Immunization in special

conditions

P R E S EN T E D BY -
D E B A B R A T A M O H A PA T R A
At the end of this presentation we should be able to answer….

Why are there special immunization

recommendations?
What are the recommendations in specific diseases?
What are the recommendations in special
populations, otherwise healthy?
Recommendations
in specific
diseases
 Recommendations in
specific diseases

Immuno-compromised states

Recipients of products containing plasma

Systemic illnesses
 Immuno-compromised states

SECONDARY IMMUNODEFICIENCIES
 HIV infection
 Steroid therapy
 Chemo-radiotherapy
 Transplant recipients
PRIMARY IMMUNODEFICIENCIES
 B-cell defects
 T-cell defects
 Complement defects
 Phagocytic defects
 HIV Infection

Adapted from IAP guidelines 13-14

 HIV Infection

 If CD4+ counts<15% or WHO stage ¾ - BCG , Measles, MMR and

Varicella are C/I (NACO vs IAP)

 Yellow fever vaccine always C/I.

 No sufficient data to recommend Rotavirus vaccines.

 Inactivated influenza vaccine annually & rest all vaccines as per schedule.

 Additional boosters based on titer for: HAV& HBV, Hib, Pneumococcus

and Meningococcus.

 OPV if IPV not affordable

Guidelines by NACO, IAP, CDC
 Steroid therapy

HIGH DOSE PREDNISOLONE > 2 mg/kg/day or for

those weighing > 10 kg, 20 mg/day or its equivalent
for > 2 weeks

Live virus vaccines - C/I until at least 1 month.

Killed vaccines - safe but less effective.

LOWER DOSES - all vaccines safe and effective.

IDSA Guidelines 2013 & CDC guidelines

 Chemo-radio therapy

LIVE VACCINES :
 Regimens including anti-B-cell antibodies (like -
Rituximab)
wait for 6 months before live vaccines

 Other regimens
wait for 3 months before live vaccines
 Chemo-radio therapy

INACTIVATED VACCINES :
 cancer patients of age>6m should receive
inactivated influenza vaccine annually
PCV at diagnosis
 rest all inactivated vaccines can be given but are
considered ineffective unless titers are protective
Preferably immunize 2 wk prior to any
immunosupression (Both Live and inactivated)
Recommendation by CDC
 Transplant recipients

 Hematopoietic stem cell transplants

3-6 months 6months 6-12 months

• 3×PCV • 3× Tdap • 3×(IPV+Hib+HepB)

• Annual IIV • 2×MCV4
• 3×HPV

 Live vaccines C/I with ongoing immunosupression or

GVHD
Blood journal 2016 How I vaccinate blood and marrow transplant recipients Paul A. Carpenter etal
 Solid organ transplant recipients

Pre-transplant
 All immunizations should be completed prior to transplant.
 Live vaccines at least 2wks prior to transplant

Post-transplant
 Live vaccine- all are C/I during therapy
 Inactivated – 6m post transplant if not received prior
 Inactivated booster- if already received prior to transplant
 Asplenia and hyposplenia

What all vaccines given?

Why are these vaccines given?

 Asplenia and hyposplenia

These patient require following vaccines

Pneumococcal
Hib
Meningococcal
typhoid

In elective splenectomy vaccination is done 2wks

prior, while in emergency surgery it’s 2 weeks after
the procedure.
 Primary immuno-deficiencies

B cell defects Severe C/I- OPV,BCG,Typhoral,LAIV

Ineffective –MMR, Varicella,
inactivated vaccines
Less severe Only OPV contra-indicated

combined defects Severe Ineffective – all vaccines

C/I- all live vaccines

Less severe C/I- all live vaccines

Given –inactivated vaccines
Complement defects All can be and Hib, meningococcus &
peumococcus must be given.

