Immunization of persons with chronic diseases: Canadian Immunization Guide

Last partial content update: October 2024

This chapter has been updated with guidance from the following statements from the National Advisory Committee on Immunization (NACI):

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• August 9, 2024: Statement on the prevention of respiratory syncytial virus (RSV) disease in older adults
• July 25, 2024: Addendum to the statement on seasonal influenza vaccine for 2024-2025: Transition from quadrivalent to trivalent influenza vaccines
• July 25, 2024: Statement on seasonal influenza vaccine for 2024-2025
• July 25, 2024: Supplemental guidance on influenza vaccination in adults 65 years of age and older
• May 17, 2024: Statement on the prevention of respiratory syncytial virus disease in infants

This information is captured in the table of updates.

Last complete chapter revision: May 2022

On this page

• Introduction and general principles
• Chronic diseases
  • Asplenia or hyposplenia
  • Autoimmune conditions
  • Cancer
  • Cochlear implants
  • Endocrine and metabolic diseases
  • Heart disease
  • Hematologic disorders (non-malignant)
    • Anemia and hemoglobinopathy
    • Bleeding disorders
  • Kidney disease and people on dialysis
  • Liver disease
  • Lung disease
  • Neurologic disorders
  • Salicylate therapy in children
• Co-morbidities
• Close contacts
• Table 1: Vaccination of persons with chronic diseases: Non-live vaccines
• Table 2: Vaccination of persons with chronic diseases: Live attenuated vaccines
• Chapter revision methodology
• Acknowledgments
• Selected references

Introduction

Chronic diseases may increase a person’s risk of infection, or increase a person’s risk of more severe disease should infection occur. There is also an increased risk of nosocomial exposure to vaccine-preventable diseases due to the increased likelihood of prolonged hospitalization and frequent outpatient visits associated with chronic disease. Therefore, it is important that people with chronic diseases who are immunocompetent be immunized with both live and non-live (e.g., inactivated or recombinant) vaccines, according to routine immunization schedules. Vaccines may be less immunogenic in this population and additional vaccines, additional doses, or higher dosages of vaccines may be required to provide adequate protection.

Ideally, vaccination is best accomplished early in the disease when the response is likely to be similar to other persons of a similar age with no chronic medical condition. If a disease progresses and immunosuppressive therapy is required, vaccine requirements and recommendations may change.

In general, individuals with chronic disease are at higher risk of invasive pneumococcal disease, influenza and influenza-related complications, and severe respiratory syncytial virus (RSV) disease, and should be immunized using the recommended vaccine and schedule, or for infants, RSV monoclonal antibodies.

COVID-19 vaccine is currently recommended for all individuals 6 months of age and older, including those with chronic conditions. This vaccine has not yet been added to Table 1, or to the text for chronic conditions other than autoimmune disease, pending recommendations for post-pandemic use.

For information about vaccination of people with immunodeficiencies, who are immunosuppressed, who have had a hematopoietic stem cell or solid organ transplant or have HIV infection, refer to Immunization of immunocompromised persons in Part 3.

Chronic diseases

Asplenia or hyposplenia

Asplenic or hyposplenic people have absent or defective splenic function. This condition can occur as a result of congenital absence of the spleen, surgical removal of the spleen, or medical conditions that result in poor or absent splenic function, such as sickle cell disease or thalassemia major, among others. All people, regardless of age, who have absent or defective splenic function, are at increased risk of fulminant bacteremia, which is associated with a high mortality rate. Risk is highest in the first 2 years following splenectomy but remains elevated for life.

Careful attention should be paid to immunization status when elective surgical splenectomy is planned so that all of the necessary vaccines are administered at least 2 weeks before surgery. In the case of an emergency splenectomy, vaccines are best given 2 weeks after the splenectomy for optimal vaccine responses. If a person is discharged earlier and there is a concern that she or he might not return, vaccines should be given before discharge.

Persons with functional or anatomic asplenia or hyposplenia should receive all routine vaccinations, including annual influenza vaccine. In addition, particular attention should be paid to ensuring that all asplenic or hyposplenic individuals receive Haemophilus influenzae type b (Hib) regardless of age or previous immunization history, quadrivalent conjugate meningococcal vaccine, serogroup B meningococcal vaccine and pneumococcal conjugate (Pneu-C-20) vaccine, as these individuals are highly susceptible to infection with encapsulated bacteria. Hepatitis B vaccines are indicated for those who require repeat transfusions, such as individuals with sickle cell anemia or thalassemia.

Refer to Table 1, Table 2 and to Influenza vaccines, Haemophilus influenzae type B vaccines, Meningococcal vaccines, Pneumococcal vaccines, and Hepatitis B vaccines in Part 4 for additional information.

Autoimmune conditions

Autoimmune conditions (referred to in former versions of the CIG as inflammatory diseases) encompass a broad category of related diseases in which an individual’s immune system attacks his or her own cells. The spectrum of autoimmune conditions is diverse. The relative degree of autoimmunity in individuals with autoimmune conditions is variable depending on the underlying condition, the severity and progression of disease, and the use of medications that impact immune function. Common autoimmune conditions include systemic inflammatory diseases such as systemic lupus erythematosus, systemic vasculitides, rheumatoid arthritis and juvenile arthritis; as well as organ-specific inflammatory conditions such as Crohn’s disease and ulcerative colitis, Graves’ disease, Hashimoto’s thyroiditis, multiple sclerosis, myasthenia gravis, Goodpasture’s syndrome, pemphigus vulgaris, psoriasis, idiopathic thrombocytopenic purpura and, autoimmune hemolytic anemia.

