Schoub, BD

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THE SOUTHERN AFRICAN JOURNAL O~ HIV MEDICINE -----------H8RUARY 200 IFIGHTING FLU(ill is influenza vaccine safe in HIV-infected persons?; and(iiil is influenza vaccine effective in HIV-infectedpersons7IS HIV INFECTION A SPECIAL INDICATION FORANNUAL INFLUENZA IMMUNISATION?Definitive, quantitative epidemiological data on the riskof influenza complications in HIV-infected persons arestill not available. However, small-scale studies haveshown more severe and prolonged influenza disease inHIV-infected persons."'" Additional factors which wouldalso need to be taken into account when consideringwhether HIV infection constitutes a special indicationfor influenza immunisationinclude the following:(i) uncomplicated influenza illness may involve consid-erable expense and inconvenience to eliminate adiagnosis of Pneumocystis disease in HIV-infectedpatients presenting with an acute febrile illness;(iil increased influenza virus shedding has been asso-ciated with depressed immunity;" and(iii) the antigenic stimulation of influenza virus infec-tion itself is associated with an increased plasmaviral load," one of the concerns raised with influ-enza vaccine (see below).INFLUENZA IMMUNISATION INHIV-INFECTED PERSONSInfluenza vaccines are widely used throughout the world.Some 80 - 85 million doses are produced annually fordistribution in the USA alone' where coverage for themajor risk group, persons over 65 years of age, was 630/0in 1997' (surpassing the 6O'lb vaccine coverage goal forthe country's Healthy People 2000 Project). The clinicaleffectiveness as well as the cost effectiveness of influ-enza vaccines have been clearly established in a numberof studies in many parts of the world.'" Influenzavaccination has also been demonstrated to reducehospitalisation significantly in elderly high-risk persons.~"In South Africa, influenza immunisation has similarlybeen demonstrated to be cost effective" and utilisationof vaccine in this country has increased markedly overthe past few years, reaching over 2 million doses admin-istered in 2000. Annual influenza immunisation is soundpreventive medicine generally, and in particular ismandated for persons at risk for complications ofinfluenza."With regard to influenza immunisation of HIV-infectedpersons, three issues need to be considered:(i) are HIV-infected persons at special risk for influenzacomplications and is annual immunisation specificallyadvocated for them?;Prof. BaD}' D Schoub, MB BCh, MM,d, MD, DSc, FRCPath, FCPath (SAl, FR5SAfDiredar: National Institute for VirologyPra{es5or of Virology, University of the Witwatersrand, Johannesburg------------- T'f S UT~H MRICAN JOURNA" OF HI'! M:OICINfThe Advisory Committee on Immunisation Practices(ACIP) of the USA has recognised persons infected withHIV as a specific targer group for influenza immunisationbecause of the increased risk of complications.'IS INFLUENZA VACCINE SAFE INHIV-INFECTED PERSONS?In uenza vaccines presemly in use are inactive subunit orsplit-product vaccines and therefore pose no risk ofdisease directly associated with the vaccine virus, as isthe case with he use of live attenuated viral vaccinesin immunosuppressed persons. The main concern aboutadminis ering influenza vaccine to HIV-infected personshas been the observed effect on plasma viral loadfollowing administration of influenza and other vaccines.In 1992, a short letter from Oavid Ho in the Lancer'drew attention to the increase in infectious HIV-l inplasma and peripheral blood mononuclear cells followinginfluenza infection as well as influenza vaccination.The rise in viraemia was, however, transient and levelsreturned to baseline by 2 - 3 weeks. Ho further cautionedin the letter that the findings 'should not be used to makeclinical decisions about influenza vaccination in HIV-linfected persons: A number of publications followedwhich demonstrated the expected rise in plasma HIV-lRNA levels following antigenic stimulation and Iympho-cyte proliferation induced by influenza and othervaccines:o-,~ It was also noted that influenza vaccine-induced stimulation of HIV replication was more likelyto occur in individuals with higher C04 cell counts, i.e.those individuals who would, in fact, be the most likelyto develop an immune response and benefit from thevaccine. However, other subsequem s udies have notshown significant increases in viraemia following influ-enza vaccine administration,"'" or alterna ively showedthat the rise in viraemia was not only transient and rarelysignificam but was also not associared with any clinicalevents."';: Where transient increases in HIV-l RNA levelshave occurred following vaccination, they have not been'allowed by any sustained deterioration in CD4 Iympho-cyte cell counts or progression of disease."IS INFLUENZA VACONE EFFECTIVE INHIV-INFECTED INDMDUALS?Resistance to influenza infection is mediated by humoralimmunoglobulin G (IgGl antibodies in plasma and sec-retory immunoglobulin A (IgA) in respiratory secretions,while recovery from infection, as demonstrated in animalmodels, is mediated by specific CTL (C08 cytotoxic Iym-phocyte) activity. Both immune responses are governedby functionally intact C04 Iymphocytes. It was thereforenot surprising that with the progressive decline of C04Iymphocyte coums there is a corresponding decline inimmune response to influenza vaccine. Individuals withCD4 coums less rhan 200/ml show a poor immune resp-onse to influenza virus infection or influenza vacci-nation." An additional administration of a second dose,however, had no beneficial effect and these non-responding vaccine recipients remained unprotectedafter a second dose." Asymptoma ically infected personsor those with persistent generalised lymphadenopathywere, however, able to mount an appropriate antibodyresponse.;<RECOMMENDATIONS FOR IMMUNISATIONOF HIV-INFECTED PERSONSHIV infection is generally regarded as a specific risk,and it is recommended hat affec ed individuals receiveannual influenza immunisation.u, It is specifically recom-mended under the following conditions:"(i) HIV-infected persons with symptoms and/or C04cell counts between 200 and 5OO/ml;(iil HIV-infected persons with another condition placingthem in a higher risk category according to generalinfluenza recommendations;u, and(iii) contacts of HIV-infected patients such as healthcare personnel and household members.It is not recommended for HIV-infected persons withCD4 cell counts below 200lml as they are unlikely tomount an adequate immune response. These individualsshould be protected with chemoprophylactic agents suchas amantadine (Symmetrel).REFERENC,S1. 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Influenza immunisation in HIV-Infected person

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Influenza immunisation in HIV-Infected person

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