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

Michael R. Page, PharmD, RPh

Received a hematopoietic stem cell transplant (HSCT) within the past 2 months, and

Does not have graft versus host disease

Patients receiving intensive chemotherapy, or

Patients who have, within 6 months, received treatment with anti–B-cell antibodies (eg, rituximab, obinutuzumab, or ofatumumab)

Have had varicella zoster infection, or

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

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/mm 3 , or children with HIV between 9 months and 5 years of age with CD4 T-cell lymphocyte percentages ≥15%)

, 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

Patients with HIV who are minimally immunocompromised, defined by: A CD4 T-cell lymphocyte count ≥200 cells/mm 3 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



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)

Disease State Contraindicated Vaccine(s) HIV infection In cases of low-level or no immunosuppression:

Live attenuated influenza vaccinea

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) vaccinea

MMR (live)/varicella (live) combination vaccinea

Rotavirus (live) vaccine

Varicella (live) vaccinea

Zoster (live) vaccinea

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) vaccinea

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) vaccinea

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) vaccinea

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]

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.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.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: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: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. since the year 2000 Although the oral polio vaccine has not been used in the United States , it is still used in other countries. Members of households that include an immunocompromised individual should not receive the oral polio 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: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. 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: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.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):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: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: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 HSCT = hematopoietic stem cell transplant; MMR = measles mumps rubella.Exceptions exist. Consult the Infections Disease Society of America 2013 guideline for vaccination of immunocompromised individuals for full information.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.