What do I need to know about immunosuppression and vaccination?
In people with immunosuppression (immunodeficiency, immunodeficiency), the immune system does not work optimally – it is more or less limited in its ability to function. The reason may be a congenital or acquired disease or immunosuppressive therapy.
Whatever the reason for immunosuppression or immunodeficiency, there are several aspects to consider in connection with vaccinations:
Increased susceptibility to infections
For people with immunosuppression, various vaccinations are even more important than for immune-healthy individuals. This is because their limited body defenses cannot resist pathogens as well. Therefore, immunosuppressed people are generally more susceptible to (severe) infections. Some examples:
- Rheumatism patients have an increased risk of influenza and pneumococcal infections. The latter can manifest as dangerous pneumonia or meningitis, for example.
- Systemic lupus erythematosus makes people more susceptible to shingles. This is caused by the reactivation of chickenpox pathogens dormant in the body.
- Anyone who receives immunosuppressants of the TNF-alpha blocker type due to rheumatism or Crohn’s disease, for example, has an increased risk of tuberculosis.
The extent of susceptibility to infection in individual patients with immunosuppression depends on several factors. Relevant factors include the cause and severity of the immunodeficiency, any concomitant diseases, and the age and body mass index (BMI) of the patient.
Vaccinations often less effective in immunosuppressed patients
People with a weak immune system therefore benefit particularly from vaccinations – provided they are sufficiently effective. However, this is not always the case: the vaccination response is often less good in immunosuppression / immunodeficiency than in an intact body defense.
This is because, in response to the vaccine administered, an impaired immune system produces fewer defensive substances (antibodies) than a fully functional immune system. In the ideal case, this nevertheless results in sufficient vaccination protection.
However, it is also possible that the vaccine response to a vaccination is almost completely absent. This can happen, for example, if someone is vaccinated with an inactivated vaccine despite therapy with immunosuppressants such as alemtuzumab or rituximab. These are artificially produced therapeutic antibodies that specifically remove certain immune cells (B or T lymphocytes) from the blood. They are suitable, for example, for the treatment of multiple sclerosis (alemtuzumab) and chronic lymphocytic leukemia (alemtuzumab, rituximab).
Live vaccines are critical
Live vaccines such as the triple vaccine against measles, mumps and rubella (MMR vaccine) are often critical in this respect. In immunocompromised individuals, such live vaccines can, under certain circumstances, trigger the very disease they are supposed to protect against.
Live vaccines contain reproducible, albeit attenuated, infectious agents. In immunocompromised individuals, these do not cause disease, but only trigger the desired formation of antibodies.
This is different in the case of immunosuppression (immunodeficiency): The impaired immune system may not be able to cope even with the attenuated pathogens from a live vaccine. Affected people then develop the corresponding disease, possibly even with severe to life-threatening complications.
In the case of immunodeficiency, vaccinations with live vaccines are therefore often “forbidden” (contraindicated). You can read more about this below in the section: “Live vaccinations: Measles, Mumps & Co.”.
In contrast to live vaccines, inactivated vaccines are generally suitable for vaccinations in immunocompromised patients. They do not contain any pathogens capable of reproducing and therefore cannot cause disease. In addition, inactivated vaccines are generally well tolerated even in patients with immune system disorders.
Vaccination intervals for therapy-related immunosuppression
However, these time intervals cannot always be observed – sometimes doctors have to initiate a therapy as quickly as possible, so that there is no time left for any live vaccinations. In this case, they usually have to be dispensed with. Only in selected cases do physicians administer live vaccinations under therapy-related immunosuppression.
Depending on the type of immunomodulatory therapy, it may also be necessary to wait with vaccinations for a certain period of time after its completion. For example, patients who have received infusions of immunoglobulin G antibodies (at least 400 mg per kg of body weight) due to a congenital immunodeficiency should not be vaccinated against measles, mumps, rubella or chickenpox until at least eight months later.
Vaccination of contacts
Because some vaccines may not be administered or may not be effective enough in people with immunosuppression, adequate vaccination protection is very important for close contacts.
So, for example, if you live in the same household as an immunosuppressed person, you should have your vaccination status clarified by a doctor and completed if necessary. By doing so, you will not only protect yourself, but more importantly, your immunocompromised roommate from potentially dangerous infections!
What are the vaccination recommendations for immunosuppression?
Special recommendations of the STIKO apply to the following vaccinations in the case of immunodeficiency:
Corona vaccination
For people with congenital or acquired immunodeficiency or therapeutic immunosuppression, experts recommend basic immunization with three vaccine doses and two booster shots from the age of five.
All available vaccines fall (in the broadest sense) into the category of dead vaccines.
