INFLUENZA

The influenza vaccine is administered annually in the fall or winter (influenza season in the United States). Two available formulations of the influenza vaccine exist—an inactivated influenza preparation administered intramuscularly (IM) and a live attenuated virus vaccine (LAIV) administered via a nasal spray. The vaccine usually contains two influenza A viruses (H3N2 and H1N1) and one B virus. A quadrivalent vaccine containing one influenza A (H3N2), one influenza A (H1N1), and two influenza B viruses (one from each lineage of circulating B viruses) is currently available in addition to the trivalent vaccine. The LAIV is available as a quadrivalent vaccine only. Seasonal influenza epidemics occur as a result of antigenic drift, prompting the need for annual reassessment of circulating strains and formulation of the vaccine. Antigenic shifts occur less frequently; however, they can result in novel influenza A subtypes and pandemics because of lack of preexisting immunity. Although the vaccine does not provide complete protection against all influenza strains, both the LAIV and the inactivated vaccine are efficacious in preventing influenza corresponding to the strains they contain.

    The inactivated influenza vaccine is recommended for persons 6 months of age and older, including pregnant women, and is specifically recommended for persons with chronic medical problems (e.g., diabetes, renal dysfunction, cardiac disease, hemoglobinopathy). Patients with compromised respiratory function or increased risk of aspiration (e.g., seizure disorder, spinal cord injury, cognitive impairment) should also receive the vaccine. Additionally, persons living in chronic care facilities or who work or live with high-risk people should be vaccinated, including all healthcare personnel. Vaccination of close contacts of vulnerable individuals is an effective infection-control measure, as it provides a ring of protection. The vaccine may also be considered for any adult interested in decreasing his or her risk of becoming ill with influenza or spreading it to others. A new intradermal vaccine (Fluzone intradermal) was recently approved for use in adults aged 18–64 years. A high-dose trivalent (Fluzone High-dose) containing 180 μg total of influenza virus hemagglutinin antigen (standard vaccine contains 45 μg total of influenza virus hemagglutinin antigen) elicited significantly higher hemagglutination inhibition (HI) titers against all three influenza virus strains compared to standard dose influenza vaccine in adults aged 65 years and older and is now approved for use in this age group, which historically had lower response rate to standard-dose influenza vaccine.

    Contraindications to receiving LAIV are similar to those of other live attenuated vaccines. The following groups should not receive the LAIV: persons younger than 5 or older than 50 years of age, persons with chronic medical illnesses or with known or suspected immunosuppressed states, pregnant women, and healthcare personnel who care for severely immunocompromised persons. The inactivated form of the vaccine is preferred over LAIV for vaccinating household members and others who have close contact with immunosuppressed persons because of a theoretical risk of person-to-person transmission of live virus.

    Administration of either vaccine is contraindicated in a person with a history of previous anaphylaxis to this vaccine or any of its components, or to eggs. Vaccination may also be deferred during moderate or severe acute illness and in any patient with a history of Guillain-Barré syndrome occurring within 6 weeks of prior influenza vaccination. As above, the live attenuated influenza vaccine is contraindicated in unvaccinated persons receiving antiviral chemoprophylaxis. In an influenza outbreak setting, these unvaccinated persons should be offered the trivalent inactivated influenza vaccine.

