It seems to be a big surprise to many folks, but kids can get most vaccines when they are immunosuppressed. In fact, they sometimes get extra some extra vaccines, like Pneumovax, because the “incidence or severity of some vaccine-preventable diseases is higher in persons with altered immunocompetence.”
They should also get all of their vaccines if they are around someone who is immunosuppressed.
Vaccines While Immunosuppressed
Which vaccines your kids can get while they are immunosuppressed is going to depend greatly on the reason why they are immunosuppressed.
Were they born with a specific immunodeficiency, like X-linked agammaglobulinemia, selective IgA deficiency, severe combined immunodeficiency, or chronic granulomatous disease?
Whatever the reason, they likely won’t get a medical exemption to skip all of their vaccines.
“Killed vaccines will not cause infection in immunodeficient or any other children. The fear of increased community-acquired vaccine-preventable diseases should lead to adherence to and completion of recommended immunization schedules in the community to reinforce herd immunity, such that all vaccine-preventable diseases become exceedingly rare.”
Recommendations for live viral and bacterial vaccines in immunodeficient patients and their close contacts
In most cases, immunocompromised kids can get all inactivated vaccines. It is only live vaccines that could pose a problem. Even then, it depends on the specific immunodeficiency as to whether avoiding live vaccines is necessary.
For example, after chemotherapy and a stem cell transplant, kids can usually get live vaccines.
Your doctors can review the latest guidelines to come up with a safe vaccination plan for your child with an immune system problem. If necessary, consultation with an infectious diseases or immunology specialist can also be helpful.
Don’t overlook other causes of possible immunosuppression when getting vaccinated, like taking daily oral steroids for more than two weeks, certain biologic immune modulators, or other medications like methotrexate, azathioprine, 6-mercaptopurine.
“Limited evidence indicates that inactivated vaccines generally have the same safety profile in immunocompromised patients as in immunocompetent individuals. However, the magnitude, breadth, and persistence of the immune response to vaccination may be reduced or absent in immunocompromised persons.”
2013 IDSA Clinical Practice Guideline for Vaccination of the Immunocompromised Host
And keep in mind that just because they can and should get vaccinated, it doesn’t mean that their vaccines are going to work as well as in someone who isn’t immunocompromised.
Vaccines for Close Contacts of Immunocompromised People
What about people who come into contacts with kids and adults who are immunocompromised?
Can they get vaccines?
“Close contacts of patients with compromised immunity should not receive live oral poliovirus vaccine because they might shed the virus and infect a patient with compromised immunity. Close contacts can receive other standard vaccines because viral shedding is unlikely and these pose little risk of infection to a subject with compromised immunity.”
Recommendations for live viral and bacterial vaccines in immunodeficient patients and their close contacts
Yes, close contacts can get vaccinated, especially since we don’t use the oral polio vaccine in the United States anymore.
There are some exceptions for the smallpox vaccine, which few people get, and Flumist, but only in very specific situations, including a recent hematopoietic stem cell transplant.
It’s easy to be anti-vaccine when you are hiding in the herd. You don’t get vaccinated and you don’t vaccinate your kids, and instead, you simply rely on the fact that everyone else around you is vaccinated to protect you from vaccine-preventable diseases.
Of course, this is a terrible strategy, as we are seeing with the increase in cases of measles and pertussis, etc. It is much better to learn about the importance and safety of vaccines, get fully vaccinated, and stop these outbreaks.
But as they continue to tell you that vaccines don’t work, how about asking what they would do in these ten high-risk situations?
Amazingly, some folks continue to try and justify skipping vaccines and accept the risk of disease, even when that risk is much higher than usual and they could be putting their child’s life in immediate danger!
How will you do with our quiz?
Would you choose to vaccinate in these situations?
1. Baby born to mother with hepatitis B.
You are pregnant and have chronic hepatitis B (positive for both HBsAg and HBeAg). Should your newborn baby get a hepatitis B shot and HBIG?
Many anti-vaccine experts tell parents to skip their baby’s hepatitis B shot, saying it is dangerous, not necessary, or doesn’t work (typical anti-vax myths and misinformation).
However, it is well known that:
from 10 (HBeAg negative) to 90% (HBeAg positive) of infants who are born to a mother with chronic hepatitis B will become infected
90% of infants who get hepatitis B from their mother at birth develop chronic infections
25% of people with chronic hepatitis B infections die from liver failure and liver cancer
use of hepatitis B immune globulin (HBIG) and hepatitis B vaccine series greatly decreases a newborn’s risk of developing a hepatitis B infection (perinatal transmission of hepatitis B), especially if HBIG and the first hepatitis B shot is given within 12 hours of the baby being born
Would your newborn baby get a hepatitis B shot and HBIG?
