Vaccination of persons with immunodeficiency

For all people who have immunodeficiency, only live vaccines that can cause disease are dangerous. The diagnosis of immunodeficiency is clinical, although requiring laboratory confirmation.

According to the WHO classification, the following types of immunodeficiency are distinguished:

• primary (hereditary);
• immunodeficiency, associated with severe diseases (mainly lymphoproliferative and oncological);
• drug and radiation immunosuppression;
• acquired immunodeficiency (AIDS).

Immunodeficiency should be suspected in a patient with severe repeated bacterial, fungal or opportunistic infections. In children without such manifestations - only on the basis of frequent ARI, general asthenia, etc. The diagnosis of immunodeficiency is groundless, such children are vaccinated as usual. The terms "secondary immunodeficiency", "decreased reactivity" and the like, which usually refer to conditions after a previous infection, which have become widespread in Russia, can not be considered equivalent to an immunodeficiency state; such a "diagnosis" can not serve as an excuse for not taking vaccines.

Laboratory confirmation of the diagnosis of "immunodeficiency" is based on the identification of immunological indicators that are outside the range of their norms (fairly broad). A child who does not have a corresponding clinical picture usually displays deviations of "immune status indicators" that do not reach the levels typical for a specific immunodeficiency state. Such changes can not in themselves serve as an excuse for refusing to vaccinate. Fluctuations in the levels of immunoglobulins and the number of T cells, changes in the ratio of subpopulations of lymphocytes, phagocytosis activity, etc., naturally arise in various diseases and conditions, without reaching threshold levels and without clinical manifestations. Their pathological significance is doubtful, they most often reflect cyclical fluctuations of very dynamic immunological parameters during illness. Huge expenditure on the production of immunograms in children without clinical manifestations of immunodeficiency is not justified, and "profound" conclusions on them are akin to horoscopes of astrologers.

General rules for immunization of people with immunodeficiency

Inactivated vaccines are completely safe in patients with immunodeficiency. Live vaccines are contraindicated in principle, although they are injected with HIV.

Primary immunodeficiency states

An increased risk of complications for these patients has been demonstrated with respect to live vaccines. This vaccine-associated poliomyelitis (VAP) in the use of OPV and encephalitis in response to measles vaccine in persons with a- and hypogammaglobulinemia, generalized BCG-it and BCG-osteitis in children with combined forms of immunodeficiency, with chronic granulomatous disease and defects in the interferon- y and interleukin 12. Clinical manifestations of immunodeficiency are absent in newborns when BCG is administered, and most often at age 3 months when OPV was administered (this is due to compensation of maternal IgG deficiency of its own immunoglobulins inov); for this reason, the total study of children of the first months for the presence of immunodeficiency is not informative, and almost impossible.

Immunization with live vaccines of people with immunodeficiency

Type of immunodeficiency	Timing of introduction of live vaccines
Primary immunodeficiencies	Live vaccines are not injected, OPV is replaced by IPV
Suppressing the immunity of disease (tumors, leukemia)	Live vaccines are introduced into remission on an individual basis
Immunosuppression, radiation therapy	Not earlier than 3 months after the end of therapy
Corticosteroids (doses indicated by prednisolone)
Inside> 2 mg / kg / day (> 20 mg / day with weight above 10 kg) for more than 14 days	After 1 month. After the end of the course
The same dose is less than 14 days or a dose of less than 2 mg / kg / day (<20 mg / day)	Immediately after the end of treatment
Supportive treatment	Against the background of the treatment
Local therapy (drops in the eyes, nose, inhalation, sprays and ointments, in the joint)	Against the background of the treatment
HIV infection
Asymptomatic - in the absence of laboratory signs of immunodeficiency	Root, parotitic, rubella - with control of antibodies after 6 months. And re-inoculation in case of their low level
With signs of immunodeficiency	Protection is carried out by immunoglobulin

The states that make you think about the possibility of primary immunodeficiency (from the subject of vaccination or from a family member) are:

• severe, especially recurrent purulent disease;
• paraproctitis, anorectal fistula;
• presence of persistent candidiasis of the oral cavity (thrush), other mucous membranes and skin;
• pneumocystis pneumonia;
• persistent eczema, including seborrhoea;
• thrombocytopenia;
• presence in the family of a patient with immunodeficiency.

In children with such conditions it is necessary to determine the content of the 3 classes of immunoglobulins, immunodeficiency is likely with a decrease in the levels of immunoglobulins of at least one class below the lower limit of the norm. Allows to suspect humoral immunodeficiency a decrease in the proportion of y-globulins below 10% in protein fractions of the blood. To assess the condition of the T-cell deficiency, use skin tests with tuberculin (In vaccinated BCG) and candidin - the loss of negative samples requires further study. Diagnosis of chronic granulomatous disease is confirmed by a sample with tetrazolium blue or similar.

BCG is not administered to newborns whose family has children with any signs of Immunodeficiency, or children who died from unrecoded pathology.

To protect children with primary immunodeficiency from measles, in case of contact with patients, human immunoglobulin is used (these children usually receive immunoglobulin replacement therapy, which protects them from infection).

