The Australian Immunisation Handbook 10th Edition 2013

3.3.3 Vaccination of immunocompromised persons
A person can be immunocompromised due to disease and/or medical
treatment. Vaccination of immunocompromised persons presents numerous
challenges. The immune protection attained from previous immunisation
may be diminished; the response to vaccines administered in the setting of
immunocompromise may be reduced, with additional booster vaccine doses
required; the risk of vaccine-preventable diseases and/or their complications
may be increased; and the risk of adverse events from live vaccines may be
increased. Degrees of immunocompromise vary from insignificant to profound,
and this, together with the risk of acquiring vaccine-preventable disease, should
be taken into account when considering a vaccination schedule.
When considering vaccination of persons on immunosuppressive therapy, it is
particularly important to consider a number of factors, including the biologic
target of the medication being used (mechanism and duration of effect on the
immune system) as well as the consequence of using combination therapies
(e.g. prednisolone and methotrexate), which can contribute to the nature,
extent and length of immunocompromise. It is also important to know the
anticipated duration of immunocompromise, whether due to therapy or the
underlying disease (see also ‘Immunocompromise associated with corticosteroid
administration’ below). In some instances, additional booster doses of vaccines
may be required to optimise protection in immunocompromised persons
(e.g. pneumococcal vaccines at diagnosis of haematological malignancy).
To determine the need for booster doses, it may be useful to measure postvaccination
antibody titres in selected groups in some circumstances, such as
for adults or children who have received haematopoietic stem cell transplants
(see ‘Haematopoietic stem cell transplant recipients’ below). Reliable serological
testing is not readily available and/or validated to measure vaccine-induced
immunity for all vaccines, and, in addition, results should be interpreted using
standardised serological correlates. (See also 2.1.5 Catch-up, ‘Use of serological
testing to guide catch-up vaccination’.) Expert advice should be sought if
required.
Many vaccine-preventable diseases are associated with an increased risk of
morbidity and mortality in immunocompromised persons. Two important
examples are influenza and invasive pneumococcal disease (IPD). Annual
influenza vaccination should be given to all immunocompromised persons
≥6 months of age (see 4.7 Influenza). Immunocompromised persons may
also require additional doses of pneumococcal vaccines; the timing, number
of doses and type of vaccine(s) vary depending on age and the underlying
risk for IPD (see 4.13 Pneumococcal disease). These, and other specific vaccine
recommendations, are discussed in more detail below.
All immunocompromised persons, irrespective of age, who receive influenza
vaccine for the first time are recommended to receive 2 vaccine doses, at least
4 weeks apart, and 1 dose annually thereafter (see 4.7 Influenza). Where it is
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3.3 GROUPS WITH SPECIAL
VACCINATION REQUIREMENTS