Vaccination of the Immunocompromised Host

Publication Date: December 4, 2013
Last Updated: September 2, 2022

Responsibility for Vaccination

1. Specialists caring for immunocompromised patients share responsibility with the primary care provider for ensuring that appropriate vaccinations are administered to immunocompromised patients.* (SR, L)
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2. Specialists caring for immunocompromised patients share responsibility with the primary care provider for recommending appropriate vaccinations for household members of immunocompromised patients.* (SR, VL)
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Timing of Vaccination

3. Vaccines should be administered prior to planned immunosuppression if feasible. (SR, M)
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4. Live vaccines should be administered ≥4 weeks prior to immunosuppression.* (SR, L)
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and should be avoided within 2 weeks of initiation of immunosuppression. (SR, L)
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5. Inactivated vaccines should be administered ≥2 weeks prior to immunosuppression. (SR, M)
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Household Members (See Table 1)

6. Immunocompetent household members of immunocompromised patients can safely receive inactivated vaccines based on the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP)’s annually updated recommended vaccination schedules for children and adults (hereafter referred to as the CDC annual schedule). (SR, H)
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or for travel. (SR, M)
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7. Household members of immunocompromised patients 6 months and older should receive influenza vaccine annually. (SR, H)

They should receive either:

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a. Inactivated influenza vaccine (IIV) or (SR, H)
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b. Live attenuated influenza vaccine (LAIV) provided they are healthy, not pregnant, and age 2-49 years. (SR, L)
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Exceptions include household members of an immunocompromised patient who is a hematopoietic stem cell transplant (HSCT) recipient within 2 months after transplant or with graft-vs-host disease (GVHD), or a patient with severe combined immunodeficiency (SCID).* In these exceptions, LAIV should NOT be administered. (WR, VL)
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or, if administered, contact between the immunocompromised patient and household member should be avoided for 7 days.

(WR, VL)
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8. Healthy immunocompetent household members of immunocompromised patients should receive the following live vaccines based on the CDC annual schedule: combined measles, mumps, and rubella vaccines (MMR), (SR, M)
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rotavirus vaccine in infants ages 2-7 months, (SR, L)
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varicella vaccine (VAR), (SR, M)
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and zoster vaccine (ZOS). (SR, M)
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They can safely receive vaccines for travel: yellow fever vaccine, (SR, M)
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and oral typhoid vaccine. (SR, L)
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9. Oral poliovirus vaccine (OPV) should NOT be administered to household members of immunocompromised patients. (SR, M)
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10. Highly immunocompromised patients should avoid handling diapers of infants vaccinated with rotavirus vaccine for 4 weeks after vaccination. (SR, VL)
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11. Immunocompromised patients should avoid contact with persons who develop skin lesions after receiving VAR or ZOS until the lesions have cleared. (SR, L)
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Table 1. Safety of Administration of Live Vaccines to Contacts of Immunocompromised Persons

Influenza, live, attenuated nasal

Shedding of Agent? (Site) Transmissibility From Vaccinated Immunocompetent Person?
Yes (nasal secretions) Rare (from 1 vaccinated toddler)
Administer; (SR, L)
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vaccinated persons to avoid close contact with persons with HSCT or SCID for 7 d. (WR, VL)
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MMR

Shedding of Agent? (Site) Transmissibility From Vaccinated Immunocompetent Person?
Measles: no
Mumps: no
Rubella: yes
(nasopharynx, in low titer; breast milk)		 No, except mother-to-infant transmission of rubella vaccine virus via breast milk
Administer (SR, M)
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Poliovirus, oral

Shedding of Agent? (Site) Transmissibility From Vaccinated Immunocompetent Person?
Yes (stool) Yes, with rare cases of vaccine-associated paralytic poliomyelitis
Do NOT administer (SR, H)
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Rotavirus, oral

Shedding of Agent? (Site) Transmissibility From Vaccinated Immunocompetent Person?
Yes (stool) Yes, but no reported cases of symptomatic infection in contacts
Administer (SR, L)
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Typhoid, oral

Shedding of Agent? (Site) Transmissibility From Vaccinated Immunocompetent Person?
No No
Administer (SR, L)
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Varicella

Shedding of Agent? (Site) Transmissibility From Vaccinated Immunocompetent Person?
Yes (skin lesions) Rare, limited to vaccinees with skin lesions
Administer (SR, M)
If skin lesions develop, avoid close contact with immunocompromised persons.
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Yellow fever

Shedding of Agent? (Site) Transmissibility From Vaccinated Immunocompetent Person?
No, except possibly shed in breast milk Yes (at least 3 cases of encephalitis in infants exposed to the vaccine via nursing)
Administer (SR, M)
except to women who are nursing.
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Zoster

Shedding of Agent? (Site) Transmissibility From Vaccinated Immunocompetent Person?
Yes (rarely recovered from injection-site vesicles) Not reported
Administer to age ≥60 y. (SR, M)
If skin lesions develop, avoid close contact with immunocompromised persons.
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International Travel

12. Clinicians may administer inactivated vaccines indicated for travel based on the CDC annual schedule for immunocompetent adults and children. (SR, L)
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13. Yellow fever vaccine generally should NOT be administered to immunocompromised persons.

(SR, M)
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If travel to an endemic area cannot be avoided, vaccination can be considered in certain adults with human immunodeficiency virus (HIV) infection who are minimally immunocompromised:

a. Asymptomatic HIV-infected adults with CD4 T-cell lymphocyte counts of ≥200 cells/mm3.

(WR, L)
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b. Asymptomatic HIV-infected children age 9 months through 5 years with CD4 T-cell lymphocyte percentages of ≥15%.

(, )
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14. With certain exceptions (eg, yellow fever vaccine and MMR-infected patients [see recommendation 13 and HIV section] and MMR in certain HSCT patients [see HSCT section]), live vaccines should NOT be given to immunocompromised persons. (SR, L)
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Specific Vaccinations

Varicella and Zoster Vaccines

VAR should be given to immunocompetent patients without evidence of varicella immunity (ie, either age-appropriate varicella vaccination, serologic evidence of immunity, clinician-diagnosed or verified history of varicella or zoster, or laboratory-proven varicella or zoster). (SR, M)
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if it can be administered ≥4 weeks before initiating immunosuppressive therapy. (SR, L)
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16. A 2-dose schedule of VAR, separated by >4 weeks for patients ≥13 years and by ≥3 months for patients 1-12 years of age, is recommended if there is sufficient time prior to initiating immunosuppressive therapy. (SR, L)
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17. VAR should NOT be administered to highly immunocompromised patients, but certain categories of patients (eg, patients with HIV infection without severe immunosuppression, or a primary immunodeficiency disorder without defective T cell-mediated immunity, such as primary complement component deficiency disorder, or chronic granulomatous disease [CGD]) should receive VAR, adhering to a 2-dose schedule separated by a 3-month interval. (SR, M)
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18. VAR can be considered for patients without evidence of varicella immunity (defined in recommendation 16) who are receiving long-term, low-level immunosuppression.* (WR, VL)
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19. VAR should be administered to eligible immunocompromised patients as the single antigen product, not varicella vaccine combined with measles, mumps, and rubella vaccines (MMRV). (SR, L)
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20. ZOS should be given to patients ≥60 years of age if it can be administered ≥4 weeks before beginning highly immunosuppressive therapy. (SR, L)
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21. ZOS should be considered for varicella-positive patients (ie, persons with a history of varicella or zoster infection or who are VZV seropositive with no previous doses of VAR) 50-59 years of age if it can be administered ≥4 weeks before beginning immunosuppressive therapy.* (WR, L)
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22. ZOS should be administered to patients ≥60 years of age receiving therapy considered to induce a low level of immunosuppression. (SR, L)
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23. ZOS should NOT be administered to highly immunocompromised patients. (SR, VL)
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Influenza

24. Annual influenza vaccination with IIV is recommended for immunocompromised patients ≥6 months of age. (SR, M)
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except for patients who are very unlikely to respond (although unlikely to be harmed by IIV), such as those receiving intensive chemotherapy.* (SR, L)
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or those who have received anti-B cell antibodies within 6 months.* (SR, M)
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25. LAIV should NOT be administered to immunocompromised persons. (WR, VL)
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Special Populations

