Immunization of immunocompromised adults

X: contraindicated (per the Advisory Committee on Immunization Practices [ACIP]); U: use as indicated for normal hosts; R: recommended for all in this patient category; P: precaution (per ACIP); OC: other considerations; C: consider; ND: no data; PCV13: 13-valent pneumococcal conjugate vaccine; PPSV23: 23-valent pneumococcal polysaccharide vaccine.
* No safety or efficacy data exist regarding use of the current formulation of CVD 103-HgR vaccine in HIV-positive adults or people with severe immunosuppression. Limited data from an older formulation of the CVD 103-HgR suggest no association between the vaccine and serious or systemic adverse events, and slightly lower immunogenicity of the vaccine in HIV-positive versus HIV-negative adults.
¶ MMR vaccination is recommended for all HIV-infected patients aged ≥12 months with (for patients aged <6 years) CD4 percentage ≥15% or (for patients aged ≥6 years) CD4 percentage ≥15% and CD4 counts ≥200/mm³ for ≥6 months if they are without evidence of measles immunity. Immune globulin may be administered for short-term protection of those facing high risk of measles and for whom MMR vaccine is contraindicated. Additional guidance is available at www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm.
Δ Varicella vaccine should not be administered to people who have cellular immunodeficiencies, but people with impaired humoral immunity (including congenital or acquired hypoglobulinemia or dysglobulinemia) may be vaccinated. HIV-positive adults with CD4 counts ≥200 cells/mm3 should be considered to receive 2 doses of vaccine spaced at 3-month intervals. VariZIG (varicella-zoster–specific immune globulin) is recommended for those exposed to varicella or herpes zoster if they do not have evidence of varicella immunity and have contraindications to vaccination.
◊ See details in Chapter 4, Yellow Fever. Yellow fever (YF) vaccination is a precaution for asymptomatic HIV-infected people with CD4 cell counts of 200 to 499/mm³. YF vaccination is not a precaution for people with asymptomatic HIV infection and CD4 cell counts ≥500/mm³. YF vaccine is also considered contraindicated by ACIP for symptomatic HIV patients without AIDS and with CD4 counts <200/mm³.
§ No data suggest increased risk of serious adverse events after use of YF vaccine in people with these conditions; however, varying degrees of immune deficit might be present, and providers should carefully weigh vaccine risks and benefits before deciding to vaccinate people with these conditions.
¥ Also contraindicated by ACIP for symptomatic HIV patients without AIDS and with CD4 counts <200/mm³. No recommendation for asymptomatic HIV patients without AIDS and with CD4 counts ≥200/mm³. Recombinant zoster vaccine is the preferred agent.
‡ Recipients of a hematopoietic stem cell transplant should be vaccinated with a 3-dose regimen 6 to 12 months after a successful transplant, regardless of vaccination history; at least 4 weeks should separate doses.
† In adults, Hib is recommended for those with asplenia only if they have not previously received Hib vaccine.
** Routinely indicated for all men who have sex with men, hemophiliacs, patients with chronic hepatitis, injection drug users, and others.
¶¶ Hepatitis B vaccination is indicated for people at risk for infection by sexual exposure, including sex partners of hepatitis B surface antigen (HBsAg)-positive people, sexually active people who are not in a long-term mutually monogamous relationship, people seeking evaluation or treatment for a sexually transmitted disease, men who have sex with men, people at risk for infection by percutaneous or mucosal exposure to blood, current or recent injection-drug users, household contacts of HBsAg-positive people, residents and staff of facilities for developmentally disabled people, health care and public safety workers with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids, people with end-stage kidney disease, international travelers to regions with high or intermediate levels (HBsAg prevalence >2 percent) of endemic HBV infection (refer to Map 4-04, available at https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-b#map404), people with chronic liver disease, and people with HIV infection.
ΔΔ Adult patients receiving hemodialysis or with other immunocompromising conditions should receive 1 dose of 40 mcg/mL Recombivax HB administered on a 3-dose schedule at 0, 1, and 6 months or 2 doses of 20 mcg/mL (Engerix-B) administered simultaneously on a 4-dose schedule at 0, 1, 2, and 6 months. Test for antibodies to hepatitis B virus surface antigen serum after vaccination and revaccinate if initial antibody response is absent or suboptimal (<10 mIU/mL). HIV-infected nonresponders may react to a subsequent vaccine course if CD4 cell counts rise to 500/mm³ after institution of highly active antiretroviral therapy. See text for discussion of other immunocompromised groups.
◊◊ HPV vaccine (3-dose schedule at 0, 1 to 2, and 6 months) is recommended through age 26 years. Should be administered as indicated for males and females but is additionally recommended for men 22 to 26 years of age in this patient category (otherwise male indication is through age 21 years). Female indication in each category is through 26 years of age.
§§ No safety or efficacy data exist regarding the use of Ixiaro in immunocompromised people. In general, inactivated vaccines can be administered safely to people with altered immunocompetence, using the usual doses and schedules, but the effectiveness might be suboptimal. The inactivated, Vero cell–derived Japanese encephalitis vaccine, Ixiaro, is the only Japanese encephalitis vaccine available in the United States; other types of Japanese encephalitis vaccines, including live vaccines, are available internationally but are not included here.
¥¥ Children aged 2 to 23 months should receive the vaccine in accordance with the age- appropriate, licensed, multidose schedule. For people aged ≥2 years, 2 doses ≥8 weeks apart are recommended. If the most recent dose was received at age <7 years, a booster dose should be administered 3 years after the primary series and every 5 years thereafter. If the most recent dose was received at age ≥7 years, a booster dose should be administered after 5 years, and every 5 years thereafter. See www.cdc.gov/mmwr/volumes/65/wr/pdfs/mm6543a3.pdf for more information.
‡‡ Previously unimmunized asplenic, HIV-infected, with chronic renal disease or nephrotic syndrome, or immunocompromised adults aged ≥5 years should receive 1 dose of PCV13 followed by 1 dose of PPSV23 ≥8 weeks later. People with these conditions previously immunized with PPSV23 should follow catch-up guidelines per ACIP.
†† For postexposure prophylaxis, both vaccine (5 doses at day 0, 3, 7, 14, 28) and immune globulin should be given to immunocompromised people, regardless of previous vaccination status.