Vaccination with Live-Attenuated Vaccines

Severe complications have followed vaccination with live-attenuated viral and live-attenuated bacterial vaccines among persons with altered immunocompetence. Persons with most forms of altered immunocompetence should not receive live vaccines (MMR, varicella vaccine, LAIV, yellow fever vaccine, oral typhoid, BCG, and rotavirus) except in certain circumstances. Patients with leukemia, lymphoma, or other malignancies whose disease is in remission and whose chemotherapy has been terminated for at least 3 months can receive live-virus vaccines.

Children with defects in phagocyte function (e.g., chronic granulomatous disease or myeloperoxidase deficiency) can receive live-attenuated viral vaccines in addition to inactivated vaccines, but should not receive live-attenuated bacterial vaccines (e.g., BCG and Ty21a oral typhoid vaccine). Children with deficiencies in complement or with asplenia can receive live-attenuated viral and live-attenuated bacterial vaccines.

Persons with severe cell-mediated immune deficiency should not receive live attenuated vaccines. However, children with HIV infection are at increased risk for complications of primary varicella and herpes zoster compared with immunocompetent children. Limited data among HIV-infected children (specifically CDC class N1, N2, A1, A2, B1, or B2) with age-specific CD4⁺ lymphocyte percentages of >15% indicate that varicella vaccine is immunogenic, effective, and safe. Varicella vaccine should be considered for children meeting these criteria. Eligible children should receive 2 doses of varicella vaccine with a 3-month interval between doses.

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. Therefore, MMR vaccination is recommended for all asymptomatic HIV-infected persons who do not have evidence of severe immunosuppression (age-specific CD4⁺ lymphocyte percentages of >15%) and for whom measles vaccination would otherwise be indicated. Similarly, MMR vaccination should be considered for mildly symptomatic (Pediatric Category A1, A2 or Adolescent/adult Category A) HIV-infected persons who do not have evidence of severe immunosuppression (age-specific CD4+ lymphocyte percentages of >15%) for whom measles vaccination would otherwise be indicated.

HIV-infected persons who are receiving regular doses of IGIV might not respond to varicella vaccine or MMR or its individual component vaccines because of the continued presence of passively acquired antibody. However, because of the potential benefit, MMR and varicella vaccines should be considered approximately 2 weeks before the next scheduled dose of IGIV (if not otherwise contraindicated), although an optimal immune response might not occur depending on the dose and interval since the previous dose of IGIV. Unless serologic testing indicates that specific antibodies have been produced, vaccination should be repeated (if not otherwise contraindicated) after the recommended interval. An additional dose of IGIV should be considered for persons on maintenance IGIV therapy who are exposed to measles or varicella 3 or more weeks after administering a standard dose (100--400 mg/kg body weight) of IGIV.

Persons with impaired humoral immunity (e.g., hypogammaglobulinemia or dysgammaglobulinemia) should receive varicella vaccine. However, the majority of persons with these disorders also receive periodic doses of IGIV. Appropriate spacing should be maintained between administration of IGIV and varicella vaccine to prevent an inadequate response to vaccination caused by the presence of neutralizing antibodies from the IGIV. Household and other close contacts of persons with altered immunocompetence should receive all age appropriate vaccines, with the exception of live OPV and smallpox vaccine.