2013 IDSA clinical practice guideline for vaccination of the immunocompromised host

The Infectious Diseases Society of America (IDSA) released guidelines on vaccination recommendations for patients with immunocompromised conditions. While not the majority of patients for most primary care practitioners, most physicians will care for patients with HIV, cancer, chronic inflammatory diseases who are on immunosuppressive therapy, sickle cell disease, and other immunocompromised states, as well as the household contacts of such patients.

Since most immunocompromised patients see both primary care physicians and specialists, the guidelines stress the importance of dialogue between specialists and primary practitioners to ensure excellence of care. The IDSA guidelines give both general and disease-specific advice and are constructed to be easy to use to look up information for patients with specific immunocompromised states. In addition to the guidelines, the IDSA has issued a podcast summary of the guidelines that is easily available from the iTunes store by searching under the term "IDSA." General recommendations include:

©Kirby Hamilton/iStock

• Administer vaccines at least 2 weeks prior to planned immunosuppression: 4 weeks prior for live vaccines, and 2 weeks prior for inactive vaccines.

• For annual vaccination, use inactivated influenza vaccine (IIV) unless the patient is unlikely to respond as a result of the underling pathology.

• Avoid use of the oral polio vaccine by both the patient and household members of the patient.

• Avoid all travel-specific live attenuated vaccines. The exception is that yellow fever vaccination can be acceptable for the clinically stable immunosuppressed patient traveling to an endemic area.

Unless otherwise stated, defer to the Centers for Disease Control and Prevention’s (CDC’s) annual vaccination guidelines.

HIV represents the most common of the immunodeficient states seen by family physicians. Vaccination recommendations include:

• Give pneumococcal conjugate (PCV13) for all individuals 2 years of age or older, followed by pneumococcal polysaccharide (PPSV23) 8 weeks later and a repeat PPSV23 5 years after that.

• Limit Haemophilus influenzae b (Hib) to one dose for all children and adolescents with no previous history of Hib vaccination.

• Give the hepatitis B virus (HBV) high-dose series to all adolescents and adults, with antibody testing after completion. In patients whose antibody confirmation test is negative, the series should be readministered.

• Use the human papillomavirus (HPV4) vaccine rather than HPV2, given its superior protection against genital warts.

• Do not administer measles/mumps/rubella (MMR) vaccine to children whose CD4 T-cell percentage is less than 15%, and adolescent/adult patients with a CD4 count under 200 cells/mm³.

• Give the varicella vaccine to those children with CD4 T-cell percentage over 15%, and adolescent/adult patients with a CD4 count above 200 cells/mm³; the two doses should be at least 3 months apart.

• Do not use the combined measles/mumps/rubella/varicella (MMRV) vaccine, given its high-potency varicella component.

Cancer also presents an immunocompromised state, secondary to the disease process itself as well as to treatment. Recommendations include:

• Withhold influenza vaccination in those receiving anti–B-cell antibodies or intense chemotherapy.

• Give PCV13 vaccination in all newly diagnosed patients, followed by PPSV23 8 weeks later.

• Avoid all live vaccinations during any chemotherapy; inactivated vaccines are permissible during maintenance chemo but should otherwise be avoided during chemotherapy.

• Restart vaccinations 3 months after chemotherapy cessation, or 6 months after anti–B-cell therapy.

Chemotherapy does not represent the only form of iatrogenic immunosuppression, since standard-of-care treatment for various chronic inflammatory conditions often dictates the use of immunosuppressants. In such circumstances, the vaccination recommendations include:

• Use PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 and a booster PPSV23 5 years later.

• Give VAR prior to immunosuppression or while the patient is on low-dose chronic immunosuppression in those patients with no evidence of varicella immunity.

• Limit use of zoster (ZOS) vaccine to those patients who are 50 years of age or older prior to starting immunosuppression or on low-dose chronic immunosuppression.

• Other than varicella and ZOS, do not administer live vaccines.

Of the congenital immunodeficiencies, sickle cell disease probably stands out as the one most likely to present to the primary care practitioner. Essentially a form of asplenia, both sickle cell disease and asplenia carry the same vaccination recommendations:

• Give PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 with a booster PPSV23 5 years later.

• For planned splenectomy, administer PPSV23 2 weeks pre- or postsurgery.

• Give one dose of Hib to all unvaccinated individuals 5 years of age or older.

• Use meningococcal vaccine (MCV4) for all patients older than 2 months of age.

• Live attenuated influenza vaccine (LAIV) is contraindicated.

Household members of immunosuppressed patients should receive vaccination guidance as well:

• Give yearly vaccination against influenza, preferably inactivated.

• Do not use oral polio vaccine.

• Those newly vaccinated against rotavirus should not have their dirty diapers handled by the immunosuppressed for at least 4 weeks following vaccination.

• Following varicella or ZOS vaccination, those individuals who develop skin lesions should avoid contact with the immunosuppressed until the lesions have cleared.

• MMR, yellow fever, and typhoid vaccinations are safe to receive.

The bottom line: Immunosuppression presents a quandary to the primary care physician with regard to the proper vaccination of both the patient and the household contacts of the patient. The IDSA recommendations nicely summarize vaccinations for such patients. In general, most patients will require an annual influenza vaccination, and their primary care physician should remain up to date on subsequent CDC recommendations, with special attention to the need for live attenuated and pneumococcal vaccinations.

Reference

Rubin, L.G., Levin, M.J., Ljungman, P., Davies, E.G., Avery, R., Tomblyn, M., Bousvaros, A., and Dhanireddy, S. (2013). 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Infect. Dis. 2014;58(3):e44-e100.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Callahan is a second-year resident in the Family Practice Residency Program at Abington Memorial Hospital.

The Infectious Diseases Society of America (IDSA) released guidelines on vaccination recommendations for patients with immunocompromised conditions. While not the majority of patients for most primary care practitioners, most physicians will care for patients with HIV, cancer, chronic inflammatory diseases who are on immunosuppressive therapy, sickle cell disease, and other immunocompromised states, as well as the household contacts of such patients.

Since most immunocompromised patients see both primary care physicians and specialists, the guidelines stress the importance of dialogue between specialists and primary practitioners to ensure excellence of care. The IDSA guidelines give both general and disease-specific advice and are constructed to be easy to use to look up information for patients with specific immunocompromised states. In addition to the guidelines, the IDSA has issued a podcast summary of the guidelines that is easily available from the iTunes store by searching under the term "IDSA." General recommendations include:

©Kirby Hamilton/iStock

• Administer vaccines at least 2 weeks prior to planned immunosuppression: 4 weeks prior for live vaccines, and 2 weeks prior for inactive vaccines.

• For annual vaccination, use inactivated influenza vaccine (IIV) unless the patient is unlikely to respond as a result of the underling pathology.

• Avoid use of the oral polio vaccine by both the patient and household members of the patient.

• Avoid all travel-specific live attenuated vaccines. The exception is that yellow fever vaccination can be acceptable for the clinically stable immunosuppressed patient traveling to an endemic area.

Unless otherwise stated, defer to the Centers for Disease Control and Prevention’s (CDC’s) annual vaccination guidelines.

HIV represents the most common of the immunodeficient states seen by family physicians. Vaccination recommendations include:

• Give pneumococcal conjugate (PCV13) for all individuals 2 years of age or older, followed by pneumococcal polysaccharide (PPSV23) 8 weeks later and a repeat PPSV23 5 years after that.

• Limit Haemophilus influenzae b (Hib) to one dose for all children and adolescents with no previous history of Hib vaccination.

• Give the hepatitis B virus (HBV) high-dose series to all adolescents and adults, with antibody testing after completion. In patients whose antibody confirmation test is negative, the series should be readministered.

• Use the human papillomavirus (HPV4) vaccine rather than HPV2, given its superior protection against genital warts.

• Do not administer measles/mumps/rubella (MMR) vaccine to children whose CD4 T-cell percentage is less than 15%, and adolescent/adult patients with a CD4 count under 200 cells/mm³.

• Give the varicella vaccine to those children with CD4 T-cell percentage over 15%, and adolescent/adult patients with a CD4 count above 200 cells/mm³; the two doses should be at least 3 months apart.

• Do not use the combined measles/mumps/rubella/varicella (MMRV) vaccine, given its high-potency varicella component.

Cancer also presents an immunocompromised state, secondary to the disease process itself as well as to treatment. Recommendations include:

• Withhold influenza vaccination in those receiving anti–B-cell antibodies or intense chemotherapy.

