TYPE Original Research

PUBLISHED 04 December 2023

DOI 10.3389/fimmu.2023.1282922

Efficacy of pegylated interferon

OPEN ACCESS a-2b plus entecavir therapy
EDITED BY
Mauro Viganò,
University of Milan, Italy
and predictors of treatment
REVIEWED BY
Yiqiong Liu,
success in children with
Second Military Medical University, China
Amy Kay Nelson,
Augsburg University, United States
chronic hepatitis B
*CORRESPONDENCE
Yilan Zeng Liang Huang †, Hong Zhang †, Xintong Kang, Zhu Chen,
[email protected]
Lin Wang and Yilan Zeng*
†
These authors have contributed equally to
this work Department of Hepatology, Public Health Clinical Center of Chengdu, Chengdu, China

RECEIVED 25 August 2023

ACCEPTED 13 November 2023
PUBLISHED 04 December 2023
Introduction: Interferon therapy, used in the treatment of chronic hepatitis B
CITATION
Huang L, Zhang H, Kang X, Chen Z, Wang L (CHB), is one of the means by which patients can achieve a functional cure.
and Zeng Y (2023) Efficacy of pegylated Pegylated interferon is currently used in the treatment of CHB. There are two
interferon a-2b plus entecavir therapy and
predictors of treatment success in
main types of pegylated interferon: a-2b and a-2a.
children with chronic hepatitis B.
Front. Immunol. 14:1282922. Methods: This study explored the efficacy, safety, and predictors of treatment
doi: 10.3389/fimmu.2023.1282922
response for a-2b plus entecavir among children in a real-world setting.
COPYRIGHT
© 2023 Huang, Zhang, Kang, Chen, Wang
and Zeng. This is an open-access article
Results: The study included 76 patients aged 3–18 years, all of whom were
distributed under the terms of the Creative treated with interferon a-2b plus entecavir. The mean duration of treatment was
Commons Attribution License (CC BY). The 401.99 days, and 31.6% (24/76) of patients achieved HBsAg clearance.
use, distribution or reproduction in other
forums is permitted, provided the original Competing risk model analyses showed that children with baseline HBsAg
author(s) and the copyright owner(s) are <1500 IU/mL (subdistribution hazard ratio [sHR]=2.643, P=0.022) and a higher
credited and that the original publication in
this journal is cited, in accordance with
baseline alanine aminotransferase (ALT) level (sHR=1.005, P=0.000) had a higher
accepted academic practice. No use, probability of achieving HBsAg clearance during treatment. Conversely, children
distribution or reproduction is permitted with a higher hepatitis B virus loading level (sHR=0.835, P=0.043) and age ≥10
which does not comply with these terms.
years (sHR=0.243, P=0.002) had a lower probability of achieving HBsAg
clearance during treatment. A decrease of >1 log10 in HBsAg level (sHR=3.479,
P=0.001) at 12 weeks of treatment was associated with a higher probability of
achieving surface antigen clearance.

Discussion: These results indicated that interferon plus entecavir therapy is a

promising means of achieving HBsAg clearance in children with CHB. Moreover,
H B sA g , AL T, v i r us l oa din g , an d a g e a r e i nd i c a to r s of t r ea t me nt
success probability.

KEYWORDS

pegylated interferon a-2b, entecavir, efficacy, chronic hepatitis B, predictors

Frontiers in Immunology 01 frontiersin.org

Huang et al. 10.3389/fimmu.2023.1282922

Introduction Three patients’ groups were defined in this study: the HBsAg
NOT clearance group (group A), which was defined as patients who
Interferons (IFNs) are immunomodulatory agents that can underwent treatment without HBsAg clearance; the HBsAg
induce the expression of hundreds of genes, including genes with clearance group (group B), which was defined as patients who
antiviral functions, thereby blocking viral replication at many levels achieved HBsAg clearance; and the treatment discontinued group
(1). There is increasing interest in functional cures for hepatitis B (group C), which was defined as patients whose treatment was
virus (HBV) infection; treatments explored for this goal include discontinued by the doctors. The patients’ clinical data were
IFNs, immune checkpoint inhibitors, therapeutic vaccines, and organized in the same way as the survival data for analysis.
gene-engineered T cells (2). Notably, IFNs combined with nucleos Ethical approval for this study protocol was obtained from the
(t)ide analogs (NUCs) or monotherapy have demonstrated promise Ethics Committee of the Chengdu Public Health Clinical Center,
in clinical practice, including a degree of efficacy in some adult and written informed consent was acquired from each patient
patients and children with favorable characteristics (3). before treatment. If the patients were over 8 years old, they
There are two types of pegylated interferons (peg-IFNs): a-2a needed to sign by themselves as well. The study complied with
and a-2b. These types substantially differ in terms of chemical and the ethical guidelines of the Declaration of Helsinki 2008.
structural characteristics, pharmacokinetic and pharmacodynamic
properties, and dosing and administration (4). To our knowledge,
there are limited available data regarding peg-IFN a-2b plus Follow-up
entecavir therapy for HBV infection in children. In this study, we
analyzed 76 patients aged <18 years with CHB who received IFN a- Baseline assessments included quantitative tests for HBsAg,
2b plus entecavir to understand its efficacy and the predictors for hepatitis B surface antibody (HBsAb), hepatitis B e antigen
treatment success. (HBeAg), hepatitis B e antibody (HBeAb), and hepatitis B core
antibody (HBcAb); blood routine, thyroid function, liver function,
and renal function tests; and the detection of hepatitis B virus DNA
(HBV-DNA). All patients underwent clinical follow-up and
Materials and methods laboratory tests approximately once per month during the
treatment process.
Patient enrollment

