Public Health Agency of Canada
Symbol of the Government of Canada

Share this page

Canadian Immunization Guide

[Previous page] [Table of Contents] [Next page]

Part 3
Vaccination of Specific Populations

Immunization of Immunocompromised Persons

General Recommendations and principles

The safety and effectiveness of vaccines in immunocompromised persons are determined by the type of immunodeficiency and degree of immunosuppression. Each immunocompromised person is different and presents unique considerations regarding immunization. The relative degree of immunodeficiency is variable depending on the underlying condition. Immunodeficiency can also vary over time in many people and the decision to recommend for or against a particular vaccine will depend upon a case-by-case analysis of the risks and benefits. There is potential for serious illness and death if immunocompromised people are under-immunized and every effort should be made to ensure adequate protection through immunization; however, inappropriate use of live vaccines can cause serious adverse events in some immunocompromised people as a result of uncontrolled replication of the vaccine virus or bacterium.

The following recommendations reflect general best practices and are subject to individual considerations and new evidence as it arises.

Inactivated vaccines

Inactivated vaccines may be administered to immunocompromised people if indicated because the antigens in the vaccine cannot replicate and there is no increase in the risk of vaccine-associated adverse events; however, the magnitude and duration of vaccine-induced immunity are often reduced. When considering immunization of an immunocompromised person with an inactivated vaccine, consultation with the individual's attending physician may be of assistance in addition to the guidance provided in this chapter and in the Part 4 vaccine-specific chapters of the Canadian Immunization Guide. For complex cases, referral to a physician with expertise in immunization and/or immunodeficiency is advised.

Live vaccines

In general, immunocompromised people should not receive live vaccines because of the risk of disease caused by the vaccine strains. People who are severely immunocompromised or in whom immune status is uncertain should not receive live vaccines. In less severely immunocompromised people, the benefits of vaccination with routinely recommended live vaccines may outweigh risks. When considering immunization of an immunocompromised person with a live vaccine, approval from the individual's attending physician should be obtained before vaccination. In complex cases, referral to a physician with expertise in immunization and/or immunodeficiency is advised.

Serologic testing and re-immunization

Immune response to vaccines may be inadequate in immunocompromised people and vaccinees may remain susceptible despite appropriate vaccination. If serologic testing is available and there is a clear antibody correlate of protection, measurement of post-immunization antibody titres to determine immune response and guide re-vaccination and post-exposure management should be considered. Refer to vaccine-specific chapters in Part 4 for additional information.

General principles

Several general principles apply to the immunization of immunocompromised individuals:

  • Maximize benefit while minimizing harm.
  • Susceptibility or degree of protection vary according to degree of immune suppression.
    • In a severely immunosuppressed person, such as someone who has had a hematopoietic stem cell transplant, there may not be complete protection even when there is a history of childhood infection or previous immunization.
  • Immunize at the time when maximum immune response can be anticipated.
    • Immunize early before immunodeficiency begins, if possible.
    • Delay immunization if the immunodeficiency is transient (if this can be done safely).
    • Stop or reduce immunosuppression to permit better vaccine response, if appropriate.
  • Consider the immunization environment broadly.
    • Vaccinate close contacts when appropriate.
    • Strongly encourage up-to-date vaccinations, including annual influenza vaccination, for all healthcare workers providing care to immunocompromised people.
  • Avoid live vaccines unless:
    • immunosuppression is mild and data are available to support their use.
    • the risk of natural infection is greater than the risk of immunization.
  • Monitor vaccinees carefully and boost aggressively.
    • The magnitude and duration of vaccine-induced immunity are often reduced in immunocompromised individuals.

Family or medical history

Immunodeficiency states may be undiagnosed in young children presenting for routine immunizations, which include live vaccines. This is particularly important to consider in infants receiving live vaccines before 12 months of age.

Clues pointing to the presence of significant immunodeficiency may be found in the medical or family history. Children with a history of failure to thrive and/or recurrent serious infections such as pneumonia or sepsis may have an immunodeficiency. A family history of congenital immunodeficiency may be known or may be suspected on the basis of a family history of early infant deaths. However, many congenital immunodeficiencies are autosomal recessive so the family history can be negative. Maternal HIV infection puts the infant at risk of immunodeficiency in the first year of life. Routine prenatal blood work in Canada includes HIV testing. A history of negative prenatal screening of the infant's mother for HIV should be obtained before administering a live vaccine to an infant less than 12 months of age. If a mother has not received routine prenatal care in Canada, the possibility of undiagnosed HIV infection should be considered.

Congenital (primary) immunodeficiency

Congenital immunodeficiency states are generally inherited and include defects in antibody production (e.g., agammaglobulinemia, isotype and IgG subclass deficiencies, common variable immunodeficiency), complement deficiencies, defects in one or more aspects of cell-mediated immunity, and mixed deficits. Individuals with defects in antibody and complement are highly susceptible to encapsulated bacteria such as Streptococcus pneumoniae, Haemophilus influenza type b (Hib) and Neisseria meningitidis. Individuals with mixed and T cell defects are particularly susceptible to virtually all viruses and some bacteria.

As a general rule, people with antibody defects can be protected from many of the vaccine preventable infections with the use of replacement immune globulin (Ig) or pathogen-specific Ig preparations; however, the level of antibody to specific pathogens may be variable and vaccination is recommended to increase the level of protection. Receipt of replacement Ig is not a contraindication for vaccination; however, Ig can interfere with the immune response to some live attenuated viral vaccines such as measles and varicella vaccine. Refer to Blood Products, Human Immune Globulin and Timing of Immunization in Part 1 for the recommended intervals between Ig and subsequent immunization.

Refer to Immunization of Persons with Chronic Diseases in Part 3 for information regarding immunization of asplenic or hyposplenic people.

Inactivated vaccines

Inactivated vaccines should be administered to people with congenital immunodeficiency states according to routine immunization schedules. All individuals with congenital immunodeficiency disorders should receive pneumococcal, hepatitis B and Hib vaccines; annual immunization with trivalent inactivated influenza vaccine is recommended. In addition, persons with complement, properdin, factor D or primary antibody deficiencies should be vaccinated with quadrivalent conjugate meningococcal vaccine. Refer to Table 1 and vaccine-specific chapters in Part 4 for additional information.

Live vaccines

All live vaccines are contraindicated for people with T cell, natural killer T cell, and mixed cellular and antibody defects (e.g. Severe Combined Immune Deficiency [SCID]). Inadvertent live vaccine administration and exposure to natural infections can be managed with rapid administration of Ig or pathogen-specific Ig with or without appropriate antiviral or antibacterial treatment.

