Published Ahead of Print 27 February 2013.
2013, 20(5):660. DOI:
Clin. Vaccine Immunol.
Caporaso, N. Imperatore, G. De Stefano, P. Iovino and C.
F. Zingone, P. Capone, R. Tortora, A. Rispo, F. Morisco, N.
Immune Response of Celiac Patients
Hepatitis B Virus Vaccination in the
Role of Gluten Intake at the Time of
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Role of Gluten Intake at the Time of Hepatitis B Virus Vaccination in
the Immune Response of Celiac Patients
F. Zingone,aP. Capone,bR. Tortora,bA. Rispo,bF. Morisco,bN. Caporaso,bN. Imperatore,bG. De Stefano,bP. Iovino,aC. Ciaccia
Department of Medicine and Surgery, University of Salerno, Salerno, Italya; Department of Clinical and Experimental Medicine, Unit of Gastroenterology, University of
Naples Federico II, Naples, Italyb
patientsingroupD(groupAversusgroupD, P<0.001;groupBversusgroupD, P?0.002;groupCversusgroupD, P?0.001)
are unknown (1–8).
In the general population, it is recognized that several factors
influence the production of protective levels of antibodies against
clude age, obesity, smoking, drug abuse, alcoholism, infections,
immune suppression, and the route of vaccination (9, 10). Addi-
tionally, hepatitis B vaccine nonresponsiveness, due to the pres-
ence of specific human leukocyte antigen (HLA) genotypes, has
been described (11–13).
and for this reason, a genetic predisposition as a possible cause of a
patients to fail to develop immunity after hepatitis B vaccination
through a Th2 response that is inadequate for B-cell differentiation
have hypothesized gluten intake as a cause of failed immunity at the
titis B surface antigen (HBsAg) protein fragments and gliadin pep-
phocytes. Competition between the proteins may result in defective
The aim of our study was to evaluate the HBV vaccination
response in relation to gluten exposure status in a series of CD
patients and healthy controls.
everal studies have reported an inadequate response to hepa-
titis B virus (HBV) vaccination in patients affected by celiac
MATERIALS AND METHODS
The study population consisted of CD patients born after 1980 and vac-
cinated as infants or as 12-year-old adolescents according to the Italian
vaccination program. Patients were consecutively recruited from the Ce-
liac Disease Centre of the University of Naples Federico II in Italy from
September 2010 to May 2012. In the study population, the recombinant
hepatitis B vaccine (Engerix-B; GlaxoSmithKline, Belgium) was adminis-
given at the ages of 3, 5, and 11 months by intramuscular injection to
infants vaccinated at birth and 3 doses of 20 g each are given at 0, 1, and 6
(GFD) for each CD patient was also confirmed.
In accordance with gluten exposure status at the time of vaccination,
we considered three groups: group A (exposed to gluten,) including pa-
tients vaccinated as 12-year-old adolescents (the CD diagnosis was estab-
lished after vaccination); group B (not exposed to gluten,) including pa-
tients vaccinated as 12-year-old adolescents on a GFD at the time of
taminase IgA antibodies at the time of vaccination); and group C (in-
fants,) including patients vaccinated at birth (all patients were fed an
we considered a control group (group D) composed of healthy subjects
vaccinated as 12-year-olds who were tested and found to be negative for
serum markers of celiac disease.
titers were measured. The cutoff value of the HBsAb titer for defining an
impaired response to vaccination was 10 mIU/ml. All celiac patients and
controls were typed for HLA-DQ2 and HLA-DQ8 alleles.
Statistical analysis. The Kruskal-Wallis test was used for analyses on
continuous nonnormally distributed variables (age at HBsAb testing and
time interval between vaccination and testing). The medians and interquar-
ences in frequencies between the groups were calculated with the ?2test. In
Received 13 December 2012 Returned for modification 30 December 2012
Accepted 19 February 2013
Published ahead of print 27 February 2013
Address correspondence to C. Ciacci, firstname.lastname@example.org.
Copyright © 2013, American Society for Microbiology. All Rights Reserved.
cvi.asm.org Clinical and Vaccine Immunologyp. 660–662May 2013 Volume 20 Number 5
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the case of undetectable HBsAb, an arbitrary value of 0.5 mIU/ml was as-
signed to enable the calculation of antibody geometric mean concentrations
(GMCs). Analysis of variance (ANOVA) was performed with and without
the ANOVA. A P value of ?0.05 was considered significant. On the basis of
previous studies, we estimated that a sample size of 38 subjects per group
would offer 80% power to detect a 30% difference in HBV vaccination out-
comes between the CD group members and the controls (assuming a mini-
This study included 163 CD patients (group A, 57 patients; group
B, 46 patients; and group C, 60 patients) and 48 controls (group
D). All subjects were found to be HBsAg negative; HLA-DQ2 was
present in 92.6% of the CD patients and 25% of the controls.
