Immunosuppression and vaccines

Background

Immunosuppression (also known as immunocompromise) 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).

Vaccination is particularly important for those who are immunosuppressed due to the increased risk of developing severe disease (hospitalisation/intensive care admission, death) if exposed to vaccine-preventable diseases. Protection from vaccines can be suboptimal in this patient group and therefore additional doses of vaccines may be recommended. Conversely, some vaccines (live-attenuated vaccines) may be contraindicated due to the potential risk of vaccine-related disease.

Taking a thorough patient history prior to vaccination is recommended to determine an individual’s degree of immunosuppression and to formulate their individual vaccination strategy.

Vaccination timing

Vaccination may need to be planned with the treating specialist. In some instances, the timing of immunosuppressive therapies may be altered to increase the response to vaccines. In other circumstances, the intervals between vaccine doses may be altered to accommodate treatment regimes.

In some instances, vaccines can be given pre-emptively to people who anticipate immunosuppression 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 immunosuppressed 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 receiving an influenza vaccine. 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 their 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, could be considered regardless of patient age or immunisation history to ensure optimal immune response.

Pneumococcal

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

Meningococcal

Those taking certain therapies or with specific medical conditions (particularly those with asplenia) are recommended to receive a primary course of meningococcal B and ACWY vaccines. Following this, booster doses are recommended for some individuals with specified medical conditions or treatment that increase their risk of invasive meningococcal disease (IMD).

COVID-19

COVID-19 vaccination is strongly recommended for all immunosuppressed individuals aged 6 months and over due to an increased risk of developing severe disease. A 3-dose primary course  is recommended for optimal protection (compared with a 2-dose course for those who are immune competent). Following a primary course, booster doses are also recommended in those aged ≥ 18 years. Children and adolescents aged 5-17 years of age with comorbidities that increase their risk of severe COVID-19 disease (including immunosuppression) should also consider a booster dose.

Contraindicated vaccines

Live-attenuated vaccines are contraindicated for most immunosuppressed individuals due to the risk of adverse events or vaccine-related disease. In some instances, an alternate inactivated vaccine may be available for use (see table 1).

Table 1: Contraindicated vaccines in immunosuppressed patients and alternative options to consider

^{^}routinely administered on the National Immunisation Program (NIP)
^#recommended vaccine for select patient group only
^¥available vaccine for those at higher risk of infection (eg. travel)
^§not on NIP but available at cost
N/A no alternate vaccine available

Inadvertent administration of a live-attenuated vaccine

If an immunosuppressed patient is inadvertently administered a live-attenuated vaccine prompt action is required. Medical review by an infectious diseases specialist or immunisation expert must be facilitated and the appropriate management commenced (e.g., anti-viral therapy, monitoring etc.).

The patient must be informed of the incident and have a clear understanding of its implications, including any signs and symptoms to monitor for [refer to resources for guidance]. The error must also be reported to the relevant authority to ensure appropriate follow up and support can be provided. In Victoria, this service is SAEFVIC.

If the error occurs out of hours, seek specialist advice from the patient’s treating specialist or an infectious diseases specialist at your local tertiary hospital.

Precautions

Mothers who are receiving immunosuppressive therapy and breastfeeding (or those who received immunosuppressive medication during pregnancy) should seek advice from a Specialist Immunisation Clinic around the safety of live-attenuated vaccines for their child (e.g., oral rotavirus vaccine or BCG).

Household contacts

Household contacts of immunosuppressed individuals should be up to date with all vaccines and are recommended to receive annual influenza vaccination as well as COVID-19 vaccines.

It is safe for household contacts to receive live-attenuated vaccines (including rotavirus and varicella). Thorough hand hygiene should always be performed when handling soiled nappies of rotavirus vaccine recipients to minimise the risk of vaccine-virus transmission. Any varicella-like blisters that occur on the vaccinee following varicella vaccination should be covered until they crust over.

Resources

• MVEC: Asplenia
• MVEC: Zoster
• MVEC: Solid organ transplant recipient: pre-transplant immunisation recommendations
• MVEC Cancer immunisation guideline: vaccine recommendations following chemotherapy and haematopoietic stem cell transplant
• MVEC: Immunisation recommendations for the older population
• Australian Immunisation Handbook: Vaccination for people who are immunocompromised
• MVEC eLearning course: Vaccine errors: Prevention, management and open disclosure [for providers]