In general, live vaccines are not recommended for individuals with other congenital immunodeficiency states, with the following exceptions:

  • People with X-linked agammaglobulinemia and Common Variable Immunodeficiency (and known intact T cell immunity) generally should not receive live vaccines. However, they should be considered for measles-mumps-rubella (MMR), and univalent varicella vaccines as appropriate for age. Regular immune globulin replacement therapy may affect the efficacy of these live vaccines. All other live vaccines such as rotavirus, Bacille Calmette-Guérin (BCG) and oral typhoid are contraindicated.
  • People with isolated IgA deficiency who have no concomitant defects in T cell function can receive most live vaccines. Live mucosal vaccines (rotavirus, live attenuated influenza vaccine [LAIV], oral typhoid) are likely safe and may be used although there may be lack of mucosal response; some experts may prefer to use inactivated vaccines (e.g., inactivated trivalent influenza vaccine, parenteral inactivated typhoid vaccine). However, given that there are limited data on the use of live mucosal vaccines, consultation with an immunologist is advised and immunization with these vaccines should be individually assessed.
    • People with IgG subclass deficiencies can receive live vaccines although response may be suboptimal. In addition, regular immune globulin replacement therapy may diminish response to a live vaccine.
  • People with phagocytic and neutrophil disorders (e.g., congenital neutropenia, leukocyte adhesion and migration defects, chronic granulomatous disease) may be vaccinated with MMR, rotavirus, univalent varicella, herpes zoster, LAIV, or yellow fever vaccine, if indicated. Live bacterial vaccines (BCG and oral typhoid vaccine) are contraindicated.
  • People with complement deficiency (e.g., properdin or factor D deficiency) may receive any live vaccine, if indicated.

Refer to Table 1 and Table 2 for recommendations for vaccination of persons with congenital immunodeficiency and vaccine-specific chapters in Part 4 for additional information.

Table 1: Vaccination of persons with congenital immunodeficiency - inactivated vaccines
(Refer to text and vaccine-specific chapters in Part 4 for additional information)
Inactivated vaccine Congenital Immunodeficiency Comments
B cell deficiency T cell, mixed defects Phagocytic & neutrophil disorders Complement deficiency
Table 1 - Footnote 1
routine use: follow routine immunization schedules with age-appropriate booster doses
Table 1 - Footnote 2
regardless of prior history of Hib vaccination and at least 1 year after any previous dose
anti-HBs:
antibody to hepatitis B surface antigen
Ig
immune globulin
Cholera and travellers' diarrhea (inactivated) Use if indicated Use if indicated Use if indicated Use if indicated  
Diphtheria Routine useTable 1 - Footnote 1 Routine use Routine use Routine use  
Haemophilus influenzae type b (Hib) Children less than 5 years of age: routine use Children less than 5 years of age: routine use Children less than 5 years of age: routine use Children less than 5 years of age: routine use
Individuals 5 years of age and older: 1 dose recommendedTable 1 - Footnote 2 Individuals 5 years of age and older: 1 dose recommendedTable 1 - Footnote 2 Individuals 5 years of age and older: 1 dose recommendedTable 1 - Footnote 2 Individuals 5 years of age and older: 1 dose recommendedTable 1 - Footnote 2
Hepatitis A Use if indicated Use if indicated Use if indicated Use if indicated
  • Pre-exposure prophylaxis for travel: consider Ig with hepatitis A vaccine
  • Post-exposure prophylaxis: Ig recommended along with vaccine
  • Refer to Hepatitis A Vaccine in Part 4 for additional information
Hepatitis B Recommended Recommended Recommended Recommended
  • Higher dosage recommended
  • Post-immunization serology testing of anti-HBs titres recommended with re-immunization if response less than 10 IU/L
  • Periodic monitoring of anti-HBs titre recommended
  • Refer to Hepatitis B Vaccine in Part 4 for additional information
HPV Routine use Routine use Routine use Routine use
  • 3-dose schedule recommended
Influenza (inactivated) Recommended Recommended Recommended Recommended
  • Recommended annually
  • Refer to Influenza Vaccine in Part 4 for additional information
Japanese encephalitis Use if indicated Use if indicated Use if indicated Use if indicated  
Meningococcal conjugate Quadrivalent conjugate meningococcal vaccine recommended Quadrivalent conjugate meningococcal vaccine recommended Routine use Quadrivalent conjugate meningococcal vaccine recommended
Pertussis Routine use Routine use Routine use Routine use  
Pneumococcal conjugate 13-valent (Pneu-C-13) Recommended Recommended Recommended Recommended
  • Fair evidence to recommend
  • Refer to Pneumococcal Vaccine in Part 4 for additional information
  • Should be followed - at least 2 months later or when reaches age 2 years - with a pneumococcal polysaccharide vaccine dose
Pneumococcal polysaccharide (Pneu-P-23) Recommended Recommended Recommended Recommended
  • One life-time re-immunization recommended
  • Refer to Pneumococcal Vaccine in Part 4 for additional information
Polio (inactivated) Routine use Routine use Routine use Routine use  
Rabies Use if indicated Use if indicated Use if indicated Use if indicated
  • Do not use intradermally
  • Post-immunization serology recommended
  • Refer to Rabies Vaccine in Part 4 for additional information
Tetanus Routine use Routine use Routine use Routine use  
Typhoid (inactivated) Use if indicated Use if indicated Use if indicated Use if indicated  
Table 2: Vaccination of persons with congenital immunodeficiencies - live attenuated vaccines
(Refer to text and vaccine-specific chapters in Part 4 for additional information)
Live attenuated vaccine Congenital Immunodeficiency Comments
B cell deficiency T cell, mixed defects Phagocytic & neutrophil disorders Complement deficiency
X-linked agammaglobulinemia
&
Common Variable Immunodeficiency
IgA deficiency
&
IgG subclass deficiency
Table 2 - Footnote 1
routine use: follow routine immunization schedules with age-appropriate booster doses
Table 2 - Footnote 2
consult with immunologist in cases of IgA deficiency
Table 2 - Footnote 3
some experts may prefer inactivated vaccine for persons with IgA deficiency
Table 2 - Footnote 4
regular immune globulin replacement therapy may affect the efficacy of the vaccine. Refer to Blood Products, Human Immune Globulin and Timing of Immunization in Part 1 for the recommended intervals between Ig and subsequent immunization.
Ig
immune globulin
BCG Contraindicated Use if indicated Contraindicated Contraindicated Use if indicated  
Herpes zoster Contraindicated Routine useTable 2 - Footnote 1 Contraindicated Routine use Routine use  
Influenza (live) Contraindicated -- use inactivated Consider useTable 2 - Footnote 2, Table 2 - Footnote 3 Contraindicated -- use inactivated May receive if indicated May receive if indicated
Measles-mumps-rubella Consider useTable 2 - Footnote 4 Routine useTable 2 - Footnote 4 Contraindicated Routine use Routine use
  • Complement deficiency: consider post-immunization serology and re-immunization, if protective titres not achieved
  • Refer to Measles Vaccine in Part 4 for additional information
Rotavirus ContraindicatedTable 2 - Footnote 3 Consider useTable 2 - Footnote 2 Contraindicated Routine use Routine use  
Smallpox Contraindicated Use if indicated Contraindicated Use if indicated Use if indicated  
Typhoid (live) Contraindicated; if indicated, use inactivated Consider useTable 2 - Footnote 2,Table 2 - Footnote 3 Contraindicated; if indicated, use inactivated Contraindicated; if indicated, use inactivated Use if indicated  
Varicella (univalent) Consider useTable 2 - Footnote 4 Routine useTable 2 - Footnote 4 Contraindicated May be given 2 doses at least 3 months apart May be given 2 doses at least 3 months apart
Yellow fever Contraindicated Use if indicated Contraindicated Use if indicated Use if indicated  

