Transcription
Post-Exposure Rabies Regimens forImmunodeficiency PatientsSuda Punrin, MD.
Immunodeficiency Primary Secondary
Secondary (acquired) immunodeficiencyChinen J, Shearer WT. J Allergy Clin Immunol 2010;125:S195-203
Rabies vaccination HIV infection Malignancy Transplantation Immunosuppressive drugs
Rabies vaccination HIV infection Malignancy Transplantation Immunosuppressive drugs
HIV & Rabies vaccinationClinical trialsDeshpande, 1999ESSEN IM57% of symptomaticHIV-infected pts hadNab 0.5Thisayakorn, 2000IM PrEP in HIVinfected childrenCD4 15% hadlower Nab1999Jaijareonsup, 1999TRC-ID ERIG4/9 of HIV-infectedpts (CD4 316-950)had Nab 0.52000Tantawichien, 2001Double TRC-ID HRIGHIV-infected pts(CD4 25 – 199)hadNab 0.5Tantawichien, 2009DoubleESSEN adjuvantHIV-infected ptsCD4 100 hadNab 0.52009Sirikwin, 2009Modified 8-sites IDHIV-infected ptsCD4 69-190 onHAARTAll had Nab 0.5Gelinck, 2009IM Day 0,84HIV-infected ptsCD4 353 -772All had Nab 0.52012Azzoni, 2012IM Day 0,7,42,378HIV-infected ptson regular HAARThad Nab 0.5Nab; neutralizing antibody
Regimens5-dose IM (ESSEN)Nab 0.5 IU/mLNab 0.5 IU/mL- 43% symptomatic(CD4 400)- 24% asymptomaticCD4 ?Anti-retroviral therapy (ARV) ?TRC-ID(2-2-2-0-1-1) ERIGDouble doses TRC-ID(4-4-4-0-2-2) HRIGDouble doses ESSEN-IM(2-2-2-2-2) Aluminium adjuvanted TTModified 8-site ID(8-8-8-8-8)55 % of CD4 300CD4 300CD4 20043% of CD4 200All on ARV5/7 (71 %) of CD4 100(4/7 patient on ARV)CD4 2502/7 (29%) of CD4 100(One patient on ARV)81% on ARV66% had CD4 200One had CD4 69
HIVon ARVCD4 300CD4 200-300Thai &WHOapprovedregimensDoubledoses (x2)Modified8-site IDDouble dosesESSEN aluminiumadjuvanted CD4 100-200 CD4 100?NA
โดนกัดมาอีกแล้ว !
Re-startBooster
Abbas AK et al. Cellular and Molecular immunology. Eighth Edition
Nab 0.5 IU/mL since day 7 - 360GMT (IU/mL)97% on HAART35Median CD4 489(range 94 – 1120)302520151050.50D0D7D14D28D90D180D360HIV Booster IM day 0,3Punrin S, et. al. Proceedings of the 22th ECCMID. 31 March - 3 April 2012, London, United Kingdom.
Remarks One AIDS participants, who was vaccinatedsince seronegativity, had anamnestic responseto booster injection One patients who had CD4 count 100,somehow, had the remaining seroprotectivetiters from the prior immunization
Remarks An AIDS patient who antecedently failed toseroconvert after PEP could evoke theimmunologic memory response afterquantitative CD4 count recovery by HAART
Cell-mediated immune responses tointradermal rabies vaccination Intradermal IntramuscularPhanuphak P et al. Asian Pacific Journal of Allergy and Immunology 1987;5:33-7Ratanavongsiri J, et. al. Asian Pac J Allergy Immunol 1985;3:187-90
100 % on HAART, median CD4 622, HIV RNA 20 copies/mL35302520Gr 1: 4 site-IDGr 2: IM Day 0,315Esp, CD4 500 (p 0.03)1050GMT (IU/mL)D0D7D 14
CD4/CD8 ratio: a re-emerging biomarker for HIVCD8 CD4 CD4 /CD8 ratio & Nab day 7A low ratio is associated with T cell activation, senescence,dysfunction and chronic inflammationSerrano-Villar S, et. al. Lancet HIV 2015;2:76-7Lu W, et. al. J Int AIDS Soc 2015;18:20052
Being primary rabies immunized during AIDS conditions had affectedsubsequent booster vaccination despite quantitative CD4 T-cell recovery
Remarks Concept of pre-immunization of HIV-infectedpersons before the immunosuppressionprogressed might be considerably applicableto those at greatest risk
Longevity of Nab in HIV Four years interval from the latestimmunization, 86.8% of patients had Nab 0.5 IU/ml One volunteer had found endurance ofseroconversion for 15 years However, a few patients who recently gotrabies vaccine within one year could notmaintain acceptable seroprotective level