Primary (Congenital) Immunodeficiency Disorders

Primary Complement Deficiencies

26. Patients with primary complement deficiencies should receive all routine vaccines based on the CDC annual schedule. None is contraindicated. (SR, L)
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27. Patients with primary complement deficiencies and who are:
a. 2-5 years old should receive 1 dose of 13-valent pneumococcal conjugate vaccine (PCV13) if they have received 3 doses of pneumococcal conjugate vaccine (PCV) (either 7-valent pneumococcal conjugate vaccine [PCV7] or PCV13) before 24 months of age, and 2 doses of PCV13 (8 weeks apart) if they have received an incomplete schedule of ≤2 doses of PCV (PCV7 or PCV13) before 24 months of age. (SR, L)
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b. 6-18 years old with a classical pathway (C1, C2, C3, C4), alternate pathway, or severe mannan-binding lectin (MBL) deficiency who have not received PCV13 should receive a single dose of PCV13. (SR, VL)
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c. ≥19 years old with a classical pathway (C1, C2, C3, C4), alternate pathway, or severe MBL-naive should receive a single dose of PCV13. (SR, VL)
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For those who have previously received 23-valent pneumococcal polysaccharide vaccine (PPSV23), PCV13 should be administered ≥1 year after the last PPSV23 dose. (WR, L)
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28. Patients ≥2 years of age with an early classical pathway, alternate pathway, or severe MBL deficiency should receive PPSV23 ≥8 weeks after PCV13 and a second dose of PPSV23 5 years later. (SR, L)
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29. Patients with primary complement deficiencies should receive conjugate meningococcal vaccine.
For children age 6 weeks through 18 months, administer a 4-dose series of bivalent meningococcal conjugate vaccine and H. influenzae type b conjugate vaccine (Hib-MenCY; MenHibrix®) at 2, 4, 6, and 12-15 months. (SR, L)
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or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4or a 2-dose primary series of quadrivalent meningococcal conjugate vaccine (MCV4) to patients with primary complement component deficiency age 9 months through 55 years (MCV4-D [Menactra®] for those 9-23 months; MCV4-D or MCV4-CRM [Menveo®] for those 2-54 years of age). (SR, L)
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For persons >55 years of age, administer MPSV4 if they have not previously received MCV4 and MCV4 if they have previously received it. (SR, L)
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For patients 9-23 months of age, administer the doses 3 months apart, and for patients 2 years and older, administer the doses 2 months apart. MCV4-D should be administered ≥4 weeks after a dose of PCV13 because of a reduced antibody response to some pneumococcal serotypes when MCV4-D and PCV7 are administered simultaneously. (SR, L)
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30. Patients with a primary complement component deficiency should be revaccinated with MCV4 (or MPSV4 for those >55 years of age who have not previously received MCV4) every 5 years. (SR, L)
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Phagocytic Cell Deficiencies

Phagocytic cell deficiencies include CGD (chronic granulomatous disease), leukocyte adhesion deficiency, and Chediak-Higashi syndrome.
31. Patients with phagocytic cell deficiencies should receive all inactivated vaccines based on the CDC annual schedule. (SR, L)
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Children 2-5 years of age should receive PCV13 as in recommendation 27a. (WR, VL)
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32. Patients ≥6 years of age with phagocytic cell deficiencies other than CGD (unless patient with CGD is receiving immunosuppressive medication) should receive PCV13 as in recommendations 27b-c. (WR, VL)
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33. Patients ≥2 years of age with phagocytic cell deficiencies other than CGD (unless patient with CGD is receiving immunosuppressive medication) should receive PPSV23 ≥8 weeks after PCV13 and a second dose of PPSV23 5 years later. (WR, L)
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34. Live bacterial vaccines, such as bacillus Calmette-Guérin (BCG) or oral typhoid vaccine, should NOT be administered to patients with a phagocytic cell defect. (SR, M)
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35. Live viral vaccines should be administered to patients with CGD and to those with congenital or cyclical neutropenia. (WR, L)
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36. Live viral vaccines should NOT be administered to patients with leukocyte adhesion deficiency, defects of cytotoxic granule release such as Chediak-Higashi syndrome (see Combined Immunodeficiencies), or any other undefined phagocytic cell defect. (SR, L)
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Innate Cytokine or Cellular Activation Defects

Innate defects in the immune system resulting in defects of cytokine generation, cytokine response, or cellular activation include defects
of the interferon-γ/interleukin 12 axis.
37. Patients with innate immune system defects resulting in defects of cytokine generation/response or cellular activation should receive all inactivated vaccines based on the CDC annual schedule. (SR, VL)
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38. For patients with innate immune system defects resulting in defects of cytokine generation/response or cellular activation, PCV13 should be administered as in recommendations 27a-c. (, )
(WR to SR-VL to L)
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39. Specialist advice should be sought on individual conditions concerning use of live vaccines in patients with innate immune system defects resulting in defects of cytokine generation/response or cellular activation/inflammation generation. (SR, L)
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40. Live bacterial vaccines should NOT be administered to patients with defects of the interferon- γ/interleukin 12 pathways. (SR, M)
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41. Live viral vaccines should NOT be administered to patients with defects of interferon ( α or γ) production. (SR, L)
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Minor Antibody Deficiencies

42. Patients with immunoglobulin A (IgA) deficiency or specific polysaccharide antibody deficiency (SPAD) should receive all routine vaccinations based on the CDC annual schedule, provided that other components of their immune system are normal. (SR, L)
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43. Children with SPAD or ataxia-telangiectasia should receive PCV13 as described in recommendations 27a-c. (, )

(WR to SR-VL to L)

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Those ≥2 years of age should receive PPSV23 ≥8 weeks after indicated doses of PCV13 and a second dose of PPSV23 5 years later. (SR, L)
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44. Monitoring of vaccine responses can be useful for assessing the degree of immunodeficiency in patients with minor antibody deficiencies and the level of protection. (WR, M)
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45. OPV should NOT be administered to IgA-deficient patients. (SR, L)
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Major Antibody Deficiencies in Patients Receiving Immunoglobulin Therapy

46. Inactivated vaccines other than IIV are NOT routinely administered to patients with major antibody deficiencies during immunoglobulin therapy. (SR, L)
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For patients with suspected major antibody deficiencies, all inactivated vaccines can be administered as part of assessing the immune response prior to immunoglobulin therapy. (SR, L)
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47. IIV can be administered to patients with major antibody deficiencies and some residual antibody production. (WR, L)
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48. Live OPV should NOT be administered to patients with major antibody deficiencies. (SR, M)
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49. Live vaccines (other than OPV) should NOT be administered to patients with major antibody deficiencies.* (WR, L)
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Combined Immunodeficiencies

50. For patients with suspected combined immunodeficiencies, all inactivated vaccines can be administered as part of assessing the immune response prior to commencement of immunoglobulin therapy. (SR, L)
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For patients with combined immunodeficiencies who are receiving immunoglobulin therapy, inactivated vaccines should NOT be routinely administered. (SR, L)
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51. For patients with combined immunodeficiencies and residual antibody production potential, IIV can be administered. (WR, VL)
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52. Children with partial DiGeorge syndrome (pDGS) should undergo immune system assessment with evaluation of lymphocyte subsets and mitogen responsiveness to decide whether they should be given live viral vaccines. Those with ≥500 CD3 T-cells/mm3, ≥200 CD8 T-cells/mm3, and normal mitogen response should receive MMR and VAR.* (WR, L)
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53. Patients with SCID, DiGeorge syndrome with CD3 T-cell lymphocyte count of <500 cells/mm3, other combined immunodeficiencies with similar CD3 T-cell lymphocyte counts, Wiskott-Aldrich syndrome, or X-linked lymphoproliferative disease and familial disorders predisposing to hemophagocytic lymphohistiocytosis, should avoid all live vaccines. (SR, M)
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HIV-Infected Adults, Adolescents, and Children (See Table 2)

