4. Immunisation of special groups

Women and other potential birthing parents who are planning pregnancy should know whether they are immune to measles, rubella and varicella (see sections 12.8.3, 21.5.3 and 24.5.4).

Measles, mumps and rubella vaccine

Two doses of MMR are recommended and funded for eligible women who do not have documented evidence of immunity to measles, mumps and rubella (see section 12.8.3 for evidence). Pregnancy should be avoided for four weeks after vaccination (see section 21.6.1).

Varicella vaccine

Two doses of VV are recommended but not funded for adults who are susceptible to varicella (see section 24.5). VV should not be given to those who are pregnant, and pregnancy should be avoided for four weeks after vaccination (see section 24.5.4).

There are no safety concerns around giving non-live vaccines in pregnancy, including subunit vaccines and COVID-19 mRNA vaccine.[1,2] Live vaccines should not be administered to a pregnant woman because of the theoretical possibility of fetal harm. Seek specialist advice in circumstances where the risk of exposure to an infection outweighs any potential risk of the fetus from immunisation.

Although MMR should not be given when pregnant, in follow-up studies of women who inadvertently received MMR during pregnancy, there was no evidence that MMR is teratogenic or harmful to the mother, her fetus or her newborn.[3] Inadvertent immunisation with a rubella-containing vaccine in early pregnancy is no longer considered an indication for termination of pregnancy.[3] See the relevant disease chapters, particularly measles (section ‎12.8.2), rubella (section ‎21.8.2) and varicella (section ‎24.8.6), for recommendations on managing exposure to diseases during pregnancy.

COVID-19 vaccine

Women and other people who are pregnant are encouraged to be routinely vaccinated with mRNA-CV at any stage of pregnancy (see sections 5.2.2, and 5.5.5) and to discuss questions or concerns with their health professional. People who are trying to become pregnant do not need to avoid pregnancy after receiving mRNA-CV.

Influenza vaccine

The quadrivalent influenza vaccine is recommended and funded for pregnant women and should be offered at any stage of pregnancy, as soon as the annual influenza vaccine becomes available (see section ‎11.5). Both the pregnant woman and the fetus are at increased risk of influenza complications;[4, 5] influenza vaccination is therefore recommended during pregnancy to reduce this risk.[6] When pregnancy spans two influenza seasons, two vaccinations (one from each season) are recommended to protect against all the predicted strains.

Maternal influenza vaccination also offers protection to the neonate through maternal antibody transfer.[3, 4] Influenza vaccines are not registered for infants aged under 6 months; therefore vaccination during pregnancy helps protect newborns and infants who are too young to be vaccinated.[4, 5] Maternal influenza vaccination is significantly associated with reduced risk of influenza virus infection[5] and hospitalisation for an influenza-like illness in infants up to 6 months of age.[5, 7]

There is no evidence that influenza vaccine prepared from a virus subunit causes harm to the fetus or neonate.[8, 9, 10]

Pertussis vaccine (Tdap)

Pertussis is a severe infection in infants too young to have been fully immunised. The tetanus, diphtheria and pertussis vaccine (Tdap) is recommended and funded to be given from 16 weeks’ gestation in every pregnancy, preferably in the second trimester, to protect both the mother and her infant from pertussis (see section ‎16.5).[11, 12, 13] Postpartum maternal Tdap vaccination can reduce the risk of a mother infecting her baby but does not have the added benefit of providing passive antibodies.

See section 16.5 for information about maternal pertussis vaccine effectiveness and safety.

Household members and other close contacts

Confirmation of pregnancy should act as a trigger to review the pertussis vaccination status of all the pregnant woman’s close contacts. This includes making sure siblings have received the usual Schedule vaccines and offering Tdap to adults, although this is only currently funded for certain special groups.

Infants born to mothers who are known to be HBsAg-positive require hepatitis B vaccine (HepB) plus hepatitis B immunoglobulin (HBIG) to be given at or as soon as possible after birth; to continue vaccination as per the Schedule at 6 weeks, 3 and 5 months; and to undergo serological testing for hepatitis B antigen and antibodies (HBsAg and anti-HBs) at 9 months of age.

Infants of mothers whose HBsAg status is unknown at the time of delivery require HepB at birth while waiting for the results of urgent HBsAg testing on the mother (see section 9.5.2). If mother is found to be HBsAg positive, HBIG will also be required.

Vaccination as per the Schedule (ie, at the usual chronological age, with the usual vaccine dosage and interval) is recommended for preterm and/or low birthweight infants. There is a potential risk of apnoea in preterm infants with respiratory immaturity. Apnoea monitoring should be considered after the first vaccination event.[12] For infants who experience apnoea after their first vaccination event, apnoea monitoring should be considered for 48–72 hours after subsequent vaccination events, but avoiding or delaying vaccination is not recommended.[14]

Hepatitis B vaccine

All preterm and low birthweight infants born to HBsAg-positive mothers should be managed the same way as term infants and receive HepB and HBIG to be given at or as soon as possible after birth (see section 9.5.2). These infants should continue vaccination as per the usual Schedule, starting at age 6 weeks.

Rotavirus vaccine

If an infant is in hospital at 6 weeks old, the Schedule vaccines, including rotavirus vaccine, should be given in hospital. Standard infection control precautions should be maintained. Administration of rotavirus vaccine to medically stable, hospitalised infants at 6 weeks of age has been shown to be well-tolerated. No increase in nosocomial rotavirus transmission has been observed within neonatal intensive care units.[15, 16,17] Rotavirus vaccine can be given to preterm infants who are receiving corticosteroids. For immunocompromised infants or mothers, also see section 4.3.3 and section 4.2.5.

Pneumococcal vaccines

Infants born before 28 weeks’ gestation are eligible for pneumococcal vaccination as part of an extended immunisation programme for high-risk groups (see section 17.5.2), ie, a three-dose primary series of PCV13 (Prevenar 13) given at ages 6 weeks, 3 months, 5 months with a booster at age 12 months; some may benefit from 23PPV beyond age 2 years, if they still have lung disease.

Infants born at 28 weeks’ gestation or later, who do not have a condition eligible for extended pneumococcal immunisation, should receive PCV13 as per the Schedule at ages 6 weeks, 5 months and 12 months.

Influenza vaccine

Preterm and/or low birth weight infants with an eligible condition are recommended to receive an annual funded influenza vaccination from 6 months of age (see Table 11.2).

Influenza vaccination is recommended (but not funded) for close contacts of preterm infants, including children from age 6 months (for funding eligibility see Table 11.2).

Pertussis vaccine (Tdap)

It is essential that siblings of preterm infants are up to date with Schedule vaccinations, to reduce the risk of pertussis transmission to the infant (see section 16.5). Adolescents should have received Tdap in year 7 or at age 11 years as part of the Schedule. Pertussis-containing vaccine is funded for primary and catch-up vaccination of all children aged under 18 years (see Appendix 2 for catch-up schedules).

A single dose of Tdap is recommended and funded for parents or primary caregivers of infants admitted to a neonatal intensive care unit or special care baby unit for more than three days and whose mother did not receive maternal Tdap vaccination at least 14 days before the baby’s birth.

Regardless of maternal vaccination history, it is recommended that all caregivers of infants born at less than 32 weeks’ gestation receive a single dose of Tdap (not funded). This is because by 28–32 weeks’ gestation the level of transplacental maternal antibodies in the infant is only half of the maternal circulating level, compared with higher than maternal levels by term.[11, 18,19]

Congenital heart disease (CHD) may occur alone (eg, a single ventricle defect or shunt dependent lesion), or with other congenital defects (eg, immunodeficiency, endocrine dysfunction and facial abnormalities in DiGeorge syndrome or asplenia in heterotaxy syndrome).

Vaccination of infants with congenital heart disease

Infants with CHD and who are immunocompetent can receive vaccination as per the Schedule including rotavirus and varicella vaccines. For infants with CHD who were also born preterm or with a low birthweight, see also section 4.2.2.

