Journal of Medical Virology 4: 327-340 (1979)

Largescale Efficacy Trials of Hepatitis

B Vaccines in the USA: Baseline Data
and Protocols
Wolf Szmuness

The Lindsley F. Kimball Research Institute o f The Mew York Blood Center, Mew York

The protocols of three placebo-controlled, randomized, double-blind clinical

trials to assess the efficacy of an inactivated hepatitis B vaccine in dialysis pa-
tients and staff, and in male homosexuals are described. Based on the pro-
jected attack rates of HBV in the controls, the vaccine efficacy and rates of
loss to follow-up, over three thousand participants followed for at least twelve
months are required to prove the efficacy of the vaccine. The results of long-
term baseline studies in these populations are also reviewed.

Key words: hepatitis B, hemodialysis, homosexuality, vaccine, clinical trials

INTRODUCTION

It is now apparent that, as with many other communicable diseases, a real break-
through in the prevention and control of hepatitis B virus (HBV) infections will be
achieved only by means of active immunization. Other prophylactic measures, such as
passive immuniLation, mass screening programs, prevention or termination of chronic
carrier states, personal hygiene and avoidance of contact (including sexual) with infected
people, are either not sufficiently effective or are difficult to implement [Prince et al,
1978; Grady et al, 1978; Beaseley and Stevens, 1978; Merigan and Robinson, 1978;
Szrnuness et al, 19751.
As early as 1971 Kmgman demonstrated that a vaccine against hepatitis B can be
prepared by boiling diluted sera from chronic asymptomatic HBV carriers and that such
a vaccine is safe, immunogenic, and protective [Krugman et al, 19711 . Subsequently, two
more sophisticated vaccines were developed in this country: the NIAID vaccine [Purcell
and Gerin, 1978a] and the Merck vaccine [Hillernan et al, 19781. Both consist of highly
purified and formalin-inactivated hepatitis B surface antigen (HBsAg) particles, adminis-
tered in aqueous or alum adjuvant formulation.

Manuscript accepted August 1, 1979.

Address reprint requests to Dr. Wolf Szmuness, Laboratory of Epidemiology, The New York Blood
Center, 310 East 67 Street, New York, NY 10021.

0146-6615/79/0404-0327$02.60 @ 1979 Alan R. Liss, Inc.

328 Szmuness

Because the NIAID vaccine is not intended for mass production, field trials on ef-
ficacy are being limited to the vaccine manufactured by Merck.
One lot (no. 751) of the Merck vaccine, consisting of HBsAg, subtype adw with
alum adjuvant, has been extensively studied in human volunteers and has been found to be
safe. highly immunogenic, and to have good stability during long-term storage. The antibody
response to this vaccine in a group of healthy volunteers vaccinated twice (one month apart)
with 10, 20, or 40 pg of the antigen was 85-95% 2-3 months later. This vaccine was also
free of possible residual infectivity or contamination with other hepatitis-causing agents.

CANDIDATE POPULATIONS FOR THE TRIAL

The basic objective of the vaccine efficacy trials is to measure the degree of protcction,
if any, against various types of HBV-related events (“end-points”) achieved in a group of
randonily selected, naturally exposed vaccinees, compared with another group of randomly
selected people similarly exposed but untreated, or treated with a placebo or with a less ef-
fective drug. Thus, the population selected for the field trial must be at high risk of HBV
infection in order to confine the trial to a study sample of reasonable size, and to assure
that the administration of the vaccine will be of direct benefit to the participants. A trial in
a low-risk population would be difficult to justify ethically and would require exceptionally
large study samples.
Babies born to carrier-mothers of HBsAg, particularly to mothers also reactive for
hepatitis B “e” antigen (HBeAg), are known to have one of the highest recorded risks: Up
to 80-85% develop a persistent carrier state [Beasley et al, 19771 . Protecting babies against
acquiring HBV vertically, the single most important route of transmission in vast areas of
the world, would thus constitute a major strategy for HBV eradication. Because carriers who
acquire the infection early in life seem to be prone to develop hepatocellular carcinoma, im-
munization of babies and children may also be important in reducing the morbidity from
this cancer [Szniuness, 19781. However, in this country, the relatively low prevalence of
HBV markers would require huge screening programs among pregnant women (at least
half a million) to identify an adequate number of babies at risk. One may also argue with
good reason that vaccination of infants qhould be postponed until more information on the
vaccine’s possible side effects is available.
Other high-risk populations in this country are drug addicts, institutionalized men-
tally retarded patients, Chinese-Anieiicans, Alaskan Indians, male homosexuals, and patients
and medical staff of dialysis centers [Szmuness et al, 19781. The last three groups appear to
be the most suitable; in the other groups a controlled clinical trial would encounter serious
legal or logistical problems. Both patients and staff from dialysis centers and male homo-
sexuals are well known to be at high risk of HBV infections, sufficient baseline information
on HBV epidemiology in these populations is available, and they are readily accessible for
clinical trials.
The epidemiologic patterns of HBV infections in these populations differ consider-
ably with respect to the mechanisms of transmission (parenteral vs sexual), the infectious
dose involved, the predominant antigen subtypes (uyw vs adw), and certain other charac-
teristics. The populations may also differ in their ability to respond to HBV infection and
presumably to HBV vaccines as well (see below). It is thus obvious that vaccine efficacy
established in one population cannot readily be extrapolated to another population and
that the vaccine should be evaluated under varying epidemiologic conditions. Furthermore,
it seems desirable to evaluate the vaccine in both settings simultaneously, since once the ef-
 Hepatitis B Vaccine Trials 329