PNEUMOCOCCUS

Streptococcus pneumoniae is an encapsulated gram-positive bacterium that remains a leading cause of pneumonia, otitis media, bacterial meningitis, and bacteremia. It is also an important cause of other invasive bacterial infections including acute sinusitis, brain abscess, osteomyelitis, septic arthritis, peritonitis, endocarditis, and pericarditis. The pneumococcal polysaccharide vaccine (PPSV) contains 23 serotypes of pneumococcal capsular polysaccharide corresponding to 85–90% of all pneumococcal disease. This vaccine is specifically recommended for all persons aged 65 years or older and persons older than 2 years at high risk of complication from pneumococcal infection; namely, persons with chronic cardiac or pulmonary disease, chronic liver disease, diabetes, alcoholism, or cerebrospinal fluid leak. Certain populations are also at higher risk for invasive pneumococcal infection, including Alaska Natives and Navajo. A conjugated polysaccharide vaccine (Prevnar) containing 13 serotypes of pneumococcal capsular polysaccharide (PCV13) is currently available for administration to infants, young children, and patients considered to be at the highest risk for poor outcome associated with pneumococcal infection. This group of patients includes those with anatomic or functional asplenia or sickle cell disease; CSF leaks; immunocompromised patients including persons with HIV infection, leukemia, lymphoma, multiple myeloma, other malignancy, chronic renal failure, or nephritic syndrome; persons receiving immunosuppressive therapy or who have received or are candidates for an organ or bone marrow transplant; and candidates for or recipients of cochlear implants. ACIP recommends that adults aged ≥19 years in this high-risk group who are pneumococcal-vaccine naïve should receive a dose of PCV13 first, followed by a dose of PPSV23 at least 8 weeks later. A second PPSV23 dose is recommended 5 years after the first PPSV23 dose in this group. Adults aged ≥19 years in the high-risk group who previously have received ≥1 doses of PPSV23 should be given a PCV13 dose ≥1 year after the last PPSV23 dose was received. For those who require additional doses of PPSV23, the first such dose should be given no sooner than 8 weeks after PCV13 and at least 5 years after the most recent dose of PPSV23.

    A onetime booster of PPSV23 is administered at least 5 years after the initial dose in patients who are older than 65 and received the first dose of PPSV23 prior to age 65, and to those at highest risk of fatal pneumococcal infection. No further doses are needed for persons vaccinated with PPSV23 at or after age 65.

MENINGOCOCCUS

Neisseria meningitidis is a leading cause of bacterial meningitis in the United States, in large part due to the successful vaccination campaigns and protection against Streptococcus pneumoniae and Haemophilus influenzae type b (administered in childhood). N. meningitidis is spread through direct contact with respiratory secretions from either infected patients or asymptomatic carriers, and disease is associated with a high fatality and morbidity rate. In the United States most cases are sporadic, although localized outbreaks have occurred. Postexposure antibiotic prophylaxis for close contacts, ideally within 24 hours after identification of the index patient, is effective in reducing nasopharyngeal carriage of N. meningitidis. Acceptable and recommended antimicrobial agents include rifampin, ciprofloxacin, and ceftriaxone; azithromycin also has activity against N. meningitidis and is approved for use among children. Meningococcal vaccination is also an important control measure in outbreak settings.

    The meningococcal vaccine is currently available in two formulations in the United States—a polysaccharide vaccine (MPSV4 or Menomune) and a polysaccharide conjugate vaccine (MCV4 or MenactraT)—and both contain purified meningococcal polysaccharides of groups A, C, Y, and W-135. Neither vaccine provides protection against all serogroups of N. meningitidis, most notably serogroup B, which is responsible for over 50% of cases among infants in the United States; however, 75% of cases of meningococcal disease among persons aged ≥11 years were caused by serogroups C, Y, or W-135.

    N. meningitidis is an encapsulated organism, and meningococcal vaccination is recommended for all adults with anatomic or functional asplenia or terminal complement component deficiencies. Vaccination is also recommended for college freshmen living in a dormitory, microbiologists who are routinely exposed to isolates of N. meningitidis, military recruits, and travelers to endemic areas such as the “meningitis belt” of sub-Saharan Africa. The government of Saudi Arabia also requires vaccination for all travelers to Mecca during the annual Hajj. The polysaccharide conjugate vaccine (MCV4) is the preferred vaccine among persons aged 11–55, although if unavailable MPSV4 is an acceptable alternative. The unconjugated vaccine, MPSV4, is recommended for persons aged >56 years. Both vaccines are usually administered as a single dose. However, for adults with functional asplenia, persistent complement component deficiencies, or HIV infection, 2 doses of MCV4 at least 2 months apart are indicated.

