Long-term safety and serologic response to measles, mumps, and rubella vaccination in HIV-1 infected adults

Protection of Vaccine Preventable Diseases in a Population of HIV-Infected Children: A 3 Years Prospective Study

Human Immunodeficiency Virus (HIV) infected children have a 30-70% chance of being incompletely immunized and may not respond serologically with the same magnitude or durability as uninfected children. The aim of the study was to describe the rate of protective antibodies titre and the persistence of the response against four recommended vaccinations in HIV infected children and adolescents. A two-phase observational study was performed in which protective IgG antibodies to measles, mumps, rubella and hepatitis B were determined and monitored for 12 and 24 months, in 26 perinatally HIV-infected children. The rate of protection for rubella and hepatitis B was significantly lower in the HIV group compared to the control group (92% vs. 65% for rubella and 78.4% vs. 45.4% for hepatitis B; p < 0.05). Children who received primary vaccination after initiating combination antiretroviral therapy (cART) had a higher rate of response. Seronegative patients who received a booster dose of vaccine had a good immunological response. HIV infection is associated with a lower response to vaccines against rubella and hepatitis. The beginning of cART before vaccination may be associated with a better response. The evaluation of the serological response is crucial in children with HIV infection in order to evaluate the protection of vaccine preventable diseases.

Measles Seroprevalence and Vaccine Responses in Human Immunodeficiency Virus-infected Adolescents and Adults: A Systematic Review

BACKGROUND

The World Health Organization (WHO) recommends an additional dose of measles-containing vaccine (MCV) for human immunodeficiency virus (HIV)-infected children receiving highly active antiretroviral therapy following immune reconstitution. We conducted a systematic review to synthesize available evidence regarding measles seroprevalence and measles vaccine immunogenicity, efficacy, and safety in HIV-infected adolescents and adults to provide the evidence base for recommendations on the need for measles vaccination.

METHODS

We conducted searches of 8 databases through 26 September 2017. Identified studies were screened independently by 2 reviewers.

RESULTS

The search identified 30 studies meeting inclusion criteria. Across studies, measles seroprevalence among HIV-infected adolescents and adults was high (median, 92%; 27 studies), with no significant difference compared to HIV-uninfected participants (10 studies). In 6 studies that evaluated the immunogenicity of MCVs among seronegative HIV-infected adults, measles seropositivity at end of follow-up ranged from 0% to 56% (median, 39%). No severe adverse events were reported following measles vaccination in HIV-infected patients.

CONCLUSIONS

Based on similar measles seroprevalence between HIV-infected and HIV-uninfected adolescents and adults, and the low response to vaccination, these studies do not support the need for an additional dose of MCV in HIV-infected adolescents and adults. These findings support WHO guidelines that measles vaccine be administered to potentially susceptible, asymptomatic HIV-infected adults, and may be considered for those with symptomatic HIV infection if not severely immunosuppressed. Measles-susceptible adolescents and adults, regardless of HIV status, may require targeted vaccination efforts to reach critical vaccination thresholds and achieve regional elimination goals.

Surprisingly Low Levels of Measles Immunity in Persons With HIV: A Seroprevalence Survey in a United States HIV Clinic

Background

Measles outbreaks have become increasingly common due to deteriorating vaccination rates, fluctuating herd immunity, and varying antibody decline. Limited knowledge exists regarding prevalence and risk factors associated with measles seronegativity among persons with HIV (PWH).

Methods

This was a cross-sectional study conducted at an academic HIV clinic in Omaha, Nebraska. Participants were screened for the presence of measles IgG antibody. Demographic and clinical information was obtained through electronic medical record review. Simple and multivariable logistic regressions were performed to identify risk factors for measles seronegativity.

Results

Three hundred fifty-one participants were enrolled, with a measles seroprevalence rate of 70.3%. The mean age (range) was 48 (20-74) years, 77% were male, and 53% were Caucasian. The mean CD4 nadir (range) was 334 (1-1675) cells/mm³. At the time of testing, 86% and 87% of the seronegative and seropositive participants had an HIV RNA <50 copies/mL, respectively. Younger age was significantly associated with measles seronegativity (P = .003), as was birth year after 1957 (P = .021). Prior history of measles infection was associated with seropositivity (P = .011). All other risk factors evaluated, including written documentation of adequate vaccination, were not associated with seronegativity.

Conclusions

Our study demonstrates a measles seroprevalence rate that is remarkably lower than previously reported in PWH (92%), and, more importantly, is considerably lower than the rate needed to maintain herd immunity (95%). With higher than expected seronegativity and absence of notable risk factors aside from age, our findings support expanded measles immunity screening for PWH who are at risk of measles exposure.