ficacy of the vaccine is proven in one population, conducting a lengthy placebo-controlled

trial in another high-risk population might be questioned ethically,
The design of a trial, the composition of its participants. its size and length depend
on a number of factors: prevalence of HBV markers and composition of individuals free of
these markers, anticipated incidence of various HBV events in the controls, the projected
efficacy of the vaccine and the HBV attack rates in the vaccine recipients, expected pro-
gram-adherence of participants and losses to follow-up. Because dialysis staff exposed to
accidental inoculations with HBsAg-contaminated instruments are frequently treated with
hepatitis B immune globulin (HBIG), other topics which required baseline studies were the
frequency of such incidents in medical staff, the proportions of those with such events who
are treated with HBIG, and the residual HBV incidence in those treated.
These and a number of related topics were pursued in the course of surveillance pro-
grams recently conducted by this laboratory [Szmuness et al, 1975; Szmuness et al, 19741 .
A brief description of pertinent findings follows.*

PREVALENCE OF HBV MARKERS

For an average period of 13.3 9.1 months, 3,155 patients and 1,976 staff members
from 21 large dialysis centers located in six states were followed by monthly blood speci-
mens for HBsAg, anti-HBs, and ALT abnormalities. A January 1979 point-prevalence tab-
ulation (Table 1) showed that 12.3% of all patients and 1.4% of staff were positive, most
for many months, for IIBsAg; the rates for anti-HBs positivity were 37.6% and 29.1%, re-
spectively. Nonwhites, those with a past history of viral hepatitis or with a long duration
of dialysis exposure had even higher rates. In randomly selected sub-samples of HBsL4gand
anti-HBs negative individuals tested for anti-HBc (CORAB technique), an additional 11.7%
of patients and 8.6% of staff were reactive for this HBV marker alone, giving a total infec-
tion rate of nearly 65% for patients and over 40% for staff.
HBV marker prevalence in male homosexuals is presented in Table TI. Altogether,
70% of those tested were found to be HBV marker positive: 5.2% for HBsAg, 54.3%for
anti-HBs, and 8-10% for anti-HBc alone. In individuals with a history of hepatitis, venereal
disease, or with a large number of sex partners the total exposure rates were close to 80%.
Very high proportions of the detected HBsAg carriers (SO% of staff, 61% of homo-
sexuals, and 71% of patients) were reactive for the HBeAg, a marker closely correlated
with infectivity (USNHLI Study Group, 1976). The predominant subtype of the virus in
dialysis patients and staff was qvw ( 8 3 4 5 % of all) and in the homosexuals, adw (90%of all).
It has been reported that kidney transplant recipients whose sera prior to trans-
plantation were anti-HBs positive had a significantly shorter graft survival than anti-HBs
negative recipients [London et al, 19771. Questions, therefore, have been raised whether
candidates for kidney transplants should be vaccinated against HBV. This surveillance pro-
vided an opportunity to reevaluate the relationship between graft survival and HBV mark-
ers. A total of 217 kidney graft recipients surveyed for HBsAg and anti-HBs at the time
of transplantation were followed for a period of up to 24 months: the overall graft rejec-
tion rate was 46.6%(70/150) in the HBV negative recipients, 50.0%(14/28) in the HBsAg
positives, and 52.6% (20/38) in the anti-HBs positives. The life-table graft survival curves