Inactivated Vaccines

54. HIV-infected patients should be vaccinated according to the CDC annual schedule for the following inactivated vaccines:
IIV, (SR, H)
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PCV13 in patients <2 years. (SR, M)
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H. influenzae type b conjugate vaccine (Hib), (SR, H)
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diphtheria toxoid, tetanus toxoid, acellular pertussis vaccine (DTaP), (SR, M)
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tetanus toxoid, reduced diphtheria toxoid, and reduced acellular pertussis vaccine (Tdap), (SR, VL)
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tetanus toxoid, reduced diphtheria toxoid vaccine (Td), (SR, L)
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hepatitis B vaccine (HepB), (SR, M)
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hepatitis A vaccine (HepA), (SR, M)
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inactivated poliovirus vaccine (IPV), (SR, M)
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and quadrivalent human papillomavirus vaccine (HPV4)* in females and males 11-26 years of age. (SR, VL)
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with additions noted below.
55. PCV13 should be administered to HIV-infected patients ≥2 years old as in recommendations 27a-c. (See Table 2) (SR, )
(SR-L to M)
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56. PPSV23 should be administered to HIV-infected children ≥2 years of age who have received indicated doses of PCV. (SR, M)
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to HIV-infected adults with CD4 T-lymphocyte counts of ≥200 cells/mm3, (SR, M)
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and to HIV-infected adults with CD4 T-lymphocyte counts of <200 cells/mm3, (WR, L)
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PPSV23 should be given ≥8 weeks after the indicated dose(s) of PCV13 and a second dose of PPSV23 should be given 5 years later. (SR, L)
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57. HIV-infected children who are >59 months of age and have not previously received Hib should receive 1 dose of Hib. (SR, L)
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Hib is NOT recommended for HIV-infected adults. (WR, L)
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58. HIV-infected children age 11-18 years should receive a 2-dose primary series of MCV4 two months apart. (SR, M)
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A single booster dose (third dose) should be given at age 16 years if the primary series was given at age 11 or 12 years, and at age 16-18 years if the primary series was given at age 13-15 years. (SR, L)
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If MCV4 is administered to HIV-infected children 2-10 years of age because of risk factors for meningococcal disease, a 2-dose primary series of MCV4 should be administered with a 2-month interval between doses and a booster dose 5 years later. (SR, VL)
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59. HIV-infected patients should receive HepB series, (SR, M)
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with consideration of high-dose HepB (40 μg/dose) for adults (WR, M)
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and adolescents.* (WR, L)
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One to two months after completion, they should be tested for anti-HBs (antibodies to hepatitis B surface antigen). (SR, L)
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If a postvaccination anti-HBs concentration of ≥10 mIU/mL is not attained, a second 3-dose series of HepB (SR, L)
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should be administered (alternative: 1 dose of HepB after which anti-HBs is tested*) using standard-dose (SR, M)
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or high-dose HepB (40 μg/dose)* (WR, L)
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for children and high-dose HepB for adolescents* and adults. (SR, L)
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60. HepB containing 20 μg of HBsAg (hepatitis B surface antigen) combined with HepAHepB containing 20 μg of HBsAg (hepatitis B surface antigen) combined with HepAHepB containing 20 μg of HBsAg (hepatitis B surface antigen) combined with HepAHepB containing 20 μg of HBsAg (hepatitis B surface antigen) combined with HepA (HepA-HepB; Twinrix®) 3-dose series can be used for primary vaccination of HIV-infected patients ≥12 years of age.* (SR, M)
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61. Internationally adopted HIV-infected children who had prior doses of OPV should receive a total of 4 doses of a combination of OPV and IPV vaccines. (SR, L)
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62. HPV4 is recommended over bivalent human papillomavirus vaccine (HPV2) because HPV4 prevents genital warts,* (SR, L)
although there are no data on differences between the vaccines for preventing cervical dysplasia in HIV-infected women.
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Live Vaccines

63. HIV-exposed or -infected infants should receive rotavirus vaccine according to the schedule for uninfected infants. (SR, L)
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64. HIV-infected patients should NOT receive LAIV. (WR, VL)
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65. MMR should be administered to clinically stable HIV-infected children 1-13 years old without severe immunosuppression (SR, M)
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and HIV-infected patients ≥14 years without measles immunity and with a CD4 T-cell lymphocyte count of ≥200/mm3. (WR, VL)
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66. HIV-infected children with a CD4 T-cell percentage of <15% (SR, M)
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or patients ≥14 years with a CD4 T-cell lymphocyte count of <200 cells/mm3 should NOT receive MMR. (SR, M)
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67. HIV-infected patients should NOT receive quadrivalent MMR-varicella vaccine (MMRV). (SR, VL)
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68. Varicella-nonimmune, clinically stable HIV-infected patients age 1-8 years with ≥15% CD4 T-lymphocyte percentage, (SR, H)
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age 9-13 years with ≥15% CD4 T-lymphocyte percentage, (SR, VL)
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and age ≥14 years with CD4 T-lymphocyte counts of ≥200 cells/mm3, (SR, VL)
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The 2 doses should be separated by ≥3 months. (SR, M)
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should receive VAR.

Table 2. Vaccination of Persons With HIV Infection

H. influenzae type b conjugate

Low-Levela or No Immunosuppression
U: age <5 y (SR, H)
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R: age 5–18 yc (SR, L)
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High-Level Immunosuppressionb
U: age <5 y (SR, H)
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R: age 5–18 yc (SR, L)
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Hepatitis A

Low-Levela or No Immunosuppression
U: (SR, M)
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High-Level Immunosuppressionb
U: age 1 y (SR, M)
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Hepatitis Bd

Low-Levela or No Immunosuppression
R: (SR, M)
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High-Level Immunosuppressionb
R: (SR, M)
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DTaP

Low-Levela or No Immunosuppression
U: (SR, M)
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High-Level Immunosuppressionb
U: (SR, M)
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Tdap

Low-Levela or No Immunosuppression
U: (SR, VL)
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High-Level Immunosuppressionb
U: (SR, VL)
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Td

Low-Levela or No Immunosuppression
U: (SR, L)
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High-Level Immunosuppressionb
U: (SR, L)
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HPV4e

Low-Levela or No Immunosuppression
U: age 11-26 y (SR, VL)
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High-Level Immunosuppressionb
U: age 11-26 y (SR, VL)
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Influenza, inactivated

Low-Levela or No Immunosuppression
U: (SR, H)
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High-Level Immunosuppressionb
U: (SR, H)
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Influenza, live attenuated

Low-Levela or No Immunosuppression
X:f (WR, VL)
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High-Level Immunosuppressionb
X: (WR, VL)
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MMR, live

Low-Levela or No Immunosuppression
U: age 12 mo to 13 y (SR, M)
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U: age ≥14 y (WR, VL)
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High-Level Immunosuppressionb
X: age 12 mo to 13 y (SR, M)
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X: age ≥14 y (SR, M)
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MMRV, live

Low-Levela or No Immunosuppression
X: (SR, VL)
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High-Level Immunosuppressionb
X: (SR, VL)
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Meningococcal conjugateg

Low-Levela or No Immunosuppression
U: age 11-18 y (SR, M)
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High-Level Immunosuppressionb
U: age 11-18 y (SR, M)
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Pneumococcal conjugate (PCV13)

Low-Levela or No Immunosuppression
U: age <5 y (SR, M)
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R: age 5 yh (SR, M)
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R: age 6-18 yh (SR, L)
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R: age ≥19 yi (SR, L)
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High-Level Immunosuppressionb
U: age <5 y (SR, M)
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R: age 5 y (SR, M)
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R: age 6-18 y (SR, L)
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R: age ≥19 yi (SR, VL)
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Pneumococcal polysaccharide (PPSV23)j

Low-Levela or No Immunosuppression
R: age ≥2 y (SR, M)
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High-Level Immunosuppressionb
R: age 2-18 y (SR, M)
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R: adult (CD4 T-lymphocytes <200 cells/mm3) (WR, L)
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Poliovirus, inactivated

Low-Levela or No Immunosuppression
U: (SR, M)
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High-Level Immunosuppressionb
U: (SR, M)
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Rotavirus, live

Low-Levela or No Immunosuppression
U: (SR, L)
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High-Level Immunosuppressionb
U: (WR, VL)
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Varicella, live

Low-Levela or No Immunosuppression
U: age 1-8 y (SR, H)
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U: age ≥9 y (SR, VL)
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High-Level Immunosuppressionb
X: (SR, M)
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Zoster, live

Low-Levela or No Immunosuppression
X: age <60 y (SR, L)
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U: age ≥60 yk, l (WR, L)
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High-Level Immunosuppressionb
X: (SR, M)
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R, recommended—administer if not previously administered or not current; such patients may be at increased risk for this vaccine-preventable infection
U, usual—administer if patient not current with recommendations for dose(s) of vaccine for immunocompetent persons in risk and age categories
X, contraindicated.

a Asymptomatic HIV infection with CD4 T-lymphocyte counts of 200-499 cells/mm3 for adults and adolescents and percentage of 15%-24% for infants and children.
b CD4 T-lymphocyte count of <200 cells/mm3 for adults and adolescents and percentage of <15% for infants and children.
c 1 dose.
d High-dose HepB (40 µg) should be considered for adults (WR, M)
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and adolescents (WR, L)
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with HIV infection. The latter recommendation deviates from CDC ACIP recommendations.
eHPV4 is preferred over HPV2 because of its activity against genital warts, a recommendation for administration of a vaccine that deviates from CDC ACIP recommendations.
fLAIV-infected patients age 5-17 years on a highly active antiretroviral therapy (HAART) regimen for ≥16 weeks with CD4 T-lymphocyte percentage of ≥15% and HIV plasma RNA of <60,000 copies.
g For HIV-infected patients, MCV4 is administered as a 2-dose primary series separated by ≥2 months. A booster dose (third dose) should be administered at age 16 years if the initial series was given at age 11-12 years and at age 16-18 years if the initial series was given at age 13-15 years.
h For patients not fully vaccinated with PCV13 by previous administration.
i For patients ≥19 years of age with HIV who have previously received PPSV23, PCV13 should be administered after an interval of ≥1 year after the last PPSV23 dose. (WR, L)
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j PPSV23 should be administered 8 weeks or longer after indicated dose(s) of PCV13. A second dose of PPSV23 should be administered 5 years after the initial dose.
k Vaccination can be considered for patients 50 through 59 years of age not previously vaccinated with varicella vaccine, (WR, L)
a recommendation for administration of a vaccine that deviates from recommendations of the Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention.
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l For patients not vaccinated with varicella vaccine.

