New & Improved Immunizations

Last year brought the introduction of two vaccines. Interestingly, they are like bookends on the adult life span. One prevents human papillomavirus and is for women and girls younger than 26. The other prevents shingles and is for people over 60. For everyone in between, there have been changes in the standard recommendations for immunizations. So we are going to look at what to do with the new vaccines and update information on the old vaccines. You should review your immunization status with your health care provider every year. When patients are first diagnosed with HIV, it is standard to update all missing immunizations. Often many years have passed since they were last received, and a patient's immunization records can be difficult to find. Some vaccines need to be repeated periodically, and others fade over time, requiring the levels of antibody response to be checked. Either way, it's important to keep up to date. Hepatitis B. It is now recommended that the double dose (40 micrograms) be used for all HIVers. This is the dose found in Recombivax but not Engerix, which has 20 micrograms. If you have been previously vaccinated, find out if you had your hepatitis B surface antibodies checked. If they were present, you are OK regardless of which vaccine was used. If they are absent, you should be revaccinated with the complete three-shot series of the higher dose. In this case, testing for hepatitis B surface antibodies should be quantitative, where a level over 10 indicates immunity. Standard commercial laboratory testing, which reports results simply as 'present' or 'absent,' can miss low-level antibodies that are still fully protective. Also consider rechecking the antibody levels if the last check was more than seven to 10 years earlier, since levels can fade over time. Finally, note that Twinrix, which contains both hepatitis A and B vaccines, uses the lower dose for hepatitis B. It should no longer be used for HIVers. Tetanus. There's a new tetanus booster that contains protection against pertussis (whooping cough) in addition to tetanus and diphtheria. Since there are still scattered cases of whooping cough around, it is recommended that all adults receive this formulation. Normally, tetanus is boosted every 10 years'or after five years if there has been a deep wound. If you get a cut, you need to get a booster within 72 hours. It is safe to get the new tetanus booster if your last regular tetanus shot was more than two years earlier. Shingles. The new vaccine for shingles (varicella zoster) is indicated for people over 60. However, it is a live-virus vaccine. Therefore, it should not be given to anyone who is HIV-positive. Also, anyone who gets the vaccine can shed active virus and should have minimal contact with any HIVer for two weeks. As a reminder, all this is also true for the chickenpox vaccine, another live varicella zoster vaccine. HPV. This vaccine has been tested only on women and is recommended for 9- to 26-year-olds. It prevents four strains of HPV that cause 70% of cervical cancer and 90% of genital warts in women. There is no live virus, so it is safe to use in HIV-positive women. Trials are under way in men. Pneumococcus. This vaccine prevents a common community-acquired pneumonia that often complicates other respiratory infections and is potentially fatal. This vaccine should be boosted once after five years. However, the response to the vaccine is reduced if a patient's CD4-cell count is below 200. If this is the case, then revaccination can occur sooner, when CD4 cells are over 200. Or the initial vaccine can be postponed until antiretrovirals are started and the CD4 count climbs above 200. These vaccines should keep you healthy at home, but if you are going to be traveling this summer, I have more recommendations coming in the next issue.