*The following participated in the baseline studies: Doctors C.E. Stevens. R. Sadovsky, and H. Alter,
MI.E. Harley, M5 A. Dwyer. Doctors M. Avram, G. Bailey, P. Bluestone. N . Deane, E. Friedman, J .
Hamilton, L. Pierce, R. Slifkin, R. Sobcrman, B. Strauch, and J . Sullivan.
330 Szmuness
TABLE I. Point-Prevalence of HBV Markers in Patients and Staff From 21 US Hernodialysis Centers in
Relation to Certain Characteristics (January 1979)

Patients Staff

Number %With %With Number %With %With

Characteristic tested HBsAg anti-HBs tested HBsAg anti-HBs

Total 1,782 12.3 37.6 85 1 1.4 29.1

Sex
Male 954 14.8 35.5 245 2.0 26.5
Female 81 1 9.4 40.2 600 1.0 30.0
Race
White 659 15.0 28.4 495 1.6 25.5
Nonwhite 1,106 10.7 43.0 349 0.9 34.1
Age
< 30 192 13.0 29.7 428 1.9 24.5
30-49 577 12.3 35.9 369 0.8 33.6
150 1,000 12.1 40.2 46 0 32.6
Birt hplace
US A 1,396 11.9 36.9 642 1.4 25.5
Other 354 14.4 40.4 182 1.1 41.2
Duration of dialysis
treatment or employment
< 6 months 208 2.4 23.6 159 1.9 14.5
6-11 244 8.2 25.0 93 1.1 20.4
12-23 368 10.6 32.3 183 1.6 21.3
24-59 64 1 13.6 43.4 246 1.2 36.6
2 60 310 21.3 51.6 144 0.7 47.2
With history of VD
Yes 212 32.1 34.4 59 3.4 69.5
No 1,540 9.2 38.3 783 1.1 26.1
Staff position
Physician 31 0 35.1
Nurse 393 1.3 31 .0
Technician 229 2.6 37.1
Nonmedical 186 0 13.4

Note: 11.7%of HBsAg and anti-HBs negative patients and 8.6% of negative staff were positive for anti-
HBc alone (CORAB).

in the three groups of recipients were also almost identical (unpublished data). These data
indicate that there is no reason at all why dialysis patients awaiting a kidney transplant
should not be vaccinated.
Over 8% of HBV negative dialysis patients and 6%of HBV negative homosexuals had
elevated ALT levels (2 45 IU); in dialysis staff this rate was the same as in healthy volun-
teer blood donors (4%). The high rates of ALT abnormalities in the absence of HBV mark-
ers which we observed in both dialysis patients and homosexuals will certainly create dif-
ficulties in monitoring the trial participants for development of biochemical evidence of
hepatitis.
The very high frequencies with which all HBV markers are prevalent in the three
populations will require screening of large numbers of people in order to identify an ade-
 Hepatitis B Vaccine T r i a l s 331

TABLE 11. Prevalence of HBV Markers in Male Homosexuals in Relation to Certain Characteristics
(July 1978)

Characteristic No. tested %With HBsAg %With anti-HBs

Total 7,914 5.2 54.3

Race
White 6,266 5.0 53.8
Nonwhite 1,516 6.1 55.8
Age
< 30 2,896 4.6 43.1
30-39 3,325 5.1 58.6
40-49 746 6.2 62.3
50 81 1 4.2 68.3
Education
High school or less 2,018 5.9 54.8
College 3,254 5.2 53.5
Graduate school 2.198 4.5 53.7
VD history
No 2,553 3.9 35.8
Gonorrhea or syphilis 3,586 5.9 58.6
Gonorrhea and syphilis 1,606 5.9 74.8
VH history
No 5,225 4.9 48.4
Yes 2,167 6.0 68.2
No. sex partners in last 6 months
<5 1,s66 5.2 42.1
5-10 1,177 5.1 47.1
11-30 2,526 5.0 55.3
130 1,713 s .4 66.0

Note: 8-1 0% of HBsAg and anti-HBs negatives were positive for anti-HBc alone (CORAB).

quate sample of eligible candidates for the trial. For instance, in the vaccine trial among
homosexuals, accession of the first 700 participants was achieved by screening almost
10,000 individuals.

