E. MacMahon

British HIV Association guidelines for immunization of HIV-infected adults 2008.

Table of contents 1.0 Introduction 1.1 General principles of immunization in HIVinfected adults 1.2 Practical aspects of immunization and general contraindication 2.0 Anthrax 2.1 Background 2.2 Epidemiology and risk groups 2.3 Anthrax vaccine 2.3.1 Vaccine efficacy 2.3.2 Vaccine safety 2.4 Recommendations for anthrax pre-exposure prophylaxis in HIV-infected adults 2.5 Post-exposure prophylaxis 3.0 Cholera 3.1 Background 3.2 Epidemiology and risk groups 3.3 Cholera vaccine 3.3.1 Vaccine efficacy 3.3.2 Vaccine safety 3.3.3 Contraindications 3.4 Recommendations for cholera pre-exposure prophylaxis in HIV-infected adults 4.0 Diphtheria 4.1 Background 4.2 Epidemiology and risk groups 4.3 Diphtheria vaccine 4.3.1 Vaccine efficacy 4.3.2 Vaccine safety 4.4 Recommendations for diphtheria pre-exposure prophylaxis in HIV-infected adults 4.5 Post-exposure prophylaxis 4.6 Auditable outcomes 5.0 Haemophilus influenzae serotype b 5.1 Background 5.2 Epidemiology and risk groups 5.3 Hib vaccine 5.3.1 Vaccine efficacy 5.3.2 Vaccine safety 5.4 Recommendations for H. influenzae pre-exposure prophylaxis in HIV-infected adults 5.5 Post-exposure prophylaxis 5.6 Auditable outcomes 6.0 Hepatitis A 6.1 Background 6.2 Epidemiology and risk groups 6.3 Hepatitis A vaccine 6.3.1 Vaccine efficacy 6.3.2 Vaccine safety 6.4 Human normal immunoglobulin 6.5 Recommendations for hepatitis A pre-exposure prophylaxis in HIV-infected adults 6.6 Post-exposure prophylaxis 6.7 Recommendations for hepatitis A post-exposure prophylaxis in HIV-infected adults 6.8 Auditable outcomes 7.0 Hepatitis B 7.1 Background 7.2 Epidemiology and risk groups 7.3 Hepatitis B vaccine 7.3.1 Vaccine efficacy 7.3.2 Vaccine safety 7.4 Recommendations for hepatitis B pre-exposure prophylaxis in HIV-infected adults 7.5 Post-exposure prophylaxis *Anna Maria Geretti, Royal Free Hospital, London; Gary Brook, Central Middlesex Hospital, London; Claire Cameron, Health Protection Agency, Colindale; David Chadwick, James Cook University Hospital, Middlesbrough; Robert S Heyderman, Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi; Eithne MacMahon, Guy’s and St Thomas’ NHS Foundation Trust, London; Anton Pozniak, Chelsea and Westminster Hospital, London; Mary Ramsay, Health Protection Agency, Colindale; M Schuhwerk, Mortimer Market Centre, London.

Patient characteristics and severity of human rhinovirus infections in children

Abstract Background It is increasingly recognized that human rhinoviruses (HRV) can be associated with severe infections. However, conflicting results have been reported on the relative prevalence and severity of the three HRV species. Objectives The relative prevalence and clinical characteristics of HRV-A, B and C, in children attending a South London teaching hospital were investigated retrospectively. Study design Children aged <16 years with episodes of respiratory tract infections and detectable entero/rhinovirus RNA in respiratory samples between November 2009 and December 2010 were investigated. Retrospective case review was performed and patients’ characteristics recorded. Results Entero/rhinoviruses were the commonest viral pathogens (498/2316; 21.5%). Amongst 204 infection episodes associated with entero/rhinovirus, 167 were typed HRV, HRV-C was the most prevalent (99/167, 59.3%) followed by HRV-A (60/167; 35.9%) and HRV-B (8/167, 4.8%). The severity spectrum of HRV-A and HRV-C infections were similar and affected all parts of the respiratory tract. Co-pathogens were observed in 54 (26.5%) episodes. Severity was increased in patients with non-viral co-pathogens and those with an underlying respiratory condition. Univariate and multiple regression analyses of potential prognostic variables including age, co-pathogens and underlying respiratory illnesses showed that mono-infection with HRV-C, as compared with other HRV species, was associated with more severe disease in young children <3 years. Conclusions HRV-C was the most prevalent species and on its own was associated with severe disease in children <3 years. The association between infection with HRV species and clinical presentation is complex and affected by many confounding factors.

