Updated December 2006
Immunizations against infectious diseases are a cornerstone of preventive medicine and are an extremely important component of care for immunosuppressed patients. Concerns regarding vaccinations in HIV-infected individuals include:
- The potential danger from live virus vaccines
- The ability of HIV-infected patients to mount an appropriate immune response to vaccine.
In general, the more intact the immune system is, the more effective and safe the vaccines are. Live virus vaccines are generally only used when 1) an inactivated version does not exist, and 2) the risk of the disease clearly outweighs the theoretical risk of vaccination.
II. RECOMMENDED IMMUNIZATIONS FOR NON-PREGNANT HIV-INFECTED ADULTS
III. RECOMMENDED IMMUNIZATIONS FOR PREGNANT HIV-INFECTED ADULTS
Routine pregnancy testing of women of childbearing age before administering a live-virus vaccine is not recommended.1
Clinicians should avoid administering immunizations late in the third trimester to avoid the theoretical possibility of the vaccines causing increased viral load levels at the time of delivery.
Because of the importance of protecting women of childbearing age against rubella, clinicians should adopt the following practices in any immunization program:
- Ask women if they are or could be pregnant or intend to become pregnant within the next 4 weeks
- Explain the potential risk of vaccination to the fetus to women who state that they are not pregnant
- Counsel women who are vaccinated to avoid pregnancy during the 4 weeks after MMR vaccination.1-3
- Do not vaccinate women who state that they are pregnant; administer rubella vaccine immediately after delivery in rubella-susceptible HIV-infected women with CD4 counts >200 cells/mm3
- Test pregnant women for rubella immunity at the first antepartum visit
Clinicians should counsel pregnant women who are inadvertently vaccinated or who become pregnant within 4 weeks after MMR or varicella vaccination about the theoretical risk to the fetus; however, exposure to MMR or varicella vaccines during pregnancy generally is not a reason to terminate a pregnancy.1,4
Risks from vaccination of the mother during pregnancy to the developing fetus are primarily theoretical. No direct evidence exists of risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids.5,6 Benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm.
Pregnancy is a contraindication for measles, mumps, rubella, and varicella vaccines. Although there is a theoretical risk to the fetus, in large follow-up studies, there were no cases of congenital rubella syndrome, congenital varicella, or abnormalities attributable to fetal infection among infants born to women who received rubella or varicella vaccines during pregnancy.1,7 All women should be tested for rubella immunity at the first antepartum visit. Rubella vaccine should be administered immediately after delivery in all rubella-susceptible women who have not undergone permanent sterilization unless they have CD4 counts <200 cells/mm3. For women who are severely immune compromised, the potential risks of receiving the vaccine should be weighed against the potential for the patient to become pregnant again before receiving appropriate ARV therapy to treat the HIV infection.
Table 2 lists recommendations for immunizations in HIV-infected pregnant women.
IV. CONCURRENT ADMINISTRATION OF ANTIMICROBIAL AGENTS AND VACCINES
Clinicians should discontinue antiviral drugs active against herpesviruses ≥24 hours before administration of varicella vaccine.
With limited exceptions, using an antibiotic is not a contraindication to vaccination. Antimicrobial agents have no effect on the response to live attenuated vaccines, except live oral Ty21a typhoid vaccine, and have no effect on inactivated, recombinant subunit, or polysaccharide vaccines or toxoids.12
Antiviral drugs used for treatment or prophylaxis of influenza virus infections have no effect on the response to inactivated influenza vaccine.9 Antiviral drugs active against herpesviruses (e.g., acyclovir or valacyclovir) might reduce the efficacy of live attenuated varicella vaccine. These drugs should be discontinued ≥24 hours before administration of varicella vaccine, if possible.
V. VACCINES AND ALLERGANS
Before administering the influenza vaccine, clinicians should ask patients whether they are able to eat eggs without adverse effects. Clinicians should not administer the influenza vaccine to patients who have a history of anaphylactic or anaphylactic-like allergy to eggs.
Clinicians should use extreme caution when administering vaccines that contain gelatin to persons who have a history of anaphylactic reaction to gelatin or gelatin-containing products.
The most common animal protein allergen is egg protein, which is found in vaccines prepared by using embryonated chicken eggs (influenza and yellow fever vaccines). Persons who are able to eat eggs or egg products can generally receive these vaccines safely; persons with histories of anaphylactic or anaphylactic-like allergy to eggs or egg proteins should not be administered these vaccines.
