Table 1.
Medical condition | How is the immune system affected | Non-live vaccines recommendation | Live-attenuated vaccines recommendation a | Additional vaccine(s) recommendation | Serological monitoring | Guidelines, references |
---|---|---|---|---|---|---|
Primary immunodeficiency disorders | Genetic abnormality affecting various pathway of the immune response | Routine b | Permitted in certain situations only |
IIV PCV (± PPSV23) MCV4 MenB if complement deficiency |
“Regularly”, but no guidance on how often |
ACIP [29] |
Oncological diseases | Most cancers and their treatment affect the immune system |
Routine during chemotherapy c Re-start vaccination as of 3m to 6m after completion of chemotherapy (including Hib, regardless of age) |
Permitted as of 3m to 6m after completion of chemotherapy |
IIV (even during chemotherapy) PCV (± PPSV23) MCV |
No indication Could be useful to monitor seroprotection against measles and varicella |
CCLG [48] IDSA [22] ACIP [29] AIEOP [55] |
Hematopoietic stem-cell transplantation | Impaired and immature immune cells, loss of Ig | Revaccination starting 3m to 6m after HSCT (including Hib, regardless of age) | Revaccination permitted in certain condition as of 1.5y to 2y after HSCT |
IIV PCV, 3d (± PPSV23) MCV, 2d |
No indication Could be useful to monitor seroprotection against measles and varicella |
CCLG [48] EBMT [49] IDSA [22] ACIP [29] |
Solid organ transplantation | Immunosuppressive treatment | Accelerated schedule before SOT. Continue after SOT (as of 2m to 6m post-SOT) | Accelerated schedule if > 4w before SOT. Permitted in certain situation after SOT, as of 1y post-SOT [47] |
IIV PCV (± PPSV23) |
Frequent monitoring to guide vaccination; it can also inform on protection against measles and varicella |
AST, IPTA [47] IDSA [22] ACIP [29] |
Asplenia/hyposplenia Sickle cell disease |
Higher risk of fulminant infection with encapsulated bacteria and parasite (highest risk in the first 2y of asplenia but persist life-long) | Routine, catch-up Hib vaccination regardless of age, HBV vaccination highly recommended if frequent transfusion. Anticipate 2w between vaccination and elective splenectomy | Permitted, as of a few days after splenectomy |
IIV PCV (± PPSV23) MCV4 2d 2m apart, then every 5y MenB |
Frequent monitoring of serotype-specific pneumococcal IgG to guide booster doses |
IDSA [22] ACIP [29] |
Human immunodeficiency virus infection | Lower CD4+ T-cell | Delay vaccination until viral load < 50 copies/mL and CD4 > 15% for 6m. Use high-dose HBV vaccine (40 μg) in adolescents. Give Hib vaccine regardless of age if not immune. DT booster at least 1×/10y. | Permitted only if CD4 > 200 cells/μl (or > 15–24% in infants and children) for > 6m |
IIV PCV (± PPSV23) MCV4 2d 2m apart |
Anti-HBs Ig periodically (if ongoing exposure) Anti-tetanus, anti-diphtheria 1×/5y Anti-measles, anti-rubella 1×/3–5y |
PENTA [56] CHIVA IDSA [22] ACIP [29] |
Immunosuppressive treatment for rheumatologic, renal, neurologic, gastrointestinal conditions | Underlying disease with dysregulated immune system, immunosuppressive treatment to control disease activity | Accelerate schedule before immunosuppression, but continue during and after | Permitted if low immunosuppression |
IIV PCV (± PPSV23) |
No indication but monitoring could guide booster doses and inform on protection, in particular against measles and varicella |
IDSA [22] Review [16] |
Complement inhibitors (eculizumab) | Medication inhibiting the deployment of the terminal complement system, high risk of meningococcal disease | Routine | Permitted |
IIV PCV MCV4 MenB |
No indication | Review [57] |
Inflammatory bowel disease | Underlying defect in immune system, immunosuppressive treatment | Accelerate schedule before immunosuppression, but continue during and after | Permitted if low immunosuppression |
IIV PCV (± PPSV23) |
No indication, but monitoring could guide booster doses and inform on protection, in particular against measles and varicella |
IDSA [22] |
Nephrotic syndrome | Urinary loss of IgG, oedema, immunosuppressive treatment | Accelerate schedule before immunosuppression, but continue during and after | Permitted if low immunosuppression, VZV vaccine highly recommended |
IIV PCV (± PPSV23) |
Monitoring of serotype-specific pneumococcal antibody useful to guide booster. Monitor seroprotection against measles and varicella could be useful as well. |
ACIP [29] Review [18] |
Prematurity |
Immune cell immaturity Low IgG level (not had time to transfer from the mother) |
Accelerated schedule, based on chronological age | Accelerated schedule, based on chronological age |
IIV PCV MCV RSV (cf country) |
No indication |
Review [58] AAP (RSV) [7] |
Diabetes mellitus | Impaired phagocytic and neutrophil function, worsen with inadequate glycaemic control | Routine, HBV vaccination highly recommended | Permitted |
IIV PCV (± PPSV23) |
Documentation of protection against HBV. No other indication, antibody response to vaccinations seems to be normal overall |
ACIP [29] Review [59] CDA (adults) [60] |
Renal failure, chronic kidney disease (including dialysis) | Mild defects in T cell function, immune response impaired by various factor; Ig loss in dialysate | Accelerate schedule before dialysis, but continue during and after, HBV vaccination highly recommended | Permitted |
IIV PCV (± PPSV23) |
No indication, but monitoring could guide booster doses and inform on protection (vaccine responses likely to be impaired) |
ACIP [29] Review [18] |
