Vaccines and Immunosuppressed Patients

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Vaccines and Immunosuppressed Patients

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Question

Which vaccines are contraindicated for immunosuppressed patients? Are there

conditions in which those same vaccines

would be indicated in an immunosuppressed patient? Are dosages modified?

Response

from Steele, MD (Staff, Department of Pediatrics, St. 's Children's

Hospital, Springfield, Missouri)

11/08/01

It is important to recognize that all immunocompromised patients are not alike

when it comes to vaccine safety and

efficacy. The degree to which a child is immunocompromised will not only affect

how at risk the child is to infection,

but will also modify that child's response to active immunization.

Unfortunately, large studies involving immunizations

in these children are rather limited, so recommendations are often made based

upon theoretical risks rather than hard

study-derived data.

As a general rule, significantly immunocompromised children should not receive

live vaccines due to the risk of

acquiring the disease from the vaccine strains. Conversely, inactivated vaccines

are generally safe in immunocompromised

patients; however, their efficacy may be reduced significantly particularly in

those whose immune deficiency is due to

poor humoral immunity. But while these are general guidelines, it is important

to look at specific immune deficiencies

to recognize where the recommendations may vary.

In those with primary immune deficiencies, live vaccines should be avoided as

stated above. However, those with

B-lymphocyte disorders may be candidates for the measles and varicella vaccine.

Because these patients typically receive

intravenous immune globulin (IVIG), the timing of these vaccines may be

difficult. In order to avoid a poor immune

response, these vaccines should be given after 6 months since the last dose of

IVIG. Ultimately, if the B-lymphocyte

disorder is so severe that little antibody production is occurring, these

children should receive passive immunization

with IVIG. Most children with complement or phagocytic dysfunction can receive

all vaccines except for live bacterial

vaccines such as the bacille Calmette-Guérin (BCG) and the Ty21a Salmonella

typhi immunizations.[1]

In patients with secondary immune deficiencies such as those with HIV, chronic

corticosteroid use, or on chemotherapy,

assessment of how severe the immune deficiency is will determine which vaccines

the child should receive. Again, live

vaccines should not be given due to the risk of severe adverse effects. However,

data in children with HIV show that

they may receive the MMR unless they are severely immunocompromised.[2] In

addition, children with HIV may receive the

varicella vaccine if the CD4 counts are greater than 25%.[3] The varicella

vaccine should be considered in those

children who are in remission with acute lymphocytic leukemia and have been off

of chemotherapy for 3 months. Some

children may have been on chemotherapy agents that have less of an effect on the

immune system. If this is the case, the

interval from the last chemotherapeutic dose and immunization may be less than 3

months. Regardless of differences about

when to give or not to give specific vaccines, dosages are not changed based

upon the immune status of the child.

Corticosteroid use when given in high doses or for long periods of time can

effectively render the child

immunocompromised. Unfortunately, there are not many studies in children to

guide the clinician as to when this

threshold has been surpassed. However, certain guidelines have been proposed.[4]

Children who are receiving topical

steroids, physiologic corticosteroid maintenance doses, or equivalent doses less

than 2 mg/kg/day of prednisone may

still receive vaccines. Those receiving more than 2 mg/kg/day of prednisone for

fewer than 14 days may receive vaccines

as soon as therapy has been discontinued. Those children who have been on

corticosteroids for more than 14 days in doses

greater than 2 mg/kg/day (either daily or every other day) should not receive

live vaccines for at least 1 month

following discontinuation of therapy. This is also true for those receiving 20

mg or more of prednisone daily or every

other day for more than 14 days. However, if the child is receiving more than 20

mg/day of prednisone, and weighs more

than 10 kg, for fewer than 14 days, immunizations may commence as soon as the

child has had corticosteroid therapy

discontinued.

References

American Academy of Pediatrics. Immunization in special circumstances. In:

Pickering LK, ed. 2000 Red Book: Report of

the Committee on Infectious Diseases. 25th ed. Elk Grove Village, Ill: American

Academy of Pediatrics; 2000: 56.

Measles, Mumps, and Rubella -- Vaccine Use and Strategies for Elimination of

Measles, Rubella and Congenital Rubella

Syndrome and Control of Mumps: Recommendations of the Advisory Committee on

Immunization Practices (ACIP). MMWR. May 22,

1998 / 47(RR-8);1-57. Available at:

http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm. Accessed November 1,

2001.

Prevention of Varicella Updated Recommendations of the Advisory Committee on

Immunization Practices (ACIP). MMWR. May

28, 1999 / 48(RR06);1-5. Available at:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4806a1.htm. Accessed November 1,

2001.

American Academy of Pediatrics. Immunization in Special Circumstances. In:

Pickering LK, ed. 2000 Red Book: Report of

the Committee on Infectious Diseases. 25th ed. Elk Grove Village, Ill: American

Academy of Pediatrics; 2000: 61-62.