IMMUNISATION PRACTICES IN CENTRES

CARING FOR CHILDREN WITH PERINATALLY

ACQUIRED HIV: A CALL FOR HARMONISATION
On behalf of PENTA-vac Group1 Elsevier Vaccine Journals

MARIA MONICA 22010116220358

VALENTINA CICILIA 22010116220364
ZAHRA QURROTA 22010116220361

PEMBIMBING: DR. GALUH HARDANINGSIH, MSI. MED, SP.A

 ABSTRACT:
ABSTRACT: RESULTS
ABSTRACT:METHODS
BACKGROUND
CONCLUSION
Results:
Background:
2465 patients completed the questionnaire.
Current national immunisation schedules differ between countries
Methods:
Conclusion:
The majority of units (67%) reported that common childhood
in terms of vaccine formulation,timing of vaccinations and
immunisation
immunisation
Vaccination were administered
online questionnaire
programme
practices forwas
funding by
completed
perinatallyandthe family
by doctor
46 experts
co-ordination.
HIV-infected or
in local
children varyhealth
services
a great rather
paediatric
deal than incountries.
between the HIV
HIV-infection fromspecialist centre.be
the Paediatric
Efforts should European
made toto
HIV infected paediatric population may be left susceptible
Network
improve
Vaccination
vaccine for Treatment
communication
histories wereand of AIDS
mostly (PENTA). of
documentation
incomplete andvaccinations
difficult to in
obtain
preventable infections.
healthcare
for 40% of
Data settings
the
were andpopulation.
studied
collected to harmonise
between recommendations
November 2013 and March
Vaccines
relating used
to in healthy
additional population
vaccines for should
HIV be
infectedsubjected
children to high
and
2014. the use of live attenuated vaccines, such as varicella and
regarding
quality
the useethical researchassays
of laboratory and betoexplicitly validated for use in children
guide immunisation.
rotavirus,
with andvaccination
special these wereneedsless frequently recommended
such as those infected with (61%
HIV.and 28%
of the units respectively).
this survey was completed to assess vaccination practices and
Monitoring
attitudes of vaccine
toward responses was employed in a minority of
vaccination
centres (41%).
 INTRODUCTION

Current national immunisation programs, developed for healthy

populations, differ between countries in terms of vaccine
formulation,
A timing ofschedules
lack of vaccination vaccinations and immunisation
designed programme
specifically for HIV-
funding and
infected co-ordination.
children and incomplete vaccine coverage in some
countries makes
Children with the needacquired
perinatally to evaluate
HIVcurrent vaccination
have special vaccination
practices
needs dueintothis population a priority.
immunodeficiency, suboptimal immune development
and more
This surveyrapid
was waning of protective
completed immunity
in order to following on
collect information
immunisation
attitudes leading torelating
and practices an increased susceptibility
to vaccination of HIVtoinfected
vaccine
preventable infections.
children.
METHOD

Investigators from 46 centres of the Paediatric European Network for Treatment of

AIDS (PENTA) completed an online questionnaire designed to gather information
on practices and attitudes relating to vaccination of HIV infected children
Data were submitted between November 2013 and March 2014 and collected in a
database.
The survey consisted of a mandatory section that included information on
demographic data, vaccination practices and utilisation and timing of serological
assays and an optional section designed to gather data on laboratory practices on
testing for immune protection.
Data were analysed and results presented as numbers and percentages.
 RESULT
1.2.Practices
Attitudesrelating
towardstovaccination
vaccinationofofHIVHIVinfected
infectedchildren
children and
Vaccination histories were mostly incomplete and difficult to
assessment
Half of of
physicians immunological
did not reportresponse
major safety concerns in
obtain for 40% of the studied population
31% of the units applied a structured follow-up program for
performing
there are 67% common vaccines in children
of HIV-infected HIV infected
comechildren.
to the family
monitoring
For childrenvaccine
attending related
an HIVserology
specialist centre who have
37%doctor
of or local
centres health services
reported concerns toon
getsafety
commonrelatedvaccines
to the type of
recently
48% of moved
physicians from abroad,
reported 39%
parental of units
concerns
Hepatitis B Virus (HBV) serological assays were the most tested
about serology
vaccine and
vaccination
28 % or (e.g. under
Hospital
recommended live attenuated vaccines,
HIV services paucity of safety data) or
safety
utilised ofimmunisations
units), followedif by
effectiveness.
(95% needed, while
Measles, 37%
Varicella ofand
units
regarding thevaccinations
patients immunological status.
majority (93%) of physicians reported anational
performed
5 %
Mumps Other (included
assays (62%, 55% according
pharmacy,
and 48% to
specialised
respectively).
forimmunisation
neednurses, etc.)
Tetanus,
evidence-
guidelines,
(37%)
based and
Pertussis, without
physicians
shared
H. testing
reported
protocols
influenzae typeserology.
doubtsandregarding
tob monitor the serology
vaccine
Poliomyelitis efficacy
antibodiesofin
Additional immunizations recommended
HIV-infected
immunisations
Regarding children.
in this population
were less frequently
assessment assessed (43%, 26%,response
of immunological 26% and to 19%
Seasonal influenza41%
respectively)
immunisation, vaccine 81%,
of units 13 valentserum
measured Pneumococcal
antibody titers
conjugate vaccine 65%,and
after immunisation Human
during Papilloma
follow-up Virus Vaccine 69%,
to evaluate possible
Hepatitis
waningAofvaccine
protective 60%,immunity.
Varicella vaccine 58%, Pneumococcal
polysaccharide vaccine 26%, Rotavirus vaccine 23%
DISCUSSION

