Introduction
Hepatitis B virus (HBV) infection remains a major health problem causing considerable morbidity and mortality despite the availability of vaccines and antiviral treatments. In order to prevent HBV transmission through blood transfusion in Italy serological screening for HBsAg was implemented using nucleic acid amplification testing (NAT) for HBV-DNA. In addition, precautionary exclusion of high-risk subjects, such as sexual partners of HBsAg carriers, became mandatory1.
Here we report the case of a repeat blood donor who developed an acute, genotype F, HBV infection in the course of anti-HBV vaccination.
Case Report
DM was a 45-year old white, male, repeat blood donor who worked as a high-seas fisherman. DM was evaluated for enrolment as a blood donor on 3 May 2007 and by 18 January 2008 had given two blood donations. On 26 April 2008, after the third blood donation, DM gave notice that his new sexual partner (second wife), TRP, a 42-year old woman, was a chronic HBsAg carrier. The blood unit was designated for elimination, but serological studies and NAT were performed. DM and TRP were both invited to our Transfusion Service for medical counselling: vaccination against HBV was recommended to DM and TRP was also evaluated.
TRP was HBsAg positive (2,500 IU/mL), anti-HBs negative, IgG anti-HBc positive with an avidity index >0.9, IgM anti-HBc negative, anti-HBe positive, HBeAg negative and HBV-DNA positive (21 IU/mL) with genotype D. She was negative for hepatitis C virus (HCV), human immunodeficiency virus (HIV) 1 and 2, and hepatitis D virus. Her alanine aminotransferase (ALT) levels were within the normal range.
The vaccination schedule for DM was completed on 27 July 2008 (first dose 25 May, second dose 25 June, third dose 27 July). A control performed on 29 July demonstrated negativity for HBsAg, anti-HBc and anti-HBs. A sample aliquot was stored frozen at −30 °C, according to routine practice in our Transfusion Service. On 11 August 2008 DM gave blood. This blood donation was HBsAg and HBV-DNA positive. A control on another blood sample taken on 13 August 2008 confirmed the reactivity for HBsAg and HBV-DNA. In the following weeks DM developed an acute HBV infection, caused by a genotype F strain. The infection was mild and he did not develop jaundice or raised levels of ALT. His main serological, virological and biochemical data are reported in Table I.
Table I.
Serological and virological course of acute HBV infection in the blood donor, DM.
| 05/03/07 First evaluation | 04/26/08 Donation (1) | 07/29/08 Control (2) | 08/11/08 Donation (4) | 08/13/08 Control | 08/23/08 Control | 08/30/08 Control | 09/05/08 Control | 09/12/08 Control | 10/11/08 Control | 11/29/08 Control | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| HBV-DNA IU/mL |
Negative | Negative | Positive (3) | Positive | Positive | Positive | Negative | Negative | Negative | Negative | Negative |
| Not tested | Not tested | 5,300 (3) | 100,000 | 28,500 (5) | 18,500 | <20 | <20 | <20 | <20 | <20 | |
| HBsAg IU/mL |
Negative | Negative | Negative | Positive | Positive | Positive | Negative | Negative | Negative | Negative | Negative |
| Not tested | Not tested | Not tested | >25,000 | >25,000 | 5,400 | Not tested | Not tested | Not tested | Not tested | Not tested | |
| Anti-HBc IgG | Negative | Not tested | Negative | Negative | Negative | Negative | Negative | Positive | Positive | Positive | Positive (6) |
| Anti-HBc IgM | Not tested | Not tested | Negative | Negative | Negative | Positive | Positive | Negative | Negative | Negative | Negative |
| Anti-HBs | Negative | Not tested | Negative | Negative | Negative | Negative | 34 IU/mL | 43 IU/mL | 56 IU/mL | 192 IU/mL | 449 IU/mL |
| Anti-HBe | Not tested | Not tested | Negative | Negative | Negative | Negative | Negative | Negative | Negative | Negative | Negative |
| HBeAg | Not tested | Not tested | Negative | Negative | Negative | Negative | Negative | Negative | Negative | Negative | Negative |
| ALT IU/mL | 20 | 19 | 21 | 22 | 18 | 21 | 19 | 15 | 17 | 16 | 14 |
Legend: 1: Blood unit discarded after notification of sexual intercourse with an HBsAg-positive woman; 2: control performed after anti-HBV vaccine schedule; 3: test performed on frozen stored samples after diagnosis of acute HBV infection; 4: blood unit discarded because of HBsAg and HBV-DNA positivity; 5: genotype F; 6: anti-HBc avidity index <0.4.
Routine serological tests for HBV, HCV and HIV were performed using an Abbott Architect analyser (Abbott Italia, Rome, Italy). The procedures used for evaluating anti-HBc IgG avidity and HBsAg quantification have been described previously2. NAT for HBV-DNA, HCV-RNA and HIV1-RNA was performed, on a single sample, using a TMA-based commercial method supplied by Chiron (Chiron Italia, Milan, Italy). To quantify HBV-DNA we adopted a commercial real-time polymerase chain reaction method (COBAS AmpliPrep/COBAS TaqMan HBV Test, v2.0, Roche Molecular System, Branchburg NJ, USA), whereas the virus was genotyped by a using reverse hybridisation line probe assay (INNO-LiPA HBV Genotyping assay, Innogenetics NV, Ghent, Belgium). Circulating immune complexes were measured using a Siemens nephelometer BNA II (Siemens Italia, Milan, Italy).
