Heidi Splete

WASHINGTON — Protect HIV-infected patients from additional illness by vaccinating them against influenza, hepatitis A and B, pneumococcal disease, and tetanus-diphtheria, Dr. David H. Spach advised at the Ryan White CARE Act meeting on HIV treatment.

As flu season begins, “vaccinate everyone for flu regardless of their CD4 count or viral load,” said Dr. Spach, of the University of Washington, Seattle.

He presented a roundup of immunization recommendations for HIV patients:

▸ Influenza. Adults with AIDS are at significantly greater risk for influenza, compared with healthy adults, and even compared with healthy persons older than 65 years, according to data from a 3-year study of deaths from influenza or pneumonia (Arch. Intern. Med. 2001;161:441–6).

Studies have shown that the flu vaccine is most effective for patients with CD4 counts greater than 100 cells/mm

Vaccinate HIV patients annually with the trivalent vaccine regardless of their CD4 count, but remember that the live vaccine is contraindicated for these patients, he said. Data from the Centers for Disease Control and Prevention for the period from 1976 to 2006 confirm that peak flu activity occurs in the 4-month period from December through March, which reinforces the current recommendations to give HIV patients the flu vaccine at a regular visit just prior to the start of flu season.

▸ Hepatitis B. Clinicians may encounter HIV patients who received one or two doses of the hepatitis B vaccine and then disappeared for years.

But if an HIV patient has missed a dose, “it's fine to pick up where you left off,” he said.

Long intervals between the first and second doses of hepatitis B vaccine appear to have little effect on immunogenicity in HIV patients, and the third dose is more like a booster dose, Dr. Spach said. The CDC's Advisory Committee on Immunization Practices recommends a standard 20-mcg dose at baseline, followed by subsequent doses at 1 month and 6 months.

Consider a double dose of hepatitis B vaccine in HIV patients who do not respond to the initial three-dose series, Dr. Spach advised. Patients with CD4 counts greater than 500 cells/mm

But regardless of CD4 count, the odds of response to a future dose are low if an HIV patient doesn't respond to the initial three-dose series, he noted.

▸ Hepatitis A. Data from a study of 133 HIV-infected adults showed that response rates to hepatitis A vaccine are significantly greater in HIV patients with CD4 counts of at least 200 cells/mm

“Those with CD4 counts under 200 really did not respond well at 7 and 9 months post vaccination,” Dr. Spach said. Vaccine response rates at 7 and 9 months were 11% and 9%, respectively, compared with 53% and 69% among patients with CD4 counts of 200–500 cells/mm

Based on these and other data, hepatitis A is not an optimal vaccine for patients with low CD4 counts.

If a patient is set to start antiviral therapy, consider postponing hepatitis A vaccination to determine whether the CD4 count increases.

▸ Pneumococcal disease. The rate of invasive pneumococcal disease in HIV-infected patients has decreased as a result of the widespread use of the seven-valent conjugate pneumococcal vaccine given to young children, Dr. Spach said.

Data from 2006 show a 20% decrease in invasive pneumococcal disease among HIV-infected adults since the childhood conjugate vaccine was licensed and became widely used, with a 60% reduction in the incidence of illness from serotypes that were contained in the vaccine and a slight increase in strains that were not contained in the vaccine (Ann. Intern. Med. 2006;144:1–9). These findings parallel other studies in adults not infected with HIV who have shown a strong herd immunity.

“This childhood vaccine probably has had a greater effect on preventing pneumococcal disease in HIV patients than our giving the standard adult polysaccharide vaccine,” Dr. Spach said.

No published data show that the 7-valent vaccine is better than the standard vaccine for HIV-infected adults, and current recommendations still call for a single dose of the 23-valent polysaccharide pneumococcal vaccine followed by another dose 5 years later. “But if you have a patient with children or who interacts with children, encourage those kids to get immunized with the conjugate vaccine,” he said.

▸ Tetanus. The new Tdap vaccine (approved in June 2005) is not a live vaccine, so it's safe for HIV patients, Dr. Spach said. Tdap is not Food and Drug Administration-approved for HIV patients specifically, but it is not contraindicated for them, and it will protect them from pertussis as well as diphtheria and tetanus.

New recommendations for non-HIV-infected adults call for replacing the next booster dose of Td (tetanus-diphtheria toxoids) with the Tdap vaccine, which should be given routinely to patients whose last Td vaccination was more than 10 years ago.

For the latest immunization information for HIV-infected patients and others, visit the CDC's National Immunization Program Web site, www.cdc.gov/nip

WASHINGTON — Protect HIV-infected patients from additional illness by vaccinating them against influenza, hepatitis A and B, pneumococcal disease, and tetanus-diphtheria, Dr. David H. Spach advised at the Ryan White CARE Act meeting on HIV treatment.

As flu season begins, “vaccinate everyone for flu regardless of their CD4 count or viral load,” said Dr. Spach, of the University of Washington, Seattle.

He presented a roundup of immunization recommendations for HIV patients:

▸ Influenza. Adults with AIDS are at significantly greater risk for influenza, compared with healthy adults, and even compared with healthy persons older than 65 years, according to data from a 3-year study of deaths from influenza or pneumonia (Arch. Intern. Med. 2001;161:441–6).

Studies have shown that the flu vaccine is most effective for patients with CD4 counts greater than 100 cells/mm

Vaccinate HIV patients annually with the trivalent vaccine regardless of their CD4 count, but remember that the live vaccine is contraindicated for these patients, he said. Data from the Centers for Disease Control and Prevention for the period from 1976 to 2006 confirm that peak flu activity occurs in the 4-month period from December through March, which reinforces the current recommendations to give HIV patients the flu vaccine at a regular visit just prior to the start of flu season.

▸ Hepatitis B. Clinicians may encounter HIV patients who received one or two doses of the hepatitis B vaccine and then disappeared for years.

But if an HIV patient has missed a dose, “it's fine to pick up where you left off,” he said.

Long intervals between the first and second doses of hepatitis B vaccine appear to have little effect on immunogenicity in HIV patients, and the third dose is more like a booster dose, Dr. Spach said. The CDC's Advisory Committee on Immunization Practices recommends a standard 20-mcg dose at baseline, followed by subsequent doses at 1 month and 6 months.

Consider a double dose of hepatitis B vaccine in HIV patients who do not respond to the initial three-dose series, Dr. Spach advised. Patients with CD4 counts greater than 500 cells/mm

But regardless of CD4 count, the odds of response to a future dose are low if an HIV patient doesn't respond to the initial three-dose series, he noted.

▸ Hepatitis A. Data from a study of 133 HIV-infected adults showed that response rates to hepatitis A vaccine are significantly greater in HIV patients with CD4 counts of at least 200 cells/mm

“Those with CD4 counts under 200 really did not respond well at 7 and 9 months post vaccination,” Dr. Spach said. Vaccine response rates at 7 and 9 months were 11% and 9%, respectively, compared with 53% and 69% among patients with CD4 counts of 200–500 cells/mm

Based on these and other data, hepatitis A is not an optimal vaccine for patients with low CD4 counts.

If a patient is set to start antiviral therapy, consider postponing hepatitis A vaccination to determine whether the CD4 count increases.

▸ Pneumococcal disease. The rate of invasive pneumococcal disease in HIV-infected patients has decreased as a result of the widespread use of the seven-valent conjugate pneumococcal vaccine given to young children, Dr. Spach said.

Data from 2006 show a 20% decrease in invasive pneumococcal disease among HIV-infected adults since the childhood conjugate vaccine was licensed and became widely used, with a 60% reduction in the incidence of illness from serotypes that were contained in the vaccine and a slight increase in strains that were not contained in the vaccine (Ann. Intern. Med. 2006;144:1–9). These findings parallel other studies in adults not infected with HIV who have shown a strong herd immunity.

“This childhood vaccine probably has had a greater effect on preventing pneumococcal disease in HIV patients than our giving the standard adult polysaccharide vaccine,” Dr. Spach said.

No published data show that the 7-valent vaccine is better than the standard vaccine for HIV-infected adults, and current recommendations still call for a single dose of the 23-valent polysaccharide pneumococcal vaccine followed by another dose 5 years later. “But if you have a patient with children or who interacts with children, encourage those kids to get immunized with the conjugate vaccine,” he said.

▸ Tetanus. The new Tdap vaccine (approved in June 2005) is not a live vaccine, so it's safe for HIV patients, Dr. Spach said. Tdap is not Food and Drug Administration-approved for HIV patients specifically, but it is not contraindicated for them, and it will protect them from pertussis as well as diphtheria and tetanus.

New recommendations for non-HIV-infected adults call for replacing the next booster dose of Td (tetanus-diphtheria toxoids) with the Tdap vaccine, which should be given routinely to patients whose last Td vaccination was more than 10 years ago.

For the latest immunization information for HIV-infected patients and others, visit the CDC's National Immunization Program Web site, www.cdc.gov/nip

WASHINGTON — Protect HIV-infected patients from additional illness by vaccinating them against influenza, hepatitis A and B, pneumococcal disease, and tetanus-diphtheria, Dr. David H. Spach advised at the Ryan White CARE Act meeting on HIV treatment.

