Vaccinations Flashcards
HPV schedule
0, 1, 4-6
CD4 count below which you cannot have live vaccines
200 - postpone until immune restoration
200-350 weigh up risks and benefits
How long should you wait between administering different live vaccines?
4 weeks
If a patient recieved blood products how does this affect the potential timing of giving live vaccines?
14 days before or 3 months after because passively acquired antibodies may interfere with response to the vaccine
Should people with CD4 <200 receive non live vaccines?
Response reduced but if at risk can still have and if indicated vaccine can be repeated following immunorestoration
Can vaccines increase HIV VL?
Transient clinically non significant increases have been reported - benefit of vaccine counterbalances this risk
What are general contraindications to vaccines?
History of previous severe adverse reaction or allergy to vaccine or it’s components
Moderate/severe febrile illness
Can pregnant women receive vaccines?
Non-replicating - yes
Replicating - contraindicated although risk to developing fetus expected to be low
Vaccinations that are completely contraindicated in HIV
TB, typhoid, NASAL flu (all live vaccines)
Live smallpox may be considered if CD4>200
For whom is anthrax vaccine indicated?
Those with significant risk of exposure eg working at MOD
How is course of anthrax vaccine given?
0,3,6 weeks, 6months, annual booster if considered at risk
Those with CD4<200 may not respond
What do HIV patients exposed to anthrax need?
Discuss with PHE
Vaccination
Antibiotics
Which HIV positive adults should receive cholera vaccines?
Those at significant risk - travel to highly endemic or epidemic areas and unable to take adequate precautions (eg disaster relief, refugee camps, remote areas with limited access to healthcare in event of outbreak)
Asia, Middle East, Africa, central and Latin America, India
Which vaccine should be given to protect against cholera?
WC/rBS
Two doses at 1 and 6 weeks, at least 1 week prior to exposure
If >6 weeks between doses restart course
Booster after 2 years if ongoing risk. Repeat course if >2 years since primary course
Post exposure prophylaxis for contact with diphtheria
Antibiotics eg erythromycin
If fully immunised - single reinforcing dose
If not - complete vaccine course
Which HIV patients should be offered Td/IPV (diphtheria tetanus inactivated polio) vaccine?
Anyone who is unvaccinated or uncertain vaccination history
3 doses 1 month apart with reinforcing doses at 5 and 10 years
Fully vaccinated individuals boosters every 10 years if ongoing risk
What extra should be considered for those at risk of diphtheria (eg lab workers)?
Check antibodies 3/12 after vaccination to confirm immunity and re vaccinate if required
Who should receive vaccines against haemophilia influenzae B?
All kids get as part of infant imms
Not routinely recommended for HIV+ adults
Recommended for those with asplenia, splenic dysfunction, complement deficiency - one dose (regardless if vaccinated in childhood)
What post exposure prophylaxis should HIV+ adults be given if a household contact of Hib?
Antibiotics eg rifampicin
Which HIV+ patients should be offered hep A vaccines?
Those in high risk groups
1. Contacts household and sexual
2. Travellers to countries where hav common
3. MSM
4. IVDU
5. Those at risk during outbreaks
6. Occupational risk eg sewage or lab workers
7. Haemophiliacs
8. Those with special needs living in residential institutions and their carers
hep A vaccine in PLWH with CD4 >350
Two vaccines at 0 and 6 months
HAV vaccine schedule for PLWH CD4 <350
0, 1, 6 months
Who gets a HAV booster and when?
Those at continued risk of exposure every 10 years
What else can be given to people with CD4 <200 who are exposed to help a
Human normal immunoglobulin (HNIG) along side the vaccine for temporary (3 ish weeks) pre exposure prophylaxis
Post exposure prophylaxis for HAV
HAV vaccine as soon as possible and within 14 days
If cd4 <200 should also receive HNIG
Do not delay while awaiting hep a igG if prior immunity now known
Why is high dose HBV vaccine used for hiv positive patients?
Improves sAb responses
What HBV vaccination schedule should be used in PLWH?
0, 1, 2, 6
40mcg (engerix or hbvaxpro - 20mcg if fendrix)
Ultrarapid course at 20mcg dose can be considered in selected patients with CD4 >500 and imperative need to complete course quickly
How often should HBsAb be tested?
4-8 weeks after last vaccine dose
Repeat yearly if non responder to 2 courses or levels 10-100 and 2-4 yearly if >100 and stable with cd4>350
Who should receive a second course of HBV vaccine?
