Contents

4 Immunisation of special groups

4.3 Immune-deficient individuals of all ages

Individuals with chronic conditions, an immune deficiency, or who are immunosuppressed for underlying disease control, are at increased risk or severity of infectious diseases. These individuals should be immunised as a matter of priority. Special care is required with some live vaccines. When considering immunising such individuals, seek advice from their specialist. See also general contraindications and precautions (section 1.4) and the vaccine data sheets.

It is important to ensure that the household contacts of these individuals are immune to vaccine-preventable diseases wherever possible.

4.3.1 Introduction

The safety and effectiveness of vaccines in individuals with immune deficiency are determined by the nature and degree of immunosuppression.8 Immune deficiency conditions can be divided into primary and secondary. Primary immune deficiencies that present in childhood are generally inherited, and include antibody deficiency (disorders of B lymphocytes or antibody production), defects of cell-mediated immunity (disorders of T lymphocytes, which most often present as combined defects affecting antibody production as well), and defects of complement and phagocytic function8 (see section 4.3.2). Secondary disorders of the immune system are acquired, and occur in people with HIV, people with malignant neoplasms, in organ transplant recipients, and in people receiving immunosuppressive treatment, chemotherapy or radiotherapy.8

Live parenteral vaccines (these include MMR, varicella and BCG) should not in general be given to individuals who are severely immunosuppressed because of the risk of disease from vaccine strains. Subunit and inactivated vaccines should be administered, because the risk of adverse reactions is not increased in immunosuppressed individuals, but the response of immunodeficient or immunosuppressed individuals to these inactivated vaccines may be inadequate.

Specific serum antibody titres can be determined to guide immunisation requirements for some vaccines and the future management of disease exposures.

Certain immune deficiencies result in specific disease susceptibility. For example, pneumococcal and meningococcal vaccines are recommended for those with poor or absent splenic function or certain complement deficiencies, because they are at increased risk of infection from encapsulated bacteria. Influenza and varicella vaccines are recommended for individuals with splenic dysfunction, asplenia and phagocyte function deficiencies, both to prevent the diseases and to reduce the risk of secondary bacterial infections. See section 4.3.4 for recommendations for individuals with splenic dysfunction or asplenia.

Household contacts

Immunologically competent siblings and household contacts may receive all the Schedule vaccines. It is important to ensure that close household contacts are immune for the added protection of the immunosuppressed individual. Infants in the household should receive rotavirus vaccine at the usual Schedule ages: there are no reported cases of symptomatic infection in immunocompromised contacts.9 There is no risk of transmission of MMR vaccine viruses to the immunocompromised individual.

Varicella vaccine can be given safely to the household contacts of immunosuppressed individuals. However, where a vaccinee (household contact) develops a vesicular rash, then that individual should be isolated from the immunosuppressed individual for the duration of the rash. Varicella vaccine is funded for household contacts of patients who are immunocompromised or undergoing a procedure leading to immunocompromise.

4.3.2 Primary immune deficienciesTop

Live vaccines are contraindicated for all individuals with T lymphocyte-mediated immune deficiencies and combined B- and T-lymphocyte disorders.8 Most of these individuals will be on intravenous immunoglobulin (IVIG) replacement therapy, which provides passive protection against most vaccine-preventable infections.

Hib, 23PPV and Td vaccines may be used in testing for primary immune deficiencies, on the recommendation of an internal medicine physician or paediatrician.

Influenza vaccine is funded for all immune-deficient individuals. Regardless of their age, all immune-deficient individuals who receive influenza vaccine for the first time are recommended to receive two vaccine doses at least four weeks apart, and one dose annually after that.10

Below is a summary of the appropriate immunisations for individuals with primary immune deficiencies, adapted from the Red Book: 2012 Report of the Committee on Infectious Diseases.8 Seek specialist advice. (See also Table 1.3 in section 1.4.2).

B lymphocyte deficiencies (humoral)

(Humoral means the development of circulating antibody.)

X-linked, agammaglobulinaemia and common variable immune deficiency

The efficacy of any vaccine that is dependent on a humoral response, such as 23PPV, is doubtful, but all inactivated vaccines are safe.

