General Best Practice Guidelines for Immunization: Altered Immunocompetence 123

8. Altered Immunocompetence

Updates

This section incorporates general content from the Infectious Diseases Society of America 

policy statement, 2013 IDSA Clinical Practice Guideline for Vaccination of the 

Immunocompromised Host (1), to which CDC provided input in November 2011. The 

evidence supporting this guidance is based on expert opinion and arrived at by consensus.

 

General Principles

Altered immunocompetence, a term often used synonymously with immunosuppression, 

immunodeficiency, and immunocompromise, can be classified as primary or secondary. 

Primary immunodeficiencies generally are inherited and include conditions defined by an 

inherent absence or quantitative deficiency of cellular, humoral, or both components that 

provide immunity. Examples include congenital immunodeficiency diseases such as Xlinked agammaglobulinemia, SCID, and chronic granulomatous disease. Secondary 

immunodeficiency is acquired and is defined by loss or qualitative deficiency in cellular or 

humoral immune components that occurs as a result of a disease process or its therapy. 

Examples of secondary immunodeficiency include HIV infection, hematopoietic 

malignancies, treatment with radiation, and treatment with immunosuppressive drugs.

The degree to which immunosuppressive drugs cause clinically significant 

immunodeficiency generally is dose related and varies by drug. Primary and secondary 

immunodeficiencies might include a combination of deficits in both cellular and humoral 

immunity. Certain conditions like asplenia and chronic renal disease also can cause 

altered immunocompetence.

Determination of altered immunocompetence is important to the vaccine provider 

because incidence or severity of some vaccine-preventable diseases is higher in persons 

with altered immunocompetence; therefore, certain vaccines (e.g., inactivated influenza 

vaccine, pneumococcal vaccines) are recommended specifically for persons with these 

diseases (2,3). Administration of live vaccines might need to be deferred until immune 

function has improved. This is primarily a safety concern, because persons who have 

altered immunocompetence and receive live vaccines might be at increased risk for an 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 124

adverse reaction because of uninhibited growth of the attenuated live virus or bacteria. 

Vaccines might be less effective during the period of altered immunocompetence. Non-live 

vaccines might best be deferred during a period of altered immunocompetence; in this 

circumstance, the concern is with effectiveness and not safety. Additionally, if a non-live 

vaccine is administered during the period of altered immunocompetence, it might need to 

be repeated after immune function has improved.

The degree of altered immunocompetence in a patient should be determined by a 

physician. The challenge for clinicians and other health-care providers is assessing the 

safety and effectiveness of vaccines for conditions associated with primary or secondary 

immunodeficiency, especially when new therapeutic modalities are being used and 

information about the safety and effectiveness of vaccines has not been characterized fully 

in persons receiving these drugs (Table 8-1). Laboratory studies can be useful for assessing 

the effects of a disease or drug on the immune system. Tests useful to assess humoral 

immunity include immunoglobulin (and immunoglobulin subset) levels and specific 

antibody levels (e.g., tetanus and diphtheria). Tests that demonstrate the status of cellular 

immunity include lymphocyte numbers (i.e., a complete blood count with differential), a 

test that delineates concentrations and proportions of lymphocyte subsets (i.e., B and T 

lymphocytes, CD4+ B lymphocytes versus CD8+ T lymphocytes), and tests that measure 

T-cell proliferation or function in response to specific or nonspecific stimuli (e.g., 

lymphocyte proliferation assays) (4,5). The ability to characterize a drug or disease 

condition as affecting cellular or humoral immunity is only the first step; using this 

information to draw inferences about whether particular vaccines are indicated or whether 

caution is advised with use of live or non-live vaccines is more complicated and might 

require consultation with an infectious diseases or immunology specialist.

 

Altered Immunocompetence as an Indication to Receive a 

Vaccine Outside of Routinely Recommended Age Groups

This section describes situations in which vaccines are recommended outside of the 

routine-age-based recommendation because the risk for vaccine-preventable disease is 

increased due to altered immunocompetence. 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 125

Persons with altered immunocompetence generally are recommended to receive 

polysaccharide-based vaccines (PCV13, PPSV23, and Hib), on the basis of increased risk 

for disease if the vaccine is withheld. For certain specific categories of altered 

immunocompetence, patients are also recommended to receive polysaccharide based 

vaccines (MenACWY, Hib-MenCY, and MPSV4).

Pneumococcal Vaccines

Two types of vaccine against invasive pneumococcal disease are available in the United 

States: PCV13 and PPSV23. PCV13 is recommended routinely for all children beginning at 

age 2 months through age 59 months and for adults aged 65 years or older. PCV13 is also 

recommended for children, adolescents, and adults with conditions that place them at 

high risk for invasive disease from Streptococcus pneumoniae. PCV13 is recommended for 

persons aged 6-64 years who have not previously received PCV13 and have congenital 

immunodeficiency disorders (including B- or T-lymphocyte deficiency, complement 

deficiencies, and phagocytic disorders), anatomic or functional asplenia (including sickle 

cell disease and other hemoglobinopathies), HIV infection, cochlear implant, 

cerebrospinal fluid leak, chronic renal failure, nephrotic syndrome, iatrogenic 

immunosuppression, or other immunocompromising conditions.

PPSV23 is licensed for use in persons aged ≥2 years and recommended routinely for 

adults aged 65 years and older. PPSV23 is also recommended for persons age 2 through 64 

years with congenital immunodeficiency disorders, anatomical and functional asplenia, 

HIV infection, cochlear implant, cerebrospinal fluid leak, and iatrogenic 

immunosuppression. Complete recommendations on use of PCV13 and PPSV23 are 

available in the Recommended Immunization Schedules for Persons Aged 0 Through 18 

Years and the Recommended Adult Immunization Schedule (2,6).

Meningococcal Vaccines

Three types of meningococcal vaccines are licensed in the United States: meningococcal 

conjugate (MenACWY and Hib-MenCY), meningococcal polysaccharide (MPSV4), and 

serogroup B meningococcal (MenB) vaccines. 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 126

Persons with functional or anatomic asplenia (including sickle cell disease), HIV infection

and persistent complement component deficiency (including persons taking eculizumab 

[Soliris]) (7) are at increased risk for meningococcal disease and should receive 

MenACWY vaccine. Persons with functional or anatomic asplenia (including sickle cell 

disease) and persistent complement component deficiency (including persons taking 

eculizumab [Soliris]) should receive MenB vaccine. For children 2 months through 23 

months of age, an age-appropriate series of meningococcal conjugate vaccine should be 

administered. If MenACWY-D (Menactra) is administered to a child with asplenia or HIV, 

it should be after 2 years of age and at least 4 weeks after the completion of all PCV13 

doses. A 2-dose primary series of either MenACWY-CRM (Menveo) or MenACWY-D 

(Menactra) should be administered to persons 2 years of age or older with asplenia or 

complement deficiency. Following the primary series of vaccine, a 3-year interval to the 

next dose is recommended for persons who received their previous dose at younger than 7 

years. A 5-year interval is recommended for persons who received their previous dose at 

age 7 years or older. Although MPSV4 is the only meningococcal vaccine licensed for 

persons older than 55 years of age, adults 56 years and older with asplenia or complement 

deficiency should be vaccinated with MenACWY-CRM or MenACWY-D rather than 

MPSV4 (8). Meningococcal serogroup B vaccines are licensed for persons 10-25 years of 

age and are recommended for persons 10 years of age or older for persons with high-risk 

conditions like functional or anatomic asplenia or persistent complement component 

deficiency. There are presently no recommendations for booster doses of either MenB 

vaccine (9,10). Complete recommendations for use of meningococcal vaccines are 

available in the Recommended Immunization Schedules for Persons Aged 0 Through 18 

Years and the Recommended Adult Schedule (2,6).

