Immunocompromised patient vaccination

Recombinant DNA vaccines offer alternatives as subunit vaccines and organisms can be engineered to produce antigens or even epitopes. A hepatitis vaccine has been engineered using yeast as the host cell. Adverse reactions are rare to subunit vaccines, making them safer for use in immunocompromised patients. 

Originally, the Committee on Infectious Diseases of the American Academy of Pediatrics and the Advisory Committee on Immunization Practices (ACIP) recommended that severely immunocompromised patients with HIV infection should not receive measles vaccine (139). However, in 1988, recognizing the severity of measles in immunodeficient individuals, it revised its measles immunization guidelines and recommended that... 

Adult immunizations are important to document as well and include vaccines such as pneumococcusl (for elderly and those at risk for pneumonia), influenza, hepatitis B, and tetanus. Although not an immunization, skin testing for tuberculosis might also be included under this section in high-risk patients (elderly, health care worker, or immunocompromised patient). 

A numher of other groups, including immunocompromised patients (e.g., leukemia, lymphoma, and multiple myeloma), dialysis patients, and acquired immunodeficiency syndrome (AIDS) patients, have reduced antibody production with the vaccine. Asymptomatic HIV-infected patients respond sufficiently to the vaccine. Patients with Hodgkin s disease respond to the vaccine better before splenectomy, chemotherapy, or radiation therapy. 

The varicella vaccine has an excellent safety record. Pain, local swelling, and erythema at the injection site occur in up to 32% of patients and fever in 10% to 15%. A varicella-like rash occurs in approximately 4% of vaccinees, accompanied by few, if any, systemic symptoms. The rash may be localized at the injection site or generalized. Lesions are usually few in number (2 to 10) and often papular rather than vesicular. Transmission of vaccine virus to susceptible close contacts has occurred, but it is very rare and is believed to occur only when the vaccinee develops a rash. Because the risk of vaccine virus transmission is very low and primary infection can be very severe, vaccination of household contacts of immunocompromised patients is recommended to prevent introduction of varicella into the household. " ... 

Infection risk In three infants, two with failure to thrive, who had dehydration and diarrhea within 1 month after their first or second rotavirus immunization and were subsequently found to have severe combined immunodeficiency, rotavirus was detected by means of reverse-transcriptase polymerase chain reaction in stool specimens the virus was confirmed by gene-sequence analysis as vaccine rotavirus [25 ]. These infections raise concerns regarding the safety of rotavirus vaccine in severely immunocompromised patients. 

Concerns have been raised about the use of adjuvanted pandemic vaccines in patients with immune disorders, such as immunodeficiency, autoimmune disorders, and solid organ transplants. To date, postmarketing surveillance has not found evidence for causality of any adverse reactions in such patients. Viral infections, such as influenza, can lead to severe complications in immunocompromised patients. 

Persons who have conditions associated with decreased immunological function that increase the risk for severe pneumococcal disease or its complications should be vaccinated. Although the vaccine is not as effective for immunocompromised patients as it is for immunocompetent persons, the potential benefits and safety of the vaccine justify its use. 

The vaccine should be considered in patients older than 5 years with sickle cell disease, asplenia, or immunocompromising diseases. 

Drug interactions Vaccination with a live vaccine in a patient immunocompromised by a chemotherapeutic agent has resulted in severe and fatal infections. 

Revaccination is sometimes necessary because only 50-70% of immunocompromised persons, especially dialysis patients, develop antibodies, and the anti-HBs titers in these cases are low. In revaccinated non-responders to primary hepatitis immunization using either 20 pg of plasma-derived vaccine or 10 pg of recombinant vaccine, depending on the vaccine used for previous doses, the revaccinations were well tolerated (81,82). Only 6.6% of the vaccinees reported slight irritation at the injection site, tenderness, minimal pain, or swelling lasting for a few hours up to 2 days. 

Using RNA-templated sequencing, vaccine-strain measles virus has been implicated as the cause of death in three immunocompromised children with inclusion body encephalitis (6). The authors referred to a case of measles vaccine virus-associated giant cell pneumonia in a patient with advanced HIV infection. 

Because of the risk of dissemination, in an outbreak situation, all hospital employees and patients should receive vaccination. Immunocompromised... 

Vaccination includes a series of doses and usually is begun in children at 2 months of age. In addition to pediatric immunization, the vaccine also should be considered in patients older than 5 years of age with the following underlying conditions sickle cell disease, asplenia, and immunocompromising diseases. Refer to the Chap. 122 for further information on dosing and administration. 

The patient population targeted for therapeutic vaccination can be immunocompromised (e.g., cancer patients and elderly patients), hence various immunostimulation techniques need to be investigated in an effort to bolster the immune system and to overcome immune tolerance to self-antigens. Various strategies to stimulate antigen presentation are under investigation, including the use of novel adjuvants. The stimulation of the immune response needs to be carefully tempered to avoid overactivation of cytotoxic T cells that could be more destructive than intended. 

However, the safety of vaccination of people with a compromised immune system (by nature of the underlying disease itself, or due to immunosuppressant agents) is an area lacking robust evidence, and decisions on what vaccines to give and when to give them are difficult for clinicians. Concerns, from both doctors and patients, regarding safety of vaccines in the immunocompromised are frequent barriers to vaccination. 

Live vaccines always trigger concern when given to immunocompromised individuals. Previously the zoster and varicella vaccines have not been recommended in transplant recipients. A study looked at the use of the varicella vaccine in paediatric liver transplant patients. Thirty-six children were vaccinated and followed up with diary cards and phone calls. Importantly, no breakthrough zoster disease was seen. The vaccine was also sufficiently seroprotective, with 97% of study participants maintaining their seroprotective titres at the long-term follow-up (median 4.1years) [78 ]. 

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