Selective IgA deficiency

All vaccines are probably effective.

T lymphocyte deficiencies (cell mediated and humoral)

Complete defects (eg, severe combined immune deficiency [SCID]) and partial defects (eg, Wiskott Aldrich syndrome, most patients with DiGeorge syndrome)

The efficacy of any vaccine depends on the degree of immune deficiency.

Complement deficiencies

Deficiency of early components (C1, C4, C2, C3)

All routine vaccines are probably effective.

Deficiency of late components (C5–9), properdin, factor B

All routine vaccines are probably effective.

Phagocytic function deficiencies

Chronic granulomatous disease (CGD), leukocyte adhesion defect, myeloperoxidase deficiency

All routine vaccines are probably effective.

4.3.3 Secondary (acquired) immune deficienciesTop

The following sections provide recommendations for individuals with diseases or therapy causing immunosuppression.

The ability of individuals with secondary immune deficiency to develop an adequate immunological response depends on when immunosuppression occurs and the severity of the immunosuppression. Before commencing a therapy that would be expected to cause significant immunosuppression, a full vaccination history should be obtained.

If circumstances permit, such as prior to commencing immunosuppressive therapy for rheumatological disease or prior to solid organ transplant, vaccination should be completed and additional non-routine vaccines (eg, varicella) may be appropriate. Similarly, in diseases such as chronic renal failure, where immune impairment is likely to be progressive, early administration of vaccines may result in better antibody responses. When immunosuppressive therapy is discontinued, immune recovery usually takes between 3 and 12 months.

Influenza vaccine is funded for immunosuppressed individuals before each influenza season, and is recommended three to four weeks after chemotherapy for malignant neoplasm is completed, once both the peripheral granulocyte and lymphocyte counts are >1.0 x 109/L. Regardless of their age, all immune-deficient individuals who receive influenza vaccine for the first time are recommended to receive two vaccine doses at least four weeks apart, and one dose annually after that.10

Individuals receiving corticosteroids

The minimum amount of corticosteroid administration sufficient to cause immunosuppression is not well defined, and is dependent on dose, duration and the underlying disease. Many clinicians consider a daily dosage equivalent to 2 mg/kg prednisone or greater, or a total daily dosage of 20 mg or greater, particularly when given for 14 days or more, is sufficient to raise concern about the safety of live virus vaccines.

The following guidelines may be used for the safe administration of live virus vaccine to individuals on corticosteroids. Table 4.2 provides a summary of the guidelines for individuals on high-dose corticosteroids.

Live virus vaccines can be administered to:

Live virus vaccines should not be administered to:

Note: these guidelines are intended to ensure safety of administration of the live virus vaccine; optimal vaccine immunogenicity may not be achieved.

Table 4.2: Guidelines for live virus vaccine administration for individuals on high-dose corticosteroids

  Infants and children <10 kg Children ≥10 kg and adults Administration of live viral vaccines after cessation of corticosteroids11
High dose
<14 days
>2 mg/kg
Daily or on alternate days
>20 mg/day Can be given immediately on discontinuation, but delay 2 weeks if possible
High dose
>14 days
>2 mg/kg
Daily or on alternate days
>20 mg/day Delay for 4 weeks

Source: Immunisation Advisory Centre

Other immunosuppressive agents (eg, for autoimmune diseases, rheumatological diseases, inflammatory bowel disease)

In recent years there has been rapid development of immunosuppressive agents, particularly targeted biological therapies, and an increasing number of patients are receiving such therapies. Table 4.3 lists the categories of agents available, according to their potential for immunosuppression.

As a general guide, low-level immunosuppression includes treatment with prednisone <2 mg/kg with a maximum of 20 mg/day; methotrexate ≤0.4 mg/kg/week; azathiaprine ≤3 mg/kg/day; or 6 mercaptopurine ≤1.5 mg/kg/day. High-level immunosuppression regimens include treatment regimens with higher than the above doses, and those on biological agents such as tumour necrosis factor antagonists or rituximab. Combination therapies increase the level of immunosuppression.