Hib Vaccines

Hib conjugate vaccines are available in single or combined antigen preparations. Hib 

vaccine is recommended routinely for all children through age 59 months. 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 127

Children 12 through 59 months who are at high risk for invasive Hib disease (i.e., 

recipients of chemotherapy or radiation for malignant neoplasms, or those with functional 

or anatomic asplenia, HIV infection, immunoglobulin deficiency, or early complement 

component deficiency) and who are unvaccinated or received only one dose of Hib vaccine 

before 12 months of age should receive 2 additional doses of Hib vaccine; those who 

received 2 or more doses of Hib before 12 months of age should receive one additional 

dose. 

A child younger than 5 years of age receiving chemotherapy or radiation therapy should 

have Hib doses repeated if the doses were received during therapy or within 14 days of 

starting therapy; repeat doses should be started at least 3 months after completion of 

therapy. Recipients of hematopoietic cell transplants should be revaccinated with 3 doses 

of Hib vaccine, starting 6-12 months after successful transplant, regardless of vaccination 

history or age. 

Children 5-18 years of age with HIV who are unimmunized(a) should receive a dose of Hib 

vaccine; Hib vaccination is not recommended in HIV-infected adults. Unimmunized(a) 

asplenic patients older than 59 months of age or adults should receive a dose of Hib 

vaccine. Anyone 15 months of age or older who is undergoing a splenectomy and is 

unimmunized(a) should receive a dose of Hib vaccine (11). Complete recommendations for 

use of Hib vaccine are available in the Recommended Immunization Schedules for 

Persons Aged 0 Through 18 Years and the Recommended Adult Immunization 

Schedule (2,6).

Zoster (Shingrix) Vaccine

Zoster (Shingrix) vaccine is recommended for persons 19 years old and older who have 

altered immunocompetence.

 

Vaccination of Contacts of Persons with Altered 

Immunocompetence

Household contacts and other close contacts of persons with altered immunocompetence 

should receive all age- and exposure-appropriate vaccines, with the exception of smallpox 

vaccine (12,13). 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 128

Receipt of vaccines will prevent the vaccine-preventable disease, so there can be no 

potential transmission to the contact with altered immunocompetence. The live MMR, 

varicella, and rotavirus vaccines should be administered to susceptible household contacts 

and other close contacts of immunocompromised patients when indicated. No specific 

precautions are needed unless the varicella vaccine recipient has a rash after vaccination, 

in which case direct contact with susceptible household contacts with altered 

immunocompetence should be avoided until the rash resolves (14,15). All members of the 

household should wash their hands after changing the diaper of an infant who received 

rotavirus vaccine. 

This minimizes rotavirus transmission, as shedding may occur up to one month after the 

last dose (16,17). Household and other close contacts of persons with altered 

immunocompetence should receive annual influenza vaccination. Introduction of low 

levels of vaccine viruses into the environment likely is unavoidable when administering 

LAIV. LAIV vaccine viruses are cold-adapted, so they can replicate in the nose and 

generate an immune response without entering the lungs (i.e., they are temperature 

sensitive and replicate poorly at core body temperatures). No instances have been 

reported of illness caused by attenuated vaccine virus infections among health-care 

providers or immunocompromised patients. LAIV may be administered to healthy 

household and other close contacts of persons with altered immunocompetence unless the 

person with altered immunocompetence is in a protective environment, typically defined 

as a specialized patient-care area with a positive airflow relative to the corridor, highefficiency particulate air filtration, and frequent air changes (3). No preference exists for 

inactivated influenza vaccine use by health-care workers or other persons who have close 

contact with persons with lesser degrees of immunosuppression (e.g., persons with 

diabetes, persons with asthma taking high-dose corticosteroids, or persons infected with 

HIV), and no preference exists for inactivated influenza vaccine use by health-care 

workers or other healthy persons aged 5-49 years in close contact with all other groups at 

high risk.
General Best Practice Guidelines for Immunization: Altered Immunocompetence 129

Non-live Vaccines: Safety

All non-live vaccines can be administered safely to persons with altered 

immunocompetence, whether the vaccine is a killed whole-organism or a recombinant, 

subunit, split-virus, toxoid, polysaccharide, or polysaccharide protein-conjugate vaccine.

 

Non-live Vaccines: Effectiveness

Except for inactivated influenza vaccine, vaccination during chemotherapy or radiation 

therapy should be avoided if possible because antibody response might be suboptimal. 

Patients vaccinated within a 14-day period before starting immunosuppressive therapy or 

while receiving immunosuppressive therapy should be considered unimmunized and 

should be revaccinated at least 3 months after therapy is discontinued if immune 

competence has been restored. Patients who have quantitative B-cell deficiencies and are 

receiving immunoglobulin therapy should not receive either non-live or live vaccines while 

receiving the immunoglobulin therapy because of concerns about effectiveness of the 

vaccines. Patients on chemotherapy with anti-B cell antibodies (e.g., rituximab) should 

wait at least 6 months after therapy before being vaccinated with non-live vaccines. Some

experts recommended longer than 6 months for some anti-B cell antibodies. For other 

forms of altered immunocompetence, if non-live vaccines are indicated, the usual 

schedules are recommended. However, the effectiveness of such vaccinations might be 

suboptimal (1).

Live, Attenuated Viral and Bacterial Vaccines: 

Effectiveness

The same rationale regarding effectiveness that exists with non-live vaccines also exists 

with live vaccines.

 

Live, Attenuated Viral and Bacterial Vaccines: Safety

Severe complications have followed vaccination with certain live, attenuated viral and live, 

attenuated bacterial vaccines among persons with altered immunocompetence (18-26). 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 130

Persons with most forms of altered immunocompetence should not receive live vaccines 

(MMR, varicella, MMRV, LAIV, yellow fever, Ty21a oral typhoid, BCG, smallpox, and 

rotavirus). However, exceptions exist, and are discussed in this section.

