1. Dr Renos Ioannou GPST2 NHS Lothian
Influenza, Pneumococcal and Hepatitis B vaccine uptake in HIV positive adults attending the Infectious Diseases Unit in Edinburgh
Dr Renos Ioannou
GPST2
NHS Lothian
WGH RIDU Audit/QIP
Scottish HIV & AIDS Group Meeting - 8th September 2017

2. Background
Annual influenza, pneumococcal and Hep B immunisation is recommended for all HIV positive adults in the UK[1]
However, HIV services do not receive specific funding to provide immunisations
Influenza is an important cause of morbidity in HIV positive adults[2]
Streptococcus pneumoniae infection is a predominant cause of bacterial infection. The incidence of IPD has declined with effective ART but HIV- positive remain at an approximately 40-times higher risk of disease[3]
There is limited information on correlates of immunity to HBV vaccination in HIV positive population but co-infected persons show increased rates of progression to cirrhosis and liver cancer and a higher mortality[4]
Geretti AM et al. British HIV Association Guidelines on the Use of Vaccines in HIV-Positive Adults HIV Med. 2016;17 Suppl 3:s2-s81.
Remschmidt C et al. Influenza vaccination in HIV-infected individuals: systematic review and assessment of quality of evidence related to vaccine efficacy, effectiveness and safety. Vaccine. 2014;32(43):
van Hoek AJ, Andrews N, Waight PA et al. The effect of underlying clinical conditions on the risk of developing invasive pneumococcal disease in England. J Infect 2012; 65: 17–24.
Martín-Carbonero L, Poveda E. Hepatitis B virus and HIV infection. Semin Liver Dis 2012; 32: 114–9

3. Methods
Objective: to determine the uptake/documentation of Influenza, Pneumococcal and Hepatitis B vaccination in our HIV cohort
Cross-sectional retrospective study
All patients who attended HIV OP clinics over 2 weeks period in Nov 2016 (21/11/ /12/16) at WGH identified from the HIV database
Demographics, biochemical, virological and vaccination data were collected from the HIV database
If data was not available or dubious, further information was taken from the electronic clinic notes (TRAK), TRAK results and APEX if not available on TRAK

4. Demographics Characteristic (Total = 102) Median age 49 (23 - 69)
Sex (M/F)
66 (65%)/36 (35%)
Ethnicity
White
Sub-Saharan Africa
Other
8 (8%)
Median CD4 count (cells/cm3)
CD4 < 100
1 (1%)
% of patients with VL <40 c/ml
91 (89%)

5. Influenza Vaccination
Flu vaccination
Total n = 102
Vaccinated
58% (59)
Yearly Vaccinated (since 2011)
7% (7)
Not Vaccinated
Declined
Unwell
Year Abroad
1% (1)
Not documented
34% (35)

6. Pneumococcal Vaccination
Total n = 102
Vaccinated within last 5 years
PCV13 (Prevnar)
PPV-23 (Pneumovax)
Both
Not Known
2% (2)
Not Vaccinated
Declined
2% (2)
Pentennial Vaccination
7% (7)
Overdue
3% (3)
Not documented
58% (59)

7. Hepatitis B Serology Hep B status Total n = 102 HBsAg Positive 2% (2)
anti-HBc
Positive
Antibody response >10
Negative
Not checked
8% (8)
anti-HBs
>100
10 < anti-HBs < 100
<10
25% (25)

8. HepB Vaccine Response (anti-HBc+)
anti-HBs >10
Total n = 11
> 100
Achieved with 3 doses
With a booster/3 doses + booster
Partial Documentation/< 3 Doses
No Documentation
91% (10)
10 < anti-HBs < 100
0% (0)
anti-HBs < 10
Total n = 6
3 Doses +booster
< 3 Documented Doses
100% (6)

9. Hep B Vaccine Response (anti-HBc -)
anti-HBs >10
Total n = 32
> 100
Achieved with 3 doses
With a booster/3 doses + booster
Partial Documentation/< 3 Doses
No Documentation
38% (12)
10 < anti-HBs < 100
3 Doses
Booster/3 Doses +booster
< 3 Documented Doses
13% (4)

10. Hep B Vaccine Response (anti-HBc -)
anti-HBs <10
Total n = 23
3 Doses
Booster/3 Doses + Booster
< 3 Documented Doses
No Documentation
57% (13)
23% (14/62) of the anti-HBc negative cohort had anti-HBs <10 and no documented Hep B vaccinations

11. Summary
58% of the cohort received Influenza vaccine, with 7% receiving yearly since 2011
40% received pneumococcal vaccine
Less than 5% declined vaccination
31% of the cohort achieved anti-HBs >100
29% of the cohort susceptible to Hep B
At least one patient from this cohort was admitted with pneumonia. One patient died and another one was admitted due to comorbidities
4 patients (4%) received vaccines at the GP practice (based on the clinic notes)
Patients reviewed by the specialist HIV nurses had good immunisation documentation. Some consultants write the immunisation history at the top of every clinic letter

12. Limitations
We relied on what was recorded in the electronic notes regarding offering vaccinations
Database vaccinations have only been recorded from onwards
33% of patients have been attending the clinic for < 5 years and many of them transferred from different clinics, 44% (11/25) of the electronically unavailable anti-HBs belong to this cohort

13. Further Plans
Finding ways to improve documentation and communication routes
Possibility of checklist for annual review?
Possibility of automatic reminders on the database?
Discussion:
? encouraging patients to be reviewed by specialist nurses at least once a year (nurses now are updating the database when vaccinating)
? best practices from other centres
?what’s really feasible for the patients’ GP vs HIV OP
Can anyone remember any new HBV infection in the HIV population? Benefit of TDF as PREP

14. Thanks
Dr Muge Cevik
Prof Clifford Leen
Linda Panton
Dr David Wilks