Table 4.3: Immunotherapy agents for immune-mediated inflammatory disease

Corticosteroids Immunosuppressive agents
Disease modifying anti-rheumatic drugs (DMARDS)
Targeted biological therapies Cytotoxics
Prednisone

Prednisolone

Methyl-prednisolone
DMARDS I

Hydroxy-chloroquine

Leflunomide

Methotrexate

Sulphasalazine
DMARDS II

Azathioprine

Cyclosporin

Mycophenolate mofetil
Biological DMARDS

Abatacept

Anakinra

Rituximab

Tocilizumab

Anti-TNF DMARDS

Adalimumab

Etanercept

Infliximab
Cyclo-phosphamide
When these agents are used singly

Table 4.3 diagram

Source: Immunisation Advisory Centre

Commencement of such treatments is often planned (elective), and the opportunity should be taken to ensure patients are up to date with their routine vaccinations (including HPV from age 9 years). If immediate treatment is required it should not be delayed to allow for vaccination. Live viral vaccines (MMR and varicella) should only be given if the patient is non-immune, is not severely immunocompromised and is ≥4 weeks prior to commencement of immunosuppressive therapy. Varicella vaccine may be given at a shorter interval at the discretion of the specialist.

Oncology patients

This section provides general guidelines for vaccination after cancer treatment. Specific vaccination questions should be discussed with an expert paediatrician, infectious diseases physician or oncologist. Annual influenza vaccine is recommended and can be given even while a patient is on treatment (two doses four weeks apart in the first year). Household contacts may be safely given MMR (funded; see chapter 11) and varicella vaccine (funded; see the ‘Household contacts’ discussion in section 4.3.1, or chapter 21), and annual influenza vaccination is recommended (not funded).

Vaccination after chemotherapy

Those who have received routine immunisations prior to cancer diagnosis do not need full re-immunisation. Booster dose(s) of a diphtheria/tetanus/pertussis containing vaccine, hepatitis B, polio (IPV) and pneumococcal vaccines (PCV13 and 23PPV) should be given, starting not less than three months after chemotherapy has ended, when the lymphocyte count is >1.0 x 109/L. Live viral vaccines should be delayed for at least six months after chemotherapy, but MMR and varicella vaccine should then be given to seronegative patients. The interval may need to be extended according to the intensity and type of therapy, radiation therapy, receipt of blood products or immunoglobulin (see Table 1.3 in section 1.4.2), underlying disease and other factors. For children aged under 18 years, suggested age-appropriate schedules and worksheets are available at: https://www.starship.org.nz/media/199142/immunisation_of_children_during_and_after_cancer_therapy_18_july_2014.pdf

Vaccination after haematopoietic stem cell transplant (HSCT)/bone marrow transplant

Many factors can affect a transplant recipient’s immunity to vaccine-preventable diseases following a successful marrow transplant. These include the donor’s immunity, the type of transplant and the interval since the transplant, the continuing use of immunosuppressive drugs, and graft versus host disease (GVHD). Some recipients acquire the immunity of the donor, but others lose all serological evidence of immunity. Complete re-immunisation is recommended, starting with inactivated vaccines 12 months after bone marrow transplant.

Routine Schedule immunisations should be given for children aged under 10 years, but from the 10th birthday Tdap should be given. Pneumococcal vaccines (PCV13 and 23PPV), meningococcal (conjugate C and quadrivalent conjugate), hepatitis B and a booster dose of Hib and IPV are all recommended.

Healthy survivors of bone marrow transplant can be given MMR and varicella vaccine not less than two years after transplant. A second dose of MMR vaccine (and varicella vaccine if aged 13 years and older) should be given four weeks or more after the first dose, unless serological response to measles (and varicella) is demonstrated after the first dose. The vaccines should not be given to individuals suffering from GVHD because of a risk of a resulting chronic latent virus infection leading to central nervous system sequelae.

