Immunizations for HIVInfected Persons Indications, Timing,

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Immunizations for HIV-Infected Persons
Indications, Timing, Response
David H. Spach, MDProfessor of
MedicineUniversity of Washington
The International AIDS SocietyUSA
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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
2001321784-91.
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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 2006551-41.
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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 199140 (RR-13)1-19.

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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 200554Q1-Q4.
(2) ACIP. MMWR 199140 (RR-13)1-25.
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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 gt 20 mIU/ml
From Rimland D, et al. AIDS 2005191702-4.
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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 200655(RR-7)1-23.
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Pneumococcal Vaccine in HIV-Infected Adults
Recommendations

• Administer 23-valent pneumococcal vaccine
• Administer one time revaccination after 5 years
• Recommended for CD4 gt 200 cells/mm3
• Consider if CD4 lt 200 cells/mm3- Consider
  repeating if CD4 improves to gt 200 cells/mm3
  as a result of HAART

From (1) ACIP. Adult Immunization Schedule. MMWR
200554(40)Q1-Q4. (2) USPHS/IDSA 2002
OI Prophylaxis Guidelines. MMWR
200251(RR-8)1-52.
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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 gt 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

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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
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Summary of Recommended Vaccines for HIV-Infected
Adults
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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 gt 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 2006194247-55.
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Immunizations in HIV-Infected ChildrenVaricella

• Indications- May consider in children with CD4
  gt 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)

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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 gt 6 months
  apart)
• (4) Influenza Vaccine- Recommended for children
  aged 6-59 months of age

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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)

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