|Year : 2016 | Volume
| Issue : 1 | Page : 131-135
Predictors of poor response to the hepatitis B vaccine among healthcare workers at the National Liver Institute Hospital
Rabie E El Bahnasy1, Mahmoud E Abu Salem1, Hewaida M El Shazly1, Wesam S Morad2, Enas M Moaz2
1 Department of Public Health and Community Medicine, Faculty of Medicine, Menoufia Governorate, Egypt
2 Department of Environmental Health of Liver, National Liver Institute, Menoufia University, Menoufia Governorate, Egypt
|Date of Submission||30-Nov-2014|
|Date of Acceptance||11-Feb-2015|
|Date of Web Publication||18-Mar-2016|
Enas M Moaz
MBBCh, Department of Environmental Health of Liver, National Liver Institute, Menoufia University, Gamal Abdel Nasser Street, Shebin Al-Kom, Menoufia 32111
Source of Support: None, Conflict of Interest: None
This study aimed to estimate the nonresponder rates to the hepatitis B vaccine and identify possible risk factors of nonresponse among a group of healthcare workers (HCWs) at the National Liver Institute Hospital.
Hepatitis B is the most important infectious occupational disease among HCWs. The most effective preventive measure is hepatitis B vaccination. Response to the hepatitis B vaccine [significant hepatitis B surface antibodies (HBsAbs) titer] ranges from 85 to 90% globally. HCWs are at a high risk of acquiring hepatitis B virus (HBV), and nonresponder rates after HBV vaccination have not been reported previously among HCWs at the National Liver Institute.
Participants and methods
A retrospective and follow-up study was carried out at the National Liver Institute. The studied group included 200 HCWs who were evaluated for immune response by measuring serum HBsAbs levels within 6 months after completing three doses of the HBV vaccine. A questionnaire was administered to them to assess the risk factors of nonresponse.
The nonresponder rate to the hepatitis B vaccine (nonsignificant HBsAbs titer) was 9%. The results showed that there was a significant relationship between nonresponse and older age, high BMI, and the presence of chronic diseases; 55.6% of the nonresponders were older than 30 years of age, 66.7% of the nonresponders had BMI above 30, and 100% of hepatitis C-infected HCWs showed no response to the vaccine (P < 0.05).
Conclusion and recommendations
Nonresponder HCWs to the HBV vaccine who work in a high-risk environment are at a high risk of acquiring HBV infection. Therefore, it is crucial to check postvaccination HBsAbs in all HCWs. This strategy will ensure safety at work by reducing nosocomial transmission, and will have a cost-effective impact at an individual as well as at a national level.
Keywords: Healthcare workers, hepatitis B vaccine, National Liver Institute
|How to cite this article:|
El Bahnasy RE, Abu Salem ME, El Shazly HM, Morad WS, Moaz EM. Predictors of poor response to the hepatitis B vaccine among healthcare workers at the National Liver Institute Hospital. Menoufia Med J 2016;29:131-5
|How to cite this URL:|
El Bahnasy RE, Abu Salem ME, El Shazly HM, Morad WS, Moaz EM. Predictors of poor response to the hepatitis B vaccine among healthcare workers at the National Liver Institute Hospital. Menoufia Med J [serial online] 2016 [cited 2019 Sep 21];29:131-5. Available from: http://www.mmj.eg.net/text.asp?2016/29/1/131/179003
| Introduction|| |
Egypt is considered an area with intermediate endemicity for the virus as the prevalence of hepatitis B virus (HBV) chronic carriers among adults in the general population ranges from 2 to 7% .
Hepatitis B infection represents a major health problem, with two billion individuals infected worldwide and more than 400 million chronic carriers of HBV . Exposure to blood and body fluids is a major risk factor for the development of HBV infection; the risk of acquisition of HBV infection after a single exposure of HBV-infected blood or body fluid ranges from 6 to 30%. Therefore, healthcare workers (HCWs) are at a high risk of developing HBV infection because of repeated exposure .
The most important approach for the prevention of occupational HBV infection is the use of the hepatitis B vaccine. The hepatitis B vaccine is generally administered intramuscularly in the deltoid region at three doses of 0-month, 1-month, and 6-month schedules. Hepatitis B vaccine protection means that the anti-HBs level of at least 10 mIU/ml following three doses of recombinant HBV vaccine has been reported to be 90-95%, respectively .
About 5-10% of those vaccinated against HBV fail to respond with the development of antibody to the HBV; HCWs who have been vaccinated against HBV infection and do not develop immunity remain at a high risk of being infected .
