Key takeaways:
- Influenza, pneumococcal, zoster and COVID-19 vaccines all are really helpful for immunocompromised sufferers.
- Vaccines could also be much less efficient when sufferers get them throughout immunosuppressive therapy.
Sufferers who’re immunocompromised nonetheless can obtain quite a lot of vaccinations based mostly on their particular wants, Cassandra Calabrese, DO, mentioned throughout her presentation at Updates in Major Immunodeficiency 2025.
“Immunocompromised sufferers are a really heterogenous inhabitants,” Calabrese, assistant professor of drugs, division of rheumatologic and immunologic illness, Cleveland Clinic Lerner School of Drugs, mentioned. “That is an individualized strategy.”
Care in scheduling
Between 3% and 6% of individuals in the USA are immunocompromised, Calabrese mentioned, however age, intercourse, social determinants of well being, stress and way of life make uniform pointers for vaccination difficult to develop.
“And addressing vaccines with sufferers throughout our visits turns into more and more troublesome with time constraints,” Calabrese added. “However that is necessary.”
Calabrese suggested physicians to assessment every affected person’s historical past of vaccinations and infections in addition to any journey plans that they could have. Sufferers who usually are not present for his or her age-appropriate vaccinations ought to be introduced up-to-date, she continued.
These vaccines embody pneumococcal pneumonia, influenza and herpes zoster in addition to HPV for these sufferers as much as aged 45 years. Reside vaccines ought to be administered not less than 4 weeks earlier than any immunosuppression the affected person has scheduled.
When sufferers require multiple vaccine, they could possibly be administered throughout a single day, if they don’t seem to be reside vaccines, however that ought to nonetheless comply with discussions with the affected person.
“It actually is determined by the affected person and their wishes and well being beliefs,” Calabrese mentioned. “However typically, I counsel towards this, particularly if sufferers have any diploma of vaccine hesitancy or wariness, or if their arms are simply going to harm much more or they’re going to really feel much more crummy the subsequent day. It might probably assist with future vaccine uptake to area them out.”
Cassandra additionally famous the impression of timing vaccinations for sufferers with immune-mediated inflammatory ailments (IMIDs) who could also be taking concomitant immunosuppressive medication equivalent to disease-modifying antirheumatic medication.
For instance, she mentioned, vaccinations for influenza, pneumococcal, tetanus and SARS-CoV-2 are much less efficient when sufferers are taking rituximab (Rituxan, Genentech).
“When you give somebody a vaccine inside a couple of months after rituximab, they’ll have little or no response,” Calabrese mentioned. “The advice is to attend so long as attainable after their final infusion, after which 2 to 4 weeks earlier than their subsequent dose.”
Methotrexate, which additionally has a detrimental impression on vaccine efficacy, ought to be held for 4 weeks earlier than and for 4 weeks after administration of a reside virus. Abatacept (Orencia, Bristol Myers Squibb) ought to be held for one dosing interval earlier than and for 4 weeks after administration of a reside virus.
In truth, she mentioned, sufferers with rheumatoid arthritis who maintain off on their methotrexate dose for two weeks after influenza or COVID-19 vaccination can have higher vaccine response with no improve in rheumatoid arthritis flares. Related sufferers who get non-live vaccinations shouldn’t have to skip their methotrexate in any respect.
“We do have discussions with our sufferers on methotrexate throughout flu season to carry a dose in the event that they really feel comfy, in the event that they’re doing properly,” Calabrese mentioned. “There aren’t any actually agency suggestions to carry any of our different immunosuppressive medication across the flu or COVID vaccine.”
Calabrese known as prednisone “an enormous wrongdoer” in decreasing vaccine efficacy at any dose and mentioned that physicians ought to taper doses of 20 mg each day or extra in the event that they plan on giving their sufferers the influenza vaccination.
“When you can wait till they’re on somewhat bit much less prednisone, they’ll have a greater response,” she mentioned. “Defer to them when you can.”
General, Calabrese mentioned, “there’s a paucity of information to information suggestions on administering reside vaccines within the setting of iatrogenic immunosuppression, for apparent causes,” and the suggestions which might be accessible are cautious and beneficiant.
Nevertheless, cytokine inhibitors and plenty of biologics used for atopic situations equivalent to dupilumab (Dupixent; Sanofi, Regeneron) and mepolizumab (Nucala, GSK) shouldn’t have any detrimental impression on vaccine responses, Cassandra mentioned, which is necessary to share with sufferers.
Influenza, pneumococcal vaccines
Sufferers with main immunodeficiencies ought to nonetheless get the influenza vaccine yearly, even when they’re aged as younger as 6 months, Calabrese mentioned.
“The one true contraindication to getting a flu vaccine is when you have a major allergy to a part of the flu vaccine,” she continued.
