Live‑attenuated vaccines and immunoglobulins or blood products

Background

Transfusions of normal human immunoglobulin (NHIg) or other donated blood products may be used in the treatment of certain medical conditions, including:

• ITP or Kawasaki disease
• traumatic injuries
• haematological conditions
• post‑exposure to some infectious diseases (e.g. tetanus, rabies and hepatitis B)
• as an adjunct to cancer treatments or surgery.

These products contain low levels of antibodies, passed on from the donor to the recipient. The donated antibodies can provide recipients with short‑term protection against certain vaccine‑preventable diseases (VPDs). However, vaccination is still required for long‑term protection.

Circulating donated antibodies can inhibit the recipient’s own immune response to certain injected live-attenuated vaccines, if the vaccines are administered too soon after the transfusion.

Recommendations

There are prescribed intervals between the transfusion of NHIg and/or a blood product and the administration of certain vaccines. This is to allow enough time for any donated antibodies to clear,  optimising long‑term effectiveness of the vaccine. The interval length depends on the type of product and the volume/dose transfused.

The following recommendations are aimed at ensuring the adequate immune response is achieved. They do not reflect concerns related to safety or adverse events following vaccine administration.

It is important to note that inactivated (non‑live) vaccines can be safely administered at any time during or following the administration of NHIg and/or blood products.

Table 1: Live‑attenuated vaccines and the action required when blood products previously given

* oral vaccine
^ Refer to the Immunisation Handbook guidance on Vaccination for people who have recently received normal human immunoglobulin and other blood products for recommended timeframes. 
# An alternative, inactivated vaccine is available and may be considered.

Patients receiving regular red blood cell transfusions

Patients requiring regular red blood cell transfusions for a chronic haematologic condition (e.g. transfusion‑dependent thalassaemia, sickle cell disease, inherited chronic haemolytic anaemias and inherited bone marrow failure syndromes) are unlikely to achieve a transfusion‑free period long enough to allow immunisation according to the standard recommendations.

There is limited direct data on which to base decisions for this group.

For patients requiring chronic red blood cell transfusions, who will not achieve a transfusion free period of more than 3 to 6 months in the foreseeable future, MVEC recommends live‑attenuated vaccines be administered per the National Immunisation Program (NIP), despite being within the usually recommended deferral period post‑transfusion. Please refer to your haematologist or an immunisation specialist for specific advice.

This recommendation is based on:

• the expectation that the vaccines will still provide protection in a number of patients (albeit potentially lower than that in the general population)
• the lack of any additional safety concerns associated with administration of the vaccine in this setting
• the alternative being indefinite deferral of immunisation.

Patients should be informed of the potential for reduced effectiveness of the vaccine.

A protocol for optimal timing of immunisation (in relation to blood transfusion, serological testing post immunisation and re‑immunisation when there is no evidence of immunity) may help to improve response rates. MVEC has produced a protocol for MMR and varicella vaccines in patients receiving regular red blood cell transfusions.

Documentation

People who have received NHIg and/or other blood products and are scheduled for upcoming vaccines should have a temporary exemption documented on the Australian Immunisation Register (AIR). This will ensure that any “no jab, no pay” and “no jab, no play” entitlements are not affected and will minimise the likelihood of vaccine administration errors.

Commonly asked questions

Resources

• Australian Immunisation Handbook: Vaccination for people who have recently received normal human immunoglobulin and other blood products
• Australian Red Cross Life Blood: Red cells
• Zabeida A, Lebel MH, Renaud C, Cloutier M, Robitaille N. Reevaluating immunization delays after red blood cell transfusion. Transfusion. 2019;59(9):2806-2811. doi:10.1111/trf.15433
• Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP): General Best Practice Guidelines for Immunization
• Siber GR, Werner BG, Halsey NA, et al. Interference of immune globulin with measles and rubella immunization. J Pediatr. 1993;122(2):204-211. doi:10.1016/s0022-3476(06)80114-9