infants with positive or negative... HUMAN VACCINES & IMMUNOTHERAPEUTICS 2019, VOL. 15, NO. 9, 2183–2186 https://doi.org/10.1080/21645515.2019.1575712 RESEARCH PAPER Comparison of antibody response to hepatitis B vaccination in infants with positive or negative maternal hepatitis B e antigen (HBeAg) in cord blood: implication for the role of HBeAg as an immunotolerogen a a a b b b b a,c Hongyu Huang *, Mingzhe Ning , Jingli Liu , Jie Chen , Jing Feng , Yimin Dai , Yali Hu , and Yi-Hua Zhou * Department of Laboratory Medicine and Jiangsu Key Laboratory for Molecular Medicine, Nanjing Drum Tower Hospital, Nanjing University Medical School, Jiangsu, China; Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Jiangsu, China; Department of Infectious Diseases, Nanjing Drum Tower Hospital, Nanjing Medical University, Jiangsu, China ABSTRACT ARTICLE HISTORY Received 20 December 2018 Hepatitis B e antigen (HBeAg) has been considered to cause immunotolerance to hepatitis B virus (HBV) Revised 8 January 2019 in newborn infants after fetal HBeAg exposure. This study compared anti-HBs responses to hepatitis Accepted 23 January 2019 B vaccination in infants who were born to HBeAg-positive and -negative mothers respectively, to investigate whether fetal HBeAg exposure may induce immunotolerance to HBV. Totally 265 infants KEYWORDS who received recommended neonatal immunoprophylaxis against hepatitis B and had no HBV infection Hepatitis B vaccination; were included. Anti-HBs levels were compared between 124 infants with cord blood positive HBeAg and HBeAg; fetal exposure; anti- 141 infants with cord blood negative HBeAg at 7–12 months of age. The infants in two groups had HBs response similar age at the follow-up (10.0 ± 2.3 vs 10.1 ± 2.3 months, P = 0.590). Overall, 259 (97.7%) of 265 infants achieved anti-HBs levels (mIU/ml) ≥10 and 6 (2.3%) others had anti-HBs <10. Of 124 HBeAg- positive infants at birth, 46.0%, 39.5%, 12.1%, and 2.4% had anti-HBs levels (mIU/ml) ≥1000, 100–999.9, 10–99.9, and <10, respectively. Of 141 HBeAg-negative infants at birth, 35.5%, 48.9%, 13.5%, and 2.1% showed ≥1000, 100–999.9, 10–99.9, and <10, respectively. The proportions of each anti-HBs level between the two groups were comparable (all P > 0.05). Additionally, the distribution of anti-HBs response levels were also comparable in infants with high and low HBeAg levels (P = 0.818). In conclusions, the fetal HBeAg exposure does not inhibit the antibody response to neonatal hepatitis B vaccination. The data suggest that HBeAg appears not inducing immunotolerance to HBV. Introduction in infants within 12 hour after birth, followed by two additional doses of vaccine at the age of 1 and 6 months respectively, Hepatitis B virus (HBV) infection remains a serious global public mother-to-infant transmission of HBV has been reduced from health problem. Mother-to-infant transmission is the most com- 70–90% to 5–10% and from 10–30% to nearly zero in infants mon form of HBV infection in endemic regions and often leads to born to HBeAg-positive and -negative carrier mothers chronicity. Before the availability of hepatitis B immunoglobulin 12-14 respectively, demonstrating the high efficiency of current (HBIG) and hepatitis B vaccine, chronic HBV infection occurred immunoprophylaxis. As HBeAg can transplacentally transfer in 70–90% and 10–30% of infants born to hepatitis B e antigen from mothers to their fetuses, the neonates born to HBeAg- 1-3 (HBeAg) positive and HBeAg negative mothers respectively. positive or -negative mothers have different HBeAg status. This HBeAg is a low-molecular-weight (15.5 kD) soluble antigen, leaves us an opportunity to compare the antibody responses to which is not a component of HBV, but a derivative of hepatitis hepatitis B vaccination in these two infant groups, in whom B core antigen (HBcAg) that is secreted into the circulation during their cord blood samples were positive and negative for HBeAg viral replication. HBeAg can traverse the placenta, making the respectively, and to investigate whether fetal HBeAg exposure fetus exposed to this antigen. It has been considered that the fetal can induce the immunologic tolerance to HBV. HBeAg exposure can cause partial tolerance of newborn infants’ immune system to HBV, leading to the impaired immune func- tions for clearing the virus after neonatal exposure to HBV during Results 5-7 the birth process and finally resulting in chronic infection. Demographic characteristic and anti-HBs response 