This study enrolled children with CHB who underwent Statistical analysis
treatment with IFN a-2b plus entecavir from 2021 to 2023. The
inclusion criteria for this study were diagnosis with HBV infection A competing risk model was used to understand the impact of
between 3 and 18 years of age, no obvious signs of liver cirrhosis, baseline status on HBsAg clearance. This type of model is useful in
and no other significant underlying diseases (e.g., psychiatric the context of censored data with competing risk. During treatment,
disorders, thyroid dysfunction, fundus abnormalities, or doctors decide to discontinue treatment based on a patient’s
autoimmune diseases). The exclusion criteria were significant response to IFN, typically when the patient shows a poor
underlying diseases or contraindications to the use of IFN treatment response. In such instances, patients who discontinue
or entecavir. treatment have a lower probability of achieving surface antigen
clearance compared with patients who continue treatment at the
same time point. Therefore, treatment discontinuation is
Study design considered a competing risk. The main endpoint in this study
was the serological clearance of HBsAg, which is considered a
The treatment comprised peg-IFN a-2b plus entecavir: 180 µg “failure event” in the model. As noted above, treatment
peg-IFN a-2b/1.73 m2 per week and 0.0015 mg entecavir/kg per discontinuation was considered a “competing risk” in the model.
day. The peg-IFN a-2b was manufactured by Techpool Bio-pharma The patients’ baseline features and early responses to treatment
Co., Ltd., and the entecavir was manufactured by Chia Tai Tianging were entered into competing risk models. Multiple regression
Pharmaceutical Group Co., Ltd. The study participants were models were constructed using various combinations of
evaluated approximately once per month to identify changes in independent variables. The best-fitting model was selected on the
medical indicators and the presence of any adverse reactions. After basis of statistical significance and professional expertise.
treatment completion, follow-up visits were initiated; participants The Kaplan–Meier (KM) method and the log-rank test were
continue to attend these visits. IFN strategies to achieve functional used to compare the survival distributions of binary independent
cures of HBV infection were optimized by response-guided variables. Subdistribution hazard ratios (sHRs) of competing risk
treatment adjustment (RGT) rules (5, 6). These rules allowed models were reported with 95% confidence intervals; all tests were
doctors to decide whether to continue or discontinue treatment two-sided, and the significant threshold was regarded as P < 0.05.
based on the patient’s hepatitis B surface antigen (HBsAg) response All analyses were performed using Stata/MP 14.1 statistical software
to the IFN treatment. (StataCorp LLC, College Station, TX, USA).

Frontiers in Immunology 02 frontiersin.org

Huang et al. 10.3389/fimmu.2023.1282922

Results without HBsAg clearance, and 42.1% (32/76) discontinued the

treatment due to doctors’ decisions. A total of 48 (63%) patients
Baseline characteristics had a treatment duration longer than 48 weeks.

