C O N T R O V E R S I E S IN G A S T R O E N T E R O L O G Y

ALLEN L. GINSBERG, MD, Editor

The Gamma Globulin Controversy

Frank Hamilton and Frank L. Iber vs Allen L. Ginsberg

INTRODUCTION In 1972 the Public Health Service Advisory Com- mittee on Immunization Practices stated flatly that standard immune serum globulin is not of value in the prevention of hepatitis B and should not be ad- ministered to persons exposed to hepatitis B. A poll taken in 1975 of members of the editorial board of this journal revealed that most accepted this posi- tion and that many were unaware that the issue has been controversial since 1971. Almost all have as- sumed that hyperimmune globulin will be the pro-

phylactic treatment of choice. These assumptions may not be valid.

Dr. Frank L. Iber, who is Professor of Medicine and Director of the Division of Gastroenterology at the University o f Maryland School of Medicine, and his associate Dr. Frank Hamilton have defend- ed the viewpoint that standard ISG is not of value in the prevention of hepatitis B. I present an opposing position.

ALLEN L. GINSBERG, MD

The Case for Not Giving Gamma Globulin in All Exposure to Hepatitis B

FRANK HAMILTON AND FRANK L. IBER University of Maryland, School of Medicine

Gamma globulin as used throughout the Western world has been changing in the last decade as to its anti-HB~ titer and further changes increasing the an- ti-HBs titers are to be anticipated in the future (1). Concentrated high-titer anti-HBs has been prepared that is approximately 10,000-fold concentrated com- pared to standard gamma globulin (2). Much ex- cellent clinical and epidemiological study is cur- rently underway utilizing the high-titer globulins.

From many of these recent studies it has been convenient to construct Table 1, indicating the ap- proximate risk of acquiring HB~Ag hepatitis from a given exposure. Whether or not there is clinical hepatitis depends upon many factors besides the na- ture of the exposure. As reviewed by Ginsberg in the accompanying article (10) high-titer gamma

globulin is of demonstrated effectiveness in many of the substantial risk situations. Thus high-titer mate- rial has altered the amount of clinical hepatitis in children born of HB Ag-positive mothers (3-5), has protected spouses of active cases of HB hepatitis, has lowered the incidence of antigenemia in the first six months after an infected needle stick (6, 7), and has diminished the numbers of cases in patients but not staff in dialysis units (8), but others have found it protective (9). Most experience has been that high-potency material is ineffective in protecting against an entire unit of transfused HB Ag-positive blood.

These studies employ amounts of anti-HB~ 10,000 times that present in 1975-1976 ordinary gamma globulin. No completely satisfactory trials exist us-

402 Digestive Diseases, Vol. 21, No. 5 (May 1976)