Immunization of children with secondary immunodeficiency

Figures & data

Table 1. Main conditions associated with secondary immunodeficiency at a pediatric age

Infectious diseases

HIV/AIDS

Malignancy

Hematological malignancies or solid tumors

Transplantation

Bone marrow (HSCT)

Solid organ (SOT)

Autoimmune disease

Miscellaneous (not addressed in this review)

Asplenia

Diabetes mellitus

Inflammatory bowel disease

Renal failure and/or dialysis

Hepatic cirrhosis

Malnutrition

Radiation, toxic chemicals

Table 2. Suggested vaccination according to underlying secondary immunodeficiency

Underlying secondary immunodeficiency	Inactivated vaccines	Live attenuated vaccines	Advice
HIV infection	All those included in the national schedules (including HPV) are strongly recommended In addition, annual influenza vaccination, a booster with PCV13 and PPSV, a dose of MCV4, hepatitis A and hepatitis B vaccines are recommended due to HIV-related risks	MMR and varicella vaccines are recommended due to available studies on their immunogenicity, safety, and tolerability Other live attenuated vaccines (including BCG) are controindicated	Vaccines should be administered once children are on HAART, have a good CD4+ count, and have an undetectable viral load
Cancer	Administration of the primary schedule or booster dose in patients off-therapy for 3 months These patients should receive at least one dose of Hib and PCV13 regardless of age when they are off-therapy since 3 months n addition, annual influenza vaccination is recommended	MMR vaccine should be administered in patients off-therapy for 6 months Varicella vaccine should be administered in patients in continuous remission for at least one year, with a lymphocyte count of >700/μL and a platelet count of >100,000/μL; if still being treated in an epidemic period, they should stop drug administration one week before and for one week after vaccination Other live attenuated vaccines can be administered in patients off-therapy for 6 months	In the presence of outbreaks, inactivated or recombinant vaccines can even been administered during the last part of maintenance therapy
Haematopoietic stem cell transplantation (HSCT)	All those included in the national schedules (including HPV) are strongly recommended 6–12 months after HSCT In addition, lifelong annual influenza vaccination and a booster with PCV13 and PPSV are recommended	MMR should be delayed for at least 24 months after HSCT in children who no longer have a need for pharmacological immunosuppression and do not have graft versus host disease Varicella vaccine should be given 24 months after HSCT to varicella seronegative patients with neither GVHD nor ongoing immunosuppression and 8–11 months after the last dose of intravenous immunoglobulin Other live attenuated vaccines are generally contraindicated	Repeat primary vaccine series with inactivated vaccines 6–12 months after HSCT
Solid organ transplantation (SOT)	Inactivated vaccines can be administered 3–6 months after SOT In addition, lifelong annual influenza vaccination and a booster with PCV13 and PPSV are recommended	Live attenuated vaccines are generally contraindicated	Vaccines should be administered once maintenance immunosuppression levels have been reached MMR and varicella vaccines should be administered 4 weeks before SOT
Rheumatologic diseases (RDs)	All those included in the national schedules (including HPV) are strongly recommended In addition, annual influenza vaccination and a booster with PCV13 and PPSV are recommended due to RD-related risks	MMR vaccine can be safely administered Other live attenuated vaccines should not be administered in the presence of severe immunosuppression	Vaccinations should be postponed only in the case of severe active RD (and then only until the child has stabilized), and a vaccine should be avoided if it has previously caused a disease relapse In patients on rituximab treatment, vaccines should be avoided until B cell levels return to normal values

GVHD: graft vs. host disease; HAART: highly active antiretroviral therapy; Hib: Haemophilus influenzae type b; HPV: human papillomavirus; HSCT: haematopoietic stem cell transplantation; MCV4: quadrivalent meningococcal conjugate vaccine; PCV13: 13-valent pneumococcal conjugate vaccine; PPSV: 23-valent polysaccharide vaccine; RD: rheumatologic disease; SOT: sold organ transplantation.