Infants with a complex single ventricle defect or shunt dependent lesion who have undergone the Norwood procedure may have an increased risk of systemic decompensation. There is limited evidence linking the onset of decompensation to vaccination. As a precautionary measure, these infants may require hospital admission for observation or close parental monitoring at home for 48–72 hours after vaccination events. Discuss monitoring requirements with the infant’s specialist prior to vaccination.[20]

Timing of vaccination may be affected when cardiac surgery is scheduled to avoid adding extra stress on these infants during this time. Vaccines should be administered at least one week before planned cardiac surgery. After cardiac surgery, administration of subunit vaccines should be delayed by 4–6 weeks for those at risk of systemic decompensation (eg, after a Norwood procedure).

For further information see Starship guidelines.

Live vaccines after blood product administration

If an infant has received blood products (eg, bypass or blood transfusion during surgery), delay administration of live vaccine is until seven months post-surgery.[20] This does not apply to administration of rotavirus vaccine.

This standdown period can be shortened to 3 months (as per UK guidelines), especially if measles is circulating in the community.  See Table A6.1 in Appendix 6 for suggested intervals between administration of blood products and MMR or VV. MMR and VV will not cause harm if given earlier than the intervals indicated in Table A6.1, but the immune response could be suboptimal, leaving a patient at risk for the relevant disease(s). In an outbreak situation (e.g. measles) immunisation may be given at any time as the benefit could outweigh the potential impaired response.

If no blood products have been given, the usual 4–6 weeks post-operative interval is recommended for those at risk of systemic decompensation, as above.

Some cardiac defects can be associated with immune deficiency, eg Di George syndrome. Most such patients can safely be given live viral vaccines when due – after assessment of immune function (see section 4.3.2). Seek specialist advice.

Pneumococcal vaccine

Children who have cardiac disease with cyanosis or failure, chronic pulmonary disease, Down syndrome, functional asplenia, immunodeficiency, or renal failure are eligible for extended pneumococcal immunisations as high-risk groups (see section 17.5.2).

Influenza vaccine

Infants and children with CHD, with or without cyanosis or failure, and children on long-term aspirin are eligible to receive funded annual influenza vaccination from 6 months of age (see Table 11.2).

Influenza vaccination is recommended (but not funded) for close contacts of infants and children with CHD, including children (see section 11.5.4).

Pertussis vaccination

It is essential that siblings and other close household members of infants with CHD are up to date with Schedule vaccinations, to reduce the risk of pertussis transmission to the infant (see section 16.5). Ensure catch-up vaccination of all children aged under 18 years (see Appendix 2 for catch-up schedules).

Varicella vaccine

Children on long-term aspirin can receive varicella vaccination as per the Schedule. There has been no reported association between varicella vaccination and the onset of Reye’s syndrome in children on long-term aspirin to prevent thrombosis. The use of aspirin during natural chickenpox infection has been associated with Reye’s syndrome.[20]

Seek guidance on immunisation of infants with severe primary immunodeficiencies (see section 4.3.3). Often these infants are unable to mount adequate responses to vaccines. Note: Rotavirus vaccine is contraindicated in any infant with possible severe combined immune deficiencies (SCID) due to the risk of chronic diarrhoea and prolonged viral shedding.[21, 22]

Some infants with congenital liver or kidney conditions are likely to need transplantation. An accelerated immunisation schedule for these infants in provided in Table 4.4. Extra immunisations may be warranted for other chronic kidney and chronic liver conditions (see sections 4.4 and 4.5). Infants with biliary atresia may have polysplenia (functional hyposplenia; see section 4.3.11).

Infants of mothers who have received immunomodulatory biologic agents (also known as biologic response modifiers) during pregnancy also may have a reduced response to the primary series vaccinations (section 4.2.5).

The following definitions are used in this Handbook:

• Immunocompetent – a broad term referring to normal immune system function.
• Immunocompromise – a broad term referring to altered immune system function. The individual’s ability to mount an immune response may be reduced or increased because of a disease, treatment or genetic disorder.
• Immunomodulation – changes in immune system function in response to medication, cancer chemotherapy or immunotherapy treatments.
• Immunostimulant – a substance able to stimulate or increase an immune response.
• Immunosuppression – a reduced ability to mount an immune response caused by medication, cancer chemotherapy or immunotherapy treatment.
• Immunodeficiency – a reduced ability to mount an immune response and fight off infection. Immunodeficiency conditions are classified as primary and secondary, dependent on the cause.

Primary immunodeficiencies that present in childhood are usually caused by an inherited genetic disorder. They can result in defects in antibody production (B‑lymphocyte disorders), defects in the development of cell-mediated immunity (T‑lymphocyte disorders), combination defects (disorders or syndromes affecting B‑ and T‑lymphocytes) and defects of complement and phagocytic function.[31]

Children with Down syndrome (trisomy 21) are at increased risk from respiratory and severe infections due to multiple immune deficits in both the innate and adaptive immune systems, as well as anatomical structural differences,[32, 33] and could be considered as primary immune deficiency. Note that live vaccines are not contraindicated for children with Down syndrome, unless an underlying comorbidity that results in severe immunocompromise is also present.

Vaccines used to test for a primary immunodeficiency

Hib-PRP, 23PPV, PCV13 and Tdap vaccines may be used in testing for a primary immunodeficiency, on the recommendation of an internal medicine physician or paediatrician. Hib-PRP, PCV13 and Tdap vaccines are funded for primary immunodeficiency testing in children aged under 18 years and eligible adults.

Vaccines for individuals with a primary immunodeficiency

Live vaccines – caution

Diagnosis of primary immunodeficiency is often not made before children start their Schedule vaccinations. For infants who have the potential to be immunodeficient (eg, have a familial history of inherited immunodeficiency) administration of live vaccines such as BCG (see section 23.6.2), rotavirus vaccine, MMR, and/or varicella vaccines may be contraindicated or need to be deferred until specialist consultation is sought.

Live vaccines are contraindicated for all individuals with T lymphocyte-mediated immunodeficiency, a combined B- and T-lymphocyte deficiency or interferon alpha receptor (IFNAR) deficiencies and signalling pathway defects.[34] Many of these individuals will be on immunoglobulin replacement therapy, which provides passive protection against most vaccine-preventable infections.

COVID-19 vaccine

Young children aged 6 months to 4 years, inclusive

Children aged 6 months to 4 years with primary immunodeficiency are recommended to receive three doses of mRNA-CV (3 µg). First and second doses are given three weeks apart and dose three is given at least eight weeks after the second dose. An additional dose of mRNA-CV (3 µg) can be given six months after the primary course. This spacing can be reduced to at least three months, on a case-by-case basis, where there is a clinical need.

Individuals aged 5 years and over

Certain individuals from 5 years of age with a primary immunodeficiency are eligible for three primary doses of mRNA-CV (10 µg or 30 µg, as age appropriate) (see section ‎5.5.2 for details); each dose is given eight weeks apart.

Regardless of any previous doses received after completion of the primary course, an additional dose of mRNA-CV (10 µg or 30 µg, as age appropriate) is recommended for all individuals aged 5 years and over with primary immunodeficiency, particularly for those eligible for three primary doses, to be given six months after a previous dose. This spacing can be reduced to at least three months, on a case-by-case basis, where there is a clinical need (see section ‎5.5.3).

If a significant adverse reaction to mRNA-CV has occurred, it is recommended to seek advice from IMAC to determine whether further doses are contraindicated.

Influenza vaccine

Influenza vaccine is funded for all individuals with primary immunodeficiency, including Down syndrome, aged 6 months or older. Regardless of their age, all immunodeficient individuals who receive influenza vaccine for the first time are recommended to receive two vaccine doses at least four weeks apart (second dose unfunded), and one funded dose annually after that. A second dose is funded for children aged 6 months to under 9 years when influenza vaccine is being used for the first time.

Pneumococcal vaccines

Pneumococcal vaccines are funded for individuals diagnosed with a primary immunodeficiency.

Infants and children aged under 5 years

Children in this age group with a diagnosed primary immunodeficiency or Down syndrome are eligible to receive extended pneumococcal immunisation for high-risk groups (see section 17.5.2).

PCV13 is given as a three-dose primary course plus booster, administer a 3-month dose in addition to the usual Schedule (ie, at ages 6 weeks, 3 months, 5 months and 12 months; see sections 17.5.2 and 17.5.3) followed by age‑appropriate 23PPV vaccinations.