This study included 76 patients [median age: 8 years (range, 3–18

years); 45 male and 31 female]. All included patients were Chinese Competing risk model results
citizens; 20 patients displayed Tibetan ethnicity, and the remaining 56
patients displayed Han ethnicity. Before treatment, the mean Independent variables were age ≥10 years or <10 years, baseline
geometric value of HBV-DNA was 6.5 log10 IU/mL, the median NEU and count, baseline ALT, baseline PLT count, surface antigen
HBsAg level was 12323 IU/mL, and the median alanine <1500 IU/mL or ≥1500 IU/mL, log10 HBV-DNA IU/mL at baseline,
aminotransferase (ALT) level was 25 IU/L. According to our Tibetan ethnicity or non-Tibetan ethnicity, sex, immune tolerance
hospital’s standards (i.e., an upper limit of 37 IU/L), 59.2% (45/76) status, and history of oral antiviral medication; these variables were
of patients had a normal ALT level. The neutrophil (NEU) and included in the baseline competing risk model. Analysis of the
platelet (PLT) counts were all within normal ranges before treatment model showed that the sHR for age ≥10 years was 0.243 (P=0.002),
(Table 1). The univariate analysis of baseline characteristics indicated indicating that children aged ≥10 years are less likely to achieve
that the HBsAg and log HBV-DNA level were statistically different in surface antigen clearance. The sHR for surface antigen <1500 IU/
three groups of patients. No other characteristics yielded positive mL was 2.643 (P=0.022), suggesting that patients with a surface
results in the univariate analysis (Table 1). antigen level <1500 IU/mL are more likely to achieve surface
antigen clearance. The sHR for baseline viral load was 0.835
(P=0.043), indicating that patients with a higher baseline viral
Outcomes load are less likely to achieve surface antigen clearance. The sHR
for baseline ALT levels was 1.005 (P=0.000), indicating that patients
The mean duration of treatment was 401.99 days (standard with a higher baseline ALT are more likely to achieve surface
deviation=147.08 days). Overall, 31.6% (24/76) of the patients antigen clearance (Table 3).
achieved HBsAg clearance, with a median interval to HBsAg An early response to treatment may also affect surface antigen
clearance of 245.5 days (interquartile range=149–354 days) seroconversion. Therefore, we constructed a model that considered
(Figure 1; Table 2). In all, 26.3% (20/76) were in active treatment whether the surface antigen level decreased by 1 log10 at 12 weeks of

TABLE 1 Baseline patient characteristics1.

Parameters All patients HBsAg NOT clearance HBsAg clearance Treatment discontinued P-
group(A) group(B) group(C) values
N=20 N=24 N=32
Age(Years) 82 (5-11)3 10.52 (5-12.5)3 5.52 (4.5-9)3 8.52 (6-11.5)3 0.0566

Sex

Male 454 (59%5) 114 (55%5) 124 (50%5) 224 (69%5) 0.3386

Female 314 (41%5) 94 (45%5) 124 (50%5) 104 (31%5)

HBsAg(IU/mL) 246162 190422 (2481.15 26072 (357.5-33641)3 42477.932 (9467.5-72122.46)3 0.0096

(2607- 69434)3 -68958.98)3

HBeAg(IU/mL) 528.1052 416.732 (2.91-593.68)3 530.5952 (367.235-601.97)3 552.2452 (498.26-625.85)3 0.2016

(243.355-610.575)3

ALT(IU/mL) 352 (22.5- 54)3 302 (23-49)3 45.52 (26- 60)3 332 (26-42.5)3 0.2586

WBC count(109/L) 62 (4.83-6.69)3 5.372 (4.64-6.39)3 6.442 (5.12-7.495)3 5.745 (4.89-6.23)3 0.1236

PLT count(109/L) 268.52 (200.5-325)3 2722 (212-319.5)3 2772 (209.5-327)3 2452 (187.5-324.5)3 0.556

NEU count(109/L) 2.332 (2.045-3.2)3 2.2752 (2.01- 3.055)3 2.92 (2.13-3.485)3 2.3152 (2.065-3.125)3 0.3756

log10 HBV-DNA 6.5 6.5 4 7 0.0057

(3-8) (1.5-8) (3-6) (5.5-8)

Tibetan ethnicity 204 (26%5) 64 (30%5) 54 (21%5) 94 (28%5) 0.8017

Previous 54 (7%5) 34 (15%5) 24 (8%5) 04 (0%5) 0.0577

antiviral treatment

Immune-tolerant 674 (88%5) 174 (85%5) 214 (88%5) 294 (91%5) 0.9037
1
(HBsAg), hepatitis B surface antigen; (HBeAg), hepatitis B e antigen; (SD), standard deviation; (IQR), interquartile range; (ALT), alanine aminotransferase; (WBC), white blood cell; (PLT),
platelet. 2Median. 3IQR. 4Count data.5Rate. 6Kruskal–Wallis H test used. 7Fisher’s exact test used.

Frontiers in Immunology 03 frontiersin.org

Huang et al. 10.3389/fimmu.2023.1282922

Follow-up results among patients who

achieved HBsAg clearance

Among the 24 patients who achieved surface antigen clearance,

11 completed follow-up HBsAb tests after treatment finished,
indicating that they had at least one systematic evaluation of HBV
infection within 3 months after treatment finished. Among the
patients who achieved HBsAg clearance, 75% had a positive
HBsAb test result (≥10 mIU/mL). In these patients, the median
surface antibody level was initially 51.13 mIU/mL. At a mean interval
of 75.83 days after treatment, the median surface antibody level
increased to 304 mIU/mL (upper limit of detection: 1000 mIU/mL).