Infections are among the most common causes of morbidity, hospitalization and death in individuals with an autoimmune condition. An increased risk of infection and infection-related complications is thought to be due to both an altered immune response associated with the autoimmune condition itself and to the immunosuppressive nature of the treatments required to control the underlying inflammatory condition.

Individuals with autoimmune disease not being treated with immunosuppressive drugs are not considered significantly immunocompromised and can receive routine immunization, including live vaccines. Rheumatic disease modifying agents, such as hydroxychloroquine, sulfasalazine, or auranofin are not generally identified as immunosuppressive, nor are topically-administered non-absorbable formulations of steroids. For children receiving chronic salicylate therapy for autoimmune conditions, inactivated influenza vaccine (IIV) rather than live attenuated influenza vaccine (LAIV) should be used (refer to Salicylate therapy in children).

Individuals with autoimmune conditions should receive, in addition to routine immunization, influenza vaccine annually. Vaccination status should be assessed promptly and routine immunizations updated if needed. Any indicated live vaccines should be given as early as possible, as immunosuppression may be required in the future and live vaccines may then be contraindicated. If immunosuppressive therapy is anticipated in the near future, Pneu-C-20 vaccine should be given. Because of immunodeficiencies associated with autoimmune inflammatory disease, some experts recommend giving these vaccines at diagnosis.

COVID-19 infection has been associated with the development of an intense inflammatory response, as well as autoimmune phenomena, in some people, though whether these occur more often in people with autoimmune conditions is unclear. There has been a theoretical concern that inflammation elicited by mRNA vaccines for COVID-19 could exacerbate existing autoimmune diseases, despite the fact that applications of mRNA technology for COVID-19 vaccines have been optimized to reduce this risk through modifications to the RNA and lipid constructs. Participants with autoimmune conditions who were not immunosuppressed were not excluded from clinical trials for mRNA COVID-19 vaccines, but they constituted a very small proportion of trial participants and represented a very narrow spectrum of autoimmune conditions. Data from observational studies in individuals with autoimmune conditions indicate that the frequency and severity of adverse events in this population is comparable to that of individuals without autoimmune conditions and to what was reported in clinical trials. The onset of new autoimmune disease or disease exacerbation following vaccination with mRNA COVID-19 vaccines has been rare or comparable to the background incidence of these events in the general population. NACI recommends that a complete vaccine series with an mRNA COVID-19 vaccine should be offered to individuals in the authorized age group with an autoimmune condition.

For individuals with dermatologic disorders, care should be taken not to administer vaccine into affected areas, as this procedure may exacerbate the condition. Bacille Calmette-Guérin (BCG) vaccine is contraindicated if there is extensive skin disease at or near the site of injection. Live replicating smallpox vaccine is contraindicated in a non-outbreak situation.

For individuals with chronic inflammatory diseases who are being treated with immunosuppressive therapies including biologic response modifiers, refer to Immunosuppressive therapy in Immunization of immunocompromised persons in Part 3.

Refer to Table 1, Table 2 and to Pneumococcal vaccines and Influenza vaccines in Part 4 for additional information.

Cancer

People with cancer have a higher risk of contracting infectious diseases and a higher risk of developing complications because many cancers and their treatments affect the immune system. Therefore, it is important that children and adults with cancer receive protection from vaccine preventable diseases whenever possible.

Generally, cancer alone, if it is not hematologic, is not sufficient to cause immunosuppression to the extent that an individual cannot receive live vaccines. If chemotherapy is not required, all routine vaccines should be given. Influenza vaccine should be given annually. Other vaccines may be indicated, depending on which organs or systems are affected by the tumour. If chemotherapy is to be given, any immunizations required, as well as annual influenza vaccine, should be completed before beginning chemotherapy whenever possible.

For hematologic cancers or for people on immunosuppressive therapies, refer to Immunosuppressive therapy in Immunization of immunocompromised persons in Part 3.

Cochlear implants

People who have received a cochlear implant are at increased risk for bacterial meningitis and for otitis media. In addition to all age appropriate vaccinations, people with cochlear implants and those who are receiving cochlear implants should receive annual influenza vaccine, pneumococcal conjugate (Pneu-C-20) vaccine, and Hib vaccine if 5 years of age or older regardless of Hib vaccination history.

Refer to Influenza vaccines, Pneumococcal vaccines, and Haemophilus influenzae type B vaccines in Part 4 for additional information.

Endocrine and metabolic diseases

People with diabetes mellitus have defects in phagocytic and neutrophil function. In addition, they often have complications of diabetes such as cardiovascular, neurovascular, renal and other end-organ dysfunction and are at greater risk of complications from infection. Persons with other metabolic disorders, such as thyroid disorders, or morbid obesity (Body Mass Index of 40 or higher) are at high risk of influenza-related complications.

Routine immunization, including annual influenza vaccine, is important for persons with endocrine (e.g., diabetes) and other metabolic disorders. In addition to routine immunization, people with diabetes should receive pneumococcal conjugate (Pneu-C-20) vaccine if they are less than 18 years of age or 50 years of age and older. Adults 18 to 49 years of age may be considered for pneumococcal conjugate vaccine with Pneu-C-15 or Pneu-C-20 at clinical discretion. A single dose of RSV vaccine is also particularly important for adults 75 years of age and older with diabetes and other metabolic disorders including obesity (defined as BMI of 40 kg/m2 and over). There is no evidence that vaccination interferes with glycemic control.

There is an association between yellow fever vaccine-associated viscerotropic disease and a history of thymus disease. Yellow fever vaccine is contraindicated in persons with a history of thymus disease associated with abnormal thymus function (e.g., thymoma, thymectomy or myasthenia gravis). If travelling to a yellow fever endemic or epidemic area, expert advice should be sought concerning the risks of exposure to yellow fever, the ability to adhere to mosquito protection measures, and the risk of vaccine-associated disease.

