What vaccine recommendations are suitable for immunocompromised (having a weakened immune system) patients?

Vaccination in Immunocompromised Patients

Immunocompromised patients should receive all indicated inactivated vaccines but must avoid live vaccines, with the critical exceptions being MMR and varicella vaccines in HIV-infected patients with adequate CD4 counts (≥200 cells/mm³ in adults or ≥15% in children). 1

Core Principle: Inactivated vs Live Vaccines

All inactivated vaccines are safe in immunocompromised patients and should be administered according to standard schedules, though immune responses may be suboptimal. 1 The key distinction is straightforward:

• Inactivated vaccines: Safe for all immunocompromised patients 1
• Live vaccines: Generally contraindicated, with specific exceptions detailed below 1

Essential Inactivated Vaccines for All Immunocompromised Patients

Annual Influenza Vaccine

• Inactivated influenza vaccine (IIV) is mandatory annually for all immunocompromised patients ≥6 months of age 2
• Live attenuated influenza vaccine (LAIV) is absolutely contraindicated 3

Pneumococcal Vaccines

• Administer PCV13 first, followed by PPSV23 at least 8 weeks later 2
• Both vaccines are specifically recommended for immunocompromised patients including those with HIV, malignancy, transplants, and functional/anatomic asplenia 1

Other Routine Inactivated Vaccines

• Tdap/Td according to standard adult schedule 2
• Hepatitis B vaccine series if not previously vaccinated 2
• HPV vaccine series if not previously completed 2
• Meningococcal vaccines (MCV4) for those at risk 2
• Hepatitis A vaccine for those at risk 2
• Recombinant zoster vaccine (Shingrix) if ≥50 years old—this is NOT live and is safe 2

Live Vaccines: Absolute Contraindications

The following live vaccines must be avoided in immunocompromised patients: 1, 2

• Live attenuated influenza vaccine (LAIV)
• Oral poliovirus vaccine (OPV)
• Yellow fever vaccine (with rare exceptions below)
• Oral typhoid vaccine (Ty21a)
• BCG vaccine
• Live zoster vaccine (Zostavax)

Oral poliovirus vaccine should never be given to household contacts of immunocompromised patients due to risk of transmission 1

Critical Exceptions: When Live Vaccines May Be Given

HIV-Infected Patients with Adequate Immune Function

MMR vaccine should be administered to HIV-infected patients when: 1, 3

• Adults: CD4 count ≥200 cells/mm³
• Children aged 1-13 years: CD4 percentage ≥15%
• Patient is asymptomatic or minimally symptomatic

Varicella vaccine (VAR) can be given to HIV-infected patients when: 1, 3

• Adults ≥14 years: CD4 count ≥200 cells/mm³, clinically stable, varicella-nonimmune
• Children aged 1-13 years: CD4 percentage ≥15%
• Use 2-dose schedule separated by ≥3 months 1

Rotavirus vaccine is a unique exception: HIV-exposed or HIV-infected infants should receive rotavirus vaccine according to standard schedule regardless of CD4 count 3

Yellow Fever Vaccine: Rare Exception for Travel

Yellow fever vaccine can be considered only when travel to endemic areas cannot be avoided AND: 1, 3

• Asymptomatic HIV-infected adults with CD4 count ≥200 cells/mm³
• Asymptomatic HIV-infected children aged 9 months-5 years with CD4 percentage ≥15%

Partial DiGeorge Syndrome

MMR and varicella vaccines may be given if ALL of the following criteria are met: 3

• CD3 T-cell count ≥500 cells/mm³
• CD8 T-cell count ≥200 cells/mm³
• Normal mitogen response

Timing of Vaccination Relative to Immunosuppression

Before Starting Immunosuppressive Therapy

When immunosuppression is planned, vaccinate immunocompetent patients as follows: 1

• Live vaccines: Administer ≥4 weeks before starting immunosuppression 1
• Inactivated vaccines: Administer ≥2 weeks before starting immunosuppression 1
• Avoid all vaccines within 2 weeks of initiating immunosuppression 1

During Active Immunosuppression

Vaccination during chemotherapy or radiation therapy should be avoided because antibody response is poor 1

Patients vaccinated while on immunosuppressive therapy should be considered unimmunized and revaccinated ≥3 months after therapy discontinuation 1

Patients with leukemia in remission may receive live vaccines only after chemotherapy has been terminated for ≥3 months 1

Corticosteroid-Specific Guidelines

Live vaccines are contraindicated when patients receive: 1

• ≥2 mg/kg/day or ≥20 mg/day total of prednisone (or equivalent)
• Duration ≥2 weeks

Wait ≥3 months after discontinuation of high-dose systemic corticosteroids before administering live vaccines 1

Live vaccines are NOT contraindicated for: 1

• Short-term therapy (<2 weeks)
• Low-to-moderate doses
• Alternate-day treatment
• Topical, aerosol, intra-articular, bursal, or tendon injection routes

Special Populations

Severe Antibody Deficiencies (e.g., CVID, X-linked Agammaglobulinemia)

These patients should avoid all live vaccines 1, 4

Inactivated vaccines have limited benefit during immunoglobulin replacement therapy, with the exception of annual influenza vaccine which may provide some T-cell-mediated protection 4

Oral poliovirus vaccine is absolutely contraindicated due to documented risk of vaccine-associated paralytic poliomyelitis 4

Severe Combined Immunodeficiency (SCID)

All live vaccines are absolutely contraindicated 1, 3

Newborn screening with TREC assay alerts physicians to defer all live vaccines including rotavirus until SCID is ruled out 1

Hematopoietic Stem Cell Transplant Recipients

Patients lose preexisting immunity and require complete revaccination 5

Live vaccines should not be administered to HSCT recipients within 2 months post-transplant or those with active GVHD 1

Household Contact Vaccination

Household members of immunocompromised patients should receive: 1, 2

• All age-appropriate inactivated vaccines
• Annual influenza vaccine (IIV or LAIV) 1
• MMR, rotavirus (infants), varicella, and zoster vaccines 1

Exception: If the immunocompromised patient is an HSCT recipient within 2 months post-transplant, has GVHD, or has SCID, household members should receive IIV instead of LAIV 1

If LAIV is administered to a household member, consider avoiding contact with severely immunocompromised patients for 7 days 1

Common Pitfalls to Avoid

1. Do not assume all live vaccines are equally contraindicated—MMR and varicella can be given to HIV patients with adequate CD4 counts 1, 3

2. Do not give varicella vaccine as MMRV combination to HIV-infected patients—use single-antigen VAR product 1

3. Do not forget that immunoglobulin therapy interferes with MMR and varicella vaccine responses—consider timing vaccination 2 weeks before next IGIV dose 1

4. Do not withhold inactivated vaccines due to concerns about safety—they are safe even if response is suboptimal 1

5. Do not forget to vaccinate household contacts—this creates a "circle of protection" 2, 4

Vaccine Administration Considerations

For patients with thrombocytopenia, intramuscular injections are safe if: 1

• Platelet count ≥30,000-50,000 cells/mm³
• Use ≤23-gauge needle
• Apply constant pressure at injection site for 2 minutes

IPV and PPSV23 may be administered subcutaneously if intramuscular route is contraindicated 1