Donald P. Francis

EPIDEMIC HEPATITIS B CAUSED BY COMMERCIAL HUMAN IMMUNOGLOBULIN

An epidemic of acute hepatitis B followed the administration of human immunoglobulin to members of the staff of a mission hospital in India and their families. Jaundice developed in 123 (38%) of 325 persons inoculated. Hepatitis-B surface antigen was detected in three of the batches of immunoglobulin which were available for testing.

Intradermal hepatitis B vaccination in an abbreviated schedule

Two low-dose intradermal regimens for hepatitis B vaccination were compared with the standard 1 ml dose administered intramuscularly to healthy, 22-42 year old individuals. All regimens were administered in an abbreviated time schedule. Nineteen individuals (ID-1 group) received three 0.1 ml (2 micrograms) doses intradermally at times 0, 1 month and 4 months. Twenty-four individuals (ID-2 group) received two injections of 0.2 ml (4 micrograms) each intradermally at time 0 and one 0.1 ml (2 micrograms) injection 4 months later. Twenty individuals (IM group) received the recommended three 1.0 ml (20 micrograms) doses intramuscularly at times 0, 1 month, and 4 months. No significant adverse reactions were attributable to the intradermal administration of vaccine although the majority of vaccinees developed small areas of induration and hyperpigmentation at the injection site that persisted for several months. One month following the last injection, all vaccinees had developed anti-HBsAg antibodies. One hundred percent of ID-1 and IM vaccinees and 95% of ID-2 vaccinees had protective levels of antibody (greater than or equal to 10 mIU ml-1). The geometric mean titre (GMT) for the IM group (2692 mIU ml-1) was somewhat higher than for the ID-1 (1230 mIU ml-1) and the ID-2 (851 mlU ml-1) groups, but the differences were not statistically significant. Since anti-HBs antibodies are thought to confer protection against hepatitis B, these results suggest that a shortened regimen of intradermal vaccine may be effective in healthy adults. However, no efficacy study has yet been done with intradermal hepatitis B vaccine.

Prospects for the future.

The worldwide impact of the AIDS epidemic will be considerable as millions of deaths occur. We can assume that for the next 5 years there will be no cure to treat infections and no vaccine to prevent them. There will be, however, palliative treatments that will prolong life to some extent. These, however, most likely will be quite expensive and carry considerable side effects. As for vaccines, there most likely will be prototypes under study, but no generally available product. In the United States and western Europe, most of the cases will continue to occur in the first wave groups, but over decades increased blurring of epidemiologic boundaries will occur as sexual partners of infected people develop the disease. Ultimately, if nothing is done to stop transmission, the epidemiology in these areas will parallel that of hepatitis B virus. But something will be done. Programs will be designed and carried out to care for patients and prevent further transmission. In the United States, the National Academy of Sciences (1) and the surgeon general (2) have outlined approaches to take. In places where well-planned programs have been implemented, improved health care and decreased transmission of the virus have resulted. Areas of the world and individuals in those areas which put forth effective treatment and prevention programs will no doubt fare better than those that do not.

Human Retrovirus in Acquired Immunodeficiency Syndrome (AIDS)

In terms of suffering, acquired immunodeficiency syndrome (AIDS) ranks high among diseases which have spread misery around the world. With its slow but inexorable progression towards death, AIDS recruits various opportunistic organisms to produce some remarkably uncomfortable disease states. Whether from the air hunger of pneumocystis carinii or cytomegalovirus pneumonia, or from the cutaneous or oral discomfort of herpesvirus or candida albicans infection, or from the local or the generalized discomfort of cryptococcal meningitis or toxoplasma gondii meningoencephalitis, or from the lassitude resulting from the wasting and emaciation, patients with AIDS suffer. Unfortunately, the numbers of cases of AIDS continues to rise. Although, recently many have tried to find optimism in the “plateauing” of the AIDS epidemic, the reality is that, although the rate of increase is slightly less, the slope of the epidemic curve is still upward (Figure 1). Over 5000 cases of AIDS have been reported as of July 1, 1984 — unfortunately, half of these have been reported in the last 6 months.

Priorities for the Use of Hepatitis B Vaccine

General recommendations for the use of hepatitis B virus (HBV) vaccine in the United States have been formulated by the Public Health Service’s Immunization Practices Advisory Committee (the ACIP) (1). The recommendations are based on information about the safety and efficacy of the vaccine and on epidemiologic data. The purpose of our presentation is to review the epidemiologic background of hepatitis, describe the existing ACIP recommendations and the issues they have raised, and assess the likely impact of the current approach in achieving control of HBV-related disease.