Despite HBV infection being a major healthcare issue in both community and healthcare settings in Egypt, and the fact that the National Liver Institute is a high-risk environment for infection by HBV, no sufficient data assessing immune response after vaccination in HCWs are available at National Liver Institute. Detection of nonresponders to the hepatitis B vaccine will enable their management as ∼30-75% of patients will response to the second vaccination series . Therefore, we carried out this study with the aim of calculating nonresponder rates to the hepatitis B vaccine among the HCWs studied and to identify the risk factors of nonresponse.
| Participants and methods|| |
This was a retrospective and follow-up study carried out at the National Liver Institute during the period from the first of August 2013 to the end of April 2014. Oral consent was obtained from all HCWs who participated in the study. The participants in the study were about 200 HCWs (45 physicians, 112 nurses, 17 workers, 26 employees) from Hepatology, Hepatobiliary surgery, Pediatric hepatology, Officers, and Secretary departments. The studied group included all HCWs who were currently subjected to the HBV vaccination standard schedule and were followed till completion of their three doses and all HCWs who had completed their course of the hepatitis B vaccine within the previous 1 year. All participants were administered a predesigned questionnaire to assess the risk factors of nonresponse, and subjected to blood investigations for antibodies to hepatitis B within 6 months from the last dose after completion of the standard vaccination. The studied group was divided according to response to the hepatitis B vaccine into negative and positive; blood samples with concentrations less than 10 mIU/ml were considered negative to the HBV vaccine, whereas others with concentrations of at least 10 IU/l were considered positive. Data were collected and analyzed statistically using SPSS (Statistical Package of Social Science, version 20, SPSS Inc., Chicago, Illinois, USA) and Epi Info 2000 (Centers for Disease Control and Prevention) (CDC) in Atlanta, Georgia (USA) programs applying both Student's t-test and the Mann-Whitney test for quantitative variables; the ν2 -test was used for qualitative variables, with a significance level of P-value less than 0.05. The protocol for this study followed ethical standards and was approved by the ethical committee of our institution.
| Results|| |
In all, 200 HCWs (45 physicians, 112 nurses, 17 workers, and 26 employees) [Figure 1] and [Figure 2] were included in the study; 25.5% of the participants were men and 74.5% were women. In all, 66.5% were younger than or 30 years of age, whereas 33.5% were older than 30 years of age; in 73%, the BMI was less than or equal to 30, whereas in 27%, the BMI was above 30 [Table 1]. The nonresponder rate to the hepatitis B vaccine among the studied group was 9% [Figure 3]. There was a statistically significant association between older age and nonresponse as 55.6% of nonresponders were older than 30 years of age. There was no statistically significant association between sex and response to the HBV vaccine. There was a statistically significant association between higher BMI and nonresponse as 66.7% of nonresponders had BMI above 30 [Table 2]. There was a statistically significant association between the presence of chronic diseases and nonresponse to the HBV vaccine as all HCWs with HCV were nonresponders to the vaccine [Table 3]. No statistically significant association was observed between long-term corticosteroid therapy or smoking and nonresponse to the HBV vaccine [Table 4].
|Figure 2: Distribution of the healthcare workers studied according to department.|
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|Figure 3: Rate of nonresponse to the hepatitis B vaccine among the healthcare workers studied.|
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|Table 2: Association between response to the hepatitis B virus vaccine and sociodemographic data|
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|Table 3: Association between the presence of chronic diseases and others and response to the hepatitis B virus vaccine|
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No statistically significant association was observed between potential exposure to risk factors of HBV infection and response to the HBV vaccine [Table 4].
|Table 4: Association between potential exposure to the risk factors of hepatitis B virus infection and response to the hepatitis B virus vaccine|
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| Discussion|| |
In this study, the nonresponder rate to the hepatitis B vaccine was about 9%, which is consistent with the nonresponder rate among 342 hospital personnel at University of Peradeniya, Sri Lanka, which was reported to be 9.9% by Chathuranga et al. . However, lower rates of nonresponders were reported by Mojtaba and Roghayyeh , who evaluated the immunologic response to the hepatitis B vaccine on 341 of the medical staff of Tabriz Shahid Madani Hospital, Iran, and found that the nonresponder rate was about 3%. The differences in the nonresponder rates between the different studies may be because of the differences in the population characteristics of each study group such as ethnicity, prevalence of hepatitis infection, or prevalence of chronic diseases.
This study showed a significant association (P = 0.038) between age and response to the HBV vaccine as 55.6% of nonresponders were older than 30 years of age. This is inconsistent with Fisman et al.  in a meta-analysis studying the effect of age on immunologic response to the recombinant hepatitis B vaccine in 24 published trials and studies that evaluated the association of age with response to the hepatitis B vaccine in which he found that the association between older age and nonresponse to the vaccine remained fairly constant, irrespective of the age cutoff below 30 years used; even age cutoff predicted an increased risk of nonresponse among older individuals. Pooling of study results suggested a significantly increased risk of nonresponse to the hepatitis B vaccine among older individuals (relative risk 1.76; 95% confidence interval, odds ratio 1.48-2.10). In contrast to this, Eltayib et al.  reported that the lower reactivity to the HBV vaccine cannot be attributed to a particular age range (P = 0.530) as the active age group (<40 years) showed no remarkable response.
