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VACCINATION RECOMMENDATIONS FOR

THE ADULT IMMUNOSUPPRESSED


PATIENT: A SYSTEMATIC REVIEW AND
COMPREHENSIVE FIELD SYNOPSIS
Journal Presentation
Introduction • Chemotherapy in solid
tumor  RR of invasive
pneumococcal infection
23x more  50x more in
HIV
• Asplenic patients
pneumococcal sepsis 
mortality rate up to 60%
• Hospitalization in
hematologic malignancies
Immunosupresion and solid tumors by
disease/immunotherapy influenza infection in 14 -
 asplenia, cancer, 21% of cases and mortality
chronic inflammatory rate ranges between 8 and
diseases, 50%
transplantation, HIV • Vaccination against influenza
 effective in
immunocompromised 
reduction of 85% 
however seroprotection
lower
• Academic societies 
Aim

Asplenia
Asplenia
Cancer
Cancer
recommendations
Review available

HIV
recommendations
vaccination in:
available

HIV
vaccination in:

Hematopoietic stem cell


Hematopoietic stem cell
and solid organ
and solid organ
transplantation
transplantation
Inflammatory bowel
Inflammatory
diseases (IBD)bowel
Review

diseases (IBD)
Primary immune
Primary immune
deficiency
deficiency
Psoriasis
Psoriasis
Inflammatory rheumatic
Inflammatory rheumatic
diseases (IRD).
diseases (IRD).
Materials and Methods
Data PubMed, EMBASE, Cochrane Library, and
Data
Sources
PubMed,society
professional EMBASE, Cochrane
websites (WHOLibrary, and
and NICE)
Sources professional
and society website
medical specialty websites(WHOsearchand NICE)
terms:
and and medical specialty website
((“Vaccination”[Mesh])  search terms:
OR “Vaccines”[Mesh])
and
searches ((“Vaccination”[Mesh]) OR “Vaccines”[Mesh])
AND “Guideline” [Publication Type]
searches AND “Guideline” [Publication Type]
Guidelines focusing on recommendations for
Guidelinesin
vaccination focusing on recommendations
adult patients (18 years) were for
Study vaccination
selected, in in adult and
patients (18language,
years) were
Study
selection selected,
English
in English
French
and and
French language,
published January 1, 2005 January, the
selection published January 1, 2005
31st of 2016 and January, the
31st of 2016
Data
Data
extractio
Titles and abstracts were screened by two
Titles and abstracts
independent were(AL
reviewers screened by two
and LPB)
extractio
n independent reviewers (AL and LPB)
n
Data Vaccination
Vaccination
Data
synthesis Informatio
Summariz
recommendations
recommendations
were listed by type
Informatio
synthesis
and
n was
n was
Summariz
ed
were
of listed(live
vaccine
of vaccine
vaccines
by type
and(live
and extracted ed vaccines and
inactivated
analysis extracted inactivated
vaccines)
analysis vaccines)
RESULT
Literature search results

389 citations
15 guidelines (Reasons for exclusion: irrelevant articles (n ¼ 149) (e.g. management of infectious
diseases, reports, safety studies, position on only one vaccine), guidelines in non-
immunocompromised patients (n ¼ 82), pediatric guidelines (n ¼ 61), non-English or French
language guidelines (n ¼ 42), animal recommendations (n ¼ 20), duplicates (n ¼ 10),:reviews (n ¼
Guidelines
6), guidelines' evaluations (n ¼ 5), sub-national recommendations (n ¼ 2).
Asplenic patients
Asplenic patients
Patients with oncologic malignancies
HIV patients
Hematopoietic stem cell
recipients
Inflammatory bowel disease patients
Primary immunocompromised patients
Patients with psoriasis
Inflammatory rheumatic disease patients
Solid organ transplant
recipients
Discussion