    Revaccination with MCV4 after 5 years is recommended for adults who previously received MCV4 or MPSV4 and who remain at increased risk for infection (functional asplenia or complement component deficiencies).

HAEMOPHILUS INFLUENZAE B

Haemophilus influenzae type b (Hib) can cause severe bacterial infections primarily in infants and children under 5 years of age, and vaccination against this infectious agent is routinely administered to infants. Owing to a paucity of data, there are currently no formal recommendations for vaccination of adults; however, this polysaccharide-protein conjugate vaccine may be considered in persons who have chronic conditions associated with an increased risk for Hib disease including patients with sickle cell disease, asplenia or hyposplenia, HIV/AIDS, or other immunosuppressed states.

TETANUS–DIPHTHERIA–PERTUSSIS

Tetanus, although not a communicable disease, is preventable with vaccination. Adult disease is generally contracted via wound contamination with toxin-producing Clostridium tetani. Diphtheria is an acute infectious respiratory illness primarily caused by strains of Corynebacterium diphtheriae and is characterized by a grayish adherent membrane in the pharynx, palate or nasal mucosa, larynx, or trachea and can lead to airway obstruction. Diphtheria toxin can also cause systemic complications, most notably cardiac and neurologic. Immunization strategies in the United States have made both tetanus and respiratory diphtheria a rare occurrence; however, exposure to diphtheria is possible during travel to endemic areas. Due to waning immunity, adult booster immunizations with Td (adult tetanus and diphtheria toxoids) are recommended every 10 years.

    Pertussis, an acute respiratory infection caused by Bordetella pertussis, remains endemic in the United States in large part due to waning immunity 5–10 years after childhood vaccination. Compared with older age groups, infants less than 12 months old are at the greatest risk for pertussis-related complications and hospitalizations, and adult close contacts have been implicated in pertussis transmission. Whereas adults are more likely to have asymptomatic infection, pertussis can cause pneumonia. In addition, prolonged paroxysmal cough is common and can lead to multiple physician visits and extensive medical evaluation when the etiology is unrecognized. Clinical complications of paroxysmal cough include rib fracture, cough syncope, and urinary incontinence, as well as aspiration, pneumothorax, inguinal hernia, lumbar disc herniation, and subconjunctival hemorrhages.

    In 2005, Tdap, consisting of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (marketed as Adacel and Boostrix), was licensed in the United States. To promote herd immunity, routine Tdap vaccination is recommended as a single replacement dose of a Td booster for all adults who have not previously received Tdap or for whom vaccine status is unknown. In addition, Tdap is specifically recommended for pregnant women during each pregnancy (preferably between 27 and 36 weeks’ gestation) to increase the likelihood of optimal protection for the pregnant woman and her infant during the first few months of the infant’s life when the child is at the highest risk for severe illness and death from pertussis. Tdap can be administered regardless of interval since the most recent tetanus or diphtheria-containing vaccine.

    Appropriate tetanus prophylaxis in the management of a contaminated wound depends on the patient’s prior tetanus vaccination history. Injuries that are associated with a risk of tetanus include wounds contaminated with dirt, feces, soil, or saliva. Puncture wounds, avulsions, or other injuries occurring as a result of frostbite, burns, crush, or missiles are also considered at increased risk for tetanus. Adults who completed the three-dose primary tetanus vaccination series and have received a tetanus-toxoid–containing vaccine (Td or Tdap) less than 5 years prior to the wound are considered protected and do not require further specific tetanus prophylaxis. Adults vaccinated ≥5 years earlier who have not received Tdap should receive Tdap rather than Td if possible. For adults vaccinated with Tdap in the past, Td should be used. Patients with unknown or uncertain previous tetanus vaccination histories may require both tetanus toxoid and passive immunization with tetanus immune globulin (TIG) for full protection.

