2.3 Groups with special vaccination requirements

Please note: due to continuous updates being made to the Immunisation Handbook, the page number on the electronic version will not always match the hard copy version.

The vaccination of individuals with impaired immune systems presents several problems. First, the immune response to vaccines may be inadequate and, second, there is a risk that some live vaccines may themselves cause progressive infection. Degrees of impaired immunity vary from insignificant to profound, and this should be taken into account when considering a vaccination schedule, as should the risk of acquiring the vaccine-preventable diseases.

Although it may seem logical to give higher or more frequent doses of vaccines to these patients, in many cases there are insufficient data to advocate such measures. Because of the uncertainty of the immune response in some patients with impaired immunity, it may be useful to measure post-vaccination antibody titres in groups such as children who have received haematopoietic stem cell transplants (see ‘2.3.3.3 Re-vaccination following haematopoietic stem cell transplantation (HSCT)’ below).

Administration of certain vaccines is a priority for some patients with medical conditions that increase the risk from infectious diseases, even in the absence of specific immune defects. These include: the use of influenza vaccine in individuals with severe asthma, chronic lung disease, congenital heart disease, diabetes and Down syndrome; pneumococcal conjugate vaccine in children with renal failure, persistent nephrotic syndrome and certain anatomical abnormalities; and pneumococcal polysaccharide vaccine in adults with certain chronic medical conditions. See the appropriate chapters for current recommendations.

Live viral and bacterial vaccines

Although most live vaccines are contraindicated in patients with significantly impaired immunity, the risk of progressive infection varies. The following is a list of current recommendations:

• Vaccines for smallpox (vaccinia virus) and tuberculosis (BCG) are always contraindicated.
• Live vaccines such as MMR and varicella and zoster vaccines must not be given to people with severely impaired immunity, but are safe to be given to the siblings or other household contacts of such people.
• MMR and varicella vaccines may be given to children with HIV infection with mildly impaired immunity (see ‘2.3.3.4 HIV-infected individuals below’). Zoster vaccine is not recommended for adults with AIDS or symptomatic HIV infection. However, adults with asymptomatic HIV infection may be considered for vaccination (see Chapter 3.26, Zoster).
• Travellers with impaired immunity should not receive oral typhoid vaccines. Use parenteral typhoid Vi polysaccharide vaccine instead.
• Yellow fever vaccine is contraindicated in travellers with impaired immunity going to endemic countries. If they must proceed with the travel, they should obtain a letter from a doctor, clearly stating the reason for withholding the vaccine. The letter should be formal, signed and dated, and on the practice’s letterhead.

Household contacts vaccinated with live vaccines who live with a person who has impaired immunity

Healthy siblings and household contacts of children with impaired immunity should be vaccinated with MMR, varicella and rotavirus vaccines (where indicated) to prevent them from infecting the children with impaired immunity. It is recommended that people ≥50 years of age, who are household contacts of a person with impaired immunity, should receive zoster vaccine (see Chapter 3.26, Zoster). Although there is no risk of transmission of the MMR vaccine viruses, and an almost negligible risk of transmission of VZV (varicella or zoster) vaccine virus, there is a small risk of transmission of the rotavirus vaccine viruses (see Chapter 3.18, Rotavirus and Chapter 3.24, Varicella and Chapter 3.26, Zoster). Annual influenza vaccination is recommended for contacts (including children ≥6 months of age) of people with impaired immunity.

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Influenza and pneumococcal vaccines

Morbidity and mortality from influenza and invasive pneumococcal disease are increased in all people with severely impaired immunity. Annual influenza vaccination should be given to all people ≥6 months of age with severely impaired immunity. Such individuals should also receive either the 7-valent pneumococcal conjugate vaccine (7vPCV), or 23-valent pneumococcal polysaccharide vaccine (23vPPV), depending on their age (see Chapter 3.15, Pneumococcal disease). Although the immune response to 23vPPV may be suboptimal in those who most need protection, the vaccine is nevertheless strongly recommended for these individuals.

While it may seem logical to give 7vPCV followed by 23vPPV to adults with impaired immunity, studies evaluating the effectiveness of such a regimen are not yet available.