Chronic liver disease | Impaired phagocyte function and defects in opsonising antibody, Ig loss in ascites, hyposplenism (with severe liver disease), higher risk of severe superimposed viral hepatitis | Routine, HAV and HBV vaccination highly recommended | Permitted |
IIV PCV (± PPSV23) |
No indication, but monitoring could guide booster doses and inform on protection | ACIP [29] |
Chronic heart disease or malformation | Infections may precipitate cardiac decompensation | Routine | Permitted |
IIV PCV (± PPSV23) RSV (cf country and underlying disease) |
No indication |
ACIP [29] AAP (RSV) [7] |
Chronic lung disease Cystic fibrosis Bronchopulmonary dysplasia Asthma |
Increased risk of severe respiratory infections. Severe lung diseases lead to poor mucociliary clearance, bronchiectasis, defects in pulmonary macrophage function | Routine | Permitted |
IIV PCV (± PPSV23) RSV (cf country and underlying disease severity) |
No indication |
ACIP [29] AAP (RSV) [7] |
Haemophilia | Historical increased risk of transfusion-related transmission of viral infection | Routine,d HAV and HBV vaccination highly recommended | Permitted d | No indication, adequate response to HBV vaccine could be documented | WFH [61] | |
Malnutrition Anorexia nervosa |
Immune response impaired due to malnutrition | Routine | Permitted |
IIV? Insufficient data to date |
No indication | Review [62] |
Obesity | Immune response slightly impaired due to overweight (and insulin resistance), higher risk of respiratory infection | Routine | Permitted | IIV | No indication, few studies reported lower vaccine responses | Reviews [63–65] |
Coeliac disease | Functional hyposplenism (reversible), impaired immune response | Routine, HBV vaccination highly recommended | Permitted |
IIV PCV (± PPSV23) ± MCV if hyposplenism confirmed |
HBV serology (data suggest poor response to HBV vaccine administered prior to gluten-free diet) | Review [66, 67] |
Chronic neurological disease and neurodevelopmental disorder | Decreased protection of airways increases risk of infection, higher risk of complication for some VPD (e.g. influenza, pneumococcus, varicella, pertussis) | Routine | Permitted, VZV vaccination highly recommended (higher risk of neurological complications) |
IIV PCV |
No indication | Recent article [68] |
Inborn errors of metabolism | Neurological defect, concomitant immunodeficiency, metabolic decompensation | Routine | Permitted |
IIV? PCV? Insufficient data to date |
Unpredictable vaccine responses, depending on underlying immune defect | Review [21] |
CNS anatomic barrier defect (e.g. CSF leak, inner ear dysplasia, or cochlear implant) |
Deficient anatomical barrier leads to higher risk of CNS infection | Routine | Permitted | PCV (± PPSV23) | No indication |
IDSA [22] ACIP [29] |
Severe dermatologic conditions (severe eczema, psoriasis) | Chickenpox particularly prone to bacterial superinfection; severe dermatologic possibly require immunosuppressive treatment | Routine | Permitted if low immunosuppression, VZV vaccination highly recommended | No indication | Review [69] | |
Parents, close contact of immune compromised individuals | ‘Cocooning’ strategy, to decrease the risk to transmit VPD to the immunocompromised children | Routine | Highly recommended if not immune, OPV and smallpox vaccine are the only LAV contra-indicated in close contact | IIV or LAIV | Documentation of immunity against measles and varicella if disease/vaccination history uncertain (or immunise regardless) |
IDSA [22] Review [53] |
The table summarises the vaccine recommendations available for various health conditions. Recommendations can differ between guidelines and between countries. In some countries, the cost of some vaccines may not be reimbursed. Recommendation for serological monitoring is rarely discussed in guidelines and the ones presented in this table summarise experts’ advices
aThe live-attenuated influenza vaccine should never be given to immune compromised children as they can receive the inactivated influenza vaccine
bEffectiveness doubtful, depend on underlying disease and whether IVIG are given regularly
cPostpone if lymphocyte count < 1.0 × 109/L. Non-live vaccine permitted during chemotherapy but will not be considered as “valid dose”
dReduce the risk of bleeding by subcutaneous injection, use smallest gauge needle and applying pressure and/or ice for 3–5 min after injection
AAP American Academy of Paediatrics, ACIP Advisory Committee on Immunization Practices, AIEOP Italian Association Paediatric Haematology Oncology, CDA Canadian Diabetes Association, CHIVA Children’s HIV Association, CSF cerebrospinal fluid, d dose, DTaP diphtheria-tetanus-pertussis vaccine, EBMT European Society for Blood and Marrow Transplantation, HAV hepatitis A virus, HBV hepatitis B virus, Hib Haemophilus influenzae type b, HSCT hematopoietic stem cell transplantation, IDSA Infectious Disease Society of America, Ig immunoglobulin, IIV inactivated influenza vaccine, IPTA International Paediatric Transplant Association, IPV inactivated poliovirus vaccine, IVIG intravenous immunoglobulins, LAIV live-attenuated influenza vaccine, LAV live-attenuated vaccine, m month, MCV meningococcal conjugated vaccine, MenB meningococcus type B vaccine, MMR measles-mumps-rubella vaccine, NLV non-live vaccine, OPV oral polio vaccine, PCV pneumococcal conjugate vaccine, PPSV23 23-valent pneumococcal polysaccharide vaccine, PENTA Paediatric European Network for Treatment of AIDS, RSV respiratory syncytial virus, SOT solid organ transplantation, VPD vaccine-preventable disease, VZV varicella vaccine, w week, WFH World Federation of Hemophilia, y year