Contraindications and Precautions to Vaccination : Immunosuppression and HIV Infection Immunosuppression
Live vaccines can cause severe or fatal reactions in immunosuppressed persons due to uncontrolled replication of the vaccine virus. Live vaccines should not be administered to severely immunosuppressed persons for this reason. Generally the ultimate determination of severe immunosuppression should be made by the provider treating the immunosuppressed patient. Persons with isolated B-cell deficiency may receive varicella vaccine. Inactivated vaccines cannot replicate, so they are safe to use in immunosuppressed persons. However, response to the vaccine may be decreased.
Both diseases and drugs can cause significant immunosuppression. Persons with congenital immunodeficiency, leukemia, lymphoma, or generalized malignancy should not receive live vaccines. However, MMR, varicella, rotavirus, and LAIV vaccines may be given when an immunosuppressed person lives in the same house. Household contacts of immunosuppressed persons may receive zoster vaccine if indicated.
Certain drugs may cause immunosuppression. For instance, persons receiving cancer treatment with alkylating agents or antimetabolites, or radiation therapy should not be given live vaccines. Live vaccines can be given after chemotherapy has been discontinued for at least 3 months. Persons receiving large doses of corticosteroids should not receive live vaccines. For example, this would include persons receiving 20 milligrams or more of prednisone daily or 2 or more milligrams of prednisone per kilogram of body weight per day for 14 days or longer. See Varicella chapter for more information about administration of zoster vaccine to immunosuppressed persons.
Aerosolized steroids, such as inhalers for asthma, are not contraindications to vaccination, nor are alternate-day, rapidly tapering, and short (less than 14 days) high-dose schedules, topical formulations, and physiologic replacement schedules.
The safety and efficacy of live attenuated vaccines administered concurrently with recombinant human immune mediators and immune modulators are not known. There is evidence that use of therapeutic monoclonal antibodies, especially the anti-tumor necrosis factor (TNF) agents adalimumab, infliximab, and etanercept, may lead to reactivation of latent tuberculosis infection and tuberculosis disease and predispose to other opportunistic infections. Because these drugs vary dramatically in the scope and number of immune system targeted components, it is prudent to avoid administration of live attenuated vaccines while patients are taking these drugs. For immunization against seasonal influenza and typhoid, inactivated injectable alternatives are available.
The period of time providers should wait after discontinuation of immune modulator drugs before administering a live-virus vaccine is not specified by ACIP or other authoritative guidelines (except in the case of zoster vaccine). Consultation with the prescribing physician (and possibly a hospital pharmacist) is recommended for management of individual patients and guidance in estimating a particular patient’s degree of immunosuppression. No basis exists for interpreting laboratory studies of immune parameters with vaccines’ safety or efficacy. Some experts recommend waiting 1 month after discontinuing etanercept and 3 months after discontinuing the other anti-TNF agents.
Lymphocyte depleting agents such as alemtuzumab and rituximab may cause prolonged immunosuppression. Restarting immunosuppression after live viral vaccination has not been studied, but some experts would recommend at least a 1-month period.
Inactivated vaccines may be administered to immunosuppressed persons. Certain vaccines are recommended or encouraged specifically because immunosuppression is a risk factor for complications from vaccine-preventable diseases (i.e., influenza, invasive pneumococcal disease, invasive meningococcal disease, invasive Haemophilus influenzae type b disease, and hepatitis B). However, response to the vaccine may be poor depending on the degree of immunosuppression present. Because a relatively functional immune system is required to develop an immune response to a vaccine, an immunosuppressed person may not be protected even if the vaccine has been given. Additional recommendations for vaccination of immunosuppressed persons are detailed in the General Recommendations on Immunization.
HIV Infection
Persons infected with human immunodeficiency virus (HIV) may have no disease manifestations, or they may be severely immunosuppressed. In general, the same vaccination recommendations apply as with other types of immunosuppression. Live-virus vaccines are usually contraindicated in those with severe immunosuppression (defined by the treating provider) but inactivated vaccines may be administered if indicated.
Varicella can be a very severe illness in persons with HIV infection and is often associated with complications. Varicella vaccine can be considered for persons with HIV infection who are not severely immunosuppressed. Zoster vaccine should not be given to persons with AIDS or clinical manifestations of HIV infection. Persons with HIV infection should not receive LAIV; they should receive inactivated influenza vaccine (IIV). Yellow fever vaccine should be considered for persons who do not have AIDS or other symptomatic manifestations of HIV infection, who have established laboratory verification of adequate immune system function, and who cannot avoid potential exposure to yellow fever virus.
Household contacts without evidence of immunity to measles, mumps, rubella, or varicella should receive MMR and varicella vaccines, and may receive rotavirus, zoster and LAIV vaccines if otherwise eligible.
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