6,8,9 While this hypothesis is supported by some evidence, the role of HBeAg in inducing neonatal immunologic tolerance to HBV Based on the HBeAg status in the umbilical cord blood 10,11 remains to be controversial. samples at birth, the infants were divided into two groups, Since the availability of HBIG and hepatitis B vaccine, 124 infants with positive HBeAg and 141 infants with negative administration of combined passive-active immunoprophylaxis HBeAg at birth. The demographics and baseline CONTACT Yi-Hua Zhou zgr03summer@126.com Departments of Laboratory Medicine and Infectious Diseases, Nanjing Drum Tower Hospital, Nanjing University Medical School, 321 Zhong Shan Road, Nanjing 210008, China These authors contributed equally to this work. © 2019 Taylor & Francis Group, LLC 2184 Y.-H. ZHOU ET AL. Table 1. Demographics and baseline characteristics of infants. HBeAg-positive HBeAg-negative Variable group, n = 124 group, n = 141 P Male infant, N (%) 75 (60.0) 79 (56.0) 0.513 Gestational period 39.6 ± 1.1 39.5 ± 1.0 0.244 (week) Birth weight (g) 3408.8 ± 426.0 3425.6 ± 439.9 0.752 Birth length (cm) 50.0 ± 0.3 50.1 ± 0.9 0.211 Infant’s age at follow- 10.0 ± 2.3 10.1 ± 2.3 0.590 up (months) HBeAg, hepatitis B e antigen. characteristics of the two group infants are shown in Table 1. Overall, the variables were comparable between the two groups. The infants with positive HBeAg at birth had the median HBeAg level 1.39 log S/CO (range 0.04–3.05) in the cord blood, much lower than the levels (median level was 2.80 log S/CO, range 0.14–3.53, P < 0.05) in their mothers. Overall, 259 (97.7%) of 265 infants achieved anti-HBs ≥10 mIU/ml. Of them, 34 (12.8%), 118 (44.5%), and 107 (40.4%) Figure 1. Proportion of different responders in infants with different hepatitis had anti-HBs levels 10.0–99.9, 100–999.9, and ≥1000 mIU/ml, B e antigen (HBeAg) status. respectively, and were accordingly defined as low, medium, and high responders, respectively. Additionally, six (2.3%) hepatitis B, we compared anti-HBs levels in infants with other infants had anti-HBs levels <10 mIU/ml (ranged different status of HBeAg. Overall, the median anti-HBs levels 6.04–7.92), and were defined as non-responders. in infants with positive and negative HBeAg in umbilical cord blood at birth were 351.7 mIU/ml and 293.12 mIU/ml respec- tively (P = 0.049). The detailed anti-HBs titers of non-, low-, Comparison of anti-HBs responses between medium-, and high-responders were comparable between the HBeAg-positive and -negative infants at birth two groups (Table 2). The distributions of responders in To investigate whether fetal exposure to HBeAg has influence infants with different HBeAg status at birth are shown in on the antibody response to neonatal vaccination against Figure 1. The proportions of high, medium, low, and non responders to hepatitis B vaccine in neonates with positive Table 3. The frequency of different responders with different HBeAg levels. HBeAg in cord blood were comparable to that in neonates with negative HBeAg in their cord blood. In addition, based HBeAg in cord blood (log S/CO)** on the median HBeAg titer (1.39 log S/CO) in cord blood, Distribution of response* ≥1.39, n = 64 <1.39, n = 60 χ P we compared the anti-HBs response levels between infants Non-responder (%) 1 (1.6) 2 (3.3) 0.932 0.818 Low-responder (%) 10 (15.6) 7 (11.7) with HBeAg titer ≥1.39 and those with HBeAg titer <1.39 Medium-responder (%) 28 (43.8) 25 (41.7) (Table 3). The distributions of anti-HBs response levels were High-responder (%) 25 (39.0) 26 (43.3) also comparable in infants with different HBeAg levels. HBeAg, hepatitis B e antigen. *The non-, low-, medium-, and high-responders were defined based on the anti- HBs levels <10, 10–99.9, 100–999.9, and anti-HBs ≥1000 mIU/ml, respectively. **HBeAg was grouped by the median level 1.39 log S/CO. Discussion Combined use of passive and active vaccination against hepa- Table 2. Anti-HBs titers of infants with different HBeAg status. titis B is the most effective way to prevent mother-to-child Anti-HBs in infants (mIU/ml) transmission of HBV. Immunologic tolerance has been con- HBeAg-positive HBeAg-negative sidered to be one of the factors affected the production of Distribution of response* Group, n = 124 Group, n = 141 P anti-HBs after vaccination against hepatitis B. Studies have Non-responder 7.23 6.35 0.275 suggested that maternal HBeAg can transfer through placenta (6.11–7.92) (6.04–6.90) 5,16 Low-responder 56.36 40.14 0.107 