INCIDENCE OF HBV EVENTS

A total of 166 HBV-related events in dialysis patients and 67 in staff were observed
during a 27-month period of surveillance. Of staff cases, 83% were classified as severe (ALT
2 400 IU or total bilirubin 2 2.0 mgm%), compared with 37% of patient cases. Conversely,
liver dysfunction, as reflected by persistence of elevated ALT levels, was more protracted
in patients, The average annual incidence of all types of HBV events (severe or mild hepa-
titis and asymptomatic antigenemia) was 14.4%in patients and 10.1% in staff. The rates
were considerably higher at the start of surveillance than at the end. All staff cases were
confined to MDs, nurses, and technicians; the incidence ir! nonmedical dialysis staff was
 332 Szmuness

negligible (Fig. I). The majority of HB cases in medical staff (38167) occurred in individ-
uals with a recent hstory of a “needle-stick”; the incidence in those with such a history
was three times higher than in those without a history. Our surveillance also confirmed the
findings of Grady et a1 [ 19781 of a relatively low efficacy of HBIC in controlling needle-
stick-associated hepatitis: for a 12-month period following these incidents the attack-rates
were 8.7% in staff treated with HBIG, 11.4% in those treated with SIG, and 14.6%in those
not treated (P > 0.05). The HBV risk in dialysis patients of advanced age (older than 70
years), as well as in those with a 10-year or longer duration of treatment, was relatively low
Because follow-up in the homosexual surveillance was limited to testing of serial
specimens (mostly 2-3) drawn 5-10 months apart, the incidence data obtained are much
less reliable. In this survey, out of 547 initially HBsAg, anti-HBs, and anti-HBc negative in-
dividuals, 25 developed HBsAg and 38 developed antibodies (usually both against surface
and core antigens), the annual attack-rates were 7.6% and 11.6%, respectively (Table 111).
The great majority of individuals who sero-converted did not recall hepatitis signs or symp-
toms, had had an average of 20 sex partners in the time interval between tests, and were
under 40 years of age.
In all three populations, the HBV risk in individuals with pre-existing anti-HBs, alone
or in combination with anti-HBc, was negligible; the incidence in anti-HBs positive subjects
was approximately 30 times lower than in anti-HBs negative subjects. These findings indi-
cate that anti-HBs is protective.

M PATIENTS
(1-I3 MEDICAL STAFF
*--*NON-MEDICAL STAFF *
W
k 20.0
F
Y

I-
15.0

i
!-
a
W 10.0
-I
m
?
LLI
5.0
u-
1
0.0
6 12 18 24 30 36 42 48
MONTHS OF EXPOSURE
Fig. 1. Life-table attack rates of hepatitis B or hepatitis B virus infections in dialysis centers by length
of dialysis treatment or employment.
 Hepatitis B Vaccine Trials 333
TABLE 111. Rates of Sera-Conversionsin a Group of HBV Susceptible Male Homosexuals Followed
With Serial Blood Specimens

Number Developed Developed

followed HBsAg antibodya
Total sero-
No. Subj/ No. Rate/ No. Rate/ converted
Characteristic subj mo subj year subj year rate

AS
< 40 450 3,229 23 8.5 36 13.4 21.9*
140 93 677 1 1.8 2 3.5 5.3*
History of VD
Yes 275 1,981 14 8.5 18 10.9 19.4
NO 258 1,864 9 5.8 18 11.6 17.4
History of VH
Yes 82 557 5 10.8 5 10.8 21.6
NO 455 3,304 17 6.2 32 11.6 17.8
Duration of
homosexual activity
< 5 years 54 343 3 10.5 2 7.0 17.5
1 5 ycars 45 1 3,283 19 6.9 35 12.8 19.7
No. sex partners in
last 6 months
< 20 332 2,377 13 6.6 18 9.1 15.7
120 157 1,135 6 6.3 14 14.8 21.1
Total 547 3,934 25 7.5 38 11.6 19.2

a Anti-HBs and/or anti-HBc

*x 2 = 6.501; P < 0.01.