Sufferers with egg allergy can nonetheless get the influenza vaccine, even when it makes use of an egg-based formulation, Calabrese mentioned.
Sufferers between aged 2 to 49 years can obtain an intranasal formulation of the influenza vaccine, she added. Sufferers aged 65 years and older with stable organ transplants can obtain high-dose, recombinant and adjuvanted influenza vaccines as properly.
“And there are knowledge to point out that sufferers with immune-mediated inflammatory ailments equivalent to rheumatoid arthritis have a greater response to high-dose flu vaccine when given youthful than 65,” Calabrese mentioned.
Additionally, Calabrese famous that Streptococcus pneumoniae is the first bacterial reason for pneumonia, meningitis and sepsis, with mortality charges starting from 5% to 32% and elevated danger for immunocompromised sufferers.
“We all know from expertise in our IMIDs sufferers that vaccines are protecting and secure,” Calabrese mentioned, though sufferers with cryopyrin-associated periodic syndromes have very extreme reactogenicity with vaccines for pneumonia, so warning is required.
Calabrese additionally mentioned that the 15-valent (PCV15), 20-valent (PCV20), and 21-valent (PCV21) pneumococcal conjugate vaccines are indicated for all PCV-naïve adults aged 50 years and older and for adults aged 19 to 64 years with underlying medical situations
However latest updates in pneumococcal steering are “complicated,” with stories that the polysaccharide vaccine most likely can be phased out, she mentioned.
“When you obtain a 20-valent pneumococcal conjugate vaccine or the 21-valent PCV, you don’t want the polysaccharide vaccine in any respect,” Calabrese mentioned. “Nevertheless, when you obtain a PCV15, you continue to want the polysaccharide vaccine, and these cowl extra serotypes which might be implicated in a larger proportion of invasive streptococcal infections.”
Zoster vaccines
Noting that the chance for herpes zoster is excessive however preventable amongst immunocompetent people, Calabrese mentioned that it will be significant for physicians to debate vaccine standing with their sufferers.
“As soon as somebody has zoster, accessible antivirals don’t absolutely defend you from problems, equivalent to post-herpetic neuralgia, which is an enormous supply of morbidity,” Calabrese mentioned. “And this therapy is difficult and never overly profitable. Prevention is preferable.”
Zoster incidence charges per 1,000 patient-years within the U.S. embody two to 3 amongst all adults, 4 amongst adults aged 50 years and older, 10 amongst sufferers with rheumatoid arthritis and 11 amongst adults aged 80 and older.
“That’s nearly tripled,” Calabrese mentioned. “That’s akin to sufferers with IMIDs throughout all ages.”
Incidence charges additionally embody a spread from six to 32 for sufferers with systemic lupus erythematosus, 39 for sufferers with rheumatoid arthritis who use tofacitinib (Xeljanz, Pfizer), 45 for sufferers with granulomatosis with polyangiitis and 69 for sufferers who use anifrolumab (Saphnelo, AstraZeneca).
“[Janus kinase (JAK)] inhibitors are very strongly related to elevated danger for zoster,” Calabrese mentioned.
Immunocompromised adults will be vaccinated towards zoster with the non-live recombinant zoster vaccine (Shingrix, GSK), which Calabrese known as “a really potent adjuvant” that’s “over 90% efficient at stopping zoster” in additional than 7 years of follow-up.
The 2 photographs within the sequence are administered 2 to six months aside, she mentioned, including that reactogenicity counseling is also necessary since one in 10 sufferers had vital native or systemic reactogenicity.
“It may be useful, I feel, to share that info with sufferers to extend critical completion,” Calabrese mentioned. “I encourage them to not get it the day earlier than a trip or they’re going to a marriage or have one thing necessary to do.”
Calabrese additionally suggested sufferers who obtained the reside zoster vaccine (Zostavax, Merck) up to now, which grew much less efficient over time and has since been phased out within the U.S., to get Shingrix.
Sufferers with autoimmune ailments who contract herpes zoster are at specific danger for stroke, Calabrese continued, together with a 36% elevated danger general and a 76% elevated danger for sufferers who’ve cranial nerve problems inside 90 days of an infection.
“There’s vital elevated danger of stroke, particularly inside 30 days after zoster, which is attenuated by a vaccine and attenuated by speedy begin of antivirals,” Calabrese mentioned.
Additional, Calabrese mentioned that sufferers could also be hesitant to get the vaccine due to anecdotes about poor reactions heard from others who’ve already obtained it.
“It’s additionally necessary to debate the reactogenicity so sufferers don’t take that reactogenicity they may expertise as an adversarial occasion,” she mentioned. “Allow them to realize it’s their immune system at work. That is good, and will probably be gone in 24 hours, and it’ll very a lot assist with vaccine acceptance.”
