Immunosuppression occurs when a person’s immune system is weakened, resulting in a decreased ability to fight infections. Causes of immunosuppression may include having certain medical conditions (e.g. autoimmune disease, cancer, transplants, functional or anatomical asplenia, advancing age and HIV) or taking specific medications (e.g. corticosteroids, disease-modifying antirheumatic drugs [DMARDs] or cancer therapies). Seroprotection from immunisation can be suboptimal in this patient group and therefore additional doses of vaccines may be recommended. Some vaccines (live-attenuated vaccines) may be contraindicated.

The degree of immune compromise should be assessed to determine individual vaccination strategies.

Many vaccines can be given pre-emptively to people who anticipate immune compromise in the future (e.g. a patient undergoing a planned splenectomy should be immunised prior to surgery).

Recommended vaccines

Inactivated vaccines are safe to administer to the immunocompromised individual but efficacy may be reduced.

Influenza

Annual influenza vaccination is recommended for all immunocompromised patients.

Those < 9-years of age are recommended to receive 2 doses of influenza vaccine, administered a minimum of 4 weeks apart, in the first year of influenza immunisation. Transplant recipients (solid organ or haematopoietic stem cell) should also receive 2 doses of influenza vaccine, a minimum of 4 weeks apart, in the first year following transplant. This is regardless of age or previous influenza vaccine history.

Where a major shift in the circulating influenza virus occurs, such as in an influenza pandemic situation, 2 doses a minimum of 4 weeks apart, should be considered regardless of patient age or immunisation history to ensure optimal immune response.

Refer to MVEC: Influenza vaccine recommendations for more information.

Pneumococcal

The timing of vaccination, the number of doses and the type of vaccine(s) depend on a person’s age and underlying risk for invasive pneumococcal disease (IPD).

Refer to MVEC: Pneumococcal disease and vaccines for more information.

Meningococcal

Those taking certain therapies or with specific medical conditions (particularly those with asplenia) require extra doses of meningococcal vaccines. This applies to both MenACWY (quadrivalent) and MenB (meningococcal B) vaccines.

Refer to MVEC: Meningococcal vaccines in special risk and immunosuppressed patients for more information.

COVID-19

COVID-19 vaccination is recommended for all immunosuppressed people due to an increased risk of developing severe disease if infected with SARS-CoV-2. Due to limitations in clinical trials there is currently no data on the safety and efficacy of COVID-19 vaccination in this group, however in principle there are no theoretical risks.

It is anticipated that the immune response to vaccination may be reduced in this patient group depending on the level of immune suppression. Hence, when vaccinating immunocompromised people, they should also be counselled about this reduced efficacy and the need to continue other prevention measures such as social distancing and mask wearing. COVID-19 vaccines registered for use within Australia require 2 doses and additional doses beyond this are not recommended at this time.

For more information on COVID-19 vaccine administration in the setting of immune suppression please refer to: COVID-19 vaccination- ATAGI clinical guidance on COVID-19 vaccine in Australia in 2021

Contraindicated vaccines

Live-attenuated vaccines (see Table 1) are contraindicated in the majority of immunocompromising situations due to the risk of adverse events or vaccine-related disease. It is important to carefully review a patient’s history to identify suitability to receive a live-attenuated vaccine. Specialist immunisation advice can be sought by contacting the Victorian immunisation hotline on 1300 882 924 if clarification is required.

Table 1: Live-attenuated vaccines

Disease Brand name
Rotavirus^ Rotarix®
MMR (measles-mumps-rubella)^ Priorix®, MMR II®
MMRV (measles-mumps-rubella-varicella)^ Priorix-tetra®, ProQuad®
Varicella (chickenpox)^ Varilrix®, Varivax®
Zoster (shingles)^ Zostavax®
Tuberculosis BCG (varying brands)
Yellow fever¥ Stamaril®
Typhoid Vivotif®
Japanese encephalitis¥ Imojev®

^recommended vaccine on the National Immunisation Program (NIP)
#recommended vaccine on NIP for select patient group only
¥available vaccine for travel

Household contacts of immune suppressed individuals should be up to date with all vaccines (including annual influenza). It is safe for household contacts to receive live-attenuated vaccines.

Precaution: Mothers who are receiving immunosuppressive therapy and breastfeeding (or those who received immunosuppressive medication during pregnancy) should seek advice from an Specialist Immunisation Clinic around the safety of live-attenuated vaccines for their child (e.g.oral rotavirus vaccine or BCG). Inactivated vaccines should be administered as per the NIP.

Inadvertent administration of a live-attenuated vaccine to an immunosuppressed person

In the event that a live-attenuated vaccine has been administered inadvertently the following steps should take place:

  • Establish how severely they are immunocompromised and the level of risk for vaccine-associated adverse effects. This will inform appropriate management (e.g. need for antiviral therapy)
  • Open disclosure with the patient and discuss the implications as well as any signs and symptoms to monitor for.
  • Seek specialist advice and notify state or territory public health authorities (refer to MVEC: Adverse events reporting Australia). In Victoria, you can seek advice from SAEFVIC.

Resources

Authors: Georgina Lewis (Clinical Manager, SAEFVIC, Murdoch Children’s Research Institute), Francesca Machingaifa (MVEC Education Nurse Coordinator) and Rachael McGuire (MVEC Education Nurse Coordinator

Date: August 2020

Reviewed: Rachael McGuire (MVEC Education Nurse Coordinator) February 2021

Materials in this section are updated as new information and vaccines become available. The Melbourne Vaccine Education Centre (MVEC) staff regularly reviews materials for accuracy.

You should not consider the information in this site to be specific, professional medical advice for your personal health or for your family’s personal health. For medical concerns, including decisions about vaccinations, medications and other treatments, you should always consult a healthcare professional.