What vaccinations are recommended for adults with special conditions, such as chronic diseases or immunocompromising conditions?

Recommended Vaccinations for Adults with Special Conditions

Adults with chronic diseases or immunocompromising conditions require specific vaccination recommendations tailored to their underlying medical conditions to reduce morbidity and mortality from vaccine-preventable diseases.

Core Vaccinations for Adults with Special Conditions

Influenza Vaccination

• Medical indications: Recommended for all adults with chronic disorders of cardiovascular or pulmonary systems (including asthma), chronic metabolic diseases (diabetes), renal or hepatic dysfunction, hemoglobinopathies, and immunosuppression 1
• Administration: Annual vaccination with inactivated influenza vaccine (IIV) or recombinant influenza vaccine (RIV) preferred over live attenuated influenza vaccine (LAIV) for adults with chronic conditions 2, 1
• Special consideration: Influenza is a risk factor for secondary bacterial infections that can cause severe disease in persons with asplenia 2

Pneumococcal Vaccination

• Medical indications: Recommended for adults with:
  • Chronic pulmonary disease (excluding asthma)
  • Chronic cardiovascular diseases
  • Diabetes mellitus
  • Chronic liver diseases (including cirrhosis)
  • Chronic alcoholism
  • Chronic renal failure or nephrotic syndrome
  • Functional or anatomic asplenia (e.g., sickle cell disease, splenectomy)
  • Immunosuppressive conditions
  • Cochlear implants and cerebrospinal fluid leaks 2
• Administration:
  • For immunocompetent adults ≥65 years: 1 dose PCV13 followed by 1 dose PPSV23 at least 1 year later 2
  • For adults with immunocompromising conditions: 1 dose PCV13 followed by 1 dose PPSV23 at least 8 weeks later, then another dose PPSV23 at least 5 years after previous PPSV23 2
• Revaccination: One-time revaccination after 5 years for persons with chronic renal failure, nephrotic syndrome, functional or anatomic asplenia, or immunosuppressive conditions 2

Tdap/Td Vaccination

• Recommendation: Adults should receive a Tdap booster if not previously received as an adult, and a Td or Tdap booster every 10 years 1
• Special consideration: For pregnant women, 1 dose Tdap during each pregnancy, preferably during weeks 27-36 2

Hepatitis B Vaccination

• Medical indications: Recommended for adults with:
  • End-stage renal disease (including hemodialysis patients)
  • HIV infection
  • Chronic liver disease 2
• Administration: Standard 3-dose series; special formulation for hemodialysis patients (40 μg/mL Recombivax HB or 2 doses of 20 μg/mL Engerix-B administered simultaneously) 2

Hepatitis A Vaccination

• Medical indications: Recommended for persons with:
  • Chronic liver disease
  • Recipients of clotting factor concentrates 2
• Administration: 2-dose schedule at 0 and 6-12 months (Havrix) or 0 and 6-18 months (Vaqta) 2

Additional Vaccinations for Specific Conditions

For Adults with Asplenia

• Meningococcal vaccination: Adults with anatomic or functional asplenia should receive meningococcal conjugate vaccine (preferred for adults ≤55 years) or meningococcal polysaccharide vaccine 2
• Haemophilus influenzae type b (Hib): May be considered for adults with asplenia, although no specific efficacy data are available 2

For Adults with HIV

• Pneumococcal vaccination: Vaccinate as close to HIV diagnosis as possible 2
• Varicella vaccination: For HIV infection with CD4 count ≥200 cells/μL with no evidence of immunity, consider 2-dose series 2
• Live vaccines: Generally avoided in severe immunocompromising conditions 2

For Adults with Chronic Liver Disease

• Hepatitis A and B: Both vaccines recommended 2

For Adults with Immunocompromising Conditions

• Zoster vaccination: For adults ≥50 years, 2-dose series of recombinant zoster vaccine (RZV) 2-6 months apart 2, 1
• Live vaccines: Generally contraindicated (including varicella and live attenuated influenza vaccine) 2

Implementation Considerations

Vaccine Effectiveness

• Vaccine effectiveness may be reduced in immunocompromised individuals 3
• Newer vaccines with improved efficacy in older adults and immunocompromised populations should be preferred when available 4

Timing of Vaccination

• For elective splenectomy, pneumococcal vaccination should be administered at least 2 weeks before surgery 2
• Sequential administration of pneumococcal vaccines (PCV13 followed by PPSV23) is recommended for optimal protection in high-risk groups 5

Monitoring and Follow-up

• Document all administered vaccines, including vaccine type, date of administration, and lot number 1
• Assess vaccination status at every healthcare encounter to identify and address gaps in vaccination coverage 6

Common Pitfalls and Caveats

1. Underutilization: Adult vaccination coverage remains low for most routinely recommended vaccines and well below Healthy People 2020 targets 6, 7
2. Missed opportunities: Failure to assess vaccination status during healthcare encounters contributes to suboptimal vaccination rates 6
3. Contraindications misunderstanding: Inappropriate withholding of inactivated vaccines in immunocompromised patients when they are actually indicated 3
4. Timing errors: Administering live vaccines too close to each other or to immune globulin products can reduce effectiveness 2
5. Inadequate dosing: Using standard hepatitis B vaccine formulation instead of higher doses for hemodialysis patients 2

By following these evidence-based recommendations, healthcare providers can help reduce the burden of vaccine-preventable diseases in adults with special conditions, ultimately improving morbidity, mortality, and quality of life outcomes.