2. Your child is bitten by a rabid dog.
Your toddler is bitten by a dog that is almost certainly rabid. Several wild animals in the area have been found to be rabid recently and the usual playful and well-mannered dog was acting strangely and died a few hours later. The dog was not vaccinated against rabies and unfortunately, the owners, fearing they would get in trouble, disappeared with the dead dog, so it can’t be quarantined. Should your child get a rabies shot?
Although now uncommon in dogs, rabies still occurs in wild animals, including raccoons, skunks, bats, and foxes. These animals can then expose and infect unvaccinated dogs, cats, and ferrets, etc.
To help prevent rabies, which is not usually treatable, in addition to immediately cleaning the wound, people should get human rabies immune globulin (RIG) and rabies vaccine.
The rabies vaccine is given as a series of four doses on the day of exposure to the animal with suspected rabies and then again on days 3, 7, and 14.
Although rare in the United States, at least 1 to 3 people do still die of rabies each year. The rabies vaccine series and rabies immune globulin are preventative, however, without them, rabies is almost always fatal once you develop symptoms. A few people have survived with a new treatment, the Milwaukee protocol, without getting rabies shots, but many more have failed the treatment and have died.
Although the first MMR vaccine is routinely given when children are 12 months old, it is now recommended that infants get vaccinated as early as age six months if they will be traveling out of the country.
Since the endemic spread of measles was stopped in 2000, almost all cases are now linked to unvaccinated travelers, some of whom start very large outbreaks that are hard to contain.
Would you both get vaccinated before making the trip?
4. Tetanus shot.
Your unvaccinated teen gets a very deep puncture wound while doing yard work. A few hours later, your neighbor comes by to give you an update on his wife who has been in the hospital all week. She has been diagnosed with tetanus. She had gotten sick after going yard work in the same area and has been moved to the ICU. Do you get him a tetanus shot?
Most children get vaccinated against tetanus when they receive the 4 dose primary DTaP series, the DTaP booster at age 4-6 years, and the Tdap booster at age 11-12 years.
Unlike most other vaccine-preventable diseases, tetanus is not contagious. The spores of tetanus bacteria (Clostridium tetani) are instead found in the soil and in the intestines and feces of many animals, including dogs, cats, and horses, etc.
Although the tetanus spores are common in soil, they need low oxygen conditions to germinate. That’s why you aren’t at risk for tetanus every time your hands get dirty. A puncture wound creates the perfect conditions for tetanus though, especially a deep wound, as it will be hard to clean out the tiny tetanus spores, and there won’t be much oxygen at the inner parts of the wound.
These types of deep wounds that are associated with tetanus infections might including stepping on a nail, getting poked by a splinter or thorn, and animal bites, etc. Keep in mind that some of these things, like a cat bite, might put you at risk because you simply had dirt/tetanus spores on your skin, which get pushed deep into the wound when the cat bites you.
Symptoms of tetanus typically develop after about 8 days and might include classic lockjaw, neck stiffness, trouble swallowing, muscle spasms, and difficulty breathing. Even with treatment, tetanus is fatal in about 11% of people and recovery takes months.
Would you get your teen a tetanus shot?
5. Cocooning to protect baby from pertussis.
Both of your unvaccinated teens go to school with a personal belief vaccine exemption. You are due in a few months and are a little concerned about the new baby because there have been outbreaks of pertussis in the community, especially at their highschool. Should everyone in the family get a Tdap shot?
Pertussis, or whooping cough, classically causes a cough that can last for weeks to months.
While often mild in teens and adults, pertussis can be life-threatening in newborns and infants. In fact, it is young children who often develop the classic high-pitched whooping sound as they try to breath after a long coughing fit.
In a recent outbreak of pertussis in California, 10 infants died. Almost all were less than 2 months old.
Since infants aren’t protected until they get at least three doses of a pertussis vaccine, usually at age 6 months, experts recommend a cocooning strategy to protect newborns and young infants from pertussis. With cocooning, all children, teens, and adults who will be around the baby are vaccinated against pertussis (and other vaccine-preventable diseases), so that they can’t catch pertussis and bring it home.
There is even evidence that a pregnancy dose of Tdap can help protect infants even more than waiting until after the baby is born to get a Tdap shot.
Would everyone in your family get a Tdap shot?
