Elsevier

The Lancet

Volume 355, Issue 9203, 12 February 2000, Pages 561-565
The Lancet

Consensus Statement
Are booster immunisations needed for lifelong hepatitis B immunity?

https://doi.org/10.1016/S0140-6736(99)07239-6Get rights and content

Summary

Long-term protection against clinically significant breakthrough hepatitis B (HB) virus infection and chronic carriage depends on immunological memory, which allows a protective anamnestic antibody response to antigen challenge. Memory seems to last for at least 15 years in immunocompetent individuals. To date there are no data to support the need for booster doses of HB vaccine in immunocompetent individuals who have responded to a primary course. All adequately vaccinated individuals have shown evidence of immunity in the form of persisting anti-HBs and/or in vitro B-cell stimulation or an anamnestic response to a vaccine challenge. Nonetheless several countries and individuals currently have a policy of administering booster doses to certain risk groups. Boosters may be used to provide reassurance of protective immunity against benign breakthrough infection. For immunocompromised patients, regular testing for anti-HBs, and a booster injection when the titre falls below 10 mIU/mL, is advised. Long-term monitoring should continue, to confirm the absence of clinically significant breakthrough episodes of hepatitis B and to find out if a carrier state develops after 15 years. Also, non-responders to a primary course should continue to be studied.

Section snippets

HB-vaccine-induced antibodies

The strength of the immune response after administration of hepatitis B surface antigen (HBsAg)–which is the basis of immunisation against hepatitis B–has historically been assessed by measuring antibody to HBs with commercial kits. Although a level above 10 mIU/mL is generally taken to be protective,3, 4, 5 the potential for low anti-HBs levels to mask significant infection (indicated by HBsAg) has led some countries to adopt a higher reference level (eg, 100 mIU/mL in the UK).6 The

Anamnestic antibody response

In the primary, three-dose course of immunisation (0, 1, 6 month schedule), the first two doses usually suffice to initiate anti-HBs production and to prime the immune system for a secondary response to antigen. The third dose stimulates this secondary response; anti-HBs titres are higher than those achieved after the first two doses, and antibody appears in the blood more rapidly. While this third dose is biologically acting as a booster, it should not be confused with the earlier definition.

Persistent immunity with waning antibody

Studies of vaccinated populations at high risk of exposure to HBV support the hypothesis that immunological memory confers long-lived protection against clinically significant breakthrough infections. For example, of 74 Chinese children vaccinated at birth because of the HBsAg positivity of their mothers (perinatal transmission rates of 70–90% have been reported16), only 38 (51%) still had an anti-HBs titre above 10 mIU/mL 9 years later. The high risk of transmission to children of

Non-responders

The administration of an additional dose of vaccine to low responders or non-responders can, in some cases, effect an antibody response and immunological priming.27 Indeed, it is likely that some apparent non-responders are in fact primed after a course of vaccination even in the absence of detectable antibody, since some can mount an anti-HBs response when given a dose of vaccine years later. Chiaramonte et al speculate that these apparent non-responders may have developed cell-mediated

Booster recommendations

The three options for ensuring protection against HBV infection and/or disease are.30

  • Reliance on immunological memory rather than booster doses to protect against clinically significant breakthrough infections

  • Provision of regular booster vaccinations to all vaccinated people without assessing anti-HBs status

  • Testing anti-HBs 1 month after the primary vaccination or booster has been administered, and administering a booster or the next booster before the minimum protective anti-HBs level is

References (38)

  • Centers for Disease Control

    Recommendations of the Immunisation Practices Advisory Committee. Recommendations for protection against viral hepatitis

    MMWR

    (1985)
  • International Group

    Immunisation against hepatitis B

    Lancet

    (1988)
  • World Health Organization

    Informal consultation on quadrivalent diphtheria-tetanus-pertussis-hepatitis B vaccine: final report

    (1992)
  • W Jilg et al.

    Hepatitis B vaccination: how long does protection last?

    Lancet

    (1994)
  • SC Hadler et al.

    Long-term immunogenicity and efficacy of hepatitis B vaccine in homosexual men

    N Engl J Med

    (1986)
  • W Jilg et al.

    Four-year experience with a recombinant hepatitis B vaccine

    Infection

    (1989)
  • W Jilg et al.

    Immune response to hepatitis B revaccination

    J Med Virol

    (1988)
  • RP Beasley

    Hepatitis B virus: the major etiology of hepatocellular carcinoma

    Cancer

    (1988)
  • Cited by (446)

    View all citing articles on Scopus

    Consensus committee members listed at end of article, with affiliations in panel 2

    View full text