LOSSES TO FOLLOW-UP
The rates of losses to follow-up in patients and staff were quite similar: 30-35%
during the first year of surveillance and 20% more during the second year. Up to 80% of
all staff losses were due to transfers to other assignments. Among patients, the most fre-
quent reason for loss to follow-up was death (47%), the second most frequent was transfer
to non-participating dialysis centers, and the third, transplantation. Yearly mortality rates
in patients varied between 6.4%in patients less than 30 years old and 37.0%in those 70
years or older. Mortality was also very high in patients with insulin-dependent diabetes,
regardless of age. The rates were higher during the first 12 months of dialysis treatment
than later in treatment; there were no differences in mortality between HBV negative
and positive patients.
Still higher were the losses to follow-up in the baseline studies among homosexuals.
Of the over 1,500 HBV negative individuals identified during the initial surveillance and
selected to be followed for sero-conversion, nearly 50% could not be located, and if lo-
cated, refused to participate. On the other hand, the cooperation and program adherence
of those who consented to participate were quite satisfactory.
Because of these high rates of loss to follow-up in our baseline studies, participants
for the trials are selected more strictly than previously; only those who express willingness
334 Szmuness
to remain in the study for at least 12 months are acceded, and extensive inquiries, home
visits, etc are used to track down lost participants. Acceded subjects subsequently trans-
planted or transferred to other dialysis centers or other assignments will be followed.
Such measures should reduce the rate of loss to follow-up to no more than 40% for a
two-year period.

PROJECTED HBV ATTACK-RATES IN VACCINE RECIPIENTS AND CONTROLS

In the immunogenicity studies conducted among small groups of volunteers, 85% of

the individuals vaccinated twice (one month apart) with the Merck adw vaccine developed
antibody two to three months after vaccination (Hilleman and Krugman, personal com-
munication). As reviewed above, our baseline studies confirmed previous observations
[Grady et al, 19781 that naturally acquired anti-HBs is protective. We assume, therefore,
that during the first two months following accession, ie, prior to the appearance of anti-
HBs, the risk in vaccinees will not differ substantially from that in unprotected individuals.
After the first two months, the attack-rate in vaccinated dialysis staff and male homosex-
uals should be equal to 15% of the attack-rate in controls. Such projections, however, may
be wrong. It is not known whether vaccine-induced anti-HBs will be as protective as anti-
body induced by natural infection. Conversely, the assumption that prior to the appear-
ance of anti-HBs the vaccine recipients will not be protected may also be wrong, since in
both clumpanzee studies [Purcell and Gerin, 197%; Hilleman et al, 19781 and in Krugman’s
early experimental studies with the crude vaccine [Krugman et al, 19711 protection was
observed in the absence of RIA-detectable anti-HBs.
Another major unknown is the efficacy of the vaccine in patients with chronic ure-
mia. These patients are well known for developing chronic HBsAg antigencmia much more
frequently than healthy adults. For instance, in our baseline surveillance 53% of patients
(compared with 1.9% of staff) newly infected with HBV failed to clear the virus and had
persistently HBsAg positive sera for six months or longer; in male patients this rate was as
high as 74% [Szmuness et al, 19781. Why a large proportion of HBV infected dialysis pa-
tients become HBsAg carriers is unclear, but probably defects in cellular immune response
are involved [Kaufman et al, 1975; DeGast et al, 19761 :humoral immune responses seem
to be intact [Ortbals et al, 19781 . In a trial now under way in France, Maupas et a1 found
that among dialysis patients given 2-3 initial doses of their aqueous vaccine and a booster
at one year, only 62% (23/37) became anti-HBs positive. In contrast, more than 90% of
dialysis staff developed antibody [Maupas et al, 19781 . We are projecting, therefore, that
up to 35% of all patients will remain unprotected (compared with 15% in staff). However,
because the alum-adsorbed vaccine used in our trials seems to produce an earlier and more
vigorous antibody response than aqueous vaccines, one might speculate that the level of
protection among our patients would be higher than the level observed in the French trial.
In any event, in order to discern the immune response of dialysis patients to the Merck
vaccine, a pre-trial inimunogenicity study is being conducted in a group of patients (see
below).
The efficacy of the vaccine can be assessed by comparing HBV attack-rates in the
vaccinees with rates observed: a) prior to the trial (“historical controls”); b) in individuals
who could not or did not wish to be vaccinated; c) in individuals treated with HBIG or
standard immune globulin (SIG); and d) in true placebo recipients. Based on the assump-
tion that presence of anti-HBs is synonymous with protection, it has been suggested that
the trial could be limited to a relatively small number of vaccinees monitored for the de-
 Hepatitis B Vaccine Trials 335
velopment of anti-HBs [Lustbader et al, 19761. The potential pitfalls and gross bias inher-
ent in a non-randomized, non-blind trial employing as “controls” people who do not wish
to participate (as in the trial now under way in France [Maupas et al, 19781 ) are too well
known to warrant further discussion. Use of historical controls, particularly in the dialysis
trial, also seems to be entirely unacceptable, because HBV incidence in dialysis settings is
constantly changing and generally declining, both in this country and in Western Europe
[Postic et al, 1978; Public Health Laboratory Service Survey, 19761. It may be argued that
treatment of controls with HBIG or SIC would be of some benefit to the participants. How-
ever, the efficacy of these preparations appears to be rather low, and in the most compre-
hensive trial among dialysis staff exposed to “needle-sticks’’ an excess of late-onset HBV
cases in HBIG recipients nullified initial evidence of protection [Grady et al, 19781 . For
these reasons, the best alternative appears to be a placebo-controlled, randomized, and
double-blind trial.
It is anticipated that among the placebo recipients in the homosexual trial the HBV
attack-rates will remain at levels observed during the baseline surveillance: 8.5% for one
year of follow-up and 14% for two years. In the two dialysis populations the incidence
will presumably decline further: in patients to 7% for one year and 11% for two, and in
medical staff to 4% and 6%, respectively.

