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  53rd ICAAC Interscience Conference on
Antimicrobial Agents and Chemotherapy
September 10-13, 2013, Denver CO
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Routine Vaccination Rates Highly Variable in French Adults With HIV
  Routine Vaccination Rates Highly Variable in French Adults With HIV
53rd ICAAC, September 10-13, 2013, Denver
Mark Mascolini
Rates of vaccination for hepatitis viruses and respiratory infections varied substantially in a single-center 2467-person study of HIV-positive adults in France [1]. While vaccine coverage was satisfactory for pneumococcal disease and hepatitis B virus (HBV), rates were low for hepatitis A virus (HAV) and seasonal influenza. The vaccination rate for A(H1N1) pandemic influenza was "remarkably high" compared with the general French adult population. The analysis showed that vaccination guidelines did not influence physicians caring for these patients.
Vaccination against certain common infections is recommended for HIV-positive people because those infections are (1) more frequent and/or severe in people with HIV (such as pneumococcal invasive disease and influenza), or (2) share epidemiologic traits or transmission routes with HIV (such as HAV and HBV). But data on vaccination coverage for these infections in HIV-positive adults are sparse.
To help fill that gap, researchers at the Croix-Rousse Hospital in Lyon conducted this single-center prospective analysis of HIV-positive people vaccinated (or not) for HAV, HBV, pneumococcal invasive disease, seasonal influenza, and pandemic A(H1N1) in 2011. French health authorities recommend vaccination against all these infections except HAV in people with HIV. But HAV vaccination is recommended for men who have sex with men (MSM), injection drug users, and people with HBV or HCV infection.
The study focused on 2467 HIV-positive adults with a median age of 46.4. Most cohort members (71.5%) were men, and 43.9% were MSM. Median follow-up reached 10 years, and 93% of cohort members took combination antiretroviral therapy. HIV infection duration averaged 10 years and combination antiretroviral therapy duration 9 years. Median nadir CD4 count was 209, current CD4 count 527, and current viral load about 40 copies. Fewer than 10% were infected with HBV (5.5%) or HCV (8.2%), and small minorities had diabetes (6.3%), chronic renal failure (5.7%), chronic heart disease (6.2%), chronic pulmonary disease (3.7%), or severe hepatic fibrosis or cirrhosis (2.7%).
Vaccination coverage rates were 47.4% for HAV, 51.1% for HBV, 64.6% for pneumococcal invasive disease, 29.4% for seasonal influenza, and 48.3% for A(H1N1) influenza. The HAV and HBV analyses excluded people with a record of a positive test for either virus.
Multivariate analysis determined that the following factors raised or lowered odds of vaccination (at the noted odds ratios [OR] and 95% confidence intervals):
-- Experienced physician (>100 patients per year): OR 2.28 (1.03-5.03) for HBV; OR 2.86 (1.32-6.19) for pneumococcal invasive disease
-- Age (per year): OR 0.95 (0.94-0.97) for HBV; OR 1.02 (1.01-1.03) for seasonal influenza; OR 1.02 (1.01-1.03) for A(H1N1)
-- Male: OR 1.54 (1.09-2.18) for HBV; OR 1.85 (1.04-3.28) for HAV
-- MSM: OR 2.81 (1.30-6.06) for HBV
-- Nadir CD4 >200: OR 1.36 (1.00-1.84) for HBV
-- Current CD4 >200: OR 2.23 (1.17-4.27) for HBV; OR 4.97 (1.56-15.85) for HAV; OR 2.26 (1.44-3.55) for pneumococcal invasive disease; OR 1.82 (1.10-3.02) for seasonal influenza
--Viral load <50 copies: OR 1.96 (1.50-2.55) for pneumococcal invasive disease; OR 1.82 (1.40-2.35) for A(H1N1)
-- HIV duration (per year): OR 1.03 (1.01-1.05) for pneumococcal invasive disease; OR 1.03 (1.02-1.05) for A(H1N1)
-- Pneumococcal vaccination: OR 3.50 (2.63-4.64) for seasonal influenza; OR 3.42 (2.76-4.23) for A(H1N1)
-- Seasonal influenza vaccination: OR 3.91 (2.97-5.17) for pneumococcal invasive disease; OR 1.79 (1.44-2.22) for A(H1N1)
-- A(H1N1) vaccination: OR 3.51 (2.83-4.35) for pneumococcal invasive disease; OR 1.69 (1.35-2.21) for seasonal influenza
-- HBV vaccination: OR 8.59 (4.17-17.69) for HAV vaccination
-- HAV vaccination: OR 9.72 (4.73-19.94) for HBV vaccination
No vaccination guidelines were associated with better vaccination odds in this analysis. From the vaccination perspective, the following variables raised chances of vaccination:
-- HBV vaccination: Experienced physician, male gender, MSM, nadir CD4 >200, current CD4 >200, and HAV vaccination, while each year of age lowered odds of HBV vaccination 5%
-- HAV vaccination: Male gender, current CD4 >200, HBV vaccination
-- Pneumococcal invasive disease vaccination: Experienced physician, current CD4 >200, viral load below 50 copies, each year of HIV infection, seasonal influenza or A(H1N1) vaccination
-- Seasonal influenza vaccination: Each year of age, current CD4 >200, pneumococcal or A(H1N1) vaccination
-- A(H1N1) vaccination: Each year of age, viral load below 50 copies, each year of HIV infection, pneumococcal or seasonal influenza infection
The Lyon team rated vaccination coverage "satisfactory" for pneumococcal invasive disease and HBV but low for HAV and seasonal influenza. Vaccination for A(H1N1), in contrast, "was remarkably high by comparison with [the] general population in France (7.9%)." Older age raised chances of vaccination for seasonal influenza or A(H1N1) while lowering chances of HBV vaccination.
The researchers concluded that "general guidelines for each of the vaccinations were poorly followed." They observed that factors influencing routine vaccinations in adults with HIV "are largely not evidence-based." And they called for greater efforts to raise awareness of vaccination guidelines among physicians--especially less experienced physicians.
1. Cotte L, Voirin N, Godinot M, et al. Vaccinations coverage rate and determinants in a French cohort of HIV-infected patients. 53rd ICAAC. September 10-13, 2013. Denver. Abstract H-1271.