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Impaired immunity associated with corticosteroid administration

In adults, daily doses of oral corticosteroids in excess of 60 mg of prednisolone (or equivalent) and, in children, doses in excess of either 2 mg/kg per day for more than a week or 1 mg/kg per day for more than 4 weeks, are associated with significantly impaired immunity. However, even lower doses may be associated with some impairment of the immune response.¹⁹

Children on daily doses of ≤2 mg/kg per day of systemic corticosteroids for less than 1 week, and those on lower doses of 1 mg/kg per day or alternate-day regimens for periods of up to 4 weeks, may be given live viral vaccines.

Children receiving >2 mg/kg per day or ≥20 mg per day in total of prednisolone (or equivalent) for >14 days can receive live viral vaccines after corticosteroid therapy has been discontinued for at least 1 month.

For adults treated with systemic corticosteroids in excess of 60 mg per day, live vaccines (such as MMR and varicella and zoster vaccines) should be postponed until at least 3 months after treatment has stopped.

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2.3.3.1 Oncology patients^16,20-24

Paediatric and adult patients undergoing cancer chemotherapy who have not completed a primary vaccination schedule before diagnosis

Live viral vaccines, including varicella and MMR, zoster and varicella vaccines, are contraindicated in cancer patients receiving immunosuppressive therapy and/or with poorly controlled malignant disease. These vaccines may be administered to seronegative children at least 3 months after completion of chemotherapy and/or high-dose steroid therapy, provided the underlying malignancy is in remission. Administration of live viral vaccines (MMR, varicella or MMRV [when available]) should be deferred if blood products or immunoglobulins have been recently administered (see Table 2.3.5 Recommended intervals between either immunoglobulins or blood products and MMR, MMRV or varicella vaccination).

Influenza vaccination is recommended annually in all cancer patients ≥6 months of age and should be started as close to the time of cancer diagnosis as possible.

During chemotherapy, and for 6 months afterwards, patients may receive inactivated vaccines (eg. DTPa if <8 years old, Hib if <5 years old, hepatitis B, IPV) according to the routine vaccination schedule, but it should be remembered that patients are unlikely to mount a full immune response while they are on therapy. Antibody responses to hepatitis B should be checked 4 weeks after completing the third dose and, where antibody titres are <10 IU/mL, HBsAg carriage should be investigated. If HBsAg negative, then patients should be given a fourth double dose of vaccine or a further 3 doses of vaccine at monthly intervals (see Chapter 3.6, Hepatitis B).

Vaccines should not be administered during times of severe neutropenia (absolute neutrophil count <0.5 x 109/L), to avoid precipitating an acute febrile episode.

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Pneumococcal vaccination is recommended in oncology patients with an increased risk of invasive pneumococcal disease (IPD), especially patients with underlying haematological malignancies (multiple myeloma, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma, chronic lymphocytic leukaemia). In patients ≥10 years of age, 23vPPV should ideally be given as early as possible after diagnosis and before chemotherapy and/or radiotherapy is initiated.^25,26 When this is not practicable, vaccination should be given after completion of chemotherapy.27 For children <10 years of age with haematological malignancies, primary and catch-up pneumococcal vaccination should be administered as detailed in Table 1.3.11 Recommendations for pneumococcal catch-up vaccination for children ≤5 years of age with underlying medical conditions (see footnote accompanying this Table).

Any deviations from these guidelines should be discussed with an oncologist.

• Paediatric and adult patients with cancer who have completed cancer therapy and have received a primary course of vaccination before diagnosis

The following schedule of booster vaccination is recommended if the patient is well and infection-free 6 months after chemotherapy, and if the underlying disease is in remission:

• DTPa if <8 years of age (use dT or adult/adolescent formulation dTpa if ≥8 years of age),
• MMR, IPV, hepatitis B, 7vPCV and Hib (if <5 years of age or with previous splenectomy/hyposplenism).

These vaccines may be given without checking antibody titres beforehand, and may be given together on 1 day. Measles and rubella antibody status should be checked 6 to 8 weeks after vaccination. Patients who have not seroconverted should receive a further dose.

Children who are seronegative to varicella-zoster virus, especially those with acute lymphoblastic leukaemia, should receive a 2-dose schedule of varicella vaccine, at least 3 months after chemotherapy has been ceased.²⁸ Administration of live vaccines (MMR, varicella or MMRV [when available]) should be deferred if blood products or immunoglobulins have been recently administered (see Table 2.3.5 Recommended intervals between either immunoglobulins or blood products and MMR, MMRV or varicella vaccination).