Patients with any defect in phagocytic function (e.g., chronic granulomatous disease, 

leukocyte adhesion deficiency, myeloperoxidase deficiency, Chediak-Higashi syndrome) 

should NOT receive live bacterial vaccines. Patients with a specific type of defect in 

phagocytic function—chronic granulomatous disease—should receive recommended live 

attenuated viral vaccines in addition to non-live vaccines but should NOT receive live 

bacterial vaccines. 

Patients with defects in phagocytic function that are undefined or known to be 

accompanied by defects in T-cell and natural killer cell function (e.g., leukocyte adhesion 

deficiency, myeloperoxidase deficiency, Chediak-Higashi syndrome) should NOT receive 

live attenuated viral or bacterial vaccines. These conditions include specific deficits in Tcell and natural killer cell function, reducing the response to live viral vaccine antigens to 

an extent not seen in chronic granulomatous disease (1). Children with deficiencies in 

complement should receive recommended live, attenuated viral and live, attenuated 

bacterial vaccines. Children with asplenia should not receive LAIV, but can receive 

recommended live, attenuated viral and live, attenuated bacterial vaccines.

Persons with severe cell-mediated immunodeficiency should not receive live, attenuated 

viral or bacterial vaccines. Patients with defects of the interferon-gamma/interleukin-12 

axis should not receive live bacterial vaccines. Patients with deficiencies of interferongamma or interferon-alpha should not receive live viral or live bacterial vaccine. These 

defects involve a deficiency in cytokine production which affects the immune response to a 

wide scope of antigens, both bacterial and viral (1). Two factors support vaccination of 

HIV-exposed or HIV-infected infants with rotavirus vaccines: 1) the HIV diagnosis might 

not be established in infants born to HIV-infected mothers before the age of the first 

rotavirus vaccine dose (only 1.5%-3% of HIV-exposed infants in the United States will be 

determined to be HIV-infected), and 2) the vaccine strains of rotavirus are considerably 

attenuated. Patients taking exogenous interferon as therapy should not receive live 

bacterial or live viral vaccines.
General Best Practice Guidelines for Immunization: Altered Immunocompetence 131

Children with HIV infection are at increased risk for complications from varicella and 

herpes zoster infection compared with immunocompetent children (27, 28). Limited data 

among HIV-infected children younger than 8 years (specifically, those individuals with 

CDC class N, A, or B with age-specific CD4+ T-lymphocyte percentages of ≥15%) indicate 

that single-component varicella vaccine is immunogenic, effective, and safe (14,28). Data 

on use of varicella vaccine in HIV-infected adolescents and adults are lacking. However, 

on the basis of expert opinion, the safety of varicella vaccine in HIV-infected persons older 

than 8 years with comparable levels of immune function (CD4+T-lymphocyte count 

greater than 200 cells/mm3) is likely to be similar to that of children aged younger than 8 

years (14). 

Varicella vaccine should be considered for persons who meet these criteria. Eligible HIVinfected persons 12 months of age or older should receive 2 doses of single-component 

varicella vaccine with a 3-month interval between doses (14,28). MMRV vaccine should 

not be administered to any HIV-infected person.

Persons with HIV infection are at increased risk for severe complications if infected with 

measles. No severe or unusual adverse events have been reported after measles 

vaccination among HIV-infected persons who did not have evidence of severe 

immunosuppression (29-32). Two doses of MMR vaccine are recommended for all HIVinfected individuals aged ≥12 months who do not have evidence of current severe 

immunosuppression (i.e., individuals aged ≤5 years must have CD4+T lymphocyte 

[CD4+] percentages ≥15% for ≥6 months, and individuals aged >5 years must have 

CD4+percentages ≥15% and CD4+≥200 lymphocytes/mm3 for ≥6 months) and do not 

have current evidence of measles, rubella, and mumps immunity. In cases when only 

CD4+cell counts or only CD4+percentages are available for those >5 years, the assessment 

of severe immunosuppression can be based on the CD4+values (count or percentage) that 

are available. In cases when CD4+percentages are not available for those aged ≤5 years, 

the assessment of severe immunosuppression can be based on age-specific CD4+counts at 

the time CD4+counts were measured; i.e., absence of severe immunosuppression is 

defined as ≥6 months above age-specific CD4+count criteria: CD4+count >750 

lymphocytes/mm3 while aged ≤12 months and CD4+count ≥500 lymphocytes/mm3 while 

aged 1 through 5 years (33). 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 132

Similarly, repeat doses of MMR vaccination are recommended for individuals with 

perinatal HIV infection who were vaccinated prior to establishment of effective 

combination antiretroviral therapy (cART). They should receive 2 appropriately spaced 

doses of MMR vaccine once effective cART has been established (individuals aged ≤5 

years must have CD4+percentages ≥15% for ≥6 months; individuals aged >5 years must 

have CD4+percentages ≥15% and CD4+≥200 lymphocytes/mm3 for ≥6 months) unless 

they have other acceptable current evidence of measles, rubella, and mumps immunity.

HIV-infected persons who are receiving regular doses of IGIV are unlikely to respond to 

varicella vaccine or MMR vaccine because of the continued presence of passively acquired 

antibody. 

However, because of the potential benefit, MMR and varicella vaccines should be 

considered approximately 14 days before the next scheduled dose of IGIV (if not otherwise 

contraindicated), although an optimal immune response might not occur depending on 

the presence of neutralizing antibodies against the vaccine virus. Vaccination should be 

repeated (if not otherwise contraindicated) after the recommended interval (see Table 3-6 

in the Timing and Spacing of Immunobiologics of this document). In most cases, this is 

after the therapy has been discontinued.

Patients with leukemia, lymphoma, or other malignancies whose disease is in remission, 

who have restored immunocompetence, and whose chemotherapy has been discontinued 

for at least 3 months can receive live-virus vaccines. Persons with impaired humoral 

immunity (e.g., hypogammaglobulinemia or dysgammaglobulinemia) may be vaccinated 

with varicella vaccine (14). However, most persons with these disorders also receive 

periodic doses of IGIV. Appropriate spacing should be maintained between administration 

of IGIV and varicella vaccine in an attempt to prevent an inadequate response to 

vaccination caused by the presence of neutralizing antibodies from the IGIV.

Zoster incidence is higher in persons with altered immunocompetence (34). Adults with 

most types of altered immunocompetence are expected to maintain residual immunity to 

varicella-zoster virus because of chronic latent infection that protects against primary 

varicella but provides incomplete protection against zoster. Zoster vaccine is not 

recommended in persons with primary or acquired immunodeficiency (e.g., lymphoma, 

leukemia, tumors involving bone marrow, and patients receiving chemotherapy) and some 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 133

HIV infected patients (34). Zoster vaccine may be administered to certain persons age 50 

or older with altered immunocompetence, such as persons receiving low dosages of 

immunosuppressive medications, those with isolated B-cell deficiencies (i.e., impaired 

humoral immunity), or those with HIV infection who have CD4+ T-lymphocyte counts 

>200 cells/mm3.

