Intradermal Versus Intramuscular Hepatitis B Vaccination in Hemodialysis Patients: A Prospective Open-Label Randomized Controlled Trial in Nonresponders to Primary Vaccination

Barraclough, Katherine A.; Wiggins, Kathryn J.; Hawley, Carmel M.; van Eps, Carolyn L.; Mudge, David W.; Johnson, David W.; Whitby, Michael; Carpenter, Sally; Playford, E. Geoffrey

doi:10.1053/j.ajkd.2009.03.010

« Previous Next »American Journal of Kidney Diseases
Volume 54, Issue 1 , Pages 95-103, July 2009

Intradermal Versus Intramuscular Hepatitis B Vaccination in Hemodialysis Patients: A Prospective Open-Label Randomized Controlled Trial in Nonresponders to Primary Vaccination

Katherine A. Barraclough, FRACP
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
- Address correspondence to Katherine A. Barraclough, FRACP, Department of Nephrology, Princess Alexandra Hospital, Ipswich Rd, Woolloongabba 4102, Queensland, Australia
Kathryn J. Wiggins, FRACP
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
Carmel M. Hawley, FRACP
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
Carolyn L. van Eps, FRACP
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
David W. Mudge, FRACP
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
David W. Johnson, PhD
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
Michael Whitby, FRACP
- Infection Management Services, Princess Alexandra Hospital, Brisbane, Australia
Sally Carpenter, BN
- Department of Nephrology, University of Queensland at Princess Alexandra Hospital, Brisbane, Australia
E. Geoffrey Playford, FRACP
- Infection Management Services, Princess Alexandra Hospital, Brisbane, Australia

Received 21 November 2008; accepted 20 March 2009. published online 01 June 2009.

Background

Primary hepatitis B virus (HBV) vaccination through the intramuscular (IM) route is less efficacious in dialysis patients than in the general population. Previous studies suggest improved seroconversion with intradermal (ID) vaccination.

Study Design

Prospective open-label randomized controlled trial.

Setting & Participants

Hemodialysis patients nonresponsive to primary HBV vaccination.

Intervention

Revaccination with either ID (5 μg of vaccine every week for 8 weeks) or IM (40 μg of vaccine at weeks 1 and 8) HBV vaccine.

Outcomes

Primary outcome: proportion of patients achieving HBV surface antibody (anti-HBs) titer of 10 IU/L or greater within 2 months of vaccination course. Secondary outcomes: time to seroconversion, predictors of seroconversion, peak antibody titer, duration of seroprotection, and safety and tolerability of vaccine.

Measurements

Anti-HBs titer to 24 months.

Results

59 patients were analyzed. Seroconversion rates were 79% ID versus 40% IM (P = 0.002). The unadjusted odds ratio for seroconversion for ID versus IM was 5.5 (95% confidence interval [CI], 1.6 to 18.4) and increased with adjustment for baseline differences. The only factor predictive of seroconversion was the ID vaccination route. The geometric mean peak antibody titer was significantly greater in the ID versus IM group: 239 IU/L (95% CI, 131 to 434) versus 78 IU/L (95% CI, 36 to 168; P < 0.001). There was a trend toward longer duration of seroprotection with ID vaccination. ID vaccine was safe and well tolerated.

Limitations

Inability to distinguish whether the mechanism of the greater efficacy of ID vaccination was the cumulative effect of multiple injections or route of administration; use of anti-HBs as a surrogate marker of protection; lack of evidence of long-term protection.

Conclusions

Significantly greater seroconversion rates and peak antibody titers can be achieved with ID compared with IM vaccination in hemodialysis patients nonresponsive to primary vaccination. ID vaccination should become the standard of care in this setting.

Index Words: Hepatitis B virus (HBV), hemodialysis, intradermal (ID), vaccination