Selected cases of HIV patients mightreceive rabies booster vaccination if Asymptomatic, on HAART, CD4 200No opportunistic infectionsNo severe chronic medical conditionsNo other immunosuppressive conditionsReceived complete post-exposure rabiesprophylaxis with cell-cultured vaccine within10 years
Suggestion for rabies booster vaccination Only single visit 4-site ID and conventional IMday 0 and 3 regimens could be used Booster with full schedule regimens for everyexposure Wound treatment is still the mandatory
Safety of rabies vaccination inHIV-infected patients Inactivated vaccineNo serious adverse reactionsNo long term effect to CD4 and HIV RNA levelNo effect to HIV progression
WHO recommendation Wound treatment Local infiltration of RIG Five IM doses of rabies vaccine(asymptomatic, on HAART, recent CD4 300)* Check rabies neutralizing antibody Observe responsible cat or dog for 10 days* When in doubt, consult specialist* Suda’s opinionsWHO Expert Consultation on Rabies. Second report. 2013;1-139
Rabies vaccination HIV infection Malignancy Transplantation Immunosuppressive drugs
MalignancyRegimensLymphoma (4)ESSEN IM HRIG Double doses ESSEN HRIGAcute myeloid leukemia (1)Double dose IM day 02-1-1-1-1(no Nab)Malignancy (non-specific) (5)ESSEN IMHay E, et. al. JAMA 2001;285:166-7Rahimi P, et. al. PLoS One 2015;10:e0139171Kopel E, et. al. Emerg Infect Dis 2012;18:1493-5Wiwanitkit V. Iran J Cancer Prev 2014;7:105-6
CA Breast stage IV (Brain & bone metastasis)On radiation & received corticosteroidsNab (IU/ml)D 0 negativeI ESSEN IM HRIGD 7 0.53D 14 0.28 **Stop radiation, Prednisolone 10 mg/dayII Booster IM Day 0,3D 28 0.28 **D 60 0.5D 74 0.5D 120 0.5Suda Punrin, et. al. Proceedings of 23th ECCMID, 27 - 30 April 2013, Berlin, Germany
Non-Hodgkin lymphoma stage IV, in remission- Completed R-CHOP course 3 mo ago- Received PEP x2 times before diagnosis of NHLsNab (IU/ml)D 0 2.41I Booster IM Day 0,3D 14 2.52II Booster IM Day 0,3D 90 2.73D 104 3.22Recurrence of NHLs in the next 4 monthsSuda Punrin, et. al. Proceedings of 23th ECCMID, 27 - 30 April 2013, Berlin, Germany
SeverityStageTreatmentImmune status
Rabies vaccination HIV infection Malignancy Transplantation Immunosuppressive drugs
Rubin LG. et. al. Clin Infect Dis 2013:1-57Eibl M., Wolf H. Immunotherapy 2015;7:1273–92
ESSEN IM (1-1-1-1-1) RIGVora M. et. al. Transpl Infect Dis 2015;17:389–95
Rabies vaccination HIV infection Malignancy Transplantation Immunosuppressive drugs
Rubin LG. et. al. Clin Infect Dis 2013:1-57Eibl M., Wolf H. Immunotherapy 2015;7:1273–92
��าสเตียรอยด์Modified TRC-ID (2-2-2-0-2)On prednisolone 20 mg/day at least 3 weeks oraccumulative dose 700 mg & receiving 10 mg/dayAutoimmune hemolytic anemia, nephrotic syndrome,hypereosinophilia, Pemphigus vulgaris, Pemphigus foliaceus,Alopecia areata, ITP, COPD, Lupus profundus,Evan syndrome and bullous LE, SLE, rheumatoid arthritis81.3% of pateints had Nab 0.5 ุ่มโรคผิวหนัง และ ��ที่มากกว่า 1 �บ Nab ที่น้อยกว่า 0.5 IU/mLอรพิน เลิศวรรณวิทย์ �มหาบัณฑิต �์ คณะแพทยศาสตร์ �าลัย 2555
U.S. ACIP recommendation Immunosuppressive agents should not beadministered during PEP Nab should be checked to ensure thatacceptable antibody response has developedManning SE, et al. MMWR Recomm Rep 2008;57:1-28
WHO recommendation Wound treatment Local infiltration of RIG Five IM doses of rabies vaccine Check rabies neutralizing antibody When in doubt, consult specialistWHO Expert Consultation on Rabies. Second report. 2013;1-139
Acknowledgements
Thank you for your attention
J Allergy Clin Immunol 2010;125:S195-203 Secondary (acquired) immunodeficiency. . Phanuphak P et al. Asian Pacific Journal of Allergy and Immunology 1987;5:33-7 Ratanavongsiri J, et. al. Asian Pac J Allergy Immunol 1985;3:187-90 . - Completed R-CHOP course 3 mo ago
