Paeds · allergy-and-immunology
Vaccination of immunocompromised children
Also known as Immunisation of the immunocompromised host · Live vaccines in immunosuppression · Vaccination in primary immunodeficiency · Post-transplant vaccination · Vaccination on biologics and chemotherapy
A fellowship approach to vaccinating the immunocompromised child: classify the immune defect first, sort every vaccine into live-attenuated (the danger) versus inactivated (generally safe but may be poorly immunogenic), time each dose to the intensity of immunosuppression, and monitor serology rather than assuming protection — so that a live vaccine is never given before a combined T-cell defect has been excluded.
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- Any live-attenuated vaccine (MMR, varicella, rotavirus, BCG, oral polio, live yellow fever, intranasal influenza) given before a combined T-cell defect is excluded — risk of disseminated vaccine-strain disease
- Disseminated BCG or vaccine-strain rotavirus enteritis in an infant — investigate for severe combined immunodeficiency before any further vaccine
- Vaccine-strain varicella in a child on chemotherapy or high-dose corticosteroids — the live vaccine was given during profound immunosuppression
- Live vaccine administered to a child receiving high-dose corticosteroids (>=2 mg/kg/day, or >=20 mg/day if >10 kg, for >=14 days) without a four-week washout
- Missed inactivated vaccines during or after chemotherapy, transplant, or rituximab — the child loses community and household protection while presumed immune
- Household contacts of a SCID patient receiving oral polio or live rotavirus vaccine — shed live virus exposes the child
- Assuming serological immunity after vaccination without checking titres in a child on anti-CD20 therapy or post-haematopoietic stem cell transplant
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- Immunisation in special-risk groups
- Live vaccine contraindications
- Post-chemotherapy catch-up vaccination
- Vaccination of the immunocompromised host
- Primary immunodeficiency and live-vaccine risk
- Post-transplant immunisation schedules
- Vaccinating the immunocompromised child
- Counselling on live-vaccine contraindication
- Catch-up scheduling after HSCT
- Vaccination planning in a child on biologics
- Household cocooning for the immunocompromised child
- Immunisation in the immunocompromised child
- Communication in chronic complex care
- Safety and quality in medication and vaccine practice
- Post-transplant immunisation
- Vaccination on immunosuppression
- Counselling a family on vaccine safety
- Catch-up scheduling in complex care
- Immunization of immunocompromised children
- Contraindications to live vaccines
- Post-HSCT immunization
- Vaccination of immunocompromised children
- Live vaccine safety
- Care coordination with immunology and oncology
- Immunization of the immunocompromised child
- Live-vaccine contraindications
- Catch-up immunization post-transplant
Once the defect is classified, the plan writes itself. Inactivated vaccines are safe and should not be withheld — the real task is optimising timing, giving extra or higher-antigen doses, and checking serology rather than assuming protection. Live vaccines — MMR, varicella, rotavirus, BCG, oral polio, live yellow fever, intranasal influenza — are the danger, contraindicated in combined and T-cell defects, during high-dose chemotherapy, on substantial corticosteroids, and in the early months after transplant. The fellowship mark goes to the candidate who coordinates with immunology, oncology, and the transplant service, vaccinates the household to cocoon the child, and rebuilds the schedule on evidence of immune reconstitution rather than on a calendar date. [1] [2]
Leukaemia / active chemotherapy or radiation · Immunodeficiency not yet excluded (especially combined / T-cell) · Very high-dose steroids (>=2 mg/kg/day, or >=20 mg/day if >10 kg, for >=14 days) · Early after transplant (before immune reconstitution). If any one applies, the live vaccine waits; an inactivated alternative or a timed catch-up is given instead. [1] [2]
Overview & Definition
Vaccination of the immunocompromised child is the deliberate matching of every scheduled and catch-up vaccine to the child's immune capacity, so that protection is maximised and harm is avoided. The immunocompromised host cannot be treated as a normal recipient: some vaccines will not work as well, and a small number — the live-attenuated vaccines — can cause the very disease they are meant to prevent. The discipline of this topic is to decide, vaccine by vaccine, what is safe, what is useful, when to give it, and how to confirm it worked. [1]
The population is broad. It includes children with primary immunodeficiencies (severe combined immunodeficiency, combined immunodeficiency, chronic granulomatous disease, antibody deficiencies on immunoglobulin replacement), children on iatrogenic immunosuppression (cytotoxic chemotherapy, high-dose corticosteroids, calcineurin and mTOR inhibitors, anti-CD20 monoclonal antibodies such as rituximab, and tumour-necrosis-factor blockers), children before and after solid organ transplant, children before and after haematopoietic stem cell transplant (HSCT), children with HIV in whom risk is stage-dependent, and children with functional or anatomical asplenia. The principles apply to all of them, but the detail is defect-specific. [1] [3] [8]
References10ShowHide
- [1]Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis, 2014.PMID 24421306
- [2]National Center for Immunization and Respiratory Diseases. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep, 2011.PMID 21293327
- [3]Danziger-Isakov L, Kumar D Vaccination in solid organ transplantation. Clin Transplant, 2019.PMID 31002409
- [4]Jansen MHA, Rondaan C, Legger GE, et al. EULAR/PRES recommendations for vaccination of paediatric patients with autoimmune inflammatory rheumatic diseases: 2021 update. Ann Rheum Dis, 2023.PMID 35725297
- [5]Gennery AR. Severe combined immunodeficiency: newborn screening and the BCG vaccination. Arch Dis Child, 2022.PMID 35973752
- [6]Mazzucchelli JT, Bonfim C, Castro GG, et al. Severe combined immunodeficiency in Brazil: management, prognosis, and BCG-associated complications. J Investig Allergol Clin Immunol, 2014.PMID 25011356
- [7]Bakare N, Menschik D, Tiernan R, Hua W, Martin D. Severe combined immunodeficiency (SCID) and rotavirus vaccination: reports to the Vaccine Adverse Events Reporting System (VAERS). Vaccine, 2010.PMID 20674876
- [8]Hudspeth MP, Hill TN, Lewis JA, et al. Post-hematopoietic stem cell transplant immunization practices in the Pediatric Blood and Marrow Transplant Consortium. Pediatr Blood Cancer, 2010.PMID 20135703
- [9]Bosaeed M, Kumar D. Seasonal influenza vaccine in immunocompromised persons. Hum Vaccin Immunother, 2018.PMID 29485353
- [10]Lee GM Preventing infections in children and adults with asplenia. Hematology Am Soc Hematol Educ Program, 2020.PMID 33275684