HBV is characterised by marked genetic variability and, based on >7.5% intergroup divergence in the complete genome, eight well-established genotypes (A to H) have been recognised as well as several subgenotypes within these genotypes. Subgenotypes are defined by more than 4% intragenotypic divergence but not greater than 7.5%. Genotypes A and D are found worldwide, genotypes B and C are prevalent in Asia, genotype E is restricted to Africa, genotypes F and H were found exclusively in Central and South America and genotype G is found in France and North America3.
In our opinion this case has several interesting features. The HBV-DNA load was 5,300 IU/mL on 29 July, 100,000 IU/mL on 11 August and 28,500 IU/mL on 13 August. It, therefore, appears that the peak of the acute infection was around the 10 to 13 August: data from the literature4 suggest that HBV DNA and HBsAg peak approximately at the same time while HBV DNA is detectable several weeks before HBsAg. Since HBsAg was detectable on 11 August, this date is likely to be closer to the peak.
If we consider that the peak of the acute infection was around 10 August, the infection must have been contracted 2–3 months earlier. Given that the dates of the vaccine injections were 25 May, 25 June and 27 July, this means the infectious contact with genotype F HBV took place between 10 May and 10 June, before or just after the first vaccine injection when full protection had not been acquired. The HBV infection and anti-HBs induced by vaccination developed essentially simultaneously. This is further supported by the fact that anti-HBc was present from 18 August onwards. However there is a recent report concerning an acute HBV infection that was probably delayed by the presence of anti-HBs5.
In naïve subjects with a primary immune response, usually, detectable antibodies induced by vaccination start being produced in plasma 8–15 days after the second injection, meaning, in this case around 10 July 106. However there are reports that primary immunisation with HBV vaccine can transiently elicit low-affinity anti-HBs antibody in B-cells lysate and, in a minority of subjects, even in plasma7. Nevertheless it is likely that antibodies were being produced and complexing HBV from 10 July onwards, making an increasing amount of immune complexes as the viral load increased6.
This hypothesis was supported by the presence of circulating immune complexes in both of the samples obtained on the 11 and 13 August. This could explain why the decrease in viral load was so quick and why anti-HBs started being in excess by 23 August. This early development of complexing HBV probably also explains why ALT levels remained normal all along. The further interesting feature is the evidence that the infection did not originate from the donor's wife but from someone else (extra-marital sex, presumably with someone from South America).
It is worth noting that DM acquired a HBV infection, presumably after extra-marital sex, without reporting his behavioural risk in the pre-donation questionnaire, to the personnel of the Transfusion Service, or even by using the post-donation confidential self-exclusion statement. Following this episode, we revised our pre-donation questionnaire and adopted a more stringent strategy regarding the personal history of putative donors.
Acknowledgments
We are grateful to Dr. M. Boscolo, Director Public Health Dept. of Chioggia for data concerning the donor's vaccination, to Dr. D. Benucci, Scientific Director of Chiron Europe, for technical assistance and to Prof. JP Allain, Head of Transfusion Medicine at Cambridge University, for helpful discussion.
Footnotes
The Authors declare no conflicts of interest.
References
- 1.Capezzuto C, Franchi E, Urbani S, et al. Occult hepatitis B in blood donors: a description of two cases. Blood Transfusion. 2010;8:297–302. doi: 10.2450/2010.0119-09. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Galli C, Orlandini E, Penzo L, et al. What is the role of serology for the study of chronic hepatitis B virus infection in the age of molecular biology? J Med Virol. 2008;80:974–9. doi: 10.1002/jmv.21179. [DOI] [PubMed] [Google Scholar]
- 3.Mathet V, Cuestas M, Ruiz V, et al. Detection of hepatitis B virus (HBV) genotype E carried even in presence of high titres of anti-HBc antibodies by an Argentinean patient of African descent who had received vaccination against HBV. J Clin Microbiol. 2006;44:3435–9. doi: 10.1128/JCM.00866-06. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Yoshikawa A, Gotanda Y, Itabashi M, et al. HBV NAT positive blood donors in the early and late stages of HBV infection: analyses of the window period and kinetics of HBV DNA. Vox Sang. 2005;88:77–86. doi: 10.1111/j.1423-0410.2005.00602.x. [DOI] [PubMed] [Google Scholar]
- 5.Wendel S, Levi JE, Biagini S, et al. A probable case of hepatitis B virus transfusion transmission revealed after a 13-month-long window period. Transfusion. 2008;48:1602–8. doi: 10.1111/j.1537-2995.2008.01723.x. [DOI] [PubMed] [Google Scholar]
- 6.Minuk G, Hoofnagle J, McAuliffe V, Purcell R. IgM antibody responses to hepatitis B surface antigen in recipients of hepatitis B virus vaccine. J Infect Dis. 1983;148:330–1. doi: 10.1093/infdis/148.2.330. [DOI] [PubMed] [Google Scholar]
- 7.Odinsen O, Owusu-Ofori S, Dompreh A, et al. Antibody detection and kinetics of antibody production during early stages of immunization with hepatitis B virus vaccine. Clin Vaccine Immunol. 2007;14:1623–8. doi: 10.1128/CVI.00158-07. [DOI] [PMC free article] [PubMed] [Google Scholar]