Prevalence of Immunity Against Hepatitis A and B in Patients With Steatotic Liver Disease in the U.S Population

Graphical abstract

Dear Editor,

The prevalence of fatty liver disease has been increasing over the past few decades and it is now the most common form of liver disease in the U.S.¹ Recently, the term steatotic liver disease (SLD) was chosen to represent all forms of fatty liver disease.² Individuals with chronic liver disease who develop superimposed hepatitis A (HAV) or hepatitis B (HBV) have a higher likelihood of developing more severe disease, and a greater risk of mortality.³ Hence, the World Health Organization recommends immunization against HAV and HBV for individuals with chronic liver disease.^4,5

There is limited published data on the degree of implementation of these immunization recommendations. This study aims to evaluate the rates of immunity against HAV and HBV, as measured by seroprevalence of hepatitis A antibody (anti-HAV) total and hepatitis B surface antibody (HBsAb) in individuals with SLD.

Data were obtained from the National Health and Nutrition Examination Survey (NHANES) conducted in 2017–2018 in which liver fat and stiffness biomarkers were assessed for the first time by transient elastography (TE). NHANES employs a robust, multistage probability design to sample the civilian U.S. population. Individuals who met the following criteria were included in the study population: age ≥12 years, complete TE examination, controlled attenuation parameter (CAP) greater than 260 dB/m, no evidence of hepatitis B or C, and availability of HAV and HBV serologies. Individuals with anti-HBs levels of >12 mIU/mL were considered to have adequate immunity. A TE-CAP score ≥260 dB/m was defined as having SLD. A liver stiffness value > 14 kPa was defined as advanced hepatic fibrosis among subjects with steatotic liver disease.⁶

The study included 2379 subjects with a mean age of 49.2 years (95% CI, 47.5–50.9). Men made up 54.7% of the study cohort. Mean levels for median CAP and liver stiffness were 312.9 dB/m and 6.35 kPa, respectively. The prevalence of anti-HAV (total) and HBsAb was 39.5% and 21.2%, respectively in the study population, and 43.9% and 27.0%, respectively in the general population (2017–18 NHANES cohort).

Anti-HAV was detected in 39.63% of individuals with early stages of fibrosis (F0–F3) versus 36.66% of those with advanced fibrosis (F4). Individuals younger than 40 in the population with SLD had a higher prevalence of anti-HAV (54.51%) and HBsAb (39.84%) compared to those older than 40 (35.27% and 16.55%, respectively) suggesting the effect of universal vaccination for children and adolescents. Compared to those without health insurance, subjects with health insurance did not have a higher prevalence of either anti-HAV or HBsAb (Table 1).

Table 1.

Factors Impacting Prevalence of Anti-HAV and HBsAb in Patients With SLD (N = 2379).

Variable	Prevalence of Hepatitis A Antibody (%)	P-value	Prevalence of Hepatitis B Antibody (%)	P-value
Age (years)
12–17.9	87.44	<0.0001	15.62	<0.0001
18–39.9	45.53		38.54
40–59.9	33.19		16.92
>60	36.04		11.42
Health Insurance
Have insurance	37.70	0.0169	21.57	0.5162
No insurance	51.78		19.36
Income Level ($)
0–19,999	49.83	0.0024	18.69	0.4390
20,000–44,999	45.48		18.72
45,000–74,999	38.07		20.00
75,000–99,999	30.73		21.69
100,000+	30.79		25.17
Educationa
<9 grade	86.35	<0.0001	16.34	0.0024
9–11 grades	48.60		13.64
GED	35.22		14.12
Some college	29.07		25.47
College graduate or above	37.65		27.49
Liver Stiffness (kPa)
F0–F1 (2–6.99)	39.70	0.5733	22.09	0.4704
F2 (7–9.99)	36.63		20.43
F3 (10–14)	47.01		14.74
F4 (>14)	36.66		14.46
Race
Mexican American	79.81	<0.0001	19.58	0.0313
Other Hispanic	73.46		21.52
Non-Hispanic White	24.01		19.60
Non-Hispanic Black	41.09		25.86
Other race: Including multi-racial	59.60		29.27
Routine place to go for healthcare?
Yes	38.32	0.3193	20.97	0.6783
No	45.73		22.20
More than 1 place	0.328		33.97

anti-HAV, hepatitis A antibody; HBsAb, hepatitis B surface antibody; GED, general education diploma.

^aFor individuals >20 years of age.

Despite guidelines recommending HAV and HBV immunization for individuals with SLD, immunity rates in this subgroup are still low and do not differ from the general population. Given the risk of decompensation related to acute HAV or HBV in patients with advanced fibrosis due to SLD, strategies to improve compliance with immunization recommendations are warranted.

Credit authorship contribution statement

Study design: Hannah Ramrakhiani.

Data collection: Hannah Ramrakhiani.

Data analysis: Hannah Ramrakhiani.

Drafting of the manuscript: Hannah Ramrakhiani.

Data interpretation, review/revision of the manuscript: All authors.

Study concept and supervision: Katerina Shetler.

Appendix A. Supplementary data

The following is the Supplementary data to this article: