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IDSA Releases Recommendations on Vaccinations in Immunocompromised Patients

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IDSA Releases Recommendations on Vaccinations in Immunocompromised Patients Practice Guidelines IDSA Releases Recommendations on Vaccinations in Immunocompromised Patients ciency; those with secondary immunodefi- Key Points for Practice ciency caused by human immunodeficiency • Vaccines should be administered before planned immunosuppression, virus (HIV) infection, cancer chemother- with live vaccines given four weeks in advance and inactivated vaccines given two weeks in advance. apy, stem cell or solid organ transplant, • Immunocompetent persons who live with an immunocompromised sickle cell disease, and surgical asplenia; patient can safely receive inactivated vaccines. and patients with chronic inflammatory • Varicella and zoster vaccines should not be administered to highly diseases who are receiving systemic corti- immunocompromised patients. costeroids, immunomodulators, or biologic • Annual vaccination with inactivated influenza vaccine is recommended agents. The guideline includes several tables, for immunocompromised patients six months and older, except those one for each condition, that list specific who are unlikely to respond. vaccines that are recommended and contra- From the AFP Editors indicated, with the level of evidence associ- ated with each recommendation. Some of Coverage of guidelines Vaccination of immunocompromised the recommendations distinguish between from other organizations patients is important because impaired host high- and low-level immunosuppression. does not imply endorse- ment by AFP or the AAFP. defenses predispose patients to an increased High-level immunosuppression includes risk of vaccine-preventable infections. These patients who have a primary immunode- A collection of Practice Guidelines published in patients also have a greater risk of exposure ficiency; who are receiving chemotherapy; AFP is available at http:// to pathogens because of their frequent con- who have received a solid organ transplant www.aafp.org/afp/ tact with medical environments. Primary within the previous two months; who practguide. care physicians who provide care for immu- have HIV infection and a CD4 cell count nocompromised persons share responsi- less than 200 per mm3 (0.20 × 109 per L; bility with subspecialists for ensuring that for adults and older children) or less than appropriate vaccines are administered to 15% (for infants and young children); who these patients and for recommending appro- are receiving daily corticosteroid therapy priate vaccinations for other members of equivalent to 20 mg of prednisone or greater the household. Recommended vaccination for at least 14 days; or who are receiving schedules for immunocompetent children biologic immunomodulators. After hemato- and adults are published annually by the poietic stem cell transplant, the duration of Advisory Committee on Immunization high-level immunosuppression depends on Practices (ACIP) of the Centers for Disease the type of transplant (longer for allogenic Control and Prevention. However, these than for autologous); type of donor and stem schedules do not address vaccinations for cell source; and posttransplant complica- immunocompromised persons who are at tions, such as graft vs. host disease. greater risk of morbidity and mortality from vaccine-preventable infections. To address Planned Immunosuppression this gap, the Infectious Diseases Society When feasible, vaccines should be adminis- of America (IDSA) recently published tered before planned immunosuppression. evidence-based recommendations for vac- Live vaccines should be given at least four cinations in immunocompromised persons weeks in advance and should be avoided in and their household members. the two weeks before immunosuppression The guideline covers children and adults is started. Inactivated vaccines should be with primary (congenital) immunodefi- administered at least two weeks in advance. 664Downloaded American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2014 American AcademyVolume of Family 90, Physicians.Number 9For ◆ theNovember private, noncom 1, 2014- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Practice Guidelines Vaccination in Household Members Healthy immunocompetent persons who live with Immunocompetent persons who live in the same house- an immunocompromised patient should receive the hold as the immunocompromised patient can safely following live vaccines based on ACIP’s recommended receive inactivated vaccines according to the recom- schedule: combined measles, mumps, and rubella mended schedule from ACIP. If the immunocompro- (MMR); rotavirus for infants two to seven months of mised patient is six months or older, household members age; varicella; and zoster (Table 1). These persons can may receive the inactivated influenza vaccine, or the safely receive the yellow fever and oral typhoid vaccines live attenuated influenza vaccine if they are healthy, not for travel. Oral polio vaccine should not be adminis- pregnant, and