Guidelines for Vaccination of Immunocompromised Individuals from the Infectious Diseases Society of America: An In-Depth Guide

Review key points from the Infectious Diseases Society of America’s updated guidelines for vaccination of immunocompromised individuals, household contacts of immunocompromised individuals, and patients who are preparing for immunosuppressive therapy.

On December 4, 2013, the Infectious Diseases Society of America released guidelines for appropriate vaccination of immunocompromised patients. These guidelines recognize that the effort to administer vaccines to patients who are immunocompromised is a shared responsibility of the entire health care team. Patients with an immunocompromised status and people who are in close contact with immunocompromised patients routinely receive vaccinations from health care professionals, such as pharmacists.

Before Induction of Immunosuppression

Immunosuppression may be induced pharmacologically through use of corticosteroids or antimetabolites for conditions ranging from cancers to rheumatoid arthritis. In these cases, patients should receive vaccines before the start of immunosuppressive therapy.

In general, in patients who will begin immunosuppressive therapy, any live vaccines should be administered at least 4 weeks before induction of immunosuppression, whereas inactivated vaccines may be administered as few as 2 weeks before administration of immunosuppressive drugs.

Household Contacts

People living in close contact with immunocompromised patients, such as in a household setting, should receive inactivated vaccines to help protect immunocompromised patients from future infections. For instance, inactivated influenza vaccines should be administered annually to all people 6 months or older living in close contact with immunocompromised individuals.

Use of the live attenuated influenza vaccine in household contacts of immunosuppressed individuals should be avoided. However, use of the live vaccine is permissible if the household contact receiving the vaccine is healthy, not pregnant, and between 2 and 49 years of age, and if the immunocompromised individual who is in regular contact with the vaccine recipient has not:

• Received a hematopoietic stem cell transplant (HSCT) within the past 2 months, and
• Does not have graft versus host disease

If the live attenuated influenza vaccine is administered to a healthy household member of an immunosuppressed individual with either of the above 2 conditions, contact between the person who received the live attenuated influenza vaccine and the immunocompromised household member must be avoided for at least 1 week.

Live vaccines that can be administered in healthy patients living with 1 or more immunocompromised household members include:

• Combined measles, mumps, and rubella (MMR) vaccine
• Varicella vaccine (as long as the healthy individual does not develop skin lesions after receiving the vaccine; if lesions appear, contact with immunocompromised individuals should be avoided until skin lesions clear)
• Zoster vaccine (as long as the healthy individual does not develop skin lesions after receiving the vaccine; if lesions appear, contact with immunocompromised individuals should be avoided until skin lesions clear)
• Yellow fever vaccine (if indicated for travel)
• Oral typhoid vaccine (if indicated for travel)

The rotavirus vaccine can be administered to infants aged 2 to 7 months living in a household with immunocompromised members. However, importantly, immunocompromised patients should not handle the diapers of infants for at least 4 weeks after the infant receives the rotavirus vaccine.

Although the oral polio vaccine has not been used in the United States since the year 2000, it is still used in other countries. Members of households that include an immunocompromised individual should not receive the oral polio vaccine.

The Influenza Vaccine

An annual dose of the inactivated influenza vaccine should be administered to most immunocompromised patients, including immunocompromised individuals 6 months or older. There are 2 exceptions to this rule. Evidence does not support use of the inactivated influenza vaccine in:

• Patients receiving intensive chemotherapy, or
• Patients who have, within 6 months, received treatment with anti—B-cell antibodies (eg, rituximab, obinutuzumab, or ofatumumab)

If the inactivated influenza vaccine is administered to an immunosuppressed individual with either of the above 2 conditions, the individual is unlikely to be harmed by the vaccine, but his or her immune system may be too suppressed to mount an immune response, so there may not be any benefit.

The live attenuated influenza vaccine should never be used in immunocompromised patients.

The Herpes Zoster Vaccine

In patients who plan to undergo immunosuppressive therapy, the herpes zoster vaccine may be administered before the usual age (60 years or older). Patients aged 50 to 59 years who will undergo immunosuppressive therapy may receive the herpes zoster vaccine early if they:

• Have had varicella zoster infection, or
• Have a documented titer indicating that they had a prior varicella infection or herpes zoster infection

Importantly, because it is a live vaccine, the herpes zoster vaccine should be administered at least 4 weeks before the start of immunosuppressive therapy.

Highly immunocompromised patients should not receive the herpes zoster vaccine.

The Varicella Vaccine

In qualifying patients (patients who do not have immunity to varicella as indicated by titers or a verified history of varicella infection), the second dose of the 2-dose varicella vaccine should be administered at least 4 weeks before initiation of immunosuppressive therapy.