As flu season begins, “vaccinate everyone for flu regardless of their CD4 count or viral load,” said Dr. Spach, of the University of Washington, Seattle.

He presented a roundup of immunization recommendations for HIV patients:

▸ Influenza. Adults with AIDS are at significantly greater risk for influenza, compared with healthy adults, and even compared with healthy persons older than 65 years, according to data from a 3-year study of deaths from influenza or pneumonia (Arch. Intern. Med. 2001;161:441–6).

Studies have shown that the flu vaccine is most effective for patients with CD4 counts greater than 100 cells/mm

Vaccinate HIV patients annually with the trivalent vaccine regardless of their CD4 count, but remember that the live vaccine is contraindicated for these patients, he said. Data from the Centers for Disease Control and Prevention for the period from 1976 to 2006 confirm that peak flu activity occurs in the 4-month period from December through March, which reinforces the current recommendations to give HIV patients the flu vaccine at a regular visit just prior to the start of flu season.

▸ Hepatitis B. Clinicians may encounter HIV patients who received one or two doses of the hepatitis B vaccine and then disappeared for years.

But if an HIV patient has missed a dose, “it's fine to pick up where you left off,” he said.

Long intervals between the first and second doses of hepatitis B vaccine appear to have little effect on immunogenicity in HIV patients, and the third dose is more like a booster dose, Dr. Spach said. The CDC's Advisory Committee on Immunization Practices recommends a standard 20-mcg dose at baseline, followed by subsequent doses at 1 month and 6 months.

Consider a double dose of hepatitis B vaccine in HIV patients who do not respond to the initial three-dose series, Dr. Spach advised. Patients with CD4 counts greater than 500 cells/mm

But regardless of CD4 count, the odds of response to a future dose are low if an HIV patient doesn't respond to the initial three-dose series, he noted.

▸ Hepatitis A. Data from a study of 133 HIV-infected adults showed that response rates to hepatitis A vaccine are significantly greater in HIV patients with CD4 counts of at least 200 cells/mm

“Those with CD4 counts under 200 really did not respond well at 7 and 9 months post vaccination,” Dr. Spach said. Vaccine response rates at 7 and 9 months were 11% and 9%, respectively, compared with 53% and 69% among patients with CD4 counts of 200–500 cells/mm

Based on these and other data, hepatitis A is not an optimal vaccine for patients with low CD4 counts.

If a patient is set to start antiviral therapy, consider postponing hepatitis A vaccination to determine whether the CD4 count increases.

▸ Pneumococcal disease. The rate of invasive pneumococcal disease in HIV-infected patients has decreased as a result of the widespread use of the seven-valent conjugate pneumococcal vaccine given to young children, Dr. Spach said.

Data from 2006 show a 20% decrease in invasive pneumococcal disease among HIV-infected adults since the childhood conjugate vaccine was licensed and became widely used, with a 60% reduction in the incidence of illness from serotypes that were contained in the vaccine and a slight increase in strains that were not contained in the vaccine (Ann. Intern. Med. 2006;144:1–9). These findings parallel other studies in adults not infected with HIV who have shown a strong herd immunity.

“This childhood vaccine probably has had a greater effect on preventing pneumococcal disease in HIV patients than our giving the standard adult polysaccharide vaccine,” Dr. Spach said.

No published data show that the 7-valent vaccine is better than the standard vaccine for HIV-infected adults, and current recommendations still call for a single dose of the 23-valent polysaccharide pneumococcal vaccine followed by another dose 5 years later. “But if you have a patient with children or who interacts with children, encourage those kids to get immunized with the conjugate vaccine,” he said.

▸ Tetanus. The new Tdap vaccine (approved in June 2005) is not a live vaccine, so it's safe for HIV patients, Dr. Spach said. Tdap is not Food and Drug Administration-approved for HIV patients specifically, but it is not contraindicated for them, and it will protect them from pertussis as well as diphtheria and tetanus.

New recommendations for non-HIV-infected adults call for replacing the next booster dose of Td (tetanus-diphtheria toxoids) with the Tdap vaccine, which should be given routinely to patients whose last Td vaccination was more than 10 years ago.

For the latest immunization information for HIV-infected patients and others, visit the CDC's National Immunization Program Web site, www.cdc.gov/nip

WASHINGTON — The challenge of paying for vaccinations will become even greater once the human papilloma virus vaccine becomes available in 2007.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11- to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention. But the price of a vaccine cannot be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, he said.

Consequently, an ACIP recommendation raises the possibility for disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children with private insurance not receiving the same vaccine because it is not paid for. Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources? “The programs are put in a tough spot,” he said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials, shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program. Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

WASHINGTON — The challenge of paying for vaccinations will become even greater once the human papilloma virus vaccine becomes available in 2007.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11- to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention. But the price of a vaccine cannot be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, he said.

Consequently, an ACIP recommendation raises the possibility for disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children with private insurance not receiving the same vaccine because it is not paid for. Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources? “The programs are put in a tough spot,” he said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials, shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program. Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

WASHINGTON — The challenge of paying for vaccinations will become even greater once the human papilloma virus vaccine becomes available in 2007.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11- to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention. But the price of a vaccine cannot be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, he said.

Consequently, an ACIP recommendation raises the possibility for disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children with private insurance not receiving the same vaccine because it is not paid for. Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources? “The programs are put in a tough spot,” he said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials, shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program. Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

WASHINGTON — The findings of a large survey reinforce the ongoing prevalence of risky sexual and substance abuse behavior among young people that could promote the spread of HIV infection, Angulique W. Outlaw, Ph.D., said in a poster at the Ryan White CARE Act meeting on HIV treatment.

To investigate the prevalence of risky behaviors and teens' and young adults' attitudes toward HIV, Dr. Outlaw of the Children's Hospital of Michigan, in Detroit, and her colleagues surveyed 751 adolescents and young adults aged 13–24 years, who received HIV counseling and testing in community-based venues. These included field locations such as parks and public events (38%), health clinics (24%), detention facilities (23%), and community drop-in centers (15%).

Overall, 12% of the respondents identified themselves as men who have sex with men (MSM) exclusively, 5% were men who have sex with men or women, 28% were high-risk heterosexuals, 54% were moderate- or low-risk heterosexuals, and 1% were “other.”

The number of respondents who defined themselves as MSM exclusively was higher than expected, Dr. Outlaw said in an interview.

A total of 82% of the respondents reported having sex without using a condom, and 23% reported having a sexually transmitted disease (chlamydia or gonorrhea) within the past 90 days.

In addition, 58% reported any alcohol use during the past year, 46% reported using marijuana during the past year, and 43% reported having sex in conjunction with alcohol or drug use.

Females were significantly less likely to use condoms compared with males, and they also had a significantly higher incidence of STDs.

Younger respondents (aged 13–18 years) reported significantly more marijuana use and had significantly higher rates of gonorrhea and chlamydia compared with those aged 19–24 years.

The survey also included questions about attitudes toward HIV and HIV testing. Overall, 56% of the respondents felt that they had placed themselves at risk for HIV during the past year, and 82% said they were “definitely ready” to get tested for HIV.

The study participants appeared to be receptive to HIV education and testing.

A majority of 89% said that they would “definitely” return for HIV test results, and 77% did return. The returning subjects included a majority of both 13− to 18-year-olds (72%) and 19− to 24-year-olds (87%).

Although the researchers did not include the results of the respondents' HIV tests, data published in 2004 by the Centers for Disease Control and Prevention indicated that 13% of HIV infections in the United States that year occurred in 13− to 24-year-olds, and ongoing research suggests that the incidence of new HIV infections in young people aged 13–24 in the United States has not declined.

The study was limited by the use of self-reports and a convenience sample, the investigators said.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — The findings of a large survey reinforce the ongoing prevalence of risky sexual and substance abuse behavior among young people that could promote the spread of HIV infection, Angulique W. Outlaw, Ph.D., said in a poster at the Ryan White CARE Act meeting on HIV treatment.

To investigate the prevalence of risky behaviors and teens' and young adults' attitudes toward HIV, Dr. Outlaw of the Children's Hospital of Michigan, in Detroit, and her colleagues surveyed 751 adolescents and young adults aged 13–24 years, who received HIV counseling and testing in community-based venues. These included field locations such as parks and public events (38%), health clinics (24%), detention facilities (23%), and community drop-in centers (15%).

Overall, 12% of the respondents identified themselves as men who have sex with men (MSM) exclusively, 5% were men who have sex with men or women, 28% were high-risk heterosexuals, 54% were moderate- or low-risk heterosexuals, and 1% were “other.”

The number of respondents who defined themselves as MSM exclusively was higher than expected, Dr. Outlaw said in an interview.

A total of 82% of the respondents reported having sex without using a condom, and 23% reported having a sexually transmitted disease (chlamydia or gonorrhea) within the past 90 days.

In addition, 58% reported any alcohol use during the past year, 46% reported using marijuana during the past year, and 43% reported having sex in conjunction with alcohol or drug use.

Females were significantly less likely to use condoms compared with males, and they also had a significantly higher incidence of STDs.

Younger respondents (aged 13–18 years) reported significantly more marijuana use and had significantly higher rates of gonorrhea and chlamydia compared with those aged 19–24 years.