Children with primary immunodeficiency are vaccinated with all inactivated vaccines, including against the background of immunoglobulin replacement therapy. Since many of them give a reduced immune response, it is desirable to determine antibody titres at the end of the primary vaccination series and to administer additional doses as needed. Response to diphtheria and tetanus toxoid is completely absent in children with hyper-IgE syndrome, antibodies deficit syndromes.

The effect of immunosuppression on antibody levels

Infection	Preservation of antibodies
	Postinfectious	Post-vaccination
Tetanus		Saved
Diphtheria		Saved
Polio		Saved
Measles		Reduced
Pneumococcal		Preserved (lymphoma)
Chickenpox	Reduced
Hepatitis B	Reduced
Flu	Reduced

Transient hypogammaglobulinemia

This so-called "late immunological start" usually lasts 2-4 years, such children can be vaccinated with killed vaccines, and after normalizing immunoglobulins, vaccinate against measles, rubella and mumps. BCG, these children usually suffer.

Associated with diseases immunodeficiency and immunosuppressive therapy

The immune response is suppressed in leukemias, lymphogranulomatosis and other lymphomas, to a lesser extent in a number of solid tumors; this is a contraindication for the introduction of live vaccines, especially since these children usually receive immunosuppressive therapy. Although the introduction of killed vaccines in the acute period is not contraindicated, the immune response to a number of vaccines is often reduced:

• The response to diphtheria and tetanus toxoid is good (per booster dose), worse for the primary series.
• Hib vaccine is usually a good response.
• The answer to Grippol does not decrease, but at preschool age 2 doses are required.
• Hepatitis B vaccine - the immune response is extremely weak.

For this reason, a number of vaccines are recommended to be administered no earlier than 4 weeks after the end of therapy (with a number of lymphocytes more than 1000 in 1 μl). Live vaccines are administered individually, at least after 3 months. After the end of immunosuppression.

Children with acute lymphoblastic leukemia who come in contact with chickenpox (or herpes zoster, often exacerbated by chickenpox survivors in the ward) must discontinue chemotherapy, prophylaxis of acyclovir, and also use IV human immunoglobulin. It is more reliable than vaccination, it is recommended by WHO and widely conducted in the world: it prevents disease in 85% of patients, in others the infection proceeds easily. For those who have been ill before, the vaccination, acting as a booster, reduces the frequency of exacerbations of the herpes zoster. Patients with leukemia are vaccinated after 1 year of remission on the background of maintenance therapy with a lymphocyte count of at least 700 in 1 μl and platelets of more than 100,000 in 1 μl. Vaccination is also effective in recipients of bone marrow transplants and solid organs.

In patients with leukemia, the risk of hepatitis B is high due to repeated blood transfusions. Currently, these patients are protected from hepatitis B infection by administering a specific immunoglobulin, usually in combination with active immunization at a later stage of treatment.

Patients with lymphogranulomatosis are vaccinated according to the above rules. Given their particular susceptibility to infections caused by capsular microorganisms, they are also advised to administer Hib vaccine, and at the age of 2 years, vaccines against pneumococcal and meningococcal A and C infections. Vaccination should be done 10-15 days before the start of the next course of therapy or after 3 months. And more after its termination. This same tactic is used in children with asplenia and neutropenia, having an increased risk of bacteremic infection with capsular microorganisms.

Immunosuppression reduces antibody levels, so vaccination (or revaccination) against diphtheria and tetanus, measles (even after 1 or 2 vaccinations), rubella and mumps, influenza, hepatitis B, chickenpox is indicated upon remission.

Children after bone marrow transplantation are vaccinated with killed vaccines for at least 6 months, live vaccines - after 2 years, twice (1 month interval)

Immune defects that cause an increased susceptibility to infection by capsular pathogens (pneumococcus, H. Influenzae type b, meningococcal). These include patients with asplenia (a defect in the formation of IgM antibodies) with a high risk of pneumonia (incidence of 226 per 100 000 patients, OR 20.5), which persists for decades after the removal of the spleen. In sickle cell anemia (functional aspiration) at the age of up to 5 years, the incidence of pneumococcal infection (6.9 per 100 person-years) is 30-100 times higher than the incidence rate of the entire population. In patients with diabetes, pneumococcal infection, although it does not occur more often than in healthy people, flows heavily, with a mortality rate of 17-42%.

Recurrences of meningococcal infection are common in persons with deficiency of properdin, C3 and a number of subsequent components of complement, they are recommended to vaccinate with polysaccharide vaccine every 3 years.

Control over the result of vaccination of individuals with immunodeficiency and immunosuppression by determining the titers of the corresponding antibodies is mandatory.

[1], [2], [3], [4], [5], [6], [7], [8],

Corticosteroid therapy

Steroids result in severe immunosuppression only when high doses are used (prednisolone> 2 mg / kg / day or> 20 mg / day for a child> 10 kg) for more than 14 days. To such children killed vaccines are introduced at the usual time for recovery, live vaccines are administered no earlier than 1 month after the end of treatment. Live and inactivated vaccines are administered in the usual way to persons receiving steroid preparations in the form of:

• short-term courses (up to 1 week) in any doses;
• courses up to 2 weeks in low or medium (up to 1 mg / kg / day prednisolone) doses;
• long-term in maintenance doses (eg, 10 mg prednisolone every other day);
• substitution therapy in low (physiological) doses;
• topically: ocularly, in inhalations, in the form of eye drops, inside the joint.

[9], [10], [11], [12]