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2.3.3.2 Solid organ transplant recipients²³

For solid organ transplant (SOT) recipients, depending on the transplanted organ, and to prevent rejection, differing doses of immunosuppressive agents are needed, which may influence the effectiveness of vaccines. Where possible, children undergoing solid organ transplantation should be vaccinated well before transplantation, and inactivated vaccines can be used 6 to 12 months after transplantation. Live vaccines are contraindicated in most post-transplantation protocols due to concerns of disseminated infection, although data in this population are limited. Recommended vaccinations for child and adult SOT recipients are given in Table 2.3.2.

Table 2.3.2: Recommendations for vaccinations for solid organ transplant (SOT) recipients

	Vaccines recommended before transplantation		Vaccines recommended after transplantation if not given beforehand		Comments
Vaccine	Child	Adult	Child	Adult
Hib vaccine	Yes		Yes		If possible complete vaccination at least 6 weeks before transplantation. 23
Hepatitis A vaccine	Yes	Yes, if seronegative	Yes	Yes, if seronegative	Recommended for all seronegative SOT recipients.
Hepatitis B vaccine	Yes	Yes, depending on serological status	Yes	Yes, depending on serological status	Recommended for all seronegative SOT recipients. Accelerated schedules can be used (see Table 3.6.2 Accelerated hepatitis B vaccination schedules ).
Influenza vaccine	Annual vaccination starting before transplantation for people ≥6 months of age.
7-valent pneumococcal conjugate vaccine (7vPCV)	Yes, if <10 years of age		Yes, if <10 years of age		The primary schedule should be completed before transplantation. For children <10 years of age, 7vPCV should be administered as detailed in Table 1.3.11 Recommendations for pneumococcal catch-up vaccination for children ≤5 years of age with underlying medical conditions (see footnote accompanying this Table).
23-valent pneumococcal polysaccharide vaccine (23vPPV)	Yes [If <10 years of age see Table 1.3.11.]	Yes	Yes [If <10 years of age see Table 1.3.11.]	Yes	See Table 3.15.3 Revaccination with 23vPPV for people ≥10 years of age.
Inactivated poliovirus vaccine (IPV)	Yes	Yes, if no booster in past 10 years	Yes	Yes, if no booster in past 10 years	The primary schedule should be completed before transplantation.
Diphtheria-tetanus- pertussis vaccine (DTPa for children <8 years of age; dTpa for people ≥8 years of age)	Yes	Yes, provided dTpa has not been given previously	Yes	Yes, provided dTpa has not been given previously	The primary schedule should be completed before transplantation.
Meningococcal C conjugate vaccine (MenCCV)	Yes, if ≥1 year of age	Yes	Yes, if ≥1 year of age	Yes
Meningococcal polysaccharide vaccine (4vMenPV)	Yes, if >2 years of age	Yes	Yes, if >2 years of age	Yes	Give 4vMenPV at an interval of at least 2 weeks after MenCCV.
MMR vaccine	Yes	Yes, unless 2 previous documented doses	Contraindicated		The primary schedule should be completed before transplantation provided the recipient is no longer on immunosuppressive therapy.
Varicella vaccine	Yes	Yes	Contraindicated		Vaccination should be completed before transplantation provided the recipient is no longer on immunosuppressive therapy.

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2.3.3.3 Re-vaccination following haematopoietic stem cell transplantation (HSCT)^29-33

Haematopoietic stem cells are sourced from peripheral blood, bone marrow or umbilical cord. Protective immunity to vaccine-preventable diseases is partially or completely lost following either allogeneic or autologous stem cell transplantation. Impaired immunity following allogeneic transplantation is caused by a combination of the preparative chemotherapy given before transplantation, graft-versus-host disease (GVHD), and immunosuppressive therapy following transplantation. Persisting impaired immunity is common, particularly in patients with chronic GVHD. Immunity is also impaired in autologous stem cell transplant recipients due to high-dose chemotherapy and radiotherapy, but GVHD is not a concern as donor and recipient are the same. In most cases, autologous transplant recipients will recover their immunity more quickly than allogeneic transplant recipients.