Refer to Influenza vaccines, Pneumococcal vaccines, and Respiratory syncytial virus (RSV) vaccines in Part 4 and Table 1 for additional information.

Heart disease

In individuals with chronic heart disease, viral and bacterial infections may precipitate cardiac decompensation and lead to hospitalization. There is evidence that giving influenza vaccine to those with coronary artery disease has some protective effect on subsequent cardiac events.

People with cardiac disease should receive routine immunization, including annual influenza vaccine, as they are at high risk of influenza-related complications. Children and adults 50 years of age and older with chronic heart disease should also receive pneumococcal conjugate vaccine (Pneu-C-20). Adults less than 50 years of age with chronic heart disease may be considered for pneumococcal conjugate vaccination with Pneu-C-15 or Pneu-C-20 at clinical discretion.

Young children with certain chronic cardiac conditions are at high risk of RSV associated hospitalization. RSV monoclonal antibodies, are recommended to protect against severe infection in infants with chronic heart disease during their first and second RSV season. RSV vaccine is particularly important for adults 75 years of age and older with chronic cardiac disease.

Live replicating smallpox vaccine is contraindicated in a non-outbreak situation for specific cardiac conditions (Table 2).

Refer to Table 1, Table 2 and to Influenza vaccines, Pneumococcal vaccines, and Respiratory syncytial virus (RSV) vaccines in Part 4 for additional information.

Hematologic disorders (non-malignant)

Non-malignant hematologic disorders include different types of chronic anemia and hemoglobinopathy, as well as bleeding disorders. For further discussion on vaccines recommended for people with anemia due to sickle cell disease or other hemoglobinopathies associated with splenic dysfunction, refer to Asplenia or hyposplenia.

Some hematologic disorders require frequent or chronic administration of blood products. Recent administration of blood products may interfere with the antibody response to live vaccines, and receipt of plasma or immunoglobulin may result in false positive antibody tests. Refer to Blood products, human immunoglobulin and timing of immunization in Part 1 for additional information.

Anemia and hemoglobinopathy

People with anemia may be at increased risk of complications from vaccine preventable diseases. In addition to routine immunization, people with chronic anemia or hemoglobinopathy should receive influenza vaccine annually. If there is a need for repeated blood transfusions, hepatitis B vaccine is required. If there is splenic dysfunction, refer to Asplenia and hyposplenia.

Refer to Table 1, Table 2 and to Influenza vaccines, and Hepatitis B vaccines in Part 4 for additional information.

Bleeding disorders

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People with bleeding disorders such as hemophilia may differ from the healthy population with respect to the potentially increased risk of infection as a result of exposure to blood products and the risk of hematoma formation from parenteral injections. In addition to routine immunization, people with hemophilia and other clotting factor disorders receiving repeated transfusions of blood or blood products should receive hepatitis B vaccines unless already infected or immune. Pre-immunization serologic testing for hepatitis B should be performed if they have already had repeated exposure to blood products. In addition, those receiving repeated infusions of plasma-derived clotting factors should receive hepatitis A vaccine.

Before beginning immunization of any child, vaccine providers should ensure that there are no symptoms or signs compatible with an undiagnosed bleeding disorder. If such indicators are present, a diagnosis should be established before commencing immunization. For example, in any child who has a history of an intramuscular (IM) hematoma following an IM injection, an undiagnosed bleeding disorder, such as hemophilia, should be considered. If a disorder is present, it should be optimally managed prior to immunization to minimize the risk of bleeding. Hemophiliacs may receive clotting factor concentrates to optimize their clotting factor level before they receive a parenteral vaccine or a passive immunizing agent.

Generally, there is no evidence of increased risk of bleeding in those with bleeding disorders following IM versus subcutaneous injections. There is evidence to suggest that IM administration is safe when given with a small gauge needle (23 gauge or smaller) and when firm pressure is applied to the injection site for ≥ 2 minutes. There is also evidence that immunization by the subcutaneous route for vaccine intended for intramuscular administration may be associated with more local reactogenicity and a diminished immune response, compared to the IM route.

Individuals receiving long-term anticoagulation may also be safely immunized through either the IM or subcutaneous route as recommended for a specific vaccine, using the same precautions as for bleeding disorders, without discontinuation of their anticoagulation therapy.

Refer to Table 1, Table 2 and to Influenza vaccines, Hepatitis A vaccines and Hepatitis B vaccines in Part 4 for additional information.

Kidney disease and people on dialysis

Bacterial and viral infections are a major cause of morbidity and mortality in people with renal disease or who are undergoing chronic dialysis (hemodialysis or peritoneal dialysis). People with chronic kidney insufficiency and dialysis may have mild defects in T cell function, while in individuals with nephrotic syndrome, urinary loss of antibody may occur. Also, because people with kidney disease and people on dialysis are in frequent contact with the health care system, they are at greater risk of hospital-acquired infection from vaccine preventable diseases.

People with chronic renal disease or those who are undergoing dialysis should receive all routine vaccinations, including annual influenza vaccine. In addition to routine immunization, hepatitis B and pneumococcal conjugate vaccine (Pneu-C-20) are recommended. Pneu-C-20 is also recommended for individuals with nephrotic syndrome. RSV vaccine is particularly important for adults 75 years of age and older with chronic renal disease. Since individuals with impaired renal function may experience a less than optimal response to immunization, higher vaccine doses and re-immunization may be required. Monitoring vaccine titers may be helpful.

For information about kidney transplant candidates and recipients, refer to Solid organ transplantation in Immunization of immunocompromised persons in Part 3.

