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รวมพลคนรักวิจัย

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รวมพลคนรักวิจัย. การศึกษาการจำแนกในระดับโมเลกุลของไวรัสตับอักเสบ บี ในทารกที่เป็นพาหะหลังจากได้รับ วัคซีนป้องกันไวรัสตับอักเสบ บี. H. HBV Genotyping. Variation in nucleotide sequence of the genome (>8% divergence between the groups). 8 Genotypes. Geographic Distribution of Genotypes

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  1. รวมพลคนรักวิจัย

  2. การศึกษาการจำแนกในระดับโมเลกุลของไวรัสตับอักเสบ บี ในทารกที่เป็นพาหะหลังจากได้รับวัคซีนป้องกันไวรัสตับอักเสบ บี

  3. H HBV Genotyping Variation in nucleotide sequence of the genome (>8% divergence between the groups) 8 Genotypes

  4. Geographic Distribution of Genotypes Hepatitis B Virus A C B D C A D E F

  5. Without HBIg With HBIg High Protective Efficacy in Neonates with or without HBIg 100 100 97.6 94.8 94.8 80 60 Protective efficacy at 1 year (%) 40 20 0 0, 1, 6 month regimen 0, 1, 2, 12 month regimen Hepatitis B vaccine, 10 mcg/dose Poovorawan, Y et al. Pediatr Infect Dis J. 1992; 11:816-21

  6. Long term follow-up of highrisk neonates vaccinated against hepatitis B vaccine in Thailand20 years follow-up Center of Excellence in Clinical Virology

  7. GMT evolution 0, 1, 2, 12 months 10000 1000 100 10 A B C 1 M1 M7 M13 M19 M25 M31 M37 M43 M49 M55 M61 M67 M73 M79 M85 M91 M97 M103 M109 M115 M121 M127 M133 M139 M145 Time (months A : booster + HBIg B : booster no HBIg C: no booster no HBIg

  8. GMT evolution 0, 1, 6 months schedule 10000 D E F G 1000 100 10 1 M1 M6 M11 M16 M21 M26 M31 M36 M41 M46 M51 M56 M61 M66 M71 M76 M81 M86 M91 M96 M101 M106 Time (Months) D : booster + HBIg E: no booster + HBIg F: booster no HBIg G: no booster no HBIg

  9. Long-term humoral and cellular immune response to hepatitis B vaccine in high risk children 18-20 years after neonatal immunizationTeeraporn Chinchai et al Viral Immunol

  10. Long-term benefit of hepatitis B vaccination in newborns of hepatitis B surface antigen-positive mothers in Thailand Poovorawan Y, et al. J Infec Dis. 2008 (revised)

  11. Twenty-year persistence of immune memory to hepatitis B vaccine in high risk infants born to hepatitis B e antigen positive mothers Yong Poovorawan et al MS in preparation

  12. Hepatitis B immunization programe in Thailand August 1988 : Demonstrate methods of incorporating HB vaccine into EPI program Program sites : 2 provinces - Chiengmai - Chonburi

  13. Impact of universal HB immunization • Reduce acute hepatitis patients • Reduce the carriers • Reduce chronic liver diseases • Cirrhosis • Hepatocellular carcinoma Viral Hepatitis Research Unit

  14. Hepatitis B Vaccine Used in Thailand’s EPI • 1989 Cheil Sugar Vaccine 3 mcg/dose • 1990-1994 Korean Green Cross10 mcg / dose • 1995-present SB. Vaccine (GPO) 10 mcg/dose

  15. Thailand EPI • At birth HB, BCG • 2 months OPV1, DPT1, HB2 • 4 months OPV2, DPT2 • 6 months OPV3, DPT3, HB3 • 9-12 months Measles or MMR • 18 Months OPV4, DPT4, JE1 & 2 ( 2 weeks apart, booster 1 yr after) • 4-6 years OPV5, DPT5, Measles

  16. Hepatitis B Vaccine Used in Thailand’s EPI • 1989 Cheil Sugar Vaccine 3 mcg/dose • 1990-1994 Korean Green Cross 10 mcg / dose • 1995-present rec HB. Vaccine (GPO) 10 mcg/dose Viral Hepatitis Research Unit

  17. Nakornsrithamarat Impact of universal HBV vaccination 2004

  18. 2004 Specimens collection 6237 samples Age: 6 mos– 60 yrs Provinces : Geographical area 1 city 2 districts

  19. 2004 Specimens collection 6000 samples Age: 6 mos – 60 yrs Provinces : Geographical area 1 city 2 districts

  20. Seroprevalence of HBsAg among different age groups in Thailand Udon N = 1725Chiengrai N = 1542 NakornSritamart = 4653 Preliminary data – Poovorawan Y.Viral Hepatitis Research Unit - Chunsuttiwat S.Ministry of Public Health

  21. Seroprevalence of HBsAg among different age groups in Thailand Udon N = 1725Chiengrai N = 1542 NakornSritamart = 4653 Preliminary data – Poovorawan Y.Viral Hepatitis Research Unit - Chunsuttiwat S.Ministry of Public Health