FIGURE 1 Major safety concerns

Kaplan–Meier failure estimates.

Among all 76 patients, three (4%) experienced thyroid

dysfunction during the treatment process, leading to temporary
treatment; the rates of decrease in white blood cell count, NEU treatment discontinuation, but they successfully recovered and
count, and PLT count; and the rate of ALT elevation. Through continued treatments. Of the patients, 78% (59/76) had an
variable selection in the model, we found that a single log10 decrease elevated ALT level, 76% (58/76) had a decreased NEU count, and
in surface antigen at week 12 was associated with surface antigen 71% (54/76) had a decreased PLT count. Statistical analyses using
clearance during treatment (Table 3). Other early response factors paired rank-sum tests were conducted to compare key safety
analyzed did not display statistical significance and were excluded parameters (e.g., ALT, NEU count, and PLT count) at baseline,
from the model. The calculation of the rate of change was rate = after 1 month of treatment, last observation during treatment
(value after first month – baseline)/baseline value. (mean time: 357.99 days), and follow-up after treatment
completion (mean time: 80.44 days after treatment completion,
n=29 patients). When ALT levels after 1 month of treatment and at
Kaplan–Meier analysis
the last observation during treatment were compared with baseline,
we observed a significant increase in ALT. However, during the
After patient stratification according to age (≥10 years vs. <10
follow-up period, ALT levels returned to baseline. In contrast, both
years), log-rank analysis showed that patients aged <10 years had a
NEU and PLT counts decreased after 1 month of treatment and at
larger area under the curve (AUC) (c2 = 9.36, P=0.0022), indicating
the last observation during treatment; during the follow-up period,
a higher probability of HBsAg clearance in such patients (Figure 2).
both counts returned to baseline levels (Table 4). Other minor
After patient stratification according to baseline surface antigen
adverse events included fever, poor appetite, skin rash, and fatigue.
level (<1500 IU/mL vs. ≥1500 IU/ml), log-rank analysis showed that
patients with a baseline HBsAg level ≥1500 IU/mL had a smaller
AUC (c2 = 4.7, P=0.0302), indicating a lower probability of HBsAg Discussion
clearance in such patients (Figure 3).
After patient stratification according to the decrease in baseline Efficacy and predictors of
HBsAg level at 12 weeks (>1 log10 vs ≤1 log10), log-rank analysis treatment success
showed that patients with a 1 log10 decrease in baseline HBsAg level
had a larger AUC (c2 = 4.57, P=0.0326), indicating a higher In this study, competing risk model analyses suggested that a
probability of HBsAg clearance in such patients (Figure 4). baseline HBsAg level <1500 IU/mL and a higher baseline ALT level

TABLE 2 Treatment outcomes1.

Parameters 0-24W 24-48W 48-72W 72-96W >96W

Patients in the period 76 67 43 15 3

Cumulative HBsAg clearance 8 16 21 23 24

HBsAg clearance 8 8 5 2 1

Cumulative treatment discontinued 1 10 29 32 32

Cumulative rate of HBsAg clearance 10.5% 21.1% 27.6% 30.3% 31.6%

Rate of HBsAg clearance in the period 10.5% 12.0% 12.0% 13.3% 33.3%
1
(W), weeks; (HBsAg), hepatitis B surface antigen.

Frontiers in Immunology 04 frontiersin.org

Huang et al. 10.3389/fimmu.2023.1282922

TABLE 3 Competing risk model results1.

95% CI
Variables sHR SE Z P-values

Baseline model

≥10 Years old 0.243 0.109 -3.150 0.002 0.101 0.586

HBsAg<1500IU/mL 2.643 1.119 2.290 0.022 1.152 6.062

Baseline Virus loading 0.835 0.074 -2.030 0.043 0.701 0.994

Baseline ALT 1.005 0.001 3.820 0.000 1.002 1.008

Log pseudo-likelihood = -78.14, P=0.00

Early response model

12-weeks HBsAg decrease >1 log10 3.479 1.357 3.200 0.001 1.620 7.471

Log pseudo-likelihood = -87.10, P=0.00

1
(sHR), subdistribution hazard ratio; (SE), standard error; (CI), confidential interval.

