Elsevier

Journal of Autoimmunity

Volume 80, June 2017, Pages 10-27
Journal of Autoimmunity

Vaccination recommendations for the adult immunosuppressed patient: A systematic review and comprehensive field synopsis

https://doi.org/10.1016/j.jaut.2017.03.011Get rights and content

Highlights

  • Pneumococcal and injectable influenza are the only two vaccines universally recommended in all cases of immunosuppression.

  • Other inactivated vaccines are not universally recommended, but only indicated in high risk patients.

  • Live vaccines are contraindicated in patients under immunosuppressive therapy or in HIV patients with CD4 cells <200/mm3.

Abstract

Background

Immunosuppressed patients are at risk of severe viral infections-related complications. National and international vaccination guidelines have been developed to decrease the mortality risk associated with these infections. However, a summary of these guidelines and the value of immunisation in this population is missing.

Objectives

To summarize specific guidelines regarding vaccination in immunosuppressed patients.

Methods

We performed a literature search based on last update vaccine guidelines in immunosuppressed adult patients published between 1/1/2005–1/31/2016 in English or French language using PubMed, Cochrane and Embase, as well as relevant medical society websites.

Results

Of the 389 citations identified, 12 guidelines were selected Three additional guidelines were selected by searching on the websites from medical societies of each specialty. 15 guidelines were included, involving 19 medical societies issued from the US (n = 6), international collaboration (n = 3), UK (n = 2), Canada (n = 1), Australia (n = 1), France (n = 1), and Germany (n = 1). These guidelines provide recommendations on vaccination in asplenic patients (n = 5), cancer patients (n = 4), HIV patients (n = 5), hematopoietic stem cell recipients (n = 4), inflammatory bowel diseases patients (n = 5), psoriasis patients (n = 4), primary immunocompromised patients (n = 3), inflammatory rheumatic diseases patients (n = 6), and solid organ transplant recipients (n = 5). All guidelines recommended pneumococcal and injectable influenza vaccines. Other inactivated vaccines were recommended only in high risk patients. Live vaccines were usually contraindicated in patients under immunosuppressive therapy and/or in HIV patients with a CD4 count under 200/mm3.

Conclusion

Pneumococcal and injectable influenza are the two essential vaccines recommended in all immunocompromised patients. Other inactivated vaccines are only indicated in high risk patients. Live vaccines are usually contraindicated.

Introduction

Immunosuppression related to disease process and/or immunosuppressive therapies is frequently encountered in patients with asplenia, cancer, chronic inflammatory diseases, transplantation, and human immunodeficiency virus (HIV) infection [1]. Various mechanisms may be involved in a given patient, leading to qualitative and/or quantitative immune deficiency [2]. In patients with solid tumors receiving chemotherapy, the relative risk (RR) of invasive pneumococcal infection is nearly multiplied by 23, and even close to 50 in case of HIV infection [3], compared to general population. Among asplenic patients, consequences could be deadly, due to increased risk of pneumococcal sepsis with a mortality rate up to 60% [4], [5]. Patients with hematologic malignancies and solid tumors are at increased risk of influenza-related complications [6]. Hospitalization is required in 14–21% of cases, and mortality rate ranges between 8 and 50%, higher in HIV patients compared to oncologic patients [7]. Vaccination against influenza is effective in immunocompromised patients, with a reduction of 85% of laboratory-confirmed infections compared to placebo [8]. However, seroprotection appears significantly lower in immunocompromised than in immunocompetent patients [9] raising the interest for alternative strategies aiming to improve vaccination efficacy [10]. Over the past decade, academic societies from different specialties have developed their own guidelines concerning vaccination modalities in clinical situations of immune defects. Despite all these struggling guiding efforts, vaccination coverage seems to remain low, being less than 20% in patients with malignancies treated in referral centers [11]. Our aim is to review available recommendations regarding vaccination in the following immune deficient conditions: 1) asplenia, 2) cancer, 3) HIV, 4) hematopoietic stem cell and solid organ transplantation, 5) inflammatory bowel diseases (IBD), 6) primary immune deficiency, 7) psoriasis and 8) inflammatory rheumatic diseases (IRD).

Section snippets

Data sources and searches

A literature search was conducted on PubMed, EMBASE, Cochrane Library, and in main professional society websites including the World Health Organization (WHO) and the National Institute for Health and Care Excellence (NICE), and websites from each medical specialty such as oncology-hematology, gastroenterology, infectious diseases, dermatology and rheumatology issued from any country worldwide. We used the following search terms: ((“Vaccination”[Mesh]) OR “Vaccines”[Mesh]) AND “Guideline”

Literature search results

During the last decade, 389 citations were identified on Medline, Embase and Cochrane, using the search keywords listed above (Appendix Fig. 1). After reviewing the title and/or the abstract of the 389 citations that were identified using the predefined search terms, a total of 12 guidelines were selected in this systematic review. Reasons for exclusion were: irrelevant articles (n = 149) (e.g. management of infectious diseases, reports, safety studies, position on only one vaccine …),

Discussion

Many of our patients have an immunosuppression state, inherited [29] or due to several drugs prescribed for a malignancy [30], a chronic inflammatory disease [31] or after transplantation [32]. In these situations, there is a significant increase of life threatening infections [5], [7]. Vaccines can decrease the mortality risk associated with infection-related complications, but vaccination coverage appears low in immunosuppressed patients. In some countries, a sense of mistrust exists against

Conclusions

In conclusion, this is the first systematic review and comprehensive field synopsis of all guidelines published over the past decade on vaccination in all types of immunocompromised patients. Pneumococcal and injectable influenza are the only two vaccines universally recommended in all cases of immunosuppression. Other inactivated vaccines are not universally recommended, but only indicated in high risk patients. Live vaccines are contraindicated in patients under immunosuppressive therapy or

Registration

None.

Funding source

None.

Guarantor of the article

Laurent Peyrin-Biroulet, M.D., Ph.D.

Specific author contribution

LPB designed research; AL and LPB conducted literature search; AL and LPB analyzed data; AL and LPB wrote the paper; LPB had primary responsibility for final content. All authors read and approved the final manuscript.

Financial support

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Potential competing interests

AL: board for Amgen, lecture fees from Vifor Pharma, research grants from Roche; XM: consulting fees from BMS, GSK, LFB, Medimmune, Novartis, Pfizer, Sanofi, UCB-Pharma; HB: consulting, advisory board, speakers bureau or investigator for Abbvie, Amgen, Baxalta, Boehringer-Ingelheim, Celgene, Eli-Lilly, Janssen, Leo Pharma, MSD, Novartis, Pfizer, Sun Pharma and UCB Pharma; AB: consulting, advisory board, speaker or investigator for Abbvie, GSK, Novartis, Pfizer; BB: consulting fees from BMS,

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