Vaccine
Talk

Non-live Vaccines: Safety

Non-live Vaccines: Effectiveness

The same rationale regarding effectiveness that exists with non-live vaccines also exists with live vaccines.

Severe complications have followed vaccination with certain live, attenuated viral and live, attenuated bacterial vaccines among persons with altered immunocompetence.

Persons with most forms of altered immunocompetence should not receive live vaccines (MMR, varicella, MMRV, LAIV, yellow fever, Ty21a oral typhoid, BCG, smallpox, and rotavirus). However, exceptions exist, and are discussed in this section. Patients with any defect in phagocytic function (e.g., chronic granulomatous disease, leukocyte adhesion deficiency, myeloperoxidase deficiency, Chediak-Higashi syndrome) should NOT receive live bacterial vaccines.

Patients with a specific type of defect in phagocytic function—chronic granulomatous disease—should receive recommended live attenuated viral vaccines in addition to non-live vaccines but should NOT receive live bacterial vaccines.

Patients with defects in phagocytic function that are undefined or known to be accompanied by defects in T-cell and natural killer cell function (e.g., leukocyte adhesion deficiency, myeloperoxidase deficiency, Chediak-Higashi syndrome) should NOT receive live attenuated viral or bacterial vaccines. These conditions include specific deficits in T-cell and natural killer cell function, reducing the response to live viral vaccine antigens to an extent not seen in chronic granulomatous disease.

Children with deficiencies in complement should receive recommended live, attenuated viral and live, attenuated bacterial vaccines.

Children with asplenia should not receive LAIV, but can receive recommended live, attenuated viral and live, attenuated bacterial vaccines.

Persons with severe cell-mediated immunodeficiency should not receive live, attenuated viral or bacterial vaccines.

Patients with defects of the interferon-gamma/interleukin-12 axis should not receive live bacterial vaccines. Patients with deficiencies of interferon-gamma or interferon-alpha should not receive live viral or live bacterial vaccine. These defects involve a deficiency in cytokine production which affects the immune response to a wide scope of antigens, both bacterial and viral.

Two factors support vaccination of HIV-exposed or HIV-infected infants with rotavirus vaccines: 1) the HIV diagnosis might not be established in infants born to HIV-infected mothers before the age of the first rotavirus vaccine dose (only 1.5%-3% of HIV-exposed infants in the United States will be determined to be HIV-infected), and 2) the vaccine strains of rotavirus are considerably attenuated.

Patients taking exogenous interferon as therapy should not receive live bacterial or live viral vaccines.

Children with HIV infection are at increased risk for complications from varicella and herpes zoster infection compared with immunocompetent children. Limited data among HIV-infected children younger than 8 years (specifically, those individuals with CDC class N, A, or B with age-specific CD4+ T-lymphocyte percentages of ≥15%) indicate that single-component varicella vaccine is immunogenic, effective, and safe. Data on use of varicella vaccine in HIV-infected adolescents and adults are lacking. However, on the basis of expert opinion, the safety of varicella vaccine in HIV-infected persons older than 8 years with comparable levels of immune function (CD4+ T-lymphocyte count greater than 200 cells/mm³) is likely to be similar to that of children aged younger than 8 years. Varicella vaccine should be considered for persons who meet these criteria. Eligible HIV-infected persons 12 months of age or older should receive 2 doses of single-component varicella vaccine with a 3-month interval between doses. MMRV vaccine should not be administered to any HIV-infected person.

Persons with HIV infection are at increased risk for severe complications if infected with measles. No severe or unusual adverse events have been reported after measles vaccination among HIV-infected persons who did not have evidence of severe immunosuppression. Two doses of MMR vaccine are recommended for all HIV-infected individuals aged ≥12 months who do not have evidence of current severe immunosuppression (i.e., individuals aged ≤5 years must have CD4+ T lymphocyte [CD4+] percentages ≥15% for ≥6 months, and individuals aged >5 years must have CD4+ percentages ≥15% and CD4+ ≥200 lymphocytes/mm³ for ≥6 months) and do not have current evidence of measles, rubella, and mumps immunity. In cases when only CD4+ cell counts or only CD4+ percentages are available for those >5 years, the assessment of severe immunosuppression can be based on the CD4+ values (count or percentage) that are available. In cases when CD4+ percentages are not available for those aged ≤5 years, the assessment of severe immunosuppression can be based on age-specific CD4+ counts at the time CD4+ counts were measured; i.e., absence of severe immunosuppression is defined as ≥6 months above age-specific CD4+ count criteria: CD4+ count >750 lymphocytes/mm³ while aged ≤12 months and CD4+ count ≥500 lymphocytes/mm³ while aged 1 through 5 years. Similarly, repeat doses of MMR vaccination are recommended for individuals with perinatal HIV infection who were vaccinated prior to establishment of effective combination antiretroviral therapy (cART). They should receive 2 appropriately spaced doses of MMR vaccine once effective cART has been established (individuals aged ≤5 years must have CD4+ percentages ≥15% for ≥6 months; individuals aged >5 years must have CD4+ percentages ≥15% and CD4+ ≥200 lymphocytes/mm³ for ≥6 months) unless they have other acceptable current evidence of measles, rubella, and mumps immunity.

HIV-infected persons who are receiving regular doses of IGIV are unlikely to respond to varicella vaccine or MMR vaccine because of the continued presence of passively acquired antibody. However, because of the potential benefit, MMR and varicella vaccines should be considered approximately 14 days before the next scheduled dose of IGIV (if not otherwise contraindicated), although an optimal immune response might not occur depending on the presence of neutralizing antibodies against the vaccine virus. Vaccination should be repeated (if not otherwise contraindicated) after the recommended interval. In most cases, this is after the therapy has been discontinued.

Patients with leukemia, lymphoma, or other malignancies whose disease is in remission, who have restored immunocompetence, and whose chemotherapy has been discontinued for at least 3 months can receive live-virus vaccines. Persons with impaired humoral immunity (e.g., hypogammaglobulinemia or dysgammaglobulinemia) may be vaccinated with varicella vaccine. However, most persons with these disorders also receive periodic doses of IGIV. Appropriate spacing should be maintained between administration of IGIV and varicella vaccine in an attempt to prevent an inadequate response to vaccination caused by the presence of neutralizing antibodies from the IGIV.

Zoster incidence is higher in persons with altered immunocompetence. Adults with most types of altered immunocompetence are expected to maintain residual immunity to varicella-zoster virus because of chronic latent infection that protects against primary varicella but provides incomplete protection against zoster. Zoster vaccine is not recommended in persons with primary or acquired immunodeficiency (e.g., lymphoma, leukemia, tumors involving bone marrow, and patients receiving chemotherapy) and some HIV infected patients. Zoster vaccine may be administered to certain persons age 50 or older with altered immunocompetence, such as persons receiving low dosages of immunosuppressive medications, those with isolated B-cell deficiencies (i.e., impaired humoral immunity), or those with HIV infection who have CD4+ T-lymphocyte counts >200 cells/mm³.