Vaccinations/malignancy/transplant Flashcards
Which HIV positive people are at increased risk of severe COVID outcomes?
Pregnant women
Nadir CD4<200
CD4<350 or ongoing viraemia
Should offer vaccination to all including low CD4 although immune response may be lower magnitude
Live (replicating) viruses that should not be given when CD4<200:
MMR
Chickenpox
Shingles
Yellow fever
Postpone until CD4 improved, ideally >350, if 200-350 depends on risk of the disease
Interval of 4 weeks between live vaccines in the immunocompetent
Hepatitis A information
- Faeco-oral transmission
- Jaundice in 1-5%. children but 70-80% adults, fulminant hepatitis rare <1%
- Those with chronic liver disease at risk of severe complications
- If high risk contact then HAV vaccine plus HNIG within 14 days, especially if CD4<200
- Standard vaccine dose is fine for CD4>350 = 2 doses 6-12 months apart
- If CD4<350 give 3 doses 0, 1 and 6 months
- Boosting dose 10 yearly if at ongoing risk
- Could screen for immunity prior
Persistence of HBV depending on age you get it:
- HBV persistent in up to 90% of infants infected perinatally
- 25-50% of children age 1-5
- 1-5% of immunocompetent adults and children
HIV increases risk of HBV and risk of chronicity
Factors that reduce immune response to hep B vaccine:
Age>40
Male
Haemodialysis
Smoking
Obesity
Immunocompromise including HIV
How to vaccinate for Hepatitis B in HIV positive
- Double dose 40mcg of Energix or HBvaxPRO (yeast based) normal 20mcg of Fendreix
- 4 doses at 0,1,2 and 6 months
- (Only consider ultra rapid course at 0, 1 and 3 weeks with normal dose vaccine if imperative for vaccination/compliance concerns and CD4>500)
- Measure HbSab at 4-8 weeks:
- If <10 give 3 further doses at monthly intervals
- If between 10-100 may give 1 booster and re-test in 4-8 weeks
Following high risk exposure to HBsAg positive source
- If evidence of current or past infection no prophylaxis needed
- If vaccinated with HbSAb>10 offer one booster dose, and if CD4<200 also HBIG
- Non responder to previous vaccination should be offered booster vaccine and HBIG regardless of CD
- Not vaccinated or uncertain -> offer vaccine course 0, 1, 2,6 and HBIG regardless of CD4
- If HBIG indicated give 2 doses 1 month apart
- Post exposure prophylaxis should be given within 7 days, up to 6 weeks may be considered
BHIVA recommendations and suggestions for HPV vaccination?
Recommend (regardless of CD4, VL, ART):
- all HIV positive up to age 26
- all MSM up to age 40
Suggest:
- all women up to age 40
- if ART naive and CD4<200 may defer until established on ART
3 doses of quadrivalent given at 0, 1-2 months and 6 months
If schedule interrupted, complete it rather than restart
Flu vaccine recommendations
- Annual between Sept and early Nov (although may be benefit until Match) with non replicating virus
- Offer vaccine to close contact of profoundly immunocompromised
Measles screening and management of exposure
Screen for measles IgG
If seronegative and CD4>200 offer 2 doses MMR at least 1 month apart
Postpone if not yet on ART
After a recognised exposure to measles:
- Test IgG within 3 days
- If measles seronegative and CD4>200: MMR within 3 days of context or NHIG within 6 days
- If measles seronegative and CD4<200L HNIG within 6 days (or IVIG up to 18 days)
(NB women of childbearing age screen for rubella and offer MMR if negative and CD4>200 and not pregnant)
Meningococcus vaccination:
- Usual vaccination is MenC as part of infant program then MenACWY recommended for adolescents/uni
- Offer these if <25 and not previously vaccinated
- For asplenia give MenC, Men B and/or MenACWY\
- Give 2 vaccines at 2 months interval
- Close contacts offer Abx and vaccination
Step pneumonia (pneumococcus)
- Most frequent bacterial co-infection with Flu
- Incidence has decreased with ART but HIV pos still have 40x higher risk than HIV neg
- HIV positive adults should receive a single dose of PCV13 regardless of CD4 (at least 3 months after any use of PPV23)
- HIV positive adults who meet indications for PPV23 vaccination with national program should also get single PPV23
Small pox vaccination
Generally just e.g. lab workers
If non urgent can give the non replicating Imvanex 2 doses 1 month apart regardless of CD4