  22. Seroprevalence of antiHBc among different age groups in Thailand Udon N = 1725Chiengrai N = 1542 NakornSritamart = 4653 Preliminary data – Poovorawan Y.Viral Hepatitis Research Unit - Chunsuttiwat S.Ministry of Public Health

  23. Impact of universal HB immunisationas part of Thailand EPI • Reduced number of acute hepatitis patients • Reduced number of carriers: HB carriers in children <10 years – 5–6 % in 1988 – 0.7% in 1999 • Reduced incidence of chronic liver disease in the future: – cirrhosis – HCC Poovorawan Y. Vaccine 2001

  24. Impact of universal Hepatitis B immunization 1999 Taiwan (1984) Age >15-20 Y <15 Carrier rate 7 0.7 (%) Thailand (1989-1992) Age >10-18 Y <10 Y Carrier rate 3.4 0.7 (%) Before universal After universal Ni YH et al. Ann Int Med 2001 Poovorawan et al. Vaccine 2001

  25. Hepatitis B Immunization Challenges • Increase coverage to level of DTP-3 • Use vaccine within EPI • Cost effective delivery • Existing reporting system • Develop reporting system for older age groups

  26. Combined DTPw-HB • Fulfilling WHO recommendations DTP + HB • Component vaccines • proven back records and superiority • Immunogenicity and reactogenicity • no (negative) interference • highly immunogenic for all antigens • improved anti-HBs reponse up to 95% after 2nd dose

  27. Combined DTPw-HB • Public Health benefits • high compliance & coverage • fast implementation • Health Economic benefits • logistical cost-savings • cost-effectiveness of DTPw

  28. Chiang Rai Field Trial (Thailand)Combined DTPw-HB DTPw and HB vaccines injected separately • Project run by Thai CDC (Dr Supamit) • Study site : Chiang Rai province • Population : 1.2m - 10% hill tribes • Study duration : July ‘94 to end Dec ‘97 • Phase I : ~ 4,000 children received DTPw + HB separately • Phase II : ~ 25,000 children received combined DTPw-HB Supamit C. Vaccine 2002

  29. Vaccine coverage rate Chusuttiwat S et al.Vaccine 2002 NS= non-signifincant

  30. Chiang Rai Field Trial (Thailand)study results • Mothers : • 64% preferred vaccine to monovalents • 78% reported less pain • 90% who had heard used 3 doses • MOH : • DTPw-HB cost beneficial vs. DTPw-HB mono

  31. Chiang Rai Field Trial (Thailand)Combined DTPw-HB vs. DTPw and HB vaccines injected separately • No difference in safety and reactogenicity profile • Immunogenicity : SP rate Infection rate* Carrier rate* DTPw + HB 88.4% 6 % 1.15 % (separately) Combined 94.8% 4 % 0.23 % DTPw-HB Chunsuttiwat S, et al. Vaccine 2002 * Chunsuttiwat S; Vaccines Today - Protecting the Future, Kuala Lumpur, March 1998

  32. Benefit of combination vaccine • Adverse reaction, Al+++ • Cost • Number of injections • Intolerable for the patients, parents • Vaccination visit. • Work load of staff • Compliance, coverage • Shipping, handling and storage

  33. Effect of dose number and interval between the first two doses of hepatitis B vaccine on the carrier rate of infants born to hepatitis B surface antigen positive mothers Tharmaphornpilas P , Rasdjarmrearnsook A, Plianpanich S , Sa-nguanmoo P, Chongsrisawat V , Poovorawan Y

  34. A B Tharmaphornpilas P , Rasdjarmrearnsook A, Plianpanich S , Sa-nguanmoo P, Chongsrisawat V , Poovorawan Y (A) Location of Chiangrai, the northern most province of Thailand (B) 11 district hospitals participating in this study The number in B stands for 1 - Khun Tan; 2 – Thoeng; 3 - Wiang Kaen; 4 - Phan; 5 - Chiang Saen; 6 - Wiang Pa Pao; 7 - Phaya Mengrai; 8 - Mae Sai; 9 - Mae Chan; 10 - Mae Fa Luang and 11 - Mueang Chiangrai districts.