Recipients of Hematopoietic Cell Transplants

A hematopoietic stem cell transplant (HSCT) results in immunosuppression because of 

the hematopoietic ablative therapy administered before the transplant, drugs used to 

prevent or treat graft-versus-host disease, and, in some cases, from the underlying disease 

process necessitating transplantation (35-37). HSCT involves ablation of the bone marrow 

followed by reimplantation of the person’s own stem cells or stem cells from a donor. The 

ablation caused by the HSCT will also gradually remove immune memory from previous 

vaccination. Antibody titers to vaccine-preventable diseases (e.g., tetanus, poliovirus, 

measles, mumps, rubella, and encapsulated bacteria) decrease 1-4 years after autologous 

or allogeneic HSCT if the recipient is not revaccinated. HSCT recipients of all ages are at 

increased risk for certain vaccine-preventable diseases, including diseases caused by 

encapsulated bacteria (e.g., pneumococcal and Hib infections). As a result, HSCT 

recipients who received vaccines prior to their HSCT should receive repeat doses routinely 

after HSCT, regardless of the source of the transplanted stem cells (35-37). Revaccination 

doses following HSCT are indicated with pneumococcal vaccines, DTaP vaccine, Tdap 

vaccine, Hib vaccine, hepatitis A vaccine, hepatitis B vaccine, IPV, inactivated influenza 

vaccines, meningococcal conjugate vaccine (for individuals 11 through 18 years or at highrisk), serogroup B meningococcal vaccine (for individuals 16 through 23 years or at highrisk), and human papillomavirus (HPV) vaccines (for individuals aged 9-26 years, or 27 

through 45 years of age based on shared clinical decision-making) (1, 35). Recombinant 

zoster vaccine may be re-administered 6-12 months after an allogeneic HSCT, and may be 

re-administered 3-12 months after an autologous HSCT. For more specificity on the 

precise timing of re-administration of RZV, note that this should optimally occur 2 

months prior to cessation of prophylactic antiviral therapy (acyclovir, famciclovir, and 

valacyclovir). Varicella and MMR vaccines may be re-administered after HSCT if 24 

months have passed since HSCT, the patient does NOT have graft-vs-host disease, and is 

considered immunocompetent. 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 134

Yellow fever vaccine, rabies vaccine, tick-borne encephalitis vaccine, and Japanese 

encephalitis vaccine are not routinely administered vaccines, so their use post-HSCT will 

be driven by a disease-specific risk such as exposure or travel. If someone has received 

yellow fever vaccine prior to an HSCT, another dose should be re-administered post-HSCT

(38). BCG, LAIV, typhoid vaccine, and rotavirus vaccine are not recommended after 

HSCT. Most non-live vaccines should be re-initiated 6 months after the HSCT (37). 

Inactivated influenza vaccine should be administered beginning at least 6 months after 

HSCT and annually thereafter for the life of the patient. A dose of inactivated influenza 

vaccine can be given as early as 4 months after HSCT, but a second dose should be 

considered in this situation (37). A second dose is recommended routinely for all children

younger than 9 years receiving influenza vaccine for the first time. Revaccination of HCST 

patients with pneumococcal vaccines is recommended regardless of whether doses were 

administered prior to HSCT. For those HSCT recipients that were vaccinated prior to 

HSCT with PCV7, PCV13, PCV15, or PCV20, sequential administration of 4 doses of 

PCV20 is recommended, beginning 3-6 months after the transplant. The first three doses 

should be separated by 4 weeks and the fourth dose of PCV20 should be administered 6 

months after the third dose or 1 year after the HSCT, whichever is later. As an alternative 

to PCV20, three doses of PCV15 separated by 4 weeks, followed by PPSV23 one year after 

the last dose of PCV15 (and at least 4 weeks after the third dose of PCV15) may be 

administered. If the patient has graft-versus-host disease, substitute a fourth dose of 

PCV15 for PPSV23. For doses of pneumococcal conjugate vaccine administered after 

HSCT consisting of PCV13 or PCV15, these doses count as post-HSCT doses, so one always 

has the option to transition FROM PCV15 to PCV20 for the post-HSCT dosing regimen. A 

3-dose regimen of Hib vaccine should be administered beginning 6 months after 

transplant; at least 1 month should separate the doses (37). The revaccination schedule for 

pertussis-containing vaccines includes 3 doses of DTaP for patients <7 years (14). For

patients ≥7 years, providers have 3 options for revaccination: 1) 3 doses of DTaP; 2) one 

dose of Tdap and 2 doses of DT; or 3) one dose of Tdap and 2 doses of Td (1).

Providers need to make a clinical judgment whether they will follow the revaccination 

schedules described above in circumstances where particular vaccines were NOT 

administered prior to the HSCT. In this circumstance, providers may just vaccinate 

according to routine recommendations for post-HSCT vaccination. For instance, there are 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 135

specific recommendations for Hib and pertussis-containing vaccines. Use of the 3-dose 

Hib schedule following HSCT is supported for both patients that received Hib prior to 

HSCT and those who did not receive Hib prior to HSCT (6, 11). For children >6 years who 

did not receive previous doses of pertussis-containing vaccine prior to the HSCT, the 

preferred schedule following HSCT is a dose of Tdap followed by 2 doses of Td (personal 

communication, subject matter experts). 

This is identical to one of the alternative regimens for revaccination doses, described 

above.

Conditions or Drugs that Might Cause 

Immunodeficiencies

Asplenia and use of corticosteroids or certain drugs have the potential to be 

immunosuppressive and are presumed to cause some degree of altered 

immunocompetence.

Anatomic or Functional Asplenia

Persons with anatomic asplenia (e.g., surgical removal or congenital absence of the spleen) 

or functional asplenia (as occurs in persons with sickle cell disease) are at increased risk 

for infection by encapsulated bacteria, especially S. pneumoniae (pneumococcus), N. 

meningitidis (meningococcus), and Hib (7-8, 39). 

Children should receive an age-appropriate series of PCV13. Unvaccinated children 2-5 

years should receive 2 doses of PCV13. Children ≥6 years should receive a dose of PCV13 if 

they have not previously received a dose of PCV13. Persons aged ≥2 years should receive 2 

doses of PPSV23 separated by 5 years, beginning 8 or more weeks after completing all 

recommended doses of PCV13 (6-7, 40-41). In circumstances where both PCV13 and 

PPSV23 are indicated, doses of PCV13 should be administered first followed by PPSV23 8 

weeks after the last dose of PCV13.