Children aged 5 years or older and adults

Children aged 5 years or older and adults with a diagnosed primary immunodeficiency or inherited complement deficiency are eligible to receive one PCV13 followed by age‑appropriate 23PPV vaccinations (see section 17.5.2).

Children with Down syndrome aged 5 years to under 18 years

Children in this age group who have received at least two doses of PCV10 and have Down syndrome are recommended and funded to receive one PCV13 followed by up to two doses of 23PPV (see section 17.5.2).

Children in this age group who have not received at least two doses of PCV10 and have Down syndrome are recommended and funded to receive up to two doses of 23PPV (see section 17.5.2).

Meningococcal vaccines

Meningococcal are recommended and funded for individuals with an inherited complement deficiency.

The current funded meningococcal vaccines are recombinant group B vaccine (MenB, Bexsero), quadrivalent group ACWY meningococcal conjugate vaccines (MenACWY, Nimenrix and MenQuadfi).

Meningococcal ACWY conjugate vaccines

Infants aged under 12 months

Infants aged under 12 months who have an inherited complement deficiency are recommended and funded to receive two doses of MenACWY (Nimenrix) given a minimum of eight weeks apart (see section 13.5). This includes infants who received MenC (NeisVac-C) prior to 1 July 2024 (ie. with no protection against groups A, W and Y).

Children aged 12–23 months

Children aged 12–23 months who are diagnosed with an inherited complement deficiency are recommended and funded to receive two doses of MenACWY (MenQuadfi) given at 8–12 weeks apart (see note below). This includes infants who received NeisVac-C prior to 1 July 2024 (ie, with no protection against groups A, W and Y). A booster dose is recommended after three years then five yearly.

Note: A second primary dose of MenQuadfi for those aged 12 months and over is off-label and requires a prescription from an authorised prescriber under section 25 of the Medicines Act.

Infants who previously received any MenACWY vaccine can complete their immunisation course with MenQuadfi. Infants who have received two previous doses of Nimenrix when aged under 12 months, can have one dose of MenQuadfi from age 12 months, given at least 6 months after the second dose.

Children aged 2 years to under 7 years

Children aged 2 years to under 7 years who are diagnosed with an inherited complement deficiency are recommended and funded to receive two doses of MenACWY given 8–12 weeks apart (a prescription is required for a second primary dose, see note above). Give a booster dose after three years if still aged under 7 years, then five yearly.

Children aged 7 years or older and adults

Children aged 7 years or older and adults who are diagnosed with an inherited complement deficiency are recommended and funded to receive two doses of MenACWY at least eight weeks apart (a prescription is required for a second primary dose, see note above). A booster dose is recommended to be given every five years.

Group B meningococcal recombinant vaccine

Vaccination with MenB (Bexsero), to protect against disease caused by the meningococcal group B, is recommended and funded for infants, children and adults with an inherited complement deficiency and an increased risk of meningococcal disease.

MenB is funded routinely as part of the Schedule for all infants, given at either ages 3 months, 5 months and 12 months, or an alternate schedule (involving additional visits) at ages 8 weeks and 4 months plus booster at 12 months. Catch-up is available for children aged 13 months to under 5 years until 31 August 2025 (see Section 13.5 for details). 

Infants aged under 12 months

Infants aged 8 weeks to <12 months who are diagnosed with an inherited complement deficiency are recommended and funded to receive two doses of MenB at least eight weeks apart, followed by a booster dose given at least six months after the second dose, from age 12 months. For those aged younger than 8 weeks, to align with the routine schedule visit, MenB can be given at ages 6 weeks and 3 months; this is off-label use and requires a prescription. No prescription is required if given as per the alternative schedule at ages 8 weeks and 4 months.

Children aged 12 to 23 months

Children aged from 12 months to 23 months who are diagnosed with an inherited complement deficiency are recommended and funded to receive two doses of MenB at least eight weeks apart, followed by a booster dose given 12–23 months after the second dose. The spacing between doses one and two can be reduced to six weeks if indicated, with a prescription.

Children from age 2 years and adults

Children aged from 2 years and adults who are diagnosed with an inherited complement deficiency are recommended and funded to receive two doses of MenB at least eight weeks apart. This can be reduced to four weeks if clinically required.

Booster doses of MenB are funded five yearly after the age of 12 months for patients with inherited complement deficiency.

Note: MenB elicits a robust immune response, and sometimes high fevers in infants. Routine use of paracetamol (or ibuprofen) with every dose of MenB in children aged under 2 years, whether given alone or with other vaccines, is recommended to reduce the risk of high fever and injection-site pain (see section 13.5.1) 

Herpes zoster vaccine

Individuals aged 18 years and over, including those aged 66 years and over, with primary immunodeficiency are recommended and funded two doses of recombinant zoster vaccine (rZV, Shingrix), given two to six months apart. See section 25.5.1.

Vaccination advice, by primary immunodeficiency

Below is a summary of the vaccination recommendations for individuals with a primary immunodeficiency.[35] (See also Table A6.1 in Appendix 6.)

Live vaccines are contraindicated for all individuals with T lymphocyte-mediated immunodeficiency, a combined B- and T-lymphocyte deficiency or interferon receptor (IFNAR) deficiencies.[34] Many of these individuals will be on immunoglobulin replacement therapy, which provides passive protection against most vaccine-preventable infections.

B lymphocyte deficiencies (humoral)

X-linked agammaglobulinaemia and common variable immune deficiency

• BCG vaccine is contraindicated.
• Only administer live-virus vaccines (rotavirus, MMR, VV) after discussion with the individual’s specialist.
• The efficacy of any vaccine that is dependent on a humoral response, such as 23PPV, is doubtful.
• During IVIG therapy, only influenza vaccination is recommended.

Selective IgA deficiency, IgG subclass deficiency and hypogammaglobulinaemia

• BCG vaccine may be contraindicated.
• Live-virus vaccines (rotavirus, MMR, VV) can be administered.
• All vaccines are probably effective.
• Influenza vaccine is recommended.

Combined lymphocyte deficiencies (T and B cell)

Complete defects (eg, SCID or athymia)

• All live vaccines are contraindicated.
• All other vaccines are likely to be ineffective prior to immune reconstitution, and passive protection must be optimised.

Partial defects (eg, most patients with DiGeorge syndrome, Wiskott Aldrich syndrome, ataxia telangiectasia)

• Provision of selected live vaccines is dependent on specialist advice after assessment of degree of immune compromise.
• Hib, pneumococcal (PCV13 and 23PPV), and meningococcal vaccines are recommended, except when the individual receives IVIG therapy. Meningococcal vaccines are not funded for these indications.
• Non-live vaccines should be provided as per the usual Schedule, except when the individual receives IVIG therapy.
• Influenza vaccination is recommended, including individuals who receive IVIG therapy.

Complement deficiencies

Deficiency of C1–9, mannose-binding lectin, properdin, factor B

• There are no specific contraindications or precautions.
• The usual Schedule vaccines are probably effective.
• Influenza, Hib, pneumococcal (PCV13 and 23PPV) and meningococcal vaccines are recommended and funded.

Phagocytic function deficiencies

Chronic granulomatous disease and cyclic neutropenia

• BCG and live-bacteria vaccines are contraindicated.
• Live-virus vaccines (rotavirus, MMR, VV) can be administered.
• The usual Schedule vaccines are probably effective.
• Influenza vaccine is recommended.

Leukocyte adhesion defect, myeloperoxidase deficiency

• All live vaccines are contraindicated.
• Influenza, Hib, pneumococcal (PCV13 and 23PPV) and meningococcal vaccines are recommended. Meningococcal vaccines are not funded for these indications.