increase of life Vaccines


Immunosuppres
threatening decrease the
sion state
infections mortality risk

In some Guidelines  a
countries, a valuable tool to improving the
sense of help clinicians quality of care
mistrust exists translate best and patient
research evidence
against into best practice
outcomes
vaccinee
review
systematic complete,
review and a unbiased,
comprehensive objective,
field transparent,
and repeatable.
Field  review complete, unbiased, objective, transparent, and
repeatable.
Live vaccines are contraindicated  immunosuppressive therapy or in HIV
patients with a CD4 count under 200/mm3
Few exceptions  The MMR and the varicella  recommended in seronegative
patients before transplantation or those with psoriasis and HIV
Renal transplant recipients  mortality rate was 30% in varicella zoster virus infection
 to better immunisation coverage for VZV  large survey from Medicare of VZV
vaccination in patients with autoimmune diseases  achieved the same protection
and the same safety as the whole population without high immunosuppression

In case of deep immunosuppression, as HIV or transplant patients the yellow


fever vaccine can be considered, but only if a true risk of infection exists (e.g.
patients residing in or traveling to endemic areas)

Yellow fever vaccine acceptable solid organ recipients

The rotavirus never recommended


Pneumococcal vaccination  recommended in all
Pneumococcal vaccination
immunocompromised patients. recommended
 In in all
a multicenter observational  mortality
immunocompromised
rate was 9% in the generalpatients. In acompared
population multicenter observational
to 24% in the  mortality
rate was 9% in thepopulation
immunosuppressed general population
 a highcompared
economic to 24% in the
burden.
immunosuppressed population  a high economic burden.
Influenza vaccination is recommended for immunocompromised
Influenza vaccination is
A recent meta-analysis recommended
showed forand
that efficacy immunocompromised
safety of the
 A recent meta-analysis showed that efficacy and
influenza vaccine in immunocompromised patients were safety of the
adequate
influenza vaccine in immunocompromised patients were adequate
Indeed, guidelines towards physicians  should be
Indeed, guidelines towards physicians  should be
emphasized more, accompanied with patients-
emphasized more, accompanied with patients-
centered strategies
centered strategies
Immunosuppressive therapy is not a contraindication to inactivated vaccines  Tdap-
Immunosuppressive
polio therapy is not
vaccination is recommended in aHIV
contraindication to inactivated
patients and transplant vaccines
recipients, HibinTdap-
polio
case ofvaccination is recommended
hematopoietic in HIV patients
stem cell transplantation and transplant
or asplenia, which recipients, Hib in
is a rare but
case ofcomplication
possible hematopoietic of stem cell transplantation
systemic or asplenia,
lupus erythematosus, which is a rare
meningococcal but is
vaccine
possible complication
recommended in case ofoftransplantation,
systemic lupus erythematosus,
asplenia, or in HIVmeningococcal
patients vaccine is
recommended in case of transplantation, asplenia, or in HIV patients
HPV vaccination is part now of many guidelines HPV prevalence is up to
HPVinvaccination
90% is part
HIV patients, now of many
but vaccination guidelines
coverage HPVHPV
against prevalence
appears is up to
very low
90% in HIV patients, but vaccination coverage against HPV appears very
in this population, under 5%, whereas the seroconversion rate is >75% with low
in this
the population,
quadrivalent HPVunder 5%, whereas the seroconversion rate is >75% with
vaccine
the quadrivalent HPV vaccine

Effectiveness of any vaccine  degree of immune


Effectiveness of any vaccine  degree of immune
suppression
suppression
Limitation

the exclusion of
the exclusion
guidelines not inof
guidelines
English not in
or French
English or French

some guidelines
some
were guidelines
also partially
were also partially did not
built on existing did not
systematically
built on existing
recommendations systematically
recommendations appraise the
 included appraise
guidelines the
for
 included
guidelines were guidelines for
guidelines were quality
not strictly quality
not strictly
independent
independent
Conclusion

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

Live vaccines are contraindicated in patients under


immunosuppressive therapy or in HIV patients with a
CD4 count under 200/mm3.
An international collaborative effort should be made to
increase awareness of available guidelines and
vaccination coverage in this population.