    Clean, minor wounds do not require tetanus prophylaxis but provide an opportunity to complete the primary tetanus vaccination series. Adults with incomplete or unknown history of vaccination should receive the three-dose primary series. The preferred schedule is a single dose of Tdap, followed by Td at ≥4 weeks and another Td dose 6–12 months later. Tdap can substitute for any of the Td doses.

MEASLES–MUMPS–RUBELLA

The MMR vaccine contains three live attenuated viruses—measles, mumps, and rubella—and is generally administered to children around age 1 and again at school entry (around 4–6 years of age). The second immunization is not a booster; rather, the objective of the second dose is to promote immunity in the small proportion of persons who do not respond to one dose. Any adult born after 1957 without serologic evidence of immunity should receive at least one dose of MMR. A second dose of MMR is recommended for (1) adults who have recently been exposed to measles or mumps or are in an outbreak setting, (2) adults previously immunized with an unknown type of measles vaccine between 1963 and 1967 or a killed measles vaccine, (3) students in postsecondary educational institutions, (4) healthcare workers, and (5) persons planning international travel. Women of childbearing age with unknown rubella vaccination history or who lack serologic evidence of immunity should also receive one dose of MMR. Women should be counseled to delay pregnancy at least 4 weeks after receiving MMR.

    Serious adverse events with MMR vaccination include encephalitis, pneumonia, epididymo-orchitis, and arthropathy (rubella), particularly in postpartum women. These adverse events, however, are quite rare and are outweighed by the risks of naturally acquired measles, mumps, or rubella disease.

VARICELLA ZOSTER VIRUS

The varicella zoster virus (VZV) can cause both primary infection (varicella, chicken pox) and recurrent or reactivated infection (herpes zoster, shingles). Infection with varicella carries the highest hospitalization rates among adults older than 19 years and infants less than 1 year (in comparison to children aged 5–9 years). Complications leading to hospitalization include skin and soft tissue infection (particularly invasive group A streptococcal infection), pneumonia, dehydration, and encephalitis. In the pre-vaccine era, prenatal infection was uncommon as the majority of women of childbearing age had acquired natural immunity to VZV through childhood infection; however, prenatal maternal infection can have adverse outcomes for the fetus and infant.

    Three vaccines are currently available in the United States, each containing increasing concentrations of the live attenuated (Oka strain) varicella virus. The varicella vaccine (Varivax) contains 1440 pfu and is recommended for children older than 12 months and any adult who does not have evidence of immunity to VZV. Evidence of immunity to varicella in adults includes any of the following: (1) born in the United States prior to 1980 (although this does not suffice as evidence for healthcare personnel and pregnant women), (2) documentation of two doses of varicella vaccine administered at least 4–8 weeks apart, (3) history of varicella based on diagnosis or verification by a healthcare provider, (4) history of herpes zoster based on healthcare provider diagnosis, or (5) laboratory evidence of immunity or confirmation of disease.

    Adolescents (aged 13 years and older) and adults without evidence of varicella immunity should receive two doses of Varivax spaced 4–8 weeks apart. Special consideration should be given to at-risk groups including school-aged children; members of households with children; college students; employees, residents, and staff of institutional settings; and nonpregnant women of childbearing age. Breakthrough varicella disease post-vaccination has been documented but is usually mild. The varicella vaccine Proquad has 9800 pfu of the live varicella vaccine (seven times Varivax) as well as MMR and is approved only for children 12 months through 12 years old. A third varicella vaccine, Zostavax, contains about 14 times the amount of live attenuated (Oka strain) varicella vaccine as the varicella vaccine and is FDA approved for adults older than 50 years of age, whether or not they report a prior episode of shingles. However, ACIP continues to recommend that zoster vaccination begin at age 60 years. For persons aged 60 and older who anticipate immunosuppressive therapy, zoster vaccine should be administered at least 14 days prior to the start of therapy. Persons taking antiviral medications active against herpes viruses (e.g., acyclovir, famciclovir, or valacyclovir) should discontinue these medications 24 hours before receiving the zoster vaccine and not resume therapy for at least 14 days after immunization. Zoster vaccine should not be administered to any person with a primary or acquired immunodeficiency including leukemia, lymphoma, and HIV infection complicated by AIDS (CD4 count <200 cells/mm³).