No significant relationship was found on studying the association between sex and response to the HBV vaccine, which was in agreement with the results of Zamani et al. . This was not in agreement with the results of Zeeshan et al. , who found that female participants had a significantly higher immune response than male participants (P<0.05); they claimed that male behavior such as smoking and certain genetic factors have been reported to be probable reasons for the decreased immune response in men. However, Senden  suggested that there was a lower response in men because of their higher body weight, but this has not been confirmed by other studies.
This study found a significant association (P = 0.000) between response to the HBV vaccine and BMI as 94.4% of the nonresponders were obese (BMI >30). This is in agreement with the result of Charles et al. , who showed that high BMI in adults had a negative influence on the efficacy of HBV vaccination and explained that the effect of deposition of the HBV vaccine in fat rather than in muscle may have led to higher failure rates. Abdolsamadi et al.  believed that hormonal effects in overweight individuals can decrease antibody titers. However, Mojtaba and Roghayyeh , reported that there was no significant effect of BMI on seroprotection of the HBV vaccine (P = 0.407).
The present study found a significant relation between response to vaccine and chronic liver disease as all chronic HCV cases were nonresponders (P = 0.01). This result is in agreement with the results of Eltayib et al. , who evaluated the seroprotection conferred by the hepatitis B vaccine among 90 HCWs at Bahri Teaching Hospital, Khartoum, Sudan. They found that none of the participants who had systemic disease, especially chronic liver disease, responded to the HBV vaccine (P = 0.048).
| Conclusion and recommendations|| |
On the basis of the findings of the present study, we can conclude that the rate of nonresponse to the hepatitis B vaccine among the HCWs studied was 9%. Older age, high BMI, and the presence of chronic diseases are the main risk factors of nonresponse. HCWs who have been vaccinated against HBV infection and who do not develop immunity remain at a high risk of being infected; thus, postvaccination testing after completion of the full course of the vaccine should be performed routinely. Up to three additional booster doses should be administered to nonresponders, with careful follow-up.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
Centers for Disease Control and Prevention (CDC). Recommendations for identification and public health management of persons with chronic hepatitis b virus infection. MMWR 2008; 57
Hou J, Z Liu, F Gu. Epidemiology and prevention of hepatitis B virus infection. Int J Med Sci 2005; 2
AA Ali, MM Ghonaim, KA Ali, HE Ali, NS El-Abd. Study of the prevalence of some infectious diseases in medical and paramedical personnel in Menoufyia University Hospitals. Menoufiya Med J 2008; 21
Mast EE, Weinbaum CM, Fiore AE, Alter MJ, Bell BP, Finelli L, et al
. Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep 2006; 55
Abe M, Akbar SM, Onji M. Zinc and hepatitis B virus vaccination. Hepatol Res2006; 35
Grabenstien R, John D. Hepatitis B vaccine, immunofacts and comparisons. J Clin Gastroenterol Hepatol 2005; 5
Chathuranga LS, Noordeen F, Abeykoon AM. Immune response to hepatitis B vaccine in a group of health care workers in Sri Lanka. Int J Infect Dis 2013; 17
Mojtaba V, Roghayyeh M. Immunologic response to hepatitis B vaccine in health care workers: a screening program and evaluation of some host-related factors role. Am J Immunol 2011; 7
Fisman DN, Agrawal D, Leder K. The effect of age on immunologic response to recombinant hepatitis B vaccine: a meta-analysis. Clin Infect Dis 2002; 35
Eltayib H, Amal O, Mohamed A. Antibody titers following hepatitis B vaccination in health care workers in Khartoum State. Sudan Int J Med Health Sci Res 2014; 1
Zamani F, Fallahian F, Hashemi F, Shamsaei Z, Alavian SM. Immune response to hepatitis B vaccine in health-care workers. Saudi J Kidney Dis Transpl 2011; 22
Zeeshan M, Jabeen K, Ali AN, Ali AW, Farooqui SZ, Mehraj V, Zafar A. Evaluation of immune response to Hepatitis B vaccine in health care workers at a tertiary care hospital in Pakistan: an observational prospective study. BMC Infect Dis 2007; 7
Senden TF. Response to intradermal hepatitis B vaccination: differences between males and females? Vaccine 1990; 8
Ingardia CJ, Kelley L, Steinfeld JD, Wax JR. Hepatitis B vaccination in pregnancy: factors influencing efficacy. Obstet Gynecol 1999; 93
Abdolsamadi HR, Vaziri BP, Abdollahzadeh SH, Kashani KHM, Vahedi M. Immune response to hepatitis B vaccine among dental students. Iranian J Publ Health 2009; 3:113-118.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]