The recommended intervals between two consecutive Corona vaccinations depend on several factors. For example, it is important which Corona vaccine an immunocompromised person has received or should receive and how many vaccinations are involved (e.g., second dose of basic immunization or first booster).
It also plays a role whether the vaccination response to the Corona vaccination is expected to be relevantly limited. This is the case, for example, in patients suffering from a severe congenital immunodeficiency. Treatment with cyclophosphamide or rituximab (immunosuppressants and cancer drugs) can also significantly dampen a patient’s body defenses.
Likewise, there may be different recommendations depending on the age group.
Ask your doctor what intervals between Corona vaccine doses make the most sense in your case.
To learn more, see Coronavirus Vaccination.
Flu vaccination
This applies, for example, to people with congenital or acquired immunodeficiency.
People with the autoimmune disease multiple sclerosis should also have regular flu shots before the age of 60. Flu (influenza) and other infectious diseases increase the risk of MS relapses in those affected.
You can find out everything you need to know about this vaccination under Influenza Vaccination.
Physicians prefer to perform the flu vaccination with dead vaccines. A live influenza vaccine is also available, which is administered as a nasal spray. You can read more about its use below in the section “Live vaccinations: Measles, Mumps & Co.”
Shingles vaccine
The same applies here as with influenza: for people who are particularly at risk because of an underlying disease, the STIKO recommends vaccination against shingles (herpes zoster) at a younger age – not only from the age of 60 as in the general population.
The recommendation is aimed, for example, at people with a congenital or acquired immune deficiency, such as an HIV infection.
Doctors should also administer the inactivated shingles vaccine before the age of 60 to people with diseases such as rheumatoid arthritis, systemic lupus erythematosus and chronic inflammatory bowel diseases (e.g. ulcerative colitis).
Hib vaccination
People who do not have a spleen (anymore) or whose spleen is not functioning should catch up on the dead vaccination against Haemophilus influenzae type b (Hib vaccination) if they did not receive it as a child. According to STIKO recommendations, the vaccination is actually intended for all infants and young children.
Making up for missing vaccination when the spleen is absent or non-functional is important for the following reason:
The spleen is an important component of the body’s defense system. When it is missing (anatomic asplenia) or non-functioning (functional asplenia) from birth or as a result of surgical removal, affected individuals are vulnerable to severe courses of disease from infections with encapsulated bacteria.
These include Haemophilus influenzae type b. The pathogen can cause infections of the ear, nose, and throat, pneumonia, and meningitis. If the spleen is absent or non-functional, such diseases can become life-threatening under certain circumstances.
The STIKO therefore recommends a single Hib vaccination for this form of immune deficiency. At present, it is not possible to assess whether a repeat vaccination is advisable at a later stage – the available data are insufficient to do so.
More information can be found in the article Haemophilus influenzae type b vaccination.
Hepatitis B
The immune system may also have difficulty coping with hepatitis B pathogens in certain underlying diseases, such as HIV infection, and during dialysis therapy. For this reason, experts recommend vaccination with the available inactivated vaccine.
Read more about the vaccination procedure under Hepatitis Vaccination.
Live vaccinations: Measles, Mumps & Co.
Live vaccinations include those against measles, mumps, rubella, chickenpox and rotavirus, as well as the flu vaccine administered as a nasal spray.
Of these, chickenpox vaccination is specifically recommended prior to immunosuppressive therapy or organ transplantation if chickenpox antibodies cannot be detected in the patient’s blood. Read more about this vaccination here.
The live influenza vaccine, administered as a nasal spray, is approved for children and adolescents between the ages of two and 17. If they have an immune deficiency, they generally do not receive the live vaccine, but instead receive an inactivated influenza vaccine (see above: Flu Vaccination).
There are general vaccination recommendations for vaccination against measles, mumps and rubella (always administered as a combination vaccine) and against rotavirus. You can read more about this in the articles MMR vaccination and rotavirus vaccination.
Congenital immunodeficiency
In the case of a congenital immunodeficiency, live vaccinations are contraindicated in many, but not all, patients. For some forms of the disease, there is clear expert testimony on this. Two examples:
- Patients with milder forms of antibody deficiency (such as IgA deficiency) can and should receive all live vaccines (as well as inactivated vaccines) recommended by the STIKO.
- If defects of the type I interferon system cause the immunodeficiency, then all vaccinations with live vaccines are contraindicated.
For other forms of congenital immunodeficiency, live vaccines are a case-by-case decision. The physician takes into account, among other things, the type and course of the underlying disease as well as various examination findings. On this basis, he can weigh up how great the benefit as well as the possible risks of a live vaccination are for the respective patient.