Refer to Table 1, Table 2 and to Influenza vaccines, Respiratory syncytial virus (RSV) vaccines, Hepatitis B vaccines, and Pneumococcal vaccines in Part 4 for additional information.

Liver disease

Chronic liver disease can impact innate and adaptive immune mechanisms. Splenic dysfunction may also occur if the liver disease is severe. Hepatic encephalopathy or chronic alcohol consumption may lead to aspiration pneumonia. People with an alcohol use disorder are also at risk for invasive pneumococcal disease. Newly acquired hepatitis A or hepatitis B in persons who already have chronic liver disease from another cause could lead to more severe disease and rapid hepatic decompensation. Those with ascites have an altered immunoglobulin production and distribution.

People with chronic liver disease, including hepatic cirrhosis and biliary atresia, should receive all routine immunizations, including annual influenza vaccine, conjugate pneumococcal vaccine (Pneu-C-20), as well as hepatitis A vaccine and hepatitis B vaccine if not already infected or immune. RSV vaccine is particularly important for adults 75 years of age and older with chronic liver disease. Vaccination should be completed early in the course of liver disease, as the immune response to vaccine is suboptimal in advanced liver disease. Since individuals with chronic liver disease may experience a less than optimal response to immunization, higher vaccine doses and re-immunization may be required.

Refer to Table 1, Table 2 and to Influenza vaccines, Pneumococcal vaccines, Respiratory syncytial virus (RSV) vaccines, Hepatitis A vaccines, and Hepatitis B vaccines in Part 4 for additional information.

Lung disease

Individuals with chronic lung diseases such as bronchopulmonary dysplasia, cystic fibrosis, asthma or chronic obstructive pulmonary diseases (COPD) are at increased risk of complications of influenza, RSV and pneumococcal infection. Those with cystic fibrosis are also at increased risk of complications from varicella infection, which may cause a transient worsening of lung function. Infants and young children with chronic lung disease, requiring ongoing assisted ventilation, oxygen therapy or chronic medical therapy in the six months prior to the start of the RSV season, are at high risk for hospitalization due to severe RSV disease and invasive pneumococcal disease. Many individuals with more severe chronic lung disease have bacterial colonization due to poor mucociliary clearance and bronchiectasis, pneumatoceles, or defects in pulmonary macrophage function.

People with chronic lung disorders should receive influenza vaccine annually in addition to other routine immunization. Live attenuated influenza vaccine (LAIV) is contraindicated for persons with current severe asthma (currently on oral or high dose inhaled glucocorticosteroids or active wheezing, or those with medically attended wheezing in the seven days prior to immunization). In these situations, non-live influenza vaccine should be used. Pneumococcal vaccines are also recommended, including for those with asthma requiring medical care in the preceding 12 months. For people with chronic lung disease, Pneu-C-20 vaccine should be given if age less than 18 years, or 50 years of age and older. For adults 18 to 49 years of age, pneumococcal vaccination with Pneu-C-15 or Pneu-C-20 may be considered at clinical discretion. RSV monoclonal antibodies are recommended to protect against severe RSV infection in infants and young children with chronic lung disease, during their first and second RSV season. RSV vaccine is particularly important for adults 75 years of age and older with pulmonary disorders including chronic obstructive pulmonary disease (COPD), asthma, cystic fibrosis with respiratory involvement and/or growth delay, and conditions affecting ability to clear airway secretions.

Refer to Table 1, Table 2 and to Influenza vaccines, Pneumococcal vaccines, and Respiratory syncytial virus (RSV) vaccines in Part 4 for additional information. Refer to Immunization of immunocompromised persons in Part 3 for additional information about vaccination of individuals receiving systemic steroids or other immunosuppressive therapy for their lung disease, as well for vaccination of lung transplant candidates and recipients.

Neurologic disorders

Persons with neurological disorders are at increased risk of hospitalization with influenza. Some studies suggest that influenza vaccine may also decrease the risk of stroke.

In addition to all routine immunizations, people with neurological or neurodevelopmental conditions should receive annual influenza vaccine (with the exception of anyone who developed Guillain-Barre Syndrome [GBS] within 6 weeks after a previous dose of influenza vaccine unless another cause was found). Some neurological conditions also predispose to more severe pneumococcal and RSV infections. Pneumococcal vaccines are recommended for those with chronic cerebrospinal fluid (CSF) leak or difficulty clearing respiratory secretions. Those less than 18 years of age and adults 50 years of age and older should receive pneumococcal conjugate (Pneu-C-20) vaccine. Adults 18 to 49 years of age with chronic neurologic conditions that impair clearance of oral secretions may be considered for vaccination with Pneu-C-15 or Pneu-C-20 at clinical discretion. Infants and young children with neuromuscular disease that impairs clearing of respiratory secretions are at increased risk for severe RSV disease and should receive RSV monoclonal antibodies during their first and second RSV season. RSV vaccine is particularly important for adults 75 years of age and older with neurologic or neurodevelopmental conditions including neuromuscular, neurovascular, neurodegenerative (e.g., dementia), neurodevelopmental conditions, and seizure disorders.

Neurological conditions are generally not a contraindication to immunization. Some neurologic conditions, such as autism spectrum disorders, are diagnosed in childhood over the time period that routine vaccines are administered, causing concern that immunization may have caused the condition. Others that are present at birth or that begin during infancy, such as cerebral palsy, spina bifida, seizure disorders, neuromuscular diseases and inborn errors of metabolism, may have symptom onset before the receipt of the vaccines routinely recommended in infancy. There is no evidence that immunization causes or aggravates these conditions and these conditions are not reasons to delay or avoid vaccinations. On the contrary, patients with chronic neurological conditions benefit from optimal vaccination.