were associated with a higher probability of surface antigen Literature reviews

clearance during treatment (sHR=2.643, P=0.022). Additionally,
age ≥10 years and a higher baseline virus loading (HBV-DNA) level Entecavir, approved for the treatment of children with hepatitis
were associated with a lower probability of HBsAg clearance B, has a strong inhibitory effect on HBV-DNA (7) but a relatively
(sHR=0.243, P=0.002 and sHR=0.835, P=0.043) during treatment. weak effect on HBsAg clearance. In contrast, IFN is an important
A baseline HBsAg level ≤1500 IU/mL and a higher ALT level conventional antiviral agent for the treatment of hepatitis B, which
associated with a higher HBsAg clearance rate during treatment. A achieves its effects through immunomodulation and the reduction
decrease of >1 log10 in HBsAg level (sHR=3.479, P=0.001) at 12 of HBsAg expression. Combination therapy involving these two
weeks of treatment was associated with a higher probability of drugs can increase the therapeutic effect and lead to a functional
achieving surface antigen clearance. The results indicated that the cure in some patients. Notably, one study showed that IFN therapy
baseline HBsAg level and virus loading were clinically important can reduce the overall risk of hepatocellular carcinoma (8). In the
factors. The younger patients had a greater chance of achieving present study, we found that the combination of peg-IFN a-2b and
HBsAg clearance during treatment. The early response of HBsAg entecavir yielded relatively good efficacy and safety. Among patients
during treatment was a good predictor for the treatment success. who received treatment over a mean duration of 401.99 days, the
However, the immune tolerance status was not statistically HBsAg clearance rate was 32%.
significant. That means immune tolerance may not closely Various studies have reported dissimilar outcomes regarding
correlated to the HBsAg clearance rate in younger patients. the efficacy of IFN in the treatment of hepatitis B (Table 5). Among
In all, 31.6% (24/76) of the patients achieved HBsAg clearance. children in the immune-active phase, studies using IFN
The results indicated the interferon a-2b plus entecavir therapy is a monotherapy have achieved surface antigen seroconversion rates
promising means for HBsAg clearance in children with CHB. of 11.1%–22.2% at the end of treatment (10, 14). Among children in

FIGURE 3
FIGURE 2 Kaplan–Meier analysis of baseline HBsAg level1. 1(CI), Confidential
1 1
Kaplan–Meier analysis of age . (CI), Confidential interval. interval; (HBsAg), hepatitis B surface antigen.

Frontiers in Immunology 05 frontiersin.org

Huang et al. 10.3389/fimmu.2023.1282922

FIGURE 4
Kaplan–Meier analysis of decrease in baseline HBsAg level1. 1 (CI), Confidential interval.

the immune-tolerant phase, a study using IFN a-2a plus entecavir European Society for Pediatric Gastroenterology Hepatology and
indicated a very low rate of surface antigen clearance and a high Nutrition only recommends performing a liver biopsy if the ALT
incidence of adverse reactions (12). However, another study level is persistently elevated; it recommends only providing treatment
(conducted in China) showed that combination therapy to children with at least moderate inflammation and fibrosis or
comprising lamivudine and IFN could achieve better results children with a positive family history of hepatocellular carcinoma
among children in the immune-tolerant phase, with a surface (19). Patients in the immune-tolerant phase of disease may exhibit
antigen clearance rate of 21.74% at the end of treatment (11). minimal fibrosis and inflammation, and they may display limited
Three studies utilizing peg-IFN (peg-IFN a-2b monotherapy in immune efficacy against HBV compared with other patients (20).
one and peg-IFN a-2a in the others) yielded surface antigen However, a considerable proportion of patients in the immune-
clearance rates ranging from 5% to 52%. Notably, Fan et al. tolerant phase display progressive liver fibrosis and inflammation
reported an HBsAg clearance rate of 52%. In that study, the (21, 22); persistently high levels of HBV-DNA over many years likely
patients exhibited a high mean baseline ALT level (126 IU/mL) cause a gradual increase in the risk of hepatocellular carcinoma,
(12). These findings are consistent with our results, which indicated despite the absence of active liver inflammation and fibrosis (22).
that the probability of achieving HBsAg clearance increased with Guidelines from the EASL recommend treatment for patients with
increasing baseline ALT level. Notably, all previous studies used HBeAg-positive CHB, defined by persistently normal ALT and high
interventions that considerably differed from the pegylated IFN a- HBV-DNA levels, if those patients are aged ≥30 years; the histological
2b plus entecavir strategy used in the present study. severity of liver lesions does not change this recommendation. The
EASL guidelines also indicate that the course of disease is generally
mild, and most affected children do not meet the standard indications
Immunology status for treatment (18). The American Association for the Study of Liver
Diseases (AASLD) supports the avoidance of treatment for patients
There remains debate regarding whether antiviral therapy is (including children) in the immune-tolerant phase (23). Thus, there
necessary for children with CHB in the immune-tolerant phase. is some evidence that treatment for children in the immune-tolerant
The European Association for the Study of the Liver (EASL) did not phase is generally not supported; however, a treatment trial achieved
suggest antiviral treatment or liver biopsy for such children (18). The limited effects in these children (12). However, there is new evidence

TABLE 4 Analysis of major safety parameters of blood routine1.