The survey also included questions about attitudes toward HIV and HIV testing. Overall, 56% of the respondents felt that they had placed themselves at risk for HIV during the past year, and 82% said they were “definitely ready” to get tested for HIV.

The study participants appeared to be receptive to HIV education and testing.

A majority of 89% said that they would “definitely” return for HIV test results, and 77% did return. The returning subjects included a majority of both 13− to 18-year-olds (72%) and 19− to 24-year-olds (87%).

Although the researchers did not include the results of the respondents' HIV tests, data published in 2004 by the Centers for Disease Control and Prevention indicated that 13% of HIV infections in the United States that year occurred in 13− to 24-year-olds, and ongoing research suggests that the incidence of new HIV infections in young people aged 13–24 in the United States has not declined.

The study was limited by the use of self-reports and a convenience sample, the investigators said.

ELSEVIER GLOBAL MEDICAL NEWS

WASHINGTON — The findings of a large survey reinforce the ongoing prevalence of risky sexual and substance abuse behavior among young people that could promote the spread of HIV infection, Angulique W. Outlaw, Ph.D., said in a poster at the Ryan White CARE Act meeting on HIV treatment.

To investigate the prevalence of risky behaviors and teens' and young adults' attitudes toward HIV, Dr. Outlaw of the Children's Hospital of Michigan, in Detroit, and her colleagues surveyed 751 adolescents and young adults aged 13–24 years, who received HIV counseling and testing in community-based venues. These included field locations such as parks and public events (38%), health clinics (24%), detention facilities (23%), and community drop-in centers (15%).

Overall, 12% of the respondents identified themselves as men who have sex with men (MSM) exclusively, 5% were men who have sex with men or women, 28% were high-risk heterosexuals, 54% were moderate- or low-risk heterosexuals, and 1% were “other.”

The number of respondents who defined themselves as MSM exclusively was higher than expected, Dr. Outlaw said in an interview.

A total of 82% of the respondents reported having sex without using a condom, and 23% reported having a sexually transmitted disease (chlamydia or gonorrhea) within the past 90 days.

In addition, 58% reported any alcohol use during the past year, 46% reported using marijuana during the past year, and 43% reported having sex in conjunction with alcohol or drug use.

Females were significantly less likely to use condoms compared with males, and they also had a significantly higher incidence of STDs.

Younger respondents (aged 13–18 years) reported significantly more marijuana use and had significantly higher rates of gonorrhea and chlamydia compared with those aged 19–24 years.

The survey also included questions about attitudes toward HIV and HIV testing. Overall, 56% of the respondents felt that they had placed themselves at risk for HIV during the past year, and 82% said they were “definitely ready” to get tested for HIV.

The study participants appeared to be receptive to HIV education and testing.

A majority of 89% said that they would “definitely” return for HIV test results, and 77% did return. The returning subjects included a majority of both 13− to 18-year-olds (72%) and 19− to 24-year-olds (87%).

Although the researchers did not include the results of the respondents' HIV tests, data published in 2004 by the Centers for Disease Control and Prevention indicated that 13% of HIV infections in the United States that year occurred in 13− to 24-year-olds, and ongoing research suggests that the incidence of new HIV infections in young people aged 13–24 in the United States has not declined.

The study was limited by the use of self-reports and a convenience sample, the investigators said.

ELSEVIER GLOBAL MEDICAL NEWS

Two methods for estimating the odds of middle ear effusion were confirmed in a review of tympanometric and otoscopic data from children younger than 3 years conducted by Clyde G. Smith, M.S., an audiologist at Children's Hospital of Pittsburgh, and his colleagues.

A total of 6,350 children were enrolled as healthy infants when they were 2–6 days old, between June 1991 and December 1995. They had monthly otoscopic evaluations until 3 years of age, at which point 3,427 children had at least one tympanogram suitable for evaluation.

The overall likelihood of middle ear effusion (MEE) increased with tympanometric measures of lower height, greater width, and negative pressure among children aged 6–35 months. Middle ear effusion in cases with flat tympanograms was diagnosed in 174 of 217 (80%) ears in children aged 6–35 months, compared with 20 of 35 (57%) ears in children younger than 6 months.

The tympanograms from most healthy children older than 6 months are at least 0.3 mL high and 200 decaPascals, or daPa, wide, and they are rarely associated with MEE, but a flat tympanogram may raise the index of suspicion, the researchers explained (Pediatrics 2006;118:1–13).

As an alternative to comparing the tympanometric findings with age-based values, the researchers created a mathematical algorithm that combined the tympanometric variables of height, pressure, and width, and applied it to the 4,761 ears for which all three of these values were available.

For example, in children aged 6–35 months, MEE was present in 1.9% of ears with a tympanometric height of 0.6 mL or higher and 0–200 daPa width and 6.3% of ears with a tympanometric height of 0.6 mL or higher and a 201–300 width. No effusion was found in ears with a tympanometric height of 0.6 mL and a width of at least 301 daPa. Based on the algorithm, the area under the curve was 0.84; values from 0.80–0.90 tend to be accurate predictors.

There were no clinically significant differences between the empirical and algorithmic methods in terms of ability to predict MEE. The study was supported in part by donations from GlaxoSmithKline and Pfizer, Inc.

Two methods for estimating the odds of middle ear effusion were confirmed in a review of tympanometric and otoscopic data from children younger than 3 years conducted by Clyde G. Smith, M.S., an audiologist at Children's Hospital of Pittsburgh, and his colleagues.

A total of 6,350 children were enrolled as healthy infants when they were 2–6 days old, between June 1991 and December 1995. They had monthly otoscopic evaluations until 3 years of age, at which point 3,427 children had at least one tympanogram suitable for evaluation.

The overall likelihood of middle ear effusion (MEE) increased with tympanometric measures of lower height, greater width, and negative pressure among children aged 6–35 months. Middle ear effusion in cases with flat tympanograms was diagnosed in 174 of 217 (80%) ears in children aged 6–35 months, compared with 20 of 35 (57%) ears in children younger than 6 months.

The tympanograms from most healthy children older than 6 months are at least 0.3 mL high and 200 decaPascals, or daPa, wide, and they are rarely associated with MEE, but a flat tympanogram may raise the index of suspicion, the researchers explained (Pediatrics 2006;118:1–13).

As an alternative to comparing the tympanometric findings with age-based values, the researchers created a mathematical algorithm that combined the tympanometric variables of height, pressure, and width, and applied it to the 4,761 ears for which all three of these values were available.

For example, in children aged 6–35 months, MEE was present in 1.9% of ears with a tympanometric height of 0.6 mL or higher and 0–200 daPa width and 6.3% of ears with a tympanometric height of 0.6 mL or higher and a 201–300 width. No effusion was found in ears with a tympanometric height of 0.6 mL and a width of at least 301 daPa. Based on the algorithm, the area under the curve was 0.84; values from 0.80–0.90 tend to be accurate predictors.

There were no clinically significant differences between the empirical and algorithmic methods in terms of ability to predict MEE. The study was supported in part by donations from GlaxoSmithKline and Pfizer, Inc.

Two methods for estimating the odds of middle ear effusion were confirmed in a review of tympanometric and otoscopic data from children younger than 3 years conducted by Clyde G. Smith, M.S., an audiologist at Children's Hospital of Pittsburgh, and his colleagues.

A total of 6,350 children were enrolled as healthy infants when they were 2–6 days old, between June 1991 and December 1995. They had monthly otoscopic evaluations until 3 years of age, at which point 3,427 children had at least one tympanogram suitable for evaluation.

The overall likelihood of middle ear effusion (MEE) increased with tympanometric measures of lower height, greater width, and negative pressure among children aged 6–35 months. Middle ear effusion in cases with flat tympanograms was diagnosed in 174 of 217 (80%) ears in children aged 6–35 months, compared with 20 of 35 (57%) ears in children younger than 6 months.

The tympanograms from most healthy children older than 6 months are at least 0.3 mL high and 200 decaPascals, or daPa, wide, and they are rarely associated with MEE, but a flat tympanogram may raise the index of suspicion, the researchers explained (Pediatrics 2006;118:1–13).

As an alternative to comparing the tympanometric findings with age-based values, the researchers created a mathematical algorithm that combined the tympanometric variables of height, pressure, and width, and applied it to the 4,761 ears for which all three of these values were available.

For example, in children aged 6–35 months, MEE was present in 1.9% of ears with a tympanometric height of 0.6 mL or higher and 0–200 daPa width and 6.3% of ears with a tympanometric height of 0.6 mL or higher and a 201–300 width. No effusion was found in ears with a tympanometric height of 0.6 mL and a width of at least 301 daPa. Based on the algorithm, the area under the curve was 0.84; values from 0.80–0.90 tend to be accurate predictors.

There were no clinically significant differences between the empirical and algorithmic methods in terms of ability to predict MEE. The study was supported in part by donations from GlaxoSmithKline and Pfizer, Inc.

Bacterial Tracheitis Gains Prominence

Bacterial tracheitis, a relatively uncommon infection, may have outpaced viral croup and epiglottitis as the most common potentially life-threatening upper airway infection in children, based on data from 127 patients treated in a single hospital between 1997 and 2006.