As shown in Table 1, gender was not significantly different
among groups (P ? 0.97). A significant difference was evident
between age at the time of testing and the interval of time from
patients vaccinated as infants (group C) were younger than other
subjects and showed a longer interval from vaccination to testing.
munization in all celiac patients compared to that in the controls
group D. Geometric mean concentrations (GMCs) of HBsAb were
(group A GMCs versus group D GMCs, 13.45 versus 250.6, P ?
adolescents who were exposed to gluten at the time of vaccination
at the time of vaccination (group B). Instead, there was a significant
difference in the prevalence of HBsAb concentrations of ?10
mIU/ml when group B was compared with the group vaccinated as
Table 4 shows the results of two ANOVA calculations that
were also adjusted for the following covariates: years from vacci-
nation (model a) and the age at HBsAb testing and the age at
vaccination (model b). Both the titers of HBsAb and the preva-
among groups pre- and postadjustment (Table 4). The results
were also statistically significant when the ANOVA models were
reanalyzed after the exclusion of group C (the sole group vacci-
nated at birth) (F ? 8.56, P ? 0.001).
In typical healthy populations, 4 to 10% of vaccine recipients fail
an efficacious response, HBsAb seroprotection persists at least 10
years; thus, a booster dose is not necessary until 10 years after the
primary immunization (14, 15).
Recently, our group reported that 31.4% of CD patients and
8.3% of controls showed HBsAb concentrations of ?10 mIU/ml
approximately 11 years after the primary vaccination. Moreover,
CD patients with HBsAb concentrations of ?10 mIU/ml showed
GMCs lower than those of controls (3).
Ahishali et al. (4) found that 68% of adults with CD were re-
sponsive to HBV vaccination; this percentage was significantly
TABLE 1 Main features of the population under scrutiny
Group A (exposed
to gluten) (n ? 57)
Group B (not exposed
to gluten) (n ? 46)
Group C (infants)
(n ? 60)
Group D (controls)
(n ? 48)P
Age at HBsAb testing (median [IQRa]) (yr)
Time interval between vaccination and
testing (median [IQR]) (yr)
25 (23, 27)
13 (11, 15)
27 (25, 28)
15 (13, 16)
19.5 (18, 20)
19.5 (18, 20)
23 (21, 26.5)
10 (9, 13)
aIQR, interquartile range (25th and 75th percentiles).
TABLE 2 HBsAb concentrations in celiac patients (group A, 57; group
B, 46; group C, 60) and in controls (48) vaccinated against hepatitis B
Group A vs controls
Group B vs controls
Group C vs controls
TABLE 3 HBsAb concentrations in celiac patientsa
No. (%) of patients with an HBsAb concn of:
?10 mIU/ml10–100 mIU/ml
aP ? 0.05 for group A versus group B for HBsAb 10–100 mIU/ml, for group A versus
group B for HBsAb ?100 mIU/ml, and for group B versus group C for HBsAb ?10
Gluten Intake and HBV Vaccination
May 2013 Volume 20 Number 5cvi.asm.org 661
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that 50% of the patients who had an autoimmune disease along Download full-text
with CD were more likely to be unresponsive to the HBV vaccine,
emphasizing the involvement of genetic factors in vaccine failure.
In a separate study, Noh et al. (5) reported that 13 of the 19 adult
patients who were either homozygous or heterozygous for HLA-
DQ2 did not respond to an HBV vaccine. However, several other
authors have shown that HLA-DQ alleles may in fact not play a
primary role in responsiveness to HBV vaccine. Nemes et al. (6)
patients vaccinated after the initiation of dietary treatment was
similar to that in healthy individuals. Furthermore, 36 out of the
37 nonresponders in this study showed seroconversion after the
administration of a booster dose of vaccine. Ertem et al. (7) dem-
onstrated that the response to the HBV vaccine in children with
in the healthy population. In a paper by Ertekin et al. (8), HBsAb
pliant with the GFD than in those who were noncompliant.
patients to HBV immunization, we did not confirm a favorable
role for a GFD in the vaccination response. Our data indicate that
not show a protective titer of HBsAb. Patients in group C (vacci-
nated in infancy) had lower levels of protective HBsAb and a
greater percentage of nonresponders than patients in groups A
and B (vaccinated as adolescents). This observation, however,
could be the result of a longer period of time from vaccination to
measurement of the HBsAb dosage level (16).
genetics, rather than gluten exposure by itself, are involved in the
impaired response to HBV vaccination in CD patients. Hence, CD
the immune response to HBV vaccination. Although evidence that
lower HBsAb titers correspond to a higher risk of HBV infection in
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TABLE 4 HBsAb, ln HBsAb, and prevalence of HBsAb at ?10 mIU/ml with and without adjustment for covariates
Covariates Group AGroup BGroup C Group DFP
HBsAb ? 10 mIU/ml (%) 43.9 34.8 58.38.311.22
HBsAb ? 10 mIU/ml (%)a
HBsAb ? 10 mIU/ml (%)b
aModel a: adjusted for years from vaccination.
bModel b: adjusted for age at HBsAb testing and age at vaccination.
Zingone et al.
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