6. Nephew is getting chemotherapy.
Your nephew was just diagnosed with leukemia and is going to start chemotherapy. Your kids have never been vaccinated against chicken pox and haven’t had the disease either. Your brother asks that you get them vaccinated, since they are around their cousin very often and he doesn’t want to put him at risk.
Do you get your kids vaccinated with the chicken pox vaccine?
Kids with cancer who are getting chemotherapy become very vulnerable to most vaccine-preventable diseases, whether it is measles, flu, or chicken pox.
According to the Immune Deficiency Foundation, “We want to create a ‘protective cocoon’ of immunized persons surrounding patients with primary immunodeficiency diseases so that they have less chance of being exposed to a potentially serious infection like influenza.”
Would your get your kids vaccinated with the chicken pox vaccine?
7. Outbreak of meningococcemia at your kid’s college.
Background information: Neisseria meningitidis is a bacteria that can cause bacterial meningitis and sepsis (meningococcemia).
Depending on the type, it can occur either in teens and young adults (serogroups B, C, and Y) or infants (serogroup B).
Although not nearly as common as some other vaccine-preventable diseases, like measles or pertussis, it is one of the more deadly. Meningococcemia is fatal in up to 40% of cases and up to 20% of children and teens who survive a meningococcal infection might have hearing loss, loss of one or more limbs, or neurologic damage.
Meningococcal vaccines are available (Menactra and Menveo) and routinely given to older children and teens to help prevent meningococcal infections (serogroups A, C, Y and W-135). Other vaccines, Bexasero and Trumenba, protect against serogroup B and are recommended for high risk kids and anyone else who wants to decrease their risk of getting Men B disease.
Would you encourage her to get vaccinated against meningococcemia?
8. Cochlear implants.
Your preschooler has just received cochlear implants. Should he get the Prevnar and Pneumovax vaccines?
Cochlear implants can put your child at increased risk for bacterial meningitis caused by the Streptococcus pneumoniae bacteria (pneumococcus).
Your child is going to have his spleen removed to prevent complications of hereditary spherocytosis. Should he get the meningococcal and pneumococcal vaccines first?
Without a spleen, kids are at risk for many bacterial infections, including severe infections caused by Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis bacteria.
In addition to their routine vaccines, kids with asplenia might need Menveo or Menactra, Bexsero or Trumenba (Men B), and Pneumovax 23.
Would your child get these vaccines that are recommended for kids with asplenia?
Ebola is returning, but this time an experimental vaccine is available.
There were nearly 30,000 cases and just over 11,000 deaths during the 2014-16 Ebola outbreak in West Africa.
You are in an area that is seeing an increasing number of Ebola cases and there is still no treatment for this deadly disease. An experimental vaccine is being offered.
Do you get the vaccine?
How Anti-Vaccine Are You?
It’s easy to be anti-vaccine when you are hiding in the herd – seemingly protected by all of the vaccinated people around you.
Specifically, there is a risk for severe infections from the Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis bacteria.
Fortunately, there are vaccines that protect against many subtypes of these bacteria, including:
Hib – protects against Haemophilus influenzae type B
Meningococcal conjugate vaccines – Menactra or Menveo, which protect against 4 common types of the Neisseria meningitidis bacteria – serogroups ACWY
Serogroup B Meningococcal vaccines – Bexsero or Trunemba, which protect against Neisseria meningitidis serogroup B
Prevnar 13 – protects against 13 subtypes of Streptococcus pneumoniae
Pneumovax 23 – protects against 23 subtypes of Streptococcus pneumoniae
Although Prevnar, Hib, and the meningococcal vaccines (Menactra or Menveo and Bexsero or Trunemba) are part of the routine immunization schedule, there are additional recommendations that can change the timing for when kids get them if they have asplenia.
According to the latest recommendations, in addition to all of the other routine immunizations that they should get according to schedule, children with asplenia should get:
one dose of the Hib vaccine if they are older than age 5 years “who are asplenic or who are scheduled for an elective splenectomy” and have not already vaccinated against Hib. Unvaccinated younger kids should get caught up as soon as possible. In general though, Hib is given according to the standard immunization schedule. This recommendation is about kids who are behind on the shot.
two doses of a meningococcal conjugate vaccine, either Menactra or Menveo, two months apart once a child with asplenia is at least two years old and a booster dose every five years. Infants with asplenia can instead get a primary series of Menveo at 2, 4, 6, and 12 months, with a first booster dose after three years, and a second booster after another five years. Older infants can get Menactra at 9 and 12 months, again, with a first booster dose after three years, and a second booster after another five years. While these vaccines are recommended for all kids, those with asplenia get them much earlier than the standard age.
either a two dose series of Bexsero or a three dose series of Trunemba, once they are at least 10 years old. The Men B vaccines are only formally recommended for high risk kids, others can get it if they want to be protected.
between one to four doses of Prevnar, depending on how old they are when they start and complete the series. Keep in mind that unlike healthy children who do not routinely get Prevnar after they are 5 years old, older children with asplenia can get a single dose of Prevnar up to age 65 years if they have never had it before. Like Hib, this recommendation is about kids who are behind on the shot.
a dose of Pneumovax 23 once they are at least two years old, with a repeat dose five years later and a maximum of two total doses. Kids who are not high risk typically don’t get this vaccine.
