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Vaccination of the immunocompromised host

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Vaccination of the Immunocompromised Hosts

Presented by Sirapassorn Sornphiphatphong, MD.

November21, 2014

Published in: Health & Medicine
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Vaccination of the immunocompromised host

  1. 1. Vaccination of the Immunocompromised Host Reviewed by Sirapassorn Sornphiphatphong, MD.
  2. 2. Overview • Introduction • Vaccines for household members of immunocompromised patients • Vaccines for immunocompromised patients – Vaccines for international travel – Varicella and zoster vaccines in immunocompromised patients – Influenza vaccines in immunocompromised patients • Vaccination of hematopoietic stem cell transplant patients
  3. 3. Overview • Vaccination of patients with primary immunodeficiency disorders – Complement deficiencies – Phagocytic cell defects – Defects of Cytokine Generation/Response or Cellular Activation – Minor Antibody Deficiencies – Major Antibody Deficiencies – Combined immunodeficiencies
  4. 4. Introduction • Impaired host defenses predispose patients to an increased risk or severity of vaccine- preventable infection • Data on safety, immunogenicity, and efficacy/effectiveness of vaccines for immunocompromised populations are limited • Immune defects vary among and within categories of patients with immune deficiencies
  5. 5. Recommendations for vaccines for household members of immunocompromised patients
  6. 6. Vaccination in household members of immunocompromised patients • Safely receive inactivated vaccines based on the CDC–ACIP’s annually updated recommended vaccination schedules for children and adults
  7. 7. Vaccination in household members of immunocompromised patients • Individuals who live in a household with immunocompromised patients age ≥6 months should receive influenza vaccine annually (a) Inactivated influenza vaccine (IIV) (b) Live attenuated influenza vaccine (LAIV) • Healthy, not pregnant, and aged 2–49 years • Exceptions: immunocompromised patient who was SCID, hematopoietic stem cell transplant (HSCT) recipient within 2 months after transplant or with GVHD
  8. 8. Vaccination in household members of immunocompromised patients • If LAIV administered, contact between the immunocompromised patient and household member should be avoided for 7 days Block SL et al. Vaccine 2008; 26:4940–6
  9. 9. • Intranasal LAIV in 344 subjects – 5–8 yrs – 9–17 yrs – 18–49 yrs • Shedding: culture of nasal swabs (on days 1–7, daily; days 9–25, every other day; and day 28) • Immunogenicity: serum strain-specific hemagglutinin inhibition (HAI) titers (days 0, 28) Block SL et al. Vaccine 2008; 26:4940–6 44% 27% 17% Shedding on days 1–11, peaked on day 2, maximum titers on days 2–3
  10. 10. Vaccination in household members of immunocompromised patients • Live vaccines based on the CDC annual schedule safely administered – MMR – Rotavirus in infants aged 2-7 mo. – Varicella vaccine – Zoster vaccine • Safe vaccines for travel: yellow fever vaccine and oral typhoid vaccine
  11. 11. Safety of vaccination in household members of immunocompromised patients • MMR – The only report of transmission of MMR viruses from immunocompetent vaccinees involved transmission to nursing neonates of rubella vaccine virus via breast milk • Yellow fever – A few case reports in 2009, 2011 of infants developed meningoencephalitis and confirmed IgM Ab for yellow fever in both serum and CSF
  12. 12. The report of transmission of MMR viruses via breast feeding Losonsky GA et al. J Infect Dis 1982; 145:661–6
  13. 13. Vaccination in household members of immunocompromised patients • Children receiving rotavirus vaccines may shed live virus in stool for 2–4 weeks and transmit vaccine virus, but symptomatic disease is rare • Highly immunocompromised patients should avoid handling diapers of infants who have been vaccinated with rotavirus vaccine for 4 weeks after vaccination