Meningococcal conjugate (MenACWY) and serogroup B (MenB) vaccines are 

recommended for persons with anatomic or functional asplenia (including sickle cell 

disease). For children 2-23 months of age, a series of MenACWY-CRM (Menveo) or HibMenCY (MenHibrix) should be administered. For persons ≥2 years of age, a 2-dose 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 136

primary series of either MenACWY-CRM or MenACWY-D (Menactra) should be 

administered. If a person with functional or anatomic asplenia is catching up on 

pneumococcal conjugate vaccine (PCV13), and the provider only carries MenACWY-D, 

indicated doses of PCV13 should be completed first and MenACWY-D should be given 4 

weeks after the PCV13 series is completed. Following the primary series of vaccine, a 3-

year interval to the next dose is recommended for asplenic children who received their last 

previous dose at age younger than 7 years. A 5-year interval for asplenic persons is 

recommended for persons who received their last previous dose at age 7 years or older. 

Meningococcal B (MenB) vaccine should be administered as either a 2-dose series of 

MenB-4C (Bexsero) or a 3-dose series of MenB-FHbp (Trumenba). The same vaccine 

product must be used for all doses. Based on available data and expert opinion, MenB-4C 

or MenB-FHbp may be administered concomitantly with MenACWY vaccines, but at a 

different anatomic site, if feasible. There are presently no recommendations for booster 

doses of either MenB vaccine.

Hib vaccine is recommended routinely for all children through age 59 months. Children 

12-59 months with functional or anatomic asplenia and who are unvaccinated or who 

received only one dose of Hib disease before 12 months of age should receive 2 doses of 

Hib vaccine; those who received 2 or more doses of Hib before 12 months of age should 

receive one additional dose. Unimmunized(a) asplenic patients older than 59 months of 

age should receive one dose of Hib vaccine. Anyone ≥15 months of age who is undergoing 

a splenectomy and is unimmunized(a) should receive one dose of Hib vaccine.

Pneumococcal, meningococcal, and Hib vaccinations should be administered at least 14 

days before elective splenectomy, if possible. If the vaccinations are not administered 

before surgery, they should be administered after the procedure as soon as the patient’s 

condition is stable.

Corticosteroids

The amount of systemically absorbed corticosteroids and the duration of administration 

needed to suppress the immune system of an otherwise immunocompetent person are not 

well defined. Although the immunosuppressive effects of steroid treatment vary, the 

majority of clinicians consider a dose equivalent to either ≥2 mg/kg of body weight or ≥20 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 137

mg/day of prednisone or equivalent for persons who weigh >10 kg when administered for 

≥14 consecutive days as sufficiently immunosuppressive to raise concern about the safety 

of vaccination with live-virus vaccines (37). This dosage is referred to as “high-dose 

corticosteroids”. Corticosteroids used in greater than physiologic doses also can reduce the 

immune response to vaccines. 

Vaccination providers should defer live-virus vaccination for at least 1 month after 

discontinuation of high-dose systemically absorbed corticosteroid therapy administered 

for ≥14 days. Following vaccination, the decision needs to be made when to restart 

immunosuppressive therapy. There are no specific recommendations about when to 

restart immunosuppressive medicines. However, when initiating immunosuppressive 

therapy, providers should wait 4 weeks after a live vaccine and 2 weeks after a non-live

vaccine. However, if patients require therapy for chronic inflammatory conditions, this 

therapy should not be delayed because of past administration of vaccines (1).

Corticosteroid therapy usually is not a contraindication to administering live-virus vaccine 

when administration is 1) short term (i.e., <14 days); 2) a low to moderate dose (i.e., <20 

mg of prednisone or equivalent per day or <2mg/kg body weight per day for a young 

child); 3) long-term, alternate-day treatment with short-acting preparations; 4) 

maintenance physiologic doses (replacement therapy); or 5) topical (skin or eyes), inhaled, 

or by intra-articular, bursal, or tendon injection (37). No evidence of an increased risk for 

more severe reactions to live, attenuated viral vaccines has been reported among persons 

receiving corticosteroid therapy by aerosol, and such therapy is not a reason to delay 

vaccination.

Other Immunosuppressive Drugs

When feasible, clinicians should administer all indicated vaccines before initiation of 

chemotherapy, before treatment with other immunosuppressive drugs, and before 

radiation or splenectomy. Persons receiving chemotherapy or radiation for leukemia and 

other hematopoietic malignancies, or for solid tumors, should be assumed to have altered 

immunocompetence. Live, attenuated vaccines should not be administered for at least 3 

months after such immunosuppressive therapy. Non-live vaccines administered during 

chemotherapy should be readministered after immune competence is regained. Children 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 138

vaccinated before receiving chemotherapy for leukemia, lymphoma, other malignancies, 

or radiation generally are thought to retain immune memory after treatment, although 

revaccination with the common childhood vaccines after chemotherapy for acute 

lymphoblastic leukemia might be indicated (42). 

In general, revaccination of a person after chemotherapy or radiation therapy is 

considered unnecessary if the previous vaccination occurred before therapy and not 

during therapy, with the exception of recipients of HSCT, who should be revaccinated as 

recommended previously. Determination of the level of immune memory and the need for 

revaccination should be made by the treating physician.

Certain immunosuppressive medications are administered to prevent solid organ 

transplant rejection. Live vaccines should be withheld for 2 months following 

discontinuation of anti-rejection therapies in patients with a solid organ transplant. 

Other immunosuppressive medications include human immune mediators like 

interleukins and colony-stimulating factors, immune modulators, and medicines like 

tumor necrosis factor-alpha inhibitors and anti-B cell agents. Non-live and live vaccines 

should be administered 2 or more weeks before initiating such therapies. Live vaccines 

should be withheld 3 months following such therapies, and both non-live and live vaccines 

should be withheld at least 6 months following therapy with anti-B cell agents. Some 

experts recommend longer than 6 months following anti-B cell agents. 

Anti-B cell agents suppress antibody-producing cells for a prolonged duration, hence the 

longer interval recommended before administering vaccines (17).

Zoster vaccine is an exception and should be withheld 1 month following anti-B cell 

agents. After vaccination, anti-B cell agents can be resumed 1 month later.

