TABLE 6.

Summary of recommendations for active vaccination of immunocompromised hosts with HIV infection or severe and mild immunosuppression^a

Vaccine	Safety in patients with:			Response rateb in patients with:			Recommendationc for patients with:
	HIV	Immunosuppression		HIV	Immunosuppression		HIV	Immunosuppression:
		Severe	Mild		Severe	Mild		Severe	Mild
MMR	Risk	Risk	Safe	Poor	Decreased	Good	Recommendd	Contraindicated	Recommend
Varicella	?	Safe	Safe	?	Moderate	Moderate	?	Recommend	Recommend
Hepatitis B	Safe	Safe	Safe	Decreased	Moderate	Good	Recommend	Recommend	Recommende
Influenza	Safef	Safe	Safe	Very poor	Decreased	Moderate	Recommendg	Recommend	Recommend
Toxoids	Safef	Safe	Safe	Decreased	Decreased	Good	Recommendg	Recommend	Recommend
Hib conjugates	Safe	Safe	Safe	Decreased	Decreased	Good	Recommendh	Recommend	Recommend
Pneumococcal	Safe	Safe	Safe	Very poor	Very poor	Poor	Recommendi	Recommend	Recommend

^aIn this table patients are stratified according to HIV status, or, for HIV-uninfected individuals, immunosuppression is characterized as “severe,” which includes patients with cancer on antineoplastic therapy, BMT recipients receiving immunosuppressive therapy, and patients receiving high-dose corticosteroids, and “mild,” which includes patients with rheumatologic disorders, those receiving lower-dose corticosteroids, those with renal diseases, and those with asplenia in the absence of intercurrent antineoplastic therapy. These categories are derived from the Committee on Immunization Practices, Centers for Disease Control and Prevention (50). 

^bThe levels of antibody that are required to protect individuals with impaired immunity are unknown and may exceed the concentrations that are thought to protect immunocompetent individuals. Individuals with impaired immunity generally respond to vaccines with lower antibody concentrations than do normal individuals. 

^cThe recommendations in this table apply to both adults and children. All routine infant and childhood vaccinations should be given to HIV-infected and other immunosuppressed children with the exception of the MMR vaccine, which should be administered only to children with HIV (50). Polio vaccines are not listed in this table because the live preparations are contraindicated in all immunosuppressed individuals (50) and their household contacts, and inactivated polio preparations should be used in these individuals. 

^dVaccinated and unvaccinated symptomatic HIV-infected individuals and unvaccinated immunocompromised patients should receive immunoglobulin following a measles exposure (50). 

^eVaccination with HBV should be considered in patients with renal disease whose titers have fallen. Similarly, health care personnel should receive vaccination when indicated. 

^fInfluenza and toxoid vaccination can increase plasma viremia in HIV-infected individuals; the long-term prognostic consequences of this phenomenon are unknown (204, 254, 255). The acellular pertussis vaccine has not been tested in immunocompromised groups (64). 

^gInfluenza and toxoid vaccination are recommended in HIV-infected individuals, although plasma viremia has been noted following vaccination as noted in footnote f. Amantadine prophylaxis is an appropriate alternative to vaccination for influenza and should be considered during influenza epidemics or in the case of exposure of a severely immunocompromised individual. 

^hHib conjugates are safe in HIV-infected individuals, but a minimum of studies on the immunogenicity of these vaccines in this group have been published to date. 

ⁱThe 23-valent pneumococcal polysaccharide vaccine is the vaccine of choice in HIV-infected individuals. Studies published to date indicate that pneumococcal conjugates are less immunogenic than the purified polysaccharide vaccines in both HIV-infected and severely immunocompromised individuals (4).