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Difficulty: HardImmunizations and Vaccine-Preventable Diseases

A 35-year-old man comes to the clinic to establish care. He was diagnosed with HIV 33 weeks ago and is preparing to initiate antiretroviral therapy. He has no significant past medical history. The patient reports receiving standard childhood vaccinations but has not received any vaccines since high school. Vital signs are within normal limits. Physical examination is unremarkable. Laboratory studies show:

CD4+ T-lymphocyte count: 180 cells/mm3180 \text{ cells/mm}^3
HIV viral load: 150,000 copies/mL150,000 \text{ copies/mL}
Hepatitis B surface antigen: Negative
Hepatitis B surface antibody: Negative
Hepatitis B core antibody: Negative
Measles IgG: Negative
Varicella IgG: Positive

Which of the following vaccines are indicated to be administered at today's visit? (Select all that apply)

  1. 20-valent pneumococcal conjugate vaccineAnswer
  2. Hepatitis B vaccineAnswer
  3. C
    Live-attenuated influenza vaccine
  4. D
    Measles, mumps, and rubella vaccine
  5. Recombinant zoster vaccineAnswer

Answer

The 20-valent pneumococcal conjugate vaccine, Hepatitis B vaccine, and Recombinant zoster vaccine are indicated to be administered today.
This patient has newly diagnosed HIV and is severely immunocompromised, indicated by a CD4 count of <200 cells/mm3< 200 \text{ cells/mm}^3. Inactivated and recombinant vaccines are safe and essential for this population. The 20-valent pneumococcal conjugate vaccine is indicated for all adults aged 19 years and older with immunocompromising conditions. The Hepatitis B vaccine is indicated because his serology demonstrates susceptibility, and HIV infection is a high-risk indication. The Recombinant zoster vaccine is a non-live vaccine explicitly recommended for adults aged 19 years and older who are immunodeficient or immunosuppressed due to disease (including HIV) to prevent herpes zoster. These can be safely administered simultaneously today.

Step-by-Step Solution

1
Analyze the patient's immune status and baseline laboratory results.
The patient has HIV with a CD4 count of 180 cells/mm³, indicating severe immunocompromise. He is non-immune to Hepatitis B and Measles.
Establishing the degree of immunocompromise and baseline immunity is required to determine vaccine indications and contraindications.
2
Identify indicated inactivated or recombinant vaccines based on his age and HIV status.
The 20-valent pneumococcal conjugate vaccine (PCV20), Hepatitis B vaccine, and Recombinant zoster vaccine (RZV) are all indicated.
These inactivated/recombinant vaccines are recommended for adults with HIV to prevent opportunistic and severe infections, and they can be safely administered regardless of CD4 count.
3
Evaluate contraindications for live-attenuated vaccines.
Both the live-attenuated influenza vaccine and the measles, mumps, and rubella (MMR) vaccine are strictly contraindicated.
Live-attenuated vaccines pose a risk of life-threatening, disseminated vaccine-strain infection in patients with a CD4 count < 200 cells/mm³.

Key Concept

Vaccination guidelines in HIV-infected patients mandate the administration of appropriate inactivated vaccines (PCV20, HepB, RZV) while strictly contraindicating live-attenuated vaccines (such as MMR and live-attenuated influenza) when the CD4 count is < 200 cells/mm³.
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Immunizations and Vaccine-Preventable Diseases

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