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Immunizations for HIV-Infected Persons Indications, Timing, & Response

Immunizations for HIV-Infected Persons Indications, Timing, & Response. David H. Spach, MD Professor of Medicine University of Washington. The International AIDS Society–USA. Influenza Vaccine Efficacy in HIV-Infected Adults. Study Design. Vaccine Effectiveness.

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Immunizations for HIV-Infected Persons Indications, Timing, & Response

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  1. Immunizations for HIV-Infected Persons Indications, Timing, & Response David H. Spach, MDProfessor of MedicineUniversity of Washington The International AIDS Society–USA

  2. Influenza Vaccine Efficacy in HIV-Infected Adults Study Design Vaccine Effectiveness • Methods - N = 38 HIV-infected adults - Investigation of 1996 outbreak From: Fine AD, et al. Clin Infect Dis 2001;32:1784-91. DHS/PP

  3. Influenza Vaccine in HIV-Infected AdultsRecommendations • Vaccinate annually with trivalent inactivated vaccine • Vaccinate regardless of CD4 cell count or HIV RNA level • Live, attenuated, trivalent vaccine CONTRAINDICATED From: MMWR 2006;55:1-41. DHS/PP

  4. Hepatitis B Vaccine: Interruption of Schedule • “In a three-dose schedule, increasing the interval between the first and second doses of hepatitis B vaccine has little effect on immunogenicity or final antibody titer.” • “The third dose confers optimal protection, acting as a booster dose. Longer intervals between the last two doses (4-12 months) result in higher final titers of anti-HBs.”CDC & Prevention. MWR 1991;40 (RR-13):1-19. DHS/PP

  5. ACIP: Hepatitis B Vaccine Recommendations Indications & Schedule HBV Protective Titers • Vaccine Indications - All HIV-infected persons without evidence of prior HBV infection (anti-HBc negative) • Vaccine Schedule (Adults) - ENGERIX-B: 20 ug (0,1,6 m) - RECOMBIVAX HB: 10 ug (0,1,6m) - TWINRIX*: 0,1,6m • Post-Vaccine Antibody Testing - Test 1-6 months after series *TWINRIX= HAVRIX 720 EL.U plus ENGERIX 20 ug From: (1) ACIP. MMWR 2005;54:Q1-Q4. (2) ACIP. MMWR 1991;40 (RR-13):1-25. DHS/PP

  6. Hepatitis A Vaccine Efficacy in HIV-Infected Adults Study Design HAV Vaccine Effectiveness* • Methods - N = 214 HIV-infected adults - Followed in Atlanta 1996-2003 - Received 2 dose of HAV vaccine - HAVRIX vaccine used *As determined by Anti-HAV IgG titer > 20 mIU/ml From: Rimland D, et al. AIDS 2005;19:1702-4. DHS/PP

  7. ACIP: Hepatitis A Vaccine: Recommendations Indications & Schedule HAV Protective Titers • Vaccine Indications - Travel to endemic region - Male-male sex - Injection-drug use - Chronic liver disease - Clotting factor disorders • Vaccine Schedule (Adults) - HAVRIX: 1440 EL.U (0, 6-12m) - VAQTA: 50 U (0, 6m) - TWINRIX: 720 EL.U (0,1,6m) From: ACIP. MMWR 2006;55(RR-7):1-23. DHS/PP

  8. Pneumococcal Vaccine in HIV-Infected AdultsRecommendations • Administer 23-valent pneumococcal vaccine • Administer one time revaccination after 5 years • Recommended for CD4 > 200 cells/mm3 • Consider if CD4 < 200 cells/mm3- Consider repeating if CD4 improves to > 200 cells/mm3 as a result of HAART From: (1) ACIP. Adult Immunization Schedule. MMWR 2005;54(40):Q1-Q4. (2) USPHS/IDSA 2002 OI Prophylaxis Guidelines. MMWR 2002;51(RR-8):1-52. DHS/PP

  9. Tdap Vaccine • Tdap Components (not a live vaccine)- Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis • June 2005: FDA Approved • October 2005: ACIP Recommended for adults 19-64 to replace the next booster dose of tetanus and diphtheria toxoids (Td) • Should be given routinely if > 10 years since last Td vaccine • May be given sooner to reduce risk of pertussis- Interval of as short as 2 years supported in Canadian study • Not contraindicated for persons with HIV infected DHS/PP

  10. Live Vaccines Contraindicated in HIV-Infected Adults • Live Attenuated Influenza Vaccine • Varicella or Zoster Vaccine • Vaccinia (Smallpox) Vaccine • Live Oral Polio Vaccine • Measles Vaccine (avoid with severe immunosuppression)* • Yellow Fever Vaccine • Typhoid Ty21a *Can be considered in patients without advanced immunosuppression DHS/PP

  11. Summary of Recommended Vaccines for HIV-Infected Adults DHS/PP

  12. Varicella Vaccine in HIV-Infected Children with Current or Past Significant Depression in CD4 Cell Count Study Design Varicella Seroconversion • Methods - N = 97 HIV-infected children - Children age 1-8 - Varicella seronegative - Given 2 doses varicella vaccine • Study Groups - (I) : CDC Category 1 - (II): B and/or 2 (CD4 > 15-24%) - (III): Previous C and/or 3 (now A or N and 1) • Outcomes - Safety - Vaccine responses SAFETY- No serious vaccine-related adverse effects From: Levin MJ, et al. JID 2006;194:247-55. DHS/PP

  13. Immunizations in HIV-Infected ChildrenVaricella • Indications- May consider in children with CD4 % > 15% and class N1 or A1 (asymptomatic or mildly symptomatic) • Timing- First Two Dose: age 12-15 months (3 months apart)- ? Booster Dose: age 4-6 (new 2006 recommendation in healthy) DHS/PP

  14. Immunizations for Healthy ChildrenSummary of New Recommendations in 2005 & 2006 • (1) Hepatitis B Vaccine- Increased emphasis on first dose given at birth • (2) Rotavirus Vaccine - Recommended for all infants at 2, 4, 6 months of age • (3) Hepatitis A Vaccine- Recommended for all children at age 1 year (2nd dose > 6 months apart) • (4) Influenza Vaccine- Recommended for children aged 6-59 months of age DHS/PP

  15. Immunizations for Healthy ChildrenSummary of New Recommendations in 2005 & 2006 • (5) Varicella- Booster dose recommended at age 4-6 • (6) Tdap (new tetanus toxoid, reduced diphtheria toxoid, & acellular pertussis)- Booster dose recommended at age 11-12 • (7) Meningococcal Conjugate Vaccine (MCV4)- Recommended at age 11-12- Recommended for unvaccinated adolescents at high school entry • (8) Human Papillomavirus- Recommended for girls at age 11-12 (and age 13-26) DHS/PP

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