Vaccinating Immunocompromised Patients
Full update December 2019
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, zoster, 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.
- Types and Contents of Vaccines Available 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.
Abbreviations: BCG = bacilli Calmette-Guerin; DMARD = disease-modifying antirheumatic drugs; HCT = hematopoietic cell transplant; HPV = human papilloma virus; Hib = Haemophilus influenzae type b; IBD = inflammatory bowel disease; LAIV = live attenuated influenza virus; MMR = measles, mumps, rubella; MS = multiple sclerosis; TNF = tumor necrosis factor
Information of Resource
WHO is or might be immunocompromised in the context of vaccination?
Patients with cancer (i.e., cancer affecting the bone marrow or lymphatics, solid tumors).1,3
Patients being treated with chemo (e.g., alkylating agents, antimetabolites) or radiation.1,3
Patients receiving certain biologics (i.e., ones that are immunosuppressive such as adalimumab or rituximab).1,3
Patients with congenital (primary) immunodeficiency.1.3
Patients receiving large doses of corticosteroids (see footnote a).1
HIV patients might be immunocompromised.2 For help identifying these patients, see footnote b resources.
Patients taking immunosuppressants (e.g., high-dose methotrexate, azathioprine, or 6-mercaptopurine doses [see footnote a]; calcineurin inhibitors).3
Asplenia (increased risk of fulminant bacteremia).2,4
Chronic renal disease.2
Can patients with immunocompromise receive INACTIVATED vaccines?
--Also see separate section on immunosuppressive MEDICATIONS, below.—
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
Special disease-considerations (medications are discussed below):
Can patients receiving immunosuppressive MEDICATIONS receive vaccines?
Can HOUSEHOLD CONTACTS of immunocompromised patients receive LIVE vaccines?
Household contacts may receive MMR, varicella, rotavirus, and LAIV (e.g., FluMist).1,3 See resources in footnote b for other vaccines recommended for contacts.
- 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).
- Additional resources:
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
- U.S.: 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).
- U.S.: 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).
Project Leader in preparation of this clinical resource (351203): Melanie Cupp, Pharm.D., BCPS; Last modified September 2021.
- CDC. Epidemiology and prevention of vaccine-preventable disease (The Pink Book). 13th edition (2015). Chapter 2: General recommendations on immunization. April 15, 2019. https://www.cdc.gov/vaccines/pubs/pinkbook/genrec.html#contraindications. (Accessed October 1, 2019).
- CDC. Altered immunocompetence. General best practice guidelines for immunization: best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Last reviewed August 20, 2019. https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/immunocompetence.html. (Accessed October 2, 2019).
- Public Health Agency of Canada. Canadian Immunization Guide: Part 3-vaccination of specific populations. Immunization of immunocompromised persons. May 2018. 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 September 10, 2021).
- Public Health Agency of Canada. Canadian Immunization Guide: Part 3-vaccination of specific populations. Immunization of persons with chronic diseases. July 2015. 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 October 2, 2019).
- 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 2019 Aug 14. doi: 10.1136/annrheumdis-2019-215882.
- 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;80:1029-72.
- Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. MMWR Morbid Mortal Wkly Rep 2018;67:103-8.
- Farshidpour M, Charabaty A, Mattar MC. Improving immunization strategies in patients with inflammatory bowel disease. Ann Gastroenterol 2019;32:247-56.
- Farez M, 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;93:584-94.
- Baumrin E, Van Voorhees A, Garg A, et al. A systematic review of herpes zoster incidence and consensus recommendation on vaccination in adult patients on systemic therapy for psoriasis or psoriatic arthritis: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol 2019;81;102-10.
- Public Health Agency of Canada. Canadian Immunization Guide: Part 4-Acitve Vaccines. Pneumococcal vaccine. October 2016. 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 October 2, 2019).
- CDC. Recommended adult immunization schedule for ages 19 years or older. 2019. https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf. (October 2, 2019).
- 13. CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices, United States, 2021-22 influenza season. August 27, 2021. https://www.cdc.gov/mmwr/volumes/70/rr/rr7005a1.htm. (Accessed September 10, 2021).
Cite this document as follows: Clinical Resource, Vaccinating Immunocompromised Patients. Pharmacist’s Letter/Prescriber’s Letter. December 2019.