  14. 14. Vaccination in household members of immunocompromised patients • OPV should not be administered – DeVries AS et al. N Engl J Med 2011. reported a 44-yr old woman with CVID developed vaccine-associated paralytic poliomyelitis (VAPP) when her child received OPV • Immunocompromised patients should avoid contact with persons who develop skin lesions after receipt VAR or ZOS until the lesions clear
  15. 15. Lorry G. Rubin et al. 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host
  16. 16. Vaccines for immunocompromised patients
  17. 17. Vaccines for international travel in immunocompromised host
  18. 18. Vaccines for international travel • Yellow fever vaccine generally should not be administered to immunocompromised persons • If travel to an endemic area cannot be avoided, vaccination can be considered in the following minimally immunocompromised (a) asymptomatic HIV-infected adults with CD4 ≥200 cells/mm3 (b) asymptomatic HIV-infected children aged 9 mo–5 yrs, CD4 ≥15%
  19. 19. Recommendations for varicella and zoster vaccines in immunocompromised patients
  20. 20. Varicella and zoster vaccines in immunocompromised patients • VAR should be given to immunocompetent patients without evidence of varicella immunity, ≥4 weeks before initiating immunosuppressive therapy • 2-dose schedule if there is sufficient time prior to initiating immunosuppressive therapy • Age ≥13 years: separated by >4 weeks • Age 1-12 years: separated by ≥3 months
  21. 21. • VAR should not be administered to highly immunocompromised patients • These groups should receive VAR, 2 doses, 3 month interval – HIV infection without severe immunosuppression – Primary immune deficiency disorder without defective T-cell–mediated immunity, such as primary complement component deficiency disorder or chronic granulomatous disease (CGD) Varicella and zoster vaccines in immunocompromised patients
  22. 22. Varicella and zoster vaccines in immunocompromised patients • VAR can be considered for patients without evidence of varicella immunity who are receiving long-term, low-level immunosuppression • VAR as the single antigen product, not MMRV • MMRV contains ≥7-fold more VZV than monovalent VAR
  23. 23. Definitions of high-level Immunosuppression • Combined primary immunodeficiency disorder: SCID • Receiving cancer chemotherapy • Within 2 months after solid organ transplantation • HIV infection with a CD4 <200 cells/mm3 for adults and adolescents or <15% for infants and children • Daily corticosteroid therapy ≥20 mg (or >2 mg/kg/day for patients who weigh <10 kg) of prednisone or equivalent for ≥14 days • Certain biologic immune modulators: TNF-α blocker or rituximab
  24. 24. Low-level immunosuppression • Asymptomatic HIV-infected patients CD4 200– 499 cells/mm3 for adults and adolescents or 15– 24% for infants and children • Lower daily dose of systemic corticosteroid than for high-level immunosuppression for ≥14 days or receiving alternate-day corticosteroid therapy • MTX ≤0.4 mg/kg/week, azathioprine ≤3 mg/kg/day, or 6-mercaptopurine ≤1.5 mg/kg/day
  25. 25. Varicella and zoster vaccines in immunocompromised patients • ZOS: aged ≥60 years ≥4 weeks before beginning highly immunosuppressive therapy • ZOS: varicella-positive patients aged 50–59 years ≥4 weeks before beginning immunosuppressive therapy • History of varicella/zoster infection • VZV seropositive with no previous doses of VAR
  26. 26. Varicella and zoster vaccines in immunocompromised patients • ZOS should be administered to patients aged ≥60 years who are receiving therapy considered to induce a low level of immunosuppression • ZOS should not be administered to highly immunocompromised patients
  27. 27. Recommendations for influenza vaccine in the immunocompromised host