For children aged under 18 years, suggested age-appropriate schedules and worksheets are available at: https://www.starship.org.nz/media/199142/immunisation_of_children_during_and_after_cancer_therapy_18_july_2014.pdf

Chronic kidney disease (CKD)

Immune response and duration of protection after immunisation decreases with advancing kidney disease, so routine Schedule and other recommended vaccines should be given as soon as disease is recognised.

Individuals immunised during the early stages of CKD generally respond to immunisation, but the magnitude of response and/or more rapid waning of immunity have an influence on how well protected they are from infection or severe disease following immunisation. Cases of children developing a disease for which they have serological evidence of immunity have been reported.12

Patients should receive routine Schedule vaccines and annual influenza vaccine. Live viral vaccines are considered safe for individuals with CKD and minimal immune compromise, but they are generally not recommended for individuals on immunosuppressive medicines because of the risk of disseminated disease from the vaccine virus.13 However, a number of small studies suggest that the risk of disseminated varicella vaccine-related disease is small and can be managed with antiviral therapy, and that varicella immunisation is a significantly lower risk for immunosuppressed individuals than community-acquired disease.11

Individuals with nephrotic syndrome, kidney failure or end-stage kidney disease (CKD stages 4–5) have an increased risk of developing bacterial peritonitis and/or sepsis. Additional pneumococcal vaccines, a Hib booster, conjugate meningococcal vaccines and annual influenza vaccine are recommended.

Dialysis patients must be hepatitis B immune, with administration of repeated courses of hepatitis B vaccine, of higher strength if required: the higher strength 40 µg hepatitis B vaccine (HBvaxPRO) is funded for adult dialysis patients.

There is no relationship between immunisation and deterioration of renal function or a reduction in the efficacy of dialysis.12

A recommended immunisation schedule and worksheet for paediatric CKD stage 4–5 and dialysis patients is available at the Starship website (https://www.starship.org.nz/media/286703/renal_-_vaccination_record_for_paediatric_ckd_july_2014.pdf).

Solid organ transplants

An accelerated immunisation schedule is recommended for individuals likely to be listed for solid organ transplant (see Table 4.1 for infant recommendations). Specialist advice should be sought in these situations.

Individuals older than 12 months who have been scheduled for solid organ transplantation should receive MMR and varicella vaccines at least four weeks before the transplant. Measles antibody titres should be measured one to two years after the transplant; immunisation may be repeated if titres are low, but only if the level of immunosuppression permits. It is advisable to check other antibody titres annually and re immunise where indicated.

The use of passive immunisation with IG after exposure to measles or chickenpox should be based on the documentation of negative antibody titres, or where immune status is unknown. See chapter 15 for further information on pneumococcal immunisation for these individuals.

In patients undergoing organ transplantation, pneumococcal vaccine (funded) should be given at least two weeks before the transplant. Hepatitis A, hepatitis B, HPV, influenza, meningococcal conjugate and varicella vaccines are funded for transplant patients. (Re-)vaccination with age-appropriate DTaP-IPV-HepB/Hib, DTaP-IPV, Tdap and Hib vaccines is also funded. (See the relevant disease chapters.)

HIV infection

All HIV-positive children, whether symptomatic or asymptomatic, are recommended to receive the routine Schedule vaccines, including MMR (if CD4+ ≥15%) and rotavirus (infants only). Asymptomatic children who are not severely immune compromised are recommended to receive MMR vaccine at age 12 months to provide early protection against the three diseases.

The efficacy of any vaccine may be reduced in HIV-positive individuals and antibody levels may wane faster than in individuals who are HIV negative. Although antiretroviral therapy may improve immune responses, it is unlikely these individuals will achieve the levels of antibodies seen in individuals who are HIV-negative. Serological testing and the need for additional doses (eg, of hepatitis B vaccine) should be discussed with the individual’s specialist.

Passive immunisation with immunoglobulin may be required for individuals with HIV infection who are exposed to chickenpox or measles.

Table 4.4 summarises the additional vaccine recommendations (funded and unfunded) and schedules for HIV-positive individuals.