(a) Patients who have not received a primary series and booster dose or at least 1 dose of Hib vaccine after 14 months of age are 

considered unimmunized.
General Best Practice Guidelines for Immunization: Altered Immunocompetence 139

Table 8-1. Vaccination of persons with primary and secondary immunodeficiencies

Category Specific types Contraindications(a) Risk-specific 

recommended 

vaccines(a)

Effectiveness 

and 

comments

Primary: Blymphocyte 

(humoral)

Severe antibody 

deficiencies (e.g., Xlinked 

agammaglobulinemia 

and common variable 

immunodeficiency)

OPV(b)

Smallpox©

LAIV

BCG

Ty21a (live typhoid)

Yellow fever

MMR

MMRV

DEN4CYD

Pneumococcal

Hib (children 

12–59 months of 

age)(d)

Recombinant 

zoster vaccine(e)

The 

effectiveness 

of any 

vaccine is 

uncertain if 

it depends 

only on the 

humoral 

response 

(e.g., 

PPSV23)

IGIV 

interferes 

with the 

immune 

response to 

measles 

vaccine and 

possibly 

varicella 

vaccine

Less severe antibody 

deficiencies (e.g., 

selective IgA 

deficiency and IgG 

subclass deficiency)

OPV(b)

BCG

DEN4CYD

Yellow fever(f)

Other live vaccines 

appear to be safe

Pneumococcal

Hib (children 

12–59 months of 

age)(d)

Recombinant 

zoster(e)

All vaccines 

likely 

effective; 

immune 

response 

might be 

attenuated

Primary: Tlymphocyte 

(cellmediated 

Complete defects 

(e.g., SCID disease, 

complete DiGeorge 

syndrome)

All live vaccines(g), (h), 

(i)

Pneumococcal

Hib (children 

12–59 months of 

age)(d)

Vaccines 

unlikely to 

be effective
General Best Practice Guidelines for Immunization: Altered Immunocompetence 140

and 

humoral)

Recombinant 

zoster(e)

Partial defects (e.g., 

most patients with 

DiGeorge syndrome, 

Wiskott-Aldrich 

syndrome, ataxiatelangiectasia)

All live vaccines(g),(h),(i) Pneumococcal 

Meningococcal 

Hib (children 12-

59 months of 

age)(d)

Recombinant 

zoster(e)

Effectiveness 

of any 

vaccine 

depends on 

degree of 

immune 

suppression

Interferon-alpha 

deficiencies, 

interferon-gamma 

deficiencies

All live vaccines(g), (h) Recombinant 

zoster(e)

Interferongamma/interleukin12 axis deficienciesLive bacterial 

vaccines(g)

Recombinant 

zoster(e)

Primary: 

phagocytic 

function

Chronic 

granulomatous 

disease

Live bacterial 

vaccines(g)

Recombinant 

zoster(e)

Live viral 

vaccines 

likely safe 

and effective

Phagocytic 

deficiencies that are 

undefined or 

accompanied by 

defects in T-cell and 

NK cell dysfunction 

(such as a ChediakHigashi syndrome, 

Leukocyte Adhesion 

Deficiency [LAD], 

and myeloperoxidase 

deficiency)

Live 

vaccines(g),(h)

Pneumococcal

Recombinant 

zoster(e)

All non-live 

vaccines safe 

and likely 

effective

Primary: 

complement

Persistent 

complement, 

properdin, or Factor 

B deficiency

None Pneumococcal

Meningococcal

Hib (children 12-

59 months of 

age)(d)

All routine 

vaccines 

likely 

effective
General Best Practice Guidelines for Immunization: Altered Immunocompetence 141

Secondary HIV/AIDS OPV(b)

Smallpox BCG

LAIV

Ty21a 

MMRV

DEN4-CYD

Withhold MMR, and 

varicella in severely 

immunocompro 

mised persons

Yellow fever vaccine 

might have a 

contraindication or a 

precaution depending 

on clinical parameters 

of immune function(j)

Pneumococcal 

Hib(d),(k) 

HepB

MenACWY

Recombinant 

zoster(e)

MMR and 

Varicella 

vaccine in 

those with 

mild 

immunosup

pression, 

rotavirus, 

and all nonlive vaccines, 

including 

inactivated 

influenza as 

per routine 

vaccination 

schedule, 

might be 

effective(l)

Generalized 

malignant neoplasm, 

transplantation, 

immunosuppressive 

or radiation therapy

Live viral and 

bacterial, depending 

on immune 

status(g),(h),(m)

Pneumococcal 

Hib(m)

Recombinant 

zoster(e)

Effectiveness 

of any 

vaccine 

depends on 

degree of 

immune 

suppression

Taking eculizumab 

(Solaris), and/or 

ravulizumab 

(Ultomiris)

None Meningococcal

Asplenia LAIV Pneumococcal 

Meningococcal 

Hib(d),(o)

Chronic renal disease None Pneumococcal 

HepB(p)

All routine 

vaccines 

likely 

effective
General Best Practice Guidelines for Immunization: Altered Immunocompetence 142

Abbreviations: AIDS = acquired immunodeficiency syndrome; BCG = bacille Calmette-Guérin; HepB = hepatitis B; Hib = 

Haemophilus influenzae type b; HIV = human immunodeficiency virus; IG = immunoglobulin; IGIV = immune globulin 

intravenous; IgA = immune globulin A; IgG = immune globulin G; LAIV = live, attenuated influenza vaccine; MenACWY = 

quadrivalent meningococcal conjugate vaccine; MMR = measles, mumps, and rubella; MMRV = measles, mumps, rubella, 

and varicella; OPV = oral poliovirus vaccine (live); PPSV23= pneumococcal polysaccharide vaccine; SCID = severe combined 

immunodeficiency; Ty21a = live oral typhoid vaccine.

Source: (43).

(a) Other vaccines that are universally or routinely recommended should be given if not contraindicated. An exception is 

patients with B-cell deficiencies receiving immunoglobulins, who should not receive either live or non-live vaccines, due 

to safety (live vaccines) and efficacy (live and non-live vaccines) concerns.

(b) OPV is no longer available in the United States.

(c) This table refers to contraindications for nonemergency vaccination (i.e., the ACIP recommendations); emergency 

response recommendations are addressed in the clinical guidance for smallpox vaccine use in an emergency.

(d) Children 12-59 months: if unimmunized or received zero or only 1 dose, and that dose was administered before 12 months 

of age, should receive 2 Hib doses, 8 weeks apart; if received 2 or more doses before age 12 months, and none after 12 

months, should receive 1 Hib dose 8 weeks after the last dose; if completed a primary series and received a booster dose at 

age 12 months or older, no additional Hib doses are recommended.

(e) 19 years and older only.

(f) There are no data to support IgA deficiency as a contraindication for yellow fever vaccine.

(g) Live bacterial vaccines: BCG and oral Ty21a Salmonella Typhi vaccine.

(h) Live viral vaccines: MMR, MMRV, OPV, LAIV, yellow fever, rotavirus, varicella, and vaccinia (smallpox). Nonemergency 

smallpox vaccination is not recommended for children younger than 18 years or the general public.

(i) Regarding T-lymphocyte immunodeficiency as a contraindication for rotavirus vaccine, data exist only for SCID.

(j) Symptomatic HIV infection or CD4+ T-lymphocyte count of <200/mm3 or <15% of total lymphocytes for children aged 

<6 years is a contraindication to yellow fever vaccine administration. Asymptomatic HIV infection with CD4+ Tlymphocyte count of 200-499/mm3 for persons aged ≥6 years or 15%-24% of total lymphocytes for children aged <6 years 

is a precaution for yellow fever vaccine administration. Details of yellow fever vaccine recommendations are available from 

CDC (44)

(k) Patients 5-18 years of age who have not received a Hib primary series and a booster dose or at least one Hib dose after 14 

months of age.

