Principles of immunisation in the immunocompromised host

Overview

Immunosuppressed patients need modified vaccination approaches - balancing infection risk (often higher than the general population) against reduced vaccine efficacy and, for live vaccines, safety
Applies broadly to solid organ/haematopoietic transplant recipients, patients on biologics/chemotherapy/high-dose corticosteroids, and those with primary immunodeficiency or HIV

Live vaccines are generally contraindicated in significant immunosuppression - risk of vaccine-strain disease from uncontrolled replication
Inactivated/subunit vaccines are safe but often produce a reduced antibody response proportional to the degree of immunosuppression

Where feasible, complete any needed live vaccinations before starting planned immunosuppression (e.g. before transplant, before starting a biologic) - timing matters more than in immunocompetent patients
Assess vaccination status and gaps as part of pre-treatment workup for any planned immunosuppressive therapy

Additional/booster doses and higher-dose formulations are often used to compensate for blunted response (e.g. high-dose influenza vaccine)
Household/close contacts should be vaccinated (cocooning) to reduce the immunosuppressed patient's exposure risk, including with vaccines the patient themselves cannot safely receive
Specific timing rules apply post-transplant/post-chemotherapy (vaccination generally deferred for a defined period after intense immunosuppression, then resumed once the treatment course allows)

Solid organ and haematopoietic stem cell transplantation, biologic/immunosuppressive therapy, HIV, primary immunodeficiency

Vaccination gaps identified before starting immunosuppression are far easier to close than gaps discovered afterward, when live vaccines may need to be deferred for months to years

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