HUMAN PAPILLOMA VIRUS

Genital human papilloma virus (HPV) is the most common sexually transmitted infection in the United States. Most HPV infections are transient and asymptomatic; however, persistent infection can result in cervical cancer in women as well as anogenital cancers and warts in both men and women. There are over 100 types of HPV, and about 40 are mucosal types that can infect the anogenital area. “High-risk” types (types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 69, 73, and 82) have been linked with low- and high-grade cervix cell changes and precancers, as well as anogenital cancers. Nearly all cases of cervical cancer are related to HPV, and about 70% are caused by HPV types 16 or 18. Genital warts, or condyloma acuminata, are associated with “low-risk” types, with approximately 90% of cases due to types 6 and 11. Low-risk types can also cause cervical cellular changes that do not develop into cancer.

    A quadrivalent HPV vaccine (HPV4, Gardasil) targeting types 6, 11, 16, and 18 is licensed for use in the United States among women and men aged 9 through 26 years. A second vaccine that targets HPV types 16 and 18 only (HPV2, Cervarix) is licensed for use in females only. Neither vaccine provides protection against persistent infection, development of genital warts, or precursor cancer lesions for an HPV type that a woman is infected with at the time of vaccination. HPV vaccination does protect, however, against disease caused by other not-yet-acquired vaccine HPV types. Ideally vaccination should occur before the onset of sexual activity and potential exposure to HPV, and the recommended age for vaccination is 11–12 years. Catch-up vaccination is recommended for women aged 13–26 years who have not yet been vaccinated. The recommended schedule is three doses administered at 0, 1–2, and 6 months, and it can be simultaneously administered with other vaccines. HPV4 is recommended for males 11–12 years of age, with catch-up vaccination recommended for males 13–21 years of age. HPV4 vaccine is also recommended for previously unvaccinated males 22–26 years of age who are immunocompromised, HIV infected, or men who have sex with men (MSM).

    Side effects include local reactions, most commonly pain, as well as swelling and erythema at the injection site. Vasovagal syncope has been observed after vaccination, especially among adolescents and young adults, and patients receiving this vaccine should be observed for 15 minutes after administration. The HPV vaccine is a recombinant vaccine produced with Saccharomyces cerevisiae (baker’s yeast) and is contraindicated for any person with a history of immediate hypersensitivity to yeast (or any vaccine component). Owing to limited data, this vaccine is not recommended for use in pregnancy. Vaccination with the HPV vaccine does not replace routine cervical cancer screening.

HEPATITIS A VIRUS

Hepatitis A virus (HAV) can cause either asymptomatic or symptomatic infection. Infection is typically asymptomatic in children under the age of 6 years and symptomatic among older children and adults. The majority of clinical syndromes last less than 2 months (although approximately 10–15% experience a prolonged or relapsing course lasting up to 6 months). Persons with chronic liver disease, especially due to HCV, are at increased risk for fulminant hepatitis A and death. In the United States, transmission is primarily via a fecal–oral route, and young asymptomatic children can act as sources of infection for others. Persons at increased risk of HAV infection include travelers to endemic areas, MSM, users of injection and noninjection drugs (suggesting infection via both percutaneous and fecal–oral routes), persons with clotting factor disorders, and persons working with nonhuman primates susceptible to HAV infection. Improvements in viral inactivation procedures, donor screening, and vaccination strategies have decreased the risk of transmission from clotting factors.