Acquired (secondary) immunodeficiency

Acquired immunodeficiency states result from diseases or infection that directly or indirectly cause immunosuppression (e.g., malignant hematologic disorders or solid tumours, hematopoietic stem cell transplantation, solid organ transplantation, HIV-infection) or long-term immunosuppressive therapy (e.g., long-term steroids, cancer chemotherapy, radiation therapy) used for organ transplantation and a range of chronic infectious and inflammatory conditions (e.g., inflammatory bowel disease, psoriasis, systemic lupus erythematosis). Refer to Immunization of Persons with Chronic Diseases in Part 3 for information regarding immunization of asplenic or hyposplenic people.

Acquired complement deficiency

People with conditions such as paroxysmal nocturnal hemoglobinuria who are receiving the terminal complement inhibitor eculizumab (Soliris™, Alexion Pharmaceuticals Inc.) should receive two doses of quadrivalent conjugate meningococcal vaccine. They must be vaccinated at least two weeks prior to receiving the first dose of eculizumab, if possible, and every 5 years thereafter if they continue to use the drug.

Malignant hematologic disorders

(e.g., leukemia, lymphomas or other malignant neoplasms affecting the bone marrow or lymphatic systems)

Inactivated vaccines

Inactivated vaccines should be administered to people with malignant hematologic disorders according to routine immunization schedules. Individuals with malignant neoplasms, including lymphoma and leukemia, should receive pneumococcal and Hib vaccines because of increased susceptibility to disease. Annual immunization with trivalent inactivated influenza vaccine is also recommended.

Live vaccines

Live vaccines are contraindicated in individuals with severe immunodeficiency due to blood dyscrasias, lymphomas, leukemias of any type, or other malignant neoplasms affecting the bone marrow or lymphatic systems and in people undergoing immunosuppressive treatment for malignancy.

Children with Acute Lymphocytic Leukemia (ALL) may be vaccinated with MMR vaccine with or without varicella vaccine if the disease has been in remission for at least 12 months, the child's total lymphocyte count is at least 1.2 × 109/L, the child is not receiving radiation therapy, and maintenance chemotherapy can be withheld for at least 1 week before to 1 week after immunization. Refer to Varicella (Chickenpox) Vaccine in Part 4 for additional information. Persons with leukemia in remission and who have not received immunosuppressive chemotherapy or radiation for at least 3 months and who do not have defects in T cell function can receive herpes zoster vaccine if indicated. Refer to Herpes Zoster (Shingles) Vaccine in Part 4 for additional information.

Malignant solid tumours
Inactivated vaccines

Inactivated vaccines should be administered to people with malignant solid tumours according to routine immunization schedules. In addition, pneumococcal vaccines should be given because of increased susceptibility to invasive pneumococcal disease. Annual immunization with trivalent inactivated influenza vaccine is also recommended.

Live vaccines

Live vaccines are contraindicated in people undergoing immunosuppressive treatment for any malignant solid tumours. In general, if a patient is 3 months post-chemotherapy and the cancer is in remission, the person is no longer considered immunocompromised.

Hematopoietic stem cell transplantation

(HSCT - autologous or allogeneic)

HSCT is the transplantation of blood-derived or bone marrow-derived hematopoietic stem cells following bone marrow ablation or non-ablative conditioning by chemotherapy or radiation. HSCT recipients receive either their own cells (autologous HSCT) or cells from a donor (allogeneic HSCT). Cells are sourced from bone marrow, peripheral blood, or umbilical cord blood.

Antibody titres to vaccine-preventable diseases decrease after allogeneic or autologous HSCT if the HSCT recipient is not revaccinated post-transplant. Virtually all HSCT recipients experience a prolonged period of immune suppression following transplantation. Allogeneic HSCT recipients experience profound immune suppression in the early post-transplant period but relatively normal immunity after 1 to 2 years if they are off immunosuppressive medication and free of graft-versus-host disease (GVHD). GVHD generally does not occur.

Immunity after transplant must be at least partially reconstituted for a vaccine to mount a clinically significant response. In general, T cells capable of responding to new antigens are generated at 6 to 12 months after transplant, earlier in young children and later in adults. The differences in responses of autologous and allogeneic HSCT recipients to vaccines are not well characterized and approaches to vaccination are the same. Efficacy data for vaccines in HSCT recipients are limited.

Vaccination in accordance with transplant centre-specific immunization guidelines is generally part of routine post-transplant care provided by many transplant centers.

Pre-HSCT

If time permits, careful consideration must be given to the pre-ablation immunization status of the HSCT candidate. If the transplant is planned during the influenza season, trivalent inactivated influenza vaccine should be given at least 2 weeks prior to transplant. People awaiting HSCT should not receive live vaccines. Donor vaccination may improve responses of the HSCT recipient to some vaccines; however, in general, due to logistical and ethical issues, donor vaccination is not practiced.

Post-HSCT

HSCT recipients should be viewed as "never immunized" and require re-immunization after transplant because the ablation of hematopoietic cells in the bone marrow pre-transplant eliminates the person's immune memory. In addition, certain vaccine preventable diseases pose increased risk for HSCT recipients of all ages (e.g., pneumococcal, Haemophilus influenzae type b, measles, varicella, and influenza). Quadrivalent conjugate meningococcal vaccine should be given if indicated by age and risk factors for invasive meningococcal disease. HSCT recipients respond poorly to polysaccharide vaccines, such as pneumococcal polysaccharide 23-valent vaccine. If serologic testing is available and there is a clear antibody correlate of protection, measurement of post-immunization antibody titres to determine immune response and guide re-vaccination and post-exposure management should be considered.

