Seroprevalence and vaccination of measles, varicella and rubella in adolescents with vertically acquired HIV infection: a multicentre audit Elgalib A 1,2, Hamlyn E 1,3, Foster C1,4, Fish R1,5, Tanna N1,6, Prime K 1,7 on behalf of the HIV in Young Persons Network (HYPNet) 1. HYPNet, 2. Croydon University Hospital NHS Trust, 3. King’s College Hospital NHS Foundation Trust, 4. Imperial College Healthcare NHS Trust, 5. Mortimer Market Centre, Central and North West London NHS Foundation Trust, 6. Body and Soul Charity, 7. St George’s Healthcare NHS Trust, London, UK BHIVA 2012 , P81 Background Results The British HIV Association immunization guidelines1 recommend that all HIV-infected individuals should be screened for measles IgG, rubella IgG and varicella zoster virus (VZV) IgG at baseline. VZV vaccine is recommended for stable, non immune patients with CD4 >400cells/ml. Measles-mumps-rubella (MMR) vaccine should be offered to measles IgG-seronegative patients with CD4 >200cell/ml and to rubella IgG-seronegative women of child-bearing age. The Paediatric European Network for Treatment of AIDS (PENTA) guidelines on vaccination in HIV-infected children 2 recommend that measles and rubella antibodies should be measured 3-5- yearly and MMR vaccine should be encouraged if the patient is seronegative to either of the two components. These guidelines also endorse recommendations of VZV vaccination in VZV-seronegative HIV-infected children aged 1-18 years3,4. There are few data on the seroprevalence of measles, rubella and varicella antibodies in HIV infected adolescents with vertically acquired infection. Previous studies have noted a marked decay in specific antibodies in HIV infected children receiving standard childhood vaccinations2. In addition, young people born overseas may have missed out on standard childhood vaccinations. We aimed to determine the seroprevalence and vaccination of measles, varicella and rubella in perinatally infected adolescents attending UK HIV centres. SEROLOGY RESULTS Results were available for VZV IgG, Rubella IgG and Measles IgG in 42, 32 and 40 patients, respectively. Results are shown in Table 2. No significant associations were seen between reported history of MMR vaccination and measles or rubella immunity, or between history of chickenpox exposure and VZV immunity. Table 2: Seroprevalence of varicella, measles and rubella in vertically infected HIV positive adolescents. Serology Positive Negative Indeterminate Total VZV IgG 28 (67%) 12 (28%) 2 (5%) 42 (100%) Rubella IgG 15 (45%) 17 (52%) 1(3%) 32 (100%) Measles IgG 15 (38%) 20 (50%) 5 (12%) 40 (100%) ELIGIBILITY AND ACCESS TO VACCINATIONS 88% (15/17) patients with a negative rubella IgG were female, 87% (13/15) of whom had a CD4 count >200 cells/ul and therefore eligible to receive MMR according to BHIVA guidelines. 58% (7/12) with a negative VZV IgG had a CD4 count >400 cells/ml. The majority (70%, 14/20) of patients with a negative measles IgG had a CD4 > 200 cells/ul. Data regarding access to MMR / VZV vaccinations and patients preferences for access are shown in Figure 1. 42/53 (79%) reported that their GP was aware of their HIV status and 40/51 (78%) reported that they would agree to visit their GP for vaccinations. However more than half of patients said they would prefer to access vaccinations through their clinic if available Figure 1: Availability and patient preference for accessing MMR and VZV vaccinations Methods Standardised questionnaires were distributed, via the HIV in Young Person’s Network (HYPnet), to all centres caring for adolescents with vertically acquired HIV infection. Data were collected using case notes review and face to face interviews on: demographics, clinical and laboratory data, measles, varicella and rubella vaccination status and preferred site for accessing vaccination . Data were collated using Microsoft Office Excel 2007 and analysed using SPSS version 17.0. Proportions were compared using chi-squared. Results BASELINE DEMOGRAPHICS Data from 5 clinical centres was available on 55 patients. Baseline demographics of the cohort surveyed are shown in table 1. The majority of patients were of Black African ethnicity and 70% were born outside the UK. Table 1: Baseline demographic data for cohort surveyed Factor Age mean (SD) 19.4 (2.2) Ethnicity: White British N (%) Black British Black African Mixed Other / missing 2 (4) 45 (82) 1 (2) 5 (9) Gender Male N (%) Female 20 (36) 35 (64) On ART N (%) 40 (72) Current CD4 median cells/ul (IQR) 474 (240-637) VL undetectable on ART N (%) 29 (73) Nadir CD4 median cells/ul (IQR) 188 (68-315) Discussion Adolescents with perinatally transmitted HIV may be susceptible to serious disease if exposed to measles, rubella or varicella infections when non-immune. Recent measles outbreaks in healthy children in London5 and across Europe6,7 highlight the real risk of infection in non-immune individuals A large proportion of adolescents with vertically acquired HIV were not immune to measles, rubella and varicella. The majority of these patients fulfil criteria for vaccinations according to National Guidelines. Nearly 90% of patients who were not immune to rubella were female. Recent reports of increased rates of pregnancy in adolescents with vertically transmitted HIV infection in the UK8 mean there is an urgent need to ensure prompt vaccination of these patients. More than half of patients would prefer to access these vaccinations through their HIV clinic, although availability varies across centres. With increasing pressure on HIV clinic budgets, we recommend developing effective and clear pathways for vaccination of HIV-infected adolescents via HIV clinics and primary care providers. PREVIOUS VACCINATION / PAST INFECTION A history of MMR and varicella vaccinations was known and documented in only 11 (20%) and 1 (2%), patients respectively. 28 (51%) patients reported a past history of chickenpox and 13 (24%) had a past history of shingles infection. A history of past infection with measles or rubella infection was reported in 3 (6%) and 2 (4%) patients, respectively. References 1 Geretti AM et al. British HIV Association guidelines for immunization of HIV-infected adults 2008. HIV Med. 2008 Nov;9(10):795-848. 2 EN Menson et al on behalf of the Paediatric European Network for Treatment of AIDS (PENTA) Vaccines Group, PENTA.. Guidance on vaccination of HIV-infected children in Europe. HIV Med HIV Med 2012 Feb 2. doi: 10.1111/j.1468-1293.2011.00982.. [Epub ahead of print] 3 Marin M, Guris D, Chaves SS et al. Prevention of varicella: recommendations of the Advisory Committee on immunization Practices (ACIP). MMWR Recomm Rep 2007; 56: 1–40. 4 Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1996; 45: 1–36. 5 www.HPA.org.uk 2010 6 Kaic B, Gjenero-Margan I, Kurecic-Filipovic S, Muscat M. A measles outbreak in Croatia, 2008. Euro Surveill 2009; 14: –3. 7 Schmid D, Kasper S, Kuo HW et al. Ongoing rubella outbreak in Austria, 2008–2009. Euro Surveill 2009; 14: 1–3. 8 B Williams, J Kenny, P Tookey and C Foster. Pregnancy outcomes in women growing up with HIV acquired perinatally or in early childhood. HIV Medicine Vol 11 Suppl 1 May 2010 p66.