Vaccination in Immunocompromised Patients

Core Principle: Inactivated vs Live Vaccines

The American College of Physicians and Infectious Diseases Society of America recommend that immunocompromised patients receive all indicated inactivated vaccines, but must avoid live vaccines, with exceptions for MMR and varicella vaccines in HIV-infected patients with adequate CD4 counts (≥200 cells/mm³ in adults or ≥15% in children) 1, 2
Inactivated vaccines are safe for all immunocompromised patients and should be administered according to standard schedules, though immune responses may be suboptimal, as stated by the Centers for Disease Control and Prevention 1, 2, 3

The Centers for Disease Control and Prevention recommend that inactivated influenza vaccine (IIV) is mandatory annually for all immunocompromised patients ≥6 months of age 5
The Advisory Committee on Immunization Practices recommends administering PCV13 first, followed by PPSV23 at least 8 weeks later, for immunocompromised patients including those with HIV, malignancy, transplants, and functional/anatomic asplenia 5, 7

The Infectious Diseases Society of America states that live attenuated influenza vaccine (LAIV) is absolutely contraindicated in immunocompromised patients 2
The Centers for Disease Control and Prevention recommend that oral poliovirus vaccine (OPV) should never be given to household contacts of immunocompromised patients due to risk of transmission 3

The American Academy of Pediatrics and the Infectious Diseases Society of America recommend that MMR vaccine should be administered to HIV-infected patients when adults have a CD4 count ≥200 cells/mm³, children aged 1-13 years have a CD4 percentage ≥15%, and the patient is asymptomatic or minimally symptomatic 1, 6
The Centers for Disease Control and Prevention recommend that varicella vaccine (VAR) can be given to HIV-infected patients when adults ≥14 years have a CD4 count ≥200 cells/mm³, are clinically stable, and varicella-nonimmune, and children aged 1-13 years have a CD4 percentage ≥15% 1, 6

The American College of Physicians recommends that live vaccines should be administered ≥4 weeks before starting immunosuppression, and inactivated vaccines should be administered ≥2 weeks before starting immunosuppression 2
The Centers for Disease Control and Prevention state that vaccination during chemotherapy or radiation therapy should be avoided because antibody response is poor, and patients vaccinated while on immunosuppressive therapy should be considered unimmunized and revaccinated ≥3 months after therapy discontinuation 3

The National Institutes of Health recommend that live vaccines are contraindicated when patients receive ≥2 mg/kg/day or ≥20 mg/day total of prednisone (or equivalent) for ≥2 weeks, and to wait ≥3 months after discontinuation of high-dose systemic corticosteroids before administering live vaccines 3, 5

The Journal of Allergy and Clinical Immunology states that patients with severe antibody deficiencies (e.g., CVID, X-linked Agammaglobulinemia) should avoid all live vaccines, and inactivated vaccines have limited benefit during immunoglobulin replacement therapy, with the exception of annual influenza vaccine 8, 4
The Infectious Diseases Society of America recommends that all live vaccines are absolutely contraindicated in patients with severe combined immunodeficiency (SCID) 8, 6

The Centers for Disease Control and Prevention recommend that household members of immunocompromised patients should receive all age-appropriate inactivated vaccines, annual influenza vaccine (IIV or LAIV), MMR, rotavirus (infants), varicella, and zoster vaccines, with exceptions for certain situations such as HSCT recipients within 2 months post-transplant or those with GVHD or SCID 2, 5

The Infectious Diseases Society of America recommends that for patients with thrombocytopenia, intramuscular injections are safe if platelet count ≥30,000-50,000 cells/mm³, using ≤23-gauge needle, and applying constant pressure at injection site for 2 minutes 1