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 Table of Contents  
ORIGINAL ARTICLE
Year : 2023  |  Volume : 3  |  Issue : 1  |  Page : 21-23

Hepatitis B, Hepatitis A, and Pneumococcal Immunization Status in Patients with Cirrhosis of the Liver: A Questionnaire Survey


1 Arihant Hospital and Research Centre, Indore, Madhya Pradesh, India
2 Department of Hepatology, Global Hospital, Mumbai, Maharashtra, India
3 Department of Hepatology, Sri Ramachandra Medical College, Chennai, Tamil Nadu, India

Date of Submission19-Oct-2022
Date of Decision25-Nov-2022
Date of Acceptance27-Nov-2022
Date of Web Publication28-Dec-2022

Correspondence Address:
Mayank Jain
Department of Gastroenterology, Arihant Hospital and Research Centre, 283-a Gumasta Nagar, Indore - 452 009, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_29_22

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  Abstract 


Background and Aims: Immunization against hepatitis A, hepatitis B, and pneumococcus has been recommended in patients with cirrhosis of the liver. This questionnaire survey was undertaken to determine the rates of vaccination against these organisms in a cohort of patients with liver disease in India. Methods: We included all patients who were willing for the study and had been seen by a gastroenterologist/hepatologist at least once. Patients offering incomplete information were excluded from the study. Serological tests for confirmation of immunological response were not done. Details of counseling and vaccination status for hepatitis B, hepatitis A, and pneumococcal infection were noted. Results: A total of 305 patients (272 males, 89%) formed the study cohort. The median age was 60 years (range 27–76 years) and the median duration of liver disease was 12 months (1–120 months). The median model of end stage liver disease (MELD) was 14 (range 7–35). Only 37 (12.1%) patients reported that they had been counseled for vaccination against these infections. The rates of vaccination were very low (<10%). Conclusion: Very dismal vaccination rates were noted in Indian patients with liver cirrhosis.

Keywords: Cirrhosis, hepatitis, vaccination


How to cite this article:
Jain M, Sanglodkar U, Venkataraman J. Hepatitis B, Hepatitis A, and Pneumococcal Immunization Status in Patients with Cirrhosis of the Liver: A Questionnaire Survey. Gastroenterol Hepatol Endosc Pract 2023;3:21-3

How to cite this URL:
Jain M, Sanglodkar U, Venkataraman J. Hepatitis B, Hepatitis A, and Pneumococcal Immunization Status in Patients with Cirrhosis of the Liver: A Questionnaire Survey. Gastroenterol Hepatol Endosc Pract [serial online] 2023 [cited 2023 Jan 27];3:21-3. Available from: http://www.ghepjournal.com/text.asp?2023/3/1/21/365723




  Introduction Top


Patients with cirrhosis of the liver have significant dysfunction in both innate and adaptive immune systems which is recognized as cirrhosis-associated immune dysfunction.[1] It is characterized by reduced opsonic and reticuloendothelial cellular activity, complement levels, poor neutrophil mobilization, and enhanced bacterial translocation.[2] Moreover, portosystemic shunting diminishes hepatic clearance of bacteria and endotoxins and thereby places these patients to a much higher risk for sepsis, multiorgan failure, and death.[3],[4] Bacterial infections occur in one-third of cirrhotic patients.[5],[6] In addition, superinfection with hepatotropic viruses such as hepatitis A (HAV) or B (HBV) in the setting of chronic liver disease significantly increases morbidity and mortality.[7],[8],[9] Patients with associated comorbid conditions like diabetes are at further risk due to reduced chemotaxis and neutrophil/macrophage phagocytic function.[10],[11]

The American Association for the Study of Liver Diseases and Center for Disease Control endorse vaccination to all susceptible chronic liver disease patients and includes vaccination against influenza, hepatitis A and B, and pneumococcal infection.[12],[13] The Government of India in its gazette notification dated July 28, 2018, has notified the measures for the elimination of viral hepatitis by 2030 and it makes a strong call for vaccination.

However, not much is known regarding vaccination practices in Indian patients with chronic liver disease. Thus, the present study was undertaken to study the vaccination practices in patients suffering from cirrhosis of the liver using a questionnaire survey.