Cancer (See Table 3)

69. Patients ≥6 months of age with hematological malignancies (SR, M)
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or solid tumor malignancies (SR, L)
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except those receiving anti-B cell antibodies* (SR, M)
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or intensive chemotherapy, such as for induction or consolidation chemotherapy for acute leukemia, (WR, L)
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should receive IIV annually.*
70. PCV13 should be administered to newly diagnosed adults with hematological (SR, VL)
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or solid malignancies (SR, VL)
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and children with malignancies (SR, VL)
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as described in recommendations 27a-c. (, )
21881

PPSV23 should be administered to adults and children ≥2 years of age

(SR, L)

at least 8 weeks after the indicated dose(s) of PCV13.

21881
71. Inactivated vaccines (other than IIV) recommended for immunocompetent children in the CDC annual schedule can be considered for children who are receiving maintenance chemotherapy. (WR, L)
21881
However, vaccines administered during cancer chemotherapy should NOT be considered valid doses (SR, L)
21881
unless there is documentation of a protective antibody level. (SR, M)
21881
72. Live viral vaccines should NOT be administered during chemotherapy. (SR, VL)
(SR-VL to M)
21881
73. Starting 3 months following cancer chemotherapy, patients should be vaccinated with inactivated vaccines (SR, VL)
(SR-VL to M)
21881
and the live vaccines VAR, (WR, VL)
21881
MMR, (SR, L)
21881
and MMRV (WR, VL)
21881
according to the CDC annual schedule routinely indicated for immunocompetent persons. (, )
21881
If regimens included anti-B cell antibodies, vaccinations should be delayed at least 6 months. (SR, M)
21881

Table 3. Vaccination of Patients With Cancer

H. influenzae type b conjugate

Prior to or During Chemotherapya
U: (WR, L)
21881

Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)

U: (SR, M)
21881

Hepatitis A

Prior to or During Chemotherapya
U: (WR, L)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U: (SR, VL)
21881

Hepatitis B

Prior to or During Chemotherapya
U: (WR, L)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U: (SR, M)
21881
R: adults (SR, VL)
21881

DTaP, Tdap

Prior to or During Chemotherapya
U: (WR, L)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U: age 0-18 y (SR, M)
21881
R: adults with acute lymphoblastic leukemia or lymphoma (WR, VL)
21881

HPV

Prior to or During Chemotherapya
U: age 11-26 y (WR, VL)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U: (SR, VL)
21881

Influenza, inactivated

Prior to or During Chemotherapya
U (SR, L)
U (SR-L to M)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U:b (SR, M)
21881

Influenza, live attenuated

Prior to or During Chemotherapya
X: (WR, VL)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U: (SR, L)
21881

MMR, live

Prior to or During Chemotherapya
X:c (SR, M)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
Starting at 3 mo: U: (SR, L)
21881

MMRV, live

Prior to or During Chemotherapya
X:c (SR, M)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
Starting at 3 mo: U: (WR, VL)
21881

Meningococcal conjugate

Prior to or During Chemotherapya
U (WR, L)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U: (SR, L)
21881

Pneumococcal conjugate-13 (PCV13)

Prior to or During Chemotherapya
R: (SR, L)
21881
R: age ≥6 yd (SR, VL)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U: (SR, L)
21881

Pneumococcal polysaccharide (PPSV23)

Prior to or During Chemotherapya
R: age ≥2 y (SR, L)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U: (SR, L)
21881

Poliovirus, inactivated

Prior to or During Chemotherapya
U: (WR, L)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
U: (SR, L)
21881

Rotavirus, live

Prior to or During Chemotherapya
X: (SR, VL)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
Not applicable (, )
21881

Varicella, live

Prior to or During Chemotherapya
Xc (SR, M)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
Starting at 3 mo: U:e (WR, VL)
21881

Zoster, live

Prior to or During Chemotherapya
X:c (SR, VL)
21881
Starting ≥3 Months Postchemotherapy and ≥6 Months After Anti–B-Cell Antibodies for Inactivated Vaccines (see each live vaccine for interval)
Starting at 3 mo: U:e (WR, VL)
21881
R, recommended—administer if not previously administered or not current; such patients may be at increased risk for this vaccine-preventable infection
U, usual—administer if patient not current with recommendations for dose(s) of vaccine for immunocompetent persons in risk and age categories
X, contraindicated.
a Administer inactivated influenza vaccine (IIV) annually to patients with hematological malignancies. (SR, M)
21881
or solid tumor malignancies (SR, L)
21881
except those receiving anti–B-cell antibodies such as rituximab or alemtuzumab or intensive chemotherapy such as for induction or consolidation chemotherapy for acute leukemia. (WR, L)
21881
Administrations of inactivated vaccines other than IIV routinely recommended for healthy children in the annually updated CDC recommendations can be considered for children with malignancies who are receiving maintenance chemotherapy. (WR, L)
21881
However, vaccines administered while receiving cancer chemotherapy should not be considered valid doses. (SR, L)
21881
b IIV can be administered ≤3 months after chemotherapy, but response rate may be low.
c These live vaccines should not be administered unless the vaccine is otherwise indicated based on the annually updated CDC recommendations AND the patient is not immunosuppressed AND there will be an interval of ≥4 weeks prior to initiation of chemotherapy.
d For patients ≥19 years of age with HIV who have previously received PPSV23, PCV13 should be administered after an interval of ≥1 year after the last PPSV23 dose. (WR, L)
21881
e Although MMR has been given safely 3 months after completion of chemotherapy, data on the safety, immunogenicity, or efficacy of varicella or zoster vaccine after completion of chemotherapy are not available.
f For patients ≥19 years of age who have previously received PPSV23, PCV13 should be administered after an interval of ≥1 year after the last PPSV23 dose. (WR, L)
21881

Hematopoietic Stem Cell Transplant (See Table 4)

Donors and Patients Before Transplantation

74. The HSCT donor should be current with routinely recommended vaccines based on age, vaccination history, and exposure history according to the CDC annual schedule, (SR, H)
21881
but MMR, MMRV, VAR, and ZOS administration should be avoided within 4 weeks of stem cell harvest. (WR, VL)
21881
Vaccination of the donor for the benefit of the recipient is NOT recommended. (WR, M)
21881
75. Prior to HSCT, candidates should receive vaccines indicated for immunocompetent persons based on age, vaccination history, and exposure history according to the CDC annual schedule if they are not already immunosuppressed. (SR, )
(SR-VL to M)
21881
and when the interval to the start of the conditioning regimen is ≥4 weeks for live vaccines. (SR, L)
21881
and ≥2 weeks for inactivated vaccines. (SR, M)
21881
76. Nonimmune HSCT candidates ≥12 months of age should receive VAR (as a 2-dose regimen if there is sufficient time) if they are not immunosuppressed and when the interval to the start of the conditioning regimen is ≥4 weeks. (SR, L)
21881