Interferon alpha receptor deficiencies

IFNAR deficiencies can increase the risk of severe reaction to some live viral vaccines. Other childhood vaccines, including oral RV and mRNA-CV, are safely received. IFNAR deficiencies are extremely rare immune disorder that can result in a defective response to certain viruses.[36,37] These disorders require genetic testing to be diagnosed and cannot be prevented. IFNAR1 deficiency was only discovered in 2019. This genetic condition increases the risk of serious illness when the individual is exposed to certain respiratory viruses, including COVID-19, influenza and RSV,[38, 39, 40] and some live vaccines such as measles, mumps and yellow fever.[41]

Secondary immunodeficiencies are acquired. They occur in individuals with HIV, individuals with malignant neoplasms, solid-organ transplant recipients, and in individuals receiving cancer chemotherapy or other immunotherapies.[35]

The ability of individuals with a secondary immunodeficiency to develop an adequate immunological response depends on the disease and/or the type and intensity of immunosuppressive therapy. After immunosuppressive therapy is discontinued, immune recovery can take weeks to years. Ideally, vaccination should be conducted prior to any planned immunosuppression.

Vaccines for individuals with acquired immunodeficiency

In diseases such as HIV or chronic renal failure, where immune impairment is likely to be progressive, ensuring the individual is up to date with Schedule and additional funded vaccines earlier in their disease and when at optimal disease control may result in better antibody responses.

Before commencing a therapy that would be expected to cause significant immunosuppression, a full vaccination history should be obtained. Then, if circumstances permit, such as prior to commencing immunosuppressive therapy for rheumatological disease or prior to solid organ transplant, vaccination should be completed following the usual Schedule (including HPV vaccine from age 9 years). Administration of additional funded vaccines (eg, varicella for children, zoster for certain adults, meningococcal or pneumococcal vaccines) may be appropriate. However, when immediate commencement of therapy is clinically indicated, it is not recommended to delay therapy to allow for vaccination.

Live vaccines – caution

Live vaccines (BCG, rotavirus, MMR and VV) are contraindicated for individuals who are immunosuppressed because of the risk of disseminated vaccine disease.

Individuals who are not considered to be significantly immunodeficient or immunosuppressed can receive live vaccines. For individuals who are due to commence elective immunosuppressive therapy, live vaccines (MMR and VV) should be administered at least four weeks prior to commencement of therapy. Live vaccines should also be administered at least four weeks before a predicted transplant.

On a case-by-case basis with appropriate follow-up in place, a specialist may recommend that VV is administered less than four weeks before a predicted transplant or to a post-transplantation paediatric patient.[42] With specialist input MMR may also be considered in clinically well patients at least one year after solid organ transplantation on low level immunosuppression.[43]

See sections 12.5 and 24.5 for information about the recommended MMR and VV vaccination schedules and eligibility criteria.

COVID-19 vaccine

Young children aged 6 months to 4 years, inclusive

Children aged 6 months to 4 years with a secondary (acquired) immunodeficiency are recommended to receive three doses of mRNA-CV (3 µg). First and second doses are given three weeks apart and dose three is given at least eight weeks after the second dose. An additional dose of mRNA-CV (3 µg) can be given six months after the primary course. This spacing can be reduced to at least three months, on a case-by-case basis, where there is a clinical need.

Individuals aged 5 years and over

Certain individuals from 5 years of age with a secondary (acquired) immunodeficiency are eligible for three primary doses of mRNA-CV (10 µg or 30 µg, as age appropriate) (see section 5.5.2 for details); each dose is given 8 weeks apart.

Regardless of any doses received after completion of the primary course, an additional dose of mRNA-CV (10 µg or 30 µg, as age appropriate) is recommended for individuals aged 5 years and over with a secondary (acquired) immunodeficiency, and particularly those eligible for three primary doses, to be given six months after the previous dose. This spacing can be reduced to at least three months, on a case-by-case basis, where there is a clinical need (see section ‎5.5.3).

If a significant adverse reaction to mRNA-CV has occurred, it is recommended to seek advice from IMAC to determine whether further doses are contraindicated.

Influenza vaccine

Influenza vaccine is funded for all individuals with immunodeficiency or immunosuppressed aged 6 months or older. Regardless of their age, all immunocompromised individuals who receive influenza vaccine for the first time are recommended to receive two vaccine doses at least four weeks apart (second dose unfunded), and one funded dose annually after that. A second dose is funded for children aged 6 months to under 9 years when influenza vaccine is being used for the first time.

Haemophilus influenzae type b (Hib-PRP) vaccines

Infants and children aged under 5 years

Vaccination against Hib disease for infants and children aged under 5 years is included in the usual Schedule. DTaP-IPV-HepB/Hib vaccine is recommended at 6 weeks, 3 months and 5 months of age followed by a booster dose of Hib-PRP vaccine at age 15 months.

Children aged 5 years or older and adults

Children aged 5 years or older and adults who have functional asplenia, or are pre-/post-solid organ transplantation, pre-/post-splenectomy, post-chemotherapy, receiving immunosuppressive therapy for longer than 28 days, or on renal dialysis, are recommended and funded to receive one dose of monovalent Hib-PRP vaccine.

A three-dose series of Hib-PRP-containing vaccine is recommended for children and adults who are post-haematopoietic stem cell transplantation (see section 4.3.9).

Pneumococcal vaccines

Infants and children aged under 5 years

Children in this age group who have functional asplenia, HIV, nephrotic syndrome or renal failure, or are pre-/post-solid organ transplantation, pre-/post-splenectomy, post-haematopoietic stem cell transplantation, or have been receiving high-dose corticosteroid therapy for more than two weeks, other immunosuppressive therapy for longer than 28 days, or radiotherapy are recommended and funded to receive additional pneumococcal vaccinations as part of an extended immunisation programme for special groups (see section 17.5.2).

PCV13 is given as a three-dose primary series plus booster, administer a 3-month dose  in addition to the usual Schedule (ie, at ages 6 weeks, 3 months, 5 months and 12 months; see sections 17.5.2 and 17.5.3) once the eligible condition has been identified followed by age-appropriate 23PPV vaccinations. For children aged 12 months to under 5 years who have not received PCV13, see Table 17.3.

Children aged 5 years to under 18 years

Children in this age group who have a condition listed in the Infants and children aged under 5 years section above are recommended and funded to receive one PCV13 followed by up to two doses of 23PPV (see section 17.5.2).

Children aged 5 years or older and adults

Children in this age group and adults who have an acquired complement deficiency, functional asplenia or HIV, or are pre-/post-solid organ transplantation, pre-/post-splenectomy, post-chemotherapy, post-haematopoietic stem cell transplantation, or on renal dialysis, are recommended and funded to receive one PCV13 followed by age-appropriate 23PPV vaccinations (see section 17.5.2).

It is recommended that individuals in this age group who will be or have been receiving high-dose corticosteroid therapy for more than two weeks or other immunosuppressive therapy for longer than 28 days receive pneumococcal vaccination (this is not funded).

Meningococcal vaccines

Infants, children and adults with acquired complement deficiency, functional asplenia, HIV, or are pre-/post-splenectomy, or are pre-/post-solid organ transplantation, are post-haematopoietic stem cell transplantation, or pre and post immunosuppression for longer than 28 days are recommended and funded meningococcal vaccination.

The current funded meningococcal vaccines are recombinant group B vaccine (MenB, Bexsero), quadrivalent group ACWY meningococcal conjugate vaccines (MenACWY, Nimenrix and MenQuadfi).

Meningococcal conjugate vaccines

Infants aged under 12 months

Infants aged 6 weeks to under 12 months who have an acquired complement deficiency, functional asplenia or HIV, or are pre-/post-splenectomy, pre-/post-solid organ transplantation, or post-haematopoietic stem cell transplantation, or pre/post immunosuppressive therapy for longer than 28 days are recommended and funded to receive two doses of MenACWY (Nimenrix) given a minimum of eight weeks apart. From age 12 months, give a dose of MenQuadfi at least six months after the second dose, then a booster dose after three years and five-yearly.

Children aged 12–23 months

Children in this age group who have an acquired complement deficiency, functional asplenia or HIV, or are pre-/post-splenectomy or pre-/post-solid organ transplantation, are recommended and funded to receive two doses of MenACWY (MenQuadfi) given at 8–12 weeks apart (see note below).

Note: A second primary dose of MenQuadfi, for those aged 12 months and over, is off-label and requires a prescription from an authorised prescriber under section 25 of the Medicines Act.

A booster dose is recommended and funded after three years, if still aged under 7 years, then five‑yearly for those with acquired complement deficiency, functional or anatomical asplenia, HIV, or are pre-/post-splenectomy, or are pre-/post-solid organ transplantation.

