Vaccine Recommendations
for Travelers with Altered Immunocompetence, Including HIV
Courtesy of the Centers for Disease Control
and Prevention
Killed or inactivated vaccines do not represent a danger to immunocompromised persons and generally should be administered as recommended for healthy persons. However, the immune response to these vaccines may be suboptimal.
Virus replication after administration of live, attenuated-virus vaccines can be enhanced and prolonged in persons with immunodeficiency diseases and in those with suppressed capacity for immune response, as occurs with HIV disease, leukemia, lymphoma, generalized malignancy, or therapy with corticosteroids, alkylating agents, antimetabolites, or radiation. Severe complications have been reported following vaccination with live attenuated virus vaccines (e.g., measles and polio) and with live bacterial vaccines (e.g., BCG [Bacillus Calmette-Guérin vaccine]) in patients with HIV disease, leukemia, and lymphoma or other persons with suppressed capacity for immune response. In general, patients with such conditions should not be given live-organism vaccines.
Evidence based on case reports has linked measles vaccine virus infection to subsequent death in six severely immunosuppressed persons. For this reason, patients who are severely immunosuppressed for any reason should not be given MMR (measles, mumps, and rubella) vaccine. Healthy susceptible close contacts of severely immunosuppressed persons may be vaccinated. MMR and other measles-containing vaccines are not recommended for HIV-infected persons with evidence of severe immunosuppression (e.g., persons with a very low CD4+ T-lymphocyte count), primarily because of the report of a case of measles pneumonitis in a measles vaccinee who had an advanced case of AIDS. Download the 1998 ACIP recommendations on MMR vaccine for additional details on vaccination of persons with symptomatic HIV infection.
Measles disease may be severe in persons with HIV infection. Available data indicate that vaccination with MMR has not been associated with severe or unusual adverse events in HIV-infected persons without evidence of severe immunosuppression, although antibody responses have been variable. MMR vaccine is recommended for all asymptomatic HIV-infected persons and should be considered for symptomatic persons who are not severely immunosuppressed. Asymptomatic children do not need to be evaluated and tested for HIV infection before MMR or other measles-containing vaccines are administered. A theoretical risk of an increase (probably transient) in HIV viral load following MMR vaccination exists because such an effect has been observed with other vaccines. The clinical significance of such an increase is not known.
In general, persons receiving large daily doses of corticosteroids (more than 2 mg/kg per day or more than 20 mg per day of prednisone) for 14 days or more should not receive MMR vaccine because of concern about vaccine safety. MMR and its component vaccines should be avoided for at least one month after cessation of high-dose therapy. Persons receiving low-dose or short-course (fewer than 14 days) therapy, alternate-day treatment, maintenance physiologic doses, or topical, aerosol, intra-articular, bursal, or tendon injections may be vaccinated. Although persons receiving high doses of systemic corticosteroids daily or on alternate days during an interval of less than 14 days generally can receive MMR or its component vaccines immediately after cessation of treatment, some experts prefer waiting until 2 weeks after completion of therapy.
Patients receiving cancer chemotherapy or radiation who have not received chemotherapy for at least 3 months may receive MMR or its component vaccines.
Patients with leukemia in remission whose chemotherapy has been terminated for at least 3 months and transplant recipients who are beyond the period of immunosuppression may receive live-virus vaccines. Most experts agree that steroid therapy usually does not contraindicate administration of live-virus vaccine when it is short term; low to moderate dose (less than 2 weeks); long-term, alternate-day treatment with short-acting steroids; maintenance physiologic doses (replacement therapy); or administered topically (i.e., on the skin or eyes) by aerosol; or by intra-articular, bursal, or tendon injection.
Children infected with HIV should receive on schedule all the routinely recommended inactivated childhood vaccines (i.e., DTaP, Hib, and hepatitis B vaccine) whether or not they are symptomatic. IPV (inactivated polio vaccine) is the polio vaccine of choice for HIV-infected asymptomatic and symptomatic persons and their household members and other close contacts. Because measles can be severe in HIV-infected persons, MMR vaccine is recommended for all asymptomatic HIV-infected persons who do not have evidence of severe immunosuppression; it should also be considered for those who are symptomatic; however, MMR should not be given to severely immunocompromised persons. Pneumococcal vaccine is recommended for any HIV-infected person who is more than 2 years old. Because influenza may result in serious illness and complications, vaccination against influenza is a prudent precaution in HIV-infected persons. Varicella (chickenpox) vaccine may be considered for asymptomatic HIV-infected persons with CD4+ percentages > 25% (CDC Class 1).
Immunosuppression increases the risk for vaccine-associated paralytic polio. OPV (oral polio vaccine) should not be given to immunosuppressed individuals or household contacts of individuals who have immune deficiency diseases, immunosuppression (due to disease or therapy), or if there is suspected familial immune deficiency. OPV should not be given to a person known to be infected with HIV regardless of the level of immunosuppression. OPV should also not be administered to a healthy family contact of a person with HIV infection. IPV should be substituted for OPV in these circumstances.
OPV should not be given to any immunocompromised patient, their household members, or their close contacts. If polio immunization is indicated for these persons, IPV is recommended. Because of the possibility of immunodeficiency in other children born to a family in which there has been a case of congenital immunodeficiency, family members should not receive OPV until the immune status of the recipient and other children in the family is known.
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