Highly effective Effectiveness of

at preventing vaccines may
infection in be suboptimal
healthy in HIV-infected
individuals. Vaccine children

Study and design vaccine schedules for patients in risk

groups, including HIV-infected individuals
Define correct dosing schedules and accurate correlates
of protection
Survey results
revealed concerns Barrier to adherence to
regarding vaccine vaccination schedules
and guidelines which
safety, especially for include live vaccines
live attenuated
vaccines
 LIVE ATTENUATED VACCINES

Hepatitis A &
VZV Rotavirus HPV Hepatitis B

Individuals
LimitedThe with HIV
dataadministration
on safety
HAV are more
of varicella
vaccine is also Guidelines
A recent recommend
study reporting thatan
Guidelines
andlikely than
efficacy
(VZV) uninfected
in HIV
vaccine has people
been
frequently recently allThis
recommend
combination
increased
girls fromrisk hasadmission
12 of
years of age,
infected populations been demonstrated
torecommended
develop conditionsadministered
Rotavirus in
(RTV)
in HIV infected irrespective
onlywith varicella
of CD4
disease
safe and immunogenic
cellin HIV-
associated withcombination
HPV vaccine with
was not administering
count,
infected
should
children
be vaccinated
compared
RTV vaccine is only
Rotavirus patients withHBV
may CD4+ T
recommended
vaccine
cell after
to infants two doses
recommended in
not be perceived
percentage P15% and
by a
the CD4+
majority T with
with
without HPV
their
vaccine
uninfected peers
byPrecancerous
specialists as a conditions of HAV vaccine was
the first 32 weeks
cell count P200of centres
cells/ll evidences of of life
cervix and anus
high risk infection widely recommendedunderutilisation
immunosuppres
of this
in HIV
sionvaccine in at risk populations
cervical and anal cancer
infected children
 Long-term vaccine induced immunity is not
ensured in late treated HIV-infected children,
although they are able to mount an initial
response to routine immunisations and can
have good immune reconstitution

Starting ART within the first
year of life helps preserve
number and function of
antigen-specific memory B-
cell
Older HIV infected children who
have not benefited from early ART
are therefore at particular risk from
incomplete protection against
vaccine-preventable infection

Children diagnosed
and ART treated by 3
months of age (26%)
Fig. 4. Issues highlighted by results from the survey and some potential
solutions and research directions.
CRITICAL APPRAISAL
USING STANDARD CRITICAL APPRAISAL FOR SECONDARY STUDY
WAS THERE A CLEAR STATEMENT OF THE AIMS OF
THE RESEARCH?

There was a clear statement of the aims of the research on

abstract (background) and introduction which is to:
Collect information on attitudes and practices relating to
vaccination of HIV infected children,
Identify areas of inconsistency, and
Provide results that can be used to guide future research and
programmatic strategies targeted at harmonization and
optimization of care relating to immunization of HIV infected
children.
IS A QUALITATIVE METHODOLOGY APPROPRIATE?