HSCT Patients Post-transplantation

77. Administer 1 dose of IIV annually. (SR, M)
21881
to persons ≥6 months of age starting 6 months after HSCT (SR, M)
21881
and starting at 4 months if there is a community outbreak of influenza as defined by the local health department. (SR, VL)
21881
For children 6 months through 8 years of age who are receiving influenza vaccine for the first time, 2 doses should be administered. (SR, L)
21881
78. Administer 3 doses of PCV13 to adults and children starting 3-6 months after HSCT. (, )
21881
At 12 months after HSCT a dose of PPSV23 should be given provided the patient does not have chronic GVHD. (SR, L)
21881
For patients with chronic GVHD a fourth dose of PCV13 can be given at 12 months after HSCT.* (WR, VL)
21881
79. Administer 3 doses of Hib starting at 6-12 months after HSCT. (SR, M)
21881
80. Administer 2 doses of MCV4 starting 6-12 months after HSCT starting 6-12 months after HSCT starting 6-12 months after HSCT starting 6-12 months after HSCT starting 6-12 months after HSCT to persons 11-18 years of age with a booster dose at age 16-18 years for those receiving the initial post-HSCT dose of vaccine at 11-15 years of age. (SR, L)
21881
81. Administer 3 doses of tetanus/diphtheria-containing vaccine starting 6 months after HSCT. (SR, L)
21881
For children <7 years of age, administer 3 doses of DTaP. (SR, L)
21881
For patients 7 years and older, administration of 3 doses of DTaP should be considered.* (WR, VL)
21881
Alternatively, administer a dose of Tdap followed by either 2 doses of diphtheria-tetanus vaccine (DT)* (WR, M)
21881
or 2 doses of Td. (WR, L)
21881
82. Administer 3 doses of HepB starting at 6-12 months after HSCT. (SR, M)
21881
If a postvaccination anti-HBs concentration of ≥10 mIU/mL is not attained, a second 3-dose series of HepB (SR, L)
21881
(Alternative: 1 dose of HepB after which anti-HBs is tested*) using standard dose (SR, M)
21881
or high dose (40 μg)* (WR, L)
21881
for children and high dose for adolescents* and adults (SR, L)
21881
should be administered.
83. Administer 3 doses of IPV starting 6-12 months after HSCT. (SR, M)
21881
84. Consider administration of 3 doses of HPV starting at 6-12 months after HSCT for female patients ages 11-26 years and HPV4 in males ages 11-26 years. (WR, VL)
21881
85. Do not administer live vaccines to HSCT patients with active GVHD or ongoing immunosuppression. (SR, L)
21881
86. Administer a 2-dose series of MMR to measles-seronegative adolescents and adults (SR, L)
21881
and to measles-seronegative children (SR, M)
21881
starting 24 months after HSCT in patients with neither chronic GVHD nor ongoing immunosuppression and 8-11 months (or earlier if in a measles outbreak situation) after the last dose of immune globulin intravenous (IGIV).
87. Administer a 2-dose series of VAR starting 24 months after HSCT to varicella-seronegative patients with neither GVHD nor ongoing immunosuppression and 8-11 months after the last dose of IGIV. (SR, L)
21881

Table 4. Vaccinations Prior to or After Allogeneic or Autologous HSCT

H. influenzae type b conjugate

Pre-HSCT
U: (SR, M)
21881
Post-HSCT
R: 3 doses (SR, M)
at 6 mo post-tx
21881

Hepatitis A

Pre-HSCT
U: (SR, VL)
21881
Post-HSCT
R: 2 doses (WR, L)
at ≥6 mo post-tx
21881

Hepatitis B

Pre-HSCT
U: (SR, L)
21881
Post-HSCT
R: 3 doses (SR, M)
at 6–12 mo post-tx
21881

DTaP, DT, Td, Tdap

Pre-HSCT
U: (SR, L)
21881
Post-HSCT
R: age <7 y: DTaP 3 doses (SR, L)
at ≥6 mo posttx
21881
R: age ≥7 y: DTaP* 3 doses (WR, VL)
at ≥6 mo post-tx
21881
OR 1 dose Tdap, followed by either 2 doses DT* or 2 doses Td (DTaP) (WR, M)
21881
DT, Td (WR, L)
21881

HPV

Pre-HSCT
U: age 11-26 y (SR, VL)
21881
Post-HSCT
U: 3 doses at ≥6 mo post-tx (WR, VL)
21881

Influenza, inactivated

Pre-HSCT
U: (SR, L)
21881
Post-HSCT
R: ≥4 mo post-tx (SR, VL)
if community outbreak;
21881
otherwise ≥6 mo post-tx (SR, M)
21881

Influenza, live attenuated

Pre-HSCT
X: (WR, VL)
21881
Post-HSCT
X: (WR, VL)
21881

MMR, live

Pre-HSCT
U:a (SR, VL)
21881
Post-HSCT
X:b (SR, L)
21881

MMRV, live

Pre-HSCT
U:a (WR, VL)
21881
Post-HSCT
X: (SR, VL)
21881

Meningococcal conjugate

Pre-HSCT
U: (SR, VL)
21881
Post-HSCT
R: age 11-18 y: 2 doses (SR, L)
at 6-12 mo post-tx
21881

Pneumococcal conjugate (PCV13)

Pre-HSCT
R:c (SR, L)
21881
Post-HSCT
R: 3 doses (SR, L)
at 3-6 mo posttx
21881

Pneumococcal polysaccharide (PPSV23)

Pre-HSCT
R:c (SR, VL)
21881
Post-HSCT
R: ≥12 mo post-tx if no GVHD (SR, L)
21881

Poliovirus, inactivated

Pre-HSCT
U: (SR, VL)
21881
Post-HSCT
R: 3 doses (SR, M)
at ≥3 mo post-tx
21881

Rotavirus, live

Pre-HSCT
X: (WR, VL)
21881
Post-HSCT
X: (WR, VL)
21881

Varicella, live

Pre-HSCT
U:a (SR, L)
21881
Post-HSCT
X:d (SR, L)
21881

Zoster, live

Pre-HSCT
R:a,e age 50–59 y* (WR, VL)
21881
U:a age ≥60 y (SR, L)
21881
Post-HSCT
X: age 50–59 y* (SR, L)
21881
X: age ≥60 y (SR, L)
21881
R, recommended—administer if not previously administered or not current; such patients may be at increased risk for this vaccine-preventable infection posttx, posttransplant
U, usual—administer if patient not current with recommendations for dose(s) of vaccine for immunocompetent persons in risk and age categories
X, contraindicated.
Footnotes to Table 4
a These live vaccines should not be administered unless the vaccine is otherwise indicated based on the annually updated CDC recommendations AND the patient is not immunosuppressed AND there will be an interval of ≥4 weeks prior to transplant. (, )
21881
b Administer to adolescents and adults (SR, L)
21881
and to children (SR, M)
21881
if measles-seronegative, the timing is ≥24 months after transplant, no GVHD is present, and the patient is not receiving immunosuppressive medication. Two doses should be administered.
c If not previously administered.
d Administer if varicella-seronegative, the timing is ≥24 months after transplant, no GVHD is present, and the patient is not receiving immunosuppressive medication. Two doses should be administered. (SR, L)
21881
e Consider if the patient is not severely immunosuppressed and the patient is varicella-immune as defined by documentation of age-appropriate varicella vaccination, serologic evidence of immunity, documentation of varicella or zoster infection, or birth in the United States before 1980 and there will be an interval of ≥4 weeks prior to transplant.

* This recommendation deviates from CDC ACIP recommendations.

Solid Organ Transplant (See Table 5)

Donors and Patients Before Transplantation

88. Living donors should be current with vaccines based on age, vaccination history, and exposure history according to the CDC annual schedule, (SR, H)
21881
but MMR, MMRV, VAR, and ZOS administration should be avoided within 4 weeks of organ donation. (WR, VL)
21881
Vaccination of donors solely for the recipient’s benefit is generally not recommended. (WR, L)
21881
89. Adults and children with chronic or end-stage kidney, liver, heart, or lung disease including SOT candidates should receive all age-, exposure history–, and immune status–appropriate vaccines based on the CDC annual schedule for immunocompetent persons. (SR, M)
21881
90. The following persons should receive PCV13 as in recommendations 27a-c: adults who are SOT candidates or have end-stage kidney disease as well as pediatric patients who are SOT candidates; those who are <6 years of age and have end-stage kidney, heart, or lung disease; and those who are 6-18 years of age and have end-stage kidney disease. (SR, VL)
21881
91. Adults and children age ≥2 years old who are SOT candidates or have end-stage kidney disease should receive PPSV23 if they have not received a dose within 5 years and have not received 2 lifetime doses. (SR, M)
21881
Patients with end-stage kidney disease should receive 2 lifetime doses 5 years apart. (SR, L)
21881
Adults and children ≥2 years of age with end-stage heart or lung disease as well as adults with chronic liver disease including cirrhosis should receive a dose of PPSV23 if they never have received a dose. (SR, L)
21881
When both PCV13 and PPSV23 are indicated, PCV13 should be completed 8 weeks prior to PPSV23. (SR, M)
21881
92. anti-HBs–negative SOT candidates should receive a HepB series, (SR, M)
21881
and if on hemodialysis and age ≥20 years they should receive a high-dose (40 µg) HepB series. (SR, M)
21881
If a postvaccination anti-HBs concentration of ≥10 mIU/mL is not attained, a second 3-dose series of HepB (SR, L)
21881
(Alternative: 1 dose of HepB after which anti-HBs is tested*) should be administered using the standard dose (SR, M)
21881
or high dose* for children (WR, L)
21881
and the high dose for adolescents* and adults. (SR, L)
21881
Hepatitis A–unvaccinated, undervaccinated, or seronegative SOT candidates (particularly liver transplant candidates) ages 12–23 months (SR, M)
21881
and those ≥2 years. (SR, M)
should receive a HepA series.
21881
93. Combined HepA-HepB vaccine can be used for SOT candidates ≥12 years of age* in whom both vaccines are indicated. (SR, M)
21881
94. HPV series should be administered to SOT candidates ages 11-26 years. (SR, )