and induce T-cell tolerance in utero. Exposure of immature (21.13–99.20) (11.63–94.84) immune system and early life to transplacental HBeAg could Medium-responder 455.57 376.04 0.099 (117.37–922.00) (102.59–975.23) induce immunotolerance in infants. Although some research- High-responder ≥1000 ≥1000 N/A ers suggested that HBV exposure triggers a state of “trained Anti-HBs, antibodies against HBsAg; HBeAg, hepatitis B e antigen. N/A, not immunity” that “challenges the role of immune tolerance in applicable. vrial persistence after neonatal infection” in utero, other *The non-, low-, medium-, and high-responders were defined based on the anti- HBs levels <10, 10–99.9, 100–999.9, and anti-HBs ≥1000 mIU/ml, respectively. investigators considered that the concept of immune tolerance † Anti-HBs level was expressed in geometric mean concentration (GMC) fol- of HBeAg is alive and well. lowed by minimum and maximum values. In the previous study, we found that as high as 89% of the ‡ Since anti-HBs was beyond the upper detection limit (1000 mIU/ml), the GMC and range of anti-HBs titers were not calculated. newborn infants born to HBeAg positive mothers were also HUMAN VACCINES & IMMUNOTHERAPEUTICS 2185 HBeAg positive in their cord blood samples, which is similar Materials and methods to the reported transplacental HBeAg transfer proportion Study subjects (94.3%, 182/193). In the present study, after vaccination against hepatitis B based the standard protocol, the anti-HBs The subjects in the present study included two groups of positive rate was as high as 97.7%, which is similar to the infants by stratified cluster sampling method. One group positive rate of 98.2% at 7 month and 97.1% at 12 month in was composed of 124 infants born to mothers with positive China reported by Wei KP et al. The birth weigh as well as for both hepatitis B surface antigen (HBsAg) and HBeAg, and the median anti-HBs levels in infants in the present study are they were also HBeAg positive in umbilical cord blood sam- also comparable to those in Wei KP et al’s report. ples collected at birth. These infants were offsprings of con- Additionally, the 265 infants included in the present study secutive pregnant women who served as a control group in were derived from stratified cluster sampling method, but not a prospective study to evaluate the safety and efficacy of deliberately selected from the infants with high or low anti- telbivudine used during the trimester to prevent perinatal HBs responses. Thus, we considered that the results obtained HBV infection in Jiangsu province; their mothers were not in these infants can generally represent those in general infant treated with any antiviral treatment before and during populations. In the present study, we compared the anti-HBs pregnancy. The other group comprised 141 infants born to response to hepatitis B vaccination between newborn infants mothers with positive HBsAg and negative HBeAg, and they with positive HBeAg in umbilical blood and those with nega- were also HBeAg negative in their umbilical cord blood col- tive HBeAg in umbilical blood. No differences in anti-HBs lected at birth. Infants who met any of followings were response rates and antibody levels were found between infants excluded: 1) mothers with co-infection of hepatitis A, C, with different HBeAg status, indicating transplacental HBeAg E or HIV; 2) low birth weight; 3) premature birth; 4) incom- in fetus did not inhibit the immune responses to hepatitis pletion or not adherence of recommended 0, 1 and 6 months B vaccine. Therefore, our present study provides evidence schedule of hepatitis B vaccination; 5) positive for antibody against the concept of HBeAg as an immunotolerance in the against hepatitis B core antigen (anti-HBc) or for HBsAg at transmission of HBV from mothers to infants. 