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Immunomodulatory therapy for chronic hepatitis B virus infection in children

Dear Editor, We read with interest the comment by Dr Dibici on our article on immunomodulatory therapy for chronic hepatitis B virus (HBV) infection [1]. Indeed, we focused on the reported literature on chronic infection in adults and not in infants. Although we recognize that children infected early in life have the highest rate of chronic infection, and achieving immune control at this stage in life may prevent progression to disease complications like cirrhosis and hepatocellular carcinoma [2], several reasons have prevented us from including reports on antiviral therapy in infants. First, the majority of the therapeutic strategies under review have a high experimental nature and have not (yet) been performed in the infant subpopulation of chronic patients. Second, the few trials with lamivudine and interferon-a, for pediatric chronic HBV infection, offer little additional insight into what is reported in our review with respect to the criteria for virologic and biochemical response to therapy. We are aware of Dr Dibici’s study which did not show a response to the GenHevac B vaccine, in immunotolerant children with chronic HBV infection. These data appear to be consistent with the studies reported in our review, which also showed that in the adult patient population a therapeutic surface vaccine is mostly not able to break tolerance leading to the clearance of the HBV. However, the data on immunomodulatory strategies to adult chronic HBV infection reported in our review article, should not conceal that pediatric chronic HBV infection represents a complex immunological and ethical problem that warrants separate analysis of the efficacy of future therapeutic options.