The Australian Immunisation Handbook 10th Edition 2013

known that a new influenza vaccine strain is circulating in the community to
which cross-protective immunity in the population is low (such as in the setting
of an influenza pandemic), it may be appropriate that immunocompromised
persons receive 2 doses of inactivated influenza vaccine, a minimum of 4 weeks
apart, to achieve an optimal immune response. For example, in the 2009–2010
H1N1 global influenza pandemic it was shown that seroconversion to influenza
vaccination in immunocompromised adolescents and adults was improved
following receipt of 2 vaccine doses. 77 Further information and annual influenza
vaccine recommendations are available on the Immunise Australia website
(www.immunise.health.gov.au).
The recommendations in this section for the use of vaccines in
immunocompromised persons have been divided where applicable into
paediatric (0–18 years) and adult (≥19 years) recommendations. This distinction
has been made on the basis of scientific evidence, where available, and to assist in
vaccine delivery in paediatric and adult special risk settings.
Immunocompromise associated with corticosteroid administration
The dose and duration of therapy with corticosteroids determines the impact
on the immune system. In adults, daily doses of oral corticosteroids in excess of
60 mg of prednisolone (or equivalent) for more than 1 week are associated with
significant immunocompromise. In children, doses in excess of either
2 mg/kg per day for more than 1 week or 1 mg/kg per day for more than
4 weeks are associated with significant immunocompromise. Live attenuated
vaccines are generally contraindicated in such persons (see also below). In
addition, for both children and adults, even lower doses may be associated with
some impairment of the immune response. 78 It is also important, once treatment
with corticosteroids is ceased, to assess whether the person has other underlying
immunocompromising disease or is receiving other immunosuppressive therapy
that may influence decisions about whether vaccines, particularly live vaccines,
can be given.
For adults treated with systemic corticosteroids in excess of 60 mg per day for
more than 1 week, live attenuated viral vaccines (such as MMR, MMRV, zoster,
varicella and yellow fever vaccines) should be postponed until at least 1 month
after treatment has stopped.
Children receiving >2 mg/kg per day or ≥20 mg per day in total of prednisolone
(or equivalent) for more than 1 week should not receive live attenuated vaccines
until after corticosteroid therapy has been discontinued for at least 1 month.
Children on daily doses of ≤2 mg/kg per day of systemic corticosteroids for
less than 1 week, and those on lower doses of 1 mg/kg per day or alternateday
regimens for periods of up to 4 weeks, may be given live attenuated viral
vaccines. Some experts suggest withholding lower doses of steroids 2 to 3 weeks
prior to vaccination with live viral vaccines if this is possible. 79,80
146 The Australian Immunisation Handbook 10th edition