two to 49 years of age. Exceptions include tered to persons who live with an immunocompromised those who live with an immunocompromised person who patient. received a hematopoietic stem cell transplant in the previ- Highly immunocompromised patients should avoid ous two months, who has graft vs. host disease, or who has handling diapers of infants who have received rotavirus severe combined immunodeficiency. Live vaccine should vaccine for four weeks after vaccination. Immunocom- not be administered to these persons or, if administered, promised patients should avoid contact with persons contact between the immunocompromised patient and who develop skin lesions after receiving varicella or household member should be avoided for seven days. zoster vaccines until the lesions resolve. Table 1. Safety of Administration of Live Vaccines to Contacts of Immunocompromised Persons Transmissibility from Recommendation for administering vaccines vaccinated immuno- (when indicated) to healthy immunocompetent Live vaccine Shedding of agent? (site) competent person? contacts of immunocompromised patients Influenza, live Yes (nasal secretions) Rare (from one vaccinated Administer; vaccinated persons should avoid attenuated, toddler) close contact for seven days with persons with nasal hematopoietic stem cell transplant or severe combined immunodeficiency Measles, Measles: no No, except mother-to- Administer mumps, and Mumps: no infant transmission of rubella Rubella: yes (nasopharynx, rubella vaccine virus via in low titer; breast milk) breast milk Polio, oral Yes (stool) Yes, with rare cases of Do not administer vaccine-associated paralytic poliomyelitis Rotavirus, oral Yes (stool) Yes, but no reported cases Administer of symptomatic infection in contacts Typhoid, oral No No Administer Varicella Yes (skin lesions) Rare, limited to vaccinees Administer; if skin lesions develop, vaccinated with skin lesions persons should avoid close contact with immunocompromised persons Yellow fever No, except possibly shed Yes (at least three cases Administer, except to women who are in breast milk of encephalitis in infants breastfeeding exposed to the vaccine via breastfeeding) Zoster Yes (rarely recovered from Not reported Administer to persons 60 years and older; if skin injection site vesicles) lesions develop, vaccinated persons should avoid close contact with immunocompromised persons Adapted with permission from Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompro- mised host. Clin Infect Dis. 2014;58(3):e63. November 1, 2014 ◆ Volume 90, Number 9 www.aafp.org/afp American Family Physician 665 Practice Guidelines Varicella and Zoster Vaccination Influenza Vaccination Varicella vaccine should not be administered to highly Annual administration of inactivated influenza vaccine immunocompromised patients. However, select patients is recommended for immunocompromised patients six (e.g., those with HIV infection who are not highly months and older, except those who are unlikely to immunocompromised, those with a primary immuno- respond (e.g., those receiving intensive chemotherapy, deficiency without defective T cell–mediated immunity) those who have received anti–B-cell antibodies within the should receive two doses of vaccine three months apart. previous six months). Live attenuated influenza vaccine Varicella vaccination can be considered in patients who should not be administered to immunocompromised do not have evidence of immunity (i.e., age-appropriate persons. varicella vaccination, serologic evidence of immunity, Guideline source: Infectious Diseases Society of America clinician-diagnosed or -verified history of varicella or zoster, or laboratory-proven varicella or zoster) and Evidence rating system used? Yes who are receiving long-term, low-dose immunosuppres- Literature search described? Yes sant drugs. When indicated, varicella vaccine should be Guideline developed by participants without relevant financial administered as a single-antigen product and not com- ties to industry? No bined with the MMR vaccine. Published source: Clinical Infectious Diseases, February 1, 2014 Zoster vaccine should be administered to patients 60 years and older who are receiving therapy to induce Available at: http://cid.oxfordjournals.org/content/58/3/e44.full low-level immunosuppression. The vaccine should not be CARRIE ARMSTRONG, AFP Senior Associate Editor ■ administered to highly immunocompromised patients. FP Essentials™ and FP Audio™ Featuring two distinct curriculums, monthly editions of FP Essentials and FP Audio allow you to earn CME when it works for you—on your schedule. Download the AAFP’s mobile app and access FP Essentials and FP Audio content from anywhere. FPE/FPA Annotate and make notes on your electronic copy of FP Essentials. Start and stop your in-app edition of FP Audio. Download your purchased subscriptions or individual editions. Subscribe to FP Essentials and FP Audio today. aafp.org/subscribe-today I (800) 274-2237 FPE FPA half Horiz.indd 1 9/15/14 11:03 AM 666 American Family Physician www.aafp.org/afp Volume 90, Number 9 ◆ November 1, 2014.
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