Separate transplant schedules for autologous and allogeneic transplant recipients have not been supported in published guidelines because of limited data. For practical purposes, a similar schedule is therefore recommended, regardless of donor source (peripheral blood, bone marrow or umbilical cord), preparative chemotherapy (ablative or reduced intensity), or transplant type (allogeneic or autologous).^32,34

HSCT recipients with ongoing GVHD or remaining on immunosuppressive therapy should not be given live vaccines. Chronic GVHD (cGVHD) is associated with functional hyposplenism and patients are therefore susceptible to infections with encapsulated organisms, especially Streptococcus pneumoniae. For patients with cGVHD who remain on active immunosuppression, antibiotic prophylaxis is recommended.³⁵

The immune response to vaccinations is usually poor during the first 6 months after HSCT. Donor immunisation with hepatitis B, tetanus, Hib and pneumococcal conjugate vaccines before stem cell harvesting has been shown to elicit improved early antibody responses in HSCT recipients vaccinated in the post-transplantation period.^36-39 However, practical and ethical considerations currently limit the use of donor immunisation.

Routine serological testing for several infectious agents increases costs, and antibody levels conferring protective immunity are poorly defined. For those vaccines that are recommended for all HSCT recipients (tetanus, diphtheria, polio, influenza, pneumococcal, Hib), pre-vaccination testing is not recommended as the response to a primary course of these vaccines is generally adequate. The serological response to pneumococcal polysaccharide vaccine is less predictable. Pneumococcal serology is only available in a few specialised laboratories and is not routinely recommended. Immunity testing before and after vaccination for hepatitis B, measles, rubella and varicella is recommended, as antibody levels will determine the need for revaccination.³⁴

A recommended schedule of vaccination is outlined in Table 2.3.3.^31,32,34

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Table 2.3.3: Post-transplantation vaccination schedules for allogeneic and autologous haematopoietic stem cell transplant recipients^32,34

Vaccine	Months after HSCT			Comments
	12	14	24
Diphtheria-tetanus-pertussis (DTPa for children <8 years of age; dTpa for people ≥8 years of age)	Yes	Yes	Yes	For recipients ≥8 years of age, give first dose as dTpa followed by 2 doses dT. If dT unavailable, dTpa may be used for all 3 doses.
Hib	Yes	Yes	Yes
Hepatitis A	Not routinely recommended, see Chapter 3.5, Hepatitis A.
Hepatitis B	Yes	Yes	Yes	High dose (H-B-VAX II dialysis formulation) vaccine is recommended.
Influenza	Annual vaccination for life, starting 6 months post HSCT, for people ≥6 months of age.
MMR	No	No	Yes	Vaccination of measles or rubella seronegative HSCT recipients at 24 months post HSCT is recommended, provided that immunosuppressive therapy has been discontinued, there is no chronic GVHD, and cell-mediated immunity has been reconstituted.
MenCCV	Yes, ≥1 year of age			People ≥1 year of age should receive 1 dose of MenCCV.
4vMenPV	Yes, ≥2 years of age (see comment)			People ≥1 year of age should receive 1 dose of MenCCV (as above). This should be followed by a dose of 4vMenPV when ≥2 years of age or, if already aged >2 years, give after an interval of at least 2 weeks following the MenCCV.
7vPCV	Although there are limited data on the effectiveness of 7vPCV in HSCT recipients, vaccination is recommended for children ≤9 years of age starting 6 months post HSCT (see Table 3.15.1 Summary table – pneumococcal vaccination schedule for children ≤9 years of age ).
23vPPV	Yes			See Table 3.15.3 Revaccination with 23vPPV for people ≥10 years of age. Adjunctive antibiotic prophylaxis is recommended for patients with chronic GVHD.
IPV	Yes	Yes	Yes
Varicella vaccine	No	No	Yes	Vaccination of seronegative HSCT recipients at 24 months post HSCT is recommended, provided that immunosuppressive therapy has been discontinued, there is no chronic GVHD, and cell-mediated immunity has been reconstituted.