The widespread immunization of children against Haemophilus influenza type b and the use of corticosteroids to treat viral croup have likely contributed to the decline in viral croup and epiglottitis, and the resulting prevalence of cases of bacterial tracheitis, reported Dr. Amelia Hopkins of the University of Colorado School of Medicine, Denver, and her colleagues (Pediatrics 2006;118:1416–21).

Respiratory failures were three times more likely to be caused by bacterial tracheitis than by viral croup and epiglottitis combined, they said. Overall, 35 children were sent to the pediatric ICU: 17 (48%) were diagnosed with bacterial tracheitis, 16 (46%) were diagnosed with viral croup, and 2 (6%) were diagnosed with epiglottitis. Of the 20 children in the PICU who developed respiratory failure, 15 (75%) had bacterial tracheitis, compared with only 3 (15%) who had viral croup and 2 (10%) who had nonclassic epiglottitis.

Of the 18 cases of bacterial tracheitis reviewed, 17 (94%) children were sent to the PICU and 15 (83%) of these needed to be intubated and five had serious complications. By contrast, only 16 (15%) of the 107 cases of viral croup that were reviewed were sent to the PICU, and 3 of these children needed to be intubated, but none experienced serious complications.

Clinical characteristics of bacterial tracheitis included cough and retractions in 17 (94%) patients, stridor in 16 (89%) patients, and hoarseness in 12 (67%) patients.

Child Care Ills Decrease With Time

Children younger than 3 years of age were at increased risk of acute respiratory infections during their first months of attendance at child care facilities, but the risk decreased as they got older and spent more time in child care, according to data from 138,821 hospital admissions among children aged 0–5 years.

The youngest children were at the greatest risk for infection within the first 6 months of child care attendance. At 6 months of age, the incidence rate ratio of hospitalizations for acute respiratory infections was 79% higher among children in child care, compared with children of the same age who were cared for at home. The incidence decreased with age, and at 1 year of age the risk of hospitalization for acute respiratory infections was 44% higher among children in child care compared with children cared for at home.

The results suggest that postponing children's enrollment in child care centers until they reach 1 year of age might reduce the incidence of acute respiratory infections in this age group, wrote Mads Kamper-Jorgensen of the Statens Serum Institut, Copenhagen, and associates (Pediatrics 2006;118:1439–46).

Menactra Protects Despite Error

Persons who mistakenly received the meningococcal conjugate vaccine (Menactra) subcutaneously rather than intramuscularly were nonetheless sufficiently protected, according to a report by the Centers for Disease Control and Prevention.

The CDC received reports that 101 persons aged 11–47 years (median age 17.5 years) in seven states received the new meningococcal vaccine (MCV4) subcutaneously, although it is licensed for intramuscular use only. Of these, 38 agreed to participate in an investigation to show whether revaccination was needed (MMWR 2006;55:1016–7).

Overall, 36 of the 38 investigation participants were protected for each of the four vaccine subgroups (A, C, Y, and W-135), based on a baby rabbit-based serum bactericidal assay (rSBA) in which titers of at least 8 were considered protective. Two patients had titers less than 8, and these involved one serogroup in each patient (one for serogroup C only and one for serogroup W-135 only).

Although the geometric mean titers (GMTs) were significantly lower for the subcutaneous vaccinees, compared with age-matched intramuscular vaccinees from the MCV4 clinical trials for serogroups A, C, and Y, there were no significant differences in GMTs for serogroup W-135.

Based on these findings, the researchers did not recommend revaccination for any of the subcutaneous vaccinees.

MCV4, a tetravalent meningococcal conjugate vaccine, was licensed in January 2005 after demonstrating safety and effectiveness, compared with the meningococcal polysaccharide vaccine (MPSV4) that has been used for 30 years.

By contrast, MPSV4 is licensed for subcutaneous use, not intramuscular use, and this is the most likely reason for the misadministration of MCV4, said health care providers who participated in the investigation.

Bacterial Tracheitis Gains Prominence

Bacterial tracheitis, a relatively uncommon infection, may have outpaced viral croup and epiglottitis as the most common potentially life-threatening upper airway infection in children, based on data from 127 patients treated in a single hospital between 1997 and 2006.

The widespread immunization of children against Haemophilus influenza type b and the use of corticosteroids to treat viral croup have likely contributed to the decline in viral croup and epiglottitis, and the resulting prevalence of cases of bacterial tracheitis, reported Dr. Amelia Hopkins of the University of Colorado School of Medicine, Denver, and her colleagues (Pediatrics 2006;118:1416–21).

Respiratory failures were three times more likely to be caused by bacterial tracheitis than by viral croup and epiglottitis combined, they said. Overall, 35 children were sent to the pediatric ICU: 17 (48%) were diagnosed with bacterial tracheitis, 16 (46%) were diagnosed with viral croup, and 2 (6%) were diagnosed with epiglottitis. Of the 20 children in the PICU who developed respiratory failure, 15 (75%) had bacterial tracheitis, compared with only 3 (15%) who had viral croup and 2 (10%) who had nonclassic epiglottitis.

Of the 18 cases of bacterial tracheitis reviewed, 17 (94%) children were sent to the PICU and 15 (83%) of these needed to be intubated and five had serious complications. By contrast, only 16 (15%) of the 107 cases of viral croup that were reviewed were sent to the PICU, and 3 of these children needed to be intubated, but none experienced serious complications.

Clinical characteristics of bacterial tracheitis included cough and retractions in 17 (94%) patients, stridor in 16 (89%) patients, and hoarseness in 12 (67%) patients.

Child Care Ills Decrease With Time

Children younger than 3 years of age were at increased risk of acute respiratory infections during their first months of attendance at child care facilities, but the risk decreased as they got older and spent more time in child care, according to data from 138,821 hospital admissions among children aged 0–5 years.

The youngest children were at the greatest risk for infection within the first 6 months of child care attendance. At 6 months of age, the incidence rate ratio of hospitalizations for acute respiratory infections was 79% higher among children in child care, compared with children of the same age who were cared for at home. The incidence decreased with age, and at 1 year of age the risk of hospitalization for acute respiratory infections was 44% higher among children in child care compared with children cared for at home.

The results suggest that postponing children's enrollment in child care centers until they reach 1 year of age might reduce the incidence of acute respiratory infections in this age group, wrote Mads Kamper-Jorgensen of the Statens Serum Institut, Copenhagen, and associates (Pediatrics 2006;118:1439–46).

Menactra Protects Despite Error

Persons who mistakenly received the meningococcal conjugate vaccine (Menactra) subcutaneously rather than intramuscularly were nonetheless sufficiently protected, according to a report by the Centers for Disease Control and Prevention.

The CDC received reports that 101 persons aged 11–47 years (median age 17.5 years) in seven states received the new meningococcal vaccine (MCV4) subcutaneously, although it is licensed for intramuscular use only. Of these, 38 agreed to participate in an investigation to show whether revaccination was needed (MMWR 2006;55:1016–7).

Overall, 36 of the 38 investigation participants were protected for each of the four vaccine subgroups (A, C, Y, and W-135), based on a baby rabbit-based serum bactericidal assay (rSBA) in which titers of at least 8 were considered protective. Two patients had titers less than 8, and these involved one serogroup in each patient (one for serogroup C only and one for serogroup W-135 only).

Although the geometric mean titers (GMTs) were significantly lower for the subcutaneous vaccinees, compared with age-matched intramuscular vaccinees from the MCV4 clinical trials for serogroups A, C, and Y, there were no significant differences in GMTs for serogroup W-135.

Based on these findings, the researchers did not recommend revaccination for any of the subcutaneous vaccinees.

MCV4, a tetravalent meningococcal conjugate vaccine, was licensed in January 2005 after demonstrating safety and effectiveness, compared with the meningococcal polysaccharide vaccine (MPSV4) that has been used for 30 years.

By contrast, MPSV4 is licensed for subcutaneous use, not intramuscular use, and this is the most likely reason for the misadministration of MCV4, said health care providers who participated in the investigation.

Bacterial Tracheitis Gains Prominence

Bacterial tracheitis, a relatively uncommon infection, may have outpaced viral croup and epiglottitis as the most common potentially life-threatening upper airway infection in children, based on data from 127 patients treated in a single hospital between 1997 and 2006.

The widespread immunization of children against Haemophilus influenza type b and the use of corticosteroids to treat viral croup have likely contributed to the decline in viral croup and epiglottitis, and the resulting prevalence of cases of bacterial tracheitis, reported Dr. Amelia Hopkins of the University of Colorado School of Medicine, Denver, and her colleagues (Pediatrics 2006;118:1416–21).

Respiratory failures were three times more likely to be caused by bacterial tracheitis than by viral croup and epiglottitis combined, they said. Overall, 35 children were sent to the pediatric ICU: 17 (48%) were diagnosed with bacterial tracheitis, 16 (46%) were diagnosed with viral croup, and 2 (6%) were diagnosed with epiglottitis. Of the 20 children in the PICU who developed respiratory failure, 15 (75%) had bacterial tracheitis, compared with only 3 (15%) who had viral croup and 2 (10%) who had nonclassic epiglottitis.