(SR-L to M)

21881
95. SOT candidates 6-11 months of age can receive MMR if they are not receiving immunosuppression and transplantation is not anticipated within 4 weeks. (WR, VL)
21881
If transplantation is delayed (and the child is not receiving immunosuppression), MMR should be repeated at 12 months of age. (SR, M)
21881
96. VAR should be administered to SOT candidates without evidence of varicella immunity (as defined in recommendation 16) if they are not receiving immunosuppression and transplantation is not anticipated within 4 weeks. (SR, M)
21881
VAR can be administered to varicella-naive SOT candidates 6-11 months of age who are not immunosuppressed provided the timing is ≥4 weeks prior to transplant.* (WR, VL)
21881
Optimally, 2 doses should be administered ≥3 months apart. (SR, L)
21881
97. SOT candidates age ≥60 years (SR, M)
21881
and varicella-positive (as defined in recommendation 22) candidates ages 50-59 years.* (WR, L)
21881
who are not severely immunocompromised should receive ZOS if transplantation is not anticipated within 4 weeks.

SOT Recipients

98. Vaccination should be withheld from SOT recipients during intensified immunosuppression including the first 2-month post-transplant period because of the likelihood of inadequate response, (SR, L)
21881
except that IIV can be administered ≥1 month after transplant during a community influenza outbreak. (WR, VL)
21881
99. Standard age-appropriate inactivated vaccine series should be administered 2-6 months after SOT based on the CDC annual schedule, (SR, )

(SR-L to M)

21881
including IIV. (SR, M)
(Table 5)
21881
100. PCV13 should be administered starting 2-6 months after SOT if not administered before SOT, with timing based on the degree of immunosuppression of the individual patient, as described in recommendations 27a-c (Table 5). (SR, )
(SR-VL to M)
21881
101. For SOT patients ≥2 years of age, 1 dose of PPSV23 should be administered starting 2-6 months after SOT with timing based on the degree of immunosuppression of the individual patient, and ≥8 weeks after indicated doses of PCV13, if not given within 5 years and if patient has received no more than 1 previous lifetime dose. (SR, M)
21881
102. HepB should be considered for chronic hepatitis B-infected recipients starting 2-6 months after liver transplant in an attempt to eliminate the lifelong requirement for hepatitis B immune globulin.* (WR, L)
21881
103. MMR and VAR should generally not be administered to SOT recipients because of insufficient safety and effectiveness data, (SR, L)
21881
except for VAR in children without evidence of immunity (as defined in recommendation 15) who are renal or liver transplant recipients and are receiving minimal or no immunosuppression and have no recent graft rejection.* (WR, M)
21881
104. Vaccination should not be withheld because of concern about transplant organ rejection. (SR, M)
21881

Table 5. Vaccinations Prior to or After Solid Organ Transplant

H. influenzae type b conjugate

Pretransplant
U: (SR, M)
21881
Starting 2–6 Months Posttransplant
U: (SR, M)
21881

Hepatitis A

Pretransplant
U: age 12-23 mo (SR, M)
21881
R: age ≥2 y (SR, M)
21881
Starting 2–6 Months Posttransplant
R: if not completed pretransplant (SR, M)
21881

Hepatitis B

Pretransplant
U: age 1-18 y (SR, M)
21881
R: age ≥18 y (SR, M)
21881
Starting 2–6 Months Posttransplant
R: if not completed pretransplanta (SR, M)
21881

DTaP, Tdap

Pretransplant
U: (SR, M)
21881
Starting 2–6 Months Posttransplant
U: if not completed pretransplant (SR, M)
21881

HPV

Pretransplant
U: females age 11-26 y (SR, M)
21881
Starting 2–6 Months Posttransplant
U: females age 11-26 y (SR, M)
21881
U: males age 11-26 y (SR, L)
21881

Influenza, inactivated

Pretransplant
U: (SR, M)
21881
Starting 2–6 Months Posttransplant
U:b (SR, M)
21881

Influenza, live attenuated

Pretransplant
X: (WR, L)
21881
Starting 2–6 Months Posttransplant
X: (WR, L)
21881

MMR, live

Pretransplant
R:c age 6-11 mo (WR, VL)
21881
U:d age ≥12 mo (SR, M)
21881
Starting 2–6 Months Posttransplant
X: (SR, L)
21881

MMRV, live

Pretransplant
U:d (SR, M)
21881
Starting 2–6 Months Posttransplant
X: (SR, L)
21881

Meningococcal conjugate

Pretransplant
U: (SR, M)
21881
Starting 2–6 Months Posttransplant
U: (SR, M)
21881

Pneumococcal conjugate (PCV13)

Pretransplant
U: age <5 y (SR, M)
21881
R: age ≥6 ye (SR, VL)
21881
Starting 2–6 Months Posttransplant
U: age 2-5 y (SR, M)
21881
R: age ≥6 y, if not administered pretransplante (SR, VL)
21881

Pneumococcal polysaccharide (PPSV23)

Pretransplant
R: age ≥2 y (SR, M)
21881
Starting 2–6 Months Posttransplant
R: age ≥2 y, if not administered pretransplant (SR, M)
21881

Poliovirus, inactivated

Pretransplant
U: (SR, M)
21881
Starting 2–6 Months Posttransplant
U: (SR, M)
21881

Rotavirus, live

Pretransplant
U:c (SR, M)
21881
Starting 2–6 Months Posttransplant
X: (SR, L)
21881

Varicella, live

Pretransplant
R:f age 6-11 mo (WR, VL)
21881
U:d (SR, L)
21881
Starting 2–6 Months Posttransplant
X:g (SR, L)
21881

Zoster, live

Pretransplant
R:h age 50-59 y (WR, L)
21881
U:i age ≥60 y (SR, M)
21881
Starting 2–6 Months Posttransplant
X: (SR, L)
21881
R, recommended—administer if not previously administered or not current; such patients may be at increased risk for this vaccine-preventable infection
U, usual—administer if patient not current with recommendations for dose(s) of vaccine for immunocompetent persons in risk and age categories
X, contraindicated.
a Consider hepatitis B vaccine for hepatitis B-infected liver transplant patients. (WR, L)
21881
b IIV may be administered to SOT recipients despite intensive immunosuppression (eg, during the immediate posttransplant period), particularly in an outbreak situation. (WR, L)
21881
c Administer only if patient is not immunosuppressed and the timing is ≥4 weeks prior to transplant.
d Administer only if patient is nonimmune, not severely immunosuppressed, and the timing is ≥4 weeks prior to transplant.
e For patients ≥19 years who have previously received PPSV23, PCV13 should be administered after an interval of ≥1 year after the last PPSV23 dose. (WR, L)
21881
f Administer only if patient is not immunosuppressed and the timing is ≥4 weeks prior to transplant.*
g Selected seronegative patients with a renal or liver transplant have been safely vaccinated.*
h Administer only if patient is not severely immunosuppressed, the timing is ≥4 weeks prior to transplant, and the patient is varicella-immune as defined by documentation of age-appropriate varicella vaccination, serologic evidence of immunity, documentation of varicella or zoster infection, or birth in the United States before 1980. *
i Administer only if patient is not severely immunosuppressed and the timing is ≥4 weeks prior to transplant.

* These recommendations deviate from CDC ACIP recommendations.