Phagocytes defects Only live bacterial vaccines contra-

indicated
 Recipients of products containing plasma

Groups Vaccines Minimum interval

1 Inactivated antigens NIL

2 Live antigens (Zooster, LAIV, Yellow NIL

fevwr, Rotavirus, Typhoral)

3 Live antigens (rest all: Measles, Vaccine 2 wks

Varicella, Mumps, Rubella) followed by
plasma
products
plasma next slide
products
followed by
Vaccine
Product Minimum interval for
vaccination

Washed RBCs None

RSV monoclonal antibody
Tetanus,HAV,HBV,Rabies IG 3 months

Varicella & measles IG 5 months

PRBC, Whole blood 6 months

FFP, Platelets 7 months

IVIG Replacement therapy 8 months
ITP 10 months
Kawasaki 11 months
 Systemic illnesses

Disease Recommendations

Acute illness Mild:- don’t postpone

Moderate to severe:- postpone

Allergic individuals Egg allergy:- Influenza and Yellow

fever vaccines contra indicated

Any hypersensitivity:- monitor after

mouse brain JE vaccine

Mild reaction to a vaccine:- can be

given
Severe hypersensitivity to a vaccine:-
contraindicated
 Systemic illnesses
Disease Recommendations

Cardio-pulmonary diseases Pneumococcal

Annual influenza vaccines

Liver diseases Check titers and give boosters

frequently for HAV and HBV

Bleeding disorders When possible give s.c. doses e.g. Hib

conjugate, IPV,PPV.
If not;
Give IM just after Factor replacement
23 gauge or smaller needle
Firm pressure, 10 min, w/o rubbing
 Systemic illnesses

Disease Recommendations

Neurological disorders In progressive neurologic diseases

Pertusis is contra-indicated

Renal diseases PCV, influenza, varicella.

Consider recent immunosupressants

CSF leak & cochlear implant PCV followed 8 weeks by PPSV

Recommendations
in special
populations,
otherwise healthy
Special population groups

 Pregnancy & lactation

 Adolescents
 Preterm and LBW babies
 Health care workers
 Travellers
 Adolescents

recommended for all 1 dose Tdap f/b Td every 10

yrs
3 doses HPV (male or female)

recommended for catch-up MMR : 2-dose series

immunization Varicella : 2-dose series
Hepatitis B : 3-dose series
Hepatitis A : 2-dose series
Typhoid : 1 dose every 3 years

recommended for certain Influenza : 1 dose every year

high-risk groups Japanese Encephalitis : up to 15
years
Pneumococcal vaccine
Meningococcal vaccine
Capua T etal. Update on adolescent immunizations: selected review of US recommendations and literature. Curr Opin
Pediatr 2013
 Preterm and LBW babies

Generally immunization at birth is delayed till stabilization,

preferably at discharge.

Babies of weight < 2 kg delay the Hep B vaccination till 1 month

Babies < 2 kg, but born to Hep B positive mothers are given
HBV vaccination within 12 hours of life f/b 1,2 and 6 months +
HBIG at birth

AAP Publication.Immunization of Preterm and Low Birth Weight Infants. Saari etal 2003 PEDIATRICS
 Health care workers

Vaccines Recommendations in brief

Hepatitis B If no serologic evidence of immunity or prior

vaccination) 3-dose series (0,1,6 m)

Flu (Influenza) 1 dose of influenza vaccine annually.

MMR (Measles, Mumps, & Rubella) MMR 2 dose series

Varicella (Chickenpox) If not had chickenpox or if no serologic evidence of

immunity or prior vaccination 2 doses ,4 weeks
apart.

Tdap (Tetanus, Diphtheria, Pertussis) Tdap as soon as possible Td boosters every 10 years
Pregnant HCWs a dose of Tdap during pregnancy.

Meningococcal Those who are routinely exposed to isolates of N.

meningitidis should get one dose.
Immunization of HCW: Recommendations ofACIP. MMWR.
2011
 Travellers
Vaccine countries

OPV Hajj pilgrims to Saudi

Africa

Meningococcal disease Hajj pilgrims to Saudi

Typhoid fever Areas of sanitary deficit

Yellow fever Africa & South America

Japanese encephalitis Asian countries

Cholera India, Pakistan, Bangladesh

Rabies Enzootic areas or country category

Hepatitis A Areas of sanitary deficit

Travellers
Travellers to india
..\Health Information for Travelers to India - Travele
r view _ Travelers' Health _ CDC.html
Travellers to USA.
..\Health Information for Travelers to United States -
Traveler view _ Travelers' Health _ CDC.html
THANK YOU