  35. Tharmaphornpilas P , Rasdjarmrearnsook A, Plianpanich S , Sa-nguanmoo P, Chongsrisawat V , Poovorawan Y Recommended HB vaccination schedule for newborns of HBsAg positive and negative mothers, Chiangrai, 2004 - 2006

  36. 997 born from HBV carrier mothers (2004 – 2005) 373 children were excluded 624 met inclusion criteria 101 children were excluded 523 mothers’ consented to the study 2 children were excluded (unable to take the blood) Eligible, enrolled population and HBV carriers in the study 521 available for serum collection 4 children were excluded (missed vaccine schedule) Group 1 277 children Group 2 240 children 4 carriers 11carriers

  37. Tharmaphornpilas P , Rasdjarmrearnsook A, Plianpanich S , Sa-nguanmoo P, Chongsrisawat V , Poovorawan Y HBV carrier rate by HB1-2 interval in the study • 4 children, received vaccine of different schedule not belong to group 1 or 2, • were excluded from this table

  38. Demographic data of HBsAg positive children and their mothers + positive, - negative, ND = no data Tharmaphornpilas P , Rasdjarmrearnsook A, Plianpanich S , Sa-nguanmoo P, Chongsrisawat V , Poovorawan Y

  39. Adjusted OR and 95% confidence interval of children becoming HBV carriers by multiple logistic regression Risk factors Adjusted OR 95% Confidence interval HBeAg positive mother 4.19-276.62 34.03 HB1-2 interval of more than 10 weeks 3.74 0.97-14.39 Tharmaphornpilas P , Rasdjarmrearnsook A, Plianpanich S , Sa-nguanmoo P, Chongsrisawat V , Poovorawan Y

  40. GMT of antiHBs in relation to number of doses of HB vaccine received and time elapsed since complete HB vaccination. Tharmaphornpilas P , Rasdjarmrearnsook A, Plianpanich S , Sa-nguanmoo P, Chongsrisawat V , Poovorawan Y

  41. สรุปHB vaccine เมื่อแรกเกิดแล้วตามด้วยDTPw-HB vaccine 2, 4, 6 months ถ้าแม่เป็น carrier ให้ HB vaccine ลูก ที่ 1 เดือนอีก 1 เข็ม

  42. Molecular part

  43. Population Study No. 14 Children 4 Children (0, 1, 2, 4, 6) Children (0, 2, 4, 6) 10* Mother of children 14* Mother HBsAg and HBeAg + 15 15 Mother HBsAg + but HBeAg - 58 Total * One pair of child and mother unable to take the blood

  44. Method Both groups of Children Mother HBsAg and HBeAg + Mother of children Mother HBsAg + but HBeAg - • Serology: Serum • ALT and AST(Hitachi 912, Roche Diagnostics, Mannheim, Germany) • HBV markers:- HBsAg, antiHBs, HBeAg, antiHBc (ELISA kit, Murex, Biotech Limited, Dartford, Kent, England) • Molecular : HBV DNA • PCR amplification :- PreC/C and complete S region • Real time PCR:- quantivative HBV DNA (copies/l) • Data analysis • - Mutation:- Core promoter T1753C, A1762T,G1764A • Pre-C region G1896A, G1899A • Pre-S1, Pre-S2 and S start codon • Deletion, Genotype • “a” determinant region:- escape mutant

  45. Results Serological Data Children Mother of children HBeAg + HBeAg - ALT (U/liter) 57.48  81.81 31.21  15.17 52.01  45.71 21.67  10.77 AST (U/liter) 71.58  101.71 36.74  26.25 46.94  42.24 22.41  6.47 2165.76 1661.80 162.35 163.71 HBsAg conc.(ng/l) * 2035.73 1667.32 2810.02 1832.59 ~2.0 x 107 ~4.0 x 107 ~7.0 x 107 ~1.4 x 103 HBV DNA (copies/l)* * P value <0.05

  46. Results HBsAg HBeAg HBV DNA Mother Mother Mother Infant Infant Infant + + + + 2.38 x 107 <200 Pair 1 1.15 x 108 + + + + 2.53 x 107 Pair 2 Pair 3 + + + + 7.98 x 107 <200 3.47 x 104 Pair 4 + + + + 3.24 x 106 Pair 5 + + + + 1.56 x 106 2.04 x 107 Pair 6 + + + + 1.57 x 106 2.60 x107 Pair 7 + + + + 1.03 x 107 2.79 x107 Pair 8 + + - - 81 1.26 x 107 Pair 9 + + + + 5.73 x 107 2.98 x 107 Pair 10 + + + + 7.29 x 106 9.76 x 107 Pair 11 + + + + 2.72 x 107 3.78 x107 Pair 12 + + + + 7.35 x 105 2.47 x107 Pair 13 + + + + 2.19 x 107 3.34 x 107 Pair 14 + + + + 6.69 x 106 <200

  47. Correlation between HBSAg and HBV DNA concentration

  48. Results Molecular Data: Mutation Children Mother of children HBeAg + HBeAg - Core promoter T1753C 0 0 1 2 1 A1762T 2 0 6 6 G1764A 2 0 1 Pre-C 5 G1896A 1 1 1 G1899A 0 0 0 0 Start codon 0 0 0 0 Pre-S1 Pre-S2 0 0 1(ATA) 1(GTG) 0 0 0 1(ACG) S

  49. Results Molecular Data: Deletion Children Mother of children HBeAg + HBeAg - Core promoter 0 0 4 1 Pre-C 0 0 0 1 0 0 1 0 Pre-S1 Pre-S2 0 0 0 1 0 0 0 S 0