If urgent, can give replicating if CD4>200, if <200 need to be careful, can give it if CD5>50, if <50 unlikely to respond so give antirvirals
Recommendations for VZV testing/vaccination
- Test for VZV IgG
- If negative and CD4>200 give 2 doses of chickenpox vaccine 3 months apart and check serology 4-6 weeks later
- If VZV IgG positive with CD4>200 can be offered VZV vaccine (Zostavax) in line with national guidelines if >70 years
What to do if VZV exposed and IgG negative
- If CD4<200: give VZIG asap and antivirals, acyclovir 800mg QDS or valaciclovir 1g TDS 7 days after exposure for 7 days
- If CD4<400 give VZIG as soon as possible, if not available give antivirals
- If CD4>400 give varivax vaccine within 3 but up to 5 days post exposure and again at 3 months
Post anthrax exposure
Ciprofloxacin and vaccinate
Contact of diphtheria
Erythromycin prophylaxis, and single reinforcing dose if already immunised or full course if not immunised
Haemophilus influenza serotype B
- Increased risk of invasive disease if HIV positive
- Household contacts given prophylaxis e.g. rifampicin
- If asplenic give dose whether previously vaccinated or not and regardless of CD4/ART/VL, e.g. Him/MenC
Hepatitis A vaccination and post exposure
- If high risk exposure then HAV vaccine plus HNIG within 14 days
- Vaccination is 2 doses 6-12 months apart if CD4>350
- CD4<350 then given 3 doses 0, 1 and 6 months
- Booster 10 yearly
- May be advisable to screen for immunity prior
Which HPV usually cause warts and cancer
- 90% warts 6 and 11
- 60% cancers 16 and 18
Measles vaccination guidelines
- Screen for IgG
- If seronegative and CD4>200 offer 2 doses of MMR at least 1 month apart, postpone if not yet on ART
Measles post exposure:
- Screen for measles IgG within 3 days
- If seronegative, CD4>200: MMR vaccine within 3 days of contact or NHIH within 6 days
- If measles seronegative and CD4<200: HNIG within 6 days, can consider it up to 18 days
Rubella screening
- Screen all women of child bearing age
- if CD4>200 and not pregnant, give MMR
Streptococcal pneumoniae vaccination
- All HIV positive should receive a single dose of PCV13 regardless of CD4 (at least 3 months after any use of PPV23)
- HIV positive adults who meet indications for PPV23 vaccination (e.g. >65 or other co-morbidity) should also get single PPV-23
- No repeats necessary
Streptococcal pneumoniae vaccination
- All HIV positive should receive a single dose of PCV13 regardless of CD4 (at least 3 months after any use of PPV23)
- HIV positive adults who meet indications for PPV23 vaccination (e.g. >65 or other co-morbidity) should also get single PPV-23
- No repeats necessary
Rabies PEP
- Nearly 100% effective if given <12-24 hours
- Vaccine is the mainstay with rapid vaccination 0, 3, 4, 7, 14 and 30 days
- If already had some vaccine then 2 doses 0 and 3-7 days
- Sometimes HRIG at the wound
BCG
Do not give in HIV
HIV specific renal transplant inclusion criteria:
- Good compliance with ART
- CD4>200 last 6 months
- VL<50 for last 6 months
HIV specific renal transplant exclusion criteria:
- CD4<200
- VL detectable
- Non adherence
- History of PML ever
- Extracutaneous KS
- EBV and HHV8 driven disorders e.g. MCD
- More than 3 class resistance and lack of future options
General exclusions from renal transplant:
- Previous or current infections at high risk reactivating
- HTLV 1
- Advanced cardiopulmonary disease
- History of neoplasms except solid tumours adequately treated with >5 disease free years
- Significant HPV cervical or anal disease including CIN/AIN III and in situ
- Hepatitis cirrhosis, e.g. F4
- Pregnancy
Pre transplant immunisations
- Recommend Hep b if abs<10, HAV, PPV23, VZV (if CD4>200), Flu annually
- Suggested that DTP to all (diptheria, tetanus, pertussis), MMR if non immune to measles and HPV to those at risk
Post transplant prophylaxis
- HIV transplant recipients lifelong PCP prophylaxis
- If recipient CMV negative and donor positive then minimum 3 months CMV prophylaxis, if recipient CMV positive 3 months prophylaxis or PCR surveillance
- Toxo IgG positive with CD4<200 lifelong prophylaxis
- CD4<50 MAC prophylaxis
AIDS defining cancers
- KS
- High grade B cell non Hodhgkin lymphoma
- Cervical cancer
KS cells stain for endothelial cells with which markers?
