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Miss Jackie Hobbs

3 rd Annual Conference of the Children’s HIV Association ‘ Young People and HIV: Back to the Future’. Miss Jackie Hobbs. Sheffield Children’s Hospital. Friday 15 May, The Bridgewater Hall, Manchester. YES! We should vaccinate HIV positive children with VZV. CHIVA: 15 th May 2009

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Miss Jackie Hobbs

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  1. 3rd Annual Conference of the Children’s HIV Association ‘Young People and HIV: Back to the Future’ Miss Jackie Hobbs Sheffield Children’s Hospital Friday 15 May, The Bridgewater Hall, Manchester

  2. YES! We should vaccinate HIV positive children with VZV CHIVA: 15th May 2009 Jackie Hobbs CNS Immunology/HIV Sheffield Children’s Hospital

  3. Chicken pox • Common childhood illness. • Generally well managed at home. • Good “test” of immune system. • Increased risk of complications is recognised in children. • Increased risk in immuno-compromised children.

  4. Chicken-pox • Missed schooling • Missed work days (parents) • Fever • Itchy • Uncomfortable • Miserable

  5. VZV – HIV infection • Can develop serious illness from varicella or zoster. • Can become secondarily infected – bacterial infections. • Longer duration of disease in HIV infected individuals. • Chicken-pox • Encephalitis • Pneumonia • Shingles

  6. Hemorrhagic varicella: More common in immuno-compromised children. Complications

  7. Vaccine • Licensed in UK for sero-negative individuals. • Live, attenuated varicella-zoster virus. • Oka strain. • Sub-cut injection into deltoid region. • 2 doses (12 weeks apart – in asymptomatic HIV infection) • 2 products available. • Varilrix & Varivaxlicensed.

  8. Just for interest… • Vaccine derived from healthy Japanese boy with natural varicella by Dr Takahashi in 1972. • “Oka” – Name of that boy.

  9. Vaccine • Not currently used in UK as part of routine vaccination schedule. • USA: FDA (1995) approved use of vaccine in children & adults who have not previously had chicken-pox. - Part of routine vaccination schedule. (VZV Research Foundation, 1996)

  10. Also recommended in: • Canada • Australia • Finland • Japan

  11. Research • Numerous studies carried out. • All conclude in the benefits of vaccination of VZV in immunosuppressed/HIV individuals. • Between 2001 – 2007: • 7 studies (+++)

  12. Outcomes • Vaccine: • Prevents varicella in 85% of children immunised. • 97% protected against severe infection – breakthrough infections - mild. • VZV Vaccine – safe and effective in HIV positive children: • CD4 %: >= 15% • CD4 Count: >200 • Recommended booster “later in life”.

  13. Recommended by BHIVA • In sero-negative individuals. • Immunogenic in susceptible children who are: • Asymptomatic. • Mildly symptomatic. • Consideration for vaccine recommended in this group.

  14. Short Term Efficacy • After 2 doses: • 60% seroconverted for VZV IgG • 83% Showed proliferative response. • 80% Showed detectable VZV immune responses - 1 year post vaccine. • In adults: • 75% Protection against VZV disease. • >95% Protection against severe disease.

  15. Long Term Efficacy • Difficult to predict. • Waning immunity manifested by mild breakthrough infection with wild type virus. • Increased titres over time suggest re-infection with wild type virus = boosting immune response. • To get better analysis of long term efficacy of vaccine: Most children would need to be vaccinated for this “booster” effect to diminish. • Studies not designed to determine long term protection.

  16. Efficacy in reducing severity of chicken-pox • “Breakthrough” chickenpox – generally milder than those not received vaccine. • Reduced incidence of fever. • Reduced incidence of lesions. • Slightly shorter illness period. • 95% effective at preventing severe disease. • Too few cases to determine rate of serious varicella complications.

  17. Side Effects/Adverse Events • 5% - Children & 10% - Adults developed vaccine associated rash within 1 month of vaccination. (needs to be reported to HPA – Wild Type/Oka). • Pain around injection site – 19% • Fever following injection – 15% • Generally well tolerated.

  18. What are the other options? • Hospital admission? • Prophylaxis: Aciclovir: QDS Varicella-zoster Immunoglobulin. • Treat with: • Anti-virals: oral or IV. • Aciclovir – 5 times a day – may not be best option. • Valaciclovir/Famciclovir • Tablet form only. • Licensed in over 12’s • Antibiotics (2ndary infections).

  19. Admission to hospital for treatment of varicella (per day) £2438 (£250 - £350 Hospital cost) Dose of varicella zoster vaccine (per dose – 2 required): £33.02 Let’s compare costs?!

  20. Conclusion • We have access to a safe and effective vaccine for use in children with HIV. • Can help to prevent complications of infection. • Decreases need for hospital admission due to VZV infection.

  21. Should we vaccinate children with varicella zoster vaccine? YES!!

  22. Thank you for your attention.

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