From the Guidelines
Live attenuated vaccines should not be given to household members of severely immunocompromised individuals, such as those with hematopoietic stem cell transplants or severe combined immune deficiency, due to the risk of viral shedding and potential transmission. According to the most recent and highest quality study, 1, household members of immunocompromised patients should receive inactivated influenza vaccine (IIV) instead of live attenuated influenza vaccine (LAIV) to minimize the risk of transmission.
The rationale for this recommendation is based on the theoretical risk that a live, attenuated vaccine virus could be transmitted to the severely immunocompromised person and cause disease, as stated in 2 and 3.
Some key points to consider:
- Household members of immunocompromised patients can safely receive inactivated vaccines, such as IIV, based on the CDC annual schedule, as recommended in 1.
- Live vaccines, such as LAIV, MMR, and varicella vaccine, can be administered to healthy immunocompetent individuals who live in a household with immunocompromised patients, but with certain precautions, as outlined in 4 and 5.
- OPV should not be administered to individuals who live in a household with immunocompromised patients, as stated in 5.
- Immunocompromised patients should avoid close contact with persons who develop skin lesions after receipt of VAR or ZOS until the lesions clear, as recommended in 5.
Overall, the priority is to minimize the risk of transmission of live, attenuated vaccine viruses to severely immunocompromised individuals, while also ensuring that household members receive necessary vaccinations to protect themselves and others from vaccine-preventable diseases.
From the Research
Live Attenuated Vaccines and Household Members
- Live attenuated vaccines can occasionally transmit the vaccine strain to others, which is a concern for household members of immunocompromised patients 6.
- However, a review of the medical literature revealed no major risk of transmission associated with any live attenuated vaccine, and the available data support routine vaccination with live attenuated vaccines for all household contacts of immunocompromised patients and for healthcare workers caring for such patients 6.
- The benefit of providing herd immunity against potentially devastating pathogens outweighs the risk, if any, of secondary transmission 6.
Specific Live Attenuated Vaccines
- The live attenuated intranasal influenza vaccine and the smallpox vaccine have a theoretical risk of transmission 6.
- The live attenuated influenza vaccine (LAIV) is approved for healthy 2- to 49-year-old individuals, but its replicative nature and higher rate of adverse events exclude at-risk populations, such as immunocompromised patients and children under 2 years old 7.
- Studies have shown that LAIV can be modified to improve its safety profile and expand its applications to high-risk populations, such as children under 2 years old and immunocompromised patients 7.
Comparison with Inactivated Vaccines
- Inactivated influenza vaccines (IIV) are licensed from 6 months of age and have a good safety profile, but they may not provide the same level of mucosal immunity as LAIV 8.
- Comparative studies of LAIV and IIV have shown inconsistent results, and further studies are needed to determine the most effective and safe vaccination strategy against influenza 9.
- LAIV and IIV can be used in combination to provide optimal protection against influenza, with LAIV priming inducing greater inhibition of virus recovery on LAIV challenge than IIV priming 10.