Parameters Baseline One month Last observation Follow-up

2 2 2
ALT (IU/mL) 35 64.5 62 252
(24-54)3 (38-128) 3
(35-99) 3 (16-42) 3
0.004 0.02 4 0.43 4

NEU (109/L) 2.332 1.812 1.812 3.092

3
(2.05-3.2) (1.35-2.52) 3 (1.45-2.54) 3
(2.01-3.97) 3

0.00 4 0.00 4 0.88 4

PLT (109/L) 268.52 1952 1652 2312

3
(200.5-325) (141.5-273) 3 (123- 217) 3
(164-312) 3

0.00 4 0.00 4 0.88 4

1
(WBC), white blood cell; (PLT), platelet; (NEU), neutrophil.
2
medians, 3 interquartile range. 4P-value vs. baseline.

Frontiers in Immunology 06 frontiersin.org

Huang et al. 10.3389/fimmu.2023.1282922

TABLE 5 Literature reviews regarding the efficacy of IFN treatment for hepatitis B for children1.

Author time Treatment Duration Patient N Results

Sokal (9) 1998 IFN a-2b 48W children 144 HBeAg clearance:26%

Hu (10) 2019 IFN a-2b vs peg-IFN a-2a 48W children 36 HBsAg clearance:
22.2% vs. 11.1%

Zhu (11) 2018 IFN+LAM 96W Immune 69 HBeAg seroconversion: 32.61%

tolerant HBsAg clearance: 21.74%

Bortolottia (3) 2000 IFN a-2a 3-6 months children 107 HBsAg clearance:25% for responders (16 patients)

Fan (12) 2019 peg-IFN a-2a 48W children 41 HBeAg clearance: 66.7% HBsAg clearance: 52%

Rosenthal (13) 2019 peg-IFN a-2a +ETV 48W Immune 60 HBsAg clearance:3%
tolerant

Wang (14) 2021 IFN a 72W Immune 411 HBeAg clearance:39.87% HBsAg clearance:11.08%
active

Choe (15) 2007 IFN a+ LAM 12 months children 59 HBeAg clearance:65%

D’Antiga (16) 2006 IFN a+LAM 10 months Immune 23 HBsAg seroconversion:17%

tolerant

Paddar (17) 2012 IFN a+LAM 52 weeks Immune 28 HBsAg seroconversion:21.4%

tolerant
1
(peg-IFN), pegylated interferon; (LAM), lamivudine; (HBsAg), hepatitis B surface antigen; (HBeAg), hepatitis B e antigen.

of underlying active disease, based on pathological and virological fever, and fatigue; however, these adverse reactions gradually
analyses (21). A high frequency of HBV-DNA integration was improve or completely resolve after IFN discontinuation.
identified by inverse polymerase chain reaction. Random insertions Although most adverse reactions to IFN therapy are reversible,
of HBV-DNA result in genomic instability and have been associated the use of IFN strategies in children should be carefully considered
with hepatocarcinogenesis (24). before implementation (25, 26).
Concerning children in the immune-tolerant phase, there have
been some reports concerning the use of IFN therapy of children, but
response rates considerably vary. In 2006, one study showed that
Data availability statement
treating children in the immune-tolerant phase with IFN plus
The data supporting the findings of this study are available from
lamivudine resulted in an HBeAg seroconversion rate of 22% and
the corresponding author YZ on request.
an HBsAg seroconversion rate of 17% (16). In 2012, a study showed
that treatment with lamivudine plus IFN resulted in an HBsAg
clearance rate of 21.4% (17). However, a 2019 study showed that
Ethics statement
an HBsAg clearance rate of only 3% was achieved with entecavir plus
IFN (12). In the present study, most patients (88%) were in the
The studies involving humans were approved by the Ethics
immune-tolerant phase. Our results showed no significant differences
Committee of the Chengdu Public Health Clinical Center (reference
in HBsAg clearance between patients in the immune-tolerant phase
number: [2018Y]001), and complied with the ethical guidelines of
and those who were not (31% vs 33%, P=1.00 according to Fisher’s
the Declaration of Helsinki 2008. The studies were conducted in
exact test). Furthermore, competing risk model analysis showed that
accordance with the local legislation and institutional requirements.
the phase of disease (immune-tolerant or not) was not statistically
Written informed consent for participation in this study was
significant. The results suggest the need for a rethink of the immune-
provided by the patients’ parents and by the patients who were
tolerant phase in children.
over 8 years old.