Because the varicella vaccine is a live vaccine, it should not be administered to immunocompromised patients, although there are 3 exceptions to this rule. The following less immunocompromised individuals may receive the single-entity varicella vaccine (but not the combination varicella/MMR vaccine):

• Patients with primary immune deficiency disorder who do not have defects of T-cell—mediated immunity (defects of T-cell–mediated immunity include, but are not limited to, complement component deficiency disorder and chronic granulomatous disease)
• Patients with HIV infection who do not have severe immunosuppression (ie, CD4 T-cell lymphocyte count ≥200 cells/mm³, or children with HIV between 9 months and 5 years of age with CD4 T-cell lymphocyte percentages ≥15%)
• Patients receiving long-term immunosuppressive therapy at low intensity

The Yellow Fever Vaccine

Immunocompromised patients should not receive the yellow fever vaccine, and should avoid travel to areas where the yellow fever vaccine is a prerequisite for travel. If travel to an area where the yellow fever vaccine is absolutely necessary, the vaccine may be administered to some immunocompromised patients, including:

• Patients with HIV who are minimally immunocompromised, defined by: A CD4 T-cell lymphocyte count ≥200 cells/mm³ in an asymptomatic HIV-infected adult A CD4 T-cell lymphocyte percentage ≥15% in asymptomatic children with HIV between 9 months and 5 years of age

Other Conditions

In patients with primary complement deficiency or primary immunodeficiency disorders, no vaccines are contraindicated, and vaccines may be administered using the usual vaccination schedules. However, patients with complement deficiencies or primary immunodeficiency may require early treatment with the pneumococcal vaccine and the conjugate meningococcal vaccine for additional protection, as recommended by guidelines.

Other conditions with specific recommendations for vaccination covered by the IDSA guidelines include:

• HIV infection
• Cancer
• Patients undergoing HSCT
• Patients undergoing solid organ transplant
• Patients with chronic inflammatory diseases and taking immunosuppressive medications
• Patients with asplenia
• Patients with sickle cell disease
• Patients with anatomic barrier defects (eg, cochlear implant or cerebrospinal fluid leak)

It is important to be aware of the vaccines that are contraindicated in each disease state (Table).

Before vaccinating patients with any of these conditions, it is important to consult the detailed evidence charts in the IDSA guideline.

Table: Vaccines that Are Contraindicated in Each Disease State

Disease State

Contraindicated Vaccine(s)

HIV infection

In cases of low-level or no immunosuppression:

Live attenuated influenza vaccine^a

MMR (live) vaccine

MMR (live)/varicella (live) combination vaccine

Zoster (live) vaccine

In cases of high-level immunosuppression:

Live attenuated influenza vaccine

MMR (live) vaccine

MMR (live)/varicella (live) combination vaccine

Varicella (live) vaccine

Zoster (live) vaccine

Cancer

Before or during chemotherapy:

Live attenuated influenza vaccine

MMR (live) vaccine^a

MMR (live)/varicella (live) combination vaccine^a

Rotavirus (live) vaccine

Varicella (live) vaccine^a

Zoster (live) vaccine^a

Three or more months after the end of chemotherapy and 6 or more months after the end of anti—B-cell therapy:

[None]

Patients undergoing HSCT

Before HSCT:

Live attenuated influenza vaccine

Rotavirus (live) vaccine

After HSCT:

Live attenuated influenza vaccine

MMR (live) vaccine

MMR (live)/varicella (live) combination vaccine

Rotavirus (live) vaccine

Varicella (live) vaccine^a

Zoster (live) vaccine

Patients undergoing solid organ transplant

Before transplant:

Live attenuated influenza vaccine

Two to 6 months after transplant:

Live attenuated influenza vaccine

MMR (live) vaccine

MMR (live)/varicella (live) combination vaccine

Rotavirus (live) vaccine

Varicella (live) vaccine^a

Zoster (live) vaccine

Patients with chronic inflammatory diseases and taking immunosuppressive medications

Planned immunosuppression:

Live attenuated influenza vaccine

Low-level immunosuppression:

Live attenuated influenza vaccine

MMR (live) vaccine

MMR (live)/varicella (live) combination vaccine

Rotavirus (live) vaccine

Varicella (live) vaccine^a

High-level immunosuppression:

Live attenuated influenza vaccine

MMR (live) vaccine

MMR (live)/varicella (live) combination vaccine

Rotavirus (live) vaccine

Varicella (live) vaccine

Zoster (live) vaccine

Patients with asplenia

Live attenuated influenza vaccine

Patients with sickle cell disease

Live attenuated influenza vaccine

Patients with anatomic barrier defects (eg, cochlear implant or cerebrospinal fluid leak)

[None]

HSCT = hematopoietic stem cell transplant; MMR = measles mumps rubella.

^aExceptions exist. Consult the Infections Disease Society of America 2013 guideline for vaccination of immunocompromised individuals for full information.

Reference

Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):309-318.