7–12 month of age. Studies on the prenatal diagnosis by amniocentesis or per- All infants were injected with HBIG (100 IU) and the first cutaneous umbilical blood sampling showed the presence of dose of the hepatitis B vaccine (yeast recombinant HBsAg, 10 HBeAg in amniotic fluid and fetal blood samples at gestation μg) within 24 h of birth, and received the two other vaccine 20,21 weeks 16–32, demonstrating that HBeAg can pass through doses at the ages of 1 and 6 months respectively. The infants placenta to fetus in the second trimester. Although it is infea- also received other routine vaccinations as recommended by sible to determine when transplacental HBeAg transfer is China Expanded Program on Immunization. initiated, the presence of HBeAg in the cord blood at birth This study was approved by the institutional review boards indicated that the fetuses had been exposed to this antigen for (IRB) of Nanjing Drum Tower Hospital. As serum samples at least several weeks in utero, rather than exposure just around used in the present study were collected in two previous 18,25 partus, However, the infants with positive HBeAg at birth did investigations, in which the mothers consented to partici- not show any inhibition of anti-HBs response to hepatitis pation and gave the written informed consent for themselves B vaccine, compared with the infants with negative HBeAg at and their infants, the exemption of written informed consent birth. This suggests that in utero exposure to HBeAg may not in this study was approved by the IRB of Nanjing Drum induce immunotolerance to HBsAg. Tower Hospital. Our study had some limitations. First, we did not include infants who were born to HBsAg negative pregnant women. As a result, we could not compare the anti-HBs response to hepatitis Laboratory tests and outcome assessment B vaccine between infants born to HBV-infected and non- Hepatitis B serologic markers, including HBsAg, antibody infected mothers. However, the findings that as high as 97.7% against HBsAg (anti-HBs), HBeAg, antibody against HBeAg (259/265) infants had anti-HBs ≥10 mIU/ml at 7–12 months of (anti-HBe), and anti-HBc, were measured with microparticle age indicate that the anti-HBs response to neonatal hepatitis enzyme immunoassay (Architect, Abbott, North Chicago). B vaccination in this cohort infants born to HBV carrier mothers The infants with anti-HBs levels <10, 10–99.9, 100–999.9, was overall comparable to that in infants born to non-HBV and ≥1000 mIU/ml were respectively defined as non-, low-, infected mothers. Second, we did not further quantitate the 23,24 medium-, and high-responders as described elsewhere. anti-HBs levles in samples that were beyond the upper detection limit (1000 mIU/ml), leaving the exact concentrations of anti- HBs unknown. However, it is generally accepted that vaccinees Statistical analysis with anti-HBs higher than 1000 mIU/ml are considered to be 23,24 high responders and will have long protection duration. Normally distributed continuous variables were shown as mean In conclusion, the present study revealed that the fetal ± SD and compared using Student’s test. Non-normally distrib- exposure to maternal HBeAg did not induce immunotoler- uted quantitative data were expressed as median and range and ance to neonatal hepatitis B vaccination. The results suggest compared using Mann-Whitney U test. Categorical variables that the transplacentally acquired maternal HBeAg in utero were compared by Chi-square or Fisher’s exact tests. Level of may be not associated with the pathogenesis of chronic HBV HBeAg was expressed as a logarithm of measured value (log S/ infection after neonatal exposure to HBV. CO). The anti-HBs were shown as geometric mean 2186 Y.-H. ZHOU ET AL. concentration (GMC) followed by minimum and maximum 11. Bertoletti A, Kennedy PT. The immune tolerant phase of chronic HBV infection: new perspectives on an old concept. Cell Mol values and compared by Mann-Whitney U tests. All statistical Immunol. 2015;12(3):258–63. doi:10.1038/cmi.2014.79. analyses were conducted using SPSS 13.0 (SPSS, Inc., Chicago, 12. Cheung KW, Seto MTY, Kan ASY, Wong D, Kou KO, So PL, IL, USA). P < 0.05 indicated statistically significant difference. Lau WL, Jalal K, Chee YY, Wong RMS, et al. Immunoprophylaxis failure of infants born to Hepatitis B carrier mothers following routine vaccination. Clin Gastroenterol Hepatol. 2018;16 Disclosure of potential conflicts of interest (1):144–45. doi:10.1016/j.cgh.2017.07.013. 13. Wei KP, Zhu FC, Liu JX, Yan L, Lu Y, Zhai XJ, Chang ZJ, Zeng Y, No potential conflict of interest was reported by the authors. Li J, Zhuang H. The efficacy of two different dosages of hepatitis B immunoglobulin combined with hepatitis B vaccine in prevent- ing mother-to-child transmission of hepatitis B virus: Funding A prospective cohort study. Vaccine. 