Vaccination Schedule

The page has been copied from www.hivwebstudy.org:

Update to HBV Vaccination at Madison (see below) [pdf]

Recommended Adult Immunization Schedule: January 2009

Annals of Internal Medicine - January 2009

Vaccines & Immunizations - CDC web site

Quick Guide - New Adult Immunization Guidelines

Pneumococcal Vaccine - Decision Tree [New - 2012]

2007-2008 Adult Schedule Figures

Figure 1 - Age based schedule
Figure 2 - Medical and Other Indications; columns 2 & 3 HIV related
Must be read with included footnotes
Click here [pdf]

Recommended Immunizations for HIV-Infected Adults

* Hepatitis B vaccination

Currently, we are providing double-dose 40 mcg recombinant HBV vaccine (2 doses of 20 mcg/ml Engerix-HB) to our patients, based on 2006 Guidelines from the Advisory Committee on Immunization Practices. However, 2008 Guidelines from the DHHS/CDC/HIVMA on Opportunistic Infections do not recommend double-dosing up front, arguing that the data in support of this practice is inadequate. We have reviewed the primary literature and agree that there is insufficient evidence to support widespread use of double-dose HB vaccine. There is some data to support its use in revaccination of non-responders. Therefore, Madison Clinic guidelines on hepatitis B immunization will be as follows:

Primary vaccination: Immunize all patients seronegative for hepatitis B surface antigen and antibody with 20 mcg of Engerix-HB at months 0, 1 and 6. [NOTE: 4 doses required only for double-dose). If patient is seronegative for both hepatitis A and B, then Twinrix – the bivalent vaccine for both HAV and HBV can be used at months 0, 1 and 6.

NOTE: Advised to start immediately soon after entry into care, esp if pt has early HIV infection and high CD4 counts. If pt has more advanced disease (esp nadir CD4 <200) and you anticipate starting HAART within next 6 months, advise waiting until viral suppression achieved as this has been shown in several studies to be associated with improved vaccine responses. It is less clear whether waiting for immune reconstitution to CD4>200 is warranted.
Isolated anti-HB core patients: The DHHS OI Guidelines note that the majority of HIV-infected patients with negative HBsAb, HBsAg and isolated anti-HBc antibody are not immune to HBV infection – i.e. studies have shown that these patients mount a slow response to vaccination similar to non-immune individuals. Therefore, these patients should receive vaccine series as described above.

Assess protective response: Check HBsAb titer 1-2 months after last vaccine dose to confirm seroconversion.
Re-vaccination: For non-responders to this primary series (esp if CD4 count now >350 and suppressed on HAART), administer 2nd vaccine series with double-dose 40 mcg of Engerix-HB at months 0, 1, 2 and 6. Again, check HBsAb titer x 1-2 months after completion of this series to assess response. There is no data to support vaccinating beyond a 2nd series for those who still do not respond.

No clear data to support annual HBsAb assessment or booster dosing beyond what is described above.

* Varicella vaccination should be considered for HIV-infected children with age-specific CD4+ T-lymphocyte percentage >15% and may be considered for "non-immune" adolescents and adults in with CD4+ T-lymphocyte count >200 cells/L.

This table has been reproduced and modified from the ACIP recommendations for routine immunizations of adults with medical conditions. Centers for Disease Control and Prevention: The Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2002-2003 and Recommended Immunizations for adults with medical conditions: United States, 2002-2003. MMWR Recomm Rep. 2002;51(40):904-8.

For the full CDC guidelines on vaccinations see: http://www.cdc.gov/mmwr/PDF/rr/rr5102.pdf

*Adobe Acrobat Reader is required for viewing or printing PDFs. Acrobat Reader is available free of charge from the Adobe website at http://www.adobe.com/prodindex/acrobat/readstep.html

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However, 2008 Guidelines from the DHHS/CDC/HIVMA on Opportunistic Infections do not recommend double-dosing up front, arguing that the data in support of this practice is inadequate. We have reviewed the primary literature and agree that there is insufficient evidence to support widespread use of double-dose HB vaccine. There is some data to support its use in revaccination of non-responders. Therefore, Madison Clinic guidelines on hepatitis B immunization will be as follows: Primary vaccination: Immunize all patients seronegative for hepatitis B surface antigen and antibody with 20 mcg of Engerix-HB at months 0, 1 and 6. [NOTE: 4 doses required only for double-dose). If patient is seronegative for both hepatitis A and B, then Twinrix – the bivalent vaccine for both HAV and HBV can be used at months 0, 1 and 6. NOTE: Advised to start immediately soon after entry into care, esp if pt has early HIV infection and high CD4 counts. If pt has more advanced disease (esp nadir CD4 <200) and you anticipate starting HAART within next 6 months, advise waiting until viral suppression achieved as this has been shown in several studies to be associated with improved vaccine responses. It is less clear whether waiting for immune reconstitution to CD4>200 is warranted. Isolated anti-HB core patients: The DHHS OI Guidelines note that the majority of HIV-infected patients with negative HBsAb, HBsAg and isolated anti-HBc antibody are not immune to HBV infection – i.e. studies have shown that these patients mount a slow response to vaccination similar to non-immune individuals. Therefore, these patients should receive vaccine series as described above. Assess protective response: Check HBsAb titer 1-2 months after last vaccine dose to confirm seroconversion. Re-vaccination: For non-responders to this primary series (esp if CD4 count now >350 and suppressed on HAART), administer 2nd vaccine series with double-dose 40 mcg of Engerix-HB at months 0, 1, 2 and 6. Again, check HBsAb titer x 1-2 months after completion of this series to assess response. There is no data to support vaccinating beyond a 2nd series for those who still do not respond. No clear data to support annual HBsAb assessment or booster dosing beyond what is described above. * Varicella vaccination should be considered for HIV-infected children with age-specific CD4+ T-lymphocyte percentage >15% and may be considered for "non-immune" adolescents and adults in with CD4+ T-lymphocyte count >200 cells/L. From:HIV Web Study <http://www.hivwebstudy.org> © 2004 University of Washington This table has been reproduced and modified from the ACIP recommendations for routine immunizations of adults with medical conditions. Centers for Disease Control and Prevention: The Advisory Committee on Immunization Practices. Recommended adult immunization schedule: United States, 2002-2003 and Recommended Immunizations for adults with medical conditions: United States, 2002-2003. MMWR Recomm Rep. 2002;51(40):904-8. For the full CDC guidelines on vaccinations see: http://www.cdc.gov/mmwr/PDF/rr/rr5102.pdf *Adobe Acrobat Reader is required for viewing or printing PDFs. Acrobat Reader is available free of charge from the Adobe website at http://www.adobe.com/prodindex/acrobat/readstep.html [top of page]
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