Summary:Allogeneic hematopoietic cell transplantation is followed by humoral immunodeficiency. We evaluated whether antibody levels can be improved by recipient vaccination on day À1 and 50 and whether the levels can be further improved by donor vaccination on day À20. A total of 85 patients were randomized or assigned to one of the following strategies of immunization with Streptococcus pneumoniae polysaccharides, Haemophilus influenzae polysaccharide-protein conjugate, tetanus toxoid (protein recall antigen) and hepatitis B surface antigen (protein neo-antigen): (1) donor on day À20, recipient on days À1, þ 50 and þ 365 (D À20 R À1,50,365 ); (2) donor nil, recipient on days À1, þ 50 and þ 365 (D N R À1,50,365 ); or (3) donor nil, recipient on day þ 365 (D N R 365 ). For H. influenzae and tetanus, IgG levels after grafting were the highest in the D À20 R À1,50,365 patients, intermediate in the D N R À1,50,365 patients and the lowest in the D N R 365 patients. For S. pneumoniae and hepatitis B, antibody levels appeared to be similar in all three patient groups. The results suggest that for polysaccharide-protein conjugate antigens or protein recall antigens, recipient immunization on days À1 and 50 improves antibody levels and that donor vaccination on day À20 further improves the levels. In contrast, neither recipient immunization on days À1 and 50 nor donor immunization on day À20 appears to be efficacious for polysaccharide antigens and poorly immunogenic protein neo-antigens. 3-6 Antibody levels can be improved either by the administration of immunoglobulin or by vaccination. The administration of immunoglobulin may decrease the rates of some infections at the time of immunoglobulin administration, but may hamper reconstitution of antibody immunity and thus increase infection rates after the immunoglobulin has been discontinued. 6 The vaccination can improve pathogen-specific immunity both at the time of vaccination as well as years after vaccination. However, vaccination during the first year after transplantation leads to only minor increases in specific antibody levels. Moderate to marked increases in specific antibody levels during the first year after transplant were achieved when both the donor and the recipient were immunized 7-10 days before transplantation and the recipient was boosted at 3 and 6 months after transplantation. 7,8 Presumably this happened because large numbers of antigen-specific lymphocytes were generated in the donors and because these lymphocytes (transferred with the graft) or their progeny proliferated and differentiated upon encounter with the antigen injected to the recipient 7-10 days before transplant and at 3 and 6 months after transplant.We set out to compare the following three vaccination strategies: (1) donor vaccination on day À20 (20 days before transplant) with recipient vaccination on days À1, þ 50 and þ 365 (D À20 R À1,50,365 ); (2) no donor vaccination and recipient vaccination on days À1, þ 50 and þ 365 (D N R À1,50,365 ) and (3) a conventional strategy of no don...

Background Hepatitis B (HBV) is prevalent in certain US populations and regular HBV disease monitoring is critical to reducing associated morbidity and mortality. Adherence to established HBV monitoring guidelines among primary care providers is unknown. Aims To evaluate HBV disease monitoring patterns and factors associated with adherence to HBV management guidelines in the primary care setting. Methods Primary providers within the San Francisco safety net healthcare system were surveyed for HBV management practices, knowledge, attitudes, and barriers to HBV care. Medical records from 1,727 HBV-infected patients were also reviewed retrospectively. Results Of 148 (45%) responding providers, 79% reported ALT and 44% reported HBV viral load testing every 6–12 months. Most providers were knowledgeable about HBV but 43% were unfamiliar with HBV management guidelines. Patient characteristics included: mean age 51 years; 54% male; 67% Asian. Within the past year, 75% had ALT; 24% viral load; 21% HBeAg tested, and 40% of at-risk patients had abdominal imaging for HCC. Provider familiarity with guidelines (OR 1.02, 95%CI 1.00–1.03), Asian patient race (OR 4.18, 95%CI 2.40–7.27), and patient age were associated with recommended HBV monitoring. Provider HBV knowledge and attitudes were positively associated, while provider age and perceived barriers were negatively associated with HCC surveillance. Conclusions Comprehensive HBV disease monitoring including HCC screening with imaging were suboptimal. While familiarity with AASLD guidelines and patient factors were associated with HBV monitoring, only provider and practice factors were associated with HCC surveillance. These findings highlight the importance of targeted provider education to improve HBV care.

BACKGROUND: Hepatitis B (HBV) represents a significant health disparity among medically underserved Asian and Hawaiian/Pacific Islander (API) populations. Studies evaluating adherence to HBV screening and vaccination guidelines in this population are limited. OBJECTIVE: The purpose of this study was to evaluate HBV screening and vaccination practices using both provider self-report and patient records. DESIGN: Medical records for 20,574 API adults were reviewed retrospectively and primary care providers were surveyed to evaluate rates and adherence to HBV screening and vaccination guidelines. PARTICIPANTS: The study included primary care providers and their adult API patients in the San Francisco safety-net healthcare system. MAIN MEASURES: Patient, practice, and provider factors, as well as HBV screening and vaccination practices, were assessed using provider survey constructs and patient laboratory and clinical data. Generalized linear mixed models and multivariate logistic regression analyses were used to identify factors associated with recommended HBV screening and vaccination. KEY RESULTS: The mean age of patients was 52 years, and 63.4 % of patients were female. Only 61.5 % underwent HBV testing, and 47.4 % of HBV-susceptible patients were vaccinated. Of 148 (44.8 %) responding providers, most were knowledgeable and had a favorable attitude towards screening, but 43.2 % were unfamiliar with HBV guidelines. HBV screening was positively associated with favorable provider attitude score (OR per unit 1.80, 95 % CI 1.18-2.74) and negatively associated with female patient sex (OR 0.82, 95 % CI 0.73-0.92), a higher number of clinic patients per week (OR per 20 patients 0.46, 95 % CI 0.28-0.76), and provider barrier score (OR per unit 0.45, 95 % CI 0.24-0.87). HBV vaccination was negatively associated with provider barrier score (OR per unit 0.48, 95 % CI 0.25-0.91). CONCLUSIONS:Rates of HBV screening and vaccination of API patients in this safety-net system are suboptimal, and provider factors play a significant role. Efforts to cultivate positive attitudes among providers and expand healthcare system resources to reduce provider barriers to HBV care are warranted. 1 Asian and Hawaiian/Pacific Islanders (API) represent a particularly high-risk population, with reported prevalence rates of 10-15 %, and are estimated to account for over 40 % of chronic HBV cases in the U.S. 2HBV is associated with increased morbidity and mortality; 15-40 % of patients will develop cirrhosis, liver failure, or hepatocellular carcinoma (HCC).3 The recent U.S. Institute of Medicine report highlights the need for increasing efforts in the United States to screen for, prevent, and treat HBV infection. 4 To meet this goal, it is imperative that we have a better understanding of the complex interplay between patient, provider, and health system factors limiting preventive care and progress towards HBV eradication. whose parents are from regions of high HBV endemicity, and persons with high-risk behaviors, among others. 1,5 While the 2004...