Of the 18 cases of bacterial tracheitis reviewed, 17 (94%) children were sent to the PICU and 15 (83%) of these needed to be intubated and five had serious complications. By contrast, only 16 (15%) of the 107 cases of viral croup that were reviewed were sent to the PICU, and 3 of these children needed to be intubated, but none experienced serious complications.

Clinical characteristics of bacterial tracheitis included cough and retractions in 17 (94%) patients, stridor in 16 (89%) patients, and hoarseness in 12 (67%) patients.

Child Care Ills Decrease With Time

Children younger than 3 years of age were at increased risk of acute respiratory infections during their first months of attendance at child care facilities, but the risk decreased as they got older and spent more time in child care, according to data from 138,821 hospital admissions among children aged 0–5 years.

The youngest children were at the greatest risk for infection within the first 6 months of child care attendance. At 6 months of age, the incidence rate ratio of hospitalizations for acute respiratory infections was 79% higher among children in child care, compared with children of the same age who were cared for at home. The incidence decreased with age, and at 1 year of age the risk of hospitalization for acute respiratory infections was 44% higher among children in child care compared with children cared for at home.

The results suggest that postponing children's enrollment in child care centers until they reach 1 year of age might reduce the incidence of acute respiratory infections in this age group, wrote Mads Kamper-Jorgensen of the Statens Serum Institut, Copenhagen, and associates (Pediatrics 2006;118:1439–46).

Menactra Protects Despite Error

Persons who mistakenly received the meningococcal conjugate vaccine (Menactra) subcutaneously rather than intramuscularly were nonetheless sufficiently protected, according to a report by the Centers for Disease Control and Prevention.

The CDC received reports that 101 persons aged 11–47 years (median age 17.5 years) in seven states received the new meningococcal vaccine (MCV4) subcutaneously, although it is licensed for intramuscular use only. Of these, 38 agreed to participate in an investigation to show whether revaccination was needed (MMWR 2006;55:1016–7).

Overall, 36 of the 38 investigation participants were protected for each of the four vaccine subgroups (A, C, Y, and W-135), based on a baby rabbit-based serum bactericidal assay (rSBA) in which titers of at least 8 were considered protective. Two patients had titers less than 8, and these involved one serogroup in each patient (one for serogroup C only and one for serogroup W-135 only).

Although the geometric mean titers (GMTs) were significantly lower for the subcutaneous vaccinees, compared with age-matched intramuscular vaccinees from the MCV4 clinical trials for serogroups A, C, and Y, there were no significant differences in GMTs for serogroup W-135.

Based on these findings, the researchers did not recommend revaccination for any of the subcutaneous vaccinees.

MCV4, a tetravalent meningococcal conjugate vaccine, was licensed in January 2005 after demonstrating safety and effectiveness, compared with the meningococcal polysaccharide vaccine (MPSV4) that has been used for 30 years.

By contrast, MPSV4 is licensed for subcutaneous use, not intramuscular use, and this is the most likely reason for the misadministration of MCV4, said health care providers who participated in the investigation.

WASHINGTON — The challenge of paying for vaccinations has become even greater now that the human papilloma virus vaccine is on the immunization schedule.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11− to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention.

However, the price of a vaccine is not allowed to be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, he said.

Consequently, an ACIP recommendation raises the possibility for disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children with private insurance not receiving the same vaccine because it is not paid for.

Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources? “The programs are put in a tough spot,” he said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials, shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). Ms. Hannan said AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program. Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

“Programs are making decisions about how to use limited funds, and they are making different decisions,” she said. The result is a patchwork of vaccination coverage. Possible solutions to the problem of patchwork coverage could include enlisting the help of ob.gyns. and dermatologists, since they treat children and adolescents and could enroll their eligible younger patients in the VFC program, Ms. Hannan said.

No one knows how the financing for HPV vaccines will play out until the vaccine actually is in use, but vaccine financing is dynamic because both the payments and the individual insurance plans change annually, said Dr. Gregory Wallace of the CDC's National Immunization Program. “Difficult decisions have to be made with competing priorities every year.”

WASHINGTON — The challenge of paying for vaccinations has become even greater now that the human papilloma virus vaccine is on the immunization schedule.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11− to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention.

However, the price of a vaccine is not allowed to be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, he said.

Consequently, an ACIP recommendation raises the possibility for disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children with private insurance not receiving the same vaccine because it is not paid for.

Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources? “The programs are put in a tough spot,” he said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials, shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). Ms. Hannan said AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program. Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

“Programs are making decisions about how to use limited funds, and they are making different decisions,” she said. The result is a patchwork of vaccination coverage. Possible solutions to the problem of patchwork coverage could include enlisting the help of ob.gyns. and dermatologists, since they treat children and adolescents and could enroll their eligible younger patients in the VFC program, Ms. Hannan said.

No one knows how the financing for HPV vaccines will play out until the vaccine actually is in use, but vaccine financing is dynamic because both the payments and the individual insurance plans change annually, said Dr. Gregory Wallace of the CDC's National Immunization Program. “Difficult decisions have to be made with competing priorities every year.”

WASHINGTON — The challenge of paying for vaccinations has become even greater now that the human papilloma virus vaccine is on the immunization schedule.

At a meeting of the National Vaccine Advisory Committee, representatives from several organizations reported that there isn't enough money to go around and that states will have to make tough choices about funding for the HPV vaccine, which is scheduled to become a standard immunization for 11− to 12-year-old girls.

The evidence used by the Advisory Committee on Immunization Practices to make vaccine recommendations includes economic factors as part of the public health perspective, said Dr. Lance Rodewald, director of the immunization services division at the Centers for Disease Control and Prevention.

However, the price of a vaccine is not allowed to be a consideration for resolutions made by the Vaccines for Children (VFC) program. The key consideration in a VFC resolution simply is whether the vaccine is recommended for VFC-eligible children, he said.

Consequently, an ACIP recommendation raises the possibility for disparity, with VFC-eligible children receiving a vaccine because it is paid for, and children with private insurance not receiving the same vaccine because it is not paid for.

Neither state-appropriated funds nor funds from Section 317 (a discretionary program within the Public Health Service Act that covers individuals whose insurance doesn't cover vaccines or who are not eligible for VFC funds) has kept up with VFC's need-based funding, Dr. Rodewald said.

What happens when the need outstrips the resources? “The programs are put in a tough spot,” he said. “The states will need to prioritize vaccinations, and we are looking to other groups to help resolve the financing dilemma.”

Dr. Poki Stewart Namkung, president of the National Association of County & City Health Officials, shared responses to a survey that solicited their members' concerns about implementing HPV vaccines. Key issues raised by the local health departments included how to vaccinate girls and young women who fall outside the bounds of public assistance given the limitations of the VFC program and Section 317.

States will receive VFC funding, but do not know what other funds to expect, said Claire Hannan, executive director of the Association of Immunization Managers (AIM). Ms. Hannan said AIM members are involved in every aspect of vaccination, including distribution, purchasing, and provider and consumer education.

Uninsured individuals aged 9–18 years will be covered by VFC, and limited coverage for uninsured females aged 9–26 years may be available through Merck & Co.'s vaccine assistance program. Insured individuals are covered in theory, but AIM members are concerned that as new, expensive vaccines are added to the vaccine schedule, more insurance plans will not cover all the vaccines, Ms. Hannan said.

“Programs are making decisions about how to use limited funds, and they are making different decisions,” she said. The result is a patchwork of vaccination coverage. Possible solutions to the problem of patchwork coverage could include enlisting the help of ob.gyns. and dermatologists, since they treat children and adolescents and could enroll their eligible younger patients in the VFC program, Ms. Hannan said.

No one knows how the financing for HPV vaccines will play out until the vaccine actually is in use, but vaccine financing is dynamic because both the payments and the individual insurance plans change annually, said Dr. Gregory Wallace of the CDC's National Immunization Program. “Difficult decisions have to be made with competing priorities every year.”

Children aged 5–8 years who have not previously received a flu vaccine need two doses of trivalent inactivated influenza vaccine, based on antibody response data from 222 children in a prospective, open-label study.

Prior studies have established the need for two doses of flu vaccine for unvaccinated infants and young children, but research in older children has been limited, said Dr. Kathleen M. Neuzil of the University of Washington, Seattle, and her colleagues (J. Infect. Dis. 2006;194:1032–9). Dr. Neuzil has received grant support from Sanofi Pasteur and MedImmune.

Among children who were seronegative at baseline, an additional 50%, 51%, and 31% developed protective responses to A/H1N1, A/H3N2, and B vaccine antigens, respectively, after a second dose of trivalent inactivated influenza vaccine (TIV).

Baseline seropositive children showed a significant increase in antibody titers after one dose, but they showed no significant additional difference in antibody titers after a second dose (see box).

The results remained significant after controlling for baseline serostatus (the strongest predictor of a protective antibody response) as well as age and sex.

Overall, the antibody titers for the B vaccine component were significantly lower than for the A components in both seronegative and seropositive children, but this finding was consistent with data from other vaccine studies, the researchers noted.

Because baseline serostatus is not easily determined and serologic testing before vaccination is not practical, the study confirms the need for two doses of TIV in previously unvaccinated 5− to 8-year-olds, Dr. Kathryn M. Edwards and Dr. Marie R. Griffin of Vanderbilt University in Nashville, Tenn., said in an editorial (J. Infect. Dis. 2006;194:1027–9).

