Update vaccine in primary immune deficiency 2018

Anchalee Senavonge. MD.
Division of Allergy & Immunology
Department of Pediatrics, Faculty of Medicine
Chulalongkorn University

Francisco A. Bonilla, MD, PhD
The Journal of Allergy and Clinical Immunology
February 2018

20152016, update 2018 8th edition

Questions
1. Which condition is considered as low level of immunodeficiency?
a) MTX 4 mg/kg/week
b) Intranasal budesonide 4 puffs/day
c) CVID
d) HIV adolescent with CD4 150 cells/mm3
2. Which DGS children could safely receive MMR vaccine?
a) CD4+Tcell 500 cells/mm3, CD8+Tcell 300 cells/mm3, normal PHA
b) CD3+Tcell 200 cells/mm3, CD8+Tcell 200 cells/mm3, normal PHA
c) ALC 500 cells/mm3, CD8+Tcell 300 cells/mm3, abnormal PHA
d) CD4+Tcell 300 cells/mm3, CD8+Tcell 500 cells/mm3, abnormal PHA
3. What vaccine is absolutely contraindicated in household members of PID patient?
a) Rotavirus
b) OPV
c) Varicella
d) MMR

Questions
4. A 10-months old boy just completed oral prednisolone 2.5 mg/kg/day (total 5 days
course). What is the appropriate time to administer MMR?
a) 4 weeks later
b) 2 weeks later
c) after the age of 1 year
d) today
5. CGD patients should absolutely avoid which vaccine
a) BCG
b) Small pox
c) Yellow fever
d) Rotavirus
6. Which vaccine has highest seroconversion rate?
a) PPSV
b) Meningococal vaccine
c) Diptheria toxoid
d) HBV

High levels Low levels
1.) CID (Severe CID or SCID)
1.) Mild Ab def.
(SAD, IgA def., IgG subclass def.)
2.) Severe Ab def. (CVID, Agammaglobulinemia) 2.) Complement def.
3.) Innate immunity (Phagocyte defect) 3.) Autoinflammatory disease
4.) Cancer chemotherapy 4.) Immune dysregulation
5.) Solid-organ transplantation within 2 mo.
6.) HIV with CD4 < 200 cells/mm3 for adults and adolescents or
<15% for infants and children
7.) Patients receiving daily corticosteroid with a dose of 20 mg (or > 2
mg/kg Wt <10 kg) of prednisone or equivalent for at least 14 d
8) MTX >0.4 mg/kg/week
AZA >3 mg/kg/day
6-MP >1.5 mg/kg/day
8.) Biologic immune modulators (such as TNF antagonists)
Bonilla FA J Allergy Clin Immunol Pract 2016;4:1066-75.

Bonilla FA. J Allergy Clin Immunol 2018;141:474-81.

DIAGNOSTIC USE OF VACCINES FOR PID

Tetanus and diphtheria toxoid
• These are potent immunogens with high seroconversion rates
– initial low determination in a fully immunized individual should have good predictive
value for diagnosis
• Normal individuals may have up to 20-30 fold increases in antibody
– Lower end of normal fold response range is not well-defined, depends on pre-
booster level
Bonilla FA. Journal of Allergy and Clinical Immunology (2018), doi: 10.1016/j.jaci.2017.12.980.

Adverse reactions to vaccines practice parameter 2012 update JACI 2012, Vol 130, No 1

PCV and PPSV
• Over 100 distinct serotypes
have been described
• Level considered protective
 PCV 0.35 mcg/mL
 PPSV 1.3 mcg/mL
• 2 or 4 fold rise is considered normal depending on pre-immunization level
(4 fold rise is less likely if pre-immunization level is high)
• Age factor
– <2 year-old: often good, but very unpredictable
– After age 5 is more consistent

PCV and PPSV
• Majority of vaccine response literature focuses on IgG
• However, IgA and IgM could also have predictive value for PID diagnosis
– readily be used in patients receiving IgG replacement
• These responses peak somewhat earlier than IgG
– 2 weeks for IgA
– 3 weeks for IgM

Orange et al. Use and interpretation of diagnostic vaccination in PID. JACI 2012;130:S1-24.
Bonilla FA. Practice parameter JACI 2015; 136:1186-205.doi: 10.1016/j.jaci.2017.12.980.