Chronic Inflammatory Disease Patients Taking Immunosupporessants (See Table 6)

105. Inactivated vaccines, including IIV, should be administered to patients with chronic inflammatory illness treated with (SR, )

(SR-L to M)

21881
or about to be treated with immunosuppressive agents. (SR, M)
21881
as for immunocompetent persons based on the CDC annual schedule.
106. PCV13 should be administered to adults and children with a chronic inflammatory illness treated with immunosuppression as described in the standard schedule for children and in recommendations 27a-c and Table 6. (SR, )
(SR-VL to M)
21881
107. PPSV23 should be administered to patients ≥2 years of age with chronic inflammatory illness with planned initiation of immunosuppression, (SR, L)
21881
low-level immunosuppression, (SR, L)
21881
and high-level immunosuppression. (SR, VL)
21881
Patients should receive PPSV23 ≥8 weeks after PCV13 and should receive a second dose of PPSV23 5 years later. (SR, L)
21881
108. VAR should be administered to patients with chronic inflammatory disease without evidence of varicella immunity (defined in recommendation 15) (SR, M)
21881
≥4 weeks prior to initiation of immunosuppression, (SR, L)
21881
if treatment initiation can be safely delayed.
109. VAR should be considered for patients without evidence of varicella immunity (defined in recommendation 15) treated for chronic inflammatory disease with long-term, low-level immunosuppression.* (WR, VL)
21881
110. ZOS should be administered to patients with a chronic inflammatory disorder who are ≥60 years of age prior to initiation of immunosuppression (SR, L)
21881
or while being treated with low-dose immunosuppression, (SR, VL)
21881
and to those who are 50-59 years of age and varicella-positive prior to initiation of immunosuppression* (WR, L)
21881
or while being treated with low-dose immunosuppression.* (WR, VL)
21881
111. Other live vaccines should NOT be administered to patients with chronic inflammatory diseases who are receiving maintenance immunosuppression: LAIV, (WR, VL)
21881
MMR in patients receiving low-level (WR, VL)
21881
or high-level immunosuppression, (WR, VL)
21881
and MMRV in patients receiving low-level (WR, VL)
21881
or high-level immunosuppression. (SR, VL)
21881
112. Otherwise recommended vaccines, including IIV and HepB, should not be withheld because of concerns about exacerbation of chronic immune-mediated or inflammatory illness. (SR, M)
21881

Table 6. Vaccination of Persons With Chronic Inflammatory Diseases on Immunosuppressive Medications

H. influenzae type b conjugate

Planned Immunosuppression
U: (SR, M)
21881
Low-Level Immunosuppressiona
U: (SR, L)
21881
High-Level Immunosuppressiona
U: (SR, L)
21881

Hepatitis A

Planned Immunosuppression
U: (SR, M)
21881
Low-Level Immunosuppressiona
U: (SR, L)
21881
High-Level Immunosuppressiona
U: (SR, L)
21881

Hepatitis B

Planned Immunosuppression
U: (SR, M)
21881
Low-Level Immunosuppressiona
U: (SR, L)
21881
High-Level Immunosuppressiona
U: (SR, L)
21881

DTaP, Td, Tdap

Planned Immunosuppression
U: (SR, M)
21881
Low-Level Immunosuppressiona
U: (SR, L)
21881
High-Level Immunosuppressiona
U: (SR, L)
21881

HPV

Planned Immunosuppression
U: age 11-26 y (SR, M)
21881
Low-Level Immunosuppressiona
U: age 11-26 y (SR, L)
21881
High-Level Immunosuppressiona
U: age 11-26 y (SR, VL)
21881

Influenza, inactivated

Planned Immunosuppression
U: (SR, M)
21881
Low-Level Immunosuppressiona
U: (SR, M)
21881
High-Level Immunosuppressiona
U: (SR, M)
21881

Influenza, live attenuated

Planned Immunosuppression
X: (WR, VL)
21881
Low-Level Immunosuppressiona
X: (WR, VL)
21881
High-Level Immunosuppressiona
X: (WR, VL)
21881

MMR, live

Planned Immunosuppression
U:b (SR, M)
21881
Low-Level Immunosuppressiona
X: (WR, VL)
21881
High-Level Immunosuppressiona
X: (WR, VL)
21881

MMRV, live

Planned Immunosuppression
U:b (SR, L)
21881
Low-Level Immunosuppressiona
X: (WR, VL)
21881
High-Level Immunosuppressiona
X: (SR, VL)
21881

Meningococcal conjugate

Planned Immunosuppression
U: (SR, M)
21881
Low-Level Immunosuppressiona
U: (SR, M)
21881
High-Level Immunosuppressiona
U: (SR, L)
21881

Pneumococcal conjugate (PCV13)

Planned Immunosuppression
R:c (SR, M)
21881
Low-Level Immunosuppressiona
U: age <6 y (SR, L)
21881
R: age ≥6 yc (SR, VL)
21881
High-Level Immunosuppressiona
U: age <6 y (SR, L)
21881
R: age ≥6 yc (SR, VL)
21881

Pneumococcal polysaccharide (PPSV23)

Planned Immunosuppression
R: age ≥2 y (SR, L)
21881
Low-Level Immunosuppressiona
R: age ≥2 y (SR, L)
21881
High-Level Immunosuppressiona
R: age ≥2 y (SR, VL)
21881

Poliovirus, inactivated

Planned Immunosuppression
U: (SR, M)
21881
Low-Level Immunosuppressiona
U: (SR, M)
21881
High-Level Immunosuppressiona
U: (SR, L)
21881

Rotavirus, live

Planned Immunosuppression
U: (SR, M)
21881
Low-Level Immunosuppressiona
X: (WR, VL)
21881
High-Level Immunosuppressiona
X: (WR, VL)
21881

Varicella, live

Planned Immunosuppression
U:d (SR, M)
21881
Low-Level Immunosuppressiona
X:d (WR, VL)
21881
High-Level Immunosuppressiona
X: (SR, M)
21881

Zoster, live

Planned Immunosuppression
R: age 50-59 y* (WR, L)
21881
U: age ≥60 y (SR, L)
21881
Low-Level Immunosuppressiona
R: age 50-59 y* (WR, VL)
21881
U: age ≥60 y (SR, VL)
21881
High-Level Immunosuppressiona
X: (WR, VL)
21881
R, recommended—administer if not previously administered or not current; such patients may be at increased risk for this vaccine-preventable infection
U, usual—administer if patient not current with recommendations for dose(s) of vaccine for immunocompetent persons in risk and age categories
X, contraindicated.

a Low-level immunosuppression includes treatment with prednisone <2 mg/kg with a maximum of ≤20 mg/day, methotrexate ≤0.4 mg/kg per week, azathioprine ≤3 mg/kg per day, or 6-mercaptopurine ≤1.5 mg/kg per day. High-level immunosuppression regimens include treatment with doses higher than those listed for low-dose immunosuppression, and biologic agents such as tumor necrosis factor antagonists or rituximab.
b Administer only if patient is nonimmune, not severely immunosuppressed, and the timing is ≥4 weeks prior to initiation of immunosuppressive medications.
c For patients ≥19 years who have previously received PPSV23, PCV13 should be administered after an interval of ≥1 year after the last PPSV23 dose. (WR, L)
21881
d Administration of VAR can be considered for non–varicella-immune patients treated for chronic inflammatory disease who are receiving long-term, low-dose immunosuppression.* (WR, VL)
21881
* These recommendations deviate from CDC ACIP recommendations.

Asplenia or Sickle Cell Diseases (See Table 7)

113. Asplenic patients or those with sickle cell diseases should receive vaccines including PCV13 for children <2 years of age as recommended routinely for immunocompetent persons based on the CDC annual schedule. None is contraindicated, (SR, M)
21881
except LAIV in patients with sickle cell disease. (WR, VL)
21881
114. PCV13 should be administered to asplenic patients or patients with sickle cell diseases who are ≥2 years of age based on the CDC annual schedule for children and as described in recommendations 27a-c. (SR, )
(SR-VL to M)
21881
115. PPSV23 should be administered to asplenic patients or patients with a sickle cell disease who are ≥2 years of age (SR, L)
21881
with an interval of ≥8 weeks after PCV13, and a second dose of PPSV23 should be administered 5 years later. (SR, L)
21881

For PPSV23--naive patients ≥2 years of age for whom a splenectomy is planned, PPSV23 should be administered ≥2 weeks prior to surgery (and following indicated dose[s] of PCV13)

(SR, M)
21881
or ≥2 weeks following surgery.* (WR, L)
21881
117. One dose of Hib should be administered to unvaccinated persons ≥5 years of age who are asplenic or have a sickle cell disease. (WR, L)
21881
118. Meningococcal vaccine should be administered to patients ≥2 months of age who are asplenic or have a sickle cell disease (SR, L)
21881

as in recommendation 29 except that MCV4--D should not be administered in patients age <2 years because of a reduced antibody response to some pneumococcal serotypes when both MCV4 and PCV are administered simultaneously.