2018;36(2):256–63. This study was supported by the National Natural Science Foundation of doi:10.1016/j.vaccine.2017.11.037. China (81672002), the Science and Technology Department of Jiangsu 14. Liu J, Xu B, Chen T, Chen J, Feng J, Xu C, Liu L, Hu Y, Zhou YH. Province (BK20161105), and the Jiangsu Provincial Department of Presence of hepatitis B virus markers in umbilical cord blood: Health (H201537), China. The funders had no role in study design, exposure to or infection with the virus? Dig Liver Dis. 2018;pii: data collection and analysis, preparation and writing of the manuscript S1590-8658(18)31222-2. doi:10.1016/j.dld.2018.11.003. and its submission. 15. Yang S, Tian G, Cui Y, Ding C, Deng M, Yu C, Xu K, Ren J, Yao J, Li Y, et al. Factors influencing immunologic response to hepatitis B vaccine in adults. Sci Rep. 2016;6:27251. doi:10.1038/ ORCID srep27251. 16. Milich D, Liang TJ. Exploring the biological basis of hepatitis B e Yimin Dai http://orcid.org/0000-0002-5266-1797 antigen in hepatitis B virus infection. Hepatology. 2003;38 Yi-Hua Zhou http://orcid.org/0000-0001-8880-0392 (5):1075–86. doi:10.1053/jhep.2003.50453. 17. Milich DR. 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Liu J, Bi Y, Xu C, Liu L, Xu B, Chen T, Chen J, Pan M, Hu Y, Schirmbeck R, Schlicht HJ. The hepatitis B virus e antigen cannot Zhou YH. Kinetic changes of viremia and viral antigens of Hepatitis pass the murine placenta efficiently and does not induce CTL B virus during and after pregnancy. Medicine (Baltimore). 2015;94 immune tolerance in H-2b mice in utero. Virology. 1998;243 (45):e2001. doi:10.1097/MD.0000000000002001. (1):45–53. doi:10.1006/viro.1998.9033. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Human Vaccines & Immunotherapeutics Taylor & Francis

Comparison of antibody response to hepatitis B vaccination in infants with positive or negative maternal hepatitis B e antigen (HBeAg) in cord blood: implication for the role of HBeAg as an immunotolerogen

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HUMAN VACCINES & IMMUNOTHERAPEUTICS 2019, VOL. 15, NO. 9, 2183–2186 https://doi.org/10.1080/21645515.2019.1575712 RESEARCH PAPER Comparison of antibody response to hepatitis B vaccination in infants with positive or negative maternal hepatitis B e antigen (HBeAg) in cord blood: implication for the role of HBeAg as an immunotolerogen a a a b b b b a,c Hongyu Huang *, Mingzhe Ning , Jingli Liu , Jie Chen , Jing Feng , Yimin Dai , Yali Hu , and Yi-Hua Zhou * Department of Laboratory Medicine and Jiangsu Key Laboratory for Molecular Medicine, Nanjing Drum Tower Hospital, Nanjing University Medical School, Jiangsu, China; Department of Obstetrics and Gynecology, Nanjing Drum Tower Hospital, Nanjing University Medical School, Jiangsu, China; Department of Infectious Diseases, Nanjing Drum Tower Hospital, Nanjing Medical University, Jiangsu, China ABSTRACT ARTICLE HISTORY Received 20 December 2018 Hepatitis B e antigen (HBeAg) has been considered to cause immunotolerance to hepatitis B virus (HBV) Revised 8 January 2019 in newborn infants after fetal HBeAg exposure. This study compared anti-HBs responses to hepatitis Accepted 23 January 2019 B vaccination in infants who were born to HBeAg-positive and -negative mothers respectively, to investigate whether fetal HBeAg exposure may induce immunotolerance to HBV. Totally 265 infants KEYWORDS who received recommended neonatal immunoprophylaxis against hepatitis B and had no HBV infection Hepatitis B vaccination; were included. Anti-HBs levels were compared between 124 infants with cord blood positive HBeAg and HBeAg; fetal exposure; anti- 141 infants with cord blood negative HBeAg at 7–12 months of age. The infants in two groups had HBs response similar age at the follow-up (10.0 ± 2.3 vs 10.1 ± 2.3 months, P = 0.590). Overall, 259 (97.7%) of 265 infants achieved anti-HBs levels (mIU/ml) ≥10 and 6 (2.3%) others had anti-HBs <10. Of 124 HBeAg- positive infants at birth, 46.0%, 39.5%, 12.1%, and 2.4% had anti-HBs levels (mIU/ml) ≥1000, 100–999.9, 10–99.9, and <10, respectively. Of 141 HBeAg-negative infants at birth, 35.5%, 48.9%, 13.5%, and 2.1% showed ≥1000, 100–999.9, 10–99.9, and <10, respectively. The proportions of each anti-HBs level between the two groups were comparable (all P > 0.05). Additionally, the distribution of anti-HBs response levels were also comparable in infants with high and low HBeAg levels (P = 0.818). In conclusions, the fetal HBeAg exposure does not inhibit the antibody response to neonatal hepatitis B vaccination. The data suggest that HBeAg appears not inducing immunotolerance to HBV. Introduction in infants within 12 hour after birth, followed by two additional doses of vaccine at the age of 1 and 6 months respectively, Hepatitis B virus (HBV) infection