Levels <10 after primary course
Who should receive HBV boosters and when?
Those with HBsAb level 10-100 after primary course or on follow up monitoring
What should you do if results show isolated core antibody positive?
One booster dose
Repeat in 4-8 weeks
If level >10 then is immune
If <10 3 further doses at 1, 2, 6 months and manage as other vaccine recipients
What course of HBV vaccines should be offered to initial non responders?
3 doses at 0, 1, 2 months
HBsAb at 4-8 weeks after
FENDRIX 20ug preferred
What to do if a PLWH has a high risk exposure to help B?
Determine sAb status
Give within 7 days
If >10 to have one booster dose and if CD4 <200 HBIg
If <10 to have booster And HBIg regardless of CD4
If never vaccinated or unclear history HBIg and offer 0, 1, 2 course regardless of CD4 count
Where indicated 2 doses HBIg can be given, 7 days apart
Which PLWH should have HPV vaccine?
All unvaccinated men and women up to 26 years
All MSM and women up to age 40
Vaccine may be deferred until patient established on ART if naive and CD4 <200
Consider for those with high grade HPV to avoid recurrence
0, 1-2, 612 and restart rather than repeat
Which PLWH should be given flu vaccine?
Everyone including pregnant people annually with non replicating vaccine
Yearly - ideally between sept and nov but potential benefit until March
Prophylaxis for flu contacts?
Consider for people who are either unvaccinated or unlikely to benefit from vaccination (CD4 <200 or unlikely to benefit from vaccination)
Should close contacts of PLWH receive any vaccinations?
Yearly flu - inactivated if PLWH is profoundly immunocompromised
How effective is influenza vaccine in PLWH?
Limited data
Adults 85%
Pregnant women 58%
Who should receive vaccine for Japanese encephalitis?
Anyone at risk of exposure - travel to south east and western pacific Asia during/just after wet season or occupational exposure.
What is the schedule or vaccines for Japanese encephalitis in PLWH?
Inactivated vero cell derived vaccine IXIARIO - 2 doses 24-28 days apart (can give one week apart of urgent need to complete primary vaccination)
If continues risk booster at 12-24 months and 10 years
Side effects of MMR vaccine
Fever and rash (5-15%) for 1-2 days starts 7-12 days after vaccine
Arthralgia and or arthritis up to 25% women usually mild and transient
Transient lymphadenopathy
Rarely - parotitis and deafness, thrombocytopenia, neurological complications, allergic reaction
Less frequent following first dose
Can pregnant or breastfeeding WLWH have MMR??
Contraindicated I. Pregnancy and not to fall pregnant until I/12 after vaccination
Ok in Brest feeding
Why is measles vaccine not given to patients with CD4 <200?
Measles vaccine associated pneumonitis and encephalitis. Policy changed in 1993 after fatal case of this in a severely immunocompromised man 1 year after vaccine
Who should be tested for measles and rubella IgG and when?
Both men and women LWH at baseline should have measles IgG checked even if history of childhood vaccination
Women of childbearing age should have rubella IgG checked at baseline
Who should receive MMR vaccine?
Measles seronegative patients with CD4 >200 and clinically stable
2 does 1 month apart
If not on ARVs unless high risky can wait til they are on them
What can be offered to PLWH who are measles seronegative but have CD4 <200 who are at high risk of measles infection?
HNIG gives ~3 weeks protection as pre exposure prophylaxis
What should be offered to PLWH exposed to measles?
Check IgG within 3 days - do not delay prophylaxis while waiting for result
Seronegative, CD4>200 with stable VL on ART - MMR within 3 days of contact or HNIG within 6 days
Other measles seroneg: HNIG within 6 days or IVIG up to 18 days after contact
CD4 <200 regardless of measles status HNIG within 6 days, in high risk cases IVIG up to 18/7
Who should receive rubella vaccination?
Women of childbearing age who are negative for rubella IgG CD4 >200 should have either one MMR followed but repeat serology at 4 weeks and 2nd dose if required or two doses one month apart
If also measles seroneg should have two doses one month apart
Should all PLWH have meningitis vaccine?
No
Only if high risk group as per green book guideline
For whom is meningococcal vaccine recommended?