• Give PCV13 vaccination in all newly diagnosed patients, followed by PPSV23 8 weeks later.

• Avoid all live vaccinations during any chemotherapy; inactivated vaccines are permissible during maintenance chemo but should otherwise be avoided during chemotherapy.

• Restart vaccinations 3 months after chemotherapy cessation, or 6 months after anti–B-cell therapy.

Chemotherapy does not represent the only form of iatrogenic immunosuppression, since standard-of-care treatment for various chronic inflammatory conditions often dictates the use of immunosuppressants. In such circumstances, the vaccination recommendations include:

• Use PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 and a booster PPSV23 5 years later.

• Give VAR prior to immunosuppression or while the patient is on low-dose chronic immunosuppression in those patients with no evidence of varicella immunity.

• Limit use of zoster (ZOS) vaccine to those patients who are 50 years of age or older prior to starting immunosuppression or on low-dose chronic immunosuppression.

• Other than varicella and ZOS, do not administer live vaccines.

Of the congenital immunodeficiencies, sickle cell disease probably stands out as the one most likely to present to the primary care practitioner. Essentially a form of asplenia, both sickle cell disease and asplenia carry the same vaccination recommendations:

• Give PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 with a booster PPSV23 5 years later.

• For planned splenectomy, administer PPSV23 2 weeks pre- or postsurgery.

• Give one dose of Hib to all unvaccinated individuals 5 years of age or older.

• Use meningococcal vaccine (MCV4) for all patients older than 2 months of age.

• Live attenuated influenza vaccine (LAIV) is contraindicated.

Household members of immunosuppressed patients should receive vaccination guidance as well:

• Give yearly vaccination against influenza, preferably inactivated.

• Do not use oral polio vaccine.

• Those newly vaccinated against rotavirus should not have their dirty diapers handled by the immunosuppressed for at least 4 weeks following vaccination.

• Following varicella or ZOS vaccination, those individuals who develop skin lesions should avoid contact with the immunosuppressed until the lesions have cleared.

• MMR, yellow fever, and typhoid vaccinations are safe to receive.

The bottom line: Immunosuppression presents a quandary to the primary care physician with regard to the proper vaccination of both the patient and the household contacts of the patient. The IDSA recommendations nicely summarize vaccinations for such patients. In general, most patients will require an annual influenza vaccination, and their primary care physician should remain up to date on subsequent CDC recommendations, with special attention to the need for live attenuated and pneumococcal vaccinations.

Reference

Rubin, L.G., Levin, M.J., Ljungman, P., Davies, E.G., Avery, R., Tomblyn, M., Bousvaros, A., and Dhanireddy, S. (2013). 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Infect. Dis. 2014;58(3):e44-e100.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Callahan is a second-year resident in the Family Practice Residency Program at Abington Memorial Hospital.

The Infectious Diseases Society of America (IDSA) released guidelines on vaccination recommendations for patients with immunocompromised conditions. While not the majority of patients for most primary care practitioners, most physicians will care for patients with HIV, cancer, chronic inflammatory diseases who are on immunosuppressive therapy, sickle cell disease, and other immunocompromised states, as well as the household contacts of such patients.

Since most immunocompromised patients see both primary care physicians and specialists, the guidelines stress the importance of dialogue between specialists and primary practitioners to ensure excellence of care. The IDSA guidelines give both general and disease-specific advice and are constructed to be easy to use to look up information for patients with specific immunocompromised states. In addition to the guidelines, the IDSA has issued a podcast summary of the guidelines that is easily available from the iTunes store by searching under the term "IDSA." General recommendations include:

©Kirby Hamilton/iStock

• Administer vaccines at least 2 weeks prior to planned immunosuppression: 4 weeks prior for live vaccines, and 2 weeks prior for inactive vaccines.

• For annual vaccination, use inactivated influenza vaccine (IIV) unless the patient is unlikely to respond as a result of the underling pathology.

• Avoid use of the oral polio vaccine by both the patient and household members of the patient.

• Avoid all travel-specific live attenuated vaccines. The exception is that yellow fever vaccination can be acceptable for the clinically stable immunosuppressed patient traveling to an endemic area.

Unless otherwise stated, defer to the Centers for Disease Control and Prevention’s (CDC’s) annual vaccination guidelines.

