Idiopathic said:
For board purposes, I would have a more clear definition, whatever you are going to believe. I would say, MMR is clearly contraindicated in anyone with symptomatic AIDS (i.e. ADL, regardless of current CD4 count) but is not contraindicated in someone with just a suppressed CD4 count (no matter how low). They will give you reasonably cut and dry cases, like the ones mentioned above. One obviously gets MMR, the other doesnt. Also, the second guy doesnt get it because he has a hx of an ADL, which is just as good as current ADl, to me.
This is copied directly from the CDC - this is the most recent definition of AIDS I could find (1993) found through the CDC site
http://wonder.cdc.gov/wonder/help/AIDS/MMWR-12-18-1992.html
CDC has revised the classification system for HIV infection to emphasize the clinical importance of the CD4+ T-lymphocyte count in the categorization of HIV-related clinical conditions. This classification system replaces the system published by CDC in 1986 (1) and is primarily intended for use in public health practice. Consistent with the 1993 revised classification system, CDC has also expanded the AIDS surveillance case definition to include all HIV-infected persons who have less than 200 CD4+ T-lymphocytes/uL, or a CD4+ T-lymphocyte percentage of total lymphocytes of less than This expansion includes the addition of three clinical conditions: pulmonary tuberculosis, recurrent pneumonia, and invasive cervical cancer -- and retains the 23 clinical conditions in the AIDS surveillance case definition published in 1987 (2); it is to be used by all states for AIDS case reporting effective January 1, 1993.
The following is also obtained from the CDC pertaining to individuals infected with HIV to be considered with MMR :
From
http://wonder.cdc.gov/wonder/prevguid/m0053391/m0053391.asp
Persons Infected with Human Immunodeficiency Virus (HIV)
Although the risk for measles exposure is currently low in most areas of the United States and the Western Hemisphere, this risk remains high in many other regions and measles continues to be imported into the United States. HIV-infected persons are at increased risk for severe complications if infected with measles (126,127). Among HIV-infected persons who did not have evidence of severe immunosuppression (Table 2), no serious or unusual adverse events have been reported after measles vaccination (123-126). Therefore, MMR vaccination is recommended for all asymptomatic HIV-infected persons who do not have evidence of severe immunosuppression and for whom measles vaccination would otherwise be indicated. MMR vaccination should also be considered for all symptomatic HIV-infected persons who do not have evidence of severe immunosuppression (Table 2) (128,129). Testing asymptomatic persons for HIV infection is not necessary before administering MMR or other measles-containing vaccine (130).
Transient increases in HIV viral load have been observed after administration of other vaccines to HIV-infected persons (131,132). The clinical significance of these increases is not known. Theoretically, a similar increase also may occur after MMR vaccination of HIV-infected persons.
Because the immunologic response to live and killed-antigen vaccines may decrease as HIV disease progresses, vaccination early in the course of HIV infection may be more likely to induce an immune response (133). Therefore, HIV-infected infants without severe immunosuppression should routinely receive MMR vaccine as soon as possible upon reaching the first birthday (i.e., at age 12 months)(130). Consideration should be given to administering the second dose of MMR vaccine as soon as 28 days (i.e., 1 month) after the first dose rather than waiting until the child is ready to enter kindergarten or first grade. In addition, if at risk for exposure to measles, HIV-infected infants who are not severely immunocompromised should be administered single-antigen measles vaccine or MMR vaccine at age 6-11 months. These children should receive another dose, administered as MMR vaccine, as soon as possible upon reaching the first birthday, provided at least 1 month has elapsed since the administration of the previous dose of measles-containing vaccine. An additional dose of MMR vaccine can be administered as early as 1 month after the second dose. If otherwise indicated, newly diagnosed HIV-infected children and adults without acceptable evidence of measles immunity (Table 1) should receive MMR vaccine as soon as possible after diagnosis, unless they have evidence of severe immunosuppression (Table 2). Data indicate that, of the HIV-infected infants born in the United States annually, approximately 5% (i.e., 50 children per year) would be classified as severely immunocompromised at age 12 months, when the first dose of MMR vaccine is recommended.
Measles vaccine is not recommended for HIV-infected persons with evidence of severe immunosuppression (Table 2) for several reasons:
a case of progressive measles pneumonitis occurred in a person with AIDS and severe immunosuppression to whom MMR vaccine was administered (134);
evidence indicates a diminished antibody response to measles vaccine among severely immunocompromised HIV-infected persons (133);
morbidity related to measles vaccination has been reported among persons with severe immunosuppression unrelated to HIV infection (135-138); and
in the United States, the incidence of measles is presently very low.
Serious illness associated with administration of rubella or mumps vaccines to HIV-infected persons has not been reported. MMR vaccine is not contraindicated for the close contacts of immunocompromised persons. All family and other close contacts of HIV-infected persons should be vaccinated with MMR vaccine, unless they have acceptable evidence of measles immunity.
Severely immunocompromised patients and other symptomatic HIV-infected patients who are exposed to measles should receive immune globulin (IG) prophylaxis regardless of vaccination status because they may not be protected by the vaccine. For patients receiving intravenous immune globulin (IGIV) therapy, a standard dose of 100-400 mg/kg should be sufficient to prevent measles infection after exposures occurring within 3 weeks after administration of IGIV; for patients exposed to measles greater than 3 weeks after receiving a standard IGIV dose, an additional dose should be considered. Although no data are available concerning the effectiveness of IGIV in preventing measles, high dose IGIV may be as effective as immune globulin administered intramuscularly. Persons receiving regular (e.g., monthly) IGIV therapy for HIV infection or other indications may not respond to MMR or its component vaccines because of the continued presence of high levels of passively acquired antibody (see Precautions and Contraindications, Recent Administration of Immune Globulin). If indicated, MMR vaccine should be administered at least 2 weeks before beginning IGIV therapy.
Idiopathic- if you have a more recent definition, I'd like to see it. However, I maintain that individuals with a CD4 count < 200 do have AIDS and hence are 'severely immunocompromised', and should not be given MMR. I think there needs to be a more clear distinction between HIV/AIDS. 'Asymptomatic HIV ' is different than AIDS. They are two different diseases.
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