    Hepatitis A vaccination is recommended routinely for children, for persons at increased risk of infection or at high risk of complications of infection (persons with chronic liver disease), and for anyone interested in obtaining immunity. During community outbreak settings, hepatitis A vaccination should be considered. Routine vaccination of all food handlers is not recommended, primarily due to cost, but may be considered. Proper hygiene to reduce the risk of fecal contamination of food and awareness of the signs and symptoms of hepatitis A remain the mainstay of food preparation safety.

    Hepatitis A vaccines currently licensed in the United States are made from inactivated HAV: two types of single-antigen vaccines (Havrix and Vaqta) and a combination vaccine containing both HAV and HBV antigens (Twinrix). Havrix and Vaqta are both available in two formulations that differ according to the patient’s age (pediatric vs. adult). In adults, Havrix is administered in two doses scheduled at 0 and 6–12 months; Vaqta is administered in two doses scheduled at 0 and 6–18 months.

    After hepatitis A exposure in nonvaccinated persons, administration of either the single-antigen hepatitis A vaccine or hepatitis A immunoglobulin (IG) is recommended for postexposure prophylaxis and should be administered as soon as possible (within 2 weeks). Hepatitis A IG is 80–90% effective in preventing hepatitis A when administered within 2 weeks postexposure. A single dose of 0.02 mL/kg of IG provides effective protection for 3 months, and a dose of 0.06 mL/kg provides protection for 3–5 months. Hepatitis A vaccine administration in exposed persons younger than 40 years of age appears to be as efficacious as IG in preventing disease. Owing to a paucity of data, hepatitis A IG is preferred among exposed persons older than 40 years or those with underlying medical illnesses, including chronic liver disease. In these groups, while hepatitis A IG is preferred, vaccine can be used if hepatitis A IG is unavailable. Persons who receive hepatitis A IG and who meet criteria for routine hepatitis A vaccination should initiate the vaccine series simultaneously with IG (at separate sites). Household and sexual contacts of, as well as people who have shared illicit drugs with, a person with serologically confirmed hepatitis A should receive postexposure prophylaxis.

    Hepatitis A vaccine can be administered as preexposure prophylaxis to travelers to endemic areas. Persons who either are allergic to a vaccine component or elect not to receive the vaccine should receive a single dose of hepatitis A IG. Persons who are older than 40 years of age, immunocompromised, or have chronic liver disease should receive IG in addition to the vaccine if they plan to travel to a high-risk area within the next 2 weeks (prior to the development of optimal protection from vaccination).

HEPATITIS B VIRUS

Hepatitis B virus (HBV) can cause both acute and chronic hepatitis with viral transmission occurring via percutaneous or mucosal exposure to infectious blood or body fluids (e.g., saliva, semen). Prior to routine hepatitis B vaccination in the United States, 30–40% of chronic infections were attributable to perinatal or early childhood transmission. Chronic hepatitis B infection carries an increased risk of cirrhosis and hepatocellular carcinoma as well as liver failure and death, thus making the hepatitis B vaccine the first vaccine effective in preventing the development of a cancer. Routine screening of pregnant women for chronic infection and universal immunization of newborns and previously unvaccinated children have greatly reduced the incidence rate of acute hepatitis B in the United States. Additionally, vaccination of healthcare workers and adherence to universal precautions have also significantly decreased the occupational hazard of HBV infection. Adult groups at increased risk for infection in the United States include injection drug users, household contacts of persons with chronic HBV infection, developmentally disabled persons in long-term care facilities, hemodialysis patients, and persons with chronic liver disease or HIV infection. Persons engaging in higher-risk sexual behaviors, such as MSM, are also more likely to contract HBV infection. Travelers to HBV-endemic areas may also be at risk if they are involved in disaster relief activities, receive medical care, or partake in drug use or sexual activity. Vaccination for hepatitis B is recommended for long-term travelers. Pregnancy is not a contraindication to vaccination.