Safety concerns Author contributions

Notably, three (4%) patients in the present study experienced LH: Conceptualization, Data curation, Methodology, Writing –
thyroid dysfunction during treatment. Patients with an elevated original draft. HZ: Conceptualization, Data curation, Investigation,
ALT level and decreased blood cell counts were able to recover after Writing – review & editing. XK: Conceptualization, Data curation,
treatment discontinuation. Overall, adverse reactions to IFN Writing – review & editing. ZC: Conceptualization, Data
therapy require close monitoring. Compared with oral antiviral curation, Writing – review & editing. LW: Conceptualization,
drugs, IFN therapy involves many adverse reactions, such as an Investigation, Writing – review & editing. YZ: Conceptualization,
elevated ALT level, decreased blood cell counts, fever, skin allergies, Writing – review & editing.

Frontiers in Immunology 07 frontiersin.org

Huang et al. 10.3389/fimmu.2023.1282922

Funding Bianji (Edanz) (www.liwenbianji.cn/), for editing the English text of

a draft of this manuscript.
The author(s) declare financial support was received for the
research, authorship, and/or publication of this article. This study
Conflict of interest
was supported by ‘Clinical assessments for improvement of
Nonalcoholic steatohepatitis through Vitamin-D intermediated
The authors declare that the research was conducted in the
immune system and intestinal flora regulation (2020YFS0485)’,
absence of any commercial or financial relationships that could be
which was granted by the Department of Science and Technology
construed as a potential conflict of interest.
of Sichuan Province. The funder had no role in the study design,
data collection and analysis, decision to publish, or preparation of
the manuscript.
Publisher’s note
All claims expressed in this article are solely those of the authors
Acknowledgments and do not necessarily represent those of their affiliated organizations,
or those of the publisher, the editors and the reviewers. Any product
We thank Professor Jun Cheng of Beijing Ditan Hospital for his that may be evaluated in this article, or claim that may be made by its
critical review. We thank Ryan Chastain-Gross, Ph.D., from Liwen manufacturer, is not guaranteed or endorsed by the publisher.

References
1. Katze MG, He Y, Gale M. Viruses and interferon: a fight for supremacy. Nat Rev 14. Wang L, Zhao J, Liu J, Zhen C, Zhang M, Dong Y, et al. Long-term benefits of
Immunol (2002) 2:675–87. doi: 10.1038/nri888 interferon-a therapy in children with HBeAg-positive immune-active chronic hepatitis
2. Wong GLH, Gane E, Lok ASF. How to achieve functional cure of HBV: Stopping B. J Viral Hepat. (2021) 28:1554–62. doi: 10.1111/jvh.13598
NUCs, adding interferon or new drug development? J Hepatol (2022) 76:1249–62. doi: 15. Choe B-H, Lee JH, Jang YC, Jang CH, Oh KW, Kwon S, et al. Long-term
10.1016/j.jhep.2021.11.024 therapeutic efficacy of lamivudine compared with interferon-alpha in children with
3. Bortolotti F. Long term effect of alpha interferon in children with chronic hepatitis chronic hepatitis B: the younger the better. J Pediatr Gastroenterol Nutr (2007) 44:92–8.
B. Gut (2000) 46:715–8. doi: 10.1136/gut.46.5.715 doi: 10.1097/01.mpg.0000243439.47334.4e

4. Foster GR. Pegylated interferons: chemical and clinical differences: REVIEW: 16. D’Antiga L, Aw M, Atkins M, Moorat A, Vergani D, Mieli-Vergani G. Combined
PEGYLATED INTERFERONS. Aliment Pharmacol Ther (2004) 20:825–30. doi: lamivudine/interferon-a treatment in ‘immunotolerant’ children perinatally infected with
10.1111/j.1365-2036.2004.02170.x hepatitis B: A pilot study. J Pediatr (2006) 148:228–233.e1. doi: 10.1016/j.jpeds.2005.09.020

5. Zhang W, Zhang D, Dou X, Xie Q, Jiang J, Chen X, et al. Consensus on pegylated 17. Poddar U, Yachha SK, Agarwal J, Krishnani N. Cure for immune-tolerant
interferon alpha in treatment of chronic hepatitis B. J Clin Transl Hepatol (2018) 6:1– hepatitis B in children: is it an achievable target with sequential combo therapy with
10. doi: 10.14218/JCTH.2018.00022 lamivudine and interferon? J Viral Hepat (2013) 20:311–6. doi: 10.1111/jvh.12007