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2.3.3.4 HIV-infected individuals

Vaccination schedules for HIV-infected patients should be determined by the patient’s age, degree of impaired immunity (CD4 count) and the risk of infection. Children with perinatally acquired HIV differ substantially from adults as immunisation and first exposure to vaccine antigens occurs after HIV infection, whereas for adults, most vaccines are inducing a secondary immune response.⁴⁰ HIV-infected individuals of any age who are well controlled on combination antiretroviral therapy (undetected or low viral load with good preservation of CD4 lymphocyte count) are likely to respond well to vaccines.
HIV-infected patients should be vaccinated as follows:

• Diphtheria-tetanus-pertussis (DTPa/dTpa), Hib and IPV vaccines – use the standard schedule.⁴¹
• MMR vaccine should be routinely administered to HIV-infected children at 12 months of age unless they have severely impaired immunity. Table 2.3.4 shows age-specific definitions of moderately and severely impaired immunity. Measles may cause severe disease in HIV-infected children and children with severely impaired immunity who are exposed to measles should, therefore, be given normal immunoglobulin (in a dose of 0.5 mL/kg), regardless of their vaccination status.⁴⁰
• While varicella vaccine is contraindicated in adults with HIV, its use may be considered for asymptomatic or mildly affected children ≥12 months and <13 years of age.⁴² The Advisory Committee on Immunization Practices (ACIP) recommends use of the vaccine, given in 2 doses, 3 months apart, in children with age-specific CD4 T-lymphocyte percentages greater than 25%.⁴³
• Zoster vaccine is not recommended for adults with AIDS or symptomatic HIV infection. However, people with asymptomatic HIV infection may be considered for vaccination. Serologic confirmation of previous VZV infection must be obtained prior to vaccination. Zoster vaccine is only registered for use in adults ≥50 years (see Chapter 3.26, Zoster).

Table 2.3.4: Immunological categories based on age-specific CD4 counts and percentage of total lymphocytes⁴⁴

Category	<12 months		1–5 years		³ 6 years
	CD4 per m L	%	CD4 per m L	%	CD4 per m L	%
No evidence of impaired immunity	³ 1500	³ 25	³ 1000	³ 25	³ 500	³ 25
Moderately impaired immunity	750–1499	15–24	500–999	15–24	200–499	15–24
Severely impaired immunity	<750	<15	<500	<15	<200	<15

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• Pneumococcal disease, both respiratory and invasive, is a frequent cause of morbidity in HIV-infected children and adults. Infants and children <10 years of age should be vaccinated with the 7vPCV (see Table 3.15.1 Summary table – pneumococcal vaccination schedule for children ≤9 years of age) and older children and adults should be vaccinated with the 23vPPV (see also Chapter 3.15, Pneumococcal disease).^45,46
• Influenza vaccine is recommended even in symptomatic HIV-infected adults and children.^47-49 Viral loads may increase after vaccination, but CD4 counts are unaffected and the benefits exceed the risk.^50-53
• Hepatitis B vaccine is safe to use, but the immunological response may be poor. HIV-positive adults should receive 3 doses of the H-B-VAX II dialysis formulation and HIV-positive children should receive 3 doses of Engerix-B adult formulation. Antibody level should be measured at the completion of the vaccination schedule. Because many HIV-positive men who have sex with men may already have been exposed to the hepatitis B and hepatitis A viruses, their susceptibility should be determined in order to avoid unnecessary vaccination.
• Susceptible HIV-infected individuals should be vaccinated against hepatitis A.⁵⁴
• BCG must not be given to HIV-infected children or adults because of the risk of disseminated BCG infection.
• Yellow fever and oral live attenuated typhoid vaccines should not be given to HIV-infected individuals. Vi polysaccharide typhoid, Japanese encephalitis and rabies vaccines are safe and can be used for the usual indications (see Chapter 2.2, Vaccination for international travel).

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2.3.3.5 Individuals with functional or anatomical asplenia^55,56

Individuals with an absent or dysfunctional spleen are at an increased risk of fulminant bacteraemia, most notably pneumococcal, for the rest of their lives.⁵⁷

Pneumococcal vaccination

All individuals with functional or anatomical asplenia should be vaccinated against invasive pneumococcal disease. In elective splenectomy, the vaccination should be completed, if possible, 2 weeks before the operation; in unplanned splenectomy, the vaccination should commence when the patient has recovered from the surgery.⁵⁸

Children ≤5 years of age with functional or anatomical asplenia should be given the age-appropriate course of pneumococcal vaccines for medical-risk children (see Table 3.15.1 Summary table – pneumococcal vaccination schedule for children ≤9 years of age and Section 1.3.5, Catch-up).

Children who develop functional or anatomical asplenia between 6 and ≤9 years of age should be given 2 doses of 7vPCV 2 months apart, followed by a dose of 23vPPV 2 months later.

