Vaccinating Immunocompromised Patients
full update September 2024
Concerns are raised when a potentially immunocompromised (i.e., immunosuppressed) patient presents for vaccination. The concern with live vaccines is that the patient might contract the disease from the vaccine. Inactivated vaccines cannot cause disease, and some inactivated vaccines are especially recommended for immunocompromised patients. However, depending on the patient’s degree of immunocompromise, response to some vaccines may be suboptimal. For some disease states/vaccinations, titers could be used to assess response. It is important to assess the patient’s degree of immunocompromise when making vaccine decisions, especially for live vaccines. When in doubt, consult the specialist caring for the patient’s immunocompromising condition.3 If possible, ensure that patients are vaccinated with routine adult vaccinations (plus any others that are specific to their condition) before immunocompromise. And keep in mind that several live vaccines have inactivated alternatives (influenza, typhoid, polio).
--Information in chart may differ from product labeling.--
For help identifying which vaccines are LIVE and which are INACTIVATED, see:
- Vaccines Licensed for Use in the United States at https://www.fda.gov/vaccines-blood-biologics/vaccines/vaccines-licensed-use-united-states.
- Contents of Immunizing Agents Authorized for Use in Canada at https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-1-key-immunization-information/page-15-contents-immunizing-agents-available-use-canada.html#p1c14t1.
Clinical Question |
Pertinent Information of Resource |
WHO is or might be immunocompromised in the context of vaccination? |
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Can patients with immunocompromise receive non-live vaccines? |
--Also see separate section on immunosuppressive MEDICATIONS, below.—
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Can patients with immunocompromise receive LIVE vaccines? |
--Also see separate section on immunosuppressive MEDICATIONS, below.-- General concepts: Avoid live vaccines unless immunocompromise is mild, data supports use of the vaccine, and the risk of natural infection is greater than the risk of immunization.3 Live vaccines should not be given to severely immunocompromised patients, or if immune status is uncertain.1,3 The ultimate determination of severe immunocompromise should be made by the provider treating the patient’s immunocompromising condition.1,3 Special disease-considerations (medications are discussed below):
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Can patients receiving immunosuppressive MEDICATIONS receive vaccines? |
General concepts
Specific medications:
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Can HOUSEHOLD CONTACTS of immunocompromised patients receive LIVE vaccines? |
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Abbreviations: ACR = American College of Rheumatology; BCG = bacilli Calmette-Guerin; HCT = hematopoietic cell transplant; HPV = human papilloma virus; Hib = Haemophilus influenzae type b; IBD = inflammatory bowel disease; IL = interleukin; LAIV = live attenuated influenza virus; MMR = measles, mumps, rubella; MS = multiple sclerosis; TNF = tumor necrosis factor
- Immunosuppressive steroid dose (i.e., high-level immunosuppression dose): prednisone ≥20 mg daily or ≥2 mg/kg daily (or equivalent) for ≥14 days.1,3 This does NOT include alternate-day regimen; rapid tapers; short (<14 day) high-dose regimen; topicals; physiologic replacement doses; or intra-articular, bursal, or tendon injection.1-3 Live vaccines can be given to patients receiving inhaled corticosteroids (Canada: with the exception of LAIV, which should not be given to patients with severe asthma receiving high-dose inhaled corticosteroids).1,3
Low-level immunosuppression examples: methotrexate ≤0.4 mg/kg/week, azathioprine ≤3 mg/kg/day, or 6-mercaptopurine
≤1.5 mg/kg/day).3
High-level immunosuppression examples: immunosuppressive corticosteroid dose (see above), methotrexate >0.4 mg/kg/week, azathioprine >3 mg/kg/day, or 6-mercaptopurine >1.5 mg/kg/day; adalimumab, certolizumab, etanercept, golimumab, infliximab, natalizumab, vedolizumab.1,3,8 Consult prescribing information for MS treatments (e.g., fingolimod).
- Additional resources:
- US: Altered immunocompetence. General best practice guidelines for immunization: best practices guidance of the Advisory Committee on Immunization Practices (ACIP). (https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html).
- US: CDC Recommended Adult Immunization Schedule (https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf).
- Canada: Canadian Immunization Guide, Immunization of Immunocompromised Persons (https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-3-vaccination-specific-populations/page-8-immunization-immunocompromised-persons.html#t5).