Certain neurologic disorders (e.g., multiple sclerosis), may be treated with immunosuppressive therapies. In this situation, recommendations for immunocompromised persons should be applied. For information, refer to Immunization of immunocompromised persons in Part 3.

Refer to Table 1, Table 2 and to Influenza vaccines, Respiratory syncytial virus (RSV) vaccines and Pneumococcal vaccines in Part 4 for additional information.

Salicylate therapy in children

Individuals less than 18 years of age receiving low doses of salicylate therapy (e.g., acetylsalicylic acid [aspirin, ASA]) require special consideration regarding live influenza and varicella vaccines because of an association between wild-type influenza or varicella infection, salicylate therapy and Reye’s syndrome. Reye’s syndrome, which causes damage to the brain and liver, is a rare complication that most commonly occurs in children taking ASA at the time of wild-type infection with these viruses.

Children and adolescents receiving chronic salicylate therapy are at high risk of influenza-related complications and should receive inactivated influenza vaccine annually (IIV). LAIV should not be administered to children currently receiving ASA.

Health care providers should weigh the theoretical risks associated with varicella vaccine against the known risks associated with wild-type varicella infection. Because adverse events have not been reported with the use of salicylates after varicella immunization, people with conditions requiring chronic salicylate therapy should be considered for immunization, with close subsequent monitoring.

Refer to Influenza vaccines and Varicella (chickenpox) vaccines in Part 4 for additional information.

Co-morbidities

Guidance on immunization for those with more than one chronic condition is an emerging area of inquiry; evidence to support guidance on immunization of people with co-morbidities is lacking. There is some evidence that co-morbidities may have additive risk for complications from vaccine preventable diseases, such as influenza and RSV. As a general principle, when considering immunization of people with co-morbidities, all conditions and medications should be considered in relation to the indications, precautions and contraindications for each vaccine.

Close contacts

Annual influenza vaccine and up-to-date routine immunizations are recommended for household members and other close contacts of people with chronic diseases, as well as for their health care workers.

There are no contraindications to family members receiving routine live vaccines.

Refer to Immunization of workers and Immunization of immunocompromised persons in Part 3 for additional information.

Table 1: Vaccination of persons with chronic diseases: Non-live vaccines

Please note that the information in the text and tables is complementary and both should be used.

Refer to vaccine-specific chapters in Part 4 for additional information, especially concerning vaccine doses, schedules and boosters.

Vaccine Asplenia/ hyposplenia Endocrine/ metabolic diseases Heart disease Hematologic disorders (non-malignant)Table 1 footnote 1 Autoimmune conditions (including chronic salicylate therapy) Kidney disease/ dialysis Liver disease Lung diseaseTable 1 footnote 2 Neurologic disordersTable 1 footnote 3, chronic cerebrospinal fluid (CSF) leak and Cochlear Implants Cholera and travellers’ diarrhea Use if indicated May be considered for diabetes mellitusTable 1 footnote 4 Otherwise, use if indicated May be considered if congestive heart failureTable 1 footnote 4 Use if indicated May be considered for inflammatory bowel diseaseTable 1 footnote 4 Otherwise, use if indicated May be considered for chronic renal failureTable 1 footnote 4 Use if indicated Use if indicated Use if indicated DiphtheriaTable 1 footnote 5 Routine useTable 1 footnote 6 Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Haemophilus Influenzae type b (Hib)Table 1 footnote 5,Table 1 footnote 7 Recommended for all agesTable 1 footnote 8 Routine use Routine use Routine use Routine use Routine use Routine use Routine use For cochlear implant recipients and those for whom implant is planned, recommended for all agesTable 1 footnote 8 Otherwise, routine use Hepatitis ATable 1 footnote 7 Use if indicated Use if indicated Use if indicated Recommended if receiving repeated replacement of plasma-derived clotting factors Use if indicated Use if indicated Recommended Use if indicated Use if indicated Hepatitis BTable 1 footnote 5,Table 1 footnote 7 Routine useTable 1 footnote 9 Routine use Routine use Recommended for hemophiliacs and others receiving repeated infusions of blood or blood products Routine use RecommendedTable 1 footnote 10 RecommendedTable 1 footnote 10,Table 1 footnote 11 Routine use Routine use Herpes ZosterTable 1 footnote 12 (RZV) Routine use Routine use Routine use Routine use Routine useTable 1 footnote 12 If immunocompromised, may be considered on a case-by-case basis Routine use Routine use Routine use Routine use HPV Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use InfluenzaTable 1 footnote 13 Recommended annually Recommended annuallyTable 1 footnote 14 Recommended annually Recommended annually for people with anemia or hemoglobinopathy Recommended annually if immunosuppressed or if aged 6 months to 18 years and receiving chronic salicylate therapy Recommended annually Routine use Recommended annuallyTable 1 footnote 15 Recommended annuallyTable 1 footnote 3Table 1 footnote 16 Japanese encephalitis Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Meningococcal, quadrivalent conjugate Recommended for all over 2 months of ageTable 1 footnote 17 Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Meningococcal, serogroup B Recommended for all over 2 months of ageTable 1 footnote 18 Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated PertussisTable 1 footnote 5 Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Pneumococcal conjugate 20-valent Recommended for all ages Recommended for children age less than 18 years and adults 50 years and older with diabetes mellitus, otherwise routine use. For adults 18 to 49 years of age, use Pneu-C-15 or Pneu-C-20 at clinical discretion. Recommended for children age less than 18 years and adults 50 years and older.Table 1 footnote 19 For adults 18 to 49 years of age, use Pneu-C-15 or Pneu-C-20 at clinical discretion. Recommended for all ages Recommended for all ages if immunosuppressed; otherwise routine use Recommended for nephrotic syndrome, end-stage renal disease, rapid progression towards dialysis or on dialysis Recommended for chronic liver disease, including biliary atresia and hepatic cirrhosis Recommended for children age less than 18 years and adults 50 years and older. For adults 18 to 49 years of age, use Pneu-C-15 or Pneu-C-20 at clinical discretion. RecommendedTable 1 footnote 20 for individuals with CSF leak and cochlear implant candidates and recipients of all ages. Recommended for children and adults 50 years and older with other neurologic conditions. For adults 18 to 49 years of age with neurologic disorders that may impair clearance of oral secretions, use Pneu-C-15 or Pneu-C-20 at clinical discretion. Polio (inactivatedTable 1 footnote 5) Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Rabies Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated RSVTable 1 footnote 21 Routine use in older adultsTable 1 footnote 14 Routine use in older adults Routine use in older adults Routine use in older adults Routine use in older adultsTable 1 footnote 15 Routine use in older adultsTable 1 footnote 16 TetanusTable 1 footnote 5 Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine use Routine useTable 1 footnote 3 Typhoid (inactivated) Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated

