Immunosuppression and vaccines

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 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 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 the meningococcal B and ACWY vaccines.

Refer to MVEC: Meningococcal for more information.

COVID-19

COVID-19 vaccination is recommended for individuals aged 6 months and over due to an increased risk of developing severe disease if infected with SARS-CoV-2. Real-world evidence has demonstrated no safety concerns relating to the administration of COVID-19 vaccines in immunocompromised individuals however, the level of protection may be reduced. It is for this reason that a 3 dose primary course of COVID-19 vaccination is recommended for optimal protection (compared with a 2-dose course for those who are immune competent). Further booster doses are also recommended if aged ≥ 18 years and can be considered in those aged 5-17 years.

Administration of COVID-19 vaccines should be planned with the treating specialist and in some instances the timing of immune suppressive therapies or the interval between vaccine doses may be modified to maximise immune responses to vaccination.

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

^{^}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)

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 a 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

• 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]