REQUIRED MINIMUM SAMPLE SIZES AND DURATION OF THE TRIAL

Table IV presents projected HBV attack-rates for the two treatment groups and the
ratio of reduction of incidence in the vaccinees. The end-points for the rates include severe
or mild hepatitis B and HBs antigenemia (transient and persistent). Because the vaccine may
not prevent infection, cases of anti-HBc sero-conversions, alone or together with anti-HBs,
are not included in the numerators. Because patients may respond to the vaccine less vig-
orously than healthy people, the reduction of incidence in vaccinated staff and homosex-
uals is anticipated to be 0 . 2 5 0 . 3 2 compared with only 0.40-0.44 in patients.
From these projections and providing that the rates of loss to follow-up for the
first year of the trial are reduced to 25% and for two years to 4056, the required minimum
sample sizes of participants have been calculated [Fleiss, 19731. As can be seen in Table V,
in order to prove the efficacy of the vaccine with a power = 0.9 and a P value < 0.05 (one-
sided test), 924 patients and 1,010 medical staff must be acceded. Similar calculations for

TABLE 1V. Projected Attack Rates of Hepatitis B and HBV Infections in Vaccinees and Controls

Attack rates (70) for

follow-up period Ratio of
Follow-up reduction
Trial population period Controls (a) Vaccinees (b) (b/al
~~

Dialysis patients 1 year 7.0 3.1 0.44

2 years 11.0 4.4 0.40
Dialysis staff 1 year 4.0 1.2 0.30
2 years 6.0 1.5 0.25
Homosexuals 1 year 8.5 2.7 0.32
2 years 14.0 3.5 0.25
336 Szmuness

TABLE V. Minimal Sample Sizes of Each Treatment Group Depending Upon Duration of Follow-Up,
Power, and Level of Statistical Significance

% Power = 0.8 Power = 0.9

Expected losses
Population to follow-up 01= 0.05 01= 0.01 01 = 0.05 01 = 0.01

Dialysis patients
1-ycar follow-up 25 5 17 835 717 1,085
2-year follow-up 40 333 5 37 462 6 97
Dialysis staff
1-year follow-up 25 529 856 736 1,111
2-y ear fo I low -up 40 363 5 87 5 05 762
Male homosexuals
1-year follow-up 25 257 355 413 537
2-year follow-up 40 145 201 234 303

the homosexual trial revealed that at least 826 participants are necessary if follow-up is
limited to one year, and 468 to two years. Of course, should the actual HBV incidence in
controls be higher. the rates in vaccinees lower, or the number o f lost to follow-up less
than that projected, then vaccine efficacy could be confirmed on smaller samples or in a
shorter than two-year period.