Sufferers with immune-mediated rheumatic illness might expertise flares triggered by the vaccine, Calabrese mentioned, however these flares don’t occur usually, and once they do, they’re delicate and manageable.
“We do keep away from giving our IMID sufferers recombinant zoster vaccine when they’re in a flare or having a tough time with their illness or on a prednisone taper,” she mentioned. “We attempt to wait till issues are quiet.”
Calabrese added that she prioritizes sufferers who’re on JAK inhibitors and anifrolumab for vaccination, in addition to sufferers who have already got had zoster and who’re in danger for getting it once more.
“Sufferers who’re 40 years outdated on a TNF inhibitor and/or methotrexate can most likely wait till they’re 50 to get the zoster vaccine,” she mentioned.
RSV, COVID-19 vaccines
Additional, Calabrese famous the hospitalization burdens that include RSV, together with as much as 160,000 adults aged 65 years and older and 80,000 kids aged 5 years and youthful every year within the U.S.
The CDC recommends RSV vaccines for all adults aged 75 years and older and adults aged 60 to 74 years with danger elements together with being immunocompromised. Arexvy (GSK) is accepted for all adults aged 50 years and older, and Abrysvo (Pfizer) is accepted for all adults together with ladies who’re between weeks 32 and 36 in being pregnant.
The continued Monet trial of Abrysvo amongst immunocompromised and different at-risk sufferers, together with rheumatology sufferers and sufferers with power kidney illness, has proven some favorable and efficient outcomes, Calabrese mentioned.
“Nevertheless, a number of months in the past, each vaccines obtained a black field warning for Guillain-Barré syndrome,” Calabrese mentioned. “That is vital and one thing to concentrate on.”
CDC and WHO suggestions for COVID-19 vaccines concentrating on circulating omicron subvariants embody extra doses for sufferers with main immunodeficiencies who face larger dangers for extreme outcomes, Calabrese mentioned.
“Who remains to be in danger for extreme illness and hospitalization?” Calabrese mentioned. “That’s largely B cell deleted sufferers, particularly iatrogenically B cell depleted sufferers on rituximab and different B cell blocking medication.”
But research have proven that sufferers with main immunodeficiencies together with sufferers receiving intravenous immunoglobulin (IVIG) therapy who’ve been vaccinated towards COVID-19 expertise will increase in neutralizing antibodies, she mentioned.
“Sufferers on immunoglobulin substitute now do have an honest quantity of safety,” Cassandra mentioned.
Along with COVID-19 vaccines, she mentioned, sufferers receiving IVIG therapy ought to have protecting titers for the MMR, pneumococcus, Haemophilus influenza and meningococcus vaccines. These sufferers additionally skilled growing ranges of neutralizing antibodies towards SARS-CoV-2 because the pandemic continued.
“But when somebody on IVIG does get a reside vaccine, there are some timing issues,” Calabrese added.
Pemivibart (Pemgarda, Invivyd) pre-exposure prophylaxis (PrEP) is offered for sufferers aged 12 years and older with main immunodeficiencies in danger for extreme COVID-19 who might not have an ample response with COVID-19 vaccination, Calabrese mentioned.
“It’s a long-acting IV formulation of anti-spike protein that lasts for 3 months after which really helpful for an additional dose,” she mentioned.
Sufferers who use rituximab and different anti-CD20 medication, who’ve obtained a stable organ transplant or hematopoietic stem cell transplantation, or who’re on energetic chemotherapy ought to be prioritized for PrEP, Calabrese mentioned, as ought to these with immunosuppression and vital comorbidities.
Different sufferers who ought to be prioritized embody these on anifrolumab, cyclophosphamide or mycophenolate, she continued, in addition to these on mixture therapies together with high-dose steroids and people with a concomitant frequent variable immunodeficiency or different inborn error of immunity.
Pemivibart has emergency use authorization from the FDA.
“We wish to deal with you and get you PrEP if we will,” Calabrese mentioned.
Speaking to sufferers
Calabrese cited the significance of communication in enhancing vaccination charges amongst immunocompromised sufferers, noting that doctor suggestions have the best impression in growing vaccine uptake.
“Take a couple of moments to speak to your sufferers about vaccines,” she mentioned. “Take a second to evaluate vaccine standing.”
Some sufferers might say that they don’t wish to get vaccinated, she added.
“I simply say, ‘Inform me extra about that,’ and go from there. In the event that they don’t wish to speak about it, transfer on,” she mentioned. “However you’ll discover you could persuade some sufferers to alter their minds.”
For extra info:
Cassandra Calabrese, DO, will be reached at allergy@healio.com.