remains a serious global public mother-to-infant transmission of HBV has been reduced from health problem. Mother-to-infant transmission is the most com- 70–90% to 5–10% and from 10–30% to nearly zero in infants mon form of HBV infection in endemic regions and often leads to born to HBeAg-positive and -negative carrier mothers chronicity. Before the availability of hepatitis B immunoglobulin 12-14 respectively, demonstrating the high efficiency of current (HBIG) and hepatitis B vaccine, chronic HBV infection occurred immunoprophylaxis. As HBeAg can transplacentally transfer in 70–90% and 10–30% of infants born to hepatitis B e antigen from mothers to their fetuses, the neonates born to HBeAg- 1-3 (HBeAg) positive and HBeAg negative mothers respectively. positive or -negative mothers have different HBeAg status. This HBeAg is a low-molecular-weight (15.5 kD) soluble antigen, leaves us an opportunity to compare the antibody responses to which is not a component of HBV, but a derivative of hepatitis hepatitis B vaccination in these two infant groups, in whom B core antigen (HBcAg) that is secreted into the circulation during their cord blood samples were positive and negative for HBeAg viral replication. HBeAg can traverse the placenta, making the respectively, and to investigate whether fetal HBeAg exposure fetus exposed to this antigen. It has been considered that the fetal can induce the immunologic tolerance to HBV. HBeAg exposure can cause partial tolerance of newborn infants’ immune system to HBV, leading to the impaired immune func- tions for clearing the virus after neonatal exposure to HBV during Results 5-7 the birth process and finally resulting in chronic infection. Demographic characteristic and anti-HBs response 6,8,9 While this hypothesis is supported by some evidence, the role of HBeAg in inducing neonatal immunologic tolerance to HBV Based on the HBeAg status in the umbilical cord blood 10,11 remains to be controversial. samples at birth, the infants were divided into two groups, Since the availability of HBIG and hepatitis B vaccine, 124 infants with positive HBeAg and 141 infants with negative administration of combined passive-active immunoprophylaxis HBeAg at birth. The demographics and baseline CONTACT Yi-Hua Zhou zgr03summer@126.com Departments of Laboratory Medicine and Infectious Diseases, Nanjing Drum Tower Hospital, Nanjing University Medical School, 321 Zhong Shan Road, Nanjing 210008, China These authors contributed equally to this work. © 2019 Taylor & Francis Group, LLC 2184 Y.-H. ZHOU ET AL. Table 1. Demographics and baseline characteristics of infants. HBeAg-positive HBeAg-negative Variable group, n = 124 group, n = 141 P Male infant, N (%) 75 (60.0) 79 (56.0) 0.513 Gestational period 39.6 ± 1.1 39.5 ± 1.0 0.244 (week) Birth weight (g) 3408.8 ± 426.0 3425.6 ± 439.9 0.752 Birth length (cm) 50.0 ± 0.3 50.1 ± 0.9 0.211 Infant’s age at follow- 10.0 ± 2.3 10.1 ± 2.3 0.590 up (months) HBeAg, hepatitis B e antigen. characteristics of the two group infants are shown in Table 1. Overall, the variables were comparable between the two groups. The infants with positive HBeAg at birth had the median HBeAg level 1.39 log S/CO (range 0.04–3.05) in the cord blood, much lower than the levels (median level was 2.80 log S/CO, range 0.14–3.53, P < 0.05) in their mothers. Overall, 259 (97.7%) of 265 infants achieved anti-HBs ≥10 mIU/ml. Of them, 34 (12.8%), 118 (44.5%), and 107 (40.4%) Figure 1. Proportion of different responders in infants with different hepatitis had anti-HBs levels 10.0–99.9, 100–999.9, and ≥1000 mIU/ml, B e antigen (HBeAg) status. respectively, and were accordingly defined as low, medium, and high responders, respectively. Additionally, six (2.3%) hepatitis B, we compared anti-HBs levels in infants with other infants had anti-HBs levels <10 mIU/ml (ranged different status of HBeAg. Overall, the median anti-HBs levels 6.04–7.92), and were defined as non-responders. in infants with positive and negative HBeAg in umbilical cord blood at birth were 351.7 mIU/ml and 293.12 mIU/ml respec- tively (P = 0.049). The detailed anti-HBs titers of non-, low-, Comparison of anti-HBs responses between medium-, and high-responders were comparable between the HBeAg-positive and -negative infants at birth two groups (Table 2). The distributions of responders in To investigate whether fetal exposure to HBeAg has influence infants with different HBeAg status at birth are shown in on the antibody response to neonatal