Vaccines in Immunocompromised Patients

Aka: Vaccines in Immunocompromised Patients, Immunodeficiency and Immunization, Immunization in Immunocompromised Patients, Vaccination in Immunocompromised Patients, Vaccination in Immunosuppressed Patients

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II. Grading: Immunosuppressants

  1. High Level Immunosuppression
    1. Biological Agent (e.g. Humira)
    2. Prednisone dose >=20 mg/day for >=14 days
  2. Low Level Immunosuppression
    1. Prednisone dose <=20 mg/day
    2. Methotrexate <=0.4 mg/kg/week
      1. Consider holding for 2 weeks after inactivated Vaccine to boost immune response
  3. Minimal Immunosuppression (should not impact Immunization, may receive live Vaccination)
    1. Prednisone for <14 days
    2. Other Corticosteroid formulations (topical, inhaled, intraarticular injections)

III. Precautions

  1. Inactivated Vaccines
    1. Not harmful, but immunodeficient patients may have reduced immunogenic response to Vaccines
    2. Best to time inactivated Vaccines at least 2 weeks before starting Immunosuppressants
    3. Do not delay indicated Vaccines in patients already immunodeficient
    4. Shingrix is safe in low Level Immunosuppression
      1. Shingrix efficacy and safety data are lacking in 2019, for those on High Level Immunosuppression
  2. Live Vaccines
    1. See Live Attenuated Vaccine
    2. Avoid Live Vaccines (e.g. MMR, Varicella) for those on high level Immunosuppression
      1. Live Vaccines are best given at least 4 weeks before starting Immunosuppression
    3. Do not use Flumist (Live Attenuated Influenza Vaccine) for Immunocompromised patients
      1. Use inactivated infuenza Vaccine instead
    4. Do not use Zostavax (live Shingles Vaccine) in HIV Infection or high level Immunosuppression
      1. Shingrix (recombinant, inactivated Vaccine released 2018) has replaced Zostavax and is preferred
      2. See Zostavax for indications (e.g. prior to Immunosuppression medications)

IV. Prevention: Routine Vaccinations Recommended for patients on Immunosuppression

  1. Influenza Vaccine yearly
    1. Consider high dose or adjuvanted Influenza Vaccine for immunosuppressed patients age 18 to 64 years
  2. Covid-19 Vaccine
    1. Roughly annual Vaccination
  3. Respiratory Syncytial Virus Vaccine (RSV Vaccine)
    1. One dose for Immunocompromised, age 60 years and older
  4. Varicella Zoster Virus Vaccine (Shingrix)
    1. Shingrix (recombinant, inactivated Vaccine) two doses, 2-6 months apart for Immunocompromised, age >18 years
    2. Do NOT use Live Vaccine (Zostavax) in Immunocompromised patients
  5. Pneumococcal Conjugate Vaccine (e.g. PCV21)
    1. Immunocompromised adults >=19 years old
    2. Dual Immunization with Pneumovax 23 is no longer needed if PCV20 or PCV21 are used
  6. Gardasil 9
    1. Give 3 doses (instead of 2 doses as used in standard series)

V. References

  1. (2024) Presc Lett 31(11): 61
  2. (2019) Presc Lett 26(12): 68
  3. (2014) Presc Lett 21(2): 10

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