HIV represents the most common of the immunodeficient states seen by family physicians. Vaccination recommendations include:

• Give pneumococcal conjugate (PCV13) for all individuals 2 years of age or older, followed by pneumococcal polysaccharide (PPSV23) 8 weeks later and a repeat PPSV23 5 years after that.

• Limit Haemophilus influenzae b (Hib) to one dose for all children and adolescents with no previous history of Hib vaccination.

• Give the hepatitis B virus (HBV) high-dose series to all adolescents and adults, with antibody testing after completion. In patients whose antibody confirmation test is negative, the series should be readministered.

• Use the human papillomavirus (HPV4) vaccine rather than HPV2, given its superior protection against genital warts.

• Do not administer measles/mumps/rubella (MMR) vaccine to children whose CD4 T-cell percentage is less than 15%, and adolescent/adult patients with a CD4 count under 200 cells/mm³.

• Give the varicella vaccine to those children with CD4 T-cell percentage over 15%, and adolescent/adult patients with a CD4 count above 200 cells/mm³; the two doses should be at least 3 months apart.

• Do not use the combined measles/mumps/rubella/varicella (MMRV) vaccine, given its high-potency varicella component.

Cancer also presents an immunocompromised state, secondary to the disease process itself as well as to treatment. Recommendations include:

• Withhold influenza vaccination in those receiving anti–B-cell antibodies or intense chemotherapy.

• Give PCV13 vaccination in all newly diagnosed patients, followed by PPSV23 8 weeks later.

• Avoid all live vaccinations during any chemotherapy; inactivated vaccines are permissible during maintenance chemo but should otherwise be avoided during chemotherapy.

• Restart vaccinations 3 months after chemotherapy cessation, or 6 months after anti–B-cell therapy.

Chemotherapy does not represent the only form of iatrogenic immunosuppression, since standard-of-care treatment for various chronic inflammatory conditions often dictates the use of immunosuppressants. In such circumstances, the vaccination recommendations include:

• Use PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 and a booster PPSV23 5 years later.

• Give VAR prior to immunosuppression or while the patient is on low-dose chronic immunosuppression in those patients with no evidence of varicella immunity.

• Limit use of zoster (ZOS) vaccine to those patients who are 50 years of age or older prior to starting immunosuppression or on low-dose chronic immunosuppression.

• Other than varicella and ZOS, do not administer live vaccines.

Of the congenital immunodeficiencies, sickle cell disease probably stands out as the one most likely to present to the primary care practitioner. Essentially a form of asplenia, both sickle cell disease and asplenia carry the same vaccination recommendations:

• Give PCV13 per CDC guidelines, followed in 8 weeks by PPSV23 with a booster PPSV23 5 years later.

• For planned splenectomy, administer PPSV23 2 weeks pre- or postsurgery.

• Give one dose of Hib to all unvaccinated individuals 5 years of age or older.

• Use meningococcal vaccine (MCV4) for all patients older than 2 months of age.

• Live attenuated influenza vaccine (LAIV) is contraindicated.

Household members of immunosuppressed patients should receive vaccination guidance as well:

• Give yearly vaccination against influenza, preferably inactivated.

• Do not use oral polio vaccine.

• Those newly vaccinated against rotavirus should not have their dirty diapers handled by the immunosuppressed for at least 4 weeks following vaccination.

• Following varicella or ZOS vaccination, those individuals who develop skin lesions should avoid contact with the immunosuppressed until the lesions have cleared.

• MMR, yellow fever, and typhoid vaccinations are safe to receive.

The bottom line: Immunosuppression presents a quandary to the primary care physician with regard to the proper vaccination of both the patient and the household contacts of the patient. The IDSA recommendations nicely summarize vaccinations for such patients. In general, most patients will require an annual influenza vaccination, and their primary care physician should remain up to date on subsequent CDC recommendations, with special attention to the need for live attenuated and pneumococcal vaccinations.

Reference

Rubin, L.G., Levin, M.J., Ljungman, P., Davies, E.G., Avery, R., Tomblyn, M., Bousvaros, A., and Dhanireddy, S. (2013). 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin. Infect. Dis. 2014;58(3):e44-e100.

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Callahan is a second-year resident in the Family Practice Residency Program at Abington Memorial Hospital.