Vaccination immunosuppressed patients

General contraindications to vaccine administration include a history of anaphylactic reaction to a previous dose or an unexplained encephalopathy occurring within 7 days of a dose of pertussis vaccine. Immunosuppression and pregnancy are temporary contraindications to live vaccines. Whenever possible, transplant patients should be immunized before transplantation. Live vaccines generally are not given after transplantation. 

The vaccine should not be given to immunosuppressed patients (except those infected with HIV) or pregnant women. HIV-infected persons who have never had measles or have never been vaccinated should be given measles-containing vaccine unless there is evidence of severe immunosuppression. The vaccine should not be given within 1 month of any other live vaccine unless the vaccine is given on the same day (as with the MMR vaccine). Measles vaccine is indicated in all persons born after 1956 or in those who lack documentation of wild virus infection either by history or antibody titers. 

Chickenpox Chickenpox is a highly contagious viral infection that causes rash-like blisters on the skin surface and mucous membranes. It is generally mild and not normally life-threatening. For adults, the symptoms are more serious and uncomfortable than for children. The disease can also be deadly for some people, such as pregnant women, people with leukemia, or immunosuppressed patients. Varivax (varicella virus vaccine live) from Merck Co. was tested on about 11,000 children and adults and was approved by the FDA in March 1995 as a chickenpox vaccine. 

AZATHIOPRINE VACCINES i effectiveness of vaccines, t risk of adverse/toxic effects of live vaccines (e.g. measles, mumps, rubella, oral polio, BCG, yellow fever, varicella, TY21a typhoid), e.g. vaccinal infections Disseminated infection due to enhanced replication of vaccine virus in the presence of diminished immunocompetence Do not vaccinate when patients are on immunosuppressants. Vaccination should be deferred for at least 3 months after discontinuing immunosuppressants/myelosuppres-sants. If an individual has been recently vaccinated, do not initiate therapy for at least 2 weeks after vaccination... 

IL-12 may also be potentially useful for adoptive immunotherapy, especially in immunosuppressed patients (caused by cancer or HIV infection) with decreased NK function and T-cell cytotoxicity. Under appropriate conditions, IL-12 has therapeutic efficacy for promoting defense against a variety of pathogens and for use as a vaccine adjuvant to enhance beneficial Thl over detrimental Th2 lymphocyte responses and provides new tools for the development of treatment and adjuvant strategies to potentiate beneficial or inhibit detrimental endogenous immune responses. ... 

If primary immunization is given to an immunosuppressed patient, an additional dose of diphtheria toxoid should be administered 1 month following the return to normal immune status. Diphtheria toxoid may be administered to persons with mild febrile illnesses and with other live or killed vaccines. ... 

Dengler TJ, Strnad N, Buhring I, et al. Differential immune response to influenza and pneumococcal vaccination in immunosuppressed patients after heart transplantation. Transplantation 1998 66 1340-1347. 

Stiehm ER, Ablin A, Kushner JH, Zoger S. Measles vaccination in patients on immunosuppressive drugs. Am JDis Child ( 966) 111, 191-4. 

In organ transplant recipients taking immunosuppressants, tetanus vaccines and inactivated polio vaccines produced protective antibody titres. The response to diphtheria vaccine was lower than in healthy controls and the antibody titre had fallen below the protective level by 12 months in 38% of patients in one study, and 24% in another. Note that live polio vaccines are not recommended in immunosuppressed patients (see Live vaccines, below). 

The antibody response to hepatitis A vaccine in patients taking immunosuppressants after organ transplantation is variable, " and declines quicker than in healthy controls. In renal transplant recipients, there is some evidence that the response is inversely related to the number of immunosuppressant drugs. ... 

The use of live vaccines in patients receiving corticosteroids has caused generalised infection, see Corticosteroids -i- Vaccines Live , p.l061. Similarly, the use of live vaccines in patients taking other immunosuppressants is not recommended probably as a consequence of this there are few published reports about the use of live vaccines with immunosuppressants. One study found that measles vaccine was effective in 7 of 18 children under 3 years old after liver transplantation, and that there were no complications directly attributable to the vaccine. ... 

Good responses to pneumococcal vaccines in patients taking immunosuppressant drugs after organ transplantation have been seen, but protee-tive antibody titres may not persist as long as in healthy subjeets. ... 

There appears to be little published experience of the use of live vaccines in patients receiving immunosuppressants (apart from corticosteroids . 

Absolute hypersensitivity to the drug or any other component of the product. Active or suspected ocular or periocular infection (herpes simplex keratitis, vaccinia, varicella, mycobacterial disease or fungal infection), systemic fungal infections, advanced glaucoma or concurrent administration of live vaccines in patients receiving immunosuppressive doses. 

Solid organ transplant recipients have a blunted immune response to vaccines because the immunosuppressive regimens used to prevent organ rejection inhibit both T- and B-cell proliferation. Many of these patients will also have secondary hypogammaglobulinemia post-transplantation. Prior to transplant, children should complete primary immunization schedules if possible accelerated schedules may be used. Adults should have all vaccinations updated prior to transplantation.16... 

Patients with chronic conditions that cause limited immune deficiency (e.g., renal disease, diabetes, liver disease, and asplenia) and who are not receiving immunosuppressants may receive live attenuated and killed vaccines, and toxoids. 

The vaccine is contraindicated in immunosuppressed or pregnant patients. Children with asymptomatic or mildly symptomatic HIV should receive two doses of varicella vaccine 3 months apart. 

Systemic fungal infections hypersensitivity to the drug IM use in ITP administration of live virus vaccines (eg, smallpox) in patients receiving immunosuppressive corticosteroid doses (see Warnings). 

Immunosuppression During therapy, do not use live virus vaccines (eg, smallpox). Do not immunize patients who are receiving corticosteroids, especially high doses, because of possible hazards of neurological complications and a lack of antibody response. This does not apply to patients receiving corticosteroids as replacement therapy. 

Drag interactions Live virus and live bacteria vaccines should not be administered to a patient receiving an immunosuppressive chemotherapeutic agent. At least three months should elapse between the discontinuation of chemotherapy and vaccination with a live vaccine. 

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