    Available hepatitis B vaccine formulations in the United States contain recombinant hepatitis B surface antigen (HBsAg) and are available both as a single-antigen and combination formulations. The licensed single-antigen vaccines for adults are Recombivax HB and Engerix-B, both produced using recombinant HBsAg. The recommended dosing schedule is three injections at 0, 1, and 6 months, and the different formulations of the vaccine may be interchanged. Twinrix, a combination formulation of recombinant HBsAg and inactivated HAV, is also licensed for adult administration.

    The response rate in adults less than 40 years of age is greater than 90% after the complete three-dose series. The protective antibody response diminishes in the elderly (only 75% of persons ≥60 develop protective antibody). Smoking, obesity, and immune suppression are also associated with lower response rates. Serologic testing for immunity is not necessary after routine vaccination of adults; however, it is recommended for healthcare workers and public safety workers, chronic hemodialysis patients, HIV-infected persons and other immune-compromised patients, and sex partners of HBsAg-positive persons. Testing should be performed 1–2 months after the completion of the series, and those with low anti-HBs concentrations (<10 mIU/mL) should be revaccinated with the three-dose series.

    Hepatitis B immune globulin (HBIG) may be administered along with hepatitis B vaccine for postexposure prophylaxis or administered alone following exposure for nonresponders to prior hepatitis B vaccination. Postexposure prophylaxis with HBIG plus hepatitis B vaccine, hepatitis B vaccine alone, and HBIG alone have all been demonstrated to be effective in preventing HBV transmission. The effectiveness of HBIG postexposure decreases with delayed administration, and the recommended interval for administration is less than 7 days after a needle stick and less than 14 days for sexual exposures.

FURTHER CONSIDERATIONS

SPACING OF MULTIPLE IMMUNIZATIONS

Inactivated vaccines may be effectively administered either simultaneously or at any time before or after another vaccine. Nonsimultaneous administration of live vaccines, however, may lead to interference in the immune response and impaired protective effect. If live vaccines are not administered on the same day, their administration should be separated in time by at least 4 weeks. Exceptions to this rule are the live oral typhoid and yellow fever vaccines.

    Blood and other antibody-containing blood products (e.g., intravenous immune globulin) may inhibit the response to live vaccines, with the inhibition potentially lasting for more than 3 months. The measles and rubella vaccines are particularly impaired in the setting of blood product administration; data regarding the mumps and varicella vaccines are more limited. No interference between blood products and Ty21a typhoid, yellow fever, or the live attenuated influenza vaccine has been observed, and with the exception of these three vaccines the administration of a live vaccine should be delayed for at least 3 months after receipt of an antibody-containing blood product to allow sufficient degradation of the passive antibody.

SPECIAL RISK GROUPS

Timing of Vaccines for Persons with Immunosuppression

Immunosuppressed adults are at increased risk for severe infection with several vaccine-preventable infections. However, as discussed above, live vaccines should be deferred until immune function improves. Inactivated vaccines administered during periods of severe immunosuppression may have to be repeated after immune function has improved.

    Although corticosteroid therapy alters immune competence, it is not a contraindication to vaccination with a live virus. Persons who may safely receive live virus vaccines include those receiving short-term oral corticosteroid therapy (<2 weeks) or low- to moderate-dose therapy (<20 mg of prednisone daily) or who are on replacement therapy.

    Adults with anatomic or functional asplenia are at increased risk of infection by encapsulated bacteria; namely S. pneumoniae, N. meningitidis, and H. influenzae b. If splenectomy is elective, vaccines against these agents should be administered at least 2 weeks prior to surgery. If not, they should be administered as soon as clinically possible. See table 4.3 for additional immunization recommendations for special risk groups.

    All hematopoietic cell transplant (HCT) recipients should be routinely revaccinated after stem cell transplantation. Most inactivated vaccines can be administered as early as 6 months after transplantation. Live vaccine (MMR, VZV) can be administered 24 months after transplantation if patients are no longer on immunosuppression and are free of Graft vs. Host Disease (GVHD).

Stay updated, free articles. Join our Telegram channel

Join