“There is no strong evidence to say that the vaccines cause shingles if you get them while immunocompromised; on the other hand, there is mounting evidence to suggest that patients are protected if on immunosuppression while getting these live virus vaccines,” he added.
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Some live vaccines, however, are not recommended for patients with chronic inflammatory disease who are on maintenance immunosuppression. These include the live attenuated influenza vaccine (LAIV) and the measles, mumps, rubella vaccine (MMR) in patients receiving low-level and high-level immunosuppression, as well as the measles, mumps, rubella, varicella (MMRV) vaccine in those receiving low- or high-level immunosuppression. The yellow fever vaccine is also strictly contraindicated in immunosuppressed individuals, and these patients should ideally avoid travel in areas where the disease is endemic.
Vaccination of Household Members
The IDSA recommends that specialists help their patients limit exposure to vaccine-preventable infections by ensuring that household members are kept up to date on vaccinations. Recommended vaccines include the annual influenza vaccine, with specific recommendations given about when to recommend the nonlive vs. the live vaccine, and other vaccinations including MMR, VAR and ZOS. The oral polio vaccine, however, should not be given to people who live with an immunocompromised person.
Other caveats are given. For example, an immunocompromised person on therapy should avoid contact with a household member who develops a rash after the VAR or ZOS vaccine until the lesions go away. Highly immunocompromised patients should not handle the diapers of an infant who has been vaccinated with the rotavirus vaccine for four weeks after vaccination because live virus may be shed in the stool for two to four weeks.
Dr. Calabrese recommends “significant conversation within the rheumatology community” about the low rate of vaccinations among immunocompromised patients. “Rheumatologists are confused, and so are most primary care physicians who see these patients taking drugs that they are unfamiliar with, such as biologics. We need to have some fundamental changes in the systems that can contribute to vaccination. Recognizing the importance of this shared responsibility is the best starting point, and this document takes on the issue forthrightly,” he said.
Kathy Holliman is a medical journalist based in Massachusetts.
Vaccines to avoid
- For patients with chronic inflammatory disease who are on maintenance immunosuppression—the live attenuated influenza vaccine (LAIV);
- For patients receiving low- and high-level immunosuppression—the measles, mumps, rubella vaccine (MMR);
- For patients receiving low- or high-level immunosuppression—measles, mumps, rubella, varicella (MMRV) vaccine; and
- For immunosuppressed individuals—yellow fever vaccine.
- Rubin LG, Levin MJ, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58:309–318.
- Singh JA, Furst DE, Bharat A, et al. 2012 Update of the 2008 American College of Rheumatology Recommendations for the Use of Disease-Modifying Antirheumatic Drugs and Biologic Agents in the Treatment of Rheumatoid Arthritis. Arthritis Care Res. 2012;64:625–639.