(l) HIV-infected children should be considered for varicella vaccine if CD4+ T-lymphocyte count is ≥15% and should receive 

MMR vaccine if they are aged ≥12 months and do not have 1) evidence of current severe immunosuppression (i.e., 
General Best Practice Guidelines for Immunization: Altered Immunocompetence 143

individuals aged ≤5 years must have CD4+T lymphocyte [CD4] percentages ≥15% for ≥6 months; and individuals aged >5 

years must have CD4+percentages ≥15% and CD4+≥200 lymphocytes/mm3 for

≥6 months) and 2) other current evidence of measles, rubella, and mumps immunity. In cases when only CD4+cell counts 

or only CD4+percentages are available for those older than age 5 years, the assessment of severe immunosuppression can 

be based on the CD4+values (count or percentage) that are available. In cases when CD4+percentages are not available for 

those aged ≤5 years, the assessment of severe immunosuppression can be based on age-specific CD4+counts at the time 

CD4+counts were measured; i.e., absence of severe immunosuppression is defined as ≥6 months above age-specific 

CD4+count criteria: CD4+count >750 lymphocytes/mm3 while aged ≤12 months and CD4+count ≥500 lymphocytes/mm3 

while aged 1 through 5 years (33).

(m) Withholding non-live vaccines also is recommended with some forms of immunosuppressive therapy, like anti-CD20 

antibodies, induction or consolidation chemotherapy, or patients with major antibody deficiencies receiving 

immunoglobulins. Inactivated influenza vaccine is an exception, but consideration should be given to repeating doses of 

any non-live vaccine administered during these therapies.

(n) Persons younger than 60 months undergoing chemotherapy or radiation therapy who have not received a Hib primary 

series and a booster dose or at least one Hib dose after 14 months of age; HSCT patients of any ages, regardless of Hib 

vaccine history.

(o) Persons older than 59 months who are asplenic and persons 15 months or older who are undergoing elective 

splenectomy who have not received a Hib primary series and a booster dose or at least one Hib dose after 14 months of 

age.

(p) Hepatitis B vaccine is recommended for all persons birth through 59 years of age. Hepatitis B vaccine is also recommended 

for patients with chronic renal disease in all age groups (including 60 years old and older) based on the risk from dialysisbased bloodborne transmission.
General Best Practice Guidelines for Immunization: Altered Immunocompetence 144

REFERENCES

1. Rubin L, Levin M, Ljungman P, et al. 2013 IDSA clinical practice guideline for 

vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-

100. DOI: 10.1093/cid/cit684

2. Kim DK, Bridges CB, Harriman KH. Advisory committee on immunization 

practices recommended immunization schedule for adults aged 19 years or 

older—United States, 2015. MMWR Morb Mortal Wkly Rep.2015;64(4):91-92.

3. Grohskopf LA, Olsen SJ, Sokolow LZ, et al. Prevention and control of seasonal 

influenza with vaccines: recommendations of the Advisory Committee on 

Immunization Practices (ACIP)—United States, 2014-15 influenza season. 

MMWR Morb Mortal Wkly Rep. 2014;63(32):691-697.

4. Markert ML, Hummell DS, Rosenblatt HM, et al. Complete DiGeorge syndrome: 

persistence of profound immunodeficiency. J Pediatr. 1998;132(1):15-21. DOI: 

10.1016/S0022-3476(98)70478-0

5. Jeffrey Modell Foundation Medical Advisory Board. 10 warning signs of primary 

immunodeficiency [Poster]. 2009; http:// www.info4pi.org/library/educationalmaterials/10-warning-signs. Accessed 9 March, 2017.

6. Strikas RA. Advisory committee on immunization practices recommended 

immunization schedules for persons aged 0 through 18 years—UnitedStates, 

2015. MMWR Morb Mortal Wkly Rep. 2015;64(4):93-94.

7. Bilukha OO, Rosenstein N. Prevention and control of meningococcal disease. 

Recommendations of the Advisory Committee on Immunization Practices 

(ACIP). MMWR Recomm Rep. 2005;54(RR-7):1-21.

8. Cohn AC, MacNeil JR, Clark TA, et al. Prevention and control of meningococcal 

disease: recommendations of the Advisory Committee on Immunization Practices 

(ACIP). MMWR Recomm Rep. 2013;62(RR-2):1-28.

9. Folaranmi T, Rubin L, Martin SW, Patel M, MacNeil JR. Use of serogroup B 

meningococcal vaccines in persons aged >/=10 years at increased risk for 

serogroup B meningococcal disease: recommendations of the Advisory 

Committee on Immunization Practices, 2015. MMWR Morb Mortal Wkly Rep. 

2015;64(22):608-612.
General Best Practice Guidelines for Immunization: Altered Immunocompetence 145

10. MacNeil JR, Rubin L, Folaranmi T, Ortega-Sanchez IR, Patel M, Martin SW. Use 

of serogroup B meningococcal vaccines in adolescents and young adults: 

recommendations of the Advisory Committee on Immunization Practices, 2015. 

MMWR Morb Mortal Wkly Rep. 2015;64(41):1171-1176. DOI: 

10.15585/mmwr.mm6441a3

11. Briere EC, Rubin L, Moro PL, Cohn A, Clark T, Messonnier N. Prevention and 

control of Haemophilus influenzae type b disease: recommendations of the 

advisory committee on immunization practices (ACIP). MMWR Recomm Rep. 

2014;63(RR-1):1-14.

12. Petersen BW, Harms TJ, Reynolds MG, Harrison LH. Use of vaccinia virus 

smallpox vaccine in laboratory and health care personnel at risk foroccupational 

exposure to orthopoxviruses - recommendations of the Advisory Committee on 

Immunization Practices (ACIP), 2015. MMWR Morb Mortal Wkly Rep. 

2016;65(10):257-262. DOI: 10.15585/mmwr.mm6510a2

13. Petersen BW, Damon IK, Pertowski CA, et al. Clinical guidance for smallpox 

vaccine use in a postevent vaccination program. MMWR Recomm Rep. 

2015;64(RR-2):1-26.

14. Marin M, Guris D, Chaves SS, Schmid S, Seward JF. Prevention of varicella: 

recommendations of the Advisory Committee on Immunization Practices (ACIP). 

MMWR Recomm Rep. 2007;56(RR-4):1-40.

15. Grossberg R, Harpaz R, Rubtcova E, Loparev V, Seward JF, Schmid DS. 

Secondary transmission of varicella vaccine virus in a chronic care facility for 

children. J Pediatr. 2006;148(6):842-844. DOI: 10.1016/j.jpeds.2006.01.038

16. Cortese MM, Parashar UD. Prevention of rotavirus gastroenteritis among infants 

and children: recommendations of the Advisory Committee on Immunization 

Practices (ACIP). MMWR Recomm Rep. 2009;58(RR-2):1-25.