A parainfluenza-3 outbreak in a SCT unit: sepsis with multi-organ failure and multiple co-pathogens are associated with increased mortality

The estimated frequency of parainfluenza virus 3 (PIV-3) infections following haematopoietic SCT (HSCT) is 2–7%, whereas reported mortality ranges from 18 to 33%. We report a retrospective outcome analysis following an outbreak of PIV-3 infection in our transplant unit. A total of 16 HSCT patients developed PIV-3 infection. All patients had upper respiratory tract infection, whereas lower respiratory tract infection occurred in 8 patients. Overall, 13 patients were treated with aerosolised Ribavirin (2 g t.d.s. for 5 days) and i.v. Ig (0.5 g/kg) as per standard protocol. One patient refused treatment, whereas two patients with full immune reconstitution were not treated. Overall mortality was 62.5%. Sepsis with multi-organ failure and the presence of pulmonary co-pathogens were both significantly associated with PIV-3-related mortality. Our series confirms that high mortality is associated with PIV-3 infection in HSCT recipients. In patients who develop PIV-3 infection, despite strict enforcement of infection control policies, the best strategy might be careful risk assessment, with effective broad-spectrum anti-microbials in those who are at risk of secondary infection.

British HIV Association Guidelines on the Use of Vaccines in HIV-Positive Adults 2015

These guidelines provide updated, GRADE-based recommendations on the use of vaccines in HIVpositive adults. Several factors have made the updating of HIV-specific vaccination guidelines important: effective antiretroviral therapy (ART) has substantially modified the natural history of HIV infection, vaccination practices are evolving, and a large number of novel vaccines are becoming available in clinical care. The update contains important new guidance regarding the use of new vaccines against human papillomavirus (HPV), shingles (herpes zoster), and pneumococcus. Further key updates are related to the use of hepatitis B, meningococcus, and pertussis vaccines. Compared with HIV-negative individuals, HIV-positive adults often have an increased risk of infection or experience more severe morbidity following exposure to vaccine-preventable diseases, and therefore a lower threshold for extending indications and offering vaccination may be appropriate relative to the general population. Improved health and prognosis mean that HIV-positive adults are also increasingly likely to engage in travel or occupations that carry a risk of exposure to infectious agents, and these otherwise healthy individuals should not be denied protection or engagement with such activities if evidence indicates vaccination is safe and immunogenic. Immune responses to vaccination are often sub-optimal in HIV-positive patients, and while these improve with ART, they often remain lower and decline more rapidly than in HIV-negative individuals. However, many of these vaccines still afford protection and for some vaccines it is possible to improve immunogenicity by offering modified vaccine schedules, with higher or more frequent doses, without compromising safety. Non-replicating vaccines (e.g., whole inactivated, polysaccharide, conjugated, and subunit vaccines, or virus-like particles) can be used safely in HIV-positive persons, whereas replicating (live) vaccines have traditionally been contraindicated. However, ART-induced Immunorestoration reduces the risk of adverse events, in many cases shifting the risk-benefit ratio in favour of vaccination, whereby the risk of disease with natural infection becomes greater than the risk of live vaccine-related adverse events. Important examples of replicating vaccines that can be used in HIV-positive persons with good immunity include those for measles, mumps and rubella (MMR), varicella-zoster virus (VZV), and yellow fever. For vaccinated individuals, the importance of infection avoidance and infection control should continue to be emphasised. It is envisaged that the HIV specialist should provide overall guidance on vaccine use and enlist the help of primary care physicians for vaccine administration. Education of health care providers and good communication are key requirements to ensure successful implementation of this guidance. Despite evidence that HIV-positive persons benefit from vaccination, there are persisting perceptions about disease incidence and burden, and vaccine effectiveness and safety, which affect vaccination practices among health professionals caring for HIV-positive patients. It is hoped that this guidance will help overcoming such barriers.