Abbreviations:

IIV: inactivated influenza vaccine IIV3: trivalent inactivated influenza vaccine IIV4: quadrivalent inactivated influenza vaccine LAIV: live attenuated influenza vaccine RIV: recombinant influenza vaccine RSV: respiratory syncytial virus RZV: recombinant zoster vaccine

Table 2: Vaccination of persons with chronic diseases: Live attenuated vaccines

Please note that the information in the text and tables is complementary and both should be used.

Refer to vaccine-specific chapters for additional information, especially concerning vaccine doses, schedules and boosters.

Vaccine Asplenia/ hyposplenia Endocrine/ metabolic diseases Heart disease Hematologic disorders (non-malignant)Table 2 footnote 1 Autoimmune conditions (including chronic salicylate therapy) Kidney Renal disease/ dialysis Liver disease Lung diseaseTable 2 footnote 2 Neurologic disordersTable 2 footnote 3 BCG Use if indicated Use if indicated Use if indicated Use if indicated

Use if indicated if no immune suppression.

Contraindicated if extensive skin disease at or near the site of injection

Use if indicated Use if indicated Use if indicated Use if indicated Influenza (LAIV)Table 2 footnote 4

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Influenza vaccine recommended annually

LAIV may be used for children age 2-17 years:

LAIV should not be used for children < 2 years of age or for adults (use IIV, see Table 1)

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Influenza vaccine recommended annually

LAIV may be used for children age 2-17 years:

LAIV should not be used for children < 2 years of age or for adults (use IIV, see Table 1)

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Influenza vaccine recommended annually

LAIV may be used for children age 2-17 years:

LAIV should not be used for children < 2 years of age or for adults (use IIV, see Table 1)

Influenza vaccine recommended annually for people with anemia or hemoglobinopathy, otherwise Routine useTable 2 footnote 5

LAIV may be used for children age 2-17 years:

LAIV should not be used for children < 2 years of age or for adults (use IIV, see Table 1)

Routine useTable 2 footnote 5

LAIV may be used for children age 2-17 years if no immune suppression and not on chronic salicylate therapy, in which case IIV4 should be used.

LAIV should not be used for children < 2 years of age or for adults (use IIV, see Table 1).

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Influenza vaccine recommended annually

LAIV may be used for children age 2-17 years:

LAIV should not be used for children < 2 years of age or for adults (use IIV, see Table 1)

Routine useTable 2 footnote 5

LAIV may be used for children age 2-17 years:

LAIV should not be used for children < 2 years of age or for adults (use IIV, see Table 1)

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Influenza vaccine recommended annually

LAIV may be used for children age 2-17 years and adults age 18-59 yearsTable 2 footnote 6

LAIV should not be used for children < 2 years of age (use IIV, see Table 1)

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Influenza vaccine recommended annually

LAIV may be used for children age 2-17 years:

LAIV should not be used for children < 2 years of age or for adults (use IIV, see Table 1)

Measles-mumps-rubella Routine use Routine use Routine use Routine use Routine use if no immune suppression Routine use Routine use Routine use Routine use MMRV Routine use Routine use Routine use Routine use Routine use if no immune suppression Routine use Routine use Routine use Routine use RotavirusTable 2 footnote 7 Routine use Routine use Routine use Routine use Routine use if no immune suppression Routine use Routine use Routine use Routine use SmallpoxTable 2 footnote 8 (live replicating) Use if indicated Use if indicated Contraindicated in non-outbreak situation Use if indicated Contraindicated in non-outbreak situation for people with immune suppression, dermatologic conditions or inflammatory eye diseaseTable 2 footnote 8 Use if indicated Use if indicated Use if indicated Use if indicated Typhoid (live) Use if indicated Use if indicated Use if indicated Use if indicated Use if indicated if no immune suppression, no acute gastrointestinal condition and no active chronic inflammatory bowel diseaseTable 2 footnote 9 Use if indicated Use if indicated Use if indicated Use if indicated Varicella (univalent) Routine use Routine use Routine use Routine use Routine use if no immune suppression If age < 18 yr and receiving chronic salicylate therapy, consider for immunization, with close monitoring Routine use Routine use Routine useTable 2 footnote 10 Routine use Yellow feverTable 2 footnote 11 Use if indicated Use if indicatedTable 2 footnote 11 Use if indicated Use if indicated Use if indicated if no immune suppression Use if indicated Use if indicated Use if indicated Use if indicated

Abbreviations:

BCG: Bacille Calmette-Guérin vaccine IIV: inactivated influenza vaccine LAIV: live attenuated influenza vaccine MMRV: Measles, Mumps, Rubella, Varicella RIV: recombinant influenza vaccine

Refer to text and vaccine-specific chapters in Part 4 and to Immunization of immunocompromised persons for additional information.

