What Is Hepatitis B?
Hepatitis B virus (HBV) is a viral infection that causes hepatitis (liver inflammation) which can be acute or cause a chronic infection. Chronic HBV can cause cirrhosis, liver failure, and hepatocellular carcinoma. The virus is transmitted through blood and body fluids (e.g., sexual contact, sharing needles, perinatal transmission).
Why Is It Important in Lupus?
People with SLE have a higher risk of infections due to their disease and/or from immunosuppressive therapy.
If they contact HBV, the disease can be more severe, and reactivation can occur when taking medications such as rituximab, cyclophosphamide, mycophenolate, or high-dose corticosteroids (prednisone). Preventing HBV through vaccination is safer than managing reactivation or chronic infection. Some SLE patients may require blood products, dialysis, or have other healthcare exposures that increase HBV risk. Our blood supply in Canada is screened for Hepatitis viruses and other viruses such as HIV.
Which Vaccines Are Used?
In Canada recombinant HepB vaccines are used (e.g., Engerix-B, Recombivax HB, Heplisav-B). The standard schedule is 2 or 3 doses depending on the product. Hepatitis B is routinely given to infants or adolescents. It can be given at any age.
A combined Hepatitis A & B vaccine (Twinrix) is also available for those at risk of both infections such as travelling to areas where either Hepatitis A or B is more prevalent.
Should Adults With SLE Receive HepB?
Yes — if not already immune.
HepB vaccination is inactivated (not live) and safe for immunosuppressed patients. It is recommended for:
-
All adults who have not previously completed the 2 or 3 HepB vaccination series.
-
Those at increased risk (healthcare workers, people with diabetes, dialysis patients, those with multiple sexual partners, injection drug users, or travelers to endemic areas).
-
Patients scheduled to receive strong immunosuppressive therapy who do not have protective antibodies.
Special Considerations in SLE
Response rates to HepB vaccine may be lower in immunosuppressed patients. Checking anti-HBs antibody titres 1–2 months after the series may be considered in high-risk SLE patients to confirm protection. However, this is not routinely done as not all people will make detectable antibodies.
If antibodies are not detected then another series can be given and considering a different vaccine product may be attempted. Antibodies can wane over time but the vaccine should still be protective as if infected with HepB, memory cells should enable an immune response to occur.
If antibody levels are <10 mIU/mL, a repeat series or double-dose vaccination may be considered.
If not previously vaccinated, consider vaccination before starting rituximab or other B-cell–depleting therapy whenever possible.
When Should I Get It?
If you were vaccinated as an infant or child you may have life-long immunity. If not vaccinated or if not immune (no detectable HepB antibodies), HepB vaccination should be given when lupus is stable and before initiation of immunosuppressive treatment. Catch-up vaccination can still be done if missed.
Side Effects and Lupus Flares
The vaccine is safe and well tolerated. Side effects are usually mild (arm soreness, low-grade fever). HepB vaccination is not associated with lupus flares.
What About Other Hepatitis Viruses?
Hepatitis A vaccination can be given with HepB vaccination.
There is no vaccination for Hepatitis C but there is now an ability to be cured with antiviral therapy. Hep C infection can occur due to sharing needles, lack of sterile equipment (medical, dental, tattoos), sexually transmitted and from mother to baby in utero.
Hepatitis B and C are routinely tested before starting some immune suppressive drugs and can be treated and usually cured with antiviral treatment (direct acting antiviral medications for 8 to 12 weeks with a cure rate of >95%).
What If I Have Hepatitis B Infection?
Chronic antiviral therapy is given for those with chronic Hepatitis B infection if they are receiving immune suppressive medications. Screening is done for detecting liver cancer and liver cirrhosis.
Authors: Daniel Tingey and Doctor Janet Pope
Note: Please consult your healthcare provider or local health authorities for up-to-date vaccine recommendations.