Those < 25 who have not been previously vaccinated, uncertain history or received last men c vaccine under age 10 - menC, menACWY possibly menB
Functional or anatomical asplenia or persisting complement deficiency - menC, menB and/or menACWY depending on vaccine history
Those at risk through travel - MenACWY
Those at risks due to an outbreak - vaccine according to epidemiological scenario
Schedule for meningococcal vaccines if given to PLWH with risk factors?
2 vaccines 2 months apart
Booster MenACWY if still at risk every 5 years
Do PLWH get post exposure prophylaxis if contact of meningococcal disease?
Yes - antibiotic prophylaxis (eg cipro) and appropriate vaccination
Are pertussis vaccines safe in PLWH?
Yes. Inactive. Safe.
Only given to children <10 and to pregnant women between weeks 28-32
What post exposure prophylaxis should be given to PLWH who have had contact with pertussis cases?
Start abx usually macrolide within 21 days of cough starting in index patient
Vaccination also considered
Risk factors for mortality from pneumococcal disease in general population
Age > 65
Alcoholism
Cancer particularly haematological
CVD
COPD - not asthma
CLD
Chronic renal disease
DM
absent or non functioning spleen eg sickle cell
Hypogammaglobulinaemia
Malnutrition
Immunocompromised
Risk factor for severe pneumococcal disease in PLWH
Low CD4
African race
IVDsmoking
Previous aids defining diagnosis
Previous pneumonia
Chronic illness
Alcoholism
Even with ART PLWH 40x higher risk of IPD
What is the difference between PCV and PPV vaccines against pneumococcus?
PPV23 - peumococcal capsular polysaccharide from 23 serotype - single dose
PCV - designed for use in infant populations where pure polysaccharide vaccines fail to induce protective immune response
Immunogenicity improved by attaching the polysaccharide to a carrier protein
What vaccine should PLWH receive to protect against pneumococcal infection?
Single dose PCV13 (prevenar) irrespective of CD4 count, ART use, viral load
Should be given at least 3/12 after use of any PPV23 (penumovax)
If meeting national criteria for penumovax can have that too (eg >65)
Which PLWH should be vaccinated against polio?
Unvaccinated or uncertain vaccination history 0,1-2,6-12 months then doses after 5 and 10 years. Partially vaccinated people to complete course.
If at risk of exposure repeat dose every 10 years
If occupational Risk check for protective antibodies 3/12 after vaccination
Do we give post exposure prophylaxis for contact with polio?
If exposed to someone who has had oral polio vaccine or wild polio consider HNIG - based on considerations of vaccination history, CD4, viral load, polio serology
Are rabies vaccines safe for PLWH?
Yea but antibody response reduced if low cd4, high viral load
Should people with HIV receive smallpox vaccinations?
Not live vaccine unless immediate risk of contracting smallpox - high risk of becoming seriously unwell
When might a PLWH be given live smallpox vaccine?
If urgent need for protection and CD4 >/= 200
Following exposure can be given preferably within 3 days but max 10/7 post exposure if CD4 >50
What should those with CD4 -<50 be given if they are a smallpox contact?
Antiviral therapy
Seek expert help
Which PLWH will need tetanus vaccines?
Anyone with incomplete/unclear history of receiving 5 doses - 0,1,2months then 5 and 10 years
10 yearly boosters if ongoing risk eg occupational (5 yearly if over 50)
What post exposure prophylaxis should be given for tetanus wounds?
Uncertain/incomplete course - 3 vaccines 0,1,2 months
If had >3 previously last being >10yrs ago and low risk wound - 1 vaccine
If high risk wound should also have TIG
After TBE vaccine what is considered a protective response?
126 Vienna Units/mL
Post-vaccination testing is not recommended routinely in healthy individuals, but may be considered in some immunocompromised persons at risk of exposure in order to guide booster requirements.
Who should be vaccinated against tick borne encephalitis?
PLWH who intend to walk, camp, or work in heavily forested regions of TBE-affected countries during late spring or summer be offered TBE vaccination, particularly if staying in areas with heavy undergrowth.
Central and Eastern Europe, Russia, former Soviet Union, asia
What is the schedule for vaccine to protect against tick-borne encephalitis?
0,1,2, 9-12 months
If rapid protection needed - 0, 2 weeks, 5-12 months - may give less protection with CD4 <400
Booster every 3-5 years if ongoing risk (3 years if cd4 < 400)
Well tolerated - contraindicated in those with severe egg allergy
