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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e31827af217
Invited Commentaries

Vaccinations in Celiac Disease

Rostami, Kamran*; Nejad, Mohammad Rostami

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*Department of Gastroenterology, Mid Staffordshire NHS Foundation Trust, Stafford, UK

Department of Gastroenterology, VU University Medical Centre, Amsterdam, The Netherlands.

Address correspondence and reprint requests to Kamran Rostami, MD, PhD, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK (e-mail: kamran.rostami@nhs.net).

Received 14 October, 2012

Accepted 16 October, 2012

The authors report no conflicts of interest.

See “Response to Hepatitis A and B Vaccination in Pediatric Patients With Celiac Disease” by Urganci and Kalyoncu on page 408.

Chronic illnesses, in particular autoimmune conditions, are a major risk factor for reliable vaccination. Some studies suggest that patients with celiac disease (CD) may have low rates of protective antibodies after some vaccinations such as hepatitis B. The level of antibodies to hepatitis B surface antigen postvaccination is reported to be lower in patients with CD compared with healthy controls (1,2) (Table 1). The failure of subjects with CD to respond to hepatitis B virus (HBV) vaccination has relevance for public health policies, and the question is whether this failure to respond is related to specific human leukocyte antigen (HLA) association, activity of disease, or exposure to gluten. Associations between HLA antigens and immunoresponse to viral or bacterial antigens have been studied with controversial results (3). There is no doubt that the intensity of antibody response is markedly influenced by immunogenetic factors; however, the intervention of environmental factors such as strict gluten-free diet (GFD) in otherwise healthy patients with CD seem to override the depressed immune response encoded by these haplotypes (4).

Table 1
Table 1
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In this issue of the Journal of Pediatric Gastroenterology and Nutrition, Urganci and Kalyoncu (5) evaluate the response to hepatitis A (HAV) and HBV vaccinations in 30 pediatric Turkish patients with CD ages 1 to 15 years compared with that of 50 healthy subjects in a 7-year follow-up. Twelve patients and 35 controls received HAV vaccine and were protected against anti-HAV antibodies, and, overall, 80% of the patients and 96% of the controls achieved seroprotection after the whole HBV vaccination series. There was a clear difference, although nonsignificant, between responders compliant with a strict GFD and noncompliant nonresponders to vaccinations. The strength of the present study was the long follow-up of 7 years, and the limitation was the lack of a validated questionnaire to measure the accuracy of GFD in all patients with CD.

It is obvious that untreated patients with celiac disease, like other patients with inadequately treated chronic conditions, have an impaired humoral immune response to recombinant HBV vaccine. This group of patients with associated HLA alleles usually presents with lower antibody titers when they are compromised by active disease. In contrast to those studies in which HLA alleles are incriminated as the reason for lack of response, several studies do not show a clear relation between HLA type and HBV vaccine nonresponsiveness (6–8) (Table 1). Most of the studies suggest that immunized patients with CD on a strict GFD usually develop protective immunity with success rates similar to healthy people. Nonresponsiveness to vaccination could be added to the high-risk list for untreated CD, and screening for CD in these cases is recommended. It is generally believed that response to HBV vaccine in patients with CD who are compliant with GFD should not be different from that in a healthy population; however, the accuracy of a GFD should be based on objective measure. The higher rate of lack of or reduced response to vaccination is unlikely to be related to the associated HLA-DQ2/8. Therefore, in most of the cases, reduced seroprotection may not be permanent, and compliance with a strict GFD usually boosts and optimizes the immune response to HBV vaccine in these patients. In light of the above evidence, response to HBV vaccination in patients with CD may be used as a marker of good or poor compliance with GFD.

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REFERENCES

1. Park SD, Markowitz J, Pettei M, et al. Failure to respond to hepatitis B vaccine in children with celiac disease. J Pediatr Gastroenterol Nutr 2007; 44:431–435.

2. Rostami Nejad M, Rostami K, Zali MR. Hepatitis B vaccination reliability in celiac disease. Hepat Mon 2011; 11:597–598.

3. Zingone F, Morisco F, Zanetti A, et al. Long-term antibody persistence and immune memory to hepatitis B virus in adult celiac patients vaccinated as adolescents. Vaccine 2011; 29:1005–1008.

4. Nemes E, Lefler E, Szegedi L, et al. Gluten intake interferes with the humoral immune response to recombinant hepatitis B vaccine in patients with celiac disease. Pediatrics 2008; 121:1570–1576.

5. Urganci N, Kalyoncu D. Response to hepatitis A and B vaccination in pediatric patients with celiac disease. J Pediatr Gastroenterol Nutr 2013; 56:408–411.

6. Ertekin V, Tosun MS, Selimoglu MA. Is there need for a new hepatitıs B vaccine schedule for children with celiac disease? Hepat Mon 2011; 11:634–637.

7. Sari S, Dalgic B, Basturk B, et al. Immunogenicity of hepatitis A vaccine in children with celiac disease. J Pediatr Gastroenterol Nutr 2011; 53:532–535.

8. Schäppi MG, Meier S, Bel M, et al. Protective antibody responses to influenza A/H1N1/09 vaccination in children with celiac disease. J Pediatr Gastroenterol Nutr 2012; 54:817–819.

Copyright 2013 by ESPGHAN and NASPGHAN

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