Inactivated vaccines

Inactivated vaccines should be repeated for HSCT recipients generally beginning 6 to 12 months post-transplant (pneumococcal conjugate vaccine may be given beginning at 3 to 9 months post-transplant, trivalent inactivated influenza vaccine may be given beginning at 4 to 6 months post-transplant). Refer to Table 3 and vaccine-specific chapters in Part 4 for recommendations for HSCT recipients.

Live vaccines

MMR and univalent varicella vaccines may be considered 24 months or more post-transplant for HSCT recipients provided there is no evidence of chronic GVHD, immunosuppression has been discontinued for at least 3 months, and the person is considered immunocompetent by a transplant specialist. Refer to Table 3 and vaccine-specific chapters in Part 4 for recommendations for HSCT recipients.

Table 3: Post-transplantation vaccination of hematopoietic stem cell transplantation (HSCT) recipients
(Refer to text and vaccine-specific chapters in Part 4 for additional information)
Vaccine Post-transplantation Comments
Table 3 - Footnote 1
if immunosuppression has been discontinued for at least 3 months, does not have chronic GVHD, and considered immunocompetent by a transplant specialist
anti-HBs
antibody to hepatitis B surface antigen
Ig
immune globulin
Inactivated vaccines

Cholera and travellers' diarrhea (inactivated)

Use if indicated

  • Beginning 6 months post-HSCT

Diphtheria

Recommended: 3 doses

  • Beginning 6 to 12 months post-HSCT
  • Refer to Diphtheria Toxoid in Part 4 for additional information

Haemophilus influenzae type b (Hib)

Recommended: 3 doses

Hepatitis A

Use if indicated

  • Beginning 6 months post-HSCT
  • Pre-exposure prophylaxis for travel: consider Ig with hepatitis A vaccine
  • Post-exposure prophylaxis: Ig recommended along with hepatitis A vaccine
  • Refer to Hepatitis A Vaccine in Part 4 for additional information

Hepatitis B

Recommended: 3 doses

  • Beginning 6 to 12 months post-HSCT
  • Higher dosage recommended
  • Post-immunization serology testing of anti-HBs titres recommended with re-immunization if response less than 10 IU/L Periodic monitoring of anti-HBs titre recommended
  • Refer to Hepatitis B Vaccine in Part 4 for additional information

HPV

Recommended if indicated: 3 doses

  • Beginning 6 to 12 months post-HSCT

Influenza (inactivated)

Recommended annually

  • Beginning 4 to 6 months post-HSCT
  • Refer to Influenza Vaccine in Part 4 for additional information

Japanese encephalitis

Use if indicated

  • Beginning 6 months post-HSCT

Meningococcal conjugate

Children and adolescents: routine use

Adults: use quadrivalent conjugate meningococcal vaccine if indicated by risk factors for invasive meningococcal disease

Pertussis

Recommended: 3 doses for children and adolescents up to age 18

1 dose for adults 18 years of age and older

  • Beginning 6 to 12 months post-HSCT
  • Refer to Diphtheria Toxoid in Part 4 for additional information

Pneumococcal conjugate 13-valent (Pneu-C-13)

Recommended: 3 doses

  • Beginning 3 to 9 months post-HSCT after discussion with transplant specialist
  • 3 doses of Pneu-C-13 vaccine at least 4 weeks apart followed by a dose of Pneu-P-23 vaccine 6 to 12 months after the last Pneu-C-13 dose
  • Refer to Pneumococcal Vaccine in Part 4 for additional information

Pneumococcal polysaccharide (Pneu-P-23)

Recommended: 1 dose

  • Consider re-immunization after 1 year
  • Refer to Pneumococcal Vaccine in Part 4 for additional information

Polio (inactivated)

Recommended: 3 doses

  • Beginning 6 to 12 months post-HSCT
  • Refer to Diphtheria Toxoid in Part 4 for additional information

Rabies

Use if indicated

  • Do not use intradermally
  • As needed for post-exposure management
  • Beginning 6 to 12 months post-HSCT for pre-exposure prophylaxis
  • Post-immunization serology recommended
  • Refer to Rabies Vaccine in Part 4 for additional information

Tetanus

Recommended: 3 doses

  • Beginning 6 to 12 months post-HSCT
  • Refer to Diphtheria Toxoid in Part 4 for additional information

Typhoid (inactivated)

Use if indicated

  • Beginning 6 months post-HSCT
Live vaccines

BCG

Contraindicated

Herpes zoster

Not recommended

Influenza (live)

Not recommended -- use inactivated vaccine

Measles-mumps-rubella

Consider use: 1 doseTable 3 - Footnote 1, followed by 2nd dose after 3 or more months if no seroconversion

  • Beginning 24 months post-HSCT
  • Serology recommended after 1st dose
  • Refer to Measles Vaccine in Part 4 for additional information

Rotavirus

Contraindicated

Smallpox

Contraindicated

Typhoid (live)

Contraindicated -- if indicated use inactivated

Varicella (univalent)

Consider use: 1 doseTable 3 - Footnote 1

  • Beginning 24 months post-HSCT
  • Pre- and post-immunizations serology recommended
  • Refer to Varicella (Chickenpox) Vaccine in Part 4 for additional information

Yellow fever

May be given if clearly indicatedTable 3 - Footnote 1

Solid organ transplantation
Pre-solid organ transplantation

Pre-transplant serology is routine at most transplant centres. Ideally, all non-immune solid organ transplantation candidates should be immunized prior to transplantation and as early in the course of disease as possible because vaccine response may be reduced in people with organ failure pre-transplant. In addition, vaccines are generally more immunogenic if given before transplantation because the immunosuppressive medications given after transplant to prevent and treat rejection of the transplanted organ may diminish the vaccine response.

Inactivated vaccines should be given at least 2 weeks before transplantation and live attenuated vaccines should be given at least 4 weeks prior to transplantation. Refer to Table 4 and vaccine-specific chapters in Part 4 for recommendations for vaccination of solid organ transplant candidates.

Post-solid organ transplantation

Solid organ recipients generally receive lifelong immunosuppression, which varies substantially depending on the organ transplanted. Usually the degree of immune suppression is greatest in the first 3 to 6 months post-transplant and less after a year, but a significant degree of immune suppression persists indefinitely. A minority of transplant recipients who experience chronic rejection, persistent organ dysfunction, or chronic infections, remain profoundly immune suppressed. In general, vaccination should not be re-initiated until 3 to 6 months post-transplant when baseline immunosuppression levels are attained. If serologic testing is available and there is a clear antibody correlate of protection, measurement of post-immunization antibody titres to determine immune response and guide re-vaccination and post-exposure management should be considered. Refer to Table 4 and vaccine-specific chapters in Part 4 for recommendations for vaccination of solid organ transplant recipients.