Individuals ≥10 years of age with functional or anatomical asplenia should be given:

• an initial dose of 23vPPV,
• revaccination with 23vPPV 5 years after the initial dose (of 23vPPV), and
• 1 further revaccination (third dose) should be given at either 5 years after the first revaccination or at 50 years (Indigenous adults) or 65 years (non-Indigenous adults) of age, whichever is later.

It should be noted that the above regimens cannot provide prolonged protection against all invasive pneumococcal disease. It is particularly important that individuals with functional or anatomical asplenia are informed of the altered immune status associated with asplenia and the increased life-long risk of severe bacterial infection, that they should seek urgent medical assessment for any febrile illness, and that they should always wear a medical alert bracelet or necklace.

NB. Children ≤5 years of age with splenic dysfunction, most frequently due to sickle cell disease, should also be treated with daily doses of penicillin V, commencing before the age of 4 months and continuing until 5 years of age (penicillin V 125 mg twice daily, increasing to 250 mg twice daily when they reach 4 years of age).

Meningococcal vaccination

All individuals ≥1 year of age with functional or anatomical asplenia should be vaccinated with a single dose of MenCCV, although the vaccine can be given from 6 weeks of age (see also Chapter 3.12, Meningococcal disease). This should be followed by a dose of the 4vMenPV at ≥2 years of age (see also Chapter 3.12, Meningococcal disease). If MenCCV is given, a period of at least 2 weeks should elapse before 4vMenPV is administered. A single revaccination with 4vMenPV is recommended 3 to 5 years later.

Hib vaccination

Children should be up-to-date with Hib vaccination. A single dose of Hib vaccine is recommended for splenectomised adults.

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2.3.3.6 Individuals with autoimmune diseases

Adults with conditions such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and multiple sclerosis (MS) should be given influenza and pneumococcal polysaccharide vaccines, due to potential morbidity and mortality from infection, despite the potential for reduced immunogenicity in some patients (described below).^59-61

For conditions such as SLE and RA, theoretical concerns that vaccines may exacerbate or cause these diseases have not been substantiated, despite a number of sporadic case reports. There is potential for reduced immunogenicity of vaccines, due to both immunosuppressive therapies and the underlying disease.⁶² Small controlled studies suggest that approximately one-third of patients with SLE or RA receiving immunosuppressive therapies may mount a lower antibody response to influenza and pneumococcal vaccines compared with healthy controls.^60,62 A small proportion of patients may mount very little or no response to the pneumococcal vaccine.⁶⁰ Importantly, clinical and laboratory measures of disease activity, and the choice, duration and dose of immunosuppressive therapies, do not predict who these poor responders will be.^60,62,63 In a study involving 149 patients with RA taking immunosuppressive agents, including tumour necrosis factor (TNF) blockers, and 47 healthy controls, patients on TNF blockers showed similar responses to pneumococcal vaccination to controls.⁶³ Patients treated with methotrexate (as monotherapy or with TNF blockers) had a reduced antibody response to vaccination.⁶³

There is clear evidence that multiple sclerosis is not exacerbated by influenza vaccination, and either insufficient or no evidence that other vaccines increase this risk.⁶⁴

References

16. Pirofski LA, Casadevall A. Use of licensed vaccines for active immunization of the immunocompromised host. Clinical Microbiology Reviews 1998;11:1-26.

19. Centres for Disease Control and Prevention (CDC). General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). [erratum appears in MMWR Morb Mortal Wkly Rep. 2006 Dec 8;55(48):1303].MMWR - Morbidity & Mortality Weekly Report 2006;55(RR-15):1-48.

20. Burroughs M, Moscona A. Immunization of pediatric solid organ transplant candidates and recipients. Clinical Infectious Diseases 2000;30:857-69.

21. Duca P, Del Pont JM, D'Agostino D. Successful immune response to a recombinant hepatitis B vaccine in children after liver transplantation. Journal of Pediatric Gastroenterology & Nutrition 2001;32:168-70.

22. Morales-Castillo ME, Alvarez-Muñoz MT, Solórzano-Santos F, et al. Live varicella vaccine in both immunocompromised and healthy children. Archives of Medical Research 2000;31:85-7.

23. Stark K, Günther M, Schönfeld C, Tullius SG, Bienzle U. Immunisations in solid-organ transplant recipients. Lancet 2002;359:957-65.