6. Peng H, Wei F, Liu J-Y, Hu H-D, Ren H, Hu P. Response-guided therapy of 18. Lampertico P, Agarwal K, Berg T, Buti M, Janssen HLA, Papatheodoridis G, et al.
regimens based on PEG-interferon for chronic hepatitis B using on-treatment hepatitis EASL 2017 Clinical Practice Guidelines on the management of hepatitis B virus
B surface antigen quantification: a meta-analysis. Hepatol Int (2015) 9:543–57. doi: infection. J Hepatol (2017) 67:370–98. doi: 10.1016/j.jhep.2017.03.021
10.1007/s12072-015-9644-y 19. Sokal EM, Paganelli M, Wirth S, Socha P, Vajro P, Lacaille F, et al. Management
7. Jonas MM, Chang M, Sokal E, Schwarz KB, Kelly D, Kim KM, et al. Randomized, of chronic hepatitis B in childhood: ESPGHAN clinical practice guidelines: consensus
controlled trial of entecavir versus placebo in children with hepatitis B envelope antigen– of an expert panel on behalf of the European Society of Pediatric Gastroenterology,
positive chronic hepatitis B. Hepatology (2016) 63:377–87. doi: 10.1002/hep.28015 Hepatology and Nutrition. J Hepatol (2013) 59:814–29. doi: 10.1016/j.jhep.2013.05.016
8. Damdinsuren B, Nagano H, Wada H, Kondo M, Ota H, Nakamura M, et al. 20. McMahon BJ. The natural history of chronic hepatitis B virus infection.
Stronger growth-inhibitory effect of interferon (IFN)-beta compared to IFN-alpha is Hepatology (2009) 49:S45–55. doi: 10.1002/hep.22898
mediated by IFN signaling pathway in hepatocellular carcinoma cells. Int J Oncol 21. Seto W-K, Yuen M-F. “Immune tolerance” in HBV infection: danger lurks. Nat
(2007) 30:201–8. doi: 10.3892/ijo.30.1.201 Rev Gastroenterol Hepatol (2016) 13:627–8. doi: 10.1038/nrgastro.2016.145
9. Sokal EM, Conjeevaram HS, Roberts EA, Alvarez F, Bern EM, Goyens P, et al.
22. Kennedy P, Litwin S, Dolman G, Bertoletti A, Mason W. Immune tolerant
Interferon alfa therapy for chronic hepatitis B in children: a multinational randomized
chronic hepatitis B: the unrecognized risks. Viruses (2017) 9:96. doi: 10.3390/v9050096
controlled trial. Gastroenterology (1998) 114:988–95. doi: 10.1016/S0016-5085(98)70318-X
10. Hu Y, Ye Y-Z, Ye L-J, Wang X-H, Yu H. Efficacy and safety of interferon alpha- 23. Terrault NA, Lok ASF, McMahon BJ, Chang K, Hwang JP, Jonas MM, et al.
2b versus pegylated interferon alpha-2a monotherapy in children with chronic hepatitis Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018
B: a real-life cohort study from Shanghai, China. World J Pediatr (2019) 15:595–600. hepatitis B guidance. Hepatology (2018) 67:1560–99. doi: 10.1002/hep.29800
doi: 10.1007/s12519-019-00303-w 24. Mason WS, Gill US, Litwin S, Zhou Y, Peri S, Pop O, et al. HBV DNA integration
11. Zhu S, Zhang H, Dong Y, Wang L, Xu Z, Liu W, et al. Antiviral therapy in and clonal hepatocyte expansion in chronic hepatitis B patients considered immune
hepatitis B virus-infected children with immune-tolerant characteristics: A pilot open- tolerant. Gastroenterology (2016) 151:986–998.e4. doi: 10.1053/j.gastro.2016.07.012
label randomized study. J Hepatol (2018) 68:1123–8. doi: 10.1016/j.jhep.2018.01.037 25. Jonas MM, Balistreri W, Gonzalez-Peralta RP, Haber B, Lobritto S, Mohan P,
12. Fan H, Lin L, Jia S, Xie M, Luo C, Tan X, Ying R, Guan Y, Li F. Interferon alpha et al. Pegylated interferon for chronic hepatitis C in children affects growth and body
treatment leads to a high rate of hepatitis B surface antigen seroconversion in Chinese composition: Results from the pediatric study of hepatitis C (PEDS-C) trial. Hepatology
children with chronic hepatitis B. J Viral Hepat (2019) 26:77–84. doi: 10.1111/jvh.13165 (2012) 56:523–31. doi: 10.1002/hep.25690
13. Rosenthal P, Ling SC, Belle SH, Murray KF, Rodriguez-Baez N, Schwarzenberg 26. Druyts E, Thorlund K, Wu P, Kanters S, Yaya S, Cooper CL, et al. Efficacy and
SJ, et al. Combination of entecavir/peginterferon alfa-2a in children with hepatitis B e safety of pegylated interferon Alfa-2a or Alfa-2b plus ribavirin for the treatment of
antigen–positive immune tolerant chronic hepatitis B virus infection. Hepatology chronic hepatitis C in children and adolescents: A systematic review and meta-analysis.
(2019) 69:2326–37. doi: 10.1002/hep.30312 Clin Infect Dis (2013) 56:961–7. doi: 10.1093/cid/cis1031

Frontiers in Immunology 08 frontiersin.org