Children in this age group who are post-haematopoietic stem cell transplantation or will be or have been receiving immunosuppressive therapy for longer than 28 days are recommended and funded to receive two doses of MenACWY given 8-12 weeks apart (see note). Booster doses of MenACWY after three years and then five‑yearly are recommended (although not funded) if immunosuppression is long-term.

Children aged 2 years to under 7 years

Children in this age group who have an acquired complement deficiency, functional asplenia, HIV, or are pre-/post-splenectomy or pre-/post-solid organ transplantation, are recommended and funded to receive two doses of MenACWY given 8-12 weeks apart (a prescription is required for a second primary dose, see note above). Give a booster dose after three years, if still aged under 7 years, then five-yearly.

Children in this age group who are post-haematopoietic stem cell transplantation or receiving immunosuppressive therapy for longer than 28 days are recommended and funded to receive two doses of MenACWY given 8–12 weeks apart. If immunosuppression is long-term, booster doses of MenACWY after three years, if still aged under 7 years, and then five-yearly are recommended (although not funded).

Children aged 7 years or older and adults

Children in this age group and adults who have an acquired complement deficiency, functional asplenia, HIV, or are pre-/post-splenectomy or pre-/post-solid organ transplantation, are recommended and funded to receive two doses of MenACWY at least eight weeks apart (a prescription is required for a second primary dose, see note above). A booster dose is recommended to be given every five years.

Children in this age group and adults who are post-haematopoietic stem cell transplantation or will be or have been receiving immunosuppressive therapy for longer than 28 days are recommended and funded to receive two doses of MenACWY at least eight weeks apart. If immunosuppression is long-term, a booster dose of MenACWY is recommended (but not funded) every five years.

Group B meningococcal vaccine

Vaccination with MenB (Bexsero), to protect against disease caused by the meningococcal group B, is recommended and funded for infants, children and adults who have an acquired complement deficiency, functional asplenia or HIV, or are pre- and post-splenectomy or pre- or post-solid organ transplantation, or post-haematopoietic stem cell transplantation, or prior to planned and following immunosuppressive therapy for longer than 28 days.

MenB is funded as part of the Schedule for all infants, given at either ages 3 months, 5 months and 12 months, or an alternate schedule (involving additional visits) at ages 8 weeks and 4 months plus booster at 12 months, and a catch-up is available for children aged 13 months to under 5 years until 31 August 2025 (see Section ‎13.5 for details).

Infants aged under 12 months

Infants aged 8 weeks to <12 months who have an acquired immunodeficiency, as listed above, are recommended and funded to receive two doses of MenB at least eight weeks apart, followed by a booster dose at least six months after the second dose, from 12 months of age. For those aged younger than 8 weeks, to align with the routine schedule visit, MenB can be given at ages 6 weeks and 3 months. This is off-label use and requires a prescription from an authorised prescriber. No prescription is required if given as per the alternative schedule at ages 8 weeks and 4 months.

Children from age 12 to 23 months

Children aged from 12 months to 23 months who are diagnosed with an acquired immunodeficiency are recommended and funded to receive two doses of MenB at least eight weeks apart, followed by a booster dose given 12–23 months after the second dose. The spacing between doses one and two can be reduced to six weeks if indicated, with a prescription.

Children from age 2 years and adults

Children aged from 2 years and adults who are diagnosed with an acquired immunodeficiency are recommended and funded to receive two doses of MenB at least eight weeks apart. This can be reduced to four weeks apart, if clinically necessary.

Booster doses are funded five yearly as required after the age of 12 months for patients pre- and post-splenectomy, with functional or anatomical asplenia, HIV, acquired complement deficiency or pre- or post-solid organ transplant.

Note: MenB elicits a robust immune response, and sometimes high fevers in infants. Routine use of paracetamol (or ibuprofen) with every dose of MenB in children aged under 2 years, whether given alone or with other vaccines, is recommended to reduce the risk of high fever and injection-site pain (see section ‎13.4.4).

Herpes zoster vaccine

Individuals from age 18 years, including those aged 66 years and over, with secondary (acquired) immunodeficiency are recommended two doses of recombinant zoster vaccine (rZV, Shingrix), given two to six months apart. Funded vaccine is limited to individuals with certain acquired immunodeficiencies and named conditions requiring immunosuppressive therapies. See section 25.5.1.

Corticosteroids reduce inflammation and generally suppress the immune system. The minimum amount of corticosteroid administration sufficient to cause immunosuppression is not well defined, and is dependent on the treatment used, dose, route of administration and duration. A daily dosage equivalent to 2 mg/kg oral prednisone or greater, or a total daily dosage of 20 mg or greater, particularly when given for 14 days or more, is considered sufficient to raise concern about the safety of live vaccines. Individuals receiving fludrocortisone or long-term dexamethasone should not receive live vaccines during treatment and for three months after discontinuation.

A single dose of dexamethasone for management of an acute respiratory illness in children is not associated with a decrease in endogenous corticosteroid levels[44] or immunosuppression. No minimum interval is required between administration of a single dose of dexamethasone and a live vaccine, as long the individual is not acutely unwell.

Rotavirus vaccine can be given to preterm infants born who are receiving corticosteroids.

Live vaccines can be administered to individuals who:

• are using topical corticosteroid therapy, including on the skin or respiratory tract (by aerosol), or receiving local intra-articular, bursal or tendon corticosteroid injections because such therapies do not usually result in immunosuppression
• are receiving maintenance physiological doses of corticosteroids
• are receiving oral budesonide or fluticasone to treat an inflammatory bowel condition
• received a single dose of dexamethasone for management of an acute respiratory illness
• are receiving low to moderate doses of systemic steroids given daily or on alternate days
• are receiving high-dose corticosteroids for fewer than 14 days.

Live vaccines should not be administered to individuals:

• receiving high dose corticosteroids daily or on alternate days for more than 14 days
• receiving long-term dexamethasone or hydrocortisone that is not for physiological maintenance or fludrocortisone
• who have a disease process that causes immunosuppression, except in special circumstances after discussion with the individual’s specialist.

See Table 4.1 for guidelines according to each corticosteroid agent.

Non-biologic agents

Hydroxychloroquine, mesalazine/5-ASA, olsalazine and sulfasalazine act on the immune system and reduce the inflammatory responses associated with immune-mediated inflammatory disease (IMID, also known as autoimmune diseases) but do not cause immunosuppression.[46]

Azathioprine, 6-mercaptopurine, methotrexate, cyclophosphamide, cyclosporine, leflunomide, mycophenolate mofetil and tacrolimus suppress immune system function to varying degrees, dependent on the agent and intensity of therapy, to reduce symptoms and tissue damage associated with IMID or prevent rejection of a transplanted organ.[46]

See Table ‎4.2 for guidelines for administration of live vaccines according to each non-biologic agent.

Biologic agents

Immunotherapeutic treatment of disease has increased rapidly over recent years. The treatment relies on administration of biologic agents that selectively target components of the immune system (eg, antibodies, cytokines and proteins) to alter an individual’s immune response to treat disease.[46]

In IMID, such as rheumatoid arthritis and inflammatory bowel disease, biologic agents target a specific part of the individual’s immune response against ‘self’ to stop the immune response creating inflammation and damage.[46] However, they also affect the immune response against genuine antigens and cause immunosuppression. Use of a combination of therapies may have a cumulative effect that increases the level of immunosuppression in an individual.

In atopic conditions and inflammation such as chronic spontaneous urticaria and allergic asthma, biologic agents inhibit the activation of allergen specific IgE antibodies and mast cells or decrease the number of eosinophils that contribute to allergy related inflammation.[46] These treatments do not cause immunosuppression.

Other biologic agents stimulate an individual’s immune response by blocking immune checkpoints on healthy cells and cancer cells to increase their anti-tumour response, see Oncology, section 4.3.8.

Live vaccines can be administered to individuals:

• receiving hydroxychloroquine, mesalazine/5-ASA, olsalazine and sulfasalazine
• with low-level immunosuppression regimens of azathioprine, 6 mercaptopurine or methotrexate
• receiving intra-ocular biologic therapy because such therapy does not usually result in immunosuppression
• taking omalizumab or mepolizumab to manage allergic conditions such as chronic spontaneous urticaria and allergic asthma.