≥1.3 µg/mL or 4-fold
(probability of 4-fold response
approached zero if preimmunization
titer 4.4-10.3 µg/mL)

Siriraj: 4, 6B, 7F, 9N, 9V, 14, 18C, 23F
Perez E, Bonilla FA, Orange JS and Ballow M. Front . Immunol. 2017; 8:586.
2,8,9N,10A,11A,12F,15B,17F,20,22F,33F
only in PPSV 23

Neoantigens: phiX174, KLH
Bacteriophage is a virus that attacks bacteria. The
phiX174 bacteriophage attacks the common
human bacteria Escherichia coli, infecting the cell
and forcing it to make new viruses.
Keyhole limpet hemocyanin (KLH) s a large, multisubunit,
oxygen-carrying, metalloprotein that is found in the
hemolymph of the giant keyhole limpet (หอยหมวกเจ๊ก),
“Megathura crenulata”
(lives off the coast of California)

Neoantigen: Salmonella typhi Vi
• 96.3% of 2-5 year-old children have 4-fold increase of Ab with
– prevaccination mean titer 0.16 and postvaccination mean titer 3.23 µg/mL
• > 3-fold considered normal because low prevaccination titer in general population

Typhoid vaccine
• A 10-fold rise in IgG antibody to S.typhi served to distinguish CVID from controls
(90.9% sensitivity and 62.5% specificity)
• One study: better than Pneumococcal
– due to a high level of pre-immunization pneumococcal IgG
• Boon MN et al 2017 compared PPSV, S. typhi response and isohemagglutinin titers
in a cohort of 100 healthy (10-65 year-old)

Schaballie et al. Front. Immunol. May 2017, Volume 8, Article 546
Only 2/100 <5th percentile both
pneumococcus and S typhi
-suggest combination of responses:
better predictive value than either
alone
isohemagglutinin titers might not
serve as a useful surrogate for PPSV
for the diagnosis of PID

Neoantigen: Meningococcal vaccine
Summary 62: In contrast to rabies, it is unlikely that MCV will be a suitable neoantigen for patients receiving IVIg
↑ application of MCV in general US population lead to ↑meningococcal Ab in plasma pools

Neoantigen: Rabies

Patients receiving immunoglobulin therapy
Measure Ab response for
a) determine if a transient antibody deficiency has improved
b) a patient may be receiving the therapy unnecessarily
Several options exist
1. The bacteriophage X174 has been used for few decade
– main drawback is a lack of convenience, available only via a research protocol at a single
institution (University of Washington, Seattle, WA)
2. Rabies virus vaccine
– Advantage: both vaccine and assays for measuring IgG are readily available.
3. Typhoid vaccine -recently been demonstrated to be useful
4. Tick-borne encephalitis virus vaccine

THERAPEUTIC USE OF VACCINES IN PID

JACI 2016/ 2018 Red book 2015 IDSA 2013
Major
Ab
deficient
 IIV because
1. IVIg may not contain Ab to
circulating strains
2. Vaccine may induce some
beneficial cellular
immunity
additional measures (prophylaxis
during outbreaks)
• Annual IIV is the only
vaccine given to pt
receiving IVIg
• Routine inactivated
vaccines (not receiving
IVIg)
IIV not routinely but can be
administered (if some residual
Ab production)
X Live bacteria* and virus+
Live bacteria* and virus+ OPV (strong, moderate)
Other live vaccine (weak, low)
*Live bacterial vaccines : BCG and Ty21a Salmonella typhi
+Live virus vaccines: LAIV , MMR, Varicella, HZV, OPV , YF, smallpox, rotavirus
Humoral deficiency
¥Age ≥2 yr-old: PPSV23 ≥8 wk after
PCV13 and 2nd dose at 5 yr later
IIV Inactivated Influenza vaccine

Minor
Ab
deficient
 All All All
SAD should receive PCV¥
X OPV BCG(Live bacteria*), OPV,
yellow fever
OPV –not to IgA deficient
Humoral deficiency
¥Age ≥2 yr-old: PPSV23 ≥8 wk after
PCV13 and 2nd dose at 5 yr later
SAD Specific Ab defciency

Middleton textbook 8th edition

HPV
• SCID
• Wiskott-Aldrich syndrome
• Ataxia telangiectasia
• NF-kappa B essential modulator
(NEMO) deficiency
• X-linked hyper-IgM syndrome
• LAD(CD18 mutation)
• WILD syndrome (disseminated warts,
immunodeficiency, lymphedema, anogenital
dysplasia)
• Epidermodysplasia verruciformis
(mutations of TMC6 or TMC8)
• GATA2 deficiency
• WHIM syndrome (warts,
hypogammaglobulinemia, infections,
myelokathexis, CXCR5 mutation)
• AR hyper-IgE syndrome (DOCK8
mutation)
• Netherton syndrome (SPINK5 mutation)

HPV
• Showed immunogenic in immunosuppressed children
– Solid organ or stem cell transplantation
– On immunomodulators for autoimmune conditions
– WHIM syndrome and HIV patients
• Exhibit improvement in cutaneous warts