Ideally, children would get these vaccines at least two to three weeks before they were going to get a planned splenectomy. Of course, that isn’t always possible in the case of the emergency removal of a child’s spleen, in which case they should get the vaccines as soon as they can.
More About Asplenia
In addition to these vaccines, preventative antibiotics are typically given once a child’s spleen is removed or is no longer working well. Although there are no definitive guidelines for all children who have had a splenectomy, many experts recommend daily antibiotics (usually penicillin or amoxicillin) until a child is at least 5 years old and for at least 1 year after their splenectomy.
Other less common bacteria that can be a risk for children with asplenia can include Escherichia coli, Staphylococcus aureus, Salmonella species, Klebsiella species, and Pseudomonas aeruginosa. Vaccines aren’t yet available for these bacteria, so you might take other precautions, such as avoiding pet reptiles, which can put kids at risk for Salmonella infections.
Children with asplenia are at increased risk for severe malaria and babesiosis (a tickborne illness) infections. That makes it important to take malaria preventative medications and avoid mosquitoes if traveling to places that have high rates of malaria and to do daily tick checks when camping, etc.
A medical alert type bracelet, indicating that your child has had his spleen removed, can be a good idea in case he ends up in the emergency room with a fever and doctors don’t know his medical history.
Keep in mind that since there are many different causes of asplenia, the specific treatment plan for your child may be a little different than that described here. Talk to your pediatrician and any pediatric specialists that your child sees.
What to Know about Vaccines for Children with Asplenia
Children with asplenia typically need extra vaccines and protection against pneumococcal disease, Hib, and meningococcal disease.
A lot of folks, even some pediatricians, are still confused about the recommendations for the meningococcal B vaccines.
Remember, two vaccines, Bexsero and Trumenba, are approved to protect against serogroup B meningococcal disease.
The Men B Vaccine for High Risk Kids
There is no confusion about the recommendation that high risk kids should get vaccinated against meningococcal B disease.
“Certain persons aged ≥10 years who are at increased risk for meningococcal disease should receive MenB vaccine.”
ACIP on Use of Serogroup B Meningococcal Vaccines in Persons Aged ≥10 Years at Increased Risk for Serogroup B Meningococcal Disease: Recommendations of the Advisory Committee on Immunization Practices, 2015
Who’s high risk?
In addition to microbiologists who work with the Neisseria meningitidis bacteria, you are considered to be high risk if you are at least 10 years old and:
have a persistent complement component deficiency, including inherited or chronic deficiencies in C3, C5–C9, properdin, factor D, or factor H
have anatomic or functional asplenia, including sickle cell disease, children with congenital asplenia, and children who’s spleen was removed (splenectomy) to prevent complications of other conditions, such as ITP, hereditary spherocytosis, pyruvate kinase deficiency, Gaucher disease, and hypersplenism, etc.
are taking the medication eculizumab (Soliris), which is used to treat two rare blood disorders, atypical hemolytic uremic syndrome (aHUS) and paroxysmal nocturnal hemoglobinuria (PNH)
And, if high risk, you should either get a 3 dose series of Trumenba or a 2 dose series of Bexsero.
Keep in mind that traveling is not usually a risk factor for Men B, but can be for the other meningococcal vaccines.
The Men B Vaccine for Healthy Teens
But what if you aren’t at high risk?
While teens should routinely get vaccinated with other meningococcal vaccines, Menactra or Menveo, that provide protection against serogroups A, C, W, Y, the recommendation for Men B vaccination is more permissive.
“A MenB vaccine series may be administered to adolescents and young adults aged 16–23 years to provide short-term protection against most strains of serogroup B meningococcal disease. The preferred age for MenB vaccination is 16–18 years.”
ACIP on Use of Serogroup B Meningococcal Vaccines in Adolescents and Young Adults: Recommendations of the Advisory Committee on Immunization Practices, 2015
When given to healthy teens who are not at high risk for meningococcal disease, both Bexsero and Trumenba can be given as a two dose series.