Live vaccines should not be administered to individuals:

• with high-level immunosuppression regimens of azathioprine, 6 mercaptopurine or methotrexate
• receiving treatment with any dose of cyclophosphamide, cyclosporine, leflunomide, mycophenolate mofetil, or tacrolimus
• receiving treatment with monoclonal antibody inhibitors, TNF inhibitors and kinase inhibitors, and immune checkpoint inhibitors (see Oncology, section 4.3.8).
• Infants aged under 12 months born to mothers who received immunomodulatory biologic agents in pregnancy may also be temporarily immunocompromised (see section 4.2.5).

A variety of immune-mediated inflammatory diseases (IMID), across many subspecialties (eg, rheumatology, dermatology, gastroenterology etc), require treatment escalation to immunosuppressive therapy over a variable time course. Routine and additional vaccinations should be given prior to any planned immunosuppression, where clinically possible.

• Complete all age-appropriate vaccinations according to the Schedule; previous doses do not need to be repeated prior to immunosuppression.
• Live viral vaccines are recommended to be administered prior to planned immunosuppression, if time permits, as they cannot be given once immunosuppression has commenced. Clinically indicated immunosuppression should not be delayed in order to give live vaccines. 
• Whilst non-live vaccines can also be given safely when receiving immunosuppression, the immune response is likely to be reduced. If immunosuppression is short-lasting, administration of non-live vaccines (eg, completion of meningococcal vaccines) can be given once immunosuppression has been reduced or stopped.
• The required interval before resuming live vaccination varies with the agents given – see Table ‎4.1 and Table ‎4.2, and seek specialist advice.

For additional and accelerated recommendations for the immunisation of infants and children diagnosed with conditions requiring immunosuppression for 28 days or longer, see Table 4.3.

For infants aged under 12 months of age, seek specialist advice.

For additional recommendations for the immunisation of adults see IMAC factsheet Immunisation for adults requiring immunosuppressive disease modifying therapy (available on the IMAC website).

All vaccines on the Schedule are funded for vaccination or re‑vaccination of individuals following immunosuppression. Note that the period of immunosuppression due to steroid or other immunosuppressive therapy must be longer than 28 days. The timing and number of doses should be discussed with the individual’s specialist. Ideally, vaccination should be conducted prior to any planned immunosuppression. See also the relevant disease chapters.

This section provides general guidelines for vaccination during and after cancer treatment. Specific vaccination questions should be discussed with an expert paediatrician, infectious diseases physician or oncologist.

Note: The exception to these guidelines is individuals being treated with immune checkpoint inhibitors for whom vaccination may be contraindicated (see below).

Vaccination during cancer chemotherapy

While administration of inactivated and subunit (non-live) vaccines is safe for individuals undergoing cancer chemotherapy, their response and subsequent protection may be reduced compared with healthy individuals.

Influenza vaccination is recommended for children age 6 months and over and adults prior to planned or when undergoing cancer chemotherapy as soon as the vaccine becomes available; there is no need to wait until three months after the individual’s last treatment.[47, 48] Influenza vaccination can be administered at any time during a cancer chemotherapy cycle.[49]

In both children and adults, administration of two influenza vaccine doses a minimum of four weeks apart could improve the immune response to vaccination.[50]

Administration of live vaccines during cancer chemotherapy is absolutely contraindicated because of the risk of disseminated vaccine disease. For recommendations regarding vaccination of close contacts of immunocompromised individuals, see section 4.3.1.

Vaccination after cancer chemotherapy

In general, booster dose(s) of a diphtheria/tetanus/pertussis-containing vaccine, and hepatitis B, polio (IPV) and pneumococcal vaccines (PCV13 followed by 23PPV) should be given, from not less than three months after cancer chemotherapy has ended (when the lymphocyte count is >1.0 × 10⁹/L).

In general, administration of age-appropriate live vaccines should be delayed for at least six months after cancer chemotherapy. This interval may need to be extended according to:

• the intensity and type of therapy
• receipt of blood products or immunoglobulin (for MMR and VV, see Table A6.1 in Appendix 6)
• underlying disease.

MMR vaccination is not required post-chemotherapy for adults born prior to 1969 or who have documented evidence of measles, mumps and rubella immunity (see section 12.8.3). Adults born in 1969 or later who do not have documented evidence of immunity to measles, mumps and rubella should receive up to two documented doses of MMR, as per the usual adult catch-up Schedule, at least six months post-chemotherapy and when their lymphocyte count is >1.0 x 10⁹/L.

For children aged under 18 years, see the Starship Clinical Guideline Immunisation of children during and after cancer therapy for age-appropriate schedules and worksheets.

For adults, see the IMAC factsheet Immunisation for adults requiring immunosuppressive disease-modifying therapy. For other adults who have received chemotherapy, see also the IMAC factsheet Immunisation for adults post chemotherapy who are not taking immunosuppressive disease-modifying drugs (both available on the IMAC website).

Herpes zoster vaccine

Individuals from age 18 years, including those aged 66 years and over, who are potentially immunocompromised post-chemotherapy or other cancer treatments are recommended  two doses of recombinant zoster vaccine (rZV, Shingrix), given two to six months apart. Funded vaccine is limited to individuals who are immunocompromised following a haematological malignacy diagnosis, or post-haematopoietic stem cell transplantation and post-cellular therapy (eg CAR T-cell therapy). See section 25.5.1.

Vaccination and radiotherapy

Individuals who are only receiving localised radiotherapy to treat a tumour or lesion can be vaccinated with subunit vaccines and live vaccines at any time prior to, during, or after radiotherapy.[51]

Immune checkpoint inhibitor (immunostimulant) therapy

A person who is currently receiving any of the four immune checkpoint inhibitor medications currently available in New Zealand – namely, nivolumab (Opdivo), pembrolizumab (Keytruda), atezolizumab (Tecentriq) and ipilimumab (Yervoy) – or has received these in the previous six months can receive any non-live vaccine, including influenza and mRNA-CV, without consulting their specialist prior to vaccination. The administration of live vaccines (MMR and VV) is contraindicated.

Haematopoietic stem cell transplantation (HSCT) is used to treat haematological disease, such as acute leukaemia, and some immunodeficiency syndromes, such as severe combined immunodeficiency. Transplant recipients undergo a conditioning regime to destroy their immune system and underlying disease then receive an infusion of cells to reconstitute a new immune system. The transplanted cells may be collected from bone marrow, umbilical cord blood, or peripheral blood. They may be donated by another person (called an allogeneic transplant), or may be the recipient’s own cells that have been processed to ensure they are disease free (called an autologous transplant).[52]

After HSCT, it takes months to years for the recipient’s new immune system to reconstitute and become functional. However, the age of the recipient, underlying disease, conditioning regime, type of transplantation and complications such as graft versus host disease (GVHD) can affect and prolong recovery time.[52, 53]

Vaccination of individuals post-HSCT

Initially, the recipient may have temporary measurable donor-derived protection against some diseases, but their reconstituted immune system will need full (re)vaccination to provide long-term protection against vaccine-preventable diseases. Administration of subunit vaccines, such as PCV13, may be recommended as early as three months post-HSCT. Annual influenza vaccination may be recommended from six months post-HSCT. It is generally recommended to commence immunisation with live viral vaccines no less than 24 months post-HSCT and in the absence of GVHD and immunosuppressive therapy.[53, 54]

For children aged under 18 years, see the Starship Clinical Guideline Immunisation of children during and after cancer therapy for age-appropriate schedules and worksheets.

For adults, see the vaccination protocol provided by the person’s New Zealand-based haematology clinic or the IMAC factsheet Immunisation for adults post-haematopoietic stem cell transplantation (HSCT) (available on the IMAC website).

For recommendations regarding vaccination of close contacts of immunocompromised individuals, see section 4.3.1.

COVID-19 vaccine

Young children aged 6 months to 4 years, inclusive

Children aged 6 months to 4 years who received HSCT in the past 24 months are recommended to receive three doses of mRNA-CV (3 µg) (maroon cap). First and second doses are given three weeks apart and dose three is given at least eight weeks after the second dose. An additional dose of mRNA-CV (3 µg) can be given six months after the primary course. This spacing can be reduced to at least three months, on a case-by-case basis, where there is a clinical need.