Preventing Measles in Immunosuppressed Cancer and Hematopoietic Cell Transplantation Patients: A Position Statement by the American Society for Transplantation and Cellular Therapy

Until recently, measles exposures were relatively rare and so, consequently, were an afterthought for cancer patients and/or blood and marrow transplant recipients and their providers. Declines in measles herd immunity have reached critical levels in many communities throughout the United States due to increasing vaccine hesitancy, so that community-based outbreaks have occurred. The reemergence of measles as a clinical disease has raised serious concerns among immunocompromised patients and those who work within the cancer and hematopoietic cell transplantation (HCT) community. Since live attenuated vaccines, such as measles, mumps, and rubella (MMR), are contraindicated in immunocompromised patients, and with no approved antiviral therapies for measles, community exposures in these patients can lead to life-threatening infection. The lack of data regarding measles prevention in this population poses a number of clinical dilemmas. Herein specialists in Infectious Diseases and HCT/cellular therapy endorsed by the American Society of Transplant and Cellular Therapy address frequently asked questions about measles in these high-risk cancer patients and HCT recipients and provide expert opinions based on the limited available data.

Viral mumps: Increasing occurrences in the vaccinated population

Before the introduction of the vaccine, mumps was the most common salivary gland disease and was one of the most common infectious diseases in children globally. Following the introduction of the mumps vaccine in 1967, the disease was almost nonexistent in the United States and was only found to occur in nonvaccinated patients, and even then, it did not present in epidemic portions because of the extent of vaccination in the population at large. Beginning in the early 2000s, viral mumps began to present itself in vaccinated populations, and currently, outbreaks are continuing to increase in number. This article presents information on the various outbreaks, a review of the virus and the disease, including symptoms and comorbidities, and new recommendations for management. Dental practitioners should be aware of the increasing incidence and prevalence of this disease, be able to recognize it, and make appropriate referrals for management.

Health Considerations for HIV-Infected International Travelers

PURPOSE OF THE REVIEW

International travel continues to steadily increase, including leisure travel, travel to one's country of origin to visit friends and relatives, travel for service work, and business travel. Travelers with HIV may have an increased risk for travel-associated infections. The pre-travel medical consultation is an important means of assessing one's risk for travel-related health issues. The aim of this review is to provide an update on key health considerations for the HIV-infected traveler.

RECENT FINDINGS

Like all travelers, the HIV-infected traveler should adhere to behavioral precautions, including safety measures with food and water consumption, safe sexual practices, and arthropod bite avoidance. HIV is a risk factor for venous thromboembolism and patients should be educated regarding this risk. Most pre-travel vaccines are safe and immunogenic in HIV-infected individuals, though live vaccines should be avoided in patients with low CD4 counts. Malaria chemoprophylaxis is strongly recommended in patients with HIV traveling to endemic areas and no significant interactions exist between the commonly used prophylactic anti-malarial agents and anti-retroviral therapy (ART). Travelers with HIV, particularly those who are not on ART or who have low CD4 cell counts, may have increased risk for tuberculosis, malaria, enteric infections, visceral leishmaniasis, American trypanosomiasis, and endemic mycoses such as histoplasmosis, talaromycosis, and coccidioidomycosis. The immune status of the HIV-infected traveler should be assessed prior to travel along with the duration, itinerary, and activities planned during travel in order to carefully consider individual risk for travel-related health issues.

Vaccinations for the HIV-Infected Adult: A Review of the Current Recommendations, Part II

Vaccination is a critical component for ensuring the ongoing health HIV-infected adults. Since this group may have reduced immune responses and shorter durations of protection post-vaccination, HIV-specific guidelines have been published. This review article provides a comprehensive discussion of the current guidelines and evidence-based data for vaccinating HIV-infected adults, including data on dosing schedules, immunogenicity studies, and safety. In the current paper, part II of the review, live vaccines, as well as vaccines for travelers and specific occupational groups, will be discussed.

Measles, mumps, rubella and VZV: importance of serological testing of vaccine-preventable diseases in young adults living with HIV in Germany

Measles, mumps, rubella (MMR) and varicella zoster virus (VZV) infection can cause serious diseases and complications in the HIV-positive population. Due to successful vaccination programmes measles, mumps and congenital rubella syndrome has become neglected in Germany. However, recent outbreaks of measles have occurred from import-associated cases. In this cross-sectional study the serostatus for MMR and VZV in 2013 HIV-positive adults from three different university outpatient clinics in Bonn (n = 544), Cologne (n = 995) and Munich (n = 474) was analysed. Sera were tested for MMR- and VZV-specific immunglobulin G antibodies using commercial immunoassays. Seronegativity was found in 3% for measles, 26% for mumps, 11% for rubella and 2% for VZV. Regarding MMR, 35% of patients lacked seropositivity against at least one infectious agent. In multivariable analysis younger age was strongly associated with seronegativity against all four viruses, measles, mumps, rubella (P < 0·001, P < 0·001 and P = 0·001, respectively) and VZV (P = 0·001). In conclusion, there is high need for MMR and VZV vaccination in people living with HIV in Germany born in 1970 or later. Thus, systematic MMR and VZV antibody screening and vaccination should be implemented in the HIV-positive population to prevent serious disease and complications of vaccine-preventable diseases.

