Good advice for immune-compromised patients
No pre-emptive vaccination for HIV-positives
Because comprehensive scientific data are lacking, health experts can only conjecture about the possible ramifications of smallpox vaccinations on people with HIV and AIDS. Here is the advice most experts are offering:
- Anyone who plans to volunteer to be vaccinated for smallpox should know their HIV status. Pre-emptive vaccination is not recommended for HIV-positive people, nor for the partner of someone who is HIV-positive.
- HIV testing, though not mandatory, should be made available to anyone who asks for it. Rapid tests (SUDS, OraQuick), if available, are preferred.
- Anyone who has close contact with a known smallpox case should be vaccinated no matter what their HIV status. "Close contact" means being within six to eight feet of a smallpox victim during period of infectiousness, which peaks once a rash appears, making it relatively easy to tell when someone is infectious. Infectiousness subsides only after scabs have fallen off.
- Patients with advanced HIV disease are probably at much greater risk for vaccine complications than those with early-stage disease. The cut-off point for "advanced disease" probably means a CD4 count less than 200/mm3, several experts say.
- The most dreaded complication for immune-impaired people is progressive vaccinia (also known as vaccinia necrosis and vaccinia gangrenosum). During the pre-HIV era, frequency of this complication ran at less than 1 per million, with death in 90% of those cases. The frequency may prove to be higher in today’s population.
- There is no cure for progressive vaccinia. Optimal therapy probably includes immune reconstitution with highly active antiretroviral therapy, coupled with vaccinia immune globulin and possibly cidofovir.
- Contact vaccinia — the inadvertent spread of vaccinia virus from the vaccination site to someone else — almost always results from direct contact. To prevent its occurrence, vaccinated persons should wash their hands with soap and water and cover the vaccination site with an occlusive dressing, a T-shirt, and long sleeves. Used bandages should be put into sealed plastic bags and discarded. Don’t share used towels, bedding, or clothing.
- No matter how carefully a person covers the vaccine site, the person shouldn’t share space with someone who is HIV-positive until he or she has stopped shedding virus. That means waiting 3-4 weeks until the scab at the vaccine site falls off. Vaccinated health care workers should either be furloughed until they are no longer shedding virus or be re-assigned to duties where they won’t be in contact with immune-compromised patients.
- Vaccinia disease may exacerbate replication of HIV, according to findings from one case, but that isn’t known as a certainty. But it is certain that being HIV-positive makes someone much more susceptible to succumbing to smallpox. So if an HIV-positive person is exposed to smallpox, he or she should get vaccinated.
Because comprehensive scientific data are lacking, health experts can only conjecture about the possible ramifications of smallpox vaccinations on people with HIV and AIDS. Here is the advice most experts are offering.
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