Individuals aged from 6 months who have received HSCT since receiving their first COVID-19 vaccination course can be revaccinated with primary course and additional dose, as age appropriate.

Individuals aged 5 years and over

Individuals aged from 5 years who have received HSCT in the previous 24 months or with ongoing immunosuppression or graft-versus-host disease for more than 24 months (see section ‎5.5.2 for details) are eligible for three primary doses of mRNA-CV (10 µg or 30 µg, as age appropriate); each dose is given eight weeks apart.

Individuals aged from 5 years who have received HSCT since receiving their first COVID-19 vaccination course can be revaccinated with primary course and additional dose, as age appropriate.

Regardless of any previous doses received after completion of the primary course, an additional dose of mRNA-CV (10 µg or 30µg, as age appropriate) is recommended for all individuals aged 5 years and over for recipients of HSCT, and particularly those eligible for three primary doses, to be given six months after the previous dose. This spacing can be reduced to at least three months, on a case-by-case basis, where there is a clinical need (see section ‎5.5.3).

If a significant adverse reaction to mRNA-CV has occurred, it is recommended to seek advice from IMAC to determine whether further doses are contraindicated.

Haemophilus influenzae type b (Hib-PRP) vaccines

Infants and children aged under 5 years

Vaccination against Hib disease for infants and children aged under 5 years is included in the usual Schedule. DTaP-IPV-HepB/Hib vaccine is recommended at 6 weeks, 3 months and 5 months of age followed by a booster dose of Hib-PRP vaccine at age 15 months.

Children and adults post-haematopoietic stem cell transplantation

A three-dose series of Hib-PRP is recommended for children and adults who are post-haematopoietic stem cell transplantation. Children aged under 18 years who are revaccinated using DTaP-IPV-HepB/Hib will receive three doses of Hib-PRP-containing vaccine (funded). For children aged 10 years and over, this is an off-label use of this vaccine which requires a prescription from an authorised prescriber or the patient’s specialist.

For adults who receive monovalent Hib-PRP, one dose is funded, and the immunisation benefit can be claimed for vaccine administration. Doses two and three are not funded. Hib-PRP can only be ordered from ProPharma and an immunisation benefit cannot be claimed for vaccine administration.

Herpes zoster vaccine

Individuals from age 18 years, including those aged 66 years and over, post HSCT are recommended and funded two doses of recombinant zoster vaccine (rZV, Shingrix), given two to six months apart. See section 25.5.1.

Vaccination of individuals pre-/post solid organ transplantation

In addition to the usual Schedule vaccines, individuals who are pre-/post-solid organ transplantation are eligible to receive additional funded vaccines. Ideally, vaccination should be conducted prior to any planned immunosuppression.[55] An accelerated immunisation schedule is provided for infants with congenital biliary or renal conditions requiring transplant (see Table 4.4).

Additional funded vaccines may include hepatitis A vaccine; hepatitis B vaccine if the person was not previously vaccinated or does not have evidence of immunity (see section 9.5.4); Haemophilus influenzae type b (Hib-PRP), influenza, pneumococcal, meningococcal and varicella vaccines.

It is recommended to follow an accelerated schedule of vaccinations for infants and children likely to be listed for solid organ transplantation, see Table 4.4 for infant recommendations.

The spleen has an important role in initiating the immune response to encapsulated bacteria, including Streptococcus pneumoniae, Neisseria meningitidis, and Haemophilus influenzae type b (Hib), and removing them from the circulatory system.

There are three main reasons why an individual may not have a fully functioning spleen:

• congenital disorders (eg, asplenia, hyposplenia or polysplenia associated with a congenital syndrome)
• disease (eg, Coeliac disease, acute leukaemia)
• surgical removal (eg, trauma, autoimmune haemolytic anaemia).

Individuals with reduced spleen function or an absent spleen are at increased risk of overwhelming infection by encapsulated bacteria.[56] This is a medical emergency and carries a high mortality rate. The risk of overwhelming infection after splenectomy is more than 50 times higher than the risk in the general population. Opinion is divided on whether this level of risk is life-long or decreases over time after the splenectomy.

Vaccination of individuals with asplenia or hyposplenia or pre-/post-splenectomy

No vaccines are contraindicated for individuals with functional or anatomical asplenia (pre-/post-splenectomy), and they are eligible for additional funded influenza, Hib, pneumococcal and meningococcal vaccines. Providers should also ensure that they are up to date with Schedule vaccines, including Tdap and MMR.

When a splenectomy is planned, individuals should ideally complete the vaccinations they require up to two weeks prior to their surgery. If this is not possible, preferably administer vaccines until 14 days before the splenectomy and continue from seven days after the splenectomy, or prior to discharge from hospital, if sooner. When the splenectomy is unexpected, for example due to trauma, commence vaccination from seven days after surgery or prior to discharge from hospital. In all cases a vaccination plan must be formulated and communicated to the GP for completion (see Table 4.5).

Individuals with reduced spleen function (eg, because of disease or partial splenectomy), are recommended (but not funded) to receive pneumococcal and meningococcal vaccines and annual influenza vaccination.

See Vaccines for individuals with acquired immunodeficiency in section 4.3.3 for eligibility and recommendations for influenza, Hib, pneumococcal and meningococcal vaccines.

Table 4.5 summarises the additional vaccine recommendations and schedules for infants and children aged under 18 years with functional or anatomical asplenia. The funded vaccines are shown in shaded rows.

Human immunodeficiency virus (HIV) infects CD4+ T cells leading to a progressive decline in CD4 cell count, increasing immunodeficiency and vulnerability to infection, and suboptimal responses to vaccines.

The efficacy of any vaccine may be reduced in HIV-positive individuals, and antibody levels within these individuals may wane faster than in individuals who are HIV‑negative. Although antiretroviral therapy may improve immune responses, it is unlikely these individuals will achieve the levels of antibodies seen in individuals who are HIV-negative. Serological testing and the need for additional doses (eg, HepB: see section 9.5.7 and Table 9.6) should be discussed with the individual’s specialist.

Vaccination of individuals with HIV infection

In addition to the usual Schedule vaccines, individuals who are HIV-positive to receive additional funded vaccines including Hib, pneumococcal, and meningococcal vaccines. Individuals who are HIV-positive are also eligible to receive funded influenza vaccination.

Live vaccines – caution

It is recommended that infants who are HIV-positive receive rotavirus vaccine as per the Schedule. Administration of BCG vaccination is contraindicated for all HIV-positive individuals regardless of their CD4+ percentage/count.[57]

MMR and VV may be administered as per the Schedule to:

• children aged 1–13 years who have a recent CD4+ lymphocyte percentage of ≥15 percent
• children aged 14 years to under 18 years who have a recent CD4+ count of ≥200 cells/ml
• MMR and VV can be administered as per the Schedule to adults aged 18 years or older who have a recent CD4+ lymphocyte count of ≥200 cells/mm³.[49]

See Vaccines for individuals with acquired immunodeficiency in section 4.3.4 for eligibility and recommendations for influenza, Hib, pneumococcal and meningococcal vaccines.

Table 4.6 (for children aged under 5 years when diagnosed) and Table 4.7 (for children aged 5 to under 18 years) summarise additional vaccine recommendations and schedules for HIV-positive children. The funded vaccines are shown in shade rows.

Individuals with CKD who are not receiving immunosuppressive therapy to manage their condition can receive vaccination as per the usual Immunisation Schedule. In addition to the usual Immunisation Schedule vaccines, individuals with CKD may be eligible to receive additional funded vaccines. These should be given as soon as the individual meets the eligibility criteria (eg, CKD stages 4–5: pre-dialysis, on dialysis, pre‑kidney transplant, post-kidney transplant). There is no relationship between vaccination and deterioration of renal function or a reduction in the efficacy of dialysis.[59]

Additional funded vaccines may include hepatitis A, hepatitis B, Haemophilus influenzae type b (Hib), pneumococcal, and meningococcal vaccines. Individuals with CKD are also eligible to receive funded influenza vaccination.