Solid organ transplant recipients are at risk of severe illness or death due to influenza. Once infected, transplant recipients develop increased viral loads and prolonged shedding which increase the potential for disease dissemination. Solid organ transplant recipients are also at increased risk of invasive pneumococcal disease, Haemophilus influenza type b disease and complications of varicella infection.

Most recently transplanted solid organ recipients receive vaccination in accordance with transplant centre-specific immunization guidelines as part of routine post-transplant care.

Table 4: Vaccination of solid organ transplant candidates and recipients
(Refer to text and vaccine-specific chapters in Part 4 for additional information)
Vaccine Pre-transplantTable 4 - Footnote 1 Post-transplant
(if not vaccinated pre-transplant)
Comments
Table 4 - Footnote 1
whenever possible, vaccine series should be completed pre-transplantation. Vaccines given post-transplant may not be sufficiently immunogenic.
Table 4 - Footnote 2
inactivated vaccines should be given at least 2 weeks before transplantation and, in general, should not be given until 3 to 6 months post-transplant when baseline immunosuppression levels are attained
Table 4 - Footnote 3
routine use: follow routine immunization schedules with age-appropriate booster doses
Table 4 - Footnote 4
regardless of prior history of Hib vaccination and at least 1 year after any previous dose
Table 4 - Footnote 5
Pneu-C-13 vaccine followed by Pneu-P-23 vaccine is recommended. Antibody titres decline after 3 years; however, experience with re-immunization after solid organ transplant is limited.
Table 4 - Footnote 6
live attenuated vaccines should be given at least 4 weeks prior to transplantation
Table 4 - Footnote 7
may be given to infants as early as 6 months of age if transplantation is anticipated before 12 to 15 months of age
anti-HBs
antibody to hepatitis B surface antigen
Ig
immune globulin
Inactivated vaccinesTable 4 - Footnote 2
Cholera and travellers' diarrhea (inactivated) Use if indicated Use if indicated  
Diphtheria Routine useTable 4 - Footnote 3 Routine use  
Haemophilusinfluenzae type b (Hib) Children less than 5 years of age: routine use

Individuals 5 years of age and older: 1 dose recommendedTable 4 - Footnote 4
  • Children less than 5 years of age: routine use
  • Individuals 5 years of age and older: 1 dose recommendedTable 4 - Footnote 4
Hepatitis A Use if indicated Use if indicated
  • Recommended for transplant candidates with chronic liver diseases
  • Pre-exposure prophylaxis for travel: consider Ig with hepatitis A vaccine
  • Post-exposure prophylaxis: Ig recommended along with hepatitis A vaccine
  • Refer to Hepatitis A Vaccine in Part 4 for additional information
Hepatitis B Routine use Routine use
  • Higher dosage recommended for post-transplant vaccine recipients
  • Post-immunization serology testing of anti-HBs recommended with re-immunization if response less than 10 IU/L
  • Periodic monitoring of anti-HBs titre recommended
  • Refer to Hepatitis B Vaccine in Part 4 for additional information
HPV Routine use Routine use
  • 3 dose schedule recommended
  • May be considered for pre-transplant administration prior to routinely recommended age, if reasonably close to minimum recommended age for vaccination
Influenza (inactivated) Recommended annually Recommended annually
Japanese encephalitis Use if indicated Use if indicated  
Meningococcal conjugate Children and adolescents: routine use

Adults: use quadrivalent meningococcal conjugate vaccine if indicated by risk factors for invasive meningococcal disease
Children and adolescents: routine use

Adults: use quadrivalent conjugate meningococcal vaccine if indicated by risk factors for invasive meningococcal disease
Pertussis Routine use Routine use  
Pneumococcal conjugate 13-valent Recommended Recommended
  • Refer to Pneumococcal Vaccine in Part 4 for additional information
  • Should be followed - at least 2 months later or when reaches age 2 years - with a pneumococcal polysaccharide vaccine doseTable 4 - Footnote 5
Pneumococcal polysaccharide Recommended Recommended
  • One life-time re-immunization recommended
  • Refer to Pneumococcal Vaccine in Part 4 for additional information
Polio (inactivated) Routine use Routine use  
Rabies Use if indicated Use if indicated
  • Do not use intradermally
  • Post-immunization serology recommended
  • Refer to Rabies Vaccine in Part 4 for additional information
Tetanus Routine use Routine use  
Typhoid (inactivated) Use if indicated Use if indicated  
Live vaccinesTable 4 - Footnote 6
Measles-mumps-rubella RecommendedTable 4 - Footnote 7 Not recommended
Varicella RecommendedTable 4 - Footnote 7 Not recommended
  • Consider post-immunization serology
  • Complete 2-dose series 4 weeks or more pre-transplant
  • Refer to Varicella (Chickenpox) Vaccine in Part 4 for additional information
Rotavirus Routine use Not recommended  
Influenza (live) Use if indicated Not recommended; use inactivated vaccine  
Herpes zoster Routine use Not recommended  
Yellow fever Use if indicated Contraindicated  
Typhoid (live) Use if indicated Contraindicated; if indicated, use inactivated vaccine  
BCG Use if indicated Contraindicated  
Smallpox Contraindicated Contraindicated  
Immunosuppressive therapy

Long-term immunosuppressive therapy (e.g., long-term steroids, cancer chemotherapy, radiation therapy) is used for organ transplantation and a range of chronic infectious and inflammatory conditions (e.g., inflammatory bowel disease, psoriasis, systemic lupus erythematosis). These therapies have their greatest impact on cell-mediated immunity, although T cell-dependent antibody production can also be adversely affected. Some chronic cancer therapies are hormonal (tamoxifen, gonadotropin release inhibitors) and have no significant immunologic effects. Some therapies for inflammatory conditions (such as hydroxychloroquine, sulfasalazine, or auranofin) are not considered immunosuppressive. The nature of the person's underlying disease should be considered. In general, if a patient is 3 months post-chemotherapy and the cancer is in remission, the person is no longer considered immunocompromised.

Refer to the list of immunosuppressive medications below. Product monographs for drugs authorized by Health Canada can be found at Health Canada's Drug Product DatabaseExternal Link.