The children received two 0.5-mL shots of TIV 2 weeks apart. Serum samples were taken at baseline, at 4 weeks after the first dose (before the second dose was given), and at 4 weeks after the second dose. The vaccine was well tolerated among all age groups and in both dosage groups, and no significant differences appeared between the dosage groups in the number of children with redness, swelling, fever, or itching after either one or two doses.

Children aged 5–8 years who have not previously received a flu vaccine need two doses of trivalent inactivated influenza vaccine, based on antibody response data from 222 children in a prospective, open-label study.

Prior studies have established the need for two doses of flu vaccine for unvaccinated infants and young children, but research in older children has been limited, said Dr. Kathleen M. Neuzil of the University of Washington, Seattle, and her colleagues (J. Infect. Dis. 2006;194:1032–9). Dr. Neuzil has received grant support from Sanofi Pasteur and MedImmune.

Among children who were seronegative at baseline, an additional 50%, 51%, and 31% developed protective responses to A/H1N1, A/H3N2, and B vaccine antigens, respectively, after a second dose of trivalent inactivated influenza vaccine (TIV).

Baseline seropositive children showed a significant increase in antibody titers after one dose, but they showed no significant additional difference in antibody titers after a second dose (see box).

The results remained significant after controlling for baseline serostatus (the strongest predictor of a protective antibody response) as well as age and sex.

Overall, the antibody titers for the B vaccine component were significantly lower than for the A components in both seronegative and seropositive children, but this finding was consistent with data from other vaccine studies, the researchers noted.

Because baseline serostatus is not easily determined and serologic testing before vaccination is not practical, the study confirms the need for two doses of TIV in previously unvaccinated 5− to 8-year-olds, Dr. Kathryn M. Edwards and Dr. Marie R. Griffin of Vanderbilt University in Nashville, Tenn., said in an editorial (J. Infect. Dis. 2006;194:1027–9).

The children received two 0.5-mL shots of TIV 2 weeks apart. Serum samples were taken at baseline, at 4 weeks after the first dose (before the second dose was given), and at 4 weeks after the second dose. The vaccine was well tolerated among all age groups and in both dosage groups, and no significant differences appeared between the dosage groups in the number of children with redness, swelling, fever, or itching after either one or two doses.

Children aged 5–8 years who have not previously received a flu vaccine need two doses of trivalent inactivated influenza vaccine, based on antibody response data from 222 children in a prospective, open-label study.

Prior studies have established the need for two doses of flu vaccine for unvaccinated infants and young children, but research in older children has been limited, said Dr. Kathleen M. Neuzil of the University of Washington, Seattle, and her colleagues (J. Infect. Dis. 2006;194:1032–9). Dr. Neuzil has received grant support from Sanofi Pasteur and MedImmune.

Among children who were seronegative at baseline, an additional 50%, 51%, and 31% developed protective responses to A/H1N1, A/H3N2, and B vaccine antigens, respectively, after a second dose of trivalent inactivated influenza vaccine (TIV).

Baseline seropositive children showed a significant increase in antibody titers after one dose, but they showed no significant additional difference in antibody titers after a second dose (see box).

The results remained significant after controlling for baseline serostatus (the strongest predictor of a protective antibody response) as well as age and sex.

Overall, the antibody titers for the B vaccine component were significantly lower than for the A components in both seronegative and seropositive children, but this finding was consistent with data from other vaccine studies, the researchers noted.

Because baseline serostatus is not easily determined and serologic testing before vaccination is not practical, the study confirms the need for two doses of TIV in previously unvaccinated 5− to 8-year-olds, Dr. Kathryn M. Edwards and Dr. Marie R. Griffin of Vanderbilt University in Nashville, Tenn., said in an editorial (J. Infect. Dis. 2006;194:1027–9).

The children received two 0.5-mL shots of TIV 2 weeks apart. Serum samples were taken at baseline, at 4 weeks after the first dose (before the second dose was given), and at 4 weeks after the second dose. The vaccine was well tolerated among all age groups and in both dosage groups, and no significant differences appeared between the dosage groups in the number of children with redness, swelling, fever, or itching after either one or two doses.

WASHINGTON — Targeting health care workers, reaching out to grandparents, promoting workplace vaccination, and extending the vaccination season are among the Centers for Disease Control and Prevention's short-term efforts to improve vaccination rates in priority groups and the general public for the 2006–2007 flu season, Dr. Jeanne M. Santoli reported at a meeting of the National Vaccine Advisory Committee.

“We looked at what can we do on short notice to try to promote vaccination this year, and what programs we could piggyback onto,” said Dr. Santoli, who is with the CDC's National Center for Immunization and Respiratory Diseases.

Several teams of health care providers are in the process of implementing plans to increase flu vaccination that were established at the National Influenza Vaccine Summit Meeting earlier this year, Dr. Santoli reported.

The team that focused on increasing flu vaccination among heath care workers has crafted joint letters from the CDC and the American Medical Association to administrators of health care facilities about the importance of vaccinating all employees. The team also designed a full-page ad to appear in the Journal of the American Medical Association.

The pediatric team's activities have included promoting flu vaccination in children aged 6–59 months in response to the current recommendations for vaccination in this age group.

In addition, the team is developing flash cards for primary care providers who are trying to reach 5− to 14-year-olds, many of whom are either high risk themselves or are household contacts of high-risk persons. “We don't always do a good job of reaching the household contacts,” Dr. Santoli noted.

The pediatrics team also initiated a joint effort with the AARP that will encourage grandparents to help make sure that their own grandchildren are vaccinated.

Another team targeted the contacts of high-risk persons and the general public by identifying venues where they could reach many people.

The team developed a joint letter to the colleges that are members of the American College Health Association (ACHA) from both the CDC and the ACHA that stressed the importance of sponsoring vaccination clinics for students.

Other efforts have included hosting a Web-based seminar for employers with information about workplace vaccinations and exploring ways to promote flu vaccination through faith-based organizations.

Another team has addressed the misperception that the flu vaccination season ends in December. Their proposed strategies include presenting an award for a provider or organization that develops an innovative approach to vaccination later in the season, and promoting a “Flu Vaccination Day” in January, when providers and patients aren't thinking about flu vaccines.

At the start of flu season, approximately 100 million doses of flu vaccine were available for distribution, Dr. Santoli said.

For updates on flu vaccination recommendations and vaccine supplies, visit www.cdc.gov/flu/about/qa/vaxsupply.htm

WASHINGTON — Targeting health care workers, reaching out to grandparents, promoting workplace vaccination, and extending the vaccination season are among the Centers for Disease Control and Prevention's short-term efforts to improve vaccination rates in priority groups and the general public for the 2006–2007 flu season, Dr. Jeanne M. Santoli reported at a meeting of the National Vaccine Advisory Committee.

“We looked at what can we do on short notice to try to promote vaccination this year, and what programs we could piggyback onto,” said Dr. Santoli, who is with the CDC's National Center for Immunization and Respiratory Diseases.

Several teams of health care providers are in the process of implementing plans to increase flu vaccination that were established at the National Influenza Vaccine Summit Meeting earlier this year, Dr. Santoli reported.

The team that focused on increasing flu vaccination among heath care workers has crafted joint letters from the CDC and the American Medical Association to administrators of health care facilities about the importance of vaccinating all employees. The team also designed a full-page ad to appear in the Journal of the American Medical Association.

The pediatric team's activities have included promoting flu vaccination in children aged 6–59 months in response to the current recommendations for vaccination in this age group.

In addition, the team is developing flash cards for primary care providers who are trying to reach 5− to 14-year-olds, many of whom are either high risk themselves or are household contacts of high-risk persons. “We don't always do a good job of reaching the household contacts,” Dr. Santoli noted.

The pediatrics team also initiated a joint effort with the AARP that will encourage grandparents to help make sure that their own grandchildren are vaccinated.

Another team targeted the contacts of high-risk persons and the general public by identifying venues where they could reach many people.

The team developed a joint letter to the colleges that are members of the American College Health Association (ACHA) from both the CDC and the ACHA that stressed the importance of sponsoring vaccination clinics for students.

Other efforts have included hosting a Web-based seminar for employers with information about workplace vaccinations and exploring ways to promote flu vaccination through faith-based organizations.

Another team has addressed the misperception that the flu vaccination season ends in December. Their proposed strategies include presenting an award for a provider or organization that develops an innovative approach to vaccination later in the season, and promoting a “Flu Vaccination Day” in January, when providers and patients aren't thinking about flu vaccines.

At the start of flu season, approximately 100 million doses of flu vaccine were available for distribution, Dr. Santoli said.

For updates on flu vaccination recommendations and vaccine supplies, visit www.cdc.gov/flu/about/qa/vaxsupply.htm

WASHINGTON — Targeting health care workers, reaching out to grandparents, promoting workplace vaccination, and extending the vaccination season are among the Centers for Disease Control and Prevention's short-term efforts to improve vaccination rates in priority groups and the general public for the 2006–2007 flu season, Dr. Jeanne M. Santoli reported at a meeting of the National Vaccine Advisory Committee.