See Vaccines for individuals with acquired immunodeficiency in section 4.3.3 for eligibility and recommendations for influenza, Haemophilus influenzae type b (Hib), pneumococcal and meningococcal vaccines.

For children aged under 18 years, see the Starship Clinical Guideline Renal vaccination record for Starship paediatric CKD.

Individuals with chronic liver disease who are not receiving immunosuppressive therapy to manage their condition can receive vaccination as per the usual Schedule.

In addition to the usual Schedule vaccines, infants and children with chronic liver disease are eligible to receive funded hepatitis A vaccination from 12 months of age (see section 8.5.1). However, if they are likely to require a liver transplant an accelerated vaccination schedule may be advised as per Table 4.4. The aim of the accelerated schedule is to maximise protection against vaccine-preventable diseases and to deliver live vaccines prior to transplantation and immunosuppression. Prior to transplantation, hepatitis A vaccine could be administered from as early as 7 months of age. Additional pre-transplantation funded vaccines include influenza, pneumococcal, meningococcal, and varicella vaccines (see section 4.3.3).

It is recommended that adults with chronic liver disease receive influenza vaccination annually but this is not currently funded. Adults who are likely to require a liver transplant are eligible for additional funded vaccines, including hepatitis A vaccine; hepatitis B vaccine, if the individual was not previously vaccinated or does not have evidence of immunity; Haemophilus influenzae type b (Hib), influenza, pneumococcal, meningococcal and varicella vaccines (see section 4.3.10).

COVID-19 vaccine

Young children aged 6 months to 4 years, inclusive

Children aged 6 months to 4 years with a chronic liver disease are recommended to receive three doses of mRNA-CV (3 µg). First and second doses are given three weeks apart and dose three is given at least eight weeks after the second dose. An additional dose of mRNA-CV (3 µg) can be given six months after the primary course. This spacing can be reduced to at least three months, on a case-by-case basis, where there is a clinical need.

Individuals aged 5 years and over

Children from 5 years of age with chronic liver disease are eligible for three primary doses of mRNA-CV (10 µg or 30 µg, as age appropriate) (see section 5.5.2 for details); each dose is given 8 weeks apart.

Regardless of any doses received after completion of the primary course, an additional dose of mRNA-CV (10 µg or 30 µg, as age appropriate) is recommended for children aged 5 years and over and adults with chronic liver disease, and particularly those eligible for three primary doses, to be given six months after the previous dose. This spacing can be reduced to at least three months, on a case-by-case basis, where there is a clinical need (see section 5.5.3).

If a significant adverse reaction to mRNA-CV has occurred, it is recommended to seek advice from IMAC to determine whether further doses are contraindicated.

Adults and children who enter New Zealand as refugees or immigrants will need an assessment of their documented vaccination status and an appropriate planned catch-up programme. The programme may require modification based on documented doses: only clearly documented doses should be considered as given. If there is no documented vaccination history, plan the catch-up schedule assuming the vaccines have not been given, see Appendix 2 for catch-up schedules.

Immunisation schedules vary from country to country. Check all migrant and former refugee children immunisation records to ensure they are up to date with the New Zealand Schedule, in particularly ensure they have received MMR as opposed to a measles-rubella vaccine only.

For assistance with planning catch-up schedules, contact your local immunisation coordinator; or call IMAC on 0800 IMMUNE/0800 466 863, or discuss with an experienced colleague.

All children aged under 18 years are eligible to receive Schedule vaccines and Well Child Tamariki Ora services regardless of their immigration and citizenship status, and providers can claim the immunisation benefit for administering the vaccines.

Adult refugees aged 18 years or older are eligible to receive Schedule vaccines, and providers can claim the immunisation benefit for administering the vaccines. Non‑residents who were aged under 18 years when they commenced HPV vaccination are currently funded to complete the course, even if they are aged 18 years or older when they complete it. Other adults aged 18 years or older must meet all the applicable eligibility criteria described in the Health and Disability Services Eligibility Direction 2011 to receive funded healthcare services, including Schedule vaccines. For more information about eligibility for publicly funded services, see the Health New Zealand website. 

See also the Recommendations for Comprehensive Post-Arrival Health Assessment for People from Refugee-like Backgrounds (2016 edition), available on the Australasian Society for Infectious Diseases website.

Tuberculosis

In New Zealand, BCG vaccination is recommended and funded for infants and children aged under 5 years at increased risk of tuberculosis (TB). For further details, see section 23.5.2 and the Ministry of Health Guidelines for Tuberculosis Control in New Zealand, 2019.

Quota refugees are screened for active TB prior to arrival in New Zealand. If they are found to have active TB, their arrival is delayed until they are treated. The requirement for active TB screening of visitors and immigrants to New Zealand varies, dependent on the country they are coming from and/or how long they intend to stay in New Zealand.[62] In New Zealand over 2010–2016, the highest number of new TB cases were in people born overseas followed by people living with a person born overseas. Over 2012–2016, the average time between arrival in New Zealand and a new diagnosis of TB was around five years.[63] See section 23.3.2 for risk factors and for countries with high incidence of TB.

Medical practitioners and laboratories are required to notify the Medical Officer of Health of suspected or confirmed cases of active TB. A person who has, or is suspected to have, active TB is entitled to the same level of funded health services as New Zealand citizens can expect.[62]

Hepatitis B

If a member of a refugee or immigrant family is found to be a hepatitis B carrier, it is recommended that all the family be screened, and vaccination offered to all those who are non-immune. Even if no one in the family is a hepatitis B carrier, it is recommended that all children aged under 18 years be vaccinated against hepatitis B. See chapter 9 for more information and Appendix 2 for catch-up schedules.

Varicella

Individuals who have grown up in the tropics are less likely to have had chickenpox in childhood and may be non-immune as adolescents and adults. Adult chickenpox can be severe, and maternal varicella occurring in the first half of pregnancy can cause the rare but devastating congenital varicella syndrome (see Table 24.4). If there is no history of chickenpox or previous varicella vaccination, VV should be offered. Funded only for those turning 11 years of age on or after 1 July 2017 and currently aged under 18 years.

COVID-19

All individuals aged from 5 years living in New Zealand are eligible for COVID-19 vaccination (age-appropriate mRNA-CV [10 µg or 30 µg]), regardless of health and disability services eligibility. Additional doses are available from age 16 years with mRNA-CV (30 µg), see 5.5.3. See section ‎5.5.4 for timing of COVID-19 vaccination following prior COVID-19 infection.

Certain occupations result in increased risk of contracting some vaccine-preventable diseases. Some infected workers, particularly health care workers and those working in early childhood education services, may transmit infections such as influenza, rubella, measles, mumps, varicella and pertussis to susceptible contacts, with the potential for serious outcomes.

Where workers are at significant occupational risk of acquiring or transmitting a vaccine-preventable disease, the employer should implement a comprehensive risk-based occupational vaccination programme, including vaccination policies, staff vaccination records, information about the relevant vaccine-preventable diseases and the management of vaccine refusal. Employers should take all reasonably practicable steps to encourage workers to be immunised as appropriate for the workplace environment and tasks. For information on what is required as evidence of immunity against vaccine preventable diseases, see the IMAC factsheet Occupation related immunisation (available on the IMAC website).

The vaccines in Table 4.9 are recommended for certain occupational groups. In addition to the vaccines listed here, all adults should be up to date with age-appropriate Schedule vaccines (see section A2.3 in Appendix 2 for catch-up vaccination advice for adults aged 18 years or older) and includes COVID-19 vaccines. 

If a non-immune individual is exposed to a vaccine-preventable disease, post-exposure prophylaxis and control measures should be administered where indicated (see the relevant disease chapters and in the Communicable Disease Control Manual.

International visitors, especially students entering New Zealand for educational purposes to attend schools and tertiary institutions, are recommended to be immunised and to check that their immunisations are appropriate for New Zealand. The recommended immunisations for adults are given in Table ‎2.4 – note, these may not be funded for all students.

All children aged under 18 years are eligible to receive Schedule vaccines regardless of their immigration and citizenship status, and providers can claim the immunisation benefit for administering the vaccines.

Adults and children who enter New Zealand as students are recommended to have an assessment of their documented vaccination status, and if necessary, an appropriate planned catch-up programme based on their documented doses.

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