Chapter revision methodology

Recent updates were made to reflect new NACI guidance on the use of RSV vaccines and RSV monoclonal antibodies for the prevention of severe RSV disease in people with certain chronic diseases. There have also been updates related to changes to influenza and pneumococcal vaccines and their use in certain populations of persons with chronic diseases.

For the last complete chapter revision published May 2022, the Part 3 Working Group conducted a literature review on recommendations for yellow fever vaccination related to thymus function. The section on Endocrine and metabolic diseases has been updated to clarify that yellow fever vaccine is contraindicated in persons with a history of thymus disease associated with abnormal thymus function (e.g., thymoma, thymectomy, myesthenia gravis). Previously, it was stated that YF vaccine was “not generally recommended” in this population.

The duration of injection site compression following immunization of individuals with bleeding disorders and individuals receiving long-term anticoagulation was brought forward as guidance requiring further assessment. The previous recommendation was to apply pressure at the injection site for 5-10 minutes. A literature review was conducted for evidence to inform recommendations on the duration of pressure application following immunization in the identified groups. An independent and systematic search of Ovid MEDLINE, Embase, Scopus, and PubMed for studies or reports published between 1946 and 2020 using keywords which include “immunization”, “vaccin*”, “anticoagulant”, “bleeding disorder or blood-clotting disorder”, “pressure”, and “intramuscular injection” yielded 99 publications addressing the application of pressure to the injection site following immunization of individuals with bleeding disorders or individuals receiving anticoagulants. The search was limited to publications in English and human studies. Although primary evidence related to the topic was scarce, the majority of the publications provided recommendations that were based on expert opinion or findings from a primary research study by Evans et al. The study reported that following the use of a 23-gauge needle and 1 to 2 minutes of pressure applied to the injection site in children with hemophilia receiving the hepatitis B vaccine, only six of 153 IM injections (4%) resulted in bruising, and none of the children required treatment with clotting factor concentrates. Findings from the literature review and the proposed recommendation were circulated among WG members who agreed on the recommendation to apply firm pressure to the injection site for ≥ 2 minutes in the specified groups.

Publications pertaining to vaccination of persons with selected specific conditions were searched using the search strategy (vaccine OR vaccination OR immunization), AND (splenectomy OR asplenia OR hyposplenia OR “chronic inflammatory disease” OR rheumatic OR IBD OR, “renal disease” OR “kidney disease” OR nephrotic OR ESRD OR diabetes) This additional literature review conducted to identify changes in evidence or vaccine recommendations for persons with the aforementioned conditions did not lead to any new findings that would warrant further revisions to the corresponding sections.

The section on ‘Asplenia or hyposplenia’ was revised to state that there are other conditions of concern in addition to sickle cell disease or thalassemia major that are associated with splenic dysfunction.

The two tables in the chapter outlining recommendations for use of non-live and live attenuated vaccines for persons with chronic diseases were updated. These tables’ contents reflect some of the information in the main text of the chapter and include extra details, and are intended to be used as a complementary resource with the text. The contents of the text and tables were extracted from the corresponding vaccine-specific chapters in Part 4 of the CIG and from NACI statements.

Acknowledgements

The Public Health Agency of Canada (PHAC) would like to acknowledge the Part 3 Working Group, consisting of D Moore (Working Group Chair); NACI Members R Harrison, K Hildebrand, and Susan Smith; and NACI Liaison Representative A Pham-Huy and external expert Deepali Kumar, for their contributions to the last complete revision of this chapter. PHAC participants on the Part 3 Working Group include C Jensen, N Mohamed, O Baclic, E Abrams and L Coward.

Recent updates were prepared by F Crane and reviewed by E Abrams, W Siu and C Jensen.

NACI gratefully acknowledges the contributions of N Haddad.

Selected references

General references

• American Academy of Pediatrics. Immunization in special clinical circumstances. In: Kimberlin DW, Brady MT, Jackson MA, Long SS (eds) Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics; 2018. pp 67-111.
• Committee to Advise on Tropical Medicine and Travel. The immunocompromised traveller. Can Commun Dis Rep 2007;33(ACS-4):1-24. Accessed June 28, 2021
• Crawford NW, Bines JE, Royle J et al. Optimizing immunization in pediatric special risk groups. Expert Rev Vaccines 2011;10:175-86.
• Kroger A, Bahta L, Hunter PKroger AT, Duchin J, Vázquez M. General best practice guidelines for immunization. Best practices guidance of the Advisory Committee on Immunization Practices (ACIP). Updated May 4, 2021.https://www.cdc.gov/vaccines/hcp/acip-recs/general-recs/index.html Accessed May 21, 2021
• Lail J, Fields E, Schoettker PJ. Quality improvement strategies for population management of children with medical complexity. Pediatrics. 2017;140(3):e20170484
• Lobermann et al. Immunization in the adult immunocompromised host. Autoimmunity Reviews 2012;11:212-218
• Lopez et al. Vaccination recommendations for the adult immunosuppressed patient: A systematic review and comprehensive field synopsis. J. Autoimmunity 2017: 80:10-27.