(SR, L)
21881
Revaccinate with MCV4 (or MPSV4 for those >55 years of age who have not previously received MCV4) every 5 years. (SR, L)
21881

Anatomic Barrier Defects (See Table 7)

119. Adults and children with profound deafness scheduled to receive a cochlear implant, congenital dysplasias of the inner ear, or persistent cerebrospinal fluid (CSF) communication with the oropharynx or nasopharynx should receive all vaccines recommended routinely for immunocompetent persons based on the CDC annual schedule. None is contraindicated. (SR, M)
(See Table 7)
21881
120. Patients with a cochlear implant, with profound deafness who are scheduled to receive a cochlear implant, or with persistent communication between the CSF and oropharynx or nasopharynx should receive PCV13 as described in the standard schedule for children and recommendations 27a-c. (SR, )
(SR-L to M)
21881
121. Patients ≥24 months of age with a cochlear implant, with profound deafness who are scheduled to receive a cochlear implant, or with persistent communication between the CSF and oropharynx or nasopharynx should receive PPSV23, preferably ≥8 weeks after PCV13. (SR, M)
21881
122. PCV13 and PPSV23 should be administered ≥2 weeks prior to cochlear implant surgery, if feasible. (SR, L)
21881

Table 7. Vaccination of Persons With Asplenia or a Sickle Cell Disease, Cochlear Implants, or CSF Leak

H. influenzae type b conjugate

Asplenia or a Sickle Cell Disease
U: age <5 y (SR, M)
21881
R: age ≥5 y (WR, L)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Hepatitis A

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Hepatitis B

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

DTaP, Td, Tdap

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

HPV

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Influenza, inactivated

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Influenza, live attenuated

Asplenia or a Sickle Cell Disease
X: (WR, VL)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

MMR, live

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

MMRV, live

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Meningococcal conjugate

Asplenia or a Sickle Cell Disease
R: age 2-55 yb (SR, L)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Meningococcal polysaccharide

Asplenia or a Sickle Cell Disease
R: age >55 yb (SR, L)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Pneumococcal conjugate (PCV13)

Asplenia or a Sickle Cell Disease
U: age <6 yc (SR, M)
21881
R: age ≥6 yd (SR, VL)
21881
Cochlear Implantsa or CSF Leak
U: age <6 yc (SR, M)
21881
R: age ≥6 yd (SR, L)
21881

Pneumococcal polysaccharide (PPSV23)

Asplenia or a Sickle Cell Disease
R: age ≥2 ye (SR, L)
21881
Cochlear Implantsa or CSF Leak
R: age ≥2 ye (SR, M)
21881

Poliovirus, inactivated

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Rotavirus, live

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Varicella, live

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881

Zoster, live

Asplenia or a Sickle Cell Disease
U: (SR, M)
21881
Cochlear Implantsa or CSF Leak
U: (SR, M)
21881
R, recommended—administer if not previously administered or not current; such patients may be at increased risk for this vaccine-preventable infection
U, usual—administer if patient not current with recommendations for dose(s) of vaccine for immunocompetent persons in risk and age categories
X, contraindicated.

a Includes patients with profound hearing loss who are scheduled to receive a cochlear implant or have inner ear-cerebrospinal fluid communication.
b A 2-dose primary series should be administered and an additional dose every 5 years.
c Two doses of cPCV13 for children 2 through 5 years of age who have not previously received doses of PCV or received <3 doses of PCV7.
d If PCV13 has not previously been administered. For patients ≥19 years who have previously received PPSV23, PCV13 should be administered after an interval of ≥1 year after the last PPSV23 dose. (WR, L)
21881
e Administer 8 or more weeks after indicated dose(s) of PCV13 and a single revaccination with PPSV23 5 years after the initial dose. (SR, M)
21881

Recommendation Grading

Overview

Title

Vaccination of the Immunocompromised Host

Authoring Organization

Infectious Diseases Society of America

Publication Month/Year

December 4, 2013

Last Updated Month/Year

October 10, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These guidelines were created to provide primary care and specialty clinicians with evidence-based guidelines for active immunization of patients with altered immunocompetence and their household contacts in order to safely prevent vaccine-preventable infections. They do not represent the only approach to vaccination. Recommended immunization schedules for normal adults and children as well as certain adults and children at high risk for vaccine-preventable infections are updated and published annually by the Centers for Disease Control and Prevention (CDC) and partner organizations. Some recommendations have not been addressed by the Advisory Committee on Immunization Practices (ACIP) to the CDC or they deviate from recommendations. The goal of presenting these guidelines is to decrease morbidity and mortality from vaccine-preventable infections in immunocompromised patients. Summarized below are the recommendations made by the panel. Supporting tables that provide additional information are available in the electronic version. The panel followed a process used in the development of other Infectious Diseases Society of America guidelines, which included a systematic weighting of the quality of the evidence and the grade of the recommendation. The key clinical questions and recommendations are summarized in this executive summary. A detailed description of the methods, background, and evidence summaries that support each recommendation can be found in the full text of the guidelines.

Target Patient Population

Patients with altered immunocompetence

PICO Questions

  1. Who is responsible for vaccinating immunocompromised patients and members of their household?

  2. When should vaccines be administered to immunocompetent patients in whom initiation of immunosuppressive medications is planned?

  3. Which vaccines can be safely administered to individuals living in a household with immunocompromised patients, and what precautions should immunocompromised patients observe after vaccination of household members?

  4. Which vaccines can be administered to immunocompromised patients contemplating international travel?

  5. Should immunocompromised patients or those scheduled to receive immunosuppressive therapy receive varicella vaccine (VAR)?

  6. Should immunocompromised patients or those who will undergo immunosuppression receive zoster vaccine (ZOS)?

  7. Should immunocompromised patients receive influenza vaccine?

  8. Which vaccines should be administered to patients with primary (congenital) complement deficiencies?

  9. Which vaccines should be administered to patients with phagocytic cell deficiencies (eg, chronic granulomatous disease [CGD], leukocyte adhesion deficiency, Chediak–Higashi syndrome)?

  10. Which vaccines should be administered to patients with innate immune defects that result in defects of cytokine generation/response or cellular activation (eg, defects of the interferon-gamma/interleukin-12 [IFN-γ/IL-12] axis)?

  11. Which vaccines should be administered to patients with minor antibody deficiencies?

  12. Which vaccines should be administered to patients with major antibody deficiencies who are receiving immunoglobulin therapy?

  13. Which vaccines should be administered to patients with combined immunodeficiencies?

  14. Which inactivated vaccines should be administered to human immunodeficiency virus (HIV)-infected patients?

  15. Should live vaccines be administered to HIV-infected patients?

  16. Which vaccines should be given to patients with cancer?

  17. Should hematopoietic stem cell transplant (HSCT) donors and patients be vaccinated before transplantation?

  18. Which vaccines should be administered to adults and children after HSCT?

  19. For adult and child SOT candidates and living donors, which vaccines should be administered during pretransplant evaluation?

  20. Which vaccines should be administered to SOT recipients?

  21. Which vaccines should be administered to patients with chronic inflammatory diseases maintained on immunosuppressive therapies?

  22. Which vaccines should be administered to asplenic patients and those with sickle cell diseases?

  23. Which vaccines should be given to individuals with cochlear implants or congenital dysplasias of the inner ear or persistent CSF communication with the oropharynx or nasopharynx?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Prevention

Diseases/Conditions (MeSH)

D016867 - Immunocompromised Host, D007114 - Immunization

Keywords

vaccination, immunosuppression, immunization, immunodeficiency, immunocompromised, asplenic

Source Citation

Lorry G. Rubin, Myron J. Levin, Per Ljungman, E. Graham Davies, Robin Avery, Marcie Tomblyn, Athos Bousvaros, Shireesha Dhanireddy, Lillian Sung, Harry Keyserling, Insoo Kang, 2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host, Clinical Infectious Diseases, Volume 58, Issue 3, 1 February 2014, Pages e44–e100, https://doi.org/10.1093/cid/cit684