A Permissive Recommendation for Men B Vaccines
This permissive recommendation for Men B is what has got folks confused…
“The recommendation is labeled as “Category B,” meaning that individual clinical decision-making is recommended. A Category A recommendation means a vaccine is recommended for everyone in an age-group or risk factor group.”
ACIP endorses individual choice on meningitis B vaccine
So there is a recommendation for older teens to get vaccinated with the Men B vaccines, it just isn’t the clear cut, get the vaccine, kind of recommendation that we are used to. The recommendation instead says that you can get the vaccine if you want to be vaccinated and protected against meningococcal B disease.
And that’s where the confusion comes from, as over 75% of doctors don’t even know what a category B recommendation really means! That’s not surprising though, as the Advisory Committee on Immunization Practices doesn’t often make category B recommendations for vaccines.
Things that factored into the decision for a permissive recommendation seemed to include that:
routine vaccination of all teens would prevent about 15 to 29 cases of Men B and two to five deaths each year, as there are about 50 to 60 cases and five to 10 deaths each year in children and young adults between the ages of 11 and 23 years, and giving it only to kids going to college would only prevent about nine cases and one death each year
there are some concerns about how effective the MenB vaccines might be, but only because vaccine effectiveness “was inferred based on an immunologic marker of protection,” as it is difficult to otherwise test how well the vaccine works because the disease has a low prevalence and there is no data yet about how long the protection will last, as they are new vaccines. Still, from 63 to 88% of people get protective levels of antibodies after getting the MenB vaccines and the protection should last for at least two to four years.
data on safety was limited, but there were no “no concerning patterns of serious adverse events”
the vaccine likely won’t reduce the nasopharyngeal colonization by MenB bacteria, so might not contribute to herd immunity
If you are still confused, you will hopefully be reassured that a combination, pentavalent MenABCW-135Y meningococcal vaccine is in the pipeline and once available, will almost certainly be recommended for all teens, replacing the need to get separate meningococcal vaccines for protection.
Making a Decision About the MenB Vaccines
So do you get your kids the Men B vaccine series?
“Pediatricians are encouraged to discuss the availability of the MenB vaccines with families.”
AAP on Recommendations for Serogroup B Meningococcal Vaccine for Persons 10 Years and Older
The one thing that is very clear is that you should make your decision after talking to your pediatrician about the risks and benefits of getting vaccinated.
Although many people think that there is no recommendation for healthy teens to get a Men B vaccine, that isn’t really true. There just isn’t a recommendation for routine vaccination of all teens.
It is true that the Men B vaccines aren’t required by most colleges, although some are starting to require them, just like they do Menactra or Menveo.
“The treating clinician should discuss the benefits, risks, and costs with patients and their families and then work with them to determine what is in their best interest.”
AAP on Recommendations for Serogroup B Meningococcal Vaccine for Persons 10 Years and Older
What are the benefits? Your child doesn’t get Men B disease, a disease that is often life-threatening.
What are the risks? In addition to extremely rare risks that you can see with any vaccine, like anaphylaxis, there are the risks that the vaccine doesn’t work, as no vaccine is 100% effective, pain from the shot, or that your child is never exposed, so didn’t actually need the shot, since Men B disease is pretty rare.
“The CDC has estimated the risk of anaphylaxis is 1.3 cases/1 million doses following administration of any vaccine. Thus, the vaccine benefit from prevention of death from MenB disease is approximately equal to the risk of anaphylaxis from MenB vaccine administration.”
H. Cody Meissner, MD on MenB vaccines: a remarkable technical accomplishment but uncertain clinical role
Although thinking about it this way, the risk of anaphylaxis vs the benefit of preventing Men B deaths seems to be equal, remember that anaphylaxis is often treatable.
What are the costs? Men B vaccines are expensive, but are covered by insurance and the Vaccines for Children Program. Still, someone is always paying for them.
What other factors come into play? Some teens are getting caught up on their HPV vaccines and are getting a booster dose of the other meningococcal vaccine at around this same time. While they can certainly all be given together, some pediatricians prioritize getting kids vaccinated and protected with Gardasil and Menactra or Menveo, and so don’t focus on the Men B vaccines.
Still, the vaccine is safe and it works, so the question really may come down to – is it necessary? Or is Men B so rare, that it is worth taking a chance and skipping this vaccine.
What to Know About the Recommendations to Get a Men B Vaccine
Talk to your pediatrician and see if your child should get the Men B vaccine series.
More on Understanding the Recommendations to Get a Men B Vaccine