Asplenia, hyposplenia

• Di Sabatino A, Carsetti R, Corazza GR. Post-splenectomy and hyposplenic states. Lancet 2011; 378: 86-97.
• Kuchar E, Miskiewicz K, Karlikowska M. A review of guidance on immunization in persons with defective or deficient splenic function. Br J Haemat 2015;171:683-694.
• Simons MD, Scott-Sheldon LAJ, Risech-Neyman Y et al. Celiac disease and increased risk of pneumococcal infection: A systematic review and meta-analysis. Am J Med 2018;131:83-89.
• Theilacker C, Ludewig K, Serr A. Overwhelming postsplenectomy infection: A prospective multicenter cohort study. Clin Infect Dis. 2016 62(7):871-878.
• Tjernberg AR, Bonnedahl J, Inghammar M. Coeliac disease and invasive pneumococcal disease: a population-based cohort study. Epidemiol. Infect. (2017), 145, 1203-1209.

Autoimmune conditions

• Bombardier C, Hazlewood GS, Akhavan P, et al. Canadian Rheumatology Association recommendations for the pharmacological management of rheumatoid arthritis with traditional and biologic disease-modifying antirheumatic drugs: Part II. Safety. J Rheumatol 2012 Aug;39(8):1583-602.
• Chaudrey K, Salvaggio M, Ahmed A, Mahmood S, Ali T. Updates in vaccination: recommendations for adult inflammatory bowel disease patients. World J Gastroenterol 2015; 21(11): 3184-3196.
• Furer V, Rondaan C, Heijstek MW et al. 2019 update of EULAR recommendations for vaccination in adult patients with autoimmune inflammatory rheumatic diseases Ann Rheum Dis. 2020 Jan;79(1):39-52.
• Groot N, Heijstek MW, Wulffraat NM. Vaccinations in paediatric rheumatology: an update on current developments. Curr Rheumatol Rep. 2015 Jul;17(7):46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4449376/pdf/11926_2015_Article_519.pdf Accessed May 21 2021.
• Heijstek MW, Ott de Bruin LM, Bijl M, EULAR recommendations for vaccination in paediatric patients with rheumatic diseases. Ann Rheum Dis 2011;70:1704-1712.
• Kantso B, Simonsen J,Hoffmann S.Inflammatory bowel disease patients are at increased risk of invasive pneumococcal disease: A nationwide Danish cohort study 1977-2013. Am J Gastroenterol 2015; 110:1582-1587
• Luijten RKMAC, Cuppen BVJ, Bijlsma JWJ, Derksen RHWM. Serious infections in systemic lupus erythematosus with a focus on pneumococcal infections. Lupus (2014) 23, 1512-1516.
• McCarthy EM, Azeez MA, Fitzpatrick FM et al. Knowledge, Attitudes and clinical practice of rheumatologists in vaccination of the at risk rheumatology patient population. J Clin Rheum 2012;18:237-41.
• Morin MP, Quach C, Fortin E et al. Vaccination coverage in children with juvenile idiopathic arthritis followed at a paediatric tertiary care centre. Rheumatology 2012;276-90.

Bleeding disorders

• Bauman ME, Hawkes M, Bruce A, Siddons S, Massicotte P. Immunizations in children requiring warfarin therapy. J Pediatr Hematol Oncol 2016;38:e329-e332.
• Casajuana J, Iglesias B, Fabregas M et al. Safety of intramuscular influenza vaccine in patients receiving oral anticoagulation therapy: a single blinded multi-centre randomized controlled clinical trial. BMC Blood Disord 2008;8:1-7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2423363/
• Evans D I K, Shaw A. Safety of intramuscular injection of hepatitis B vaccine in haemophiliacs. BMJ 1990;300:1694-5
• Kroger A, Bahta L, Hunter P. General Best Practice Guidelines for Immunization. Best Practices Guidance of the Advisory Committee on Immunization Practices (ACIP). Vaccinating Persons with Increased Bleeding Risk p159-160. [www.cdc.gov/vaccines/hcp/acip-recs/general-recs/downloads/general-recs.pdf]. Accessed on May 21, 2021
• Raj G, Kumar R, McKinney WP. Safety of intramuscular influenza immunization among patients receiving long-term warfarin anticoagulation therapy. Arch Intern Med.1995;155:1529-1531
• van Aalsburg R, van Genderen PJ. Vaccination in patients on anticoagulants. Travel Med Infect Dis 2011;9: 310-11.

Kidney disease

• Esposito S, Mastrolia MV, Prada E, Pietrasanta C, Principi N. Vaccine administration in children with chronic kidney disease. Vaccine. 2014 Nov 20;32(49):6601-6.
• Mathew R, Mason D, Kennedy JS. Vaccination issues in patients with chronic kidney disease.Expert Rev Vaccines. 2014 Feb;13(2):285-98.
• Soni R, Horowitz B, Unruh M. Immunization in end-stage renal disease: opportunity to improve outcomes. Semin Dial. 2013 Jul-Aug;26(4):416-26.

Other conditions

• Centers for Disease Control and Prevention. Use of hepatitis B vaccination for adults with diabetes mellitus: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR, 2011;60(50):1709-1711.
• Centers for Disease Control and Prevention. Clinical guidance for smallpox vaccine use in a postevent vaccination program. MMWR 2015;64(RR2):1-26
• Langer-Gould A, Qian L, Tartof SY. Vaccines and the risk of multiple sclerosis and other central nervous system demyelinating diseases JAMA Neurol. 2014;71(12):1506-1513
• Natarajan P, Cannon CP. Myocardial infarction vaccine? Evidence supporting the influenza vaccine for secondary prevention. Eur Heart J 2011;32:1701-03.
• Schanzer DL, Langley JM, Tam TW. Co-morbidities associated with influenza-attributed mortality, 1994-2000, Canada. Vaccine. 2008 Aug 26;26(36):4697-703.

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