“We looked at what can we do on short notice to try to promote vaccination this year, and what programs we could piggyback onto,” said Dr. Santoli, who is with the CDC's National Center for Immunization and Respiratory Diseases.

Several teams of health care providers are in the process of implementing plans to increase flu vaccination that were established at the National Influenza Vaccine Summit Meeting earlier this year, Dr. Santoli reported.

The team that focused on increasing flu vaccination among heath care workers has crafted joint letters from the CDC and the American Medical Association to administrators of health care facilities about the importance of vaccinating all employees. The team also designed a full-page ad to appear in the Journal of the American Medical Association.

The pediatric team's activities have included promoting flu vaccination in children aged 6–59 months in response to the current recommendations for vaccination in this age group.

In addition, the team is developing flash cards for primary care providers who are trying to reach 5− to 14-year-olds, many of whom are either high risk themselves or are household contacts of high-risk persons. “We don't always do a good job of reaching the household contacts,” Dr. Santoli noted.

The pediatrics team also initiated a joint effort with the AARP that will encourage grandparents to help make sure that their own grandchildren are vaccinated.

Another team targeted the contacts of high-risk persons and the general public by identifying venues where they could reach many people.

The team developed a joint letter to the colleges that are members of the American College Health Association (ACHA) from both the CDC and the ACHA that stressed the importance of sponsoring vaccination clinics for students.

Other efforts have included hosting a Web-based seminar for employers with information about workplace vaccinations and exploring ways to promote flu vaccination through faith-based organizations.

Another team has addressed the misperception that the flu vaccination season ends in December. Their proposed strategies include presenting an award for a provider or organization that develops an innovative approach to vaccination later in the season, and promoting a “Flu Vaccination Day” in January, when providers and patients aren't thinking about flu vaccines.

At the start of flu season, approximately 100 million doses of flu vaccine were available for distribution, Dr. Santoli said.

For updates on flu vaccination recommendations and vaccine supplies, visit www.cdc.gov/flu/about/qa/vaxsupply.htm

Women who have no chance of becoming pregnant, as well as men, no longer need to observe a 23-day lockout period before starting a new prescription of isotretinoin for the treatment of acne, according to a statement from the Food and Drug Administration.

To take advantage of this change, however, patients must repeat the qualification process to confirm that they meet the qualifying criteria to skip the 23-day lockout.

The iPLEDGE program was designed as a risk management plan to prevent, because of its severe teratogenic side effects, the use of isotretinoin by females who are or may become pregnant. The program initiated a universal set of strict criteria to be met before any patients could receive isotretinoin, regardless of their childbearing potential.

According to the original criteria, all female patients who wanted to take isotretinoin had to undergo a pregnancy test, and all patients had to be counseled that two types of contraception are essential while taking isotretinoin.

Once these criteria were met, patients had 7 days to fill a prescription. If they didn't fill it within that time, they would have to wait for 23 days, a time frame designed to accommodate another pregnancy test for women who could become pregnant. This process was to be repeated for each refill, which increased the administrative workload for clinicians and put pressure on patients.

Since then, clinicians' frustration with the iPLEDGE criteria has led to efforts by the American Academy of Dermatology and other organizations to convince the FDA and drug manufacturers that iPLEDGE needed revision.

For more information about the changes to the iPLEDGE program, visit the Web site at www.ipledgeprogram.com

Women who have no chance of becoming pregnant, as well as men, no longer need to observe a 23-day lockout period before starting a new prescription of isotretinoin for the treatment of acne, according to a statement from the Food and Drug Administration.

To take advantage of this change, however, patients must repeat the qualification process to confirm that they meet the qualifying criteria to skip the 23-day lockout.

The iPLEDGE program was designed as a risk management plan to prevent, because of its severe teratogenic side effects, the use of isotretinoin by females who are or may become pregnant. The program initiated a universal set of strict criteria to be met before any patients could receive isotretinoin, regardless of their childbearing potential.

According to the original criteria, all female patients who wanted to take isotretinoin had to undergo a pregnancy test, and all patients had to be counseled that two types of contraception are essential while taking isotretinoin.

Once these criteria were met, patients had 7 days to fill a prescription. If they didn't fill it within that time, they would have to wait for 23 days, a time frame designed to accommodate another pregnancy test for women who could become pregnant. This process was to be repeated for each refill, which increased the administrative workload for clinicians and put pressure on patients.

Since then, clinicians' frustration with the iPLEDGE criteria has led to efforts by the American Academy of Dermatology and other organizations to convince the FDA and drug manufacturers that iPLEDGE needed revision.

For more information about the changes to the iPLEDGE program, visit the Web site at www.ipledgeprogram.com

Women who have no chance of becoming pregnant, as well as men, no longer need to observe a 23-day lockout period before starting a new prescription of isotretinoin for the treatment of acne, according to a statement from the Food and Drug Administration.

To take advantage of this change, however, patients must repeat the qualification process to confirm that they meet the qualifying criteria to skip the 23-day lockout.

The iPLEDGE program was designed as a risk management plan to prevent, because of its severe teratogenic side effects, the use of isotretinoin by females who are or may become pregnant. The program initiated a universal set of strict criteria to be met before any patients could receive isotretinoin, regardless of their childbearing potential.

According to the original criteria, all female patients who wanted to take isotretinoin had to undergo a pregnancy test, and all patients had to be counseled that two types of contraception are essential while taking isotretinoin.

Once these criteria were met, patients had 7 days to fill a prescription. If they didn't fill it within that time, they would have to wait for 23 days, a time frame designed to accommodate another pregnancy test for women who could become pregnant. This process was to be repeated for each refill, which increased the administrative workload for clinicians and put pressure on patients.

Since then, clinicians' frustration with the iPLEDGE criteria has led to efforts by the American Academy of Dermatology and other organizations to convince the FDA and drug manufacturers that iPLEDGE needed revision.

For more information about the changes to the iPLEDGE program, visit the Web site at www.ipledgeprogram.com

WASHINGTON — Protect HIV-infected patients from additional illness by vaccinating them against influenza, hepatitis A and B, pneumococcal disease, and tetanus-diphtheria, Dr. David H. Spach advised at the Ryan White CARE Act meeting on HIV treatment.

As flu season begins, “vaccinate everyone for flu regardless of their CD4 count or viral load,” said Dr. Spach, of the University of Washington, Seattle. He presented a roundup of immunization recommendations for HIV patients:

▸ Influenza. Adults with AIDS are at significantly greater risk for influenza, compared with healthy adults, and even compared with healthy persons older than 65 years, according to data from a 3-year study of deaths from influenza or pneumonia (Arch. Intern. Med. 2001;161:441–6). Studies have shown that the flu vaccine is most effective for patients with CD4 counts greater than 100 cells/mm

Vaccinate HIV patients annually with the trivalent vaccine regardless of their CD4 count, but remember that the live vaccine is contraindicated for these patients, he said. Data from the Centers for Disease Control and Prevention from 1976–2006 confirm that peak flu activity occurs in the 4-month period from December through March, which reinforces the current recommendations to give HIV patients the flu vaccine at a regular visit just prior to the start of flu season.

▸ Hepatitis B. Clinicians may encounter HIV patients who received one or two doses of the hepatitis B vaccine and then disappeared for years.

But if an HIV patient has missed a dose, “it's fine to pick up where you left off,” Dr. Spach said. Long intervals between the first and second doses of hepatitis B vaccine appear to have little effect on immunogenicity in HIV patients, and the third dose is more like a booster dose, he said. The CDC's Advisory Committee on Immunization Practices recommends a standard 20-mcg dose at baseline, with subsequent doses at 1 month and 6 months.

Consider a double dose of hepatitis B vaccine in HIV patients who do not respond to the initial three-dose series, Dr. Spach said. Patients with CD4 counts greater than 500 cells/mm

▸ Hepatitis A. Data from a study of 133 HIV-infected adults showed that response rates to hepatitis A vaccine are significantly greater in HIV patients with CD4 counts of at least 200 cells/mm

“Those with CD4 counts under 200 really did not respond well at 7 and 9 months post vaccination,” Dr. Spach said. Vaccine response rates at 7 and 9 months were 11% and 9%, respectively, compared with 53% and 69% among patients with CD4 counts of 200–500 cells/mm

Based on these and other data, hepatitis A is not an optimal vaccine for patients with low CD4 counts. If a patient is set to start antiviral therapy, consider postponing hepatitis A vaccination to see whether the CD4 count increases.

▸ Pneumococcal disease. The rate of invasive pneumococcal disease in HIV-infected patients has decreased as a result of the widespread use of the seven-valent conjugate pneumococcal vaccine given to young children, Dr. Spach said.

Data from 2006 show a 20% decrease in invasive pneumococcal disease among HIV-infected adults since the childhood conjugate vaccine became widely used, with a 60% reduction in the incidence of illness from serotypes that were contained in the vaccine and a slight increase in strains that were not contained in the vaccine (Ann. Intern. Med. 2006;144:1–9). These findings parallel other studies in adults not infected with HIV who have shown a strong herd immunity. “This childhood vaccine probably has had a greater effect on preventing pneumococcal disease in HIV patients than our giving the standard adult polysaccharide vaccine.”