Previously, it was thought that patients with a history of anaphylactic reactions following ingestion of eggs were at increased risk for serious reactions following measles- or mumps-containing vaccines because they are grown in chick embryo fibroblast tissue culture. However, the risk for serious allergic reactions such as anaphylaxis following administration of measles- or mumps-containing vaccines is actually extremely low in this population.1 Therefore, skin-testing or desensitization to egg protein is not required before administering MMR in patients who are allergic to eggs. Rubella and varicella vaccines are grown in human diploid cell cultures and can safely be administered to persons with histories of severe allergy to eggs or egg proteins.13
The rare serious allergic reaction after measles or mumps vaccination or measles, mumps, and rubella (MMR) is not believed to be caused by egg antigens, but by other components of the vaccine (e.g., gelatin). MMR, its component vaccines, and other vaccines contain hydrolyzed gelatin as a stabilizer. Extreme caution should be exercised when administering vaccines that contain gelatin to persons who have a history of an anaphylactic reaction to gelatin or gelatin-containing products. Before administering gelatin-containing vaccines to such persons, skin testing for sensitivity to gelatin can be considered. However, no specific protocols for this approach have been published.14-17
1. Centers for Disease Control and Prevention. Measles, mumps, and rubella: Vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps—Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1998;47(RR-8):1-57. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm
2. Centers for Disease Control and Prevention. Control and prevention of rubella: Evaluation and management of suspected outbreaks, rubella in pregnant women, and surveillance for congenital rubella syndrome. MMWR Recomm Rep 2001;50(RR-12):1-24. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5012a1.htm
3. Centers for Disease Control and Prevention. Revised ACIP recommendation for avoiding pregnancy after receiving a rubella-containing vaccine. MMWR Morbid Mortal Wkly Rep 2001;50:1117. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5049a5.htm
4. Centers for Disease Control and Prevention. Prevention of varicella: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 1996;45(RR-11):8. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00042990.htm
5. Koren G, Pastuszak A, Ito S. Drugs in pregnancy. N Engl J Med 1998;338:1128-1137. [PubMed]
6. Grabenstein JD. Pregnancy and lactation in relation to vaccines and antibodies. Pharm Pract Manag Q 2001;20:1-10. [PubMed]
7. Shields KE, Galil K, Seward J, et al. Varicella vaccine exposure during pregnancy: Data from the first 5 years of the pregnancy registry. Obstet Gynecol 2001;98:14-19. [PubMed]
8. Centers for Disease Control and Prevention. Diphtheria, tetanus, and pertussis: Recommendations for vaccine use and other preventive measures: Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep 1991;40(RR-10):1-28. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00041645.htm
9. Centers for Disease Control and Prevention. Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2001;50(RR-4):1-44. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5004a1.htm
10. Neuzil KM, Reed GW, Mitchel EF, et al. Impact of influenza on acute cardiopulmonary hospitalizations in pregnant women. Am J Epidemiol 1998;148:1094-1102. [PubMed]
11. Centers for Disease Control and Prevention. Hepatitis B virus: A comprehensive strategy for eliminating transmission in the United States through universal childhood vaccination—Recommendations of the Immunization Practices Advisory Committee. MMWR Recomm Rep 1991;40(RR-13):1-25. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00033405.htm
12. Centers for Disease Control and Prevention. Typhoid immunization recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 1994;43(RR-14):1-7. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00035643.htm
13. Centers for Disease Control and Prevention. Measles, mumps, and rubella — Vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 1998;47(RR-8):1-57. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm
14. Kelso JM, Jones RT, Yunginger JW. Anaphylaxis to measles, mumps, and rubella vaccine mediated by IgE to gelatin. J Allergy Clin Immunol 1993;91:867-872. [PubMed]
15. Sakaguchi M, Ogura H, Inouye S. IgE antibody to gelatin in children with immediate-type reactions to measles and mumps vaccines. J Allergy Clin Immunol 1995;96:563-565. [PubMed]
16. Sakaguchi M, Yamanaka T, Ikeda K, et al. IgE-mediated systemic reactions to gelatin included in the varicella vaccine. J Allergy Clin Immunol 1997;99:263-264. [PubMed]
17. Sakaguchi M, Nakayama T, Inouye S. Food allergy to gelatin in children with systemic immediate-type reactions, including anaphylaxis, to vaccines. J Allergy Clin Immunol 1996;98:1058-1061. [PubMed]