17. Anderson EJ. Rotavirus vaccines: viral shedding and risk of transmission. Lancet 

Infect Dis. 2008;8(10):642-649. DOI: 10.1016/s1473-3099(08)70231-7

18. Sixbey JW. Routine immunizations and the immunosuppressed child.Adv 

Pediatr Infect Dis. 1987;2:79-114.
General Best Practice Guidelines for Immunization: Altered Immunocompetence 146

19. Wright PF, Hatch MH, Kasselberg AG, Lowry SP, Wadlington WB, Karzon DT. 

Vaccine-associated poliomyelitis in a child with sex-linked agammaglobulinemia. 

J Pediatr. 1977;91(3):408-412. DOI: 10.1016/S0022-3476(77)81309-7

20.Wyatt HV. Poliomyelitis in hypogammaglobulinemics. J Infect Dis. 

1973;128(6):802-806. DOI: 10.1093/infdis/128.6.802

21. Davis LE, Bodian D, Price D, Butler IJ, Vickers JH. Chronic progressive 

poliomyelitis secondary to vaccination of an immunodeficient child. N Engl J 

Med. 1977;297(5):241-245. DOI: 10.1056/nejm197708042970503

22.CDC. Disseminated Mycobacterium bovis infection from BCG vaccination of a 

patient with acquired immunodeficiency syndrome. MMWR Morb Mortal Wkly 

Rep. 1985;34(16):227-228.

23.Ninane J, Grymonprez A, Burtonboy G, Francois A, Cornu G. DisseminatedBCG 

in HIV infection. Arch Dis Child. 1988;63(10):1268-1269. DOI: 

10.1136/adc.63.10.1268

24.Redfield RR, Wright DC, James WD, Jones TS, Brown C, Burke DS. 

Disseminated vaccinia in a military recruit with human immunodeficiency virus 

(HIV) disease. N Engl J Med. 1987;316(11):673-676. DOI: 

10.1056/nejm198703123161106

25.CDC. Measles pneumonitis following measles-mumps-rubella vaccination of a 

patient with HIV infection, 1993. MMWR Morb Mortal Wkly Rep. 

1996;45(28):603-606.

26.Cono J, Casey CG, Bell DM. Smallpox vaccination and adverse reactions. 

Guidance for clinicians. MMWR Recomm Rep. 2003;52(RR-4):1-28.

27. Derryck A, LaRussa P, Steinberg S, Capasso M, Pitt J, Gershon AA. Varicella and 

zoster in children with human immunodeficiency virus infection. Pediatr Infect 

Dis J. 1998;17(10):931-933. DOI: 10.1097/00006454-199810000-00023

28.Levin MJ, Gershon AA, Weinberg A, Song LY, Fentin T, Nowak B.Administration 

of live varicella vaccine to HIV-infected children with current or past significant 

depression of CD4(+) T cells. J Infect Dis. 2006;194(2):247-255. DOI: 

10.1086/505149
General Best Practice Guidelines for Immunization: Altered Immunocompetence 147

29.Sprauer MA, Markowitz LE, Nicholson JK, et al. Response of human 

immunodeficiency virus-infected adults to measles-rubella vaccination. J Acquir 

Immune Defic Syndr. 1993;6(9):1013-1016.

30.McLaughlin M, Thomas P, Onorato I, et al. Live virus vaccines in human 

immunodeficiency virus-infected children: a retrospective survey. Pediatrics. 

1988;82(2):229-233.

31. Onorato IM, Markowitz LE, Oxtoby MJ. Childhood immunization, vaccinepreventable diseases and infection with human immunodeficiency virus. Pediatr 

Infect Dis J. 1988;7(8):588-595.

32.Palumbo P, Hoyt L, Demasio K, Oleske J, Connor E. Population-based study of 

measles and measles immunization in human immunodeficiency virus-infected 

children. Pediatr Infect Dis J. 1992;11(12):1008-1014.

33.McLean HQ, Fiebelkorn AP, Temte JL, Wallace GS. Prevention of measles, 

rubella, congenital rubella syndrome, and mumps, 2013: summary 

recommendations of the Advisory Committee on Immunization Practices (ACIP). 

MMWR Recomm Rep. 2013;62(RR-4):1-34.

34.Harpaz R, Ortega-Sanchez IR, Seward JF. Prevention of herpes zoster: 

recommendations of the Advisory Committee on Immunization Practices (ACIP). 

MMWR Recomm Rep. 2008;57(RR-5):1-30; quizCE32-34.

35.Tomblyn M, 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(10):1143-1238. DOI: 

10.1016/j.bbmt.2009.06.019

36.Ljungman P, Cordonnier C, Einsele H, et al. Vaccination of hematopoietic cell 

transplant recipients. Bone Marrow Transplant. 2009;44(8):521-526. DOI: 

10.1038/bmt.2009.263

37. American Academy of Pediatrics. Immunization in special clinical circumstances. 

In: Pickering L, Baker C, Kimberlin D, Long S, eds. Red Book: 2009 Report of the 

Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American 

Academy of Pediatrics; 2009.
General Best Practice Guidelines for Immunization: Altered Immunocompetence 148

38.Staples JE, Bocchini JA, Jr., Rubin L, Fischer M. Yellow fever vaccine booster 

doses: Recommendations of the Advisory Committee on Immunization Practices, 

2015. MMWR Morb Mortal Wkly Rep. 2015;64(23):647-650.

39.CDC. Haemophilus b conjugate vaccines for prevention of Haemophilus

influenzae type b disease among infants and children two months of age and 

older. Recommendations of the Immunization Practices Advisory Committee 

(ACIP). MMWR Recomm Rep. 1991;40(RR-1):1-7.

40.CDC. Prevention of pneumococcal disease: recommendations of the Advisory 

Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 

1997;46(RR-8):1-24.

41. Nuorti JP, Whitney CG. Prevention of pneumococcal disease among infants and 

children - use of 13-valent pneumococcal conjugate vaccine and 23-valent 

pneumococcal polysaccharide vaccine - recommendations of the Advisory 

Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 

2010;59(RR-11):1-18.

42.Brodtman DH, Rosenthal DW, Redner A, Lanzkowsky P, Bonagura VR. 

Immunodeficiency in children with acute lymphoblastic leukemia after 

completion of modern aggressive chemotherapeutic regimens. J Pediatr. 

2005;146(5):654-661. DOI: 10.1016/j.jpeds.2004.12.043

43.American Academy of Pediatrics. Passive immunization. In: Pickering L, 

Baker C, Kimberlin D, Long S, eds. Red Book: 2012 Report of the 

Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: 

American Academy of Pediatrics;2012.

44.Staples JE, Gershman M, Fischer M. Yellow fever vaccine: 

recommendations of the Advisory Committee on Immunization Practices 

(ACIP). MMWR Recomm Rep. 2010;59(RR-7):1-27.