ELIGIBILITY TO PARTICIPATE IN THE TRIAL

Participants must meet the following criteria: age above 16 years, no history of acute
or chronic hepatitis, no history of HBlG administration within the last four months, a neg-
ative test result {or HBsAg, anti-HBs, and anti-HBc (all by radioimmunoassays) within the
last ten days, ALT levels below 100 1U in dialysis patients and below 45 IU in the two
other populations, signed informed consent, and willingness to complete the entire follow-
up process. In addition, dialysis patients 70 years old or older and those with poor progno-
sis are not eligible. Excluded from the trial because of a low HBV risk are dialysis staff not
involved in direct patient care and homosexuals 40 years or older and those with only one
sex partner during the preceeding six months.

STUDY PREPARATIONS AND INJECTION SCHEDULES

Two lots of the Merck vaccine, both in alum formulation, are being used: one of sub-
type adw (no. 751) in the homosexual trial, and another of subtype ayw (no. 761) in the
dialysis trial. In cross-immunity chimpanzee experiments, protection against the hetero-
typic virus was found to be as solid as against the homotypic virus [Purcell and Gerin,
1978bI. However, because of the large differences in predominant subtypes between the
populations mentioned above, the use of two monovalent vaccines seems to be preferable.
The placebo consists of the vaccine dilutant with alum and is visually indistin-
guishable from the vaccine. Vials containing the two preparations are coded with random
numbers; vials given to an individual participant have the same code followed by A for
first injection, B for second, etc. Within each study population assignment to placebo or
vaccine treatment is done at random in a ratio 1: 1. Both preparations are administered in
 Hepatitis B Vaccine Trials 337

the volume of 1 cc intramuscularly; the dose of HBsAg protein concentration in 1 cc of

the vaccine is 20 pg on 40 pg. The injection schedule in dialysis staff and homosexuals is
the same: three injections during the first six months and a booster injection 18 months
later. The exact number of injections and doses and their timing in dialysis patients will
be set up after completion of a pre-trial immunogenicity study.

PILOT IMMUNOGENICITY STUDY

The aim of this study is to evaluate the immune responses of dialysis patients to the
vaccine and to establish the most effective treatment schedule. Patients from low-incidence
centers are assigned at random to one of two treatment groups. One group is treated with
two 20 pg on 40 pg doses of the vaccine given one month apart and a booster at six months.
Another group is treated with four 20 pg on 40 pg doses of the vaccine given one month
apart and a booster at six months. In addition to sex, antibody responses (proportions and
titers) will be correlated with specific HLA antigens, particularly of the DR locus. A Sam-
ple of 104 patients is required to detect a difference between 65% and 90% in the propor-
tions of anti-HBs responders in the two groups (with a power = 0.8 and a one-sided signif-
icance level = 0.05).

FOLLOW-UP
Dialysis patients and staff will be followed with blood specimens drawn at monthly
intervals for a 2- to 3-year period. The follow-up schedule in the homosexual trial is
one month after randomization, 2 months, 3 , 6 , 9, 12, 18, and 24. Regular follow-up speci-
mens are tested for presence of HBsAg, anti-HBc, and ALT levels. In order to maintain the
blind nature of the study regular follow-up specimens are not tested routinely for anti-HBs.
Availability of assays for anti-HBc determinations will be very helpful in distinguishing be-
tween vaccine-induced antibody (sera positive for anti-HBs alone) and antibodies induced
by active infection (sera positive for both).
Additional weekly specimens are drawn when a participant develops evidence of hep-
atitis or HBV infection until the diagnosis is confirmed or refuted.
If a randomized dialysis staff member is exposed to a needle-stick with an HBsAg-
positive instrument his seruni drawn immediately prior to the accident is tested for pres-
ence of anti-HBs. Should the previous serum be anti-HBs positive (25.0 ratio units in the
AUSAB technique), the participant will be told not to get HBIG treatment and to con-
tinue his normal vaccination and follow-up schedule. If this serum is found to be anti-HBs
negative, the participant will be advised to get HBIG treatment. If the person’s vaccination
schedule is incomplete, administration of preparations will be postponed until the passively
administered anti-HBs disappears. Such participants will remain in the study but will be
analyzed separately.

SAFETY AND DATA MONITORING

Since the Principal Investigator, the study staff (except the study’s biostatistician),
and the staff of the participating clinics will remain blind up to the end of the trials, two
separate committees consisting of outside, independent investigators have been created.
Their function is to monitor the safety of the study preparations, the frequencies of ad-
verse reactions, the proper conduct of the trials, trends in incidences of HBV infection in
participants, and to review the final results.
338 Szmuness

The sample size and duration of the homosexual trial are basically fixed and there-
fore analyses of vaccine efficacy will be carried out only when the last acceded participant
has been followed for a 12-month period. At that time, should the efficacy of the vaccine
be established unequivocably, the trial will be terminated and participants who were given
placebo and are still susceptible will be vaccinated. If the difference in attack-rates between
the two treatment groups is still not significant, follow-up will continue for another 6-12
months.
Since neither attack-rates in control dialysis patients and staff nor vaccine efficacy
in patients are presently completely predictable, the exact sample size and the length of
the dialysis trial will be established after the trial begins. It is essential, therefore, that this
trial be monitored by the committee at various points of time to adjust the reviewed pro-
jections, so that decisions can be made about when to stop entry of participants and when
to stop follow-up and carry out final analyses of efficacy. A three-step analysis of data will
be conducted during the dialysis trial:

1) Monitoring for Immune Response

Sera taken six months after enrollment will be tested for anti-HBs. These data to-
gether with the results of the pre-trial immunogenicity study will be used in an evaluation
of the immune response to the vaccine and to alter efficacy and sample size projections
if indicated.
2) Monitoring for Efficacy to Stop Entry
Entry of participants is scheduled to continue for one to two years after the trial
begins. Preliminary assessment of attack-rates in the vaccinees and controls will be carried
out at 12 and 18 months. If the trends in incidence suggest better or worse efficacy than
anticipatcd, the sample size and entry period will be adjusted accordingly,
3) Monitoring of Efficacy to Stop Follow-Up
When the last acceded participant has been followed for 12 months, vaccine effi-
cacy will be analyzed. If the HBV incidence in the two treatment groups differs signifi-
significantly, the trial will be stopped; if the attack rates do not differ significantly, follow-
up will be continued. Similar analyses will be conducted at six-month intervals.

THE PLACE O F THE VACCINE IN CONTROL OF HBV INFECTIONS

In the course of our surveillance it became apparent that the incidence of HB in
both dialysis patients and staff can be substantially reduced by general preventive mea-
sures such as comprehensive regular screening programs, segregation of patients and staff
according to their HBV status, use o€ separate dialyzers for infected patients, etc. Similar
observations were reported from other U S . centers and Great Britain [Postic et al, 1978;
Public Health Laboratory Service Survey, 19761.
In view of this experience, the question arises as to the place of a vaccine in con-
trolling dialysis-associated hepatitis. The present-day attack-rates may appear low com-
pared with rates observed in the early 1970s, yet they are still 10-20 times higher than in
other groups of hospitalized patients and medical staff [Szmuness et al, 19781 . Although
acute HB in dialysis patients is usually a relatively mild disease, it frequently does pro-
gress into chronic active hepatitis or even cirrhosis [Redeker, 19781 . The reservoir of HBV
infection in most U.S. dialysis centers is huge, and it will remain so in the foreseeable fu-
 Hepatitis B Vaccine Trials 339

ture; in many of the centers participating in our surveillance up to 1/3 of all patients under
dialysis are persistent HBsAg carriers. Our experience showed that under such conditions
the smallest laxity in isolation techniques can lead to an outbreak, Thus, despite the de-
clining HB incidence, active immunization of both patients and staff will become an inte-
gral part of prevention. As far as sexually transmitted HBV infection is concerned, active
immunization appears to be the only rational means of prevention [Szmuness et al, 19751 .
The vaccine should also play a major role in controlling HBV infection in: institu-
tionalized mentally retarded patients, staff of institutions for the retarded, military units
with drug addiction problems, prison populations, recipients of large volumes of blood
from commercial sources, non-dialysis medical staff, particularly oral surgeons, dentists,
and laboratory workers. Preliminary evidence has been presented that because of the long
incubation period of HBV, the vaccine may be efficacious when administered after expo-
sure (R. Purcell, personal communication). Should be this confirmed, the vaccine may be-
come an important preventive measure in medical staff accidentally exposed to “needle-
sticks .”
It is anticipated that the first data on the vaccine’s efficacy in preventing sexually
transmitted HBV infections will become available in mid-1980, and in preventing dialysis-
associated hepatitis in 1982.

ACKNOWLEDGMENTS

This study was supported by grant HL 09011-15 from the National Heart, Lung,
and Blood Institute, and by contract A1-62512 from the National Institute of Allergy
and Infectious Diseases, and in part by a grant from Merck, Sharp & Dohme, Inc.

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