Background Rheumatoid arthritis (RA) as well as anti-rheumatic treatment can cause immune suppression (1). Presumably that is why RA patients have an increased risk for morbidity and mortality by infections (2). Several serious infections can be effectively prevented by vaccinations (3). The efficacy and safety of some vaccinations, as with influenza vaccination, have been investigated in RA patients, but knowledge about hepatitis B vaccination is limited to its safety. Although the risk to be infected with hepatitis B in Western Europe is small, worldwide it is a problem, especially in the pacific region and central and south-east Asia (4). Because of the immune suppression in RA patients, they might not respond well to hepatitis B vaccinations, especially when using biological response modifiers.

Objectives To evaluate whether there is a difference between RA patients and the general population, in protection by hepatitis B vaccination (anti-HBsAg titre >10 IU/L) after 28 weeks.

Methods RA patients (n=47) were compared to healthcare workers (n=156). In both groups the vaccination was performed according to the standard regimen (0, 1, and 6 months) with HBVAXPRO-10 (10 microgram/litre), anti-HBsAg was determined after 28 weeks. Patients with a titre >10 IU/L were regarded as responders and accordingly as being protected against hepatitis B infections. The proportions of responders in the patient group and the control group were compared. In the patient group, it was analysed whether there was a difference in response between user of anti-TNF or DMARDs, and anti TNF or rituximab.

Results The proportion of females was similar (62%) in patients and controls, while patients were older on average (59 years for patients and 51 years for controls). There was a large difference between RA patients and controls in response to hepatitis B vaccination: in the patient group there were 11% (5/47) responders, while there were 83% (129/156) responders in the control group (p<0.001). Accordingly, RA patients had a higher risk for non response than controls, with an OR (95% CI) of 44 (14-148) corrected for age and gender. There was no difference in response between patients using anti-TNF (n=26) or DMARDs (n=8), and anti-TNF or rituximab (n=9), with or without being on DMARD combination therapy.

Conclusions The majority of RA patients were not protected by a hepatitis B vaccination in contrast to the general population; within RA patients there was no difference between users of anti-TNF and DMARDs or rituximab.

References

1. Singh JA, Christensen R, Wells GA, et al. Biologics for rheumatoid arthritis: an overview of Cochrane reviews. The Cochrane database of systematic reviews. 2009(4):CD007848. Epub 2009/10/13.

2. Doran MF, Crowson CS, Pond GR, O'Fallon WM, Gabriel SE. Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis and rheumatism. 2002;46(9):2287-93. Epub 2002/10/02.

3. van Assen S, Agmon-Levin N, Elkayam O, et al. EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Annals of the rheumatic diseases. 2011;70(3):414-22. Epub 2010/12/07.

4. Zanetti AR, Van Damme P, Shouval D. The global impact of vaccination against hepatitis B: a historical overview. Vaccine. 2008;26(49):6266-73. Epub 2008/10/14.

Disclosure of Interest None declared