- If the drug has more than one approved dosing frequency, hold for the longest approved dosing interval; however, for IL-6 or IL-1 inhibitors, in children with systemic juvenile rheumatoid arthritis or other autoinflammatory disorder, shorter hold times can be considered if live vaccination is critical and the risk of disease flare is high.19
References
- CDC. Epidemiology and prevention of vaccine-preventable disease (The Pink Book). 14th edition (2021). Chapter 2: General recommendations on immunization. August 18, 2021. https://www.cdc.gov/vaccines/pubs/pinkbook/genrec.html#contraindications. (Accessed June 25, 2024).
- CDC. Altered immunocompetence. General best practice guidelines for immunization: Updated August 1, 2023. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html. (Accessed June 25, 2024).
- Public Health Agency of Canada. Canadian Immunization Guide: Part 3-vaccination of specific populations. Immunization of immunocompromised persons. Last complete update May 2018. Last modified March 22, 2024. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-3-vaccination-specific-populations/page-8-immunization-immunocompromised-persons.html. (Accessed June 25, 2024).
- Public Health Agency of Canada. Immunization of persons with chronic diseases: Canadian Immunization Guide. Last complete revision May 2022. Last partial content update June 2024. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-3-vaccination-specific-populations/page-7-immunization-persons-with-chronic-diseases.html#p3c6a11. (Accessed June 25, 2024).
- Furer V, Rondaan C, Heijstek MW, et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases. Ann Rheum Dis. 2020 Jan;79(1):39-52.
- Alnaimat F, Sweis JJG, Jansz J, et al. Vaccination in the Era of Immunosuppression. Vaccines (Basel). 2023 Sep 1;11(9):1446.
- Papp KA, Haraoui B, Kumar D, et al. Vaccination Guidelines for Patients With Immune-Mediated Disorders on Immunosuppressive Therapies. J Cutan Med Surg. 2019 Jan/Feb;23(1):50-74.
- Farshidpour M, Charabaty A, Mattar MC. Improving immunization strategies in patients with inflammatory bowel disease. Ann Gastroenterol. 2019 May-Jun;32(3):247-256.
- Otero-Romero S, Lebrun-Frénay C, Reyes S, et al. European Committee for Treatment and Research in Multiple Sclerosis and European Academy of Neurology consensus on vaccination in people with multiple sclerosis: Improving immunization strategies in the era of highly active immunotherapeutic drugs. Eur J Neurol. 2023 Aug;30(8):2144-2176.
- Farez MF, Correale J, Armstrong MJ, et al.. Practice guideline update summary: Vaccine-preventable infections and immunization in multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2019 Sep 24;93(13):584-594.
- Public Health Agency of Canada. Canadian Immunization Guide: Part 4-Acitve Vaccines. Pneumococcal vaccine. Date modified May 31, 2024.. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-16-pneumococcal-vaccine.html#tb3. (Accessed June 26, 2024).
- CDC. Recommended adult immunization schedule for ages 19 years or older. 2024. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. (June 26, 2024).
- CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices-United States, 2023-24 influenza season. MMWR Suppl 2023;72(2):1-26. (Accessed June 27, 2024).
- Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol. 2019 Apr;80(4):1029-1072.
- US Department of Health and Human Services. Immunization. Vaccine types. Content last reviewed December 22, 2022. https://www.hhs.gov/immunization/basics/types/index.html. (Accessed June 25, 2024).
- Kamboj M, Bohlke K, Baptiste DM, et al. Vaccination of Adults With Cancer: ASCO Guideline. J Clin Oncol. 2024 May 10;42(14):1699-1721.
- Bemben NM, Berg ML. Efficacy of inactivated vaccines in patients treated with immunosuppressive drug therapy. Pharmacotherapy. 2022 Apr;42(4):334-342.
- Chat VS, Ellebrecht CT, Kingston P, et al. Vaccination recommendations for adults receiving biologics and oral therapies for psoriasis and psoriatic arthritis: Delphi consensus from the medical board of the National Psoriasis Foundation. J Am Acad Dermatol. 2024 Jun;90(6):1170-1181.
- Bass AR, Chakravarty E, Akl EA, et al. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken). 2023 Mar;75(3):449-464.
- Imran M, Ali S, Ibrahim AA, et al. Effect of methotrexate hold on COVID-19 vaccine response in the patients with autoimmune inflammatory disorders: a systematic review and meta-analysis. Clin Rheumatol. 2024 Jul;43(7):2203-2214 [abstract].
Cite this document as follows: Clinical Resource, Vaccinating Immunocompromised Patients. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. September 2024. [400966]