Human Papilloma Virus (HPV) Vaccination Recommendations

Human Papilloma Virus (HPV) vaccination is recommended for all females aged 11 through 26 years, regardless of sexual activity or clinical evidence of previous HPV infection, who have not completed the vaccine series. Ideally, vaccination should be given before potential exposure to HPV through sexual activity and may be given as early as age 9 years. The complete series consists of 3 doses, with the second dose given 2 months after the first dose and the third dose 6 months after the first dose.
(Morb Mortal Wkly Rep. 2009;57(53))

Hepatitis Vaccination Recommendations

Hepatitis A vaccination is indicated for persons with chronic liver disease, those who receive clotting factor concentrates, men who have sex with men, illegal drug users, laboratory workers exposed to hepatitis A virus–infected primates, persons traveling to or working in countries with high or intermediate endemicity of hepatitis A, and those seeking protection from hepatitis A virus infection. Single-antigen vaccine formulations should be given in 2 doses either at 0 and 6 to 12 months (Havrix, GlaxoSmithKline) or at 0 and 6 to 18 months (Vaqta, Merck). Combined hepatitis A and hepatitis B vaccine (Twinrix, GlaxoSmithKline) should be given in 3 doses at 0, 1, and 6 months or in 4 doses on days 0, 7, and 21 to 30, followed by a booster dose at month 12.
Hepatitis B vaccination is indicated for persons with end-stage renal disease, HIV infection, or chronic liver disease; for healthcare personnel and public-safety workers exposed to blood or other potentially infectious body fluids; for sexually active persons not in a long-term, mutually monogamous relationship; for persons seeking evaluation or treatment of a sexually transmitted infection; for current or recent injection-drug users; and for men who have sex with men. Other indications and settings are also listed, as well as special formulation indications.
(Morb Mortal Wkly Rep. 2009;57(53))

Influenza Vaccination

Influenza vaccination should be given to those with medical, occupational, or other indications. Medical indications are chronic disorders of the cardiovascular or pulmonary systems, chronic metabolic diseases, immunocompromising conditions, or any condition that compromises respiratory function or that increases risk for aspiration. All healthcare personnel and caregivers of children younger than 5 years should receive influenza vaccination, as should residents of nursing homes and other long-term care and assisted-living facilities, persons likely to transmit influenza to persons at high risk, and others who wish to decrease their risk of getting influenza. Healthy, nonpregnant adults younger than 50 years without high-risk medical conditions who are not contacts of severely immunocompromised persons in special care units can receive either intranasally administered live, attenuated influenza vaccine (FluMist, MedImmune) or inactivated vaccine, but others should receive the inactivated vaccine.
(Morb Mortal Wkly Rep. 2009;57(53))

Maternal Vaccination for Influenza is Safe

In pregnant women and young infants Influenza could induce a serious disease. The maternal antibodies can pass transplacentally, therefore, it can protect infants during the first months of life. Currently, it is recommended that pregnant women be immunized with the inactivated trivalent influenza vaccine. However, compliance with this recommendation is low. The vaccine is not licensed for infants less than 6 months of age, and antiviral agents are not licensed for children younger than 1 year of age. Thus prevention of influenza by other means is an important goal. A study performed in Bangladesh provides data indicating that maternal vaccination for influenza is safe and efficacious. The vaccine also reducing illness among both mothers and infants, therefore antenatal immunization should be considered as an important strategy for the prevention of influenza.
(N Engl J Med 359:1555, 2008)

New Recommendation of Childhood and Adolescent Immunization Schedules

The American Academy of Pediatrics, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the American Academy of Family Physicians approved new recommendations of childhood and adolescent immunization schedules. For children 6 months through 18 years of age it is recommended to have annual influenza vaccine administration. All eligible close contacts of children 0 through 59 months of age should also receive influenza vaccine, as should contacts of children 5 through 18 years of age who have an underlying medical condition predisposing them to complications of influenza.

Another new recommendation is a harmonization of the dosing schedules for the 2 licensed rotavirus vaccines. The first dose of either vaccine should be administered at 6 weeks through 14 weeks 6 days of age, and the final dose by 8 months 0 days of age. Immunization should not be started for infants 15 weeks 0 days of age or older.

(Pediatrics. 2009;123;189–190)

Beware for Prolonged Initial Antibiotic Therapy for Extremely-Low-Birth-Weight Infants

In extremely-low-birth-weight (ELBW, birth weight of <1000 g) infants, prolonged initial empiric antibiotic therapy should be used with caution. It could cause an increased risk for necrotizing enterocolitis (NEC) or death. Although cultures from normally sterile sites usually do not yield any bacterial agents and the incidence of culture-proven bacterial sepsis is low in this population, ELBW infants admitted to intensive care nurseries usually receive empirical antibiotic treatment in the first postnatal days. A study suggested that cefotaxime for the first 3 postnatal days is associated with higher mortality risk, even for the most preterm infants.
(Pediatrics. 2009;123;58-66).