  Methods Top


The present questionnaire survey was done at two centers located in Indore and Chennai. The questionnaire [Table 1] included details of demography, etiology, and duration of liver cirrhosis. Further particulars regarding counseling for vaccination and details of vaccination were recorded. Serological tests for confirmation of immunological response were not done as this was not the aim of the study. The questionnaire was validated initially in 10 patients.
Table 1: Questionnaire used in the study

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We included all patients who were willing for the study and had been seen by a gastroenterologist/hepatologist at least once. We excluded patients who were already under regular follow-up at our centers as most of them were duly counseled and vaccinated. Patients offering incomplete information were also excluded from the study. The study was approved by the institutional ethics committees of the respective centers.

The sample size was 278, based on the calculation that at least 1000 new cases would be seen over 2 years based on prior records, 95% confidence interval with a 5% margin of error. The data were expressed as median, range, and percentages. A P < 0.05 was considered statistically significant.


  Results Top


A total of 328 patients were interviewed. Of these, 23 did not provide complete information and so were excluded from the analysis. Thus, a total of 305 patients (272 males, 89%) formed the study cohort. The median age was 60 years (range 27–76 years) and the median duration of liver disease was 12 months (1–120 months). The median MELD was 14 (range 7–35). The etiology for liver cirrhosis was nonalcoholic steatohepatitis (107, 35%), alcohol (70, 23%), hepatitis B (53, 17.2%), hepatitis C (20, 6.6%), cryptogenic cirrhosis (45, 14.8%), and autoimmune hepatitis (15, 4.9%). One hundred and forty-five patients (47.5%) had diabetes mellitus. 85% of the respondents were literate. As per the modified Kuppuswamy classification,[14] 17 (5.6%) belonged to socioeconomic class I, 65 (21.3%) to class II, 108 (35.4%) to class III, 80 to class IV (26.2%), and 35 (11.4%) to class V.

Only 37 (12.1%) patients reported that they had been counseled for vaccination against these infections. The rates of vaccination are shown in [Table 2]. These were very low for all three vaccines. Out of 24 patients who were vaccinated for HBV, 23 had taken all three recommended doses and one patient had taken two doses.
Table 2: Vaccination rates for hepatitis A and B and pneumococcal infection

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  Discussion Top


The present study highlights very dismal vaccination rates in Indian patients with liver cirrhosis. Younossi and Stepanova assessed vaccination rates from 1999 to 2008 in chronic liver disease patients in the United States and noted that overall vaccination rates remained low at 20% for hepatitis A and 32% for hepatitis B.[15]

Although the safety and tolerability of vaccinations in chronic liver disease are well documented, immunogenicity of these vaccines in advanced liver disease is questionable.[16],[17],[18],[19],[20] Individuals with more severe liver disease are less likely to seroconvert.[20] Thus, vaccination should be instituted early, preferably at the time of diagnosis of liver disease. Earlier studies from India have questioned the use of hepatitis A vaccine in patients with chronic liver disease as the seroprevalence of the infection is high in the Indian setting.[21],[22]

A multicenter study from India has reported that despite the availability of various guidelines for the management of patients with cirrhosis, the real-life practice experience is different and these guidelines are not followed adequately even at tertiary care centers.[23] The same holds true for vaccination practices as well.

It is imperative for gastroenterologists and hepatologists to hold discussions regarding the safety and importance of vaccinations in chronic liver disease with patients and fellow doctors to promote awareness and implementation of successful vaccination programs.

Limitations

Serological status was not checked and this is a questionnaire-based study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bonnel AR, Bunchorntavakul C, Reddy KR. Immune dysfunction and infections in patients with cirrhosis. Clin Gastroenterol Hepatol 2011;9:727-38.  Back to cited text no. 1
    
2.
Wiest R, Lawson M, Geuking M. Pathological bacterial translocation in liver cirrhosis. J Hepatol 2014;60:197-209.  Back to cited text no. 2
    
3.
Ghassemi S, Garcia-Tsao G. Prevention and treatment of infections in patients with cirrhosis. Best Pract Res Clin Gastroenterol 2007;21:77-93.  Back to cited text no. 3
    
4.
Tandon P, Garcia-Tsao G. Bacterial infections, sepsis, and multiorgan failure in cirrhosis. Semin Liver Dis 2008;28:26-42.  Back to cited text no. 4
    