  28. 28. Influenza vaccine in the immunocompromised host • Annual IIV is recommended for immunocompromised patients aged ≥6 months • Except for patients who are very unlikely to respond (although unlikely to be harmed by IIV), such as those receiving intensive chemotherapy or those who have received anti–B-cell antibodies within 6 months • LAIV should not be administered to immunocompromised persons
  29. 29. Recommendations for vaccination of patients with primary immunodeficiency disorders
  30. 30. Vaccines in primary complement deficiencies • All routine vaccines based on the CDC annual schedule; none are contraindicated • Aged 2–5 years: – 1 dose of PCV13 (pneumococcal conjugate vaccine) if received 3 doses of PCV (either PCV7, PCV13) before age 24 months – 2 doses of PCV13 (8 weeks apart) if they have received an incomplete schedule of ≤2 doses of PCV7/PCV13 before age 24 months
  31. 31. Vaccines in primary complement deficiencies • A classic pathway (C1, C2, C3, C4), alternate pathway, or severe mannan-binding lectin (MBL) deficiency aged ≥6 years who have not received PCV13 should receive a single dose of PCV13 • For those who received pneumococcal polysaccharide vaccine-23 (PPSV23), PCV13 should be administered ≥1 year after the last PPSV23 dose
  32. 32. Vaccines in primary complement deficiencies • Aged ≥2 years: PPSV23 ≥8 weeks after PCV13, and a second dose of PPSV23 should be given 5 years later • ≥2 years: PCV13 → PPSV23 → PPSV23 ≥8 wks 5 yrs
  33. 33. Vaccines in primary complement deficiencies • Aged 6 wks-18 mo: 4 doses at age 2, 4, 6, and 12–15 months – Bivalent meningococcal conjugate vaccine – Haemophilus influenzae type b conjugate vaccine (Hib) • Aged 9 mo-55 yrs: 2 doses of meningococcal conjugate vaccine, quadrivalent (MCV4)
  34. 34. Vaccines in Phagocytic cell deficiencies • All inactivated vaccines based on the CDC annual schedule • Aged ≥2 years with phagocytic cell deficiencies other than CGD (unless patient with CGD is receiving immunosuppressive medication) • Should receive PCV13 → PPSV23 → PPSV23 ≥8 wks 5 yrs
  35. 35. Vaccines in Phagocytic cell deficiencies • Staphylococcus aureus: major pathogen in individuals with phagocytic defects • Annual influenza vaccination is important • Influenza infection may predispose to respiratory infection with S. aureus Lyn Finelli et al. Pediatrics 2008;122;805
  36. 36. Lyn Finelli et al. Pediatrics 2008;122;805
  37. 37. Vaccines in Phagocytic cell deficiencies • Live bacterial vaccines, such as BCG or oral typhoid vaccine, should not be administered to patients with a phagocytic cell defect
  38. 38. Vaccines in Phagocytic cell deficiencies • Live viral vaccines should not be administered to – Leukocyte adhesion deficiency – Defects of cytotoxic granule release such as Chediak–Higashi syndrome – Any other undefined phagocytic cell defect • Live viral vaccines should be administered to CGD, congenital or cyclical neutropenia
  39. 39. Vaccines in Minor Antibody Deficiencies • Patients with IgA deficiency or specific polysaccharide antibody deficiency (SPAD) should receive all routine vaccinations • Children with SPAD or ataxia–telangiectasia should receive PCV13
  40. 40. Vaccines in Minor Antibody Deficiencies • Monitoring of vaccine responses can be useful for assessing the degree of immunodeficiency of patients with minor antibody deficiencies and level of protection • OPV should not be administered to IgA-deficient patients
  41. 41. Vaccines in Major Antibody Deficiencies • Inactivated vaccines other than IIV are not routinely administered to patients with major antibody deficiencies during immunoglobulin therapy • IIV can be administered to patients with major antibody deficiencies and some residual antibody production
  42. 42. Vaccines in Major Antibody Deficiencies • All inactivated vaccines can be administered as part of immune response assessment prior to immunoglobulin therapy • Live vaccines including OPV should not be administered to patients with major antibody deficiencies