List of immunosuppressive medications and example brand name
(Adapted from: Guidelines to Determining Immunosuppressing Conditions or Medications for which MMR is contraindicated. Nova Scotia Department of Health and Wellness)

  • 6-mercaptopurine - PURINETHOL® (Novopharm Ltd.)
  • Abatacept - Orencia™ (Bristol-Myers Squibb Canada)
  • Adalimumab - Humira® (Abbott Laboratories Ltd.)
  • Alemtuzumab - MabCampath® (Genzyme Canada, Div. Of Sanofi-Aventis Canada Inc.)
  • Anti-thymocyte globulin - Thymoglobulin® (Genzyme Canada, Div. Of Sanofi-Aventis Canada Inc.)
  • Azathioprine - IMURAN (Triton Pharma Inc.)
  • Basiliximab - SIMULECT™ (Novartis Pharmaceuticals Canada Inc.)
  • Current or recent radiation
  • Cyclophosphamide - PROCYTOX (Baxter Corp.)
  • CYTOXAN
  • Cyclosporine - NEORALT™ (Novartis Pharmaceuticals Canada Inc.)
  • Etanercept - Enbrel® (Immunex Corp.)
  • High-dose systemic corticosteroids (2 mg/kg per day for a child or 20 mg/day or more of prednisone or its equivalent for an adult) for 14 days or more
  • Infliximab - REMICADE® (Janssen Inc.)
  • Leflunomide - ARAVA® (Sanofi-Aventis Canada Inc.)
  • Methotrexate
  • Mitoxantrone
  • Most cancer chemotherapies (except tamoxifen and hydroxyurea)
  • Mycophenolatemofetil - CellCept® (Hoffman-LaRoche Ltd.)
  • Rituximab - RITUXAN® (Hoffman-LaRoche Ltd.)
  • Sirolimus - Rapamune® (Pfizer Canada Inc.)
  • Tacrolimus - Prograf® (Astellas Pharma Canada Inc.)
Prior to immunosuppressive therapy

Vaccination status should be reviewed for immunocompetent persons who might be anticipating initiation of immunosuppressive treatments or who have diseases that might lead to immunodeficiency. Ideally, all appropriate vaccines or boosters should be administered before the initiation of immunosuppressive therapy so that optimal immunogenicity is achieved. Although inactivated vaccines can be safely administered at any time before, during or after immunosuppression, inactivated vaccines should be administered at least 14 days before initiation of immunosuppressive therapy to optimize immunogenicity. Live vaccines should be administered at least 4 weeks before immunosuppressive therapy is started to reduce the risk of disease caused by the vaccine strain.

During or after immunosuppressive therapy

If vaccines cannot be given prior to initiation of immunosuppressive therapy, a period of at least 3 months should elapse after immunosuppressive drugs (except high-dose systemic corticosteroids) have been stopped before administration of inactivated vaccines (if possible to ensure immunogenicity) and live vaccines (to reduce the risk of disease caused by the vaccine strain). A period of at least 4 weeks should elapse between discontinuation of high-dose systemic steroids and the administration of vaccines. The interval between discontinuation of immunosuppressive drugs and vaccine administration may vary with the intensity of the immunosuppressive therapy, underlying disease and other factors (e.g., inactivated vaccines can be administered if required for post-exposure or outbreak management).

If immunosuppressive therapy cannot be stopped, live vaccines are generally contraindicated, although the risk to benefit ratio may favour immunization if only low doses of immunosuppressive drugs are required and there is significant risk of development of disease. The safety and efficacy of live, attenuated vaccines during low dose intermittent or maintenance therapy with immunosuppressive drugs (other than corticosteroids) are unknown. Immunosuppressive drugs have been reported to cause reactivation of latent tuberculosis infection and predisposition to other opportunistic infections. Therefore, until additional information becomes available, avoidance of live vaccines during intermittent or low dose chemotherapy or other immunosuppressive therapy is prudent. The use of live vaccines in persons on low dose immunosuppression is under review by the National Advisory Committee on Immunization (NACI). Inactivated vaccines should be given when the person is least immunosuppressed unless a vaccine is urgently needed (such as based on exposure risk to circulating diseases or for post-exposure management).

Corticosteroid therapy is not a contraindication to vaccine administration when steroid therapy is short-term (i.e., less than 14 days); or a low-to-moderate dose (less than 2 mg/kg/day for a child or less than 20 mg/day of prednisone or its equivalent per day for an adult); or long-term, alternate-day treatment with short-acting preparations; or maintenance physiologic replacement therapy; or administered topically, inhaled, or locally injected (e.g., joint injection).

Monoclonal antibodies

Monoclonal antibodies are laboratory-produced substances that can bind to B cells (such as rituximab) or tumor necrosis factor and are called TNF inhibitors (such as infliximab and adalimumab) to induce a therapeutic immunosuppression. Monoclonal antibodies have many applications, including the treatment of cancer, prevention of transplant rejection, and treatment of autoimmune diseases (such as Crohn's disease or rheumatoid arthritis) and infectious diseases (such as RSV). Refer to Immunization of Persons with Chronic Diseases in Part 3 or Passive Immunizing Agents in Part 5 for additional information.

Monoclonal antibodies taken during pregnancy will be transferred to the fetus and their effects may persist after birth. For example, ritximab taken during pregnancy is associated with B cell depletion in both mother and fetus. Infants who have been exposed to rituximab, either during pregnancy or from breastfeeding, should have B-cell enumeration prior to immunization. Consultation with an immunologist is advised. Refer to Immunization in Pregnancy and Breastfeeding in Part 3 and to Bacille Calmette-Guérin (BCG) Vaccine in Part 4 for additional information.

The advice for vaccines is the same with monoclonal antibodies as other immunosuppressive agents. Vaccination status should be reviewed prior to commencing monoclonal antibodies. If vaccines cannot be given prior to initiation of therapy, a period of at least 3 months should elapse after monoclonal antibody exposure before administration of inactivated vaccines (if possible to ensure immunogenicity) and live vaccines (to reduce the risk of disease caused by the vaccine strain).

In general, live attenuated vaccines are contraindicated during monoclonal antibody treatment (or in infants exposed to monoclonal antibodies). There is evidence that use of therapeutic monoclonal antibodies, may lead to reactivation of latent tuberculosis infection and tuberculosis disease and predis­pose to other opportunistic infections. One exception to this is palivizumab which is specific for the preven­tion of respiratory syncytial virus (RSV) infection; it will not interfere with the response to a live vaccine.

Additional recommended vaccines

People undergoing immunosuppressive therapy are at higher risk of invasive pneumococcal disease and influenza-related complications; therefore, they should receive pneumococcal vaccine as well as annual immunization with trivalent inactivated influenza vaccine. Hib vaccine may be recommended in some circumstances, such as following organ transplants. Refer to vaccine-specific chapters in Part 4 for additional information.