ADVERSE EFFECTS OF VACCINES IN PID

BCG
• SCID and defects of the IFN-γ/IL-12 axis
• significant localized disease (e.g., axillary lymphadenopathy) or FH of
BCG complication -potential warning sign of an underlying PID

J.D.Sarmiento et al.Vaccine 34 (2016) 1611–1616

MMR and Varicella vaccine
• Several studies have demonstrated safety and efficacy in milder forms of T cell
defects such as DiGeorge syndrome
• Criteria for live vaccine use in DiGeorge syndrome
a) CD4 T cells ≥ 500/mm
b) CD8 T cells ≥ 300/mm
c) normal/near-normal in vitro T cell response to mitogens and recall antigens
d) good response to non-viable vaccines

Major  Inactivated vaccines are of no value Inactivated vaccines-
Ineffective
•IIV can be administered (if
residual Ab production)
•PCV in AT
Inactivated vaccines should not
be routinely administered in pt
receiving IVIg
•IIV can be administered (if some
residual Ab production)
•PCV in AT
X All live vaccines
Mild  Partial DGS
1. ≥500 cell/mm3CD4
2. ≥300 cell/mm3CD8
3. normal mitogen response
4. good response to non-viable
vaccines
should receive MMR, VAR
Partial DGS
1. ≥500 cell/mm3CD3, and
2. ≥200 cell/mm3CD8, and
3. normal mitogen response
should receive MMR, VAR
X All live vaccines except above
+Live virus vaccines: LAIV , MMR, Varicella, HZV, OPV , YF, smallpox, rotavirus AT; ataxia-telangiectasia
Cell-mediated and humoral deficiency

 All inactivated
recommend PCV, Hib, MCV
All inactivated
including IIV, PCV
All inactivated,
recommend HPV4, PCV, Hib, MCV
In children CD4 ≥15%
Older CD4+ ≥200 cells/mm3
Can receive MMR, VAR
Age <5 years CD4 ≥15%
Age ≥5 years CD4+ ≥200
cells/mm3
Can receive MMR, VAR
Age 1-13 yearsCD4 ≥15%
Age ≥14 years CD4 ≥200 cells/mm3
should receive MMR, VAR 2 doses 0,3 m
Not MMRV
X Live Live Live
HIV

CD4+T cells<200/mm3 or <15% (in
children <6 yr) are contraindicated to
Yellow fever vaccine

MMR and Varicella vaccine
• A late complication of rubella vaccine in immunodeficient hosts reported
• Cutaneous granulomatous inflammation (granuloma annulare, occasionally with
ulceration) occurs in predominantly cellular dysfunction, mainly humoral defects
• U/d activated PI3 kinase delta syndrome, ataxia-telangiectasia, cartilage-hair
hypoplasia, RAG1 or RAG2 mutation, and unspecified CID

 All inactivated
Live virus+ should give for CGD,
congenital neutropenia
All inactivated
(Additional pneumococcal vaccine is not
indicated for CGD beyond standard
recommendations, because CGD not at
increased risk for pneumococcal disease)
Live virus+ probably safe and effective
All inactivated
(≥6 yr with phagocytic defect other than
CGD should receive PCV13)
(≥2 yr with phagocytic defect other than
CGD should receive PPSV23 after PCV13
and 2nd dose 5 yr later)
Live virus+ should give for CGD,
congenital neutropenia
X Live-bacteria vaccines* not to
CGD
Live virus+ not to LAD, cytotoxic
granule release defect eg.
Chediak-Higashi syndrome
Live-bacteria vaccines* and OPV,
smallpox, BCG, MMRV , LAIV)
•MMR and varicella in highly
immunocompromised
•YF depend on immune function
Live-bacteria vaccines* not to phagocytic
defect
Live virus+ not to LAD, cytotoxic granule
release defect eg. Chediak-Higashi
syndroime
Phagocytic defect

 All inactivated vaccines are safe
and effective
Consider encapsulated bacteria
(PCV/PPSV, Hib, MCV)
All inactivated and live-virus vaccines
are safe and probably are effective
1. PPSV23 at 2 years or older
2. MCV4 vaccine are recommended
in addition to standard vaccines
All routine vaccines
1) PCV and PPSV
2) 4-dose series of MCV4 and Hib,
reactivate with MCV4 every 5 years
X none none none
Complement defect