No published data show that the 7-valent vaccine is better than the standard vaccine for HIV-infected adults, and current recommendations still call for a single dose of the 23-valent polysaccharide pneumococcal vaccine followed by another dose 5 years later. “But if you have a patient with children or who interacts with children, encourage those kids to get immunized with the conjugate vaccine,” he said.

▸ Tetanus. The new Tdap vaccine (approved in June 2005) is not a live vaccine, so it's safe for HIV patients. Tdap is not Food and Drug Administration-approved for HIV patients specifically, but it is not contraindicated for them, and it will protect them from pertussis, diphtheria, and tetanus. New recommendations for non-HIV-infected adults call for replacing the next booster dose of Td (tetanus-diphtheria toxoids) with the Tdap vaccine, which should be given routinely to patients whose last Td vaccination was more than 10 years ago.

For the latest immunization information, visit the CDC's National Immunization Program Web site, www.cdc.gov/nip

WASHINGTON — Protect HIV-infected patients from additional illness by vaccinating them against influenza, hepatitis A and B, pneumococcal disease, and tetanus-diphtheria, Dr. David H. Spach advised at the Ryan White CARE Act meeting on HIV treatment.

As flu season begins, “vaccinate everyone for flu regardless of their CD4 count or viral load,” said Dr. Spach, of the University of Washington, Seattle. He presented a roundup of immunization recommendations for HIV patients:

▸ Influenza. Adults with AIDS are at significantly greater risk for influenza, compared with healthy adults, and even compared with healthy persons older than 65 years, according to data from a 3-year study of deaths from influenza or pneumonia (Arch. Intern. Med. 2001;161:441–6). Studies have shown that the flu vaccine is most effective for patients with CD4 counts greater than 100 cells/mm

Vaccinate HIV patients annually with the trivalent vaccine regardless of their CD4 count, but remember that the live vaccine is contraindicated for these patients, he said. Data from the Centers for Disease Control and Prevention from 1976–2006 confirm that peak flu activity occurs in the 4-month period from December through March, which reinforces the current recommendations to give HIV patients the flu vaccine at a regular visit just prior to the start of flu season.

▸ Hepatitis B. Clinicians may encounter HIV patients who received one or two doses of the hepatitis B vaccine and then disappeared for years.

But if an HIV patient has missed a dose, “it's fine to pick up where you left off,” Dr. Spach said. Long intervals between the first and second doses of hepatitis B vaccine appear to have little effect on immunogenicity in HIV patients, and the third dose is more like a booster dose, he said. The CDC's Advisory Committee on Immunization Practices recommends a standard 20-mcg dose at baseline, with subsequent doses at 1 month and 6 months.

Consider a double dose of hepatitis B vaccine in HIV patients who do not respond to the initial three-dose series, Dr. Spach said. Patients with CD4 counts greater than 500 cells/mm

▸ Hepatitis A. Data from a study of 133 HIV-infected adults showed that response rates to hepatitis A vaccine are significantly greater in HIV patients with CD4 counts of at least 200 cells/mm

“Those with CD4 counts under 200 really did not respond well at 7 and 9 months post vaccination,” Dr. Spach said. Vaccine response rates at 7 and 9 months were 11% and 9%, respectively, compared with 53% and 69% among patients with CD4 counts of 200–500 cells/mm

Based on these and other data, hepatitis A is not an optimal vaccine for patients with low CD4 counts. If a patient is set to start antiviral therapy, consider postponing hepatitis A vaccination to see whether the CD4 count increases.

▸ Pneumococcal disease. The rate of invasive pneumococcal disease in HIV-infected patients has decreased as a result of the widespread use of the seven-valent conjugate pneumococcal vaccine given to young children, Dr. Spach said.

Data from 2006 show a 20% decrease in invasive pneumococcal disease among HIV-infected adults since the childhood conjugate vaccine became widely used, with a 60% reduction in the incidence of illness from serotypes that were contained in the vaccine and a slight increase in strains that were not contained in the vaccine (Ann. Intern. Med. 2006;144:1–9). These findings parallel other studies in adults not infected with HIV who have shown a strong herd immunity. “This childhood vaccine probably has had a greater effect on preventing pneumococcal disease in HIV patients than our giving the standard adult polysaccharide vaccine.”

No published data show that the 7-valent vaccine is better than the standard vaccine for HIV-infected adults, and current recommendations still call for a single dose of the 23-valent polysaccharide pneumococcal vaccine followed by another dose 5 years later. “But if you have a patient with children or who interacts with children, encourage those kids to get immunized with the conjugate vaccine,” he said.

▸ Tetanus. The new Tdap vaccine (approved in June 2005) is not a live vaccine, so it's safe for HIV patients. Tdap is not Food and Drug Administration-approved for HIV patients specifically, but it is not contraindicated for them, and it will protect them from pertussis, diphtheria, and tetanus. New recommendations for non-HIV-infected adults call for replacing the next booster dose of Td (tetanus-diphtheria toxoids) with the Tdap vaccine, which should be given routinely to patients whose last Td vaccination was more than 10 years ago.

For the latest immunization information, visit the CDC's National Immunization Program Web site, www.cdc.gov/nip

WASHINGTON — Protect HIV-infected patients from additional illness by vaccinating them against influenza, hepatitis A and B, pneumococcal disease, and tetanus-diphtheria, Dr. David H. Spach advised at the Ryan White CARE Act meeting on HIV treatment.

As flu season begins, “vaccinate everyone for flu regardless of their CD4 count or viral load,” said Dr. Spach, of the University of Washington, Seattle. He presented a roundup of immunization recommendations for HIV patients:

▸ Influenza. Adults with AIDS are at significantly greater risk for influenza, compared with healthy adults, and even compared with healthy persons older than 65 years, according to data from a 3-year study of deaths from influenza or pneumonia (Arch. Intern. Med. 2001;161:441–6). Studies have shown that the flu vaccine is most effective for patients with CD4 counts greater than 100 cells/mm

Vaccinate HIV patients annually with the trivalent vaccine regardless of their CD4 count, but remember that the live vaccine is contraindicated for these patients, he said. Data from the Centers for Disease Control and Prevention from 1976–2006 confirm that peak flu activity occurs in the 4-month period from December through March, which reinforces the current recommendations to give HIV patients the flu vaccine at a regular visit just prior to the start of flu season.

▸ Hepatitis B. Clinicians may encounter HIV patients who received one or two doses of the hepatitis B vaccine and then disappeared for years.

But if an HIV patient has missed a dose, “it's fine to pick up where you left off,” Dr. Spach said. Long intervals between the first and second doses of hepatitis B vaccine appear to have little effect on immunogenicity in HIV patients, and the third dose is more like a booster dose, he said. The CDC's Advisory Committee on Immunization Practices recommends a standard 20-mcg dose at baseline, with subsequent doses at 1 month and 6 months.

Consider a double dose of hepatitis B vaccine in HIV patients who do not respond to the initial three-dose series, Dr. Spach said. Patients with CD4 counts greater than 500 cells/mm

▸ Hepatitis A. Data from a study of 133 HIV-infected adults showed that response rates to hepatitis A vaccine are significantly greater in HIV patients with CD4 counts of at least 200 cells/mm

“Those with CD4 counts under 200 really did not respond well at 7 and 9 months post vaccination,” Dr. Spach said. Vaccine response rates at 7 and 9 months were 11% and 9%, respectively, compared with 53% and 69% among patients with CD4 counts of 200–500 cells/mm

Based on these and other data, hepatitis A is not an optimal vaccine for patients with low CD4 counts. If a patient is set to start antiviral therapy, consider postponing hepatitis A vaccination to see whether the CD4 count increases.

▸ Pneumococcal disease. The rate of invasive pneumococcal disease in HIV-infected patients has decreased as a result of the widespread use of the seven-valent conjugate pneumococcal vaccine given to young children, Dr. Spach said.

Data from 2006 show a 20% decrease in invasive pneumococcal disease among HIV-infected adults since the childhood conjugate vaccine became widely used, with a 60% reduction in the incidence of illness from serotypes that were contained in the vaccine and a slight increase in strains that were not contained in the vaccine (Ann. Intern. Med. 2006;144:1–9). These findings parallel other studies in adults not infected with HIV who have shown a strong herd immunity. “This childhood vaccine probably has had a greater effect on preventing pneumococcal disease in HIV patients than our giving the standard adult polysaccharide vaccine.”

No published data show that the 7-valent vaccine is better than the standard vaccine for HIV-infected adults, and current recommendations still call for a single dose of the 23-valent polysaccharide pneumococcal vaccine followed by another dose 5 years later. “But if you have a patient with children or who interacts with children, encourage those kids to get immunized with the conjugate vaccine,” he said.

▸ Tetanus. The new Tdap vaccine (approved in June 2005) is not a live vaccine, so it's safe for HIV patients. Tdap is not Food and Drug Administration-approved for HIV patients specifically, but it is not contraindicated for them, and it will protect them from pertussis, diphtheria, and tetanus. New recommendations for non-HIV-infected adults call for replacing the next booster dose of Td (tetanus-diphtheria toxoids) with the Tdap vaccine, which should be given routinely to patients whose last Td vaccination was more than 10 years ago.

For the latest immunization information, visit the CDC's National Immunization Program Web site, www.cdc.gov/nip