vaccination against Figure 1. The proportions of high, medium, low, and non responders to hepatitis B vaccine in neonates with positive Table 3. The frequency of different responders with different HBeAg levels. HBeAg in cord blood were comparable to that in neonates with negative HBeAg in their cord blood. In addition, based HBeAg in cord blood (log S/CO)** on the median HBeAg titer (1.39 log S/CO) in cord blood, Distribution of response* ≥1.39, n = 64 <1.39, n = 60 χ P we compared the anti-HBs response levels between infants Non-responder (%) 1 (1.6) 2 (3.3) 0.932 0.818 Low-responder (%) 10 (15.6) 7 (11.7) with HBeAg titer ≥1.39 and those with HBeAg titer <1.39 Medium-responder (%) 28 (43.8) 25 (41.7) (Table 3). The distributions of anti-HBs response levels were High-responder (%) 25 (39.0) 26 (43.3) also comparable in infants with different HBeAg levels. HBeAg, hepatitis B e antigen. *The non-, low-, medium-, and high-responders were defined based on the anti- HBs levels <10, 10–99.9, 100–999.9, and anti-HBs ≥1000 mIU/ml, respectively. **HBeAg was grouped by the median level 1.39 log S/CO. Discussion Combined use of passive and active vaccination against hepa- Table 2. Anti-HBs titers of infants with different HBeAg status. titis B is the most effective way to prevent mother-to-child Anti-HBs in infants (mIU/ml) transmission of HBV. Immunologic tolerance has been con- HBeAg-positive HBeAg-negative sidered to be one of the factors affected the production of Distribution of response* Group, n = 124 Group, n = 141 P anti-HBs after vaccination against hepatitis B. Studies have Non-responder 7.23 6.35 0.275 suggested that maternal HBeAg can transfer through placenta (6.11–7.92) (6.04–6.90) 5,16 Low-responder 56.36 40.14 0.107 and induce T-cell tolerance in utero. Exposure of immature (21.13–99.20) (11.63–94.84) immune system and early life to transplacental HBeAg could Medium-responder 455.57 376.04 0.099 (117.37–922.00) (102.59–975.23) induce immunotolerance in infants. Although some research- High-responder ≥1000 ≥1000 N/A ers suggested that HBV exposure triggers a state of “trained Anti-HBs, antibodies against HBsAg; HBeAg, hepatitis B e antigen. N/A, not immunity” that “challenges the role of immune tolerance in applicable. vrial persistence after neonatal infection” in utero, other *The non-, low-, medium-, and high-responders were defined based on the anti- HBs levels <10, 10–99.9, 100–999.9, and anti-HBs ≥1000 mIU/ml, respectively. investigators considered that the concept of immune tolerance † Anti-HBs level was expressed in geometric mean concentration (GMC) fol- of HBeAg is alive and well. lowed by minimum and maximum values. In the previous study, we found that as high as 89% of the ‡ Since anti-HBs was beyond the upper detection limit (1000 mIU/ml), the GMC and range of anti-HBs titers were not calculated. newborn infants born to HBeAg positive mothers were also HUMAN VACCINES & IMMUNOTHERAPEUTICS 2185 HBeAg positive in their cord blood samples, which is similar Materials and methods to the reported transplacental HBeAg transfer proportion Study subjects (94.3%, 182/193). In the present study, after vaccination against hepatitis B based the standard protocol, the anti-HBs The subjects in the present study included two groups of positive rate was as high as 97.7%, which is similar to the infants by stratified cluster sampling method. One group positive rate of 98.2% at 7 month and 97.1% at 12 month in was composed of 124 infants born to mothers with positive China reported by Wei KP et al. The birth weigh as well as for both hepatitis B surface antigen (HBsAg) and HBeAg, and the median anti-HBs levels in infants in the present study are they were also HBeAg positive in umbilical cord blood sam- also comparable to those in Wei KP et al’s report. ples collected at birth. These infants were offsprings of con- Additionally, the 265 infants included in the present study secutive pregnant women who served as a control group in were derived from stratified cluster sampling method, but not a prospective study to evaluate the safety and efficacy of deliberately selected from the infants with high or low anti- telbivudine used during the trimester to prevent perinatal HBs responses. Thus, we considered that the results obtained HBV infection in Jiangsu province; their mothers were not in these infants can generally represent those in general infant treated with any antiviral treatment before and during populations. In the