CD34
CD31
Identification of HHV8 in lesions using a monoclonal antibody again LANA (HHV8 latent nuclear antigen) is the most useful immunostaining technique
Poor prognostic factors in KS
- Tumour associated oedema or ulceration
- Extensive oral disease (not confined to palate)
- Gastrointestinal KS or other non nodal viscera
- CD4<150
- History of HIs and/or thrush
- ‘B’ symptoms present
- Performance status <70
- Other HIV related illness
Side effects of liposomal doxorubicin (Caylex)
Given as infusion 3 weekly, overall response rate of 76% in HIV
- Grade IV neutropenia 5%, risk of infection
- Hand feet syndrome (redness/soreness)
- GI upset
- Rash
- Les commonly hairloss
- Rarely cardiomyopathy with liposomal
- Does not appear to suppress CD4
Why is paclitaxel second line?
- More neutropenia and alopecia with comparable progression free survival
- Need to give steroids prior to prevent allergic reaction
DLBCL treatment
R CHOP
Burkitt’s treatment
CODOX-M/IVAC, hyperCVAD
EBV DNA in CSF
- Very high sensitivity and specificity for PCSNL (?in the setting of brain lesion)
- Negative does not exclude PCSNL though
EBV DNA in CSF
- Very high sensitivity and specificity for PCSNL (?in the setting of brain lesion)
- Negative does not exclude PCSNL though
Diagnosis of PCNL
- CT/MRI/SPECT
- LP for cytology and EBV
- Brain biopsy sometimes
- Look for systemic disease with CTCAP
- SPECT showing high uptake and/or positive EBV DNA on CSF has very high sensitivity so can avoid biopsy
- if hypoactive lesion and negative EBV DNA on CSF then empiric toxoplasmosis treatment
- Discordant SPECT/PCR -> brain biopsy
- Ring enhancement may be seen in up to 50%
Treatment of PCNSL
- Prognosis dismal
- ART
- Steroids for symptoms
- Consider IV high dose methotrexate
Treatment of Hodgkin lymphoma
- ABVD +/- radiotherapy
OI prophylaxis in chemotherapy
- Septrin 480mg OD
- Fluconazole 50mg OD
- Valaciclovir 500mg BD or acyclovir 400-800mg bD
- Azithromycin 1250mg/week
NB in KS reviewing Caelyx not at increased risk of CD4 decline so not needed unless already on
PIS and vinblastine
Neurotoxicity and neutropenia
Treatment of multi centric Castleman’s disease
- Rituximab
Diagnosis of MCD
- CTCAP +/- PET +/- bone marrow
- Biopsy: characteristic onion skin appearance, and HHV8 expression (LANA) and IgM lamda
- Serum HHV8 DNA significantly higher than in KS
- Rise in HHV8 can predict relapse
- 88% 5 year survival with treatment
- Can be relapsing remitting