HIV infection
In HIV infection, live vaccines are contraindicated if the patient is severely immunosuppressed or has an AIDS-defining disease.
The latter refers to diseases that develop in the context of HIV-related immunodeficiency. These can be, for example, infections (such as fungal infections, tuberculosis, pneumonia) and various cancers (e.g. Kaposi’s sarcoma).
Autoimmune diseases
If immunosuppressive therapy is planned, physicians should administer live vaccines to their patients at least four weeks in advance, if possible. The recommended time interval is even longer if immunosuppression with ocrelizumab or alemtuzumab is imminent: Then live vaccines may be administered up to a maximum of six weeks before the start of therapy.
As a rule, patients with autoimmune diseases may not receive live vaccines during immunosuppressive therapy. Only in justified individual cases is this permitted. The prerequisite is that the attending physician first weighs up the benefits and risks of vaccination individually for his patient. Only if the expected benefit outweighs the risks can a live vaccination be considered.
This may be the case, for example, if immunosuppressive therapy consists solely of the administration of low-dose glucocorticoids (“cortisone”). If the immune system is only slightly suppressed as a result, the patient in question may be able to be vaccinated against measles, mumps, rubella and/or chickenpox.
Other chronic inflammatory diseases
For patients with chronic inflammatory diseases such as Crohn’s disease, ulcerative colitis or osteoarthritis, the same STIKO recommendations regarding live vaccinations apply as for patients with autoimmune diseases (see above).
Meningococcal bacteria exist in different variants (serogroups). Various inactivated vaccines are available to match these.
According to the STIKO, children, adolescents and adults with congenital or acquired immunodeficiency should be vaccinated against meningococci more comprehensively than immunocompromised persons. This is because they are particularly susceptible to (severe) disease.
For this reason, STIKO experts recommend two meningococcal vaccinations for them: the combination vaccination against meningococci of serogroups A, C, W135 and Y and the vaccination against meningococci of serogroup B.
In the case of the following immunodeficiencies or immunosuppressive therapies, this multiple meningococcal vaccination protection is particularly advisable:
- Complement/properdin deficiency: defect of the complement system (important part of the immune system), e.g. in systemic lupus erythematosus
- Therapy with so-called C5 complement inhibitors such as eculizumab (e.g. in neuromyelitis optica)
- Hypogammaglobulinemias: Diseases in which there are too few antibodies circulating in the blood
- Absent or non-functioning spleen (anatomic or functional asplenia), e.g., in sickle cell disease
Some patients are also advised by their treating physician to receive booster vaccinations to maintain meningococcal vaccine protection. For example, people with complement deficiency should get the meningococcal ACWY vaccine every five years.
No vaccination with regular antibody infusions.
Patients with congenital immunodeficiency who receive permanent immunoglobulin replacement therapy do not need meningococcal vaccinations. They are adequately protected against these and other pathogens (such as diphtheria and tetanus bacteria, pneumococci) by regular antibody infusions.
This applies to immunoglobulin preparations manufactured in Europe!
Pneumococcal vaccination
Pneumococci can cause, among other things, (severe) meningitis and pneumonia. People with a congenital or acquired immunodeficiency, for example, are particularly at risk. They should therefore be vaccinated against pneumococci regardless of their age. Specifically, this is advisable in the following cases, for example:
- Deficiency or dysfunction of T-cells (type of lymphocytes)
- B-cell or antibody deficiency (such as hypogammaglobulinemia)
- impaired splenic function or absence of spleen
- Cancer
- HIV infection
- after bone marrow transplantation
- immunosuppressive therapy, such as autoimmune diseases or after organ transplantation (vaccination should be given before starting therapy, if possible)
For affected patients, vaccination with two different inactivated vaccines is provided according to the following schedule:
- Six to 12 months later, patients receive the PPSV23 vaccine (a polysaccharide vaccine that immunizes against 23 different pneumococcal serotypes).
If appropriate, physicians recommend that their patients repeat the vaccination every six years. This may be appropriate if a patient has an individually increased risk of severe pneumococcal disease.
Read more about these vaccines and their use in the article Pneumococcal Vaccination.
Other vaccinations
In addition, people with immunosuppression should, if possible, also receive all vaccinations that are generally recommended by the STIKO. These include vaccinations against diphtheria, pertussis and tetanus. Patients can obtain more detailed information for individual cases from their doctor.
Talk to your doctor!
Whether immunosuppression or not, vaccinations are important protective measures against pathogens, but they are not useful for every patient. All information in this article is for guidance only when it comes to the complex topic of immunosuppression and vaccination. When which vaccinations are advisable in your specific case is best discussed with your doctor!