present study, we compared the anti-HBs pregnancy. The other group comprised 141 infants born to response to hepatitis B vaccination between newborn infants mothers with positive HBsAg and negative HBeAg, and they with positive HBeAg in umbilical blood and those with nega- were also HBeAg negative in their umbilical cord blood col- tive HBeAg in umbilical blood. No differences in anti-HBs lected at birth. Infants who met any of followings were response rates and antibody levels were found between infants excluded: 1) mothers with co-infection of hepatitis A, C, with different HBeAg status, indicating transplacental HBeAg E or HIV; 2) low birth weight; 3) premature birth; 4) incom- in fetus did not inhibit the immune responses to hepatitis pletion or not adherence of recommended 0, 1 and 6 months B vaccine. Therefore, our present study provides evidence schedule of hepatitis B vaccination; 5) positive for antibody against the concept of HBeAg as an immunotolerance in the against hepatitis B core antigen (anti-HBc) or for HBsAg at transmission of HBV from mothers to infants. 7–12 month of age. Studies on the prenatal diagnosis by amniocentesis or per- All infants were injected with HBIG (100 IU) and the first cutaneous umbilical blood sampling showed the presence of dose of the hepatitis B vaccine (yeast recombinant HBsAg, 10 HBeAg in amniotic fluid and fetal blood samples at gestation μg) within 24 h of birth, and received the two other vaccine 20,21 weeks 16–32, demonstrating that HBeAg can pass through doses at the ages of 1 and 6 months respectively. The infants placenta to fetus in the second trimester. Although it is infea- also received other routine vaccinations as recommended by sible to determine when transplacental HBeAg transfer is China Expanded Program on Immunization. initiated, the presence of HBeAg in the cord blood at birth This study was approved by the institutional review boards indicated that the fetuses had been exposed to this antigen for (IRB) of Nanjing Drum Tower Hospital. As serum samples at least several weeks in utero, rather than exposure just around used in the present study were collected in two previous 18,25 partus, However, the infants with positive HBeAg at birth did investigations, in which the mothers consented to partici- not show any inhibition of anti-HBs response to hepatitis pation and gave the written informed consent for themselves B vaccine, compared with the infants with negative HBeAg at and their infants, the exemption of written informed consent birth. This suggests that in utero exposure to HBeAg may not in this study was approved by the IRB of Nanjing Drum induce immunotolerance to HBsAg. Tower Hospital. Our study had some limitations. First, we did not include infants who were born to HBsAg negative pregnant women. As a result, we could not compare the anti-HBs response to hepatitis Laboratory tests and outcome assessment B vaccine between infants born to HBV-infected and non- Hepatitis B serologic markers, including HBsAg, antibody infected mothers. However, the findings that as high as 97.7% against HBsAg (anti-HBs), HBeAg, antibody against HBeAg (259/265) infants had anti-HBs ≥10 mIU/ml at 7–12 months of (anti-HBe), and anti-HBc, were measured with microparticle age indicate that the anti-HBs response to neonatal hepatitis enzyme immunoassay (Architect, Abbott, North Chicago). B vaccination in this cohort infants born to HBV carrier mothers The infants with anti-HBs levels <10, 10–99.9, 100–999.9, was overall comparable to that in infants born to non-HBV and ≥1000 mIU/ml were respectively defined as non-, low-, infected mothers. Second, we did not further quantitate the 23,24 medium-, and high-responders as described elsewhere. anti-HBs levles in samples that were beyond the upper detection limit (1000 mIU/ml), leaving the exact concentrations of anti- HBs unknown. However, it is generally accepted that vaccinees Statistical analysis with anti-HBs higher than 1000 mIU/ml are considered to be 23,24 high responders and will have long protection duration. Normally distributed continuous variables were shown as mean In conclusion, the present study revealed that the fetal ± SD and compared using Student’s test. 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Journal

Human Vaccines & Immunotherapeutics – Taylor & Francis

Published: Sep 2, 2019

Keywords: Hepatitis B vaccination; HBeAg; fetal exposure; anti-HBs response

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