Table 4.4: Additional vaccine recommendations (funded and unfunded) for HIV-positive individuals

Note: HIV-positive individuals should receive the routine Schedule vaccines, including rotavirus vaccine, but see the MMR recommendations in the table below. BCG should not be given. Funded vaccines are in the shaded rows, however vaccinators are advised to refer to the Pharmaceutical Schedule (www.pharmac.govt.nz) for any changes to funding decisions.

Age at diagnosis Vaccine
(trade name)
Recommended vaccine schedule
Infants aged under 12 months PCV13
(Prevenar 13)
PCV13a at ages 6 weeks, 3, 5 and 15 months (usual childhood Schedule) or age-appropriate catch-up schedule:
  • if commencing immunisation at ages 7–11 months, give 2 doses of PCV13 at least 4 weeks apart, followed by a booster dose at age 15 months
  • for children aged 7–11 months who have completed the primary course with PCV10, give 1 dose of PCV13, followed by the scheduled PCV13 booster at age 15 months.
23PPV
(Pneumovax 23)
Following the completion of the PCV course, give 1 dose of 23PPV at age ≥2 years. There must be at least 8 weeks between the last PCV dose and the 23PPV dose.

Revaccinate once with 23PPV, 5 years after the first 23PPV.
Influenza
(Influvac or Fluarix)
Annual immunisation from age 6 months.

In the first year, give 2 doses 4 weeks apart, then 1 dose in each subsequent year.
MenCCV
(NeisVac-C) and MCV4-D (Menactra)
Use the age-appropriate MenCCV schedule:
  • if aged under 6 months at diagnosis, give 2 doses 8 weeks apart, with a booster at age 12 months
  • ​if aged 6–11 months at diagnosis, give 1 dose, with a booster at age 12 months.
At age 2 years, give 2 doses of MCV4 D8 weeks apart, then a booster after 3 years, then 5-yearly.
Children aged 12 months to under 5 years PCV13
(Prevenar 13)
The PCV13a,c age-appropriate catch-up schedule is:
  • if commencing immunisation at ages 12 months or older, give 2 doses of PCV13,c 8 weeks apart 
  • children aged >17 months who have completed the primary course of PCV10 but not received PCV13, give 1 dose of PCV13.c,d
23PPV
(Pneumovax 23)
Following the completion of the PCV course, give 1 dose of 23PPV at age ≥2 years. There must be at least 8 weeks between the last PCV dose and the 23PPV dose.

Revaccinate once with 23PPV, 5 years after the 1st 23PPV.
Influenza
(Influvac or Fluarix)
Annual immunisation.

In previously unvaccinated children, give 2 doses 4 weeks apart, then 1 dose in each subsequent year.
MMR
(MMR II)
If CD4 lymphocyte percentage is ≥15%:
  • give the 1st MMR dose at age 12 months, followed by the 2nd dose 4 weeks later.
Varicellae
(Varilrix)
If CD4 lymphocyte percentage is ≥15%:
  • give 2 doses (starting 4 weeks after the 2nd MMR), at least 3 months apart.
MenCCV
(NeisVac-C) and MCV4-D
(Menactra)
If aged 12–23 months at diagnosis, give 1 dose of MenCCV; followed by MCV4-Db at age 2 years, 2 doses 8 weeks apart; then a booster of MCV4-D after 3 years; then 5-yearly.

If aged ≥2 years at diagnosis, give 2 doses of MCV4-Db 8 weeks apart; then a booster of MCV4-D after 3 years; then 5-yearly.
Children aged 5 to under 18 years HPV4 or HPV9 (Gardasil or Gardasil 9) From age 9 years, give 3 doses of HPV at 0, 2 and 6 months.f,g
PCV13
(Prevenar 13)
For children who have not previously received PCV13, give 1 dose of PCV13.c
23PPV
(Pneumovax 23)
1 dose of 23PPV at least 8 weeks after the PCV13 dose.

Revaccinate once with 23PPV, 5 years after the 1st 23PPV.
Influenza
(Influvac or Fluarix)
Annual immunisation.