HIV-infection

The degree of immune suppression varies widely among HIV-infected individuals, reflecting disease stage and response to antiretroviral therapy. Immune suppression is approximately predicted by a recent CD4 count and CD4 percentage. Elevated viral loads may diminish the effectiveness of some vaccines although this is not a reason to delay vaccination.

Inactivated vaccines

When possible, vaccines should be given early in the course of HIV infection although there is no contraindication to the use of inactivated vaccines at any time. Inactivated vaccines should be administered to HIV-infected people according to routine immunization schedules and annual immunization with trivalent inactivated influenza vaccine is recommended. HIV-infected people should receive pneumococcal vaccines (conjugate followed by polysaccharide) and Hib vaccine; quadrivalent conjugate meningococcal vaccine should be considered.

Live vaccines

The risks and benefits of a live vaccine (and the alternative therapies available) need to be carefully considered in consultation with an infectious disease specialist/immunologist. In general, with the exception of BCG, smallpox, and oral, live typhoid vaccines, there are no contraindications to the use of any vaccine early in the course of HIV-infection. As the disease progresses, the risk of using live vaccines increases and consensus "cut-offs" based on clinical and immunologic categories have been determined for the use of MMR and univalent varicella vaccines as follow:

  • Measles-mumps-rubella vaccine (MMR): HIV-infected children 12 months of age and older, and with Centers for Disease Control and Prevention (CDC) clinical category N, A or B and immunologic category 1 or 2 (i.e., CD4 counts ≥15%) may receive two doses of MMR vaccine 3 to 6 months apart. Immunization with two doses of MMR vaccine administered 3 months apart may be considered for susceptible HIV-infected adolescents and adults with CD4 cell count ≥200 x 106/L and CD4 percentage ≥15%. MMR vaccine is contraindicated in persons with advanced HIV/AIDS.
  • Univalent varicella vaccine: HIV-infected children 12 months of age and older, and with CDC clinical category N, A or B and immunologic category 1 or 2 (i.e., CD4 percentage ≥15%) may receive two doses of univalent varicella vaccine 3 to 6 months apart. There are no published data on the use of varicella vaccine in susceptible HIV-infected adolescents and adults. HIV-infected adolescents and adults should be asked for a history of varicella disease or vaccination, and if negative for both, serology should be requested to confirm susceptibility. Based on expert opinion, immunization with two doses of univalent varicella vaccine administered 3 months apart may be considered for susceptible HIV-infected adolescents and adults with CD4 cell count ≥200 x 106/L and CD4 percentage ≥15%. Varicella vaccine is contraindicated in persons with advanced HIV/AIDS.

No specific cut-off has been determined with regard to the safety of using Zoster vaccine. Refer to Table 5 for recommendations for vaccination of HIV-infected persons and vaccine-specific chapters in Part 4 for additional information.

Table 5: Vaccination of HIV-infected persons
(Refer to text and vaccine-specific chapters in Part 4 for additional information)
Vaccine Recommendation Comments
Table 5 - Footnote 1
routine use: follow routine immunization schedules with age-appropriate booster doses
Table 5 - Footnote 2
regardless of prior history of Hib vaccination and at least 1 year after any previous dose
Table 5 - Footnote 3
if not significantly immunocompromised anti-HBs: antibody to hepatitis B surface antigen
Inactivated vaccines
Cholera and travellers' diarrhea (inactivated) Use if indicated  
Diphtheria Routine useTable 5 - Footnote 1  
Haemophilus influenzae type b (Hib) Children less than 5 years of age: routine use

Individuals 5 years of age and older: 1 dose recommendedTable 5 - Footnote 2
Hepatitis A Use if indicated
  • Recommended for HIV-infected individuals with risk factors such as men who has sex with men or illicit drug use
  • Pre-exposure prophylaxis for travel: consider Ig with hepatitis A vaccine
  • Post-exposure prophylaxis: Ig recommended along with hepatitis A vaccine
  • Refer to Hepatitis A Vaccine in Part 4 for additional information
Hepatitis B Recommended
  • Higher dosage recommended
  • Post-immunization serology testing for anti-HBs recommended with re-immunization if response less than 10 IU/L.
  • Periodic monitoring of anti-HBs titre recommended
  • Refer to Hepatitis B Vaccine in Part 4 for additional information
HPV Routine use
  • 3-dose schedule recommended
Influenza (inactivated) Recommended
  • Recommended annually
  • Refer to Influenza Vaccine in Part 4 for additional information
Japanese encephalitis Use if indicated  
Meningococcal conjugate Children: consider quadrivalent conjugate meningococcal vaccine

Adults: consider quadrivalent conjugate meningococcal vaccine
Pertussis Routine use  
Pneumococcal conjugate 13-valent Recommended
  • Refer to Pneumococcal Vaccine in Part 4 for additional information
  • Should be followed - at least 2 months later or when reaches age 2 years - with a pneumococcal polysaccharide vaccine dose
Pneumococcal polysaccharide Recommended
  • One life-time re-immunization recommended
  • Refer to Pneumococcal Vaccine in Part 4 for additional information
Polio (inactivated) Routine use  
Rabies Use if indicated
  • Do not use intradermally
  • Post-immunization serology recommended
  • Refer to Rabies Vaccine in Part 4 for additional information
Tetanus Routine use  
Typhoid (inactivated) Use if indicated  
Live vaccines
BCG Contraindicated  
Herpes zoster Contraindicated in advanced HIV/AIDS
  • Consult specialist in HIV infection/immunologist
Influenza (live) Not recommended, use inactivated vaccine  
Measles-mumps-rubella Children 12 months of age and older: may receive 2 doses 3-6 months apartTable 5 - Footnote 3

Adolescents and adults: consider useTable 5 - Footnote 3

Contraindicated in advanced HIV/AIDS
  • Refer to criteria for administration of MMR vaccine in text above
  • Refer to Measles Vaccine in Part 4 for additional information
Rotavirus Routine useTable 5 - Footnote 1, Table 5 - Footnote 3
  • Approval from the infant's attending physician should be obtained and referral to a consultant with expertise in immunization and/or immunodeficiency is advised.
Smallpox Contraindicated  
Typhoid (live) Contraindicated; if indicated, use inactivated vaccine  
Varicella (univalent) Children 12 months of age and older: may receive 2 doses 3-6 months apartTable 5 - Footnote 3

Adolescents and adults: consider useTable 5 - Footnote 3

Contraindicated in advanced HIV/AIDS
  • Refer to criteria for administration of univalent varicella vaccine in text above
  • Refer to Varicella (Chickenpox) Vaccine in Part 4 for additional information
Yellow fever May be considered (if asymptomatic and not severely immune compromised)
  • Consult specialist in HIV infection/immunologist
  • Vaccinate well in advance of travel to monitor potential adverse events
  • Consider post-immunization serology
  • Refer to Yellow Fever Vaccine in Part 4 for additional information

Close contacts

Up-to-date routine immunizations are recommended for household members and other close contacts of immunocompromised individuals, including health care workers. Non-immune close contacts of immunocompromised people should be immunized against measles, mumps, rubella, varicella, rotavirus and influenza as appropriate for age. Non-immune household or close contacts of immunocompromised people should be given hepatitis B vaccine. In addition, non-immune close contacts of HSCT recipients and close contacts of solid organ transplant candidates and recipients should receive hepatitis A vaccine if other risks are present.

