乙型肝炎疫苗初次免疫成年无应答者再次免疫后24个月免疫持久性观察

Anti-HBs persistence after revaccination with three doses of hepatitis B vaccines among non-responsive adults：24-month of follow-up

目的：评价乙型肝炎疫苗（HepB）初次免疫成年无应答者加强免疫后24个月的免疫持久性效果。方法于2009年9月，以山东省章丘市3个乡镇共79个村为研究现场，选取既往无乙型肝炎病毒（HBV）感染史或HepB免疫史、居住6个月以上、健康状况良好的18~49岁居民，共24237名，采集静脉血3~5 ml，采用ELISA法检测乙型肝炎表面抗原（HBsAg）、乙型肝炎表面抗体（抗-HBs）和乙型肝炎核心抗体（抗-HBc）。经检测，以上3项指标均为阴性者11590名，采用整群随机抽样方法，将其分为4组，按照0-1-6免疫程序分别接种3剂次20μg重组酿酒酵母HepB（HepB-SC）、20μg重组中国仓鼠卵巢细胞（HepB-CHO）、10μg HepB-SC和10μg重组汉逊酵母HepB（HepB-HP）进行初次免疫；并分别按照0-1-6程序，采用以上4种HepB，对其中的初次免疫无应答者进行再次免疫，其所属组别不变，于再次免疫后1个月（T1）、24个月（T24）分别采集静脉血5 ml，采用化学发光微粒子免疫分析法检测抗-HBs、HBsAg和抗-HBc。采用χ2检验分析不同组间年龄、性别、BMI及T1和T24时抗-HBs阳性率差异；采用方差分析比较不同组别调查对象抗体几何平均浓度（GMC）差异；分别采用多因素非条件logistic回归模型和多因素线性回归模型分析抗-HBs阳性和抗体GMC的影响因素。结果11590名调查对象中，无应答者为900名，其中，完成3剂次HepB再次免疫及T1时血标本采集者占71.7%（645/900）。T24时，共随访到再次免疫者467名（72.4%）。再次免疫者抗-HBs阳性率由T1时的85.65%（95%CI：82.14%~88.71%）下降到T24时的60.60%（95%CI：56.01%~65.06%），抗体GMC由T1时的175.62（95%CI：139.03~221.84）mU/ml下降到T24时的21.43（95%CI：17.62~26.06）mU/ml。多因素分析显示，T24时20μg HepB-CHO再次免疫者抗-HBs阳性率高于20μg HepB-SC再次免疫者[OR（95%CI）值为2.16（1.10~4.23）]，女性高于男性[OR（95%CI）值为1.88（1.07~3.31）]，T1时抗体GMC为50~99和≥100 mU/ml者高于T1时抗体GMC〈50 mU/ml者[OR（95%CI）值分别为3.43（1.55~7.60）和21.26（12.12~37.29）]；T24时，T1时抗体GMC为50~99和≥100 mU/ml者的抗体GMC高于T1时抗体GMC〈50 mIU/ml者[β（95%CI）值分别为0.95（0.35~1.54）和2.90（2.54~3.25）]。T24时未发现HBsAg阳转者，抗-HBc阳转率为3.64%（17/467）。结论 HepB成年无应答者3剂次再次免疫24个月后抗-HBs阳性率和抗体GMC下降，但多数人仍维持在保护水平以上；无应答者再次免疫后的抗体持久性主要与疫苗种类、性别和再次免疫1个月时的抗体GMC有关。

Objective To access the antibody persistence 24-month after revaccination with 3-dose of hepatitis B vaccine （HepB） among non-response adults. Methods A total of 24 237 healthy adults who had no histories of hepatitis B infection and hepatitis B vaccination, resided in the local area for more than six months and were aged 18-49 years were selected from 79 villages of Zhangqiu county, Shandong province, China in 2009. Blood samples were obtained and hepatitis B surface antigen （HBsAg）, antibody against hepatitis B surface antigen （anti-HBs） and antibody against hepatitis B core antigen （anti-HBc） were detected using ELISA method. A total of 11 590 persons who were negative for all of these indicators were divided into four groups by cluster sampling methods. Each group was vaccinated with one of the following four types of HepB at 0-, 1-, 6- months schedule： 20 μg HepB derived in Saccharomyces Cerevisiae （HepB-SC）, 20 μg HepB derived in Chinese hamster ovary cell （HepB-CHO）, 10 μg HepB-SC and 10 μg HepB derived in Hansenula Polymorpha （HepB-HP）. Blood samples were collected one month after the third dose of primary immunization and tested for anti-HBs using chemiluminescence microparticle immunoassay （CMIA）. The non-responders were revaccinated with three doses of HepB at 0-, 1-, 6-months schedule and the type of HepB was the same as which was used for primary immunization. Blood samples were collected one month （T1） and two years （T24） after revaccination and anti-HBs, antibody against hepatitis B core antigen （anti-HBc） and hepatitis B surface angtigen （HBsAg） （if anti-HBs〈10 mU/ml） were detected by CMIA.χ2 test was used to compared age, gender and body mass index （BMI） between different groups and the anti-HBs positive rate at T1 and T24; analysis of variance （ANOVA） was used to compare the geometric mean concentration （GMC） of anti-HBs between difference groups. The risk factors associated with positive rate of anti-HBs and GMC of anti-HBs were identified by multiple logistic regression analysis and multifactor linear regression model analysis respectively. Results A total of 900 non-responders were identified and 71.7%（645/900） of them completed three-dose revaccination and blood collection after revaccination. 467 （72.4%） non-responsive adults were followed up at T24. The anti-HBs positive rate decreased from 85.65%（95%CI：82.14%-88.71%） at T1 to 60.60%（95%CI：56.01%-65.06%） at T24 and the corresponding GMC decreased from 175.62 （95%CI： 139.03-221.84）mU/ml to 21.43 （95%CI：17.62-26.06）mU/ml. Multivariate analysis showed that positive rate of anti-HBs at T24 was associated with gender, HepB type for revaccination and anti-HBs level at T1, but only anti-HBs level at T1 was associated with the anti-HBs titer at T24. No subject showed HBsAg seroconversion and anti-HBc conversion rate was 3.64%（17/467） at T24. Conclusion Anti-HBs titer decreases rapidly two years after HepB revaccination among non-responsive adults, but more than half non-responderd still kept anti-HBs above protective level. The immunity durability after revaccination was associated with gender, HepB type for revaccination and anti-HBs titer one month after revaccination.