Regardless of age, if previously unvaccinated, give 2 doses4 weeks apart. Then give 1 dose in each subsequent year.
MMR
(MMR II)
If aged ≤13 years and CD4 lymphocyte percentage is ≥15%, or

if aged ≥14 years and CD4 lymphocyte count is ≥200 cells/mm3:
  • give 2 MMR doses at least 4 weeks apart.
Varicellae
(Varilrix)
If no history of varicella disease or immunisation, and

if aged ≤13 years and CD4 lymphocyte percentage is ≥15%, or

if aged ≥14 years and CD4 lymphocyte count is ≥200 cells/mm3:
  • give 2 doses (starting 4 weeks after 2nd MMR), at least 3 months apart.
MCV4-D
(Menactra)
Give 2 doses of MCV4-Db 8 weeks apart, and:
  • if the 1st MCV4-D dose was given at age <7 years, give a booster after 3 years, then 5-yearly, or
  • ​if the 1st MCV4-D dose was given at age ≥7 years, give a booster dose every 5 years.
Adults aged 18 years and older HPV4 or HPV9 (Gardasil or Gardasil 9) For individuals aged 26 years and under:
  • give 3 doses of HPV9 at 0, 2 and 6 months.f
PCV13
(Prevenar 13)
1 dose of PCV13.c
23PPV
(Pneumovax 23)
Give a maximum of 3 doses of 23PPV in a lifetime, a minimum of 5 years apart. The 1st 23PPV dose is given at least 8 weeks after PCV13, the 2nd a minimum of 5 years later, the 3rd dose at age ≥65 years.
Influenza
(Influvac or Fluarix)
Annual immunisation. If previously unvaccinated, give 2 dosesh 4 weeks apart. Then give 1 dose in each subsequent year.
MMR
(MMR II)
If born in 1969 or later and has no record of 2 previous MMR doses and CD4 lymphocyte count is ≥200 cells/mm3:
  • give 1 or 2 MMR doses 4 weeks apart (so individual has 2 documented doses of MMR).
Varicellae
(Varilrix)
If no history of varicella disease or immunisation and CD4 lymphocyte count is ≥200 cells/mm3:
  • give 2 doses at least 3 months apart.
Hepatitis B
(HBvaxPRO)
If previously unvaccinated, give 3 doses, at 0, 1 and 6 months.i
MCV4-D
​(Menactra)
Give 2 doses of MCV4-D 8 weeks apart, then 1 dose every 5 years.b
a PCV13 replaces PCV10 (Synflorix) on the Schedule.
b Give MCV4-D at least 4 weeks after PCV13 (see section 12.4.4).
c If 23PPV has already been given (prior to any doses of PCV13), wait at least 1 year before administering PCV13.
d There are no safety concerns, regardless of the interval between the last dose of PCV10 and the 1st dose of PCV13.
e Give varicella vaccine on the advice of an HIV specialist.
f Individuals who started with HPV4 may complete their remaining doses with HPV4 or with HPV9 when available.
g Registered for use from age 9 years.
h The 2nd dose of influenza vaccine is not funded for individuals aged 9 years and older.
i Consider screening for seroconversion after vaccination (see section 8.5.5).
​Source: Starship Children’s Health.

4.3.4 AspleniaTop

There are three main reasons why an individual may not have a functioning spleen:

All asplenic individuals are at increased risk of fulminant bacteraemia, which is associated with a high mortality rate. The risk is greatest for infants, and probably declines with age and with the number of years since onset of asplenia.

The degree of risk of death from sepsis is also influenced by the nature of the underlying disease: it is increased 50 times (compared with healthy children) in asplenia after trauma and 350 times in asplenia with sickle cell disease, and the risk may be even higher post-splenectomy for thalassaemia.

Streptococcus pneumoniae is the pathogen that most often causes fulminant sepsis in these individuals. Other less frequent pathogens are Neisseria meningitidis, Haemophilus influenzae type b, other streptococci, Staphylococcus aureus, Escherichia coli and other gram-negative bacilli (eg, Klebsiella, Salmonella species and Pseudomonas aeruginosa). There is an increased fatality from malaria for asplenic individuals.