24. Casswall TH, Fischler B. Vaccination of the immunocompromised child. Expert Review of Vaccines 2005;4:725-38.

25. Siber GR, Weitzman SA, Aisenberg AC, Weinstein HJ, Schiffman G. Impaired antibody response to pneumococcal vaccine after treatment for Hodgkin's disease. New England Journal of Medicine 1978;299:442-8.

26. Addiego JE, Jr., Ammann AJ, Schiffman G, et al. Response to pneumococcal polysaccharide vaccine in patients with untreated Hodgkin's disease. Children's Cancer Study Group Report. Lancet 1980;2:450-3.

28. Sartori AM. A review of the varicella vaccine in immunocompromised individuals. International Journal of Infectious Diseases 2004;8:259-70.

29. Avigan D, Pirofski LA, Lazarus HM. Vaccination against infectious disease following hematopoietic stem cell transplantation. Biology of Blood & Marrow Transplantation 2001;7:171-83.

30. Singhal S, Mehta J. Reimmunization after blood or marrow stem cell transplantation. Bone Marrow Transplantation 1999;23:637-46.

31. Ljungman P, Cordonnier C, de Bock R, et al. Immunisations after bone marrow transplantation: results of a European survey and recommendations from the infectious diseases working party of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplantation 1995;15:455-60.

32. Centers for Disease Control and Prevention (CDC). Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients: recommendations of CDC, the Infectious Disease Society of America, and the American Society of Blood and Marrow Transplantation. [erratum appears in MMWR Recomm Rep. 2004 May 14;53(19):396]. MMWR - Morbidity & Mortality Weekly Report 2000;49(RR-10):1-125.

33. Vance E, George S, Guinan EC, et al. Comparison of multiple immunization schedules for Haemophilus influenzae type b-conjugate and tetanus toxoid vaccines following bone marrow transplantation. Bone Marrow Transplantation 1998;22:735-41.

34. Ljungman P, Engelhard D, de la Cámara R, et al. Vaccination of stem cell transplant recipients: recommendations of the Infectious Diseases Working Party of the EBMT. Bone Marrow Transplantation 2005;35:737-46.

35. Antibiotic Expert Group. Therapeutic guidelines. Antibiotic. Version 13. Melbourne: Therapeutic Guidelines Limited, 2006.

36. Storek J, Dawson MA, Lim LC, et al. Efficacy of donor vaccination before hematopoietic cell transplantation and recipient vaccination both before and early after transplantation. Bone Marrow Transplantation 2004;33:337-46.

37. Molrine DC, Guinan EC, Antin JH, et al. Donor immunization with Haemophilus influenzae type b (HIB)-conjugate vaccine in allogeneic bone marrow transplantation. Blood 1996;87:3012-8.

38. Molrine DC, Antin JH, Guinan EC, et al. Donor immunization with pneumococcal conjugate vaccine and early protective antibody responses following allogeneic hematopoietic cell transplantation. Blood 2003;101:831-6.

39. Ilan Y, Nagler A, Adler R, et al. Adoptive transfer of immunity to hepatitis B virus after T cell-depleted allogeneic bone marrow transplantation. Hepatology 1993;18:246-52.

40. American Academy of Pediatrics, Committee on Infectious Diseases and Committee on Pediatric AIDS. Measles immunization in HIV-infected children. Pediatrics 1999;103:1057-60.

41. Tovo PA, de Martino M, Gabiano C, Galli L. Pertussis immunization in HIV-1-infected infants: a model to assess the effects of repeated T cell-dependent antigen administrations on HIV-1 progression. Italian Register for HIV infection in children. Vaccine 2000;18:1203-9.

42. Levin MJ, Gershon AA, Weinberg A, et al. Immunization of HIV-infected children with varicella vaccine. Journal of Pediatrics 2001;139:305-10.

43. Centers for Disease Control and Prevention (CDC). Prevention of varicella. Update recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR - Morbidity & Mortality Weekly Report 1999;48(RR-6):1-5.

44. Wilfert CM, Gross PA, Kaplan JE, et al. Quality standard for the enumeration of CD4+ lymphocytes in infants and children exposed to or infected with human immunodeficiency virus. Clinical Infectious Diseases 1995;21(Suppl 1):S134-5.

45. Kroon FP, van Dissel JT, Ravensbergen E, Nibbering PH, van Furth R. Enhanced antibody response to pneumococcal polysaccharide vaccine after prior immunization with conjugate pneumococcal vaccine in HIV-infected adults. Vaccine 2000;19:886-94.