Amlodipine Plus Benazepril Combination For Hypertension Therapy

Although the optimal pharmacotherapy regimen for hypertension is not yet determined, current guidelines recommend inclusion of a diuretic. The guidelines prefer to use diuretics as monotherapy or to use diuretics and an ACE inhibitor in combination therapy. However, recommendation of thiazide-type diuretics as initial therapy for most patients with hypertension needs to be reexamined. Combination therapy is probably a good initial strategy for high-risk patients, rather than starting with one drug and going slow.

Treatment with antihypertensive combination therapy (the angiotensin-converting enzyme (ACE) inhibitor benazepril plus the calcium-channel blocker amlodipine) is more effective than treatment with the ACE inhibitor and diuretic. Studies suggest that the calcium-channel blocker amlodipine effectively increases the availability of vascular endothelial nitric oxide and that the combined effects of amlodipine and an ACE inhibitor on nitric oxide are greater vs the effect with either drug alone.

In patients with hypertension who were at high risk for cardiovascular events, the benazepril-amlodipine combination was superior to the benazepril-hydrochlorothiazide combination in reducing the primary composite outcome of cardiovascular events and death. The single-tablet benazepril-amlodipine combination reduced the risk of morbidity and mortality by 20% compared with conventional therapy. Putting patients on either combination doubled their control rate, so combination therapy is something clinicians need to think about, even if they want to keep the diuretic. But the drug that gives superior cardiovascular outcomes is the calcium-channel blocker and ACE inhibitor.

The cardiovascular benefits of specific classes of antihypertensive drugs may go beyond their effect on blood pressure. The combination of amlodipine and benazepril appears to synergistically reduce left ventricular hypertrophy and arterial stiffness, suggesting that they may protect target organs independently of the drugs' antihypertensive effects.

References:

Jamerson K, Weber MA, Bakris GL, et al. 2008. Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 359: 2417-2428.

Chobanian AV. 2008. Does it matter how hypertension is controlled? N Engl J Med. 359:2485-2488.

New Guidelines for HIV Treatment

In AIDS 2008-XVII International AIDS Conference, the International AIDS Society–USA recommends new guidelines for HIV treatment. This recommendation is simplified and strengthened. One change in the recommendations is a greater emphasis on full virologic suppression. In this recommendation, deciding whether to start treatment in patients with a CD4 cell count of 350 cells/μL or more should be individualized based on the presence of comorbidities, risk factors for progression to AIDS and non-AIDS diseases, and patient willingness to begin treatment. Individuals with incomplete virologic suppression have greater morbidity and mortality than those who more completely suppress it.
The guidelines move aggressively toward earlier initiation of antiretroviral therapy. Treatment should be started before CD4 cell count decreases to less than 350/μL if there are correlates of faster HIV disease progression such as high plasma viral load (>100,000 copies/mL), rapidly decreasing CD4 cell count (>100/μL per year), active hepatitis B or C virus coinfection (resulting in faster progression of liver disease), cardiovascular disease risk, and HIV-associated nephropathy. Initiation of therapy in patients within the 200 to 350/μL CD4 cell count range should be strongly considered and individualized. The recommendations to start therapy in any patient with symptomatic HIV disease, regardless of CD4 count or viral load, and asymptomatic patients with less than 200/μL CD4 cell count.
Clinicians are encouraged to evaluate the whole patient, not just the status of HIV disease, but all coexisting conditions. Resistance testing should be conducted in all patients as part of their baseline workup. There is a little change in recommendations for an initial regimen in patients who are not infected with resistant virus. The first-line choice is a backbone of either an NNRTI or a ritonavir-boosted protease inhibitor (PI), combined with a dual nucleoside reverse transcriptase inhibitor (NRTI) component. The initial treatment regimen for HIV infection must be individualized, particularly in patients with comorbid conditions, but typically includes efavirenz or a ritonavir-boosted PI plus 2 NRTIs (tenofovir or emtricitabine or abacavir or lamivudine). Better not using darunavir as part of an initial regimen but holding it in reserve to use with patients who develop resistance to other PIs. Current first-line regimens are good and simple to use, and there is still concern about holding some drugs in reserve for patients who develop resistance to existing drugs. Even in heavily pretreated patients, the goal of treatment is an HIV-1 RNA level below assay detection limits. Treatment failure should be promptly identified and managed.

Depending on the NRTI mutations present, one might want to consider use of etravirine. Failure of a PI-based regimen can be more complicated, depending upon the genetic barriers. If caught early, changing the NRTI component to 2 active drugs might be sufficient to save the regimen. But as resistance points accumulate, one should consider use of darunavir or tipranavir.

The 3 drugs approved since the last version of the guidelines in 2006 are maraviroc, the first drug to target the CCR5 co-receptor on the surface of the cell; raltegravir, the first drug in the integrase inhibitor class; and etravirine, a second-generation nonnucleoside reverse transcriptase inhibitor (NNRTI) with clear activity against some NNRTI-resistant viruses. Enfurvitide remains an important option for the heavily treatment experienced population, but problems associated with daily injections and the emergence of other therapeutic alternatives such as raltegravir or maraviroc have reduced its use.

(AIDS 2008: XVII International AIDS Conference. Antiretroviral Treatment of Adult HIV Infection, 2008 Recommendations of the International AIDS Society–USA Panel. Presented August 3, 2008. JAMA. 2008;300:555-570)