Immunisation of asplenic individuals

No vaccines are contraindicated for individuals with functional or anatomical asplenia. It is important to ensure that the individual is up to date with the routine immunisations according to the National Immunisation Schedule, especially pneumococcal, Hib and MMR.

In addition to the routine Schedule vaccines, including HPV for males and females aged 26 years and under, the following vaccines are funded and/or recommended as soon as the asplenic condition is recognised. The immunisation schedules are age-dependent and are provided in Table 4.5 below.

For elective splenectomy, immunisations should be commenced as soon as possible and at least two weeks pre-operatively. For emergency splenectomy, commence immunisations two weeks post-operatively.

Prior to commencing immunisation, discuss with the individual’s specialist.

Table 4.5: Additional vaccine recommendations (funded and unfunded) and schedules for individuals with functional or anatomical asplenia

Note: Individuals with functional or anatomical asplenia should receive the routine Schedule vaccines, including HPV for males and females aged 26 years and under, following recommended catch-up schedules if necessary. Funded vaccines are in the shaded rows, however vaccinators are advised to refer to the Pharmaceutical Schedule (www.pharmac.govt.nz) for and any changes to funding decisions.

Age at diagnosis Vaccine
(trade name)
Recommended vaccine schedule
Infants aged under 12 months with functional asplenia or pre-a or post-splenectomy PCV13
(Prevenar 13)
PCV13 at age 6 weeks, 3, 5 and 15 months (usual childhood Schedule).

If commencing immunisation at ages 7–11 months, give 2 doses of PCV13 at least 4 weeks apart, followed by a booster dose at age 15 months.
23PPV
(Pneumovax 23)
Following the completion of the PCV course, give 1 dose of 23PPV at age ≥2 years. There must be at least 8 weeks between the last PCV dose and the 23PPV dose.

Revaccinate once with 23PPV, 5 years after the 1st 23PPV.
MenCCV
(NeisVac-C)
and
MCV4-D (Menactra)
Age-appropriate MenCCV schedule:
  • if aged under 6 months at diagnosis, give 2 doses 8 weeks apart, with a booster at age 12 months
  • ​if aged 6–11 months at diagnosis, give 1 dose, with a further dose at age 12 months.
At age 2 years, give 2 doses of MCV4 D8 weeks apart, then a booster dose after 3 years, then 5 yearly.
Influenza
(Influvac or Fluarix)
Annual immunisationc from age 6 months.

In the first year, give 2 doses 4 weeks apart, then 1 dose in each subsequent year.
Children aged 12 months to under 18 years with functional asplenia or pre-a or post-splenectomy PCV13
(Prevenar 13)
PCV13d age-appropriate catch-up schedule:
  • previously unimmunised children aged ≥12 months to under 5 years require 2 doses of PCV13,d 8 weeks apart
  • previously unimmunised children aged 5 years to under 18 years require 1 dose of PCV13d
  • children aged >17 months who have completed the primary course of PCV10 but have not received PCV13, give 1 dose of PCV13.e
23PPV
(Pneumovax 23)
Following the completion of the PCV13 course, give 1 dose of 23PPV at age ≥2 years. There must be at least 8 weeks between the last PCV13 dose and the 23PPV dose.

Revaccinate once with 23PPV, 5 years after the 1st 23PPV.
MenCCV
(NeisVac-C)
and
MCV4-D
(Menactra)
If aged 12–23 months at diagnosis, give 1 dose of MenCCV, followed by MCV4 Db at age 2 years, 2 doses 8 weeks apart; then a booster of MCV4-D after 3 years, then 5 yearly.