  43. 43. Vaccines in Combined immunodeficiencies • All inactivated vaccines can be administered as part of immune response assessment prior to immunoglobulin therapy • Received immunoglobulin therapy, inactivated vaccines should not be routinely administered • IIV can be administered in one who has residual antibody production potential
  44. 44. Vaccines in Combined immunodeficiencies • Partial DiGeorge syndrome should undergo immune system assessment with evaluation of lymphocyte subsets and mitogen responsiveness • Those with CD3 ≥500, CD8 ≥200 cells/mm3, and normal mitogen response should receive MMR vaccine and VAR
  45. 45. Vaccines in Combined immunodeficiencies • Avoid all live vaccines in – SCID – DGS with a CD3 <500 cells/mm3 – other combined immunodeficiencies with similar CD3 T-cell lymphocyte counts – Wiskott–Aldrich syndrome – X-linked lymphoproliferative disease
  46. 46. CDC January 2011
  47. 47. ตำรำวัคซีนและกำรสร้ำงเสริมภูมิคุ้มกันโรค ปี 2556
  48. 48. ตำรำวัคซีนและกำรสร้ำงเสริมภูมิคุ้มกันโรค ปี 2556
  49. 49. Recommendations for vaccination of hematopoietic stem cell transplant patients
  50. 50. Vaccination of Donors of hematopoietic stem cell transplant • Routine recommended vaccines based on age, vaccination history, and exposure history • Vaccination of the donor for the benefit of the recipient is not recommended • ≥4 weeks for live vaccines and ≥2 weeks for inactivated vaccines • Aged ≥12 months should receive VAR (as a 2- dose regimen if there is sufficient time)
  51. 51. Vaccination of Recipients of hematopoietic stem cell transplant • IIV should be administered annually to persons aged ≥6 months • Starting 6 months after HSCT and starting 4 months after if there is a community outbreak of influenza • Do not administer live vaccines to HSCT patients with active GVHD or ongoing immunosuppression
  52. 52. Lorry G. Rubin et al. 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host
  53. 53. Vaccination of Recipients of hematopoietic stem cell transplant • 2 doses of MMR, VAR to seronegative patients, 24months after HSCT in patients Lorry G. Rubin et al. 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host
  54. 54. ตำรำวัคซีนและกำรสร้ำงเสริมภูมิคุ้มกันโรค ปี 2556
  55. 55. Vaccination of patients with chronic inflammatory diseases on immunosuppressive medications
  56. 56. Before starting immunosuppressive medications • Vaccines should be administered prior to planned immunosuppression if feasible • Live vaccines ≥4 weeks prior to immunosuppression and should be avoided within 2 weeks of initiation of immunosuppression • Inactivated vaccines ≥2 weeks prior to immunosuppression
  57. 57. High-level Immunosuppression • Daily corticosteroid therapy ≥20 mg (or >2 mg/kg/day for patients who weigh <10 kg) of prednisone or equivalent for ≥14 days • Certain biologic immune modulators: TNF-α blocker or rituximab • Receiving cancer chemotherapy • Within 2 months after solid organ transplantation
  58. 58. Low-level immunosuppression • Lower daily dose of systemic corticosteroid than for high-level immunosuppression for ≥14 days or receiving alternate-day corticosteroid therapy • MTX ≤0.4 mg/kg/week • Azathioprine ≤3 mg/kg/day • 6-mercaptopurine ≤1.5 mg/kg/day
  59. 59. Vaccination of patients on immunosuppressive medications • Inactivated vaccines, including IIV and HBV should be administered to patients with chronic inflammatory illness even treated with immunosuppressive • PCV13 should be administered • PPSV23 in aged ≥2 years • PPSV23 ≥8 weeks after PCV13, and a second dose of PPSV23 should be given 5 years later
  60. 60. Vaccination of patients on immunosuppressive medications • VAR and ZOS should be administered: – Long-term, low-level immunosuppression • Other live vaccines should not be administered
  61. 61. Lorry G. Rubin et al. 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host
  62. 62. ตำรำวัคซีนและกำรสร้ำงเสริมภูมิคุ้มกันโรค ปี 2556
  63. 63. ตำรำวัคซีนและกำรสร้ำงเสริมภูมิคุ้มกันโรค ปี 2556
  64. 64. Thank you

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