Vaccine viruses in MMR vaccine are not transmitted to contacts. Susceptible close contacts of immunocompromised people should receive herpes zoster or varicella-containing vaccine as appropriate for age and risk factors. If the vaccine recipient develops a varicella-like rash, the rash should be covered and the vaccinee should avoid direct contact with the immunocompromised person for the duration of the rash. Secondary transmission from people with post-varicella vaccination varicella-like rashes is rare.

Infants living in households with persons who have or are suspected to have immunosuppressive conditions or who are receiving immunosuppressive medications can receive rotavirus vaccine. Following administration of rotavirus vaccine, viral antigen shedding in the stool may be detected in some vaccinees. Data on the potential for transmission of vaccine virus from vaccinees to household contacts has not been published; however, many experts believe that the benefit of protecting immunocompromised household contacts from naturally occurring rotavirus by immunizing infants outweighs the theoretical risk of transmitting vaccine virus. To minimize the risk of transmission of vaccine virus, careful hand washing should be used after contact with the vaccinated infant, especially after handling feces (e.g., after changing a diaper), and before food preparation or direct contact with the immunocompromised person.

Annual influenza immunization with trivalent inactivated influenza vaccine is recommended for close contacts of immunocompromised persons. Because of the theoretical risk for transmission, recipients of live attenuated influenza vaccine should avoid close association with persons with severe immunocompromising conditions (e.g., bone marrow transplant recipients requiring isolation) for at least two weeks following vaccination.

Oral polio vaccine should not be administered to household contacts of an immunocompromised person. Oral polio vaccine is not available in Canada.

Generally, smallpox vaccine should not be administered to household contacts of an immunocompromised person in a non-emergency situation. If vaccination is required in an outbreak situation, precautions should be taken for unvaccinated household and other close contacts.

Immunocompromised travellers

A growing number of Canadians with reduced immune competence are travelling to tropical and low-income countries. Although the degree and range of infectious disease risks can increase significantly when an immunocompromised individual travels to other countries, the principles outlined above apply. For additional information about immunization of immunocompromised travellers, refer to the Committee to Advise on Tropical Medicine and Travel (CATMAT) statement on The Immunocompromised Traveller and vaccine-specific chapters in Part 4.

Selected References

  • American Academy of Pediatrics. In: Pickering LK, Baker CJ, Kimberlin DW et al. (editors). Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.
  • American Society of Transplantation. Guidelines for vaccination of solid organ transplant candidates and recipients. Am J Transplant 2004;4(Suppl 10):S160-63.
  • Ballout A, Goffin E, Yombi JC et al. Vaccinations for adult solid organ transplant recipients: current recommendations. Transplant Proc 2005;37(6):2826-27.
  • Campbell AL, Herold BC. Immunization of pediatric solid-organ transplantation candidates: immunizations in transplant candidates. Pediatr Transplant 2005;9(5):652-61.
  • Centers for Disease Control and Prevention. General Recommendations on Immunization
    Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2011;60(RR-02):1-61.
  • Centers for Disease Control and Prevention. Guidelines for preventing opportunistic infections among hematopoietic stem cell transplant recipients. MMWR Morb Mortal Wkly Rep 2000;49(RR-10):1-125.
  • Committee to Advise on Tropical Medicine and Travel. The immunocompromised traveller. Can Commun Dis Rep 2007;33(ACS-4):1-24.
  • Committee to Advise on Tropical Medicine and Travel. Statement on travellers and HIV/AIDS. Can Commun Dis Rep1994;20(17):147-49.
  • Danzinger-Isakov L, Kumar D and the AST Infectious Diseases Community of Practice. Guidelines for vaccination of sold organ transplant candidates and recipients. Am J Transplant 2009;9(Suppl 4):S258-S262.
  • Duchini A, Goss JA, KarpenA et al. Vaccinations for adult solid-organ transplant recipients: current recommendations and protocols. Clin Microbiol Rev 2003;16(3):357-64.
  • Gershon AA, Steinberg SP. Persistence of immunity to varicella in children with leukemia immunized with live attenuated varicella vaccine. N Engl J Med 1989;320(14):892-97.
  • Kumar D, Blumberg EA, Danziger-Isakov L et al. Influenza vaccination in the organ transplant recipient: review and summary recommendations. Am J Transplant 2011;11:2020-30.
  • Landrum M, Dolan M. Routine vaccination in HIV-infected adults. Infect Dis Clin Pract 2008;16(2):85-93.
  • LaRussa P, Steinberg S, Gershon AA. Varicella vaccine for immunocompromised children: results of collaborative studies in the United States and Canada. J Infect Dis 1996;174(Suppl 3):S320-23.
  • Ljungman P, Cordonnier C, Einsele H et al. Vaccination of hematopoietic cell transplant recipients. Bone Marrow Transplant 2009;44:521-6.
  • McFarland E. Immunizations for the immunocompromised child. Pediatr Ann 1999;28(8):487-96.
  • Mileno MD, Bia FJ. The compromised traveler. Infect Dis Clin North Am 1998;12(2):369-412.
  • Molrine DC, Hibberd PL. Vaccines for transplant recipients. Infect Dis Clin North Am 2001;15(1):273-305.
  • Molrine DC. Recommendations for immunizations in stem cell transplantation. Pediatr Transplant 2003;7(Suppl 3):S76-85
  • Sartori AM. A review of the varicella vaccine in immunocompromised individuals. Int J Infect Dis 2004;8(5):259-70.
  • Somani J, Larson RA. Reimmunization after allogeneic bone marrow transplantation. Am J Med 1995;98(4):389-98.
  • Tomblyn M, T. Chiller T. Einsele H et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant 2009;15:1143-1238.
  • Weber DJ, Rutala WA. Immunization of immunocompromised persons. Immunol Allergy Clin North Am 2003;23(4):605-34.
  • Yeung CY, Liang DC. Varicella vaccine in children with acute lymphoblastic leukemia and non Hodgkins lymphoma. Pediatr Hematol Oncol 1992;9(1):29-34.

[Previous page] [Table of Contents] [Next page]