If aged ≥2 years at diagnosis, give 2 doses of MCV4-Db 8 weeks apart, and:
  • if the 1st MCV4-D dose was given at age <7 years, give a booster after 3 years, then 5-yearly, or
  • ​if the 1st MCV4-D dose was given at age ≥7 years, give a booster dose every 5 years.
Hib
(Act-HIB)
If aged 12–15 months, give 1 dose at age 15 months as per the National Immunisation Schedule.f

If aged 16 months to under 5 years and has not received a single Hib dose after age 12 months, give 1 dose.f

If aged 5 years and older, give 1 dose, even if fully vaccinated.f
  Influenza
(Influvac or Fluarix)
Annual immunisation.c In previously unimmunised children aged under 9 years, give 2 doses 4 weeks apart, then 1 dose in each subsequent year.
Varicella
(Varilrix or Varivax)
If no history of varicella disease or immunisation, give 2 doses at least 6 weeks apart.
Adults ≥18 years, pre-a or post-splenectomy or with functional asplenia PCV13
(Prevenar 13)
1 dose of PCV13.d
23PPV
(Pneumovax 23)
Give a maximum of 3 doses of 23PPV in a lifetime, a minimum of 5 years apart. The 1st 23PPV dose is given at least 8 weeks after PCV13; the 2nd a minimum of 5 years later; the 3rd dose at age ≥65 years.
MCV4-D
(Menactra)
Give 2 doses of MCV4-D, 8 weeks apart, then 1 dose every 5 years.b,g
Hib (Act-HIB) Give 1 dose of Hib, regardless of previous vaccination history.
Tdap (Boostrix) Give 3 doses of Tdaph 4 weeks apart.
Influenza
(Influvac or Fluarix)
Annual immunisation.c
Varicella
(Varilrix or Varivax)
If no history of varicella disease or immunisation, give 2 doses, at least 6 weeks apart.
a Where possible, the vaccines should be administered at least 2 weeks before elective splenectomy. For emergency splenectomy, the vaccines should be administered 2 weeks post-operatively.
b Give MCV4-D at least 4 weeks after PCV13 (see section 12.4.4).
c Influenza vaccine is recommended but not funded for individuals with functional asplenia.
d If 23PPV has already been given (prior to any doses of PCV13), wait at least 1 year before administering PCV13.
e There are no safety concerns, regardless of the interval between the last dose of PCV10 and the 1st dose of PCV13.
f Hib is not required if the child is being revaccinated with DTaP-IPV-HepB/Hib.
g MCV4-D is registered for individuals aged 9 months to 55 years, but there are not expected to be any safety concerns when administered to adults older than 55 years.
h Although Tdap is not registered for use as a primary course, there are expected to be to be no safety concerns.
Source: Starship Children’s Health.

Antimicrobial prophylaxis

The effectiveness of antimicrobial prophylaxis in asplenic children has been proven only for sickle cell disease, but it is recommended for all such children aged under 5 years and for at least one to two years after splenectomy. Monthly benzathine penicillin injections have been shown to reduce episodes of pneumococcal bacteraemia in asplenic children as compared with rates observed in untreated children. Oral penicillin daily also reduces the incidence of severe bacterial infection by 84 percent in asplenic children, compared with the rates observed in placebo-treated controls.

It is reasonable to extrapolate this data to other asplenic children with a high risk of bacteraemia (eg, asplenic children with malignancies, thalassaemia, etc). There is less agreement regarding the use of chemoprophylaxis in children who have been splenectomised following trauma.

Chemoprophylaxis is recommended for:

There are no studies that help decide the age at which chemoprophylaxis should be discontinued. This decision has to be made according to clinical judgement.

The recommended dosage is:

An alternative recommended by some experts is amoxycillin 20 mg/kg per day (up to a maximum of 500 mg).

Parents/guardians should be advised that all febrile illnesses are potentially serious and that they should seek immediate medical help in these circumstances. Individuals should be hospitalised if bacteraemia is a possibility. In hospital, the usual treatment would be cefotaxime, ceftriaxone, or another regimen effective against S. pneumoniae, H. influenzae type b and N. meningitidis.

4.3.5 Other high-risk individualsTop

Individuals with chronic lung diseases should receive influenza and pneumococcal vaccines. See chapters 10 and 15.

4.3.6 (Re-)vaccination following immunosuppressionTop

All vaccines on the National Immunisation Schedule are funded for (re-) vaccination of individuals following immunosuppression. (Note that the period of immunosuppression due to steroid or other immunosuppressive therapy must be longer than 28 days.) The timing and number of doses should be discussed with the individual’s specialist.

See also the individual disease chapters.