Measles immunity among pregnant women aged 15-44 years in Namibia, 2008 and 2010

Background:

Namibia experienced a large measles outbreak starting in 2009, with 38% of reported cases in adults, including women of reproductive age. Population immunity was assessed among pregnant women to determine whether immunization activities were needed in adults to achieve measles elimination in Namibia.

Methods:

A total of 1708 and 2040 specimens sampled from Namibian pregnant women aged 15–44 years who were included in the 2008 and 2010 National HIV Sentinel Survey, respectively, were tested for measles immunoglobulin G antibody. The proportion of women seropositive overall and by 5-year age strata was determined, and factors associated with seropositivity were analyzed by logistic regression, including age, facility type, gravidity, HIV status, and urban/rural setting. Seropositivity in 2008 versus 2010 was compared.

Results:

In both analysis years, measles seropositivity was lower in 15–19-year-olds (77%) and 20–24-year-olds (85–87%) and higher in 25–44-year-olds (90–94%) (2008, p < 0.001; 2010, p < 0.001). Overall measles seropositivity did not differ between 2008 (87%) and 2010 (87%) (p = 0.7). HIV status did not affect seropositivity.

Conclusions:

Late in a large measles outbreak, 13% of pregnant women in Namibia, and almost one in four 15–19-year-old pregnant women, remained susceptible to measles. In Namibia, immunization campaigns with measles-containing vaccine should be considered for adults.

Seroprevalence of antibodies to measles, mumps, and rubella, and serologic responses after vaccination among human immunodeficiency virus (HIV)-1 infected adults in Northern Thailand

BACKGROUND

After the global implementation of national immunization programs for prevention of measles, mumps, and rubella (MMR), the prevalences of protective antibodies to these viruses are high in general population. However, there are limited data among human immunodeficiency virus (HIV)-1 infected individuals. This study aimed to determine the seroprevalence of antibodies to these viruses, and the serologic responses after vaccination among HIV-infected adults in Northern Thailand.

METHODS

A cross-sectional study was conducted in 500 HIV-infected adults, aged 20-59 years, receiving combination antiretroviral therapy, CD4 cell count ≥200 cells/mm(3), and plasma HIV-1 RNA <50 copies/mL, and 132 HIV-uninfected controls, aged 20-59 years, at Chiang Mai University Hospital during July and August 2011. Prevalences of protective antibodies to these viruses as well as serologic responses after MMR vaccination in those without protective antibody to at least one of the three viruses were compared between groups.

RESULTS

The prevalences of protective antibodies to measles, mumps, and rubella were 94.2, 55.0, and 84.6 % among HIV-infected adults, and 97.7, 67.5, and 89.4 % among HIV-uninfected controls, respectively. The prevalence of protective antibody to mumps was significantly lower in HIV-infected adults (p-value = 0.010). MMR vaccination was done in 249 HIV-infected and 46 HIV-uninfected controls; at week 8 to 12 after vaccination, the seroprotective rates against measles, mumps, and rubella in HIV-infected adults were 96.4, 70.7, and 98.0 %, respectively, whereas those in HIV-uninfected controls were 100, 87, and 100 %, respectively. No serious adverse effects were observed.

CONCLUSIONS

In contrast to measles and rubella, the prevalence of protective antibody to mumps was low in both HIV-infected adults and HIV-uninfected controls in northern Thailand. The seroprotective rates after MMR vaccination in both groups were considerably high, except only for mumps. Therefore, MMR vaccination should be considered in all HIV-infected adults receiving antiretroviral therapy with undetectable plasma HIV-1 RNA and CD4 cell count ≥200 cells/mm(3).

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02724852 , registered on March 31, 2016.

Vaccination in HIV-infected individuals

Vaccinations are key to limiting the increased risk of severe infectious diseases in HIV-infected patients for whom the risk–benefit ratio has been re-evaluated. Vaccine safety and immunogenicity depend on both vaccine type and immune deficiency, while vaccine-induced immune activation promotes a transient increase in viral load. Vaccine immunogenicity is reduced and wanes more rapidly, strengthening the need for revaccination. While inactivated vaccines are safe, attenuated vaccines are theoretically contraindicated, but the risk of infectious diseases outweighs the risks of severe adverse events in endemic areas, where the majority of HIV-infected individuals live, thus allowing their use when immune deficiency is moderate. Immune reconstitution with HAART has improved vaccine immune response, highlighting the importance of global access to and early initiation of therapy.