This is a descriptive research which uses survey method.

Qualitative methodology is appropriate because the research
sought to gather information regarding each center
experiences on practices and attitudes relating to vaccination
of HIV infected children.
WAS THE RESEARCH DESIGN APPROPRIATE TO
ADDRESS THE AIMS OF THE RESEARCH?

The research design was appropriate to address the aims of the

research despite the lack of research design justification by the
researchers. The research offers various information on
demographic data, vaccination practices, utilizations, and timing of
serological assays and data regarding laboratory practices on
testing for immune protection. These informations will eventually
help formulate a vaccination schedule and recommendation for
HIV infected children.
 WAS THE RECRUITMENT STRATEGY APPROPRIATE
TO THE AIMS OF THE RESEARCH?
The researchers did not explain why they selected these participants,
how they decide how many people to sample, how the participants/
experts choose their patients (sampling method), and the eligibility
standards for participation.
The researchers also did not provide adequate information regarding
the patients thus making it hard to decide whether or not these data
can be applied to Indonesian patients.
Because the research involved only 17 countries (14 from Europe),
the informations from the study are mostly useful only in European
countries and are not representative for Indonesia.
The informations are very useful in regards to vaccination
recommendation in HIV infected children.
WAS THE DATA COLLECTED IN A WAY THAT
ADDRESSED THE RESEARCH ISSUE?

Survey research was efficient in gathering information about a

population especially in very large and disperse geographic
area thus helped to achieve the research aims.
Survey research did not allow the researchers to develop
intimate understanding of individual circumstances or the local
culture that might be the root cause of respondent behavior.
There was also a possible misconception on understanding the
questionnaire and uncontrollable variation (e.c respondents
mood) which may affect the study.
HAS THE RELATIONSHIP BETWEEN RESEARCHER AND
PARTICIPANTS BEEN ADEQUATELY CONSIDERED?

Regarding conflict of interest, the researchers had stated that

none of the authors had direct financial interest in the subject
matter or materials of the research discussed in the present
manuscript.
In the study, the researchers offered every experts to
participate voluntarily by collecting patient data and answering
questionnaire.
Because the experts critically examined their own role as
physicians, there were potential bias and influence during data
collection and sample recruitment.
HAVE ETHICAL ISSUES BEEN TAKEN INTO
CONSIDERATION?

The researchers mentioned that all PENTA centers were invited

to complete the survey on a voluntary basis but the researchers
did not provide sufficient details of how the research was
explained to participants for the reader to assess whether ethical
standards were maintained. The researchers also did not
discussed issues around informed consent or confidentiality.
There were not any information regarding approval from the
ethics committee.
 WAS THE DATA ANALYSIS SUFFICIENTLY
RIGOROUS?
There were not any in-depth description of the analysis process in
this study but it was clear how two themes were derived from the
data. The author separated the questionnaire into two sets of
questions.
The first one was about practices relating to vaccination of HIV
infected children and assessment of immunological response
The second one was about attitudes towards vaccination of HIV
infected children.
The amount of data presented in the study was only sufficient to
representate the findings on European countries because the sample
used in the study was only taken from the European countries.
 IS THERE A CLEAR STATEMENT OF FINDINGS?

The results were based from the findings on the questionnaire and
presented as numbers and percentages in table and diagrams. The
findings were explicit and related back to the original question.
The researchers also present data that contradicts their argument, for
example in the last question (Would an evidence-based protocol for
checking vaccine serology help your practice?), the researcher
displayed all the answers (Yes, No, Other) not just the answer that
aligned with the research goal (Yes). It would be better if the
researchers elaborate the answer written in the Other column. The
researcher did not discuss the credibility of the study.
 HOW VALUABLE IS THE RESEARCH?

The study provided information on practices and prevalent attitudes

towards immunisation in the PENTA network, issues, and potential
solutions. These information are very important due to the rising
trend of HIV/ AIDS morbidity rate.
The PENTA data can be seen as a recommendation/ second opinion
regarding immunization practice in HIV infected patient in Indonesia.
The research also identify new areas where research is necessary:
additional key vaccinations needed and use of assays for measuring
vaccine induced protection in HIV infected children, new strategy to
enhance communication between professionals, and standard
documentation of vaccination (to optimize vaccination coverage).
THANK YOU
ANY QUESTION?