 All inactivated vaccines are safe
and effective
1. IRAK4- and MyD88-deﬁcient:
PCV/PPSV
2. Congenital asplenia: PCV/PPSV,
Hib, MCV4
Should receive all inactivated as
schedule
Should receive all inactivated
Cytokine generation/response defect
should receive PCV13
X Live-bacteria vaccines* not to IFN-
γ/IL-12 pathways defect
Live virus+ not to type 1 IFN-α/β
All live not to NFkB pathway
defect
Live bacteria and virus vaccines not
to interferon production defect
Live-bacteria vaccines* not to IFN-γ/IL-
12 pathways defect
Live virus+ not to IFN (alpha or gamma)
production defect
Innate immunity defect

 All inactivated and live vaccines
except below
All inactivated vaccines and annual IIV or LAIV except
LAIV not if patient: HSCT recipient within 2 months or GVHD or SCID
Pregnant women at high risk of
having a baby with PID should
receive PCV, Hib, MCV
Should receive MMR, varicella
(Varivax, MMRV, and zoster),
rotavirus for infants 2 -7 months,
yellow fever and oral typhoid
vaccines for travel
-
X 1. OPV
2. If close contact develops a
rash after VAR, isolate PID
patient and give zoster Ig
1. OPV
2. avoid contact with persons who
develop skin lesions after receipt
VAR or ZOS until lesions clear
1. OPV
2. avoid contact with persons who
develop skin lesions after receipt
VAR or ZOS until lesions clear
3. Highly immunocompromised
should avoid handling diapers of
infants vaccinated with rotavirus for
4 weeks after vaccination
Household members

Before
CS
Inactivated ≥2 weeks prior
if feasible, or deferred until after
stopping therapy
Live n/a
Inactivated ≥2 weeks prior
live virus ≥4 weeks prior
After
CS
Topical, local injections, or aerosol use- no effect
Systemic ≥2 mg/kg/day or its equivalent, or ≥20 mg/day if Wt>10 kg
for<14 days-delay live virus vaccines 2 weeks
for ≥14 days-delay live-virus vaccines 4 weeks
after discontinuation
On immunosuppressive drugs

Low
Dose
Safe
MTX ≤0.4 mg/kg/week (Thai 15 mg/m2/wk)
AZA ≤3 mg/kg/day
6-MP ≤1.5 mg/kg/day
High
Dose
Inactivated ≥2 weeks before or during therapy and
possibly repeating after terminating therapy
Live vaccines administered ≥4 weeks prior to initiation
n/a
On Immunosuppressive drugs
Common dosage
MTX 0.65-1 mg/kg/wk, 20-30 mg/m2/wk
AZA 1-3 mg/kg/day
6-MP 1.25-2.5 mg/kg/day

“Immunoglobulin preparation given within 2 weeks after virus
vaccination could prevent adequate immunization”
“MMR and varicella vaccines either should be administered ≥2
weeks before receipt of a blood product”
CDC; general recommendations for vaccination and immunoprophylaxis

Transplantation and immunosuppression
• Within 2 months after SOT
• Within 2 months after HSCT and frequently for a much longer
period
– depending on type of transplant (longer for allogeneic than for
autologous)
– type of donor and stem cell source
– post-transplant complications such as GVHD and their treatments
Immunization in Immunocompromised Children. Red book 2015

HSCT recipients
• should receive inactivated vaccines (including IIV) interval to
conditioning period is ≥2 weeks
• Should receive live-virus vaccines if the patient is not already
immunosuppressed and interval to the start of the conditioning
period is ≥4 weeks
• Household members should be counseled regarding risks of
infection
Immunization in Immunocompromised Children. Red book 2015

• 1 dose of IIV 6 mo after HSCT and 4 mo after HSCT if a
community outbreak
• 3 doses of PCV13 3–6 mo, 1 dose of PPSV 12 mo after HSCT
• 3 doses of Hib, MCV4, HBV (if anti-HBs <10U/ml) 6-12 mo
after HSCT
• 3 doses of DTaP 6 mo after HSCT
Rubin LG, et al. 2013 IDSA Clinical practice guideline for vaccination of the immunocompromised host
HSCT recipients

SOT recipients
• Withheld during first 2-month because of inadequate response
– However, IIV can be administered ≥1 month after transplant during a community
influenza outbreak
• inactivated vaccine should be administered 2 to 6 months after SOT consider PCV-
PPSV, HBV for chronic HBV recipients
• MMR VAR should generally not be administered because of insufficient safety and
effectiveness data
– except for VAR in children without evidence of immunity who are renal or liver
transplant recipients, are receiving minimal or no immunosuppression, and have
no recent graft rejection
Rubin LG, et al. 2013 IDSA Clinical practice guideline for vaccination of the immunocompromised host

Update vaccine in primary immune deficiency 2018

Update vaccine in primary immune deficiency 2018

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Update vaccine in primary immune deficiency 2018