5.
Jain M, Varghese J, Michael T, Kedarishetty CK, Balajee G, Swaminathan S, et al. An insight into antibiotic resistance to bacterial infection in chronic liver disease. J Clin Exp Hepatol 2017;7:305-9.  Back to cited text no. 5
    
6.
Almasio PL, Amoroso P. HAV infection in chronic liver disease: A rationale for vaccination. Vaccine 2003;21:2238-41.  Back to cited text no. 6
    
7.
Keeffe EB. Acute hepatitis A and B in patients with chronic liver disease: Prevention through vaccination. Am J Med 2005;118 Suppl 10A: 21S-27S.  Back to cited text no. 7
    
8.
Koff RS. Risks associated with hepatitis A and hepatitis B in patients with hepatitis C. J Clin Gastroenterol 2001;33:20-6.  Back to cited text no. 8
    
9.
Reiss G, Keeffe EB. Review article: Hepatitis vaccination in patients with chronic liver disease. Aliment Pharmacol Ther 2004;19:715-27.  Back to cited text no. 9
    
10.
Geerlings SE, Hoepelman AI. Immune dysfunction in patients with diabetes mellitus (DM). FEMS Immunol Med Microbiol 1999;26:259-65.  Back to cited text no. 10
    
11.
Peleg AY, Weerarathna T, McCarthy JS, Davis TM. Common infections in diabetes: Pathogenesis, management and relationship to glycaemic control. Diabetes Metab Res Rev 2007;23:3-13.  Back to cited text no. 11
    
12.
Ghany MG, Strader DB, Thomas DL, Seeff LB, American Association for the Study of Liver Diseases. Diagnosis, management, and treatment of hepatitis C: An update. Hepatology 2009;49:1335-74.  Back to cited text no. 12
    
13.
Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2013*. Ann Intern Med 2013;158:191-9.  Back to cited text no. 13
    
14.
Sharma R. Revised Kuppuswamy's socioeconomic status scale: Explained and updated. Indian Pediatr 2017;54:867-70.  Back to cited text no. 14
    
15.
Younossi ZM, Stepanova M. Changes in hepatitis A and B vaccination rates in adult patients with chronic liver diseases and diabetes in the U.S. population. Hepatology 2011;54:1167-78.  Back to cited text no. 15
    
16.
Arguedas MR, Johnson A, Eloubeidi MA, Fallon MB. Immunogenicity of hepatitis A vaccination in decompensated cirrhotic patients. Hepatology 2001;34:28-31.  Back to cited text no. 16
    
17.
Chalasani N, Smallwood G, Halcomb J, Fried MW, Boyer TD. Is vaccination against hepatitis B infection indicated in patients waiting for or after orthotopic liver transplantation? Liver Transpl Surg 1998;4:128-32.  Back to cited text no. 17
    
18.
Dumot JA, Barnes DS, Younossi Z, Gordon SM, Avery RK, Domen RE, et al. Immunogenicity of hepatitis A vaccine in decompensated liver disease. Am J Gastroenterol 1999;94:1601-4.  Back to cited text no. 18
    
19.
McCashland TM, Preheim LC, Gentry MJ. Pneumococcal vaccine response in cirrhosis and liver transplantation. J Infect Dis 2000;181:757-60.  Back to cited text no. 19
    
20.
Smallwood GA, Coloura CT, Martinez E, Stieber AC, Heffron TG. Can patients awaiting liver transplantation elicit an immune response to the hepatitis A vaccine? Transplant Proc 2002;34:3289-90.  Back to cited text no. 20
    
21.
Roni DA, Pathapati RM, Kumar AS, Nihal L, Sridhar K, Tumkur Rajashekar S. Safety and efficacy of hepatitis B vaccination in cirrhosis of liver. Adv Virol 2013;2013:196704.  Back to cited text no. 21
    
22.
Joshi N, Rao S, Kumar A, Patil S, Rani S. Hepatitis A vaccination in chronic liver disease: Is it really required in a tropical country like India? Indian J Med Microbiol 2007;25:137-9.  Back to cited text no. 22
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23.
Amarapurkar D, Dharod MV, Chandnani M, Baijal R, Kumar P, Jain M, et al. Care of patients with liver cirrhosis: How are we doing? J Public Health Epidemiol 2015;7:51-8.  Back to cited text no. 23
    



 
 
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