46. Tasker SA, Wallace MR, Rubins JB, et al. Reimmunization with 23-valent pneumococcal vaccine for patients infected with human immunodeficiency virus type 1: clinical, immunologic, and virologic responses. Clinical Infectious Diseases 2002;34:813-21.

47. Tasker SA, Treanor JJ, Paxton WB, Wallace MR. Efficacy of influenza vaccination in HIV-infected persons. A randomized, double-blind, placebo-controlled trial. Annals of Internal Medicine 1999;131:430-3.

48. Pinto LA, Blazevic V, Anderson SA, et al. Influenza virus-stimulated generation of anti-human immunodeficiency virus (HIV) activity after influenza vaccination in HIV-infected individuals and healthy control subjects. Journal of Infectious Diseases 2001;183:1000-8.

49. Fine AD, Buxton Bridges C, De Guzman AM, et al. Influenza A among patients with human immunodeficiency virus: an outbreak of infection at a residential facility in New York City. Clinical Infectious Diseases 2001;32:1784-91.

50. Sullivan PS, Hanson DL, Dworkin MS, et al. Effect of influenza vaccination on disease progression among HIV-infected persons. AIDS 2000;14:2781-5.

51. Keller M, Deveikis A, Cutillar-Garcia M, et al. Pneumococcal and influenza immunization and human immunodeficiency virus load in children. Pediatric Infectious Disease Journal 2000;19:613-8.

52. Fuller JD, Craven DE, Steger KA, et al. Influenza vaccination of human immunodeficiency virus (HIV)-infected adults: impact on plasma levels of HIV type 1 RNA and determinants of antibody response. Clinical Infectious Diseases 1999;28:541-7.

53. Macías J, Pineda JA, Leal M, et al. HIV-1 plasma viremia not increased in patients receiving highly active antiretroviral therapy after influenza vaccination. European Journal of Clinical Microbiology & Infectious Diseases 2001;20:46-8.

54. Weinberg A, Gona P, Nachman SA, et al. Antibody responses to hepatitis A virus vaccine in HIV-infected children with evidence of immunologic reconstitution while receiving highly active antiretroviral therapy. Journal of Infectious Diseases 2006;193:302-11.

55. Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force. Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. BMJ 1996;312:430-4.

56. Centers for Disease Control and Prevention (CDC). Preventing pneumococcal disease among infants and young children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR - Morbidity & Mortality Weekly Report 2000;49(RR-9):1-35.

57. Holdsworth RJ, Irving AD, Cuschieri A. Postsplenectomy sepsis and its mortality rate: actual versus perceived risks. British Journal of Surgery 1991;78:1031-8.

58. Shatz DV, Schinsky MF, Pais LB, et al. Immune responses of splenectomized trauma patients to the 23-valent pneumococcal polysaccharide vaccine at 1 versus 7 versus 14 days after splenectomy. Journal of Trauma-Injury Infection & Critical Care 1998;44:760-5.

59. Battafarano DF, Battafarano NJ, Larsen L, et al. Antigen-specific antibody responses in lupus patients following immunization. Arthritis & Rheumatism 1998;41:1828-34.

60. Elkayam O, Paran D, Caspi D, et al. Immunogenicity and safety of pneumococcal vaccination in patients with rheumatoid arthritis or systemic lupus erythematosus. Clinical Infectious Diseases 2002;34:147-53.

61. Moriabadi NF, Niewiesk S, Kruse N, et al. Influenza vaccination in MS: absence of T-cell response against white matter proteins. Neurology 2001;56:938-43.

62. Fomin I, Caspi D, Levy V, et al. Vaccination against influenza in rheumatoid arthritis: the effect of disease modifying drugs, including TNFα blockers. Annals of the Rheumatic Diseases 2006;65:191-4.

63. Kapetanovic MC, Saxne T, Sjöholm A, et al. Influence of methotrexate, TNF blockers and prednisolone on antibody responses to pneumococcal polysaccharide vaccine in patients with rheumatoid arthritis. Rheumatology 2006;45:106-11.

64. Rutschmann OT, McCrory DC, Matchar DB, Immunization Panel of the Multiple Sclerosis Council for Clinical Practice Guidelines. Immunization and MS: a summary of published evidence and recommendations. Neurology 2002;59:1837-43.

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