The Hepatitis B Vaccine and Celiac Disease: More Lights Than Shadows?

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Actually, in literature, it is known that HLA-DQ2 haplo-type is over-represented in celiac population and since both HBsAg protein fragments and gliadin peptides bind to HLA-DQ2 molecules; their competition may favors a defective antibody response against the recombinant HB-sAg vaccine in active celiac disease (1). On the other hand, some studies demonstrate that in celiac individuals, the gluten intake at the time of vaccination influences the vaccine-induced immune response (2). All these hypotheses are still argument of debate because the non-responsiveness of celiac patients to the HBV vaccine remains a significant public health problem, although there is no convinced evidence that patients with viral hepatitis B show an increased risk of celiac disease (3). It would be important to assess the possible vaccination strategy in order to reduce this potential " healthy-reservoir " of infection. Regarding to this, new vaccination strategies for ce-liac patients were proposed in literature: the first one was the use of booster doses of HBV vaccine by intra-muscular route (IM), using higher doses or a higher number of injections after a gluten free diet; the second was the performance of vaccine boosters by intra-dermal route (ID) (4). The rational of the second strategy is that as opposed to intramuscular vaccination (IM), which relies on a T-cell mediated response, the vaccine directly introduced into the skin activates a dendritic-cell-mediated immune response, using a lower dose of antigen (5). The comparison of both routes suggests that both ID and IM routes are effective options to administer a booster dose of HBV vaccine in celiac patients although the ID route seems to result in a higher percentage of patients with an anti-HBs titer > 1000 IU/L (6). A recent retrospective cost-benefit analysis of ID hepatitis B vaccination reported a cost reduction exceeding 50% in comparison with a standard IM vaccine regimen (7). In fact the increase of anti-HBs antibodies is satisfactory after ID injection in all patients, a lower dose of the vaccine can be used, the cellular immune responsiveness to HBsAg can be easily assessed by the development of a skin reaction at the injection site (8) and thanks to